Piles Surgery - MITR

Piles Surgery

Introduction

Blood filled vessels are normally located in the rectum (last part of the colon) and the anus which play an important part in the process of defecation (act of passing stools per anus). These vessels can become big and tense leading to a condition called Hemorrhoids. As these are blood filled, the outer layer of these vessels can shed, causing bleeding. The normal discharge of the lining of the colon along with blood can also cause irritation and discomfort of sitting. Finally, these vessels can get swollen with blood causing immense pain.

Location

Blood vessels form an integral part of the wall of the rectum. These vessels lie in the second layer of the wall from inside out. Thus, loss of the innermost layer can lead to exposure and breakdown of vessel wall causing bleeding, especially in case of swollen vessels.

Problems

Hemorrhoids can cause painless bleeding, itching near anal opening, inability to sit, swelling near anus and pain

Symptoms

Hemorrhoids may or may not cause problems. The most common symptom of anorectal diseases is pain. It needs to be differentiated from a Fissure-in-ano. Otherwise, hemorrhoids can present with following symptoms –

1. Passing blood after stools – Usually bright red in color
2. Pain – Initially painless. Pain occurs either along with a fissure in ano or in the presence of large swollen hemorrhoids thrombosed hemorrhoids)
3. Passing white discharge – Causes itching
4. Need to scratch around the anal opening
5. Discomfort while sitting especially for prolonged hours like in a desk-job, driving a two wheeler, etc.
6. Prolonged time needed to pass stools – Some might read a book or newspaper
7. Excessive force needed to pass stools
8. Frequent normal stools in view of sense of incomplete bowel movements
9. Swelling near anus – Usually seen in later stages following falling of the internal hemorrhoids out of the anus or with external thrombosed hemorrhoids

Types

Understanding types of Hemorrhoids helps determine treatment options. Hemorrhoids can present as –

1. Internal Hemorrhoids
2. External Hemorrhoids

Internal Hemorrhoids

Hemorrhoids are usually present within the rectum and anal canal. As they become bigger, they grow to protrude out of the anal canal. The internal hemorrhoids are further sub-divided as

Grade
Grade I
Grade II
Grade III
Grade IV
Size
Small
Larger
Larger than II
Larger than III
Location
Lie within anal canal
Lie within anal canal
Outside anal canal
Outside anal canal
Prolapse
Never
Along with stools
Always
Always
Reducibility
NA
Immediately after stools
With a finger can be pushed back in
Never
External Hemorrhoids

External Hemorrhoids present as swelling at the edge of the anal opening following bleeding. The blood within the swelling usually clots. Hence, they are also called as perianal hematoma. These hemorrhoids can cause intense pain and require urgent medical treatment.

When to worry

Any bleeding after stools should prompt you to see a doctor. Painful swelling near the anus should prompt you to see a surgeon. Longer duration of bowel movement, discomfort in sitting, itchiness are some vague indicators to look out. Other alarming symptoms include loss of weight, sudden change in bowel habits like changing diarrhea and constipation, giddiness after bowel movement.

Tests to diagnose hemorrhoids

Hemorrhoids can be diagnosed and treated by your family physician. In case you don’t feel better or you need to be examined, you should consult a surgeon.

Digital rectal examination

Your family physician may advise you to get examined further. The first step is examination by inserting the index finger through the anus wearing gloves. Following lubrication with a jelly, the finger can feel and help detect abnormalities in the lower part of the rectum and anal canal. At times, it may not be possible to insert the finger like in an acute fissure, prolapsed and thrombosed hemorrhoids. A gentel examination is performed after explaining to the patient. In case of pain during digital examination, one must inform the examining doctor immediately.

Proctoscopy

The next step is to visualize the same two areas – lower rectum and canal using a proctoscope and light. A proctoscope is an instrument devised to visualize and diagnose hemorrhoids. This instrument can help treat hemorrhoids like putting a band and to take a biopsy from a swelling if needed.

Sigmoidoscopy / Colonoscopy

In case of elderly patients, bleeding per anus warrants further testing to look for any abnormality beyond the rectum and anal canal. It is prudent to evaluate even in the presence of hemorrhoids as they can co-exist with cancer of colon. A long slender tube is passed after putting the patient to sleep with mild sedative to see the proximal colon.

Treatment

Initial treatment consists of lifestyle changes

Lifestyle changes
1. Fiber rich diet increases the volume of the stools making evacuation easier. Foods rich in fiber include vegetables, fruits and salads.
2. Adequate water intake maintains water balance in the body. With inadequate water intake, the colon absorbs water from the lumen to maintain body water, thus making the stools hard. Generally, 2-3 liters of water intake would suffice an adult.
3. Walking as an exercise is supposed to improve bowel movement. A dedicated brisk walk for about 35 – 40 minutes daily is adequate.
4. Avoid prolonged hours of sitting in the toilet, excessive straining, straining to pass stools to finish off the process before leaving for work.
5. Pass stools following a stimulus. Postponing bowel movement in spite of a stimulus causes the stools to harden.
6. Cleaning after passing stools is preferably done with water or patting with wet wipes. Avoid dry tissues, rubbing and forceful jet of water.

Local Applications

Local applications of medicated creams help relieve the symptoms of hemorrhoids. There are many components each of which plays a different role in reducing discomfort.

1. Topical anesthetic – Lignocaine 2% preparation are used to relieve discomfort after passing stools
2. Steroids – Reduce swelling especially in thrombosed hemorrhoids

Oral medications

1. Pain relieving drugs – Especially when associated with moderate to severe pain
2. Hemorrological agents – These are drugs which are supposed to reduce the congestion of the blood vessels and help drain the blood and reduce symptoms
3. Laxatives – Osmotic laxatives like lactulose help retain water in the colon, thus softening stools to make passage easier and without much straining
4. Bulk laxatives – Increase the bulk of stools similar to high fiber diet. Available in powder form and consumed along with water

Interventions

1. Banding – A rubber band is applied usually to Grade II or III Hemorrhoids. This band snaps the blood supply to the hemorrhoid, thus shrinking it. In about 7-10 days, the hemorrhoid detaches and falls. This is an out-patient procedure. There can cause some discomfort following the procedure followed passage of blood, mucus after hemorrhoid falls.
2. Injection therapy or Sclerotherapy – This procedure involves injection of a chemical solution which causes the hemorrhoid to clot and eventually decrease in size. This is also an out-patient procedure. After this procedure, there can be some pain and bleeding which will eventually settle.
3. Infrared coagulation – Infrared light is used as a means to burn the tissue around the hemorrhoid to stop its blood supply.

Options in surgical treatment

Usually reserved for Grade III or IV. Options are

1. Open surgery
2. Stapler surgery

Open Surgery
Stapler Surgery
Anesthesia
General / Spinal
General / Spinal
Cut of Surgery
Yes
No
Site of cut
Skin and Anal canal
No cut
Pain after surgery
Yes
Less
Dressing after Surgery
Yes
No
Scar
Yes
No scar
Recovery time
2 – 3 weeks
3 – 7 days
Discharge
48 hrs
24 hrs