MANAGEMENT

OF
Haemorrhoids (piles)

Haemorrh
oids

VARIOUS CONDITIONS IN
ANO RECTAL REGION

Imperforate Anus
Piles
Fistula
Fissure
Ischio- rectal Abscess
Proctitis
Enlarged Pappila
Rectal Polyps / Warts
Pilo Nidal sinus
Carcinoma
Pruritis

Any Problem
Around The
Anus
Is Called As..
Piles

HAEMORROIDS (PILES)
Definition :

1.These are the dilated veins within the anal canal in the sub-epithelial
region formed by radicals of Superior, Middle and Inferior rectal
veins.
2. Piles can be described as masses or clumps ("cushions") of tissue
within the anal canal that contain blood vessels and the surrounding,
supporting tissue (hemorrhoidal cushions).
Haemorrhoides
Piles

Haima = blood
Roos = flowing

Pila = ball

Anal cushions :
These are submucus venous plexus containing
arterial twigs, venules, smooth muscles, elastic tissue
& connective tissue. Symptomatic anal cushions are
called as piles / haemorrhoides.

INTRODUCTION &
INCIDENCE
Humans suffer from piles as a
disadvantage of their erect
posture.
50% of people over 50 yrs age
suffer from some degree of
piles.
30% of pregnant females suffer
from piles
Asymptomatic piles are found in
many patients on routine
examination
Sex ratio approx. 2M : 1F

TYPES OF HAEMORRHOIDS

According to Symptoms1. Bleeding Piles

2. Non Bleeding Piles
According to Origin1. Hereditary Pile mass is present by birth
2. Acquired Pile mass developed after birth

According to etiology1. Primary Due to indulgence in unsalutary diets & habits

2. Secondary Due to some other underlying disorders
According to Location-

1. Internal Piles It is covered with mucous membrane. It arise from Internal

Hemorrhoidal plexus & above dentate line.
2. External piles It is situated outside the anal orifice & is covered by skin.
It arise
from External Hemorrhoidal plexus & below dentate line
3. Internal + External Combination variety can also co- exist & is known as
Interno- External haemorrhoids.

Degrees of Internal Piles

1st-degree
Projects into anal lumen
internally
2nd-degree
Protrusion outside anal canal
at
defecation with
spontaneous reduction

3rd-degree
Protrusion outside anal
canal at
defecation straining
needs digital
repositioning
4th-degree
Permanently prolapsed
irreducible piles

Positions of Piles
PRIMARY
Right anterior ( 11-oclock)
Right posterior ( 7-oclock)
Left lateral ( 3-oclock)
Accessory
At every oclock position
DGHAL
Arterial cushions at every
odd oclock position
i.e. 1 / 3 / 5 / 7/ 9 / 11 oclock

ETIOLOGICAL FACTORS

Congenital This is due to Shukra- Shonit beej dosh.

Pile mass is present by birth.

Anatomical The haemoroidal veins are situated in anal sub-mucosa in

longitudinal direction & does not have support of any other
surrounding tissue. So, being valve less structure (either
due to
any pressure/ obstruction on portal vein or due to gravity)
they
are always filled with blood which results in its dilatation,
elongation & torsion.

Sedentary lifestyle Long term sitting job, daily

traveling
for long distance, engaged in driving or
abstinence
from any kind of physical exercise may
result in
the haemoroidal veins.
Alcohol Excessive alcohol overfilling
intake canincause
Hepatitis
resulting in portal hypertension
which
ultimately exert pressure on the
haemoroidal

Suppression of urge of daefication/

micturation:
Suppression of urge of daefication vitiates vat
which
may result in constipation & further straining
while
daefication, exerting pressure on the
haemoroidal
veins. Similarly, frequent IBS or diarrhea may
cause mucosal irritation & inflammation resulting
in protrusion of pile mass.

Asthma:
Asthma or COPD is associated with vigorous
& frequent coughing which increases the intra
abdominal pressure, thus ultimately exerts
pressure on the haemoroidal veins.
Similarly, lifting heavy weight can also cause
pressure on anal veins.

Enlargement of Prostate:
The male suffering from BPH usually strains
while micturation & this forceful micturation
exerts
pressure on the haemoroidal veins. Similarly,
patients suffering from urinary calculus &
frequent
UTI are also prone to such conditions.

