Diagnosis and treatment of piles (Haemorrhoids)

Haemorrhoids or piles can be diagnosed by a general physician or a surgeon. More often than not patients feel little or no symptoms that resolve on its own or after using over the counter creams or gels for pain available at pharmacies.

However, if there is bleeding, pain or other more severe symptoms of strangulation the condition should be assessed by a surgeon in detail and other causes of bleeding from the anus ruled out. Notable among these is colon cancer as both piles and colon cancer risk rises with age. 1-7

Diagnosis of piles

Diagnosis of piles involves:

• Detailed history - This includes history of similar condition among anyone in family, history of long standing constipation, cough, liver disease or long term anal intercourse. These raise the risk of getting piles.

• Patient is asked if there is recent loss of weight, change of bowel movements, change in color of stools, bleeding or mucus in stools or pain.

• Patient is examined thoroughly. Over weight, obese, pregnant and those with anal infections or ascitis are at a greater risk of piles. These conditions are examined.

• The patient’s anus and rectum is examined in detail. This is performed by the Digital Rectal Examination. The doctor first lubricates the anal canal using a local anethetic cream or gel and then gently inserts a gloved finger to feel if there is any discomfort within the rectum and around the anus.

• Proctoscopy - This is a procedure that involves use of an instrument called the protoscope which is a hollow tube with a light on tip. The instrument is lubricated with a local anesthetic gel and inserted into the rectum. The inner walls of the rectum are visualized with the instrument.

• A biopsy may be taken while a proctoscopy is performed. A small area is anesthetized and a bit of tissue is taken from the affected areas. This tissue is then stained on a slide and examined under the microscope. This is done to examine the pathology and rule out other diseases like bowel cancer.

Piles treatment

Some treatments of piles include:

• Piles may not produce symptoms in many individuals at all times. The symptoms may be aggravated with special causes like pregnancy, constipation etc. In these situations often creams and gels available over-the-counter at pharmacies may help in reduction of pain and discomfort and relieve itching around the anus.

• First therapy is directed towards making stools soft and ease constipation. This is achieved by including at least 25-30g of insoluble fibre a day. This includes cereals, whole grains, fruit and vegetables. This fibre is not absorbed by the body and passes through the bowels making it soft. Patient is advised to drink at least 6-8 glasses of water each day and avoid caffeine containing drinks like tea, coffee and cola.

• Self and home care includes avoidance of straining to pass stools, usage of moist toilet paper or baby wipes rather than dry toilet paper to clean to prevent erosions and bleeding and warm soaks for the bottom called Sitz baths to ease the pain and swelling of the blood vessels.

• Over the counter medications include creams, gels, ointments and suppositories. These ease the pain and inflammation and numb the area. These types of medicines should only be used for 5-7 days at a time.

• Those with severe inflammation may be prescribed corticosteroid cream. These are hormones that ease the inflammation. These however can make the skin around that anus weaker and thinner and should not be used for more than a week at a time.

• Pain medications and laxatives are prescribed to ease discomfort. NSAIDs (Non steroidal anti-inflammatory drugs like Paracetamol, Ibuprofen etc.) may be used. Laxatives may be those that form increased bulk including bran, ispaghula etc. and stool softener medications. These are used to ease constipation.

Banding to treat piles

In this procedure the second and third degree haemorrhoids are treated using a tight elastic band that is placed around the base of the haemorrhoid to cut off their blood supply. The haemorrhoids usually fall off within seven days of having the treatment.

The procedure is performed in day care and is usually accompanied by slight pain or discomfort. Patient usually is fit to joint his or her work the next day.

Most patients do not see or feel their haemorrhoids dropping off as it passes into the toilet. However if there is some mucus discharge within a week of the procedure, it means that the piles have dropped off.

Complications include bleeding, infections or ulcers and these are rare and easily treated.

Sclerotherapy to treat piles

This is an alternative to banding. In this therapy a strong chemical solution is injected into the blood vessels of the piles. This numbs the pain as well as hardens the tissue of the haemorrhoid leading to formation of a scar.

The haemorrhoid may take 4 to 6 weeks to completely shrink and shrivel up. Patients may resume normal activity in a day or so.

Infrared therapy

In this infrared light is used to coagulate the blood vessels of the piles. One or two bursts of infrared light can cut off the circulation of small grade one or two piles.

Other therapies include burning the piles using freezing (cryotherapy) or laser therapy.

Surgical therapy for piles

Grade three of four internal piles may need surgical therapy. This includes haemorrhoidectomy that is an operation to remove the piles. This is performed after failure of banding or sclerotherapy to ease the piles.

This operation is performed under general anaesthesia and patient may need hospital stay for around a week. This therapy is usually curative and piles do not return provided adequate preventive lifestyle measures are adopted.

Another surgical therapy is stapling or haemorrhoidopexy. This is an alternative to haemorrhoidectomy. In this the piles are stapled to the wall of the anal canal. This stops their blood supply and reduces their size. This is preferred for hanging piles.

Some patients are advised Haemorrhoidal artery ligation (HALO) (also known as transanal haemorrhoidal dearterialisation). In this the blood flow to the piles is cut off. A special ultrasound instrument called Doppler probe is used to find out the large arteries that are supplying the piles. Once identified these are stitched up and tied off. This blocks the blood supply to the piles and shrinks them over a few days or weeks. This surgery is less painful and shows early recovery than other procedures.