MANAGEMENT OF Haemorrhoids (piles)

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MANAGEMENT OF Haemorrhoids (piles)
Presented by Dr.Amar P. Dwivedi M.S.
(Ayu.) Ph.D.(Sch.) Associate professor
I/C, Shalya Tantra Dept. Dr.D.Y.Patil Medical
(Ayu.) college, Navi Mumbai Contact number
09323097013/09757445151 Email
dramar_d_at_yahoo.co.in
dramar.sarc_at_gmail.com Website
www.amarayurved.com
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• Attachments
• Shri Sai Hospital, Thakkar House
• Castle Mill Naka,Thane-W
• Arogyadham Ayurved Hospital
• Manpada, Thane- W
• Deerghayu Ayurved Clinic
• Devarshi Garden, Majiwada,
• Nr. Rutu Park Soc. Thane- W
• Aashray Hospital, Gokuleshdham
• Sector 5, Ghansoli, Navi Mumbai
• Asso.Prof. In Charge
• Shalya Tantra Department
• Dr. D.Y.Patil College of Ayurved

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• Haemorrhoids

Presented by Dr. Amar P. Dwivedi
Profile

• Awarded with
• Aryabhatta Award, Las Vegas, USA
• Dhanvantari Award, Rajkot, Gujrat
• International Excellence Award, Malaysia
• Panacea Excellence Award, SriLanka
• Best Scientific Research Paper winner at
• 5th World Ayurved Congress, Bhopal-India
• National Conference-Anusandhan 2010.
• Vice President,NIMA- Thane Branch

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VARIOUS CONDITIONS IN ANO RECTAL REGION

• Imperforate Anus
• Piles
• Fistula
• Fissure
• Ischio- rectal Abscess
• Proctitis
• Enlarged Pappila
• Rectal Polyps / Warts
• Pilo Nidal sinus
• Carcinoma
• Pruritis

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• Any Problem
• Around The Anus
• Is Called As..
• Piles

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HAEMORROIDS (PILES)

• Definition
• 1.These are the dilated veins within the anal
  canal in the sub-epithelial
• region formed by radicals of Superior,
  Middle and Inferior rectal veins.
• 2. Piles can be described as masses or clumps
  ("cushions") of tissue
• within the anal canal that contain blood
  vessels and the surrounding,
• supporting tissue (hemorrhoidal cushions).
• Haemorrhoides Haima blood
• Roos
  flowing
• Piles Pila ball
• Anal cushions
• These are submucus venous plexus
  containing
• arterial twigs, venules, smooth
  muscles, elastic tissue
• connective tissue. Symptomatic anal
  cushions are

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INTRODUCTION INCIDENCE

• Humans suffer from piles as a disadvantage of
  their erect posture.
• 50 of people over 50 yrs age suffer from some
  degree of piles.
• 30 of pregnant females suffer from piles
• Asymptomatic piles are found in many patients on
  routine examination
• Sex ratio approx. 2M 1F

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TYPES OF HAEMORRHOIDS

• According to Symptoms-
• 1. Bleeding Piles
• 2. Non Bleeding Piles
• According to Origin-
• 1. Hereditary Pile mass is present by birth
• 2. Acquired Pile mass developed after birth
• According to etiology-
• 1. Primary Due to indulgence in unsalutary
  diets habits
• 2. Secondary Due to some other underlying
  disorders
• According to Location-
• 1. Internal Piles It is covered with mucous
  membrane. It arise from Internal
• Hemorrhoidal
  plexus above dentate line.
• 2. External piles It is situated outside the
  anal orifice is covered by skin. It arise
• from External
  Hemorrhoidal plexus below dentate line
• 3. Internal External Combination variety
  can also co- exist is known as
• 
  Interno- External haemorrhoids.

