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       What are haemorrhoids (piles) and what causes them?
 
         Posted on :16:43:58 Jan 12, 2018
   
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       Last edited on:17:30:28 Jan 12, 2018
         Tags: haemorrhoids, cause
 

Piles are swellings that develop from the inner lining of the anus and lower rectum (last parts of large intestine). Symptoms range from temporary and mild, to persistent and painful. In many cases, piles are small and settle down without any treatment. If required, there are various effective treatment options which should be decided only after proper evaluation by a surgeon.

There is a network of small veins within the inside lining of the anus and lower rectum. These sometimes become stretched and filled with more blood than usual. These engorged veins and the overlying tissue may then form into one or more small swellings called piles which progressively protrudes out of the anus.

The exact reason why these changes occur and lead to piles is not clear. Some piles seem to develop for no apparent reason. However, it is thought that the increased pressure in and around the anus can be a major factor in many cases. About half the people may develop one or more piles at some stage. Certain situations that increase the chance of developing piles are:

Constipation: Passing large, hard stools and straining at the toilet due to increased pressure in and around the veins in the anus.

Pregnancy: Piles are common during pregnancy. This is probably due to pressure of the baby lying above the rectum and anus, and the effect that the change in hormones during pregnancy can have on the veins.

Ageing: The tissues in the lining of the anus may become less supportive as we get older.

Hereditary factors: Some people may inherit a weakness of the wall of the veins in the anal region.

What are the types of piles?

1. Internal piles

These form in the anus about 2 to 4 cm above the  opening. Their severity and size are classified into grades 1 to 4.

Grade 1 are small swellings that cannot be seen or felt from outside the anus. They are common and may not need treatment.

Grade 2 are larger and may be partly pushed out of the anus when you go to the toilet, but quickly go back in.

Grade 3 hang out from the anus. You may feel one or more small, soft lumps. However, you can push them back inside the anus with a finger.

Grade 4 permanently hang down from the anus, and you cannot push them back inside. They sometimes become quite large.

Symptoms can vary. Small piles are usually painless. The most common symptom is bleeding after going to the toilet. Larger piles may cause a mucus discharge, some pain, irritation and itch as the discharge may irritate the skin around the anus. You may have a sense of fullness or a feeling of not fully emptying your bowel when you go to the toilet.

A possible complication of piles that hang down (grade 3 to 4) is a blood clot (thrombosis) which can form within the piles. This is uncommon, but causes intense pain if it occurs.

2. External piles (perianal haematoma)

This is less common and is a small lump that develops on the outside edge of the anus. Many do not cause symptoms. However, if a blood clot forms in the piles ('thrombosed external haemorrhoid') it can suddenly become very painful and need urgent treatment. The pain is relieved if it ruptures but may bleed for a few days. It then gradually shrinks to become a small skin-tag.

Some people develop internal and external piles at the same time.

How to prevent and treat piles?

Avoid constipation and straining by keeping the motions soft.

Eat plenty of fibre such as fruit, vegetables, cereals, wholemeal bread, etc and have lots of fluids to drink. Adults should aim to drink at least two litres (10-12 cups) per day. Most sorts of drink will do, but alcoholic drinks can be dehydrating and are not good. Also intake of spicy foods should be reduced.

If a high fibre diet and fluids is not helping, you can take bran, or other fibre supplements ('bulking agents') such as ispaghula husk, which you can buy at a pharmacy.

Certain painkillers and medicines taken for other reasons are a common cause of constipation and may have to be changed or stopped.

Go to the toilet as soon as possible after feeling the need. Some people suppress this feeling and plan to go to the toilet later. This may result in bigger and harder motion which are then more difficult to pass. Do not strain on the toilet simply because of a tempting feeling of  'fullness’. Do not spend too long on the toilet which may encourage you to strain. (For eg, do not read newspaper or emails!)

The above measures may help prevent piles and in early cases, often ease symptoms such as bleeding and discomfort. It may be all that you need to treat small piles (grade 1) which often settle down over time.