 Other factors causing Piles:

In females1) During pregnancy the intra abdominal pressure is
increased (due to the foetus) resulting in portal
hypertension.
2) At the time of labour (delivery) there is tremendous
pressure
on the anal canal causing anal fissure and prolapsed
piles.
3) Fibroid in uterus may cause pressure on anal veins.

Some other factors mentioned in Sushrut samhita

1)
2)
3)
4)
5)
6)
7)
8)

Straineous work (Balvad vigrah)

Anger or sorrowful emotions (Shok)
Contradictory food consumption (Adhyashan)
Over sex indulgence (Stri prasang)
Squatting posture (Utkatasan)
Horse riding (or long drive)
Suppression of natural urge (veg dharan)
Diminished Appetite (Mandagni)

SYMPTOMS
Bleeding
Swelling / Prolapse
Straining / Pain /
Discomfort
Constipation
Itching, Irritation
Incomplete evacuation
Digital evacuation /
instrumentation
Abdominal bloating =
GAS TROUBLE
Lethargy/ Wt. Loss
Black-out episodes
Symptoms of ANAEMIA

Pathogenesis of Bleeding
Hard stools

Disruption of sinusoids
by straining / irritation

Straining at defecation
Bruising of engorged
venous cushions

Bleeding from pre-sinusoidal

arteries

De epithelization

Constipation+Straining+IAS
spasm

Ulceration

Venous back flow

Bleeding

Mucosal strech
Tear & Bleed

Bleeding
Occasional to regular / recurrent
Bright red ( from presinusoidal arterial twigs)
Initally Streaks specially with hard stools
Later

Steady drip

Advanced Squirts / stream / drip with defecation

&
Also apart from defecation
(blood spotting on undergarments)

Examination
Gain the Confidence
of the Patient
Position
Light (Angle- Poise Lamp)
Instruments required likeGloves, Jelly, Torch, Guaze,
Proctoscopes ,Forecep

Position of
patient

SIMS position
Lithotomy position
Knee-Chest position
Prone position

What else is to be kept

ready??

Ears open
Eyes open
MIND open
Gentleness
Respect towards
patient
Soft words &
politeness
Understanding the
patient

What thing to keep away

Arrogance
Mobile phones
Sharp instruments
Ego
Fo

o
h
t
ul

s
t
h
ug

d
e
k
Wic
s
e
y
e

Inspection
Spread buttocks apart gently
Focus the light source
Observe the peri-anal region
& anal verge
Skin discoloration
Scars, Pruritus, Sinuses,
Soiling, Discharge = Pus, Blood
etc.
External Tag, Swellings
(Boil/Induration)
? Sphincter Tone/Spasm
(Refluxes)
Other Pathologies

Physical examination
INSPECTION:
1ST-degree = Nil evidence
2nd-degree = Bogginess at anal verge at affected side,
gentle traction on bogginess reveals mucosa
3rd-degree = Inner red/purplish mucosa & outer skin
covered bogginess with linear furrow in between
4th-degree = Evident irreducible prolapse
White Pannus
Pruritic signs
Soiled perineum

INSPECTION
(Most neglected but most informative)

Fissure
Hematoma
Wart
Pilonidal sinus
Pruritis ani
Prolapsed Piles
Sentinal pile / tag
Bleeding /
Discharge

External opening of
fistula
Abscess
Sphincter tone
Soiling
Prolapse during
valsalva
Stricture / Stenosis
Sphincter spasm
Worm infestations

D.R.E
(DIGITAL RECTAL EXAMINATION)
P/R examination

Physical examination
D.R.E. (Digital Rectal Examination)

Ask patient to bear down & gently insert lubricated gloved finger
inside

Early piles = Soft, easily collapsible venous swellings

Late piles = Fibrosis of connective tissue

Piles are palpable as soft longitudinal folds

Also appreciate :

Anal tone
Ano-rectal sling level
Anal canal length
.Squeeze pressure
Inspect the finger for blood / mucus / feces
Exclusion of other diseases esp. Ca

PALPATION &
DIGITAL RECTAL EXAMINATION (DRE)
Anal Canal
Sphincter tone
Ano-rectal sling
Fibrosis
Internal opening of
Fistula
Induration
Tenderness.

