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Piles (Hemorrhoids)

 

Hemorrhoids are clusters of vascular tissues, smooth muscles, and connective tissues that lie along the anal canal in three columns—left lateral, right anterior, and right posterior positions. Hemorrhoids are present universally in healthy individuals. Hemorrhoids aid in the process of bowel movement.  Nonetheless, the term “hemorrhoid” is commonly invoked to characterize the pathologic process of symptomatic hemorrhoid disease instead of the normal anatomic structure.

 

As the supporting tissue of the anal cushions weakens, downward displacement of the cushions can occur, causing venous dilation and prolapse.

 

What Causes Hemorrhoids?

There’s no single cause of hemorrhoids. Most often, though, they are caused by too much pressure on the anal canal. This can be due to:

  • Chronic (ongoing) constipation
  • Straining during bowel movements
  • Diarrhea
  • Pregnancy and childbirth
  • Sitting too long on the toilet
  • Strenuous exerciseor heavy lifting
  • Aging

 

 

Classification of a hemorrhoid:

External hemorrhoids

located below the dentate line and are covered with anoderm, composed of squamous epithelium, and are innervated by somatic nerves supplying the perianal skin and thus producing pain.

 

Internal hemorrhoids

lie above the dentate line and are covered by columnar epithelium, innervated by visceral nerve fibers and thus cannot cause pain.

 

Grading:

  • Grade I hemorrhoids do not protrude from the anus. They may bleed, but otherwise cause few symptoms.
  • Grade II hemorrhoidsprotrude from the anus during bowel movements. They reduce back in to the anal canal when straining stops.
  • Grade III hemorrhoids protrude on their own or with straining. They do not reduce by themselves, but can be pushed back into place.
  • Grade IV hemorrhoids protrude and cannot be reduced at all. They can also be painful and may require prompt treatment.

 

 

Symptoms and Presentation:

A total of 40% of individuals with hemorrhoids are asymptomatic. For symptomatic hemorrhoids, there is great variance in the constellation of symptoms.

For internal hemorrhoids,

  • Bleeding: The most commonly reported symptom. The occurrence of bleeding is usually associated with defecation and almost always painless.
  • Sensation of tissue prolapse: Prolapsed internal hemorrhoids may accompany mild fecal incontinence, mucus discharge, sensation of perianal fullness, and irritation of perianal skin.
  • Pain is significantly less common with internal hemorrhoids than with external hemorrhoids, but can occur in the setting of prolapsed, strangulated internal hemorrhoids that develop gangrenous changes due to the associated ischemia

In contrast, in external hemorrhoids,

  • pain is most common due to activation of perianal nerves associated with thrombosis. Patients typically describe a painful perianal mass that is tender to palpation.
  • Bleeding can also occur if ulceration develops from necrosis of the thrombosed hemorrhoid
  • Painless external skin tags often result from previous edematous or thrombosed external hemorrhoids.

 

Evaluation:

  • Digital examination: to exclude distal rectal mass and anorectal abscess or fistula. Evaluation of sphincter integrity during the digital examination is important.
  • Anoscopy
  • Rigid or flexible proctosigmoidoscopy
  • Colonoscopy: for complete colonic evaluation

 

Management:

 Conservative Medical Treatments

Lifestyle and dietary modification are the mainstays of conservative medical treatment of hemorrhoid disease. Specifically, lifestyle modifications should include increasing oral fluid intake, reducing fat consumptions, avoiding straining, and regular exercise.

Diet recommendations should include increasing fiber intake, which decreases the shearing action of passing hard stool.

 

Nonsurgical Office-based Procedures

Rubber Band Ligation

Rubber band ligation is the most commonly performed procedure in the office and is indicated for grade II and III internal hemorrhoids

Sclerotherapy

Sclerotherapy is indicated for patients with grade I and II internal hemorrhoids and may be a good option for patients on anticoagulants.

Infrared Coagulation

Infrared coagulation refers to direct application of infrared light waves to the hemorrhoidal tissues and can be used for grade I and II internal hemorrhoids

Cryotherapy

Based on the concept that freezing the internal hemorrhoid at low temperatures can lead to tissue destruction

 

Operative Managements:

For symptomatic Grade ΙΙΙ-ΙV hemorrhoids and hemorrhoids resistant to nonoperative procedures, a surgical approach can be adopted. This is required in only 5-10% of patients.

Hemorrhoidectomy

There are two major types of hemorrhoidectomy:

Ferguson, or closed hemorrhoidectomy and

Milligan–Morgan, or open hemorrhoidectomy

 

Stapled Hemorrhoidopexy

An alternative to operative hemorrhoidectomy is stapled hemorrhoidopexy, in which a circular stapling device is used to resect and fixate the internal hemorrhoid tissues to the rectal wall. This technique is also known as ‘procedure for prolapse and hemorrhoids (PPH)’. PPH is significantly less painful and allows quicker recovery.

 

Doppler-guided Hemorrhoidal Artery Ligation

It involves a Doppler transducer allowing sequential identification of the position and depth of superior rectal arterial branches, which are then selectively ligated 2-3 cm above the dentate line. The interference with the blood supply suppresses the bleeding and volume of the hemorrhoids and symptomatic relief is usually evident within 6-8 weeks.