7. TYPES
1. ABOVE PECTINATE LINE - INTERNAL 2. BELOW PECTINATE LINE - EXTERNAL
• ENDODERMORIGIN • ECTODERM ORIGIN
• COLUMNAR CELLS
• COMMONLY IN ANAL CUSHIONSAT 3, 7, 11’O
CLOCK POSITION
• SQUAMOUSCELLS
• CIRCUMFERENTIALVEINAT ANALVERGE
• NO PAIN • WITH PAIN ( pudental nerve)
• PROLAPSE OF HAEMORRHOIDS • THROMBOSIS
3. INTERO-EXTERNAL
8. A. PRIMARY VS B.SECONDARY PILES
B. ANYVENOUS DILATION OTHERTHANTHE PRIMARY SITES ( 3, 7, 11’O CLOCK)
9. LOW FIBER DIET
LESS BULKY STOOLS
STRAINING AT DEFECATION
INCREASED INTRA-ANAL PRESSURE
DECREASEDVENOUS RETURN
ENLARGED HAEMORRHOIDAL VENOUS
CUSHIONS
ETIOPATHOGENESIS
10. EXTERNAL PILES
1. VARICOSITIES OF CIRCUMFERENTIALVEIN OR EXTERNAL PLEXUS
NEAR ANALVERGE
2. SEEN LATERALTO ANAL MARGIN ASTENSE ANDTENDER SWELLING,
CAN OCCUR ANYWHERE
3. LATER OFTEN BECOMES THROMBOSED OR LEAVE SKINTAGS
12. EXTERNAL PILES – CLINICAL FEATURES
• BLEEDING DEFECATION
• PAINFUL SWELLING OR LUMP AROUND ANUS
• BURNING OR ITCHING AROUND ANALVERGE
13. INTERNAL PILES
• VARICOSITIES OF BRANCHES OF SUPERIOR RECTALVEIN SITUATED
WITHIN ANAL CANAL AND INTERNALTO ANAL ORIFICE
• GRADING: GRADE 1TO GRADE 4
14. INTERNAL PILES - ETIOLOGY
PRIMARY CAUSES SECONDARY CAUSES
HEREDITARY : CONGENITAL WEAKNESS OFVEIN
WALLS
CA , BPH , URETHRAL STRICTURE : INTRA
ABDOMINAL PRESSURE INCREASES – COMPRESSES
SUPERIOR RECTALVEINS
ANATOMICAL : ERECT POSTURE OF MANKIND ,
VEINS LIABLE TO BE CONSTRICTED DURING
DEFECATION
PREGNANCY : ENLARGED UTERUS COMPRESS
PELVIC VEIN , RISED PROGESTRONE DECREASES
TONE
EXCITING CAUSE : INDUCED BY PURGATION OR
STRAINING IN CONSTIPATION
PORTAL HTN
PHYSIOLOGICAL CAUSE
DIET : LOW FIBER DIET
15. INTERNAL PILES – CLINICAL FEATURES
• BLEEDING DURING DEFECATION – SPLASH IN PAN , PAINLESS, CAN
RESULT IN CHRONIC ANAEMIA IF NEGLECTED
• PROLAPSE – GRADE 1 TO 4
• MUCUS DISCHARGE – DUETO PRURITIS / IN CASE OF GRADE 4
• PAIN – UNCOMMON, IN GRADE 4 , ASSOCIATED WITH INFECTION,
FISSURE ORTHROMBOSIS
17. EXAMINATION
• INSPECTION : GRADE 4- EASILYVISIBLE
GRADE 2 & 3 – ON STRAINING
GRADE 1 – NO EVIDENCE
• DIGITAL RECTAL EXAMINATION :TONE OF ANAL CANAL ,TENDERNESS
INTERNAL HAEMORRHOIDS ARE NOT PALPABLE MOSTLY UNTILTHROMBOSED
• PROCTOSCOPY : BULGING BLUEVEINS OR CHERRY RED MASS
26. LORD’S ANAL DILATION
• BY PETER LORD 1968
• ANAL CANAL IS STRECHED GRADUALLY BY INSERTING FINGER BY FINGER
UNTIL FOUR FINGERS OF EACH HAND IS INSERTED
• HAEMORRHOID PATIENTSTENDSTO HAVE A HIGHER RESTING PRESSURE IN
ANAL CANAL ANDTHAT OUTLET OBSTRUCTION LEDTO STRAINING AND
FURTHER PILES - “AIM IS MANUAL DILATION AND REDUCE ANAL PRESSURE”
• UNCOMMON NOWADAYS -TOO MUCH DILATION CAN RESULT IN SPHINCTER
INJURY AND INCONTENENCE
27. INDICATION GRADE 3 AND GRADE 4
SURGERY
OPEN
HAEMORRHOIDECTOMY -
Milligan-Morgan
CLOSED
HAEMORRHOIDECTOMY -
Ferguson
STAPLED
HAEMORRHOIDECTOMY
28. BRIEF AYURVEDIC PERSPECTIVE
Acharya Sushruta has considered four curative measures for the treatment of
Arsha (hemorrhoids)
• Bheshaja
• Kshara Karma
• Agni Karma
• Shastra Karma
29. BRIEF AYURVEDIC PERSPECTIVE
• Pratisaraneeya teekshna kshara
• Kshara Basti
• Chiruvilwadi Kashayam
• Tablet Gandhaka Rasayana
• Maha SankhaVati
• Triphala Guggulu
• Sukumaram Kashayam
• Takrarishta
• Jīmūtaka Lepa
• Per rectum: Narayana Taila
• Lukewarm sitz bath with Panchavalkala kwatha
• Jalaukawacharana in the management of thrombosed piles
