Hemorrhoids (Piles)

Commonly known as piles, haemorrhoids are abnormally engorged and swollen blood vessels in the anus and lower rectum. These may rupture and cause bleeding or slip out of place during defecation. Piles cause discomfort and itching, affecting a person's daily lifestyle. This is when treatment may be required, and is referred to as haemorrhoidal disease. It is a common condition, but many people are too embarrassed to see their doctor about it until the pain or discomfort becomes unbearable, or when there is bleeding, causing worry that it may be something more serious.

There is more than one type of haemorrhoid. Internal haemorrhoids develop within the rectum. They may be present but cause no pain or discomfort. However, straining during bowel movement may cause them to bleed and protrude as a result of prolapse. Defecation can cause trauma and bleeding, while the presence of stool and constant moisture in the anal canal can lead to anal itchiness, although itchiness is not a common symptom of haemorrhoids. Less common - the haemorrhoid protrudes from the anus and cannot be pushed back inside, a condition referred to as incarceration of the haemorrhoid.

External haemorrhoids develop around the anus and can be felt as bulges at the anus, but usually cause few of the symptoms typical of internal haemorrhoids. When irritated, they may itch or bleed. External haemorrhoids can cause a very painful anal lump when blood clots inside them (thrombosis).

The symptoms of piles can mimic and mask the symptoms of cancer. It is important for any patient complaining of symptoms that might be attributed to piles to consult their specialist surgeon for a full examination, before dismissing their symptoms as mild and haemorrhoid-related.

Some signs and symptoms that patients can look out for include:

• Bleeding at times other than defecation
• Sensation of incomplete emptying that is present all the time, despite defecation
• Change in the calibre and character of the stools
• Change in bowel habits
• Obvious hard mass at the anus
• Unexplained loss of appetite and weight

There are multiple factors resulting in a person having symptomatic piles. These are generally associated with any condition that can cause an increase in intra-abdominal pressure, including:

• Persistent straining during bowel movement and chronic constipation or diarrhoea, or even prolonged sitting on the toilet. The extra pressure during prolonged straining causes these vessels to swell and enlarge.
• Inadequate fibre intake
• Obesity
• Genetics. The tendency to develop haemorrhoids may run in the family.
• Tumour. A less common factor is the existence of an intra-adbomonial or pelvic tumour.
• Pregnancy. A common cause for piles for women is during pregnancy, where the growing foetus and labour exertion causes pressure on these blood vessels.

The treatment of piles depends on the severity and the type of symptoms affecting the patient. Simple preventive measures include having a balanced diet and adequate water intake to allow regular bowel movement without straining. If this doesn't help, other treatments available include:

• Oral medications or topical suppositories. These can be used to treat small bleeding piles.
• Ligation. This rubber band treatment works effectively on internal haemorrhoids that protrude with bowel movements. A small rubber band is placed over the haemorrhoid, cutting off its blood supply. The haemorrhoid and the band fall off in a few days and the wound usually heals in a week or two. This procedure sometimes produces mild discomfort and bleeding.
• Injection. For this procedure, the doctor injects a chemical solution into the haemorrhoid, causing it to shrivel and subsequently fall off. This method is relatively painless and can also be used on bleeding haemorrhoids that don't protrude.

Piles that are not prolapsed can be ligated or injected. These are simple procedures that can be done in an outpatient clinic and do not require hospitalisation. But these procedures may not be extremely effective, and may require more than one treatment.

More definitive measures are needed for severe cases, such as when clots repeatedly form in external haemorrhoids, or Iigation fails to treat internal haemorrhoids, or when a protruding haemorrhoid cannot be reduced, or when there is persistent bleeding. Surgical techniques under general anaesthesia include:

• Haemorrhoidectomy:
  This is surgery to remove excessive tissue causing the bleeding and protrusion. It is the best method for the permanent removal of large, prolapsed haemorrhoids.
  
  Haemorrhoidectomy can be performed in the conventional manner, or through stapled haemorrhoidectomy. This is a form of surgery performed under general anaesthesia. A device is used to excise the piles internally and the internal wound is closed via a row of "staples". Compared to the conventional "open" method of haemorrhoidectomy, where there is a raw wound, stapled haemorrhoidectomy causes less discomfort and a shorter duration of pain to the patient in the immediate postoperative period. It's effective in treating large piles that protrude from the anus during defecation.
• Transanal haemorrhoidal dearterialisation (THD):
  This procedure involves using an ultrasound to locate the problematic blood vessels and stitching the piles. As methods may vary slightly from person to person, patients are advised to consult their surgeons to figure out the right treatment for them.