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Degrees of Internal Piles

• 1st-degree
• Projects into anal lumen internally
• 2nd-degree
• Protrusion outside anal canal at
• defecation with
• spontaneous reduction

• 3rd-degree
• Protrusion outside anal canal at
• defecation straining
• needs digital repositioning
• 4th-degree
• Permanently prolapsed
• irreducible piles

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Positions of Piles

• PRIMARY
• Right anterior ( 11-oclock)
• Right posterior ( 7-oclock)
• Left lateral ( 3-oclock)
• Accessory
• At every oclock position
• DGHAL
• Arterial cushions at every
• odd oclock position
• i.e. 1 / 3 / 5 / 7/ 9 / 11 oclock

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ETIOLOGICAL FACTORS

• Congenital This is due to Shukra- Shonit beej
  dosh.
• Pile mass is
  present by birth.
• Anatomical The haemoroidal veins are situated
  in anal sub-mucosa in
• longitudinal
  direction does not have support of any other
• surrounding
  tissue. So, being valve less structure (either
  due to
• any pressure/
  obstruction on portal vein or due to gravity)
  they
• are always
  filled with blood which results in its
  dilatation,
• elongation
  torsion.

• Sedentary lifestyle Long term sitting job,
  daily traveling
• for long distance, engaged in
  driving or abstinence
• from any kind of physical
  exercise may result in
• overfilling in the haemoroidal
  veins.

• Alcohol Excessive alcohol intake can cause
  Hepatitis
• resulting in portal
  hypertension which
• ultimately exert pressure on
  the haemoroidal
• veins resulting in protrusion
  of pile pedicle .

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• Suppression of urge of daefication/ micturation
• Suppression of urge of daefication vitiates
  vat which
• may result in constipation further
  straining while
• daefication, exerting pressure on the
  haemoroidal
• veins. Similarly, frequent IBS or diarrhea
  may
• cause mucosal irritation inflammation
  resulting
• in protrusion of pile mass.
• Asthma
• Asthma or COPD is associated with vigorous
• frequent coughing which increases the
  intra
• abdominal pressure, thus ultimately exerts
• pressure on the haemoroidal veins.
• Similarly, lifting heavy weight can also
  cause
• pressure on anal veins.

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• Other factors causing Piles
• In females-
• 1) During pregnancy the intra abdominal
  pressure is
• increased (due to the foetus)
  resulting in portal hypertension.
• 2) At the time of labour (delivery) there
  is tremendous pressure
• on the anal canal causing anal fissure
  and prolapsed piles.
• 3) Fibroid in uterus may cause pressure on
  anal veins.
• Some other factors mentioned in Sushrut
  samhita
• 1) Straineous work (Balvad vigrah)
• 2) Anger or sorrowful emotions (Shok)
• 3) Contradictory food consumption
  (Adhyashan)

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SYMPTOMS

• Bleeding
• Swelling / Prolapse
• Straining / Pain / Discomfort
• Constipation
• Itching, Irritation
• Incomplete evacuation
• Digital evacuation / instrumentation
• Abdominal bloating GAS TROUBLE
• Lethargy/ Wt. Loss
• Black-out episodes
• Symptoms of ANAEMIA

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Pathogenesis of Bleeding

• Hard stools
• Straining at defecation
• Bruising of engorged venous cushions
• De epithelization
• Ulceration
• Bleeding

• Disruption of sinusoids
• by straining / irritation
• Bleeding from pre-sinusoidal arteries
• ConstipationStrainingIAS spasm
• Venous back flow
• Mucosal strech
• Tear Bleed

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Bleeding

• Occasional to regular / recurrent
• Bright red ( from presinusoidal arterial twigs)
• Initally ? Streaks specially with hard stools
• Later ? Steady drip
• Advanced ? Squirts / stream / drip with
  defecation
• Also apart from defecation
• (blood spotting on undergarments)

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Examination

• Gain the Confidence
• of the Patient
• Position
• Light (Angle- Poise Lamp)
• Instruments required like-
• Gloves, Jelly, Torch, Guaze, Proctoscopes
  ,Forecep

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Position of patient

• SIMS position
• Lithotomy position
• Knee-Chest position
• Prone position

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What else is to be kept ready??

