Back to Topics<<<<

HAEMORRHOIDS OR PILES

This is a varicose condition of the veins of the anorectum, which means that the veins are congested, dilated, elongated and, therefore, tortuous.

In the beginning, a clear differentiation should be made between an internal piles and an external. In the former variety, the veins are covered by mucous membrane, and in the latter, they are covered by skin. There may be combination, when the veins are clothed above by the mucosa and below by the skin, and this variety is called the interno-external piles. An interno-external pile just represents an advanced stage of an internal piles.

While internal piles represents single category, external piles denotes several distinct clinical entities and these are:
  • In association with an internal piles, i.e. interno-external piles
  • In association with an anal fissure i.e., sentinel piles
  • Dilatation of the veins of the anal verge, as is seen in persons of sedentary, life, during straining
  • Perianal haematoma (acute external plexus haematoma), which results from bruising of anal venule during strainingThere is a painful, small superficial haematoma, often termed as thrombotic pile. The condition either by itself in about a week or requires a small incision to drain the haematoma.
The majority of cases of piles are internal, and etiologically there are two groups:
  • Idiopathic or primary: There is no definite cause to explain the varicosity. The factors believed to play their role are:
    • Anatomical Factors:
      • The veins in the anal canal lack proper support since they lie in the lax submucous coat
      • The veins have no vlaves
      • The veins have to drain against gravity
      • The veins pass through muscle mass and may, therefore, be constricted by the contraction of these muscles during defaecation
    • Hereditary Factors:

      • This condition often runs in families (? Congenital weakness of vein wall.)
    • Exciting Factors:

      • Long continued strain e.g. constipation (very common), over purgation, colitis, dysenteries etc.
  • Symptomatic or Secondary: The haemorrhoids are secondary to pressure effects, caused by some other pathology:
    • Carcinoma of rectum
    • Pregnancy, uterine tumours
    • Persistent straining at micturition e.g. enlarged prostate
    • Portal hypertension systemic hypertension, inferior vena caval congestion etc. (rare)
Clinical Features:
The patient typically complains of fresh blood coming out with stool (hence called bleeding piles). In an uncomplicated case, the condition is always painless. Almost always there is history of constipation.
As the veins get heavier in weight due to varicosity, the overlying mucosa (being very loosely attached to the underlying musculature) tends to hang down through the anal opening, together with the varicose veins underneath. Thus, there is a partial prolapse of the rectum. Depending on this factor, piles are grades as follows:
  • First degree: No associated mucosal prolapse
  • Second degree: Prolapse occurring during defaecation, but getting reduced spontaneously after defaecation
  • Third degree: Same as above, but the prolapse has to be reduced manually
  • Fourth degree: The piles always keep prolapsed
A digital examination should always be done-piles can never be felt by the digit but this examination may sometimes detect a carcinoma or a polyp.

The piles are well visualized with an anal speculum or with a proctoscope.
Typically, they are seen at 3, 7, and 11 ‘O’ clock position, since these are the sites where the anorectal veins are normally bunched together. While the piles in these situations termed as primary piles, anastomotic veins often develop between these sets of veins, in long-standing case. These may get varicose, and then they are termed secondary piles.

Treatment:
  • Conservative Treatment:
    This consists of regular use of laxatives and local application of astringent ointments. Injection of sclerosing agents into the submucous coat of the gut often works well. The idea is to cause thrombosis of the piles as well as the vessels draining them, and to create fibrosis the submucous coat, so that the lax mucous membrane retracts. The commonly used agents are 5% phenol in almond oil or arachis oil, or 3 % sodium morphate. The injection is made with a special syringe and needle, under direct vision with an anal speculum. There are tow types of injection:
    • High Injection: Made into the submucosa, just above a prop of piles (usually preferred nowadays)
    • Low Injection: Made directly into the centre of the piles itself (done usually where high injections fail)

    Injection treatment is best indicated in all cases of first degree piles but it is effective in other cases as dwell, where the prolapse can be replaced, i.e. second and third degree piles.

    The disadvantages of this otherwise simple procedure are:
    • The results are unpredictable and the injection may have to be repeated, often frequently
    • It is contra-indicated:
      • Where the piles tend to remain prolapsed (fourth degree)
      • In case of arterial piles (i.e. piles, where an artery communicates with the venous mass: diagnosed by presence of pulsation in the piles)
      • In presence of infection
  • Operative Treatment:
    • Ligation of the Piles at its pedicle, after drawing the piles down. The idea is that the veins will be thrombosed, fibrosed and obliterated. This is only rarely done
    • Excision of Piles: There are two methods:
      • Ligation of the pedicle as above, and then excising the mass of piles, together with the overlying mucosa and perianal skin, in the form of a wedge. This method of excision is easier but the loss of mucosa (particularly when three piles are excised in this way) may lead to stricture formation
      • Submucous dissection (Park’s): An incision is made longitudinally on the mucosa, over the mass of the piles. The mucosal flaps are raised up on either side, and venous mass is dissected out from the underlying musculature. The pedicle of the piles is now ligated. The venous mass, together with the abundant perianal skin below it, is excised. The mucosal flaps are resutured and the mucocutaneous junction is restored. The triangular gap on the skin is left open, to heal by granulation. This is much better and logical method of excision as it avoids the risk of stricture formation
  • Clamp and Cautery Operation: A special clamp is applied on the piles, on which the excess of the piles is excised. Thereafter, the tissues held in the clamp are cauterized by special technique. This method is nowadays obsolete.
Complications of Piles:
  • Profuse haemorrhage
  • Strangulation: The piles, prolapsed out, are gripped by the internal sphincter and get irreducible. This complication is often loosely termed as ‘prolapsed piles’ or ‘acute attack of piles’
  • Thrombosis, occurring on strangulated piles
  • Ulceration, occurring on strangulated and thrombosed piles
  • Fibrosis – an after-effect of thrombosis
  • Gangrene- if the constriction at the internal sphincter is sufficient to cause arterial obstruction, the mass of piles gets gangrenous
  • Suppuration, due to infection in strangulated piles
  • Portal pyaema (pyelophlebitis, which is rare
Back to Topics<<<<                            Top of this page^^^^
This article has been written by Dr. M. Javed Abbas.
If you have any comments please do not hesitate to sign my Guest Book.
11:25 10/02/2003