Piles

Overview

Piles or hemorrhoids are caused by the inflammation of blood vessels located on the walls of the anus and rectum. These blood vessels act as cushions for the passage of stool in the body. Occasionally the walls of these blood vessels stretch thin and the veins are swollen causing hemorrhoids. They are one of the most important causes of rectal bleeding

The word hemorrhoid is derived from a Greek word “hemorrhoids” meaning veins that are liable to discharge blood. It is commonly seen in the age group of 45-65 years.

The cause of hemorrhoids is unknown, a few factors that cause hemorrhoids are constipation, the increased pressure on the blood vessels during pregnancy and sustained weight gain, persistent diarrhea and prolonged sitting on the toilet, straining to lift heavy objects. They may reduce within 1-2 weeks but when persistent symptoms like rectal bleeding occur when a physician must be consulted immediately.

Itching and discomfort can also be seen in few patients. Typically it is not always associated with symptoms like pain and rectal bleeding.

Types of Piles

1) Internal Hemorrhoids

• They are located on the upper 2/3rd of the anus (on the inner lining of the rectum). These piles usually do not cause pain and are not observed unless swollen. In case of prolapse (hemorrhoids that come out of the rectum), the spasm of the sphincter complex occurs causing perianal pain(pain surrounding the anus).
• Sometimes external thrombosis (blood clot) is formed that causes severe acute pain and requires emergency treatment.
• These are mostly painless and bleeding on bowel movements (passing stools) is seen. On passing hard stools, the covering epithelium is breaks and the blood vessels (veins) underlying it bleed.
• Hemorrhoids that are present internally, can occasionally come out of the rectum (prolapse ). In such cases, the mucus contains small amounts of stool in it causing local dermatitis (inflammation of the skin around the anus) which is known as “Pruritis Ani.

2) External hemorrhoids

• They are located in the lower 1/3rd of the anus and are covered by skin. These piles can become painful due to their nerve supply. Symptoms are observed when a blood clot is formed in one of the veins near the opening of the anus (Thrombosed hemorrhoid).
• Rapid distention of the innervated skin by blood along with edema (swelling in the area) results in pain. The pain decreases as the blood clot resolves usually within 1-2 weeks.
• They are often seen in young and middle-aged adults.
• Recurrence is very common in these cases. Skin tags (excess skin left after the blood clot resolves) are often seen in cases causing hygiene problems.
• Symptoms are often relieved in many people by minor lifestyle changes, home treatments, pain can be relieved by intake of painkillers (like NSAID’s), food habits like an increase in fiber intake, using medicated creams. If the symptoms are persistent (for a prolonged period) without any relief,  then minor surgeries may be performed.

Causes

Piles are caused due to several reasons. These causes increase the pressure within the blood vessels supplying the anus and rectum and cause the vessels to swell.

Piles causes are :

• Watery or hard bowel movements (stools)
• Diet low in fiber
• Diseases of the liver that cause increased blood pressure in the vessels that supply the anus and rectum (portal hypertension), Ascites (accumulation of fluid in the abdomen)
• Family history
• Prolonged diarrhea
• Physical straining to lift heavy objects
• Rectal cancers
• Excessive weight gain
• A persistent cough, sneezing and vomiting (prolonged)
• Prolonged Squatting while defecating
• Anal Intercourse

Symptoms

Symptoms can occur due to the enlargement of the vessels, bleeding or due to the slippage of the blood vessels outside the anus. Any of the following symptoms may be experienced, if you have piles

• Pain which increases on straining or sitting
• Bleeding from the anus
• Protrusion of soft, bulging  vessels through the anus
• Itching around the anal opening
• Sometimes a clot may form within the protruding blood vessels and cause extreme pain. This is known as thrombosed piles
• If any of the above symptoms are present, you need to seek the advice of a doctor. Severe bleeding from a ruptured (torn) pile can cause extreme blood loss and lightheadedness.
• Most commonly we can identify them when we observe blood on a toilet paper or purple/pink bumps are seen around the edge or bulging out from the anus.

Risk Factors

The risk factors for developing piles are

• Prolonged constipation
• Sitting for a long duration
• Vigorous straining
• Chronic diarrhea
• Colon cancer
• Alcoholic Liver diseases (causing portal hypertension and  ascites)
• Lifting of heavy objects
• Poor posture (lack of erect posture)
• Family history of piles
• Elevated anal resting pressure
• Loss of the tone of rectus muscle (muscle in rectum)
• Episiotomy (It is a surgical incision done during delivery by an obstetrician for the baby to pass without any complications through the birth canal)
• Anal Intercourse
• Inflammatory bowel diseases like Ulcerative colitis and Crohn’s diseases.
• Surgeries related to the anal canal and rectum.

Diagnosis

• Doctors diagnose piles by enquiring about the patient’s symptoms and clinical history and by conducting a physical examination.
• During the physical examination, the anal region is inspected for any bulging piles through the anal orifice. Rectal examination is also done. For the examination of the rectum, the patient is made to lie on his left side with knees folded on to the chest. The doctor inserts a gloved finger through the anal orifice and examines the walls of the anus and rectum for swellings and other abnormalities. Usually, piles can also be diagnosed with a visual examination of the anal region and digital rectal examination.
• Anoscopy or proctosigmoidoscopy is done to further visualize the rectum and anus and rule out causes of rectal bleeding other than piles. In this procedure, the surgeon inserts a tube into the rectum through the anus and visually inspects the region using a light.
• Blood tests like hemoglobin, complete blood counts, blood coagulation studies and liver function tests are also done as additional tests.
• Barium enema (injection of a radio contrast fluid, barium sulfate, into the rectum from the anus) is taken by the patient and then the Barium X- RAY is done to observe the entire colon.

