PILES; By W/Bro Andre Kwasi-Kumah, Supreme Physician
Haemorrhoids or piles are a pathological condition arising out of abnormalities occurring in the blood vessels located within the rectum precisely within the anal canal. The anal canal is the last four centimeters of the rectum that opens up externally as the anus. In physiological or non-pathological states, these vessels together with the connective and elastic tissue as well as the muscle tissues in the region serve as a cushion that aid the smooth passage of stool. When they become swollen or inflammed then symptoms appear and they are known as haemorrhoids or piles.
TYPES OF HAEMORRHOIDS
There are basically two types of haemorroids: internal and external. External haemorrhoids are those that occur outside the anal canal near the anus. They are sometimes painful and often accompanied by swelling and irritation. Itching often thought to be a symptom of external haemorrhoids, is more commonly due to skin irritation. External haemorrhoids are prone to thrombosis which is what happens when the vein ruptures and/ or a blood clot develops. Unlike internal haemorroids, it is not clear how external haemorroids form.
Internal haemorrhoids are those that occur inside the rectum. As this area lacks pain receptors, internal haemorrhoids are usually not painful and most people are not aware they have them. Internal haemorrhoids may bleed when irritated and untreated internal haemorrhoids can lead to two severe forms of haemorrhoids namely prolapsed and strangulated haemorrhoids. Prolapsed haemorrhoids are internal haemorrhoids that are so distended that they are pushed outside the anus. If the anal sphincter or valve goes into spasm and traps a prolapsed haemorrhoid outside the anal opening, the supply of blood is cut off and the haemorrhoid becomes a strangulated haemorrhoid. Internal haemorrhoids can further be graded by the degree of prolapse: Grade I-No prolapse. Grade II-Prolapse upon defecation but spontaneously reduce. Grade III :Prolapse upon defecation and must be manually reduced. Grade IV – Prolapsed and cannot be manually reduced.
SIGNS AND SYMPTOMS
Haemorrhoids are usually present with itching, rectal pain, rectal bleeding or swelling around the anus. In most cases, symptoms will resolve within a few days. External haemorrhoids are painful, while internal haemorrhoids usually are not unless they become thrombosed or necrotic. The most common symptom of internal haemorrhoids is bright red blood covering the stool, on toilet paper or in the toilet bowl and they may protrude through the anus. This bleeding results from the fact that the haemorroids in the anal canal becomes exposed to the trauma of passing stool especially hard stool associated with constipation. The rectal lining that has been pulled down secretes mucus and moistens the anus and the surrounding skin. Stool can also leak onto the anal skin. The presence of stool and constant moisture can cause anal itchiness, a condition referred to as pruritus ani, though this is not a usual symptom of haemorroids.
WHAT CAUSES HAEMORRHOIDS
There are a number of factors and theories that can be used to explain how haemorrhoids form. Factors leading to increased pressure in the rectum are believed to be contributory factors to the formation of haemorrhoids and some of these factors include straining during bowel movements, sitting for long periods of time on the toilet seat, chronic diarrhoea or constipation, obesity, pregnancy, tumours in the pelvis and anal sex.
One theory proposes that it is the pulling force of stool, particularly hard stool passing through the anal canal that drags the haemorrhoidal cushions downwards. Another theory suggests that with age or an aggravating condition, the supporting tissue that is responsible for anchoring the haemorrhoids to the underlying muscle of the anal canal deteriorates. With time, the haemorrhoidal tissue loses its hold and slides down into the canal. One physiological fact that is known however is that the pressure within the anal sphincter which is the valve that allows us to hold faeces is increased. What is not very clear however is whether the increased pressure preceded the condition or resulted from it. Another possible cause of haemorrhoids is the absence of valves within the haemorrhoidal veins and also the possibility that the risk of developing haemorroids could be inherited. Low-fibre diet has also been blamed to be a factor in the development of haemorroids. Fibre can be obtained from diets such as wheat, vegetables, fruits, roughage, nuts etc.
If left untreated, haemorrhoids can lead to:
Anaemia. This is a result of chronic blood loss from bleeding piles. A symptom of anaemia is fatigue and weakness and it results from the lack of adequate red blood cells to carry oxygen to the body’s cells.
Strangulated haemorrhoids. If blood supply to an internal haemorrhoid is cut off, the haemorrhoid may be ‘strangulated’ which can cause extreme pain and lead to tissue death or gangrene.
A visual examination of the anus and surrounding area may be able to diagnose external or prolapsed haemorroids. A rectal exam may be performed to detect possible rectal tumours, polyps, an enlarged prostate, or abscesses. This examination may not be possible without appropriate sedation due to pain, although most internal haemorrhoids are not present with pain.
Visual confirmation of internal haemorrhoids is via anoscopy or proctoscopy. This device is basically a hollow tube with a light attached at one end that allows one to see the internal haemorrhoids, as well as polyps in the rectum.
TREATMENT AND DRUGS
Conservative treatment typically consists of increasing dietary fibre, oral fluids to maintain hydration, pain killers, sitz baths and rest. A sitz bath is a bath in which a person sits in warm water up to the hips. It is used to relieve discomfort and pain in the lower part of the body, for example due to haemorrhoids, anal fissures, rectal surgery, episiotomy, uterine cramps, and infections of the bladder, prostate or vagina. It works by keeping the affected area clean and increasing blood flow to it. One could use just water or add salt or vinegar. Increased fibre intake has been shown to improve outcomes and may be achieved by dietary alterations or the consumption of fibre supplements. Although there are several agents to be used on the skin and some inserted, there is very little evidence to support their use. Steroid containing agents should not be used for more than 14 days as they cause thinning of the skin. Skin protectants such as petroleum jelly or zinc oxide cream may potentially reduce injury and itching.
Rubber band ligation is a procedure in which elastic bands are applied to internal haemorrhoids to cut off its blood supply. Within 5 – 7 days, the withered haemorrhoid falls off with a cure rate of about 87 %
Sclerotherapy involves the injection of an agent into the haemorrhoid which causes the vein walls to collapse and the haemorrhoids shrivel up. Success rate four years after is 70%.
The use of electrocautery, infrared radiation, laser or cryosurgery techniques are also available for use.
Haemorrhoidectomy which is the surgical removal of the haemorrhoids is also used in severe cases.
Some preventive measures can be instituted so one can avoid getting the haemorroids in the first place. These include eating high fibre foods: drinking at least 6 – 8 glasses of water and other non-alcoholic fluids every day, taking fibre supplements, avoiding straining and holding your breath during bowel movement:
Others include exercising to prevent constipation and pressure on the veins as well as help lose excess weight and avoiding long periods of standing or sitting especially reading papers while moving the bowel.