Piles or Haemorrhoids

Here is a description of piles or haemorrhoids mentioned, just an overview. For teaching purposes only.

1. PILES OR HAEMORRHOIDS (ARSHA) ( अर्श,पाइल्स,बवाशीर ) 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 1

2. Haemorrhoid [Greek] = haima = bleed + rhoos = flowering means bleeding Blood to ooze. Piles [Latin] = pila means a ball ball or mass like apperance Described in 400 B.C. by Hippocrates They are not varicose veins, They are prolapsed anal cushions The piles are dilated plexus of superior haemorrhoidal veins in relation to anal canal Piles can be mucosal (in old) or vascular (in young)-Graham Stewart 1963 HAEMORRHOIDS, PILES 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 2

3. Related Anatomy Anal Cushion (Thomson 1975) Present in fetus, in embryo Present in all Above the dentate line Contains blood vessels, elastic connective tissue, smooth muscles .. Two system of veins Portal- Internal hemorrhoidal cushion Systemic - External hemorrhoidal cushion Intercommunicates 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 3

4. Function of Anal Cushion Speculative Adds to resting anal pressure (15-20%) Aid in continence : relaxation filling, squeeze empty Aids in closure of the anal canal (washer function) – 7-8 mm gap remains at rest Discontinuous: Allows anal canal to dilate without tearing Aids in defecation Smooth glide Voluntary and involuntary control (conjoined longitudinal muscle) 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 4

5. Etiology and Pathogenesis Still not known Evolving theories Varicose vein theory Pecten band theory Vascular hyperplasia theory Sliding anal cushion theory (best and latest) 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 5

6. Sliding anal Cushion Theory Straining at stool/ tenesmus Results in disruption of Treitz’s muscle Leads to loss of anchoring and flattening action Leads to protrusion and prolapse Increased anal tone, improper diet 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 6

7. ETIOLOGY OF ARSHA Dietic factors - All those factor which leads to indigestion can cause arsha ie piles. 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 7

8. . HABITS – Sexual act in wrong position Lack of exercise Divaswapna /day sleep Suppression or pravahana of natural urges i.e. faecus , flatus and urine Continue……. 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 8

9. . PRESSURE OR IRRITATION IN ANAL CANAL Excessive riding on horse, camel, or vehicles Defective sitting posture ( utkattashana ) Local contact with hard or rough object miscarriage or abortion obstructed labour Continue………. EMACIATION FROM PROLONG ILLNESS 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 9

10. Pathology Position - 3, 7, 11 o’ clock position Components – Pedicle ( ano -rectal ring) Internal component External component Arterio -venous channels Prolapse 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 10

11. Clinical Grading Degree of haemorrhoid 1˚ No prolapse 2˚ Prolapse during defecation spontaneous reposition 3˚ Prolapse during defecation manual reposition 4˚ Always remain prolapsed 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 11

12. Ist degree ‘Splash in the pan’ type of bleeding P/R Hypertrophy of internal haemorrhoidal plexus Anal mucosal suspensory ligament intact 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 12

13. . IInd degree – Anal suspensory ligament become lax Pile prolapsed during defecation Spontaneous reduction 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 13

14. . III rd degree – Piles prolapsed during defecation or exercise Reduction by manually Haemorrhoid mucosa undergoes sqamous metaplasia . 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 14

15. . IVth degree – Prolapsed pile mass does not reduced 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 15

16. Clinical features / Presentation Painless bleeding following defecation (splash in the/on pan) Something coming out of anus Multiple prolapsed soft masses at anus Perianal moistness(discharge) Incontinence Mucous discharge, irritation, Itching ( Pruritus ani ) Rarely Pain (think of thrombosis/strangulation) Burning sensation (thrombosis of external hemorrhoids) Anemia (?) Permanent prolapse mass cause pain, discomfort, difficult in gas passes 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 16

17. 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 17

18. TYPES of PILES PRIMARY & SECONDARY PILE MASS EXTERNAL PILEMASS & INTERNAL PILE MASS BLEEDING AND NON BLEEDING A. Primary haemorrhoids Located at 3,7, 11 O’clock, related with superior haemorrhoidal vessels B. Seconadary haemorrhoids occure in b/w primary site A. Internal haemorrhoids – located above the dentate line and covered with mucous membrane. B. External haemorrhoids- located at anal verge covered with skin. C. Interno-eexternal haemorrhoids 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 18