• Ears open
• Eyes open
• MIND open
• Gentleness
• Respect towards patient
• Soft words politeness
• Understanding the patient

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What thing to keep away
Wicked eyes

• Arrogance
• Mobile phones
• Sharp instruments
• Ego

Foul thoughts
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Inspection

• Spread buttocks apart gently
• Focus the light source
• Observe the peri-anal region
• anal verge
• Skin discoloration
• Scars, Pruritus,
  Sinuses,
• Soiling,
  Discharge Pus, Blood etc.
• External Tag, Swellings (Boil/Induration)
• ? Sphincter
  Tone/Spasm (Refluxes) Other
  Pathologies

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Physical examination

• INSPECTION
• 1ST-degree Nil evidence
• 2nd-degree Bogginess at anal verge at affected
  side, gentle traction on bogginess reveals
  mucosa
• 3rd-degree Inner red/purplish mucosa outer
  skin covered bogginess with linear furrow in
  between
• 4th-degree Evident irreducible prolapse
• White Pannus
• Pruritic signs
• Soiled perineum

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INSPECTION (Most neglected but most informative)

• External opening of fistula
• Abscess
• Sphincter tone
• Soiling
• Prolapse during valsalva
• Stricture / Stenosis
• Sphincter spasm
• Worm infestations

• Fissure
• Hematoma
• Wart
• Pilonidal sinus
• Pruritis ani
• Prolapsed Piles
• Sentinal pile / tag
• Bleeding / Discharge

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D.R.E

• (DIGITAL RECTAL EXAMINATION)
• P/R examination

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Physical examination

• D.R.E. (Digital Rectal Examination)
• Ask patient to bear down gently insert
  lubricated gloved finger inside
• Early piles Soft, easily collapsible venous
  swellings
• Late piles Fibrosis of connective tissue
• Piles are palpable as
  soft longitudinal folds
• Also appreciate
• Anal tone
• Ano-rectal sling level
• Anal canal length
• .Squeeze pressure
• Inspect the finger for blood / mucus / feces
• Exclusion of other diseases esp. Ca

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PALPATION DIGITAL RECTAL EXAMINATION (DRE)

• Rectum
• Collapsed , ballooned
• Loaded / empty
• Wall irregularity nodularity
• Stenosis / stricture
• Polyp / mass
• Cervix uterus in females
• Prostate seminal vesicles in males
• Blummer shelf deposits
• Examine the finger after P/R for
  blood/mucus/pus/stools
• P.V. examination with separate gloves

• Anal Canal
• Sphincter tone
• Ano-rectal sling
• Fibrosis
• Internal opening of Fistula
• Induration
• Tenderness.

Peri anal Tenderness, Induration
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ANOSCPOY / PROCTOSCOPY

• Proper instruments and lighting
• Position
• Technique
• Many things can be diagnosed

Physical Examination With scope inside anal
canal, ask patient to bear down inspect while
withdrawing the scope. Look for bulge site /
covering mucosa colour Bleeding points Rectal
mucosa status Other lesions
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MANAGEMENT

• Acute stage Conservative Treatment
• In Allopath, the line of treatment is as
  follows
• 1. In Acute stage i.e. if the patient comes
  with symptoms like severe pain with haematoma,
  then Analgesics Anti inflammatory Anaesthetic
  agent like Xylocaine oint. / jelly is prescribed.
  
• Also, patient is asked to take Hot Seitz
  bath with KMNO4. Haemostatic drugs like Stredron
  or Ethamsilate can be given to arrest bleeding
• Generally, the swelling resolves itself.
  But if the condition do not improved, then it
  may suppurate or may fibrose giving rise to
  cutaneous tag or may burst giving rise to
  bleeding.
• 2. If haematoma do not resolve, then it is
  Incised under local anesthesia the wound is
  allowed to heal by granulation tissue.

