The document discusses haemorrhoids (piles), which are swollen veins in the anal canal. It defines haemorrhoids and their related anatomy. Piles are classified based on their location and degree of prolapse. Common causes include straining during bowel movements and prolonged sitting. Symptoms include painless rectal bleeding, anal mass protrusion, irritation and itching. Treatment options range from conservative measures like sitz baths to procedures like rubber band ligation, injection sclerotherapy, cryotherapy and surgery. Complications include bleeding, thrombosis and prolapse if left untreated. The document provides detailed information on piles including etiology, pathology, grading, clinical features, investigations, differential diagnosis, and management approaches.
2. Haemorrhoid [Greek] =
haima = bleed + rhoos = flowering means bleeding
Blood to ooze.
Piles [Latin] = pila means a ball
ball or mass like apperance
Described in 400 B.C. by Hippocrates
They are not varicose veins, They are prolapsed anal cushions
The piles are dilated plexus of superior
haemorrhoidal veins in relation to anal canal
Piles can be mucosal (in old) or vascular (in young)-Graham
Stewart 1963
HAEMORRHOIDS, PILES
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3. Related Anatomy
Anal Cushion (Thomson 1975)
Present in fetus, in
embryo
Present in all
Above the dentate line
Contains blood vessels,
elastic connective
tissue,
smooth muscles
..
Two system of
veins
Portal- Internal
hemorrhoidal
cushion
Systemic - External
hemorrhoidal
cushion
Intercommunicates
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4. Function of Anal Cushion
Speculative
Adds to resting anal pressure (15-20%)
Aid in continence : relaxation filling, squeeze empty
Aids in closure of the anal canal (washer function) – 7-8 mm gap remains at rest
Discontinuous: Allows anal canal to dilate without tearing
Aids in defecation
Smooth glide
Voluntary and involuntary control (conjoined longitudinal muscle)
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5. Etiology and Pathogenesis
Still not known
Evolving theories
Varicose vein theory
Pecten band theory
Vascular hyperplasia theory
Sliding anal cushion theory (best and latest)
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6. Sliding anal Cushion Theory
Straining at stool/ tenesmus
Results in disruption of Treitz’s muscle
Leads to loss of anchoring and flattening action
Leads to protrusion and prolapse
Increased anal tone, improper diet
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7. ETIOLOGY OF ARSHA
Dietic factors -
All those factor which leads to indigestion can
cause arsha ie piles.
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8. .
HABITS –
Sexual act in wrong position
Lack of exercise
Divaswapna/day sleep
Suppression or pravahana of natural urges
i.e. faecus, flatus and urine
Continue…….
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9. .
PRESSURE OR IRRITATION IN ANAL
CANAL
Excessive riding on horse, camel, or vehicles
Defective sitting posture ( utkattashana )
Local contact with hard or rough object
miscarriage or abortion
obstructed labour
Continue……….
EMACIATION FROM
PROLONG ILLNESS
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11. Clinical Grading
Degree of haemorrhoid
1˚ No prolapse
2˚ Prolapse during
defecation
spontaneous reposition
3˚ Prolapse during
defecation
manual reposition
4˚ Always remain prolapsed
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12. Ist degree
‘Splash in the pan’ type of bleeding
P/R
Hypertrophy of internal
haemorrhoidal plexus
Anal mucosal suspensory ligament
intact
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13. .
IInd degree –
Anal suspensory ligament become lax
Pile prolapsed during defecation
Spontaneous reduction
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14. .
III rd degree –
Piles prolapsed during defecation or
exercise
Reduction by manually
Haemorrhoid mucosa undergoes
sqamous metaplasia.
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15. .
IVth degree –
Prolapsed pile mass does not reduced
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16. Clinical features / Presentation
Painless bleeding following defecation (splash in the/on pan)
Something coming out of anus
Multiple prolapsed soft masses at anus
Perianal moistness(discharge)
Incontinence
Mucous discharge, irritation, Itching
(Pruritus ani)
Rarely Pain (think of thrombosis/strangulation)
Burning sensation (thrombosis of external
hemorrhoids)
Anemia (?)