19. Complication of Haemorrhoid Bleeding Thrombosed pile Prolapsed pile mass- cause pain Strangulation, ischaemia Gangrene Fibrosis Ulceration , secondary infection, Suppuration Pylephlebitis Chronic anaemia Rarely portal hypertension cause massive bleeding. 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 19

20. DIFFERENTIAL DIAGNOSIS RECTAL PROLAPSE FISSURE IN ANO WITH SENTINAL TAG CA RECTUM PERIANAL WARTS 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 20

21.  Careful history  Abdominal Examination  P/R, DRE/ Anorectal Examination  Investigation e.g., Proctoscopy Sygmoidoscopy , colonoscopy Haematocrit etc Diagnosis Your .Text Here 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 21

22. Common position for examination Lithotomy position Left lateral position 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 22

23.  A. Conservative treatment  B. Specific treatment  Injection of sclerosant’s .  Barron’s rubber band banding  Cryosurgery  Lord’s manual dilation  Haemorrhoidectomy Treatment of Piles 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 23

24. A. Conservative Management Sitz Bath – Luke warm water, 5-10 min, 2-3 times/day It reduces pain and oedema , patient got comfort. 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 24

25. . Bowel Regulation – Decrease toileting time Avoid excessive defecation straining Intake of fiber rich diet Intake of bulk forming agents Laxative Local treatment – Ointment and suppository Management of anaemia - Iron rich diet and formulation 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 25

26. B.Specific management a) Injection Therapy – Mode of action – Sclerosant injection into submucosa above the dentate line. They firstly produce chemical thrombosis in haemorrhoidal plexus and secondly produce a fibrous reaction in submucosal layer which will fix the mucous membrane to inner muscle layer and draw up pile . Ideal Agent – 5% phenol in almond oil Gabriel syringe, Proctoscope 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 26

27. . Method -- 3 - 5 ml of sclerosant injected into submucosal plane just above ano -rectal ring to the pedicle . All three piles can be injected separately . Technique can be repeated after 6 weeks. INDICATION CONTRAINDICATION First degree and initial stage Prolapsed piles of IInd degree haemorrhoid Arterial piles Infected piles COMPLICATION Ulcerative colitis Necrosis and Injection ulcer Crohn’s disease Submucous abscess 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 27

28. b) Rubber band ligation Done in Ist or IInd degree haemorrhoid No need of anesthesia or hospitalisation No need of assistance 2 band can simultaneously used Ligation causes haemorrhoidal necrosis in 24-48 hrs and slough of in about 7 days. Main disadvantages are pain in Ist 24-48 hrs and secondary bleeding. 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 28

29. c) Cryosurgery Mode of action – Extreme cold temperature causes coagulation of tissue and ultimately necrosis of pile mass. Equipments – Cryoprobe Nitrous oxide (-98 ‘c) Liquid nitrogen (-196 ‘c) Painless procedure No need of anesthesia 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 29

30. d) Infra- red Coagulation Infra-red light produces extreme heat which coagulate pile mass and pile fall off. e) Laser therapy- It is also a treatment modality and the mode of action same as infra- red coagulation 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 30

31. . DGHAL – DOPPLER GUIDED HAEMORRHOIDAL ARTERY LIGATION 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 31

32. (B)surgical procedure- METHODS Ligation & excision method Submucosal haemorrhiodectomy Closed haemorrhidectomy Stapled haemorrhoidopexy . Anal stretching – Recaimer Lord’s 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 32

33. INDICATIONS 3 rd degree piles Fibrosed piles Failure of non operative methods POST OPERATIVE COMPLICATION Pain Retention of urine Reactionary hemorrhages Anal stricture Anal fissure POST OPERATIVE COMPLICATION Sitz bath with luke warm water Diet –soft, fluid intake Analgesics Antibiotics Bulk purgative 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 33

34. Cause – Due to rupture of dilated anal vein as result of sever straining.  sudden onset of painful lump at the anus.  The swelling tense & tender, bluish in colour covered with smooth shining skin.  Treatment: LA evacuation if the patient come within 48h 0, otherwise if late conservative treatment.  if untreated the haematoma undergoes:  resolution  ulceration  supporation to forms in abscess  fibrosis which give rise to skin tag. External haemorrhoids (perianal haematoma ) 9/2/2021 Piles-Haemorrhoids Dr Mahesh Kumar 34

35. THANK YOU 35 9/2/2021 Note-For educational purpose BAMS student only THANK YOU THANK YOU Thanks for patience listening…….. Piles-Haemorrhoids Dr Mahesh Kumar