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Conservative Management

• Diet Fiber rich, balanced (easy to digest) diet
• Ointments - Hydrocortesone acetate,Heparin
  sodium,
• Aminobenzoate,Lignocai
  ne hydrochloride, Zinc oxide
• Laxatives - Liquid paraffin, Lactulose, Isabgol,
  Senna,Castor oil,
• Bisacodyl
• Suppository- Bisacodyl,Glycerene
• Analgesics / Antibiotics / Prokinetics
• Oral preparations- Sodium picosulphate, Calcium
  dobesilate,
• 
  Tranexamic acid
• Iron supplement
• Seitz Bath

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Ayurvedic Management

• Sushruta has mentioned four fold regimen
  for piles
• Aushadhi Chikitsa i.e Internal medicine effective
  in I and II grade piles
• Kshar chikitsa i.e application of kshar locally
  or internally effective in I and II grade piles
  
• Agni Karma i.e Excision of pile pedicle by
  Cauterization
• Shalya Karma i.e Ligation and Excision of Pile
  pedicle
• effective in III grade and prolapsed pile mass.

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Ayurvedic Conservative treatment

• Deepan and pachan chikitsa
• The main objective is to restore the digestive
• power ( Jatharagni) by
• 1. Ajmodadi churna or
• Hingavasthak churna
• 2. Chitrakadi or ampachak vati
• 3. Shankha vati ( form of mild kshar)
• Vata anuloman chikitsa
• For this purpose Avipatikar churna or
  Panchasakar churna can be prescribed
• Mal Sarak chikitsa-(To treat constipation)
• Haritaki churna
• Abhaya arishta
• Triphala churna

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• To arrest bleeding Nagkeshar Churna, Bolbaddha
  ras or Kutaj Churna can be given.
• Bhalatak kalp in non bleeding piles and kutaj
  churna
• for bleeding piles is choice of drug mentioned in
  Sushrut.
• Various combination for local application
• is advocated for initial stage like
• a. Latex of snuhi turmeric powder
• b. Kasisadi taila
• c. Turmeric podwer Pippli churna Gomutra
• d. Nimbadi malhara etc.

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• Specific guidelines mentioned in Sushrut Samhita
• In initial stage of piles local application of
  inform of lep is mentioned which may promote
  frbrosis and delay the protrusion of pile pedicle
• Snuhi latex Turmeric powder can be tried
• Turmeric Pippali churna Gomutra can be
  applied
• Specific instruction regarding Diet
• Shali, Shasti, Jau or wheat grain mixed
• with ghrit and milk and gruel is made.
• This is to taken as diet regularly
• Lot of green leafy vegetables
• Shatavari mula kalka along with milk
• Apamarga mula cooked with rice
• Butter milk should be taken regularly
• after food
• Jaggery with haritaki

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Kshar Karma in Piles

• This is indicated for II Grade internal piles.
  The kshar is applied to the dilated pile pedicles
  with the help of specially designed probe known
  as Jambaushatha shalaka under the guidence of
  proctoscope (Arsho darshan yantra) having slit on
  its side.
• After mild kshar application the pile pedicle is
  washed with sour gruel (Dhanyaamla) or water and
  followed by local application of yashtimadu
  ghrita at the site.
• Each pile pedicle is treated differently at the
  interval of one week.
• This may cause fibrosis of the tissues which
  prevents the pile pedicle from protrusion. Also
  to some extend it works similar to sclerosing
  therapy

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Use of Kshar sutra in Piles

• Some Ayurvedic surgeons prepare a separate kshar
  sutra which is mild in nature and have less
  coatings for the ligation of internal pile
  pedicle.
• According to them this medicated Kshar
  sutra simultaneously necroses the pile pedicle,
  and at the same time they promote fibrosis over
  the peripheral tissues.
• This technique is practiced in few places
• northern India and is not popular enough.
• However this mild kshar sutra can
• be effectively used in external piles
• and external sentinel tags.

