Piles (Hemorrhoids)
If Piles (hemorrhoids) are detected at an early stage it can be treated effectively without having to do surgery. The management of less severe cases is possible through dietary changes, medicines and minimally invasive techniques and ligation techniques: DG HAL (HALO).
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What is a hemorrhoid (piles)?
Often described as "varicose veins of the anus and rectum", hemorrhoids are dilated and swollen cushions (pads of tissue) in the anal canal, they may project into the anal canal to form visible swellings.

There are two types, external and inteSrnal.

External hemorrhoids are near the anus and covered by skin.

Internal hemorrhoids develop within the anus beneath the anal lining.
piles


What causes hemorrhoids (Piles)?
Causes of piles are constipation and excessive straining during bowel movement. There are several theories, including inadequate intake of fiber, and prolonged sitting on the toilet. Pregnancy is a cause of enlarged hemorrhoids.

What are the symptoms of piles?
  • Bleeding during bowel movement.
  • Protrusion during bowel movement.
  • Lump
  • Pain
  • Itching and irritation
Four degrees of hemorrhoids:-

First-degree hemorrhoids:Hemorrhoids that bleed but do not prolapse.

Second-degree hemorrhoids: Hemorrhoids that prolapse and retract on their own (with or without bleeding).

Third-degree hemorrhoids: Hemorrhoids that prolapse but must be pushed back in by a finger.

Fourth-degree hemorrhoids: Hemorrhoids that prolapse and cannot be pushed back in.

How are hemorrhoids diagnosed?

Any rectal bleeding should always be checked out by a Qualified Surgeon or Colo-rectal surgeon to rule out certain serious causes of bleeding. even if it is suspected to be from a hemorrhoid.

History of symptoms gives fair clue to diagnosis.

The diagnosis of an external hemorrhoid is easy if the hemorrhoid protrudes from the anus. For non protruding hemorrhoids rectal examination with a gloved finger is required.

Thorough examination for internal hemorrhoids is done by proctoscope and also other causes of Hemorrhoid-like symptoms can be diagnosed.

If there is rectal bleeding, the colon above the rectum needs to be examined to exclude important causes of bleeding other than piles (hemorrhoids).

Other serious causes include colorectal cancer or polyps or inflammatory bowel disease. This examination can be done by either flexible sigmoidoscopy or colonoscopy.


What is the Hemorrhoid (Piles) Treatment?

    i. General measures (Home Care) for piles

    ii. Medical management

    iii. Painless minimally invasive procedures for piles treatment

    • Ligation by rubber band, cutting off blood supply.
    • Injection and sclerotherapy
    • LASER, Infrared or coagulation
    • DG HAL & HAL-RAR: FDA approved safe and painless procedure for piles.
    • MIPH (stapler surgery) for piles
    iv. Open piles surgery (Hemorrhoidectomy): - when ligation fails, bleeding is persistent & protruding hemorrhoid can not be reduced.


General measures (home care)

Anal Hygiene: Proper Cleaning techniques Avoid rubbing with toilet paper. This aggravates the hemorrhoids and irritates the skin.

Rinse the area in a bath or a shower without using soap. Then gently dry the area by blotting it with a towel.

Alternatively disposable baby wipes can be a used for gentle cleaning when bathing is impractical.

Moist anal area is prone to irritation and infection so keep it dry. Sprinkle baby powder or place large cotton pad to absorb any moisture.

Bowel Movement

Use the toilet as soon as you feel the urge to have a bowel movement, even if it is several times throughout the day. Do not delay as you might get a reflex constipation.

Avoid prolonged sitting or excessive straining while on the toilet; Limit your time 3-5 minutes for any one sitting. If you can't have a bowel movement in that time, come back later.

Don't read, watch TV, talk on the phone, or play video games while sitting on the toilet.

Diet

Take High Fiber Diet beans, whole grains, bran cereals, fresh fruits, and vegetables.

Limit food that have little or no fiber such as ice cream, cheese, meat, and processed foods.

Avoid soda beverages, citrus fruits and juices, beer and wine, and caffeinated products.

Drink 8-10 glasses of water, exercise regularly.

Enemas

Enemas may be used to relieve constipation and fecal impaction. To keep the bowels clean, plain warm water enemas can be effective.

Ice Packs

Apply an ice pack to the anal area on and off for 10-15 minutes for inflamed piles.

