The word ‘Piles’ has been much abused and often causes undue fear. Most people attribute the term to problems such as bleeding, swelling, pain and difficulty in passing stools or even itching in around or the anus. All are clubbed together under the term piles. But,it actually can be any of the three entities haemorrhoids, fissures or abscesses /fistula.
HEMORRHOIDS is the actual scientific term for piles .‘Heme’ means blood and‘roids’ means swelling ...so its a blood containing swelling and the symptoms include bleeding usually after the stool is passed as a spurting jet of blood or dripping of blood. There may also be a soft swelling which sticks out of the anus which can usually be put back inside by the patient himself. The most important aspect is lack of pain .The haemorrhoids in its initial stages (grade 1) manifest as bleeding only. Later with a protruding swelling easily going back inside by itself, which is grade 2 and then later it fails to go back inside by itself which is grade 3. Grade 4 is prolapsed haemorrhoids when all around the swelling is outside the anus and can’t be put back inside and the patient is in great discomfort. This usually happens in longstanding cases where timely consultation with a surgeon is not sought. All stages are easily treatable most of them easily in the office setting, without surgery or any pain. Only the lowermost, two cm of the anal lining is sensitive to pain but all haemorrhoids originate even higher by two cms where the lining cannot perceive pain. All treatments are directed here. For grade 1-3 injection of a sclerosing solution which shrinks the dilated haemorrhoids is used or a rubberband is applied high up at the base by a procedure called banding. For grade 3 -4 surgery maybe required which is done under anaesthesia by a pro-cedure called stapler haemorrhoidectomy which is also painless as a ring of stapling at the painless part of the anal canal is applied at one go. Patients are discharged home in a few hours.
FISSURE This is typically associated with severe pain and difficulty in passing stools and can be also associated with bleeding when stools are passed. But the bleeding is usually less than in case of haemorrhoids. This fissure is a tear in the lowermost pain sensitive area of the anus caused by hard stool passage. The underlying anal sphincter muscles go into painful spasm as stool passes over it. It may also produce bleeding as the wound is opened. The spasm worsens the difficulty in passing stools and a vicious cycle ensues. Treatment is usually initially by creams aimed at relieving the spasm and stools softening with laxatives . Success usually is 80-90 percent. Surgery is required in the rest which is minor but under anaesthesia and usually involves loosening these sphincter muscles by dilating or by a small nick. Patients again are discharged in a fewhours. More recently Botox injections have become popular as an alternative to surgery. Botulinum toxin (BOTOX) injection relieves spasm of the sphincters.
ABSCESS The last component is abscess which is an extremely painful pus filled swelling occurring around the anus due to infection in a blocked anal gland which when large enough will point at the skin around the anus. This either ruptures by itself or is incised by the surgeon. These abscess cavities may not heal completely and may progress to fistula when a communicating track is left behind between the skin outside the anus and the inside lining of the anus. This presents as intermittent discharge ,not at the time of passing stools, staining the patients' underwear unexpectedly. It may or may not be associated with fever or pain. Depending on the anatomy of the tract, the fistula is called low or high. This is best delineated by an MRI scan before treatment. A small tract is called low and a complicated tract going through many muscles is called high tract. All fistulae eventually require surgery as spontaneous healing is rare. Surgery is done under anaesthesia and is straightforward in case of a low fistula and needs to be done in stages in cases of a high fistula.— Dr Bejoy Abraham, Consultant GastroSurgeon