Peri anal Tenderness,

Induration

Rectum
Collapsed , ballooned
Loaded / empty
Wall irregularity & nodularity
Stenosis / stricture
Polyp / mass
Cervix & uterus in females
Prostate & seminal vesicles in
males
Blummer shelf deposits
Examine the finger after P/R for
blood/mucus/pus/stools
P.V. examination with separate
gloves

ANOSCPOY / PROCTOSCOPY

Proper instruments and lighting

Position
Technique
Many things can be diagnosed

Physical Examination
With scope inside anal canal, ask patient to
bear down & inspect while withdrawing the
scope.
Look for = bulge site / covering mucosa
colour
Bleeding points
Rectal mucosa status
Other lesions

MANAGEMENT
Acute stage Conservative Treatment:
In Allopath, the line of treatment is as follows

1. In Acute stage i.e. if the patient comes with symptoms

like severe pain with haematoma, then Analgesics+ Anti
inflammatory + Anaesthetic agent like Xylocaine oint. /
jelly is prescribed.
Also, patient is asked to take Hot Seitz bath with KMNO 4.
Haemostatic drugs like Stredron or Ethamsilate can be given to arrest
bleeding

Generally, the swelling resolves itself. But if the condition

do not improved, then it may suppurate or may fibrose giving
rise to cutaneous tag or may burst giving rise to bleeding.

2. If haematoma do not resolve, then it is Incised under local

anesthesia & the wound is allowed to heal by granulation tissue.

Conservative Management
Diet Fiber rich, balanced (easy to digest) diet
Ointments - Hydrocortesone acetate,Heparin sodium,
Aminobenzoate,Lignocaine hydrochloride, Zinc oxide
Laxatives - Liquid paraffin, Lactulose, Isabgol, Senna,Castor oil,
Bisacodyl
Suppository- Bisacodyl,Glycerene
Analgesics / Antibiotics / Prokinetics
Oral preparations- Sodium picosulphate, Calcium dobesilate,
Tranexamic acid
Iron supplement
Seitz Bath

Ayurvedic Management
Sushruta has mentioned four fold regimen for piles:
1. Aushadhi Chikitsa i.e Internal medicine effective
in I and II grade piles
2. Kshar chikitsa i.e application of kshar locally or
internally effective in I and II grade piles
3. Agni Karma i.e Excision of pile pedicle by
Cauterization
4. Shalya Karma i.e Ligation and Excision of Pile
pedicle
effective in III grade and prolapsed pile mass.

Ayurvedic Conservative treatment

Deepan and pachan chikitsa
The main objective is to restore the digestive
power ( Jatharagni) by:
1. Ajmodadi churna or
Hingavasthak churna
2. Chitrakadi or ampachak vati
3. Shankha vati ( form of mild kshar)

- Vata anuloman chikitsa

For this purpose Avipatikar churna or Panchasakar churna can be
prescribed

- Mal Sarak chikitsa-(To treat constipation)

- Haritaki churna
- Abhaya arishta
- Triphala churna

To arrest bleeding Nagkeshar Churna,

Bolbaddha ras or Kutaj Churna can be
given.
Bhalatak kalp in non bleeding piles and kutaj
churna
for bleeding piles is choice of drug mentioned
in Sushrut.
Various combination for local application
is advocated for initial stage like :
a. Latex of snuhi+ turmeric powder
b. Kasisadi taila
c. Turmeric podwer + Pippli churna+ Gomutra
d. Nimbadi malhara etc.

 Specific guidelines mentioned in Sushrut Samhita

In initial stage of piles local application of inform of lep is
mentioned which may promote frbrosis and delay the protrusion
of pile pedicle

Snuhi latex + Turmeric powder can be tried

Turmeric + Pippali churna + Gomutra can be
applied
Specific instruction regarding Diet
Shali, Shasti, Jau or wheat grain mixed
with ghrit and milk and gruel is made.
This is to taken as diet regularly
Lot of green leafy vegetables
Shatavari mula kalka along with milk
Apamarga mula cooked with rice
Butter milk should be taken regularly
after food
Jaggery with haritaki

Kshar Karma in Piles

This is indicated for II Grade internal piles. The kshar is applied
to the dilated pile pedicles with the help of specially designed
probe known as Jambaushatha shalaka under the guidence
of proctoscope (Arsho darshan yantra) having slit on its side.

