Piles Treatment and every single fact you should know 

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Hello and welcome to Chennai Laser Gastro Clinic!, this is Dr. Karthik Gunasekaran and in this awesome roundup article, I am going to tell everything under the sun about piles & piles treatment.

Now let’s move on the good stuff.

So, let’s move on to the first fundamental question

A. What are piles?

Piles is also referred to as hemorrhoids from the scientific jargon. A hemorrhoid or piles is nothing but a mass that is made up of a collection of support tissue, blood vessels, muscle fibers present in and around the anal canal. Classically piles are of two types internal and external.

While most individuals have piles/hemorrhoids,  piles symptoms need not be always obvious. The incidence of piles in the US stands at 4.4% of the total population.

On an average more than 10 million people every year suffer from symptomatic piles and are admitted.

In over 40% of individuals interestingly, piles remain asymptomatic or silent. Piles/hemorrhoids affect men and women in equal measure, with peak incidence occurring in the age of 45 to 65 years of age.

Patients most of the time remain asymptomatic and usually unaware of the underlying piles mass.

B. Causes of Piles?

The most well-accepted theory about the cause of piles is that they are abnormal dilatation of the veins and connective tissue in the anal area.

Numerous factors are believed to predispose patients in developing a piles problem or hemorrhoids.

One common cause seen is elevated anal sphincter pressure that can result from constant straining while passing stools. Straining can usually result from

1. Inadequate intake of fresh fruits and vegetables
2. Prolonged sitting time in the lavatory
3. Chronic untreated constipation problems
4. diarrhea
5. pregnancy
6. Ascites and in some cases pelvic masses that frequently go undiagnosed

Interestingly, a family history of piles disease has also been suggested. This is not surprising though since food habits and family customs go hand in hand.

C. Types of piles:-

Hemorrhoids or piles are globally classified into two types. These are namely internal piles and external piles. Piles are classified or graded basis their reference to what’s called the ‘DENTATE LINE’.

A piles mass is considered external if it originates distal to the DENTATE LINE. A piles mass is internal if it originates proximal to the DENTATE LINE.

External piles mass have a rich supply of pain nerve fibers due to their nature of origin, thus external piles can cause excruciating pain. On the other hand, internal piles may not always produce pain apart from the usual obstructive bowel symptoms

Sometimes a mixed piles mass can also be seen in a few patients!

Internal piles are usually classified into 4 grades as per popular classification systems. Let us briefly go through them below.

A proper understanding of the various grades of piles is important since different grades of piles can be handled with different therapeutic approaches

1st-degree hemorrhoids/piles:-

A first-degree hemorrhoid/piles mass protrudes into the anal canal lumen but does not project outside the canal as such. Veins in the region are enlarged and can bleed

2nd-degree hemorrhoids/piles:-

Second-Degree hemorrhoid or piles mass can present as  mass outside the sphincter and can be visible while emptying the bowel but usually returns back to the position inside the canal

3rd-degree hemorrhoids/piles:-

A third-degree piles mass requires manual reduction and is usually always visible outside the canal

4rth degree hemorrhoids/piles:-

A fourth-degree piles mass, on the other hand, cannot be reduced or put back in position inside and are constantly prolapsed.

D. Piles symptoms

It’s not uncommon to see patients with piles complaint of many varieties of symptoms like bleeding, painful mass, anal swelling, discharge, hygiene based issues, itch, and soiling problems.

Of all symptoms though, the most frequent complaint is ‘painless bleeding’ that can occur fairly early in the course of the disease.

Interestingly, many patients with grade 3 and grade 4 piles also have functional bowel disturbances as well.  Bleeding associated with severe pain, however, is usually a thrombosed piles mass. A thrombosed piles mass contains a blood clot and requires immediate medical attention.

Once again, an important fact must be restated that ‘Internal piles can remain very silent’. External piles, however, can be sometimes trouble free or sometimes associated with acute pain and discomfort.

In older men especially in men >45 years of age, where there are piles along with blood in the stools it is highly recommended that they are undergoing a full-fledged colon evaluation to rule out the risk of a malignancy.

A side viewing anoscope is probably the most accurate instrument that can be used for evaluating hemorrhoids. As compared to other routine instruments like sigmoidoscopy, this instrument allows the piles mass to drop into its examination barrel thus allowing better visualization of the lesion

E. Piles Treatment:

Piles treatment can be done by utilizing different modalities. One of the most important piles treatment strategies is lifestyle modification. Let look at that below

Lifestyle modifications:-

Lifestyle modifications are an integral part of piles treatment strategies and should be offered to all patients regardless of the stage of the haemorrhoidal disease.

Lifestyle strategies can be both preventive and curative in nature. Simple measures that can be advised to patients include

1. Increased intake of dietary fiber
2. Improving anal hygiene
3. Improving fluid intake
4. Avoiding straining while passing stools
5. Using warm water baths (also called Sitz Baths)

Piles medications –

Numerous drugs have been extensively studied for treating piles. Most of these drugs originate from experimental studies on treating varicose veins & venous ulcers.