Hot Sitz Bath

Fill up your bathtub with warm water and sit in it for 10-15 minutes.

Topical Ointments and Creams

Petroleum jelly can be applied to the anal area to soothe irritated skin surfaces.

Applying ointment to the anal passage just prior to a bowel movement can help alleviate pain caused by the passage of a hard or difficult stool.



Medical Management: -

Generally constipation and straining for bowel movements promote piles (hemorrhoids) and hard stools can traumatize existing hemorrhoids. Therefore, Mild symptoms can be treated by increasing fluid and fiber intake, in the diet, along with eliminating straining factors. Fiber supplements, pain relieving creams and suppositories are also prescribed.

A hot-sitz bath (sitting in plain warm water) for about 10-15 minutes provides some relief.

Vasoconstrictors applied to the perianal area may reduce swelling, pain and itching due to their mild anesthetic effect.

Daflon is micronized purified flavonoid fraction (MPFF) associated with fiber supplement is equivalent to rubber-band ligation plus fiber supplement in stopping anal bleeding due to hemorrhoids.



Painless minimally invasive procedures for piles: -

Major surgery for hemorrhoids can generally be avoided with advanced methods of treatment.

Surgical treatment of haemorrhoids has significantly changed by advanced techniques which are safe, pain free and minimally invasive. These procedures can be performed as outpatient basis or with short hospital stay and allows patients to return to work earlier compared to conventional treatment options.

Rubber band ligation

A special instrument fits a tight rubber band over base of the hemorrhoid to cut off blood supply. Died tissue falls in a few days time and resulting wound heals in a week or two. It can be used with first-, second-, and third-degree hemorrhoids. It can be done as an out patient procedure.



During the first 24 hours, some patients may experience a feeling of fullness or a dull pain in the rectum. This can be relieved with an over-the-counter pain medication.

You should rest at home for the day and resume full activity the next day. You can have normal bowel movements during this time and Sitz bath can be taken (a warm tub with a tablespoon of table salt added)

Sclerotherapy

Special chemical Sclerosant (hardening agent) is injected into the hemorrhoids causing the vein walls to collapse and the hemorrhoids to shrink. Multiply sessions may be required. Infrared Coagulation

Heat energy is used to cut off the blood supply to the hemorrhoids. This procedure takes less than 10 minutes.

LASER

Piles is simply vaporized or excised with pin point accuracy and precision. Co2 Laser beam allows operating in a bloodless field without pain sensation because of sealing of small nerves and blood vessels.

The result is less discomfort, less medication, and faster healing. A hospital stay is generally not required.

DG HAL /HAL/HALO:-

Doppler Guided Haemorrhoidal Artery Ligation (DG HAL) and Recto-Anal Repair (HAL RAR) or Hemorrhoid Artery Ligation operation (HALO) is a new FDA approved operation designed to eradicate piles without the need for cutting or a general anaesthetic.

DG HAL is particularly effective for Grade II and III haemorrhoids, It is coupled with Recto-Anal-Repair (HAL RAR) for some Grade III and most Grade IV haemorrhoids.

This procedure has been performed in Europe, North America and U.K. now for a few years with excellent results. 85% of patients have a complete resolution of their symptoms and over 90% are satisfactory results.

DG-HAL Technique-

DG-HAL uses ultrasonic blood flow detector (Doppler) to identify the arteries supplying the piles. Surgeon ties these blood vessels by placing a suture around it through a small window in the device.

Tying off arteries that feed piles (hemorrhoids) causes them to shrink. It causes prompt resolution of most bleeding and protrusion caused by hemorrhoids, over next few days symptoms resolve completely.


Procedure can be done as an office procedure with or without any sedation or anaesthesia, or alternatively local rectal anaesthesia is given and nitroglycerin cream is applied to the rectum to enhance blood flow, making it easier to identify blood vessels.

The procedure generally takes about 20-30 minutes, and Mild post operative Pain can be managed with simple analgesics. Patients can go home a few hours later.
Benefit of DG-HAL
  • Much simpler procedure and much faster recover time.
  • As no incisions (cutting) are made it is relatively painless
  • It can be carried out as a day care procedure.
  • Procedure can be carried out without the need for general anaesthetic.
  • High success rate
Technique of DG HAL RAR

Through the window of device Recto-Anal- Repair (R.AR.) can also be done to reposition the prolapsed tissue.