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INJECTION SCLEROTHERAPY

• HISTORY
• Jhon Morgan of Dublinintroduced this procedure
  using persulphate of iron
• Mitchell of Clinton-Illionis, USA, used
  carbolic acid (2795) olive oil
• HE SOLD THE SECRET TO QUACKS BEFORE HIS DEATH
• Andrews of Chicago, discovered the secret from
  Quacks and gave it to the world.

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Principle of Sclerotherapy

• Injection of irritant solution evokes
  inflammatory
• reaction in submucosa where haemorrhoidal vessels
  lie.
• This results in
• 1) Encasement,
• which prevents defecatory trauma thus
  prevents bleed
• 2) Blockage of hemorrhoidal vessels,
• which do not bulge on straining
• 3) Fibrosis,
• which fixes mucosa to muscle prevents
  prolapse.

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INDICATIONS FOR SCLEROTHERAPY

• INTERNAL PILES ONLY
• BEST for Grade I, Bleeding Piles
• GOOD for Grade II bleeding piles
• PALLIATIVE for Grade III bleeding piles

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Contra Indications for Sclerotherapy

• External Piles
• Associated Anal Lesions eg fissure, fistula,
  skin tags
• Attack of thrombosed internal piles
• Pregnancy
• Crohns / Ulcerative colitis

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Solutions used for Injection
Dosage per pile mass

• Phenol
• Various vegetable oils eg. Almond / olive /
  coconut
• STD (sodium tetradecyl sulphate)
• Carbolic acid
• Sodium morrhuate
• Quinine urea hydrochloride
• Glycerine
• Polidocanol

• 5 7ml (max 10 ml)
• 1 2ml

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Site of Injection -In submucosa-Into pile
mass - At the pedicle of the pile mass at ano-
rectal ring (ALBRIGHTS method)
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Post-procedure Instructions

• Mild discomfort
• Tenesmus
• Follow up after 3 wks
• Watch for fever / pain / bleeding. inform sos

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Advantage of Sclerotherapy

• Easily learned procedure
• Stops bleeding in 24 - 48 hrs in majority of
  cases
• Cost effective
• Office procedure so early return to work
• Painless
• Can be repeated

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Complications of Sclerotherapy

• Fainting / Giddiness
• Necrosis
• Re-Bleed
• Abscess
• Stricture
• Urine retension
• Burning itching
• Fistula formation

• Injection ulcer
• Paraffinoma

13/41
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Results after Sclerotherapy

• Grade I piles 98
• Grade II piles 68
• Grade III piles 31
• Overall 77 successful
• Especially in stopping bleeding
• But has less effect on prolapsing element of pile

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RUBBER BAND LIGATION (RBL)orBANDING
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Principle of RBL

• Rubber ring ligature applied to the mucosal
  covered part of the Internal Pile through a
  proctoscope
• This strangulates the feeding vessel to the pile
  and gradually cuts through the mucosa
• The pile thus sloughs off after 7 14days

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Indication for RBL

• Ideal for Grade II internal piles
• Early Grade -- III internal piles

• Contra-indications
• Bleeding diathesis (???)
• Infection ( fistula / abscess)
• Fissure

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Post procedure Instructions

• Dull ache / fullness of rectum may be present
• Urge to defecate may be there
• Bleeding may occur ----- clots 1-2days
• ----- spots
  5 14days
• Follow-up after 2 weeks

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Advantage of RBL

• No learning curve
• Effective symptomatic relief in 80 90 cases
• Safe procedure
• Virtually painless if done properly
• Can band all 3 piles in one sitting
• Can be repeated after 3 weeks
• Cost effective

DISADVANTAGE OF RBL Has no effect on skin
covered component Complications present (
avoidable )
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Complication of RBL

• Pain Immediate / delayed
• Bleeding Immediate / delayed
• Thrombosis
• Fissure
• Slippage of band
• Sepsis

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• I.R.C.
• INFRA - RED COAGULATION
• (Modified Agnikarm)

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INDICATION FOR I.R.C.

