CONTENTS
1. Definition
2. Types
3. Etiology
4. Features
5. Differential Diagnosis
6. Investigation
7. Complications
8. Treatment
PILES/HAEMORRHOIDS
Piles - a ball or mass, Haemorrhoids = blood to ooze, Figs = a fruit
(Anjoora).
The word 'Haemorrhoids' is derived from Greek word Haima (bleed) +
Rhoos (flowering), means bleeding. The pile is derived from the Latin
word 'Pila' means Ball.
DEFINITION:-
It is downward sliding of anal cushions abnormally due to straining or
other causes.
Anal cushions (Thomson, 1975) are aggregation of blood vessels
(arterioles, venules), smooth muscles and elastic connective tissue in
the submucosa that normally reside in left lateral, right posterolateral
and right anterolateral anal canal. Piles can be mucosal or vascular
(Graham Stewart, 1963). Vascular type is seen in young,mucosal is seen
in old.
*Present concept is weakening of Park's ligament which is the
lower end of the external sphincter.
Types
1. Internal-above the dentate line, covered with mucous membrane.
2. External -below the dentate line, covered with skin.
3. Interno-external-together occurs.
ANATOMICAL LOCATIONS OF INTERNAL AND EXTERNAL PILES.
CLASSIFICATION I
• Primary haemorrhoids. Located at 3, 7, 11 o'clock positions, related to the branches of
the superior haemorrhoidal vessel which divides on the right side into two; left side it
continues as one.
• Secondary haemorrhoids: One which occurs between the primary sites.
POSITION OF HAEMORRHOIDS
CLASSIFICATION ||
First degree haemorrhoids:-
Piles within that may bleed but does not come out
Second degree haemorrhoids:-
Piles that prolapse during defaecation, but returns back spontaneously
Third degree haemorrhoids:
Piles prolapsed during defaecation, can be replaced back only by manual help
Fourth degree haemorrhoids
Piles that are permanently prolapsed.
AETIOLOGY
• Hereditary.
• Morphological - weight of the blood column without valves causes high pressure .Veins in the
lower rectum are in loose submucosal plane, but the veins above enter the muscular layer,
which on contraction increases the venous congestion below (more prevalent in patients with
constipation) Superior rectal veins have no valves (as they are tributaries of portal vein) and so
more congestion.
• Other causes are straining, diarrhoea, constipation, hard stool, low fibre diet, overpurgation,
carcinoma rectum, pregnancy, portal hypertension (rare cause).
• During pregnancy factors causing haemorrhoids-raised progesterone relaxes the venous wall
and reduces its tone, enlarged uterus compresses the pelvic vein, and constipation is common
problem.
DIFFERENT TYPES OF PROLAPSED PILES
• Bulging of haemorrhoidal plexus occurs due to raised luminal pressure and transmission of
arterial pressure; pressure in rectal ampullary pump (Wannas) during straining raises the portal
as well as systemic pressure causing obstruction to venous outflow causing haemorrhoids
• Disruption of suspensory tissues which hold plexus in position (sliding lining theory); raised
basal anal pressure; unsupported superior haemorrhoidal vein in the loose submucosal
connective tissue in the anorectum when passes through the muscular coat gets constricting
effect leading into congestion of haemorrhoidal plexus-are the other theories of haemorrhoid
formation.
• Idiopathic Causes It is very difficult to pinpoint the cause for production of piles.
FEATURES
❖ The prevalence rate of piles is 4.4% in the world, in about 10 million people.
❖ It may occur at any age but mostly seen in the age between 30 to 65 years.
❖ Incidence is equal in both the sexes.
❖ Bleeding-1st symptom-Splash in the pan-bright red and fresh-occurs during defecation.
❖ Mass per anum; Anaemia-secondary.
❖ Discharge a mucoid discharge; Pruritus.
❖ Pain-may be due to prolapse, infection or spasm.
❖ On inspection, prolapsed piles will be visualized.
❖ On P/R examination, only thrombosed piles can be felt.
❖ Through proctoscopy exact position can be made out as a bulge into the proctoscope.
❖ Points to be noted during proctoscopy:
➢ The numbers, degrees and size.
➢ The surface and appearance of piles.
➢ Features, chronicity of the prolapse.
➢ One should look for other rectal lesion such as external tags, anal papillae and fissure,
proctitis.
❖ Any gynaecological, genitourinary or abdominal condi tions like carcinoma of rectum, polyps,
tumours, features of ulcerative colitis should be identified.
❖ Presence of other discharge like blood, pus, mucous.
