Piles (full version)

Piles (haemorrhoids)

Piles are swellings on the inside of the anal canal, the short, muscular tube that connects the rectum (back passage) with the anus, in areas known as the anal cushions. They are round swellings that can reach the size of a grape. Piles are varicose veins.

Types of piles

Although piles develop from inside the anal canal, they can hang down out of their normal place.
Piles can be described as follows.

– First degree piles are swellings on the inside lining of the anal canal (dental line). They bleed but can’t be seen from outside the anus.
– Second degree piles are larger and can stick out (or prolapse) from the anus when someone open his/her bowels, but return on their own afterwards.
– Third degree piles are similar, but hang out from the anus and only return inside when pushed back in.
– Fourth degree piles permanently hang down from the anus and can’t push them back inside. They may become extremely swollen and painful if the blood in them clots.

External piles

Swellings that develop from below the anal cushions are sometimes called external piles. They can be more painful than the other types of piles. Other causes of lumps around the anus can include a „sentinel pile”, which is the painless skin tag that develops when a crack in the anus (an anal fissure) heals up. Also, a collection of blood under the skin, called a peri-anal haematoma, may also be referred to as a type of external pile. The treatment of these conditions is different from true piles.

Symptoms of piles

Common symptoms of piles include:

• bright red blood from your anus, which you may notice on the toilet paper when wiping, or in the toilet bowl a lump on the anus
• pain and discomfort after you have opened your bowels
• a slimy discharge of mucus, which may cause itching
• a feeling that your bowels haven’t emptied completely
• soiling underwear (with third or fourth degree piles)

Bright red blood from the anus is most likely to come from piles, rather than anything more serious. However, if you are unsure whether the bleeding is due to piles, you should visit a surgeon specialized for proctology for advice.

Causes of piles

The exact cause of piles isn’t known. One theory is that it’s due to weakness of the tissue that connects the anal cushions to the muscle layers underneath. Due to this weakness, the anal cushions slide out of their normal place and down the back passage.

You have an increased risk of getting piles if you:

• strain to empty your bowels (eg if you have constipation)
• eat a low-fibre diet
• have long-lasting (chronic) diarrhoea
• are pregnant – due to the effect of hormones on the blood vessels, plus the increasing weight of the baby within your abdomen
• have a family history of piles
• have cancer or growths in your pelvis or bowel, which may put increased pressure on your abdomen

Diagnosis of piles

Your surgeon will ask about your symptoms and examine you. This may involve a rectal examination, where he will gently insert a gloved finger into your back passage. Your surgeon may also ask you about your medical history.

To examine the walls of the anal canal, your doctor may use a proctoscope (also called an anoscope). This is a short tube with transparent walls, which can be gently passed into your back passage. You won’t need to have an anaesthetic.

A similar examination, using a longer tube called a sigmoidoscope, allows your doctor to view the lower part of the large bowel and helps to rule out problems in the rectum.

At hospital, the whole of your large bowel can be viewed with a colonoscopy. A colonoscopy is a test that allows your doctor to look inside your large bowel using a narrow, flexible, tube-like endocope called a colonoscope.

Treatment

Self-help

If you have daily bowel movements that are solid but soft, and you don’t need to strain, faeces will pass easily and will not put pressure on the blood vessels in your anal area.

To keep your bowel movements soft, you should:

– eat plenty of fibre-rich foods such as fruit, vegetables and wholegrain cereals (eg brown rice, wholemeal bread and wholemeal pasta)
– drink plenty of water (2-3l/day)

You shouldn’t spend too much time on the toilet (reading, for example). Regular warm baths may relieve irritation and help to keep the area clean.

If you are still passing hard or infrequent faeces, you could try a fibre supplement such as ispaghula husk (eg Paraffin oil, Fybogel) or mild laxatives such as lactulose, which soften faeces. Don’t use strong laxatives, such as the stimulant laxative senna, unless your doctor advises you to.

Medicines

There are a number of treatments that can help relieve the symptoms of piles, but won’t cure them.

– Soothing creams, ointments and suppositories may ease pain and itchiness. There are many different products available without prescription. Some contain a local anaesthetic such as lidocaine.
– Products containing corticosteroids, such as Anugesic and Proctosedyl, may reduce inflammation and pain.

If these self-help measures don’t work, or you have a higher grade of piles, you may need treatment with one of the following procedures.
Out-patient treatments/hospital treatments

Out-patient treatments

These are treatments that you can have in an outpatient clinic.

Banding (Rubber band ligation)

This is used mostly for second and third degree piles, but you can also have it if self-help treatments haven’t worked for your first degree piles.

Your doctor will place a small elastic band just above the pile. This will cut off the blood supply to the pile, causing it to die and fall off after a few days. The raw area left behind will heal up naturally.

Cryosurgery freezes the pile to destroy it. It is not used much, because it causes a watery discharge afterwards.

Infrared coagulation uses infrared light to destroy the pile. This method is not commonly used, because it is not as effective as other methods.

Sclerotherapy

This is an injection of an oily solution known as a sclerosant into first or second degree piles. The oil causes the pile to shrink and fall off.

In-patient treatments

These are treatments that you have in hospital. You may need to stay overnight so that your doctors can monitor your progress afterwards.

Haemorrhoidectomy

This is the surgical removal of piles. Your doctor may suggest a haemorrhoidectomy if you have third or fourth degree piles, or if banding or sclerotherapy hasn’t worked.

The operation is done under general anaesthetic. This means you will be asleep during the operation and feel no pain. Typically, you must not eat or drink for about six hours before a general anaesthetic. However, some anaesthetists allow occasional sips of water until two hours beforehand.

Your surgeon will cut the pile away from the muscle underneath and tie off the blood vessels to prevent bleeding. The exposed wound area will then heal naturally. Your surgeon may use stitches to close the wound.

Haemorrhoidopexy

This is a newer surgical technique that involves removing a doughnut shaped piece of tissue to lift up the anal cushions, preventing them from prolapsing. Because a stapling instrument is used to join the two sides of the resulting wound, the operation is also called a stapled haemorrhoidectomy (PPH, Procedure for Prolaps and Haemorrhoids, op sec Longo).

Longo, PPH, Stapled haemorrhoidectomy

A newer operation, called ‘stapled haemorrhoidectomy, PPH, Procedure for Prolaps and Haemorrhoids, op sec. LONGO’, involves cutting away a 2-3 cm strip of the lining of the rectum and joining the cut edges with a special stapler. People recover much quicker from ‘stapling’ than from the ordinary operation. It is not yet a common operation in Hungary, because of its expenses.

Prevention

You can reduce your risk of developing piles by eating a diet with plenty of fibre and fluids, especially water.
Further information call dr. Regőczi, phone #: 36 30 625 3886