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Piles

Most anorectal complaints are associated with haemorrhoids or piles. Patients present themselves with abnormal swelling of blood vessels in the lower rectum. The anorectum universally contains haemorrhoidal venous cushions that tend to prolapse and are known to be common causes of anal pathology. Individuals are usually embarrassed to seek treatment due to their anatomic orientation. Haemorrhoids originate in the anal canal and are positioned on the dentate line.

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Haemorrhoids are categorized into:

Internal haemorrhoids: develop at the line of the columnar epithelium of the anal mucosa; usually don’t cause pain because of the absence of somatic sensory nerves.

External haemorrhoids: covered by squamous cell epithelium develop from the ectoderm; external haemorrhoidal veins have the tendency to cause problems anywhere around the circumference of the anus.

Causes and risk factors

  • Straining – canal resting tones are higher than normal

  • Constipation – low fibre diets lead to straining during defecation, which interferes with the venous return; the same mechanism also causes tension of the internal sphincter muscle during pregnancy also causing haemorrhoidal problems.

  • Aging – support structures tend to weaken with age facilitating prolapse

  • Anorectal varices – patients with anorectal varices commonly present with portal hypertension, in which case varices form between the inferior rectal veins and the portal system

  • Familial tendencies

  • Obesity

  • Hepatic disease

  • Chronic diarrhoea

  • Lack of erect posture

  • Rectal surgery

  • IBD or inflammatory bowel disease

  • Anal intercourse

  • Injury to the spinal cord

  • Episiotomy

Signs and symptoms

Internal haemorrhoids

  • No cutaneous pain

  • Painless bleeding

  • Perianal itching and irritation

  • Perianal pain due to prolapse

  • Acute pain due to incarceration and strangulation

  • Deposit of microscopic stool contents in the mucous causes localized dermatitis called pruritus ani

External haemorrhoids

  • Acute thrombosis due to physical strain and exertion, change in dietary habits

  • Rapid distention of innervated skin leading to pain that lasts for about 14 days

  • Problems with hygiene due to excess skin in the perianal area (interference with cleaning)

  • Swelling, soreness and redness of the area

  • Bright red bleeding after defecation

  • Excess redundant, hanging skin also known as skin tags

  • Infection and formation of abscesses

  • Bluish appearance due to rectal prolapse

  • Presence of a tender perianal mass

Diagnosis

  • Physical examination will include digital rectal examination, proctosigmoidoscopy, and visualization of the anoderm including the distal anal canal.

  • Haematological tests: CBC as a marker for infection, anaemia, haematocrit testing and coagulation studies

  • Anoscopy and flexible sigmoidoscopy: Anoscopy is a mandatory study for haemorrhoids (side-viewing) and flexible sigmoidoscopy is done for an exclusion of the presence of any proximal disease.

  • Proctography to indicate rectal prolapse

  • Virtual colonoscopy with barium enema for complete large bowel evaluation

Treatment and medication

Patients are referred to surgical intervention and long-term monitoring due to the potential risks associated with haemorrhoids. As medication, stool softeners such as docusate sodium (Dulcolax) help avoid straining during defecation by softening the stool. Topical anaesthetics like Lidoderm and Regenecare increase permeability and reduce pain. Mild astringents are prescribed to relieve itching and analgesics are recommended for pain control.

Dr. Deepak takes an initiative to educate and counsel the patient about piles. He proves to be the perfect confidant for the treatment and cure of haemorrhoids.

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