Piles, also known as haemorrhoids, are swollen veins in the anal canal. They are classified based on their location and severity. Piles are caused by factors that increase pressure in the anal veins like straining during bowel movements, pregnancy, obesity, etc. Common symptoms include bleeding, pain, itching and bulging of veins near the anus. Piles are diagnosed through examination of the anus and rectum. Treatment options range from lifestyle and diet changes to medical procedures like banding or surgery. Complications can include thrombosis, prolapse or gangrene if piles are left untreated.

1. en love da Homoeopathy
PILES/
HAEMORRHOIDS

2. PILES/
HAEMORRHOIDS

3. PILES/HAEMORRHOIDS
DEFINIION
• Piles = a ball or mass,
Haemorrhoids = blood to
ooze, Figs = a fruit
(Anjoora).
• The word ‘Haemorrhoids’ is
derivedfromGreekword
Haima (bleed) + Rhoos
(flowering), meansbleeding.
• The pile is derivedfromthe
Latinword ‘Pila’ means Ball.
• It is downwardsliding of anal
cushions abnormallydue to
straining or other causes.

4. ANAL CUSHIONS
• Anal cushions are
aggregationof blood vessels
(arterioles, venules), smooth
muscles and elastic
connective tissue in the
submucosa
• that normally reside in left
lateral, rightposterolateral
and right anterolateral anal
canal.
TYPES
• Piles can be
• Mucosal – seen in old
• Vascular – seenin
young
Present concept is weakening of
Park’s ligamentwhich is the
lower end of theexternal
sphincter.
• Internal—above the dentate
line, coveredwith mucous
membrane
• External—below the
dentate line, coveredwith
skin

5. • Interno-external—together
occurs
CLASSIFICATION
ClassificationI
• Primary haemorrhoids:
Located at 3, 7, 11 o’clock
positions, relatedto the
branches of the superior
haemorrhoidal vessel which
divides on the right side into
two; left side it continues as
one.
• Secondaryhaemorrhoids:
One whichoccurs between
the primary sites.
ClassificationII
• First degree haemorrhoids
Piles within that may bleed
but does not come out
• Seconddegree haemorrhoids
Piles that prolapseduring
defaecation, but returns back
spontaneously

6. • Thirddegree haemorrhoids
Piles prolapsedduring
defaecation, can be replaced
back only by manual help
• Fourthdegree haemorrhoids
Piles that are permanently
prolapsed
AETIOLOGY
• Piles begin as pedicle and it
is located at the origin of the
internal pile, i.e. at the level
of anorectum.
• Hereditary.
• Morphological
weight of theblood column
↓
without valves causes high
pressure
↓
Veins in the lower rectumare in
loose submucosal plane

7. ↓
but the veins above enter the
muscular layer
↓
whichon contraction increases
the venous congestion below
(more prevalent in patients with
constipation).
↓
Superior rectal veins have no
valves (as theyare tributaries of
portal vein) and so more
congestion.
• Other causes are
• straining,
• Diarrhoea
• Constipation
• hardstool
• low fibre diet
• Overpurgation
• carcinoma rectum
• Pregnancy
• portal hypertension
(rare cause).

8. • During pregnancy factors
causing haemorrhoids
↓
raised progesterone relaxes the
venous wall
↓
and reduces its tone, enlarged
uterus
↓
compresses the pelvicvein, and
constipationis common
problem.
• Bulging of haemorrhoidal
plexus (anal corpus
cavernosum, by Stelzner)
occurs due to raised
luminal pressure and
transmission
• Arterial pressure
↓
pressure in rectal ampullary
pump (Wannas)
↓
during straining raises the
portal
↓
as well as systemic pressure

9. ↓
causing obstructionto venous
outflowcausing haemorrhoids.
↓
Disruptionof suspensory
tissues whichhold plexus in
position(sliding lining theory)
↓
raised basal anal pressure
↓
unsupportedsuperior
haemorrhoidal vein in the
loose submucosal connective
tissue
↓
in the anorectumwhenpasses
through the muscular coat
↓
gets constricting effect leading
intocongestionof haemorrhoidal
plexus
↓
are the other theories of
haemorrhoidformation.
• Idiopathiccause: It is very
difficult to pinpoint the
cause for production
of piles.

10. CLINICALFEATURES
• The prevalence rate of
piles is 4.4%in the
world, in about 10
millionpeople.
• It may occur at any age
but mostlyseenin the
age between 30 to 65
years.
• Incidence is equal in both
the sexes.
• Bleeding—1st symptom—
‘Splashin the pan’—‘bright
red and fresh’—occurs
during defecation.
• Mass per anum.
• Discharge—a mucoid
discharge
• Pruritus.
• Pain—maybe due to
prolapse, infectionor spasm.
• Anaemia—secondary.
• On inspection, prolapsed
piles will be visualized.

11. • On P/R examination, only
thrombosedpiles can be felt.
• Throughproctoscopy, exact
positioncan be made out as
a bulge into theproctoscope.
• Points to be notedduring
proctoscopy:
• The numbers, degrees
and size.
• The surface and
appearance of piles.
• Features chronicity of
the prolapse
ON EXAMINATION
• rectal lesion such as external
tags, anal papillae and
fissure, proctitis.
• Any gynaecological,
genitourinaryor abdominal
conditions like
• carcinoma of rectum
• Polyps
• Tumours
• features of ulcerative
colitis should be
identified.

12. • Presence of other
discharge likeblood,
pus, mucous.
• Sigmoidoscopyor
colonoscopyor barium
enema should be done if
there is any suspicionof
associatedmalignancy
DIFFERENTIAL DIAGNOSIS
• Causes for bleeding per
anum
• Piles
• Carcinoma rectum
• Fissure-in-ano
• Carcinoma colon
• Polyps
• Diverticulitis
• Ulcerative colitis
• Intussusception
• Amoebiccolitis

13. • Vascular anomaly of the
colorectum
• Fistula-in-ano
• Mesentericischaemia
• Carcinoma
• Rectal prolapse
• Perianal warts
INVESTIGATION
• Haematocrit
• Colonoscopy to evaluate
proximallyfor any cause
• Bariumenema
• X-ray
COMPLICATION
• Profuse haemorrhage which
may require blood
transfusion.
• Strangulation—piles is
being grippedby anal
sphincter.

14. • Thrombosis—piles appear
dark purple/black, feels
solid and tender.
• Ulceration.
• Gangrene.
• Fibrosis.
• Stenosis.
• Suppuration, leads to
perianal or submucosal
abscess.
• Pylephlebitis (Portal
pyaemia) is rare, but can
occur in 3rd degree piles
after surgery.
TREATMENT
• Preventive
• Therapeutic/curative
• Diet—more fibre/liquid
Laxatives
• Medical
• local applications
• sitzbath
• Diet
• laxatives, drugs—
analgesics

15. • Parasurgical
• Sclerotherapy
• Banding
• Cryotherapy
• Infraredcoagulation
(IRC)
• Laser therapy
Doppler-guided haemorrhoidal
arteryligation(DGHAL)
Surgical • Open
haemorrhoidectomy• Closed
haemorrhoidectomy• Stapled
haemorrhoidopexy • Anal
stretching—Recamier, Lord’s
REFERENCE
1. SRB's Manual of Surgery
by SriramBhat M
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das

16. A
Special Thanks
To A Very
Special Doctor