Permanent prolapse mass cause pain,
discomfort, difficult in gas passes
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18. TYPES of PILES
PRIMARY & SECONDARY PILE MASS
EXTERNAL PILEMASS & INTERNAL PILE MASS
BLEEDING AND NON BLEEDING
A. Primary haemorrhoids
Located at 3,7, 11 O’clock, related with
superior haemorrhoidal vessels
B. Seconadary haemorrhoids
occure in b/w primary site
A. Internal haemorrhoids – located
above the dentate line and
with mucous membrane.
B. External haemorrhoids- located
at anal verge covered with skin.
C. Interno-eexternal haemorrhoids
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20. DIFFERENTIAL DIAGNOSIS
RECTAL PROLAPSE
FISSURE IN ANO WITH
SENTINAL TAG
CA RECTUM
PERIANAL WARTS
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22. Common position for examination
Lithotomy position
Left lateral position
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23. A. Conservative treatment
B. Specific treatment
Injection of sclerosant’s.
Barron’s rubber band banding
Cryosurgery
Lord’s manual dilation
Haemorrhoidectomy
Treatment of Piles
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24. A. Conservative Management
Sitz Bath – Luke warm water, 5-10 min,
2-3 times/day
It reduces pain and oedema,
patient got comfort.
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25. .
Bowel Regulation –
Decrease toileting time
Avoid excessive defecation straining
Intake of fiber rich diet
Intake of bulk forming agents
Laxative
Local treatment – Ointment and suppository
Management of anaemia- Iron rich diet and formulation
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26. B.Specific management
a) Injection Therapy –
Mode of action – Sclerosant injection into submucosa
above the dentate line. They firstly produce chemical
thrombosis in haemorrhoidal plexus and secondly produce a
fibrous reaction in submucosal layer which will fix the
mucous membrane to inner muscle layer and draw up pile.
Ideal Agent – 5% phenol in almond oil
Gabriel syringe, Proctoscope
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27. .
Method -- 3 - 5 ml of sclerosant injected into submucosal plane
just above ano -rectal ring to the pedicle . All three piles can be
injected separately . Technique can be repeated after 6 weeks.
INDICATION CONTRAINDICATION
First degree and initial stage Prolapsed piles
of IInd degree haemorrhoid Arterial piles
Infected piles
COMPLICATION Ulcerative colitis
Necrosis and Injection ulcer Crohn’s disease
Submucous abscess
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28. b) Rubber band ligation
Done in Ist or IInd degree haemorrhoid
No need of anesthesia or hospitalisation
No need of assistance
2 band can simultaneously used
Ligation causes haemorrhoidal necrosis in 24-48 hrs
and slough of in about 7 days.
Main disadvantages are pain in Ist 24-48 hrs and
secondary bleeding.
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29. c) Cryosurgery
Mode of action – Extreme cold temperature causes
coagulation of tissue and ultimately necrosis of pile
mass.
Equipments – Cryoprobe
Nitrous oxide (-98 ‘c)
Liquid nitrogen (-196 ‘c)
Painless procedure
No need of anesthesia
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30. d) Infra- red Coagulation
Infra-red light produces extreme heat which coagulate
pile mass and pile fall off.
e) Laser therapy-
It is also a treatment modality and the mode of
action same as infra- red coagulation
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33. INDICATIONS
3rd degree piles
Fibrosed piles
Failure of non operative methods
POST OPERATIVE COMPLICATION
Pain
Retention of urine
Reactionary hemorrhages
Anal stricture
Anal fissure
POST OPERATIVE COMPLICATION
Sitz bath with luke warm water
Diet –soft, fluid intake
Analgesics
Antibiotics
Bulk purgative
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34. Cause – Due to rupture of dilated anal vein as result of sever straining.
sudden onset of painful lump at the anus.
The swelling tense & tender, bluish in colour covered with smooth shining
skin.
Treatment: LA evacuation if the patient come within 48h0, otherwise if
late conservative treatment.
if untreated the haematoma undergoes:
resolution
ulceration
supporation to forms in abscess
fibrosis which give rise to skin tag.
Externalhaemorrhoids
(perianal haematoma)
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