Oral micronized flavonoid extract taken from citrus fruit exerts an excellent pile treatment effect in terms of reducing the size of hemorrhoid and also providing wound healing.

Many studies have suggested at least some benefit of flavonoid based piles treatment. However, this treatment modality is yet to get a US-FDA approval.

Piles treatment creams:-

Interestingly, over the counter gels, lotions, pads, ointments, creams have all been massively advertised for piles treatment. These preparations contain a variety of ingredients ranging from anesthetics to keratolytic, steroid and antiseptics.

However, while most of these products may help maintain personal hygiene, whether they genuinely help treat piles is doubtful.

In fact, some of these creams contain corticosteroid preparations that can permanently damage the anal skin.

Thrombosed piles treatment:-

A special mention should be made about thrombosed piles treatment. Since this is seriously painful in nature. Conservative piles treatment strategy for thrombosed piles includes

1. Using a sitz bath for 2 – 3 weeks
2. Using stool softeners
3. Mild analgesics

In a few patients, this conservative approach will help the thrombus mass be absorbed after a period of 7-10 days. The pain will usually subside after 2 to 4 days at most

However, a better treatment strategy that can give patients excellent pain relief is surgical excision. Surgical excision can be performed very safely in an outpatient setting. When done right, the recurrence rate of the piles is very low in general.

While conservative treatment strategies definitely work, the average time to complete recovery is usually 21 days as compared to 5days when surgical treatment is instituted.

Thus, proceeding with a surgical approach allows patients exceedingly quick recovery times.

Piles treatment: Surgical approaches

Sclerotherapy:-

This technique was originally described close to 2 centuries back for hemorrhoid treatment. This technique is currently recommended for treating Grade 1 and Grade 2 piles disease.

In this procedure, the surgeon injects a hypertonic salt solution into the base of the piles mass. The solution causes scarring and fibrosis thereby reducing the piles mass itself.

This procedure has a few disadvantages though..

Sclerotherapy for piles treatment cannot be used for large grade 3 and grade 4 hemorrhoids as such. Moreover, accidental injection of the solution into the veins can lead to ‘severe abdominal pain’.

Some patients have also reported ‘Erectile dysfunction’ post sclerotherapy due to accidental injection into the nerves around the prostate. Burning pain and discomfort are frequently reported by patients who have multiple injections post therapy.

Rubber Band ligation:-

Rubber band ligation, as the name suggests is another office based piles treatment procedure that as involves the use of a ‘rubber band’ [you guessed it right] for ligating the piles mass.

Usually one sitting is all that is required. Although some surgeons prefer to use 1 band per pile mass placed sequentially over 4 weeks. Once again, this procedure should be done very carefully and skilfully.

Complications are rare but not uncommon. Patients have reported severe pain, slippage of the band, late bleeding (1-2 weeks post procedure). In very rare cases, severe complications like Fournier’s gangrene has been reported.

Some surgeons advocate a combination therapy that combines both sclerotherapy and rubber band ligation. Piles treatment success rates are usually excellent in combination therapies

Infrared coagulation of piles:-

Infrared light has the property of penetrating tissue and then converting to heat. The one major advantage of using infrared light for piles treatment is that, the procedure is super fast. Complications are very minimal.

Although anesthesia is required, a recent large-scale meta-analysis the studied over 800 plus patients found that Infrared based piles treatment was better than sclerotherapy and was also better than rubber band ligation. The complications and adverse events were also very low.

Cryosurgery:-

Although this modality of piles treatment received much attention, freezing the piles mass creates more problems than solution. The procedure is first of all time consuming, and patients usually have prolonged recovery times

Haemorrhoidectomy:-

Haemorrhoidectomy as a procedure is usually reserved as a surgical modality of treatment for large hemorrhoids. Excision of the mass is done using laser, cautery, scissors or a harmonic scalpel.

These techniques all require a high degree of specialized training. When done the absence of appropriate training, complications can definitely result.

Longo’s piles treatment procedure:-

This technique is also popularly called as the stapler haemorrhoidectomy. This technique was introduced in 1995. This technique requires special training and can be used for Grade 3 and Grade 4 piles. The technique per say is now well proven for the treatment of piles.

To summaries, piles is rather a very common problem. Where dietary interventions or preventive treatments fail, surgical therapy can be considered. The choice of piles treatment should ultimately be individualized to the patient and his comfort.

References:-

1. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation: an epidemiologic study. Gastroenterology. 1990 Feb 1;98(2):380-6.
2. Schubert MC, Sridhar S, Schade RR, Wexner SD. What every gastroenterologist needs to know about common anorectal disorders. World journal of gastroenterology: WJG. 2009 Jul 14;15(26):3201.
3. Loder PB, Kamm MA, Nicholls RJ, Phillips RK. Haemorrhoids: pathology, pathophysiology and aetiology. British Journal of Surgery. 1994 Jul;81(7):946-54 
4. 4. Ahmad MM, Nadeem R, Husain M, Nazir I, Ahmad M. Stapled haemmorhoidopexy versus open haemorrhoidectomy: our initial experience. International Surgery Journal. 2017 Apr 22;4(5):1672-7.