❖ Sigmoidoscopy or colonoscopy or barium enema should be done if there is any suspicion of
associated malignancy.
DIFFERENTIAL DIAGNOSIS:
Carcinoma; Rectal prolapse, Perianal warts.
INVESTIGATIONS:
Haematocrit, Colonoscopy to evaluate proximally for any cause; Barium enema X-ray.
COMPLICATIONS:-
• Profuse hemorrhage which may require blood transfusion.
• Strangulation. ---Piles is begin gripped by anal sphincter.
A and B: PROLAPSED ,STRANGULATED PILES
• Thrombosis ---Piles appear dark purple/black ,feels solid and tender.
• Ulceration,Gangrene,fibrosis,stenosis
• Suppuration,leads to perianal or submucosal abscess.
• Pylephlebitis (Portal pyaemia ) is rare ,but can occur in 3rd degree piles after surgery.
TREATMENT:-
1) Nonoperative:
• Sitz bath
• Local applications to reduce pain, itching and oedema can be used.
• Antibiotics, laxatives, anti-inflammatory drugs are beneficial,
• Fibre diet 35 g/day, plenty of water.
• Laxatives such as lactulose solution which soften bowel motions and relieve the
constipation.
2) In case of inflamed, permanently prolapsed, oedematous piles, initially, manual stretching of the
anal canal sphincter is tried. This prevents congestion of anal cushions and relaxes the anal
sphincter, as a result of which the prolapsed piles gets reduced-Lord's dilatation (8. fingers).
Once oedema subsides, in 1-2 weeks, formal procedure is done.
3) Injection-Sclerosant therapy.
4) Barron’s banding ( it is done for 2nd degree piles. It causes ischaemic necrosis and piles fall off.
Band should be placed 2cm above the dentate line.)
5) Cryosurgery – using nitrous oxide (-98°) or liquid nitrogen (-196°),extreme cold temperature is
used to coagulate and cause necrosis of piles which gets separated and fall off subsequently.
6) Infrared calculation
7) Laser therapy for piles
8) Stapled haemorrhoidopexy ( It is circumferential excision of the mucosa and submucosa 4cm
above the dentate line using circular hemorrhoidal stapler passed per anally)
9) OPEN OPERATIVE METHODS :- STILL GOLD STANDARD
Indications:-
• 3rd degree piles
• Fibrosed piles
• Failure of non operative methods.
Haemorrhoidectomy is the best treatment for hemorrhoids.The haemorrhoidectomy is
performed using an open and closed technique. The open technique is known as Milligan -Morgan
operation and the close technique is kown as Hill Ferguson. Both involve ligation and excision of the
haemorrhoid, but in the open Technique the anal mucosa and skin are left open to heal by second
intention , and in the close Technique the wound is sutured.
❖ MILLIGAN -MORGAN (OPEN METHOD)
Ligation and excision of piles -----commonly done procedures.
o Under anaesthesia, in lithotomy position, initially the sphincter should be dilated to
reduce the postoperative pain. Later skin is held with Allis forceps, internal pile is held
with artery forceps. Skin is cut in "V" shaped manner and internal sphincter is
separated and pushed up. Pedicle is transfixed with vicryl or catgut and distal part is
excised. All the three piles can be dealt in a single sitting.
o Postoperatively, sitz bath, antibiotics, laxatives , analgesics, local applications are given.
Often few finger dilatation of the anal canal is required to prevent stenosis.
❖ HILL-FERGUSON CLOSED METHOD:
Here patient in prone position, under GA/caudal anaesthesia, retraction is done using Hill-
Ferguson retractor. Incision is made around pile mass, pedicle is dissected to its proximal base; it
is ligated with transfixation using 2-zero vicryl or silk, mucosa and anal skin is sutured using 3-
zero vicryl/dexon after proper haemostasis using cautery.
“During haemorrhoidectomy, skin part is held with Allis forceps; internal pedicle is held with artery
forceps. A 'V' cut is placed over the outer skin up to mucocutaneous junction. Dissection is deepened to
visualise the internal sphincter. Once pedicle is dissected, it is transfixed using vicryl suture material.
Distal tissue is excised. Technique is repeated on other sites also.”
EXTERNAL PILES
Causes:-
As a part of internal piles , Sentinel pile associated with anal fissure, Anal skin
tags.
Treatment:-
The cause is treated , sitz bath , Excision.
Problems :-
Pruritus ani , perianal haematoma ,perianal abscess formation.
TYPICAL EXTERNAL PILE.
