Hemorrhoids, also called piles, are characterized by prolapse of anal cushions resulting in swollen and inflamed veins around the anus or in the lower part of the rectum, classified as external hemorrhoids, which form under the skin around the anus and internal hemorrhoids, which form in the lining of the anus and lower part of the rectum. The primary symptoms manifested by hemorrhoids are anal itching, one or more hard tender lumps near the anus, anal pain especially when sitting along with rectal bleeding.
The development of hemorrhoidal disease begins from dilatation within the cavernous bodies of the anal cushions primarily due to passing hard stool or straining at defecation, leading to, bruising of engorged venous cushions and rupture of artero-venous shunts resulting in bleeding (spontaneous or during defecation).
Several advanced procedures to fibrosis the hemorrhoidal clumps onto the underlying internal ring-opening, thus restoring subsistence of the vascular cushions and thus preventing prolapse.
Conservative Approach
The preferential approach for managing piles is the conservative aspects that consist of a
- Self-care: Diet & lifestyle recommendations with a high-fiber, fiber supplementation, increased water intake, hot sitz baths for an acute flare-up, and natural stool softeners along with regular physical exercise, healthy toileting habits by avoiding straining or lingering (eg; reading) on the toilet are some measures to avoid piles.
- Over-the-counter Applicants: Topical preparations with a combination of local anesthetics, corticosteroids, astringents, and antiseptics help to reduce symptoms of pruritus and discomfort in haemorrhoidal disease but long term usage is discouraged, particularly steroid creams, as they can permanently damage or cause ulceration of the perianal skin.
- Local medications: Applying ointments or using suppositories (a medicine that is inserted into the rectum) may help to relieve mild pain, swelling, and itching of external hemorrhoids.
Modern Treatment Procedures
Treatment for internal hemorrhoids depends on the severity of symptoms and response to conservative management. The modern aspects of treatment for hemorrhoids include both non-invasive & surgical procedures that can effectively treat piles refractory to medical therapies. In general, the lower the grade, the more likely an office-based procedure will be successful, whereas recurring and grade III or IV hemorrhoids are more amenable to the surgical approach.
The two types of the management approach are;
Non-invasive Procedure
When dietary and lifestyle modifications fail to reduce symptoms then non-invasive office-based therapies are taken into account. Office treatments include the following:
1: Rubber band ligation
- This procedure is used to treat bleeding or prolapsing internal hemorrhoids. In this method, a special rubber band is placed around the base of the pile mass. The band cuts off the blood supply resulting in shriveling & falling off the sprouted mass within a week leaving scar tissue in the remaining part of hemorrhoid.
- Ligation of the sprouted tissue with a rubber band causes a restriction in blood supply with resultant damage to tissue and scarring. The scar tissue helps in the fixation of the connective tissue to the rectal wall.
- This band-ligating method is a simple, quick, and effective means of treating first- and second-degree hemorrhoids and selected patients with third-degree who are compliant to in-office treatment.
- The success rate is 65–75% but can still be considered if one is attempting to avoid surgery.
2: Sclerotherapy.
- This therapy involves injecting a chemical-based saltwater solution into the blood vessel or tissue that causes the collapse of the underlying muscle by fibrosis forming scar tissue as a remnant that cuts off the blood supply resulting in squeezing of the pile mass.
- The rationale injections cause local thrombosis and fibrosis, reducing vascularity and cutting the blood supply to the pile mass.
- This method is effective in 60–80% of first and second-degree internal haemorrhoids, moreover, sclerotherapy is not as effective on large prolapsing haemorrhoids.
3: Infrared photocoagulation
- This procedure involves a tool that directs infrared radiations over the lump, producing enough amount of heat to coagulate the tissue forming a scar tissue, which cuts off the blood supply causing shrinkage of the haemorrhoid mass.
- The actual process involves burning up to the submucosa, causes tissue destruction & evokes an inflammatory reaction, ultimately results in scarring.
- This method, if done properly, is relatively painless with a few to minimal complications.
4: Cryotherapy
- This method sheds and wears off the hemorrhoidal tissue with a freezing cryoprobe.
- This method is less painful as the sensory nerve endings get destroyed in the affected area at low temperature.
5: Haemorrhoid Laser Procedure
- This procedure works by means of doppler-guided laser coagulation that ceases the arterial flow feeding the hemorrhoidal plexus.
- Laser photocoagulation is expensive and carries a greater risk of complications from unrecognized deep tissue destruction.
6: Electrocoagulation
- It involves usage of an electric current into the internal haemorrhoid lump causing a thermal injury to fibrose the hemorrhoidal tissue, ultimately forming a scar tissue that cuts off the blood supply leading to the shrinkage of pile mass.
- This method involves direct current electrotherapy that requires more time and discomfort but has a high success rate in treating fourth-degree haemorrhoids.
Surgical Procedures
Surgical hemorrhoidectomy is indicated for grade III and IV hemorrhoids and when non-operative approaches have failed or complications have occurred.
A: Excisional Hemorrhoidectomy
- This surgical procedure involves the removal of large external hemorrhoids and prolapsing internal hemorrhoids that don’t respond to other non-invasive measures.
- The Ligasure type of hemorrhoidectomy is very effective with less post-operative pain, brief hospitalization, rapid wound healing and recovery as compared to diathermy hemorrhoidectomy.
- This method has a major drawback of post-operative pain.
B: Haemorrhoid stapling
- The stapling technique is used to remove enlarged internal hemorrhoidal tissue followed by a repositioning of the remaining tissue back into the anus under the effect of anesthesia.
- In this method, the stapler cuts off the peripheral ring of swollen piles tissue and fix together the upper and lower borders of the cut tissue.
- The stapled hemorrhoidopexy gains over excisional hemorrhoidectomy in terms of less post-operative pain, with no perineal wound, and early return to the normal day-to-day schedule.
Thrombectomy of External Hemorrhoid
- External hemorrhoid thrombosis with severe pain credits to a clot. Thus thrombectomy is the only measure left to treat the condition and avoid ulcer formation. This is done by an incision and evacuation of the clot or excision of the entire hemorrhoidal complex, performed under local anesthesia & then the wound is allowed to heal by granulation tissue.
The restorative aspects of modern treatment of hemorrhoids range from dietary and lifestyle alteration to absolute surgical approach, depending on the grading and intensity of manifestations. The modern techniques exhibit a good number of surgical, para surgical and medicinal treatments advocated to excise the sprouted mass clumps. But after excision, the patient complains of dissoluteness. Hence it is better to go through Ayurveda for early relief.
