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What is a hemorrhoid (piles)?
What causes hemorrhoids (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.
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.
Itching and irritation
Four degrees of hemorrhoids:-
Hemorrhoids that bleed but do not prolapse.
Hemorrhoids that prolapse and retract on their own
(with or without bleeding).
Hemorrhoids that prolapse but must be pushed back in by a finger.
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).
What is the Hemorrhoid (Piles) Treatment?
Other serious causes include colorectal cancer or polyps or inflammatory bowel disease.
This examination can be done by either flexible sigmoidoscopy or colonoscopy.
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.
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.
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 may be used to relieve constipation and fecal impaction. To keep the bowels clean,
plain warm water enemas can be effective.
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.
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)
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.
Heat energy is used to cut off the blood supply to the hemorrhoids. This procedure takes less than 10 minutes.
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
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 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
Technique of DG HAL RAR
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
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
Preparation for procedure-
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
Post operative what to expect?
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.
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.
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.
What are the advantages of Piles stapler surgery (MIPH)?
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.
Although rare, there are risks that accompany this procedure:
Smaller incisions resulting in reduced pain and discomfort
Greater surgical precision
Less blood loss and a decreased need for blood transfusions
Reduced risk of infection
Shorter hospital stays
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
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
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:
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.
45 mls mixed with an equal volume of clear liquids of your choice, to be repeated after 2 hours
What should you do following anal surgery?
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.
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.