Piles of pregnancy usually settle after the birth of the child. Some medicines should be avoided during pregnancy but the general preventive measures may be tried.

How to get yourself checked?

When the general measured described above don't work or the symptoms persist or increase you should consult a surgeon. The surgeon will examine you by passing a finger inside to feel the anus and also perform an endoscopy test to look into the anus to assess the severity of piles and to look for any other dangerous conditions like cancer which can rarely occur along with piles. Many times, self treatment or treatment done by ‘quacks’ who advertise magical cures, end up in disaster as they are not qualified to accurately examine you or do such tests.

Are medical treatments available?

Only a qualified doctor should prescribe medicines. Laxatives may be given to soften and quicken the motion. Ointments, creams, and suppositories are also commonly used for short periods. They do not 'cure' piles but may ease symptoms such as constipation, discomfort and itch. Some medicines reduce bleeding and help to shrink the piles.

Very painful protruding piles are uncommon but can be an emergency. The pain may be eased by an ice pack pressed on for 15-30 minutes and strong painkillers may be needed. Surgery is needed when piles progress despite taking medicines, do not respond well to medicines or when complications like severe pain, infections or bleeding occurs.

What are the various surgical options?

1. Outpatient procedures: These include banding, laser, radio-frequency ablation, cryotherapy, infrared coagulation etc.

They are commonly used for internal grade 2 piles and also to treat grade 1 piles which have not settled with the preventive measures described above. It is usually done by a surgeon in the clinic without major anesthesia. Treatment is directed at the base of the piles by cutting off the blood supply to the piles which then 'dies' and drops off after a few days. These methods are usually painless as the upper anus where the piles originate is not sensitive to pain.

In about 8 in 10 cases, the piles are 'cured' by these techniques and you can have a repeat treatment if needed. Complications are uncommon if done by experienced surgeons.

2. Haemorrhoidectomy (piles operation): An operation to cut away the piles is an option to treat grade 4 piles and sometimes for smaller grade piles not successfully treated by banding or other methods. The operation is done under anaesthesia in an operation theatre and is usually successful. However, it can be quite painful in the days following the operation.

3. Stapled hemorrhoidopexy (Stapler surgery): This is the latest and popular procedure nowadays. In this procedure a circular stapling device is used to cut out a circular section of the lining of the anal canal above the piles. This has an effect of pulling the piles back up into the anal canal and reducing the blood supply to the piles which shrink as a consequence. Because the cutting is above the piles, it is usually a less painful procedure than the traditional operation.

4. Haemorrhoidal Artery Ligation (HAL procedure): In this, the small vessels that supply blood to the piles are identified using a scanner and tied. This causes them to shrink. This procedure is not usually painful and is gaining in popularity as a treatment option.

What are the benefits of surgery?

Surgery for piles avoids protrusion, painful thrombosis and bleeding which over a period can cause anaemia (reduced hemoglobin). Occasionally bleeding can be severe and life threatening!

Surgery in specialised hospitals is safe and complications are rare.

After surgery

You should avoid driving for one to two weeks, it is advisable to sit in warm baths twice a day and you should avoid constipation by taking a high fibre diet. You may be offered a course of medicines and creams for some days to reduce the discomfort and ease the passage of motions.

Summary

Hemorrhoids or piles is a common problem which is mainly caused by our diet and lifestyle habits. Rarely it can be a sign of more serious underlying disease like cancer. It is important not to hide your symptoms or resort to self treatment. Remember not to fall for quacks and advertisements promising magical cures.

A qualified surgeon can easily diagnose the problem and can offer you effective medicines. Sometimes a surgery may be required but latest technology has made it more painless and less complicated. Whatever the treatment is done, a proper diet, good toilet habits and lifestyle modification are essential for a successful outcome.

Dr. Shafy Ali Khan
Consultant Surgeon
KIMS Hospital
Thiruvananthapuram

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