• INTERNAL PILES ONLY
• BEST Bleeding Piles of Grade I,
• GOOD Bleeding piles of Grade II

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24 K Gold Plated Reflector
Solid Quartz Light Guide
Trigger
Contact teflon tip
15volt tungsten- halogen lamp
Light energy Heat energy
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Principle of I.R.C.

• It causes actual burn upto the submucosa
• Light energy converted to heat energy
• Causes tissue destruction
• Evokes inflammatory reaction
• Results in scarring

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• Site of application
• Above the pile mass, At or just below A/R sling
• ( same as for sclerotherapy)

• Pre-op instruction
• Patient may feel slight warmth

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ADVANTAGES

• No operation
• No bleeding
• No pain
• No anesthesia
• No admission to hospital
• No need to take leave from work
• Safe for patients with Diabetes
• Safe for patients with High Blood Pressure
• Safe for patients with Heart Problems
• Safe for Pregnant patients suffering from piles.

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Cryo - Therapy

• Principle
• Freezing the pile mass with cryo-probe to
  subzero
• temperature of upto -700C with Nitrous
  oxide /
• -1800C with Liquid Nitrogen Causing
  thrombosis of micro-
• circulation gradual necrosis and
  sloughing off of the pile.
• When cryoprobe is placed on the tissue the ice
  ball forms a visible white area which will
  eventually slough
• The procedure usually takes 10-15 min. and the
  patient is observed for 30 min.

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Disadvantage of Cryo - Therapy

• Needs Local anesthesia / sedation
• Post-op pain present
• Copious foul smelling browny discharge for wks
  till the would sloughs heals
• Secondary haemorrhage
• Delayed return to work
• Thus it use is abandoned in current era

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Procedures Recommended

• Grade I piles I.R.C. / Sclerotherapy
• Grade II piles I.R.C. / R.B.L. / scleroRx
• Grade III piles Palliative Rx with
• R.B.L. / scleroRx

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Important Instruction to Doctors

• Piles has a multifactorial causative etiology
• CURE should never be promised to any patient
• Just mention that this is the right treatment for
  your patient under his current circumstances.
• REMOVE FEAR

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Open Surgery for Piles

• There are two established methods of
  haemorroidectomy
• Open haemorroidectomy
• Closed haemorroidectomy

Pre-operative piles
Post - operative
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Haemorroidectomy
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Breakthrough in Haemorroid SurgeryStapler M.I.P.H
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DOS DONTS (Pathyapathya)

• After Kshar sutra procedure patient is asked to
  follow the below mentioned instructions-
• To have balanced (easy to digest) diet.
• To avoid Heavy meals.
• To avoid suppression of urge and Constipation.
• To regularize the food and bowel habits.
• To avoid cold beverages, Alcohol and Smoking
• Note All the above mentioned factors are
• Responsible for Agnimandya and can vitiate the
  vaat dosh.
• .

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• To avoid Ratri- jagaran Day time sleep.
• No heavy exercise.
• No (over) sex indulgence.
• No horse riding (or motor bike/ car- long drive).
• To control anger or emotions.
• To maintain the local hygiene.
• To avoid long time or awkward sitting posture.
• Anal Exercises - Contraction relaxation of
  anus for 5 to 10 minutes in a day will give more
  strength to anal canal.
• Yogasanas - Practise of specific yogasanas like
  Shirshasana, Uttanpadasan will reduce the
  pressure over the anal mucosa.

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Beware of these Quacks
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shri vyankateshwar Balaji