Treatment

Piles treatment depends on the patient’s condition and his or her symptoms. The treatment can be done using non-surgical or surgical methods.

1) Non-Surgical Methods

Most patients are initially advised to increase the fiber content of their diet, drink plenty of water, and avoid straining, sitting for long durations and lifting heavy objects. In mild cases, the symptoms can resolve with changes in the lifestyle of the patient. Patients who have hard stools may be prescribed medications to soften the stools. These medications are called laxatives.

Some patients are also advised to perform a “sitz” bath. In this procedure, a large tub is filled with warm water and a pinch of salt is added to it. Then the patient sits in the tub, with the water reaching up to the hip level for 10-15 minutes (3 times a day).  This procedure can relieve inflammation, constipation and pain.

If the pile symptoms are not relieved by lifestyle changes, then patients may have to undergo procedures for treatment. Patients on blood thinners are advised to stop these medications before any surgical procedure to avoid chances of bleeding. Non-surgical procedures are those that can be performed without anesthesia.

After passing stools, the anal area may be cleaned with wet toilet paper. Avoid using dry toilet paper.

Cold compresses and ice packs can be used to reduce the swelling in the anal region.

Topical treatments are often used such as hydrocortisone suppository and pads containing numbing agents.

Piles treatment methods available in India include:

• The most common procedure done is rubber band ligation for internal piles. In this procedure, the surgeon looks at the piles through an anoscope and rubber bands are placed at the base of the blood vessels. This shuts off the blood supply to the pile mass and causes them to shrink and fall off.
• Sclerotherapy involves injecting a chemical into the tissue surrounding the enlarged piles. This chemical damages the tissue and shuts off the blood supply to the piles leading to its shrinkage. This treatment may have to be repeated to prevent recurrence of the hemorrhoids.
• Infrared coagulation is also practiced but less often. In this procedure, infrared light is used to destroy the blood vessels and reduce the size of the hemorrhoids

2) Surgical Procedures

Patients who are distressed due to a large, swollen and prolapsed pile may have to be treated with surgery. Surgery for piles may be performed under local, spinal or general anesthesia. Cleaning of the lower gut (rectum and anus) is performed before the surgery by an enema.

Surgical hemorrhoidectomy is the most effective treatment in India for all types of hemorrhoids. It is preferred in patients who have piles for a long period with repeated bleeding, severe pain and swelling. The surgeon performs this procedure by removing the enlarged vessels using a surgical scalpel or laser. Once the blood vessels are removed, the resulting gap in the anal region is either left open or sutured using stitches. When left open, the wound takes a longer duration to heal but is associated with lesser stitch related complications.

Stapling for piles is a procedure in which the enlarged piles are first removed.  A circular stapler is then inserted into the anus and a ring of tissue around the anus is removed. This procedure may have to be repeated to prevent reoccurrence of piles.

Doppler-guided trans-anal “hemorrhoidal dearterialization” is a modern technique which uses Doppler to locate the blood vessels causing piles and remove them.

3) Home Remedies to Treat Piles

Although piles go away on their own within a couple of weeks or so, they can cause pain and discomfort. Here are some home remedies to treat piles:

• Witch hazel: Witch hazel comes with anti-inflammatory properties. Applying it in the form of soap or liquid can help soothe pain and itching.
• Aloe vera: Applying pure aloe vera pulp or aloe vera-based lotions or ointments can help alleviate the irritation caused by piles.
• Cold compresses: Applying cold compresses or ice bags to the affected area can help eliminate the inflammation. It is especially effective on large and painful piles.
• Warm bath: According to Harvard Health, warm baths of around 20 minutes can relieve irritation and pain due to piles.
• Cotton clothing: Avoid wearing tight-fitting outfits made from unbreathable fabric. One of the best options is to wear loose-fitting cotton clothes. It can help reduce irritation and itching.

Prevention of Piles

The practices that can prevent the occurrence of piles and reduces the intensity of the disease are :

• Consuming high-fiber diet which contains fruits (pears, bananas, apples, raspberries), legumes(lentils, black beans, lima beans) vegetables (green peas, broccoli, brussels sprouts) and whole grains(oatmeal, barley, brown rice). Recommended total daily fiber consumption is 20-38 grams in both men and women.
• Drinking adequate water ( 6-8 glasses of water) and fluids.
• Practicing good bowel habits such as going to the toilet as soon as the urge for defecation appears.
• Regular exercise and weight loss (hemorrhoids causing Constipation can be prevented by staying active and maintaining proper BMI).
• Avoid straining while passing stools.
• Avoid prolonged hours of sitting especially on a toilet, prolonged posture of squatting (the knees and hips are bent while the weight of the body falls on the feet).
• Supplemental fibers (Methylcellulose, Calcium polycarbophil and psyllium) can be used to increase the fiber intake in the body.
• Occasionally Stool softeners can be used for easy passing of stools without straining..

FAQs

Will changing my lifestyle reduce my risk of developing piles?

Yes. The risk for piles can be reduced by following regular exercise and consuming food with high-fiber content.

Can I get piles again after treatment?

Yes. It is possible for the piles to recur after treatment. This can be avoided by eating foods rich in fiber and drinking plenty of water.

Do piles during pregnancy require treatment?

Yes. Treatment of piles during pregnancy is required if they become bothersome.

Can piles be treated without surgery?

Yes. Piles can be treated with lifestyle modifications and non-surgical methods.

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