Piles in India is generally used as a loose common
term to include piles, fistulas and fissures with skin tags.
Fistulas are an abnormal small opening next to the anus from
where discharge keeps occurring. This is due to a tunnel like tract
between the anal canal and the skin. This condition always requires surgery
for cure.
Fissure with skin tags lead to painful bleeding due to a small
cut at the anal margin. It is usually associated with skin tags that are
mistakenly called piles. This condition resolves in majority of the
patients by use of creams and medicines to treat constipation. Rarely the
patient needs surgery.
True piles are those that present with PAINLESS BLEEDING due to
swelling up of blood vessels in the anal canal.
In this article, only piles and their treatment are dealt and fistulas
and fissures will be covered in a subsequent article.
Piles and their symptoms, which are one of the most
common afflictions in the Western world, are also seen commonly in
India. Not many people like to talk about it hence true statistics in India
are not available. In the west over half the population over the age of
50 suffer from it. However they can occur at any age and can affect
both women and men.
Because the presence of pile tissue is normal, it acts as a
compressible lining which allows the anus to close completely. Disease should be
thought of as pile tissue that causes significant symptoms.
Unfortunately, piles tend to get worse over time, and disease should be treated as
soon as it occurs.
Proposed causative factors include
Piles may be caused by more than one factor. Piles can be either internal or external, and patients may have both types. External piles occur below the dentate line and are generally painful. When inflamed they become red and painful, and if they become clotted, they can cause severe pain and be felt as a painful mass in the anal area. Internal piles are located above the dentate line and are usually painless. Dentate line is a line seen in the anal canal that demarcates the area with pain sensation from that without it.
Piles that protrude into but do not prolapse out of the anal canal they are classed as grade I; if they prolapse on defecation but spontaneously reduce they are grade II; piles that require manual reduction are grade III; and if they cannot be reduced they are grade IV. Piles that remain prolapsed may develop thrombosis and gangrene.
Symptoms of piles can include
The diagnosis is made by examining the anus and anal canal, and it is important to exclude more serious causes of bleeding, such as cancer. No relation between piles and cancer has been found
The best treatment is prevention. A diet high in fibre and bulk can prevent constipation. If the diet cannot be modified in this way, adding bulk laxatives may be necessary; they can prevent worsening of the condition. There are numerous creams and suppositories that can relieve anal irritation and pain, but they rarely provide long term benefit.
The treatment choices for piles include :
For patients with grade I or grade II piles or who have larger piles but wish to avoid surgical treatment, outpatient procedures, such as injection sclerotherapy, infrared coagulation, rubber band ligation, and cryotherapy, may be appropriate. Sclerotherapy is usually indicated only in first and second degree lesions.
Cryotherapy is little used because of the profuse and prolonged discharge, the complications such as excessive sloughing and muscle injury that occur occasionally. It is essential that local treatments be applied to the lining above the piles; if applied too low, they may cause excessive pain.
The least expensive and possibly the most widely used equipment is a rubber band ligator. This is suitable for first to third degree piles. The treatment can cause severe pain if the bands are placed too low. Rubber band treatment works effectively on internal piles that protrude during defecation. The procedure sometimes produces mild discomfort and bleeding, but it is generally the treatment of choice for patients who have piles and for whom piles surgery is considered too radical, or when the patient specifically wishes to avoid surgical excision.
The infrared coagulator is gaining rapid acceptance for outpatient treatment of internal first and second degree piles and some third degree ones. A special bulb provides high intensity infrared light that coagulates vessels and tethers the lining to subcutaneous tissues.
The radiofrequency coagulation unit uses a disposable probe with an electrical current flowing between two flat electrodes (positive and negative) aligned at the tip. Activating the unit for two seconds in three or four areas of the same pile complex effectively coagulates the vessels.
The direct current units use a probe with two sharp points as electrodes. They are promoted for use in all grades of piles but seem to have two drawbacks. Firstly, each treatment takes eight to 12 minutes of probe contact. This is considerably longer than the six to 10 seconds required for infrared and radiofrequency units. Secondly, the probes can penetrate deeply unless the operator is careful to stabilise them during treatment.
Excessive activity of the internal anal muscle is often associated with bleeding; for such patients gentle anal stretch under general anaesthesia is advisable. It is important to recognise that stretching the muscle inevitably attenuates the external muscle as well as the internal; spasms of the internal muscle may be relieved by injections of botulinum toxin or topical application of nitroglycerine ointment.
If symptoms recur after topical treatment the patient can be treated with a further application, a different treatment may be applied topically, or piles surgery may be considered for more definitive control of symptoms.
Piles surgery (Standard Scalpel surgery) is necessary when clots repeatedly form in external piles, ligation fails to treat internal piles, the protruding pile cannot be reduced, or there is persistent bleeding. Piles surgery is done under general anaesthesia and requires admission to hospital.
The standards task force of the American Society of Colon and Rectal Surgeons states that surgery should be reserved for those who "fail more conservative measures" or who have "third and fourth degree piles ... with severe symptoms.
Several operative techniques have been described. The surgeon's choice of technique is primarily based on personal experience and technical training, and only a competently performed technique produces satisfying results. If technical guidelines are rigorously followed, the feared complications associated with surgical procedures, such as anal narrowing and muscle injuries, are largely reduced. Furthermore, certain medicines suppress postoperative pain, increase patients' satisfaction, and allows them to return to work earlier.
A lot has been talked about laser surgery. Most studies across the world have shown that Laser piles surgery has no advantages over standard techniques; it is also quite expensive and no less painful.
Studies suggest that stapled piles surgery is an effective treatment, reducing postoperative pain, the length of hospital stay, and encouraging a rapid return to normal activities when compared with conventional piles surgery. This technique potentially provides a tool for reducing some of the complications associated with conventional surgery, provided that the operator has the technical experience. However, stapling increases operative costs; advanced surgical skills are necessary.
The clear advantages of the modern methods for outpatient treatment of internal piles are that they are quick and relatively painless. Patients lose little if any time from work, the complications are minor, and the cure rates are high. Pain is generally attributable to placing the treatment probes too far down.
Patients may have a little spotting of blood for a few days and slightly more bleeding may occur after 10-14 days, when the eschar sloughs, but major bleeding do not occur as in the old style surgical approaches. No episodes of infection, death, or impotence have been reported with the newer methods. The failure rates are reported to be 10-20%, but all that is needed is further treatment.
Formal surgical intervention is still occasionally necessary, but patients dislike it because of the associated severe pain and morbidity. Modern treatment methods may be mastered by doctors, and they provide a prompt effective treatment in most cases.