The device is so designed that only the prolapsing tissue is caught in the needle, hemorrhoids that are hanging down are lifted up to the place where they belong.. HAL-RAR takes Twenty minutes to complete. Most patients experience only minor discomfort and can return to work within one or two days.

Benefit of HAL-RAR

  • No cutting and no open wounds
  • Short procedure time
  • Only one day in hospital
  • Back to work the next day
  • Very high success rates worldwide
Preparation for procedure-

  • On the day of you will be given enema or suppository for bowel preparation.
  • You will not be allowed to eat / drink 6 hours prier to surgery.
Post operative what to expect?

  • You may have soft pad in place but no internal dressing
  • You will be allowed to drink when you are fully awake.
  • Usually no pain medication is required.
  • You may feel the need to defecate frequently throughout the first 24 hours.
  • There's usually little or no postoperative bleeding, and return to work within 48 hours.
  • Diet- Eat diet reach in fiber, drink 8-10 glasses of water.
  • Activities- You can resume your routine activities and work same day. Avoid driving for 24 hours.
Limitation

DGHAL is avoided for acute haemorrhoidal thromboses or clots, and patients on Coumadin or aspirin therapy (blood thinners). Purely external hemorrhoids are not good candidates for DGHAL but must be excised.

Stapler Hemorrhoidectomy:-

Minimally invasive stapler hemorrhoidectomy (MIPH) is less painful and allows patients to return to work and other normal activities much earlier than with the conventional procedure.

This technique uses a stapling device.

The mucosa above the dentate line, which contains part of the pile mass, is excised and stapled with the stapler gun, thus taking care of bleeding and prolapse - the two major components of piles. The titanium staples cut and seal simultaneously, thus causing minimal bleeding and as the cut line is above the nerves, there is reduction in post operative pain. Additionally there is no incision on the perianal skin or lower part of anal canal there is no need to do any post operative dressing. It should be done by a surgeon who is especially trained in doing stapler surgery.


What are the advantages of Piles stapler surgery (MIPH)?

  • Smaller incisions resulting in reduced pain and discomfort
  • Minimal scarring
  • Greater surgical precision
  • Fewer complications
  • Less blood loss and a decreased need for blood transfusions
  • Reduced risk of infection
  • Shorter hospital stays
  • Faster recoveries
Although rare, there are risks that accompany this procedure:

  • Damage to the rectal wall.
  • The internal muscles of the sphincter may stretch, resulting in short-term or long-term dysfunction.
  • Pelvic sepsis has been reported following stapled hemorrhoidectomy.
  • Persistent pain and fecal urgency after stapled hemorrhoidectomy
Diathermy hemorrhoidectomy

Surgical removal of hemorrhoids (hemorrhoidectomy) usually is reserved for patients with third or fourth-degree hemorrhoids. NSAIDs are prescribed for Post surgical pain relief. Bleeding occurs in 1-2% of patients 7-14 days post-surgery. Wound infections are uncommon.

Pre- operative preparation for anal surgery

Bowel Preparation
The large intestine needs to be clear of faeces for adequate visualization. Medication to evacuate stool plus a liquid diet at least 6 hours prior is necessary for colonoscopy: Clear liquids
Water, tea or coffee without milk, barley water, sugar cane, chrysanthemum tea, fruit juice without pulp like apple juice, broth and jelly without milk or coconut. Drink at least 2 liters. Oral Fleet
45 mls mixed with an equal volume of clear liquids of your choice, to be repeated after 2 hours

  • If local anaesthesia is used, no fasting is required. If general anaesthesia is required, no solids or liquids are to be taken at least 6 hours before surgery.
  • You may continue to take antihypertensive medication with a sip of water on the morning of surgery but avoid diabetic medication, aspirin, Ticlid or other similar cardiac drugs.


What should you do following anal surgery?

  • Shower-spray the anal area with warm water the morning following surgery.
  • Perform sitz baths twice each day and after each bowel movement (10-15 minute soak in warm water).
  • For prolonged sitting, use a pillow or styrofoam pad.
  • Take 1 tablespoon of fiber supplement once each day. Dissolve this in a glass of water or juice. Drink 8-10 glasses of water per day.
  • Pain Medication if required can be taken
  • Rest for the day. Avoid heavy lifting or vigorous exercise for 5 days.
  • You can have a regular high fiber diet
  • Straining due to constipation should be avoided; you should not sit longer than two minutes on the toilet. If you can't have a bowel movement in that time, come back later.
 
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