After mild kshar application the pile pedicle is washed with

sour gruel (Dhanyaamla) or water and followed by local
application of yashtimadu ghrita at the site.

Each pile pedicle is treated differently at the interval of one

week.
This may cause fibrosis of the tissues which prevents the pile
pedicle from protrusion. Also to some extend it works similar
to sclerosing therapy

Use of Kshar sutra in Piles

Some Ayurvedic surgeons prepare a separate kshar sutra

which is mild in nature and have less coatings for the
ligation of internal pile pedicle.
According to them this medicated Kshar sutra
simultaneously necroses the pile pedicle, and at the same
time they promote fibrosis over the peripheral tissues.

This technique is practiced in few places

northern India and is not popular enough.

However this mild kshar sutra can

be effectively used in external piles
and external sentinel tags.

TREATMENT OPTIONS FOR PILES

NON-SURGICAL

SURGICAL

(office procedures)

BANDING

SCLEROTHERAPY

I.R.C
**
LASER
**
HAL

STAPLER
M.I.P.H

OPEN
**
CLOSED
**
Harmonic

INJECTION SCLEROTHERAPY
HISTORY
1869= Jhon Morgan of Dublinintroduced this procedure using
persulphate of iron

1871= Mitchell of Clinton-Illionis, USA, used carbolic acid (27

95%) & olive oil

HE SOLD THE SECRET TO QUACKS BEFORE HIS

DEATH
1879= Andrews of Chicago, discovered the secret from Quacks and
gave it to the world.

Principle of Sclerotherapy
Injection of irritant solution evokes inflammatory
reaction in submucosa where haemorrhoidal vessels lie.
This results in
1) Encasement,
which prevents defecatory trauma & thus prevents bleed
2) Blockage of hemorrhoidal vessels,
which do not bulge on straining
3) Fibrosis,
which fixes mucosa to muscle & prevents prolapse.

INDICATIONS FOR SCLEROTHERAPY

INTERNAL PILES ONLY
BEST =

for Grade I, Bleeding Piles

GOOD =

for Grade II bleeding piles

PALLIATIVE = for Grade III bleeding piles

Contra Indications for Sclerotherapy

External Piles
Associated Anal Lesions eg; fissure, fistula, skin tags
Attack of thrombosed internal piles
Pregnancy

Crohns / Ulcerative colitis

Solutions used for Injection:

Phenol
Various vegetable oils eg. Almond /
olive / coconut
STD (sodium tetradecyl sulphate)
Carbolic acid
Sodium morrhuate
Quinine & urea hydrochloride
Glycerine
Polidocanol

Dosage per pile mass

5 7ml (max = 10 ml)

1 2ml

Site of Injection
-In submucosa
-Into pile mass
- At the pedicle of the pile mass at anorectal ring (ALBRIGHTS method)

Post-procedure Instructions
Mild discomfort
Tenesmus
Follow up after 3 wks
Watch for fever / pain / bleeding.& inform sos

Advantage of Sclerotherapy
Easily learned procedure

Stops bleeding in 24 - 48 hrs in majority of cases

Cost effective
Office procedure so early return to work
Painless
Can be repeated

Complications of Sclerotherapy

Fainting / Giddiness
Necrosis
Re-Bleed
Abscess
Stricture
Urine retension
Burning & itching
Fistula formation

Injection ulcer
Paraffinoma

13/41

Results after Sclerotherapy

Grade I piles == 98 %
Grade II piles == 68%
Grade III piles == 31%
Overall 77% successful
Especially in stopping bleeding
But has less effect on prolapsing element of pile

RUBBER BAND LIGATION

(RBL)
or
BANDING

Principle of RBL
Rubber ring ligature applied to the mucosal covered part
of the Internal Pile through a proctoscope
This strangulates the feeding vessel to the pile and
gradually cuts through the mucosa
The pile thus sloughs off after 7 14days

