INTRODUCTION: Hemorrhoids result from the distention and congestion of the internal and external venous plexuses around the anal canal. They are usually associated withconstipation and straining at defecation, or may occur during pregnancy. There are three degrees (first, second and third) of piles. Patients with piles either complain of bright-red bleeding after defecation, or prolapse of something through rectum which disappears after defecation or some may complain that something comes out which has to be pushed back (prolapsed piles) or there may be a tag (sentinel piles) of skin. Other symptoms include pruritus, pain, mucus discharge. Piles may be asymptomatic. Treatment is to avoid constipation and straining at stool. Injection sclerotherapy or band ligation is required for most of the patients with bleeding piles. Hemorrhoidectomy is required as a curative measure in some patients with prolapsed piles.
ATIOLOGY: Anyone can get symptomatic hemorrhoids, even teenagers. (Because hemorrhoids take a while to develop, they’re uncommon in children.) You may be more at risk if you:
- Are overweight or obese.
2. Are pregnant.
3. Eat a low-fiber diet.
4. Have chronic constipation ordiarrhea.
5. Regularly lift heavy objects.
6. Spend a lot of time sitting on the toilet.
7. Strain while having bowel movements.
TYPES : Hemorrhoids can happen inside or outside the rectum. The type depends on where the swollen vein develops. Types include:
External: Swollen veins form underneath the skin around the anus. External hemorrhoids can be itchy and painful. Occasionally, they bleed. Sometimes they fill with blood that can clot. This is not dangerous, but can result in pain and swelling.
Internal: Swollen veins form inside the rectum. Your rectum is the part of the digestive system that connects the colon (large intestine) to the anus. Internal hemorrhoids may bleed, but they usually aren’t painful.
Prolapsed: Both internal and external hemorrhoids can prolapse, meaning they stretch and bulge outside of the anus. These hemorrhoids may bleed or cause pain.
CLASSIFICATION
- Primary/Idiopathic Haemorrhoids
Causes
1. Standing Position – Is partly responsible for piles because blood has to flow against gravity.
2. Anatomical Factor- The veins, when they pass through the sub mucosa of the rectum, get constricted during the act of defecation.
3. Familial or Genetic – Absence of valves or congenital weakness of vein wall.
4. Constipation – Causes excessive straining.
2. Secondary Haemorrhoids
Causes
1. Carcinoma of rectum by blocking the veins can produce back pressure and can manifest as piles.
2. Portal hypertension is an uncommon cause of piles (rectalvarices)
3. Pregnancy, due to compression of superior rectal veins or due to progesterone which relaxes smooth muscles in the wall of the veins.
LOCATION:
Classically situated in the 3, 7, 11 o’clock position. Superior haemorrhoidal artery (vein) gives 2 branches on the right side and I branch on the left side.
CLINICAL FEATURE:
1. Painless bleeding. Fresh bleeding occurs after defecation. Haemorrhoids which bleed are called Grade 1 Haemorrhoids.
2. As the straining increases, the haemorrhoids partly prolapse outside.
After defecation, it returns back or can be digitally replaced-Grade IL Haemorrhoids.
3. Permanently prolapsed pile outside – Grade III haemorrhoids. Patient complains of pain or discomfort.
4. Constipation.
5. Discharge of mucus and irritation of perianal skin; pruritus is a common feature.
INVESTIGATION:
1. Haemorrhoids cannot be felt by rectal examination unless they are thrombosed.
2. Proctoscopy-As the obturator is removed, piles prolapse into the lumen of proctoscope as cherry red masses.
COMPLICATIONS:
1. It can cause chronic anaemia.
2. A prolapse causes pain.
3.Ulceration and secondary infection. 4.Thrombosis and fibrosis.
TREATMENT :
- Lord’s Dilatation-Ulcer GA., the internal sphincter is widely stretched which is supposed to relieve the venous congestion and improve the piles. This is indicated in Grade I varices.
- Injection of Sclerosant It produces aseptic thrombosis of the pilemass and is indicated in grade 1.
3. Barron’s Band Application.
4. Haemorrhoidectomy-Indicated in Grade II and Grade III hemorrhoids.
5. Cryosurgery
GENERAL MANAGEMENT:
1. A recent meta-analysis confirmed that fibre supplements moderately improve overall symptoms and bleeding and should be recommended at an early stage.
2. Other lifestyle modifications such as improving anal hygiene.
3. Taking sitz baths.
4. Increasing fluid intake, relieving constipation, and avoiding straining are used in primary care and may help in the treatment and prevention of haemorrhoids.
Over the counter topical preparations that contain a combination of local anaesthetics, corticosteroids, astringents, and antiseptics are available, and these can alleviate symptoms of pruritus and discomfort in haemorrhoidal disease. Long term use ofthese agents should be discouraged, particularly steroid creams, which can permanently damage or cause ulceration of the perianal skin. No randomised controlled trials are available to support their widespread use.
Venotonics such as flavonoids have been used as dietary supplements in the treatment of haemorrhoids.
HOMOEOPATHIC MANAGEMENT:
A proper homeopathy treatment not only manages the symptoms but also offers a long term relieve and cure to the ailment.
(1)Aesculus hippocastanum
Haemorrhoids are sore and aching, with a swollen feeling. Pain may last for hours after the bowels have moved. People who need this remedy often have the sensation of a lump, or a feeling that a lot of small sharp sticks are inside the rectum, poking them.
(2) Aloe
Haemorrhoids that are swollen and protrude “like a bunch of grapes” and are soothed by cold soaks or compresses may be helped with this remedy. Haemorrhoids may alternate with diarrhoea, and the person may have a lot of flatulence.
(3) Graphites
Relieves constipation without urges, very large and dry stools, with feeling of heaviness in the lower abdomen, and often associated with anal itching and burning and haemorrhoids.
(4) Nux vomica
Relieves haemorrhoids caused by a sedentary lifestyle, and overeating and drinking, especially of spicy and rich foods and alcohol.
(5) Pulsatilla
When this remedy is indicated, haemorrhoids are itchy and uncomfortable, with sticking pains. They are likely to protrude, with improvement after lying down. Warmth often aggravates the symptoms. This is a very helpful remedy for haemorrhoids that appear during pregnancy or around the menstrual period.
(6) Sulphur
Itching, burning, oozing haemorrhoids accompanied by a feeling of fullness and pressure in the abdomen suggest a need for this remedy. The anus is inflamed and red and may protrude significantly. The person may feel worse from warmth and bathing, and have flatulence with a strong, offensive odor.
(7)Arnica Montana
Sore, bruised-feeling haemorrhoids may be relieved with this remedy, especially when straining or over-exertion (for instance, childbirth or heavy lifting) has brought on the haemorrhoids.
(8) Calcarea fluor
This remedy may be indicated for haemorrhoids with bleeding and itching in the anal region, or internal haemorrhoids causing soreness in the very low back and sacrum. The person may also have problems with flatulence and constipation.
(9) Hamamelis virginiana
Improves venous circulation and relieves haemorrhoids that are painful with the slightest contact and bleed easily.
(10) Ignatia
Haemorrhoids accompanied by spasms and stabbing pain in the rectum suggest a need for this remedy—especially if the person is sensitive and emotional. Stitching pains can be felt in the rectal area when coughing. Bleeding and pain are often worse when the stool is loose, and rectal prolapse sometimes follows bowel movements.
