Piles of Trouble
In the West, over half the population above the age of 50 years is known to suffer from piles. Accurate Indian statistics are not available because we as a people, are mostly embarrassed to talk about it. Unfortunately, piles tend to worsen over time, and every disease deserves be treated as soon as it occurs.
In India, ‘piles’ is used as a loose common term to include piles, haemorrhoids, fistulas and fissures with skin tags. Fistulas are abnormal small openings next to the anus from where discharge keeps occurring. This is due to a tunnel like tract between the anal canal and the skin. This condition always requires surgery for cure.
Fissure with skin tags leads to painful bleeding, due to a small cut at the anal margin. It is usually associated with skin tags that are mistakenly called piles. This condition resolves in majority of the patients by use of creams and medicines to treat constipation. Rarely does the patient need surgery. True piles are those that present with painless bleeding, due to the swelling up of blood vessels in the anal canal.
An exact cause is unknown; however, the upright posture of humans alone forces a great deal of pressure on the rectal veins, which sometimes causes them to bulge. Other contributing factors include:
2. Chronic constipation or diarrhoea.
5. Faulty bowel function due to overuse of laxatives or enemas; straining during bowel movements.
6. Spending long periods of time (e.g. reading the newspaper) on the toilet.
Whatever the cause, the tissues supporting the veins stretch. As a result, the veins dilate; their walls become thin and bleed. If the stretching and pressure continue, the weakened veins protrude.
The Thin Red Line
Piles can be either internal or external, and patients may have both types.
- External piles occur below the dentate line (a line seen in the anal canal that demarcates the area with pain sensation from that without it) and are generally painful. When inflamed, they become red and painful, and if they become clotted, can cause severe pain. They can be felt as a painful mass in the anal area.
- Internal piles are located above the dentate line and are usually painless.
Do You Make the Grade?
This is how your doctor classifies your type of piles:
- Piles that protrude into but do not prolapse out of the anal canal, are classed as grade I.
- If they prolapse on defecation but spontaneously reduce, they are grade II.
- Piles that require manual reduction are grade III.
- If they cannot be reduced, they are grade IV. Piles that remain prolapsed maydevelop thrombosis and gangrene.
How Does It Feel?
Internal haemorrhoids cannot cause pain in the skin, but they can bleed and prolapse. Prolapsing internal haemorrhoids can cause pain around the anus by causing a spasm of the sphincter complex (a ring of muscle that contracts to close the anal opening). This spasm results in discomfort while the prolapsed haemorrhoids are exposed.
Internal haemorrhoids can also cause acute pain when caught for room (doctors call it ‘incarcerated’ or ‘strangulated’!). Again, the pain is related to the sphincter complex spasm. Strangulation with necrosis, the localised death of living cells from infection or the interruption of blood supply, may cause more deep discomfort. When these catastrophic events occur, the sphincter spasm often causes external thrombosis (blood clot), which causes acute pain on the surface.
Looking Down Under
The diagnosis is made by examining the anus and anal canal – the doctor has to exclude more serious causes of bleeding, such as cancer (though no relation between piles and cancer has been found till now).
- A simple look inside is done by a procedure called proctoscopy where a three-inch long hollow instrument with a diameter of about one inch is introduced in the rectum and with the help of a torch, the inside is looked at by the doctor. The procedure is painless but uncomfortable and lasts about a minute and is done in the outpatient clinic.
- A more detailed look is done by a procedure called sigmoidoscopy that is done under sedation or anaesthesia. A look upto 25 cm is done to rule out any sinister disease that may be associated.
- Occasionally, a barium examination or colonoscopic examination of the large intestine may be required if other diseases are suspected.
Making Things Better
The symptoms are due to prolapse, thrombosis, and vascular bleeding, so solutions like creams and salves don’t have much of a role in treating haemorrhoidal complaints.
Aggressive therapy is reserved for patients who have persistent symptoms after one month of conservative therapy. Treatment
is directed solely at symptoms and not at the haemorrhoids’ appearance. Many patients have been referred for surgery because they have severely swollen prolapsed haemorrhoids or very large external skin tags – but are asymptomatic. Doctors consider it prudent to treat haemorrhoids only if they cause the patient problems. Similarly, patients often ask when they should have surgery.
We remind them that their haemorrhoids do not bother anyone else, and they should opt for aggressive treatment only when symptoms become bothersome.