Indication for RBL

Ideal for Grade II internal piles
Early Grade -- III internal piles

Contra-indications
Bleeding diathesis (???)
Infection ( fistula / abscess)
Fissure

Post procedure Instructions

Dull ache / fullness of rectum may be present
Urge to defecate may be there
Bleeding may occur ----- clots = 1-2days
----- spots = 5 14days
Follow-up after 2 weeks

Advantage of RBL
No learning curve

Effective symptomatic relief in 80 90% cases

Safe procedure

Virtually painless if done properly

Can band all 3 piles in one sitting
Can be repeated after 3 weeks
Cost effective
DISADVANTAGE OF RBL
Has no effect on skin covered component
Complications present ( avoidable )

Complication of RBL
Pain

Immediate / delayed

Bleeding

Immediate / delayed

Thrombosis
Fissure
Slippage of band
Sepsis

I.R.C.
INFRA - RED COAGULATION
(Modified Agnikarm)

INDICATION FOR I.R.C.

INTERNAL PILES ONLY

BEST = Bleeding Piles of Grade I,
GOOD = Bleeding piles of Grade II

24 K Gold Plated Reflector

Solid Quartz Light
Guide
Trigg
er
15volt tungstenhalogen lamp

Light energy
energy

Heat

Contac
t teflon
tip

Principle of I.R.C.
It causes actual burn upto the submucosa
Light energy converted to heat energy
Causes tissue destruction
Evokes inflammatory reaction
Results in scarring

Site of application:
Above the pile mass, At or just below A/R sling
( same as for sclerotherapy)

Pre-op instruction
Patient may feel slight warmth

ADVANTAGES

No operation
No bleeding
No pain
No anesthesia
No admission to hospital
No need to take leave from work
Safe for patients with Diabetes
Safe for patients with High Blood Pressure
Safe for patients with Heart Problems
Safe for Pregnant patients suffering from
piles.

Cryo - Therapy
Principle :
Freezing the pile mass with cryo-probe to subzero
temperature of upto -700C with Nitrous oxide /
-1800C with Liquid Nitrogen Causing thrombosis of microcirculation & gradual necrosis and sloughing off of the pile.
When cryoprobe is placed on the tissue the ice ball forms a
visible white area which will eventually slough
The procedure usually takes 10-15 min. and the patient is
observed for 30 min.

Disadvantage of Cryo - Therapy

Needs Local anesthesia / sedation
Post-op pain present

Copious foul smelling browny discharge for

wks till the would sloughs & heals
Secondary haemorrhage
Delayed return to work
Thus it use is abandoned in current era

Procedures Recommended
Grade I piles :

I.R.C. / Sclerotherapy

Grade II piles:

I.R.C. / R.B.L. / scleroRx

Grade III piles:

Palliative Rx with
R.B.L. / scleroRx

Important Instruction to Doctors

Piles has a multifactorial causative etiology

CURE should never be promised to any patient
Just mention that this is the right treatment for your
patient under his current circumstances.
REMOVE

FEAR

Open Surgery for Piles

There are two established methods of
haemorroidectomy
1. Open haemorroidectomy
2. Closed haemorroidectomy

Pre-operative piles

Post - operative

Haemorroidectomy

Breakthrough in Haemorroid
Surgery
Stapler M.I.P.H

DOS & DONTS (Pathyapathya)

After Kshar sutra procedure patient is asked to follow the below
mentioned instructions To have balanced (easy to digest) diet.
To avoid Heavy meals.
To avoid suppression of urge and Constipation.
To regularize the food and bowel habits.
To avoid cold beverages, Alcohol and Smoking
Note: All the above mentioned factors are
Responsible for Agnimandya and can vitiate the vaat dosh.
.

 To avoid Ratri- jagaran & Day time sleep.

No heavy exercise.
No (over) sex indulgence.
No horse riding (or motor bike/ car- long
drive).
To control anger or emotions.
To maintain the local hygiene.
To avoid long time or awkward sitting
posture.

Anal Exercises :- Contraction & relaxation

of anus for 5 to 10 minutes in a day will give
more strength to anal canal.
Yogasanas :- Practise of specific yogasanas
like Shirshasana, Uttanpadasan will reduce
the pressure over the anal mucosa.