Piles Management
Piles Management
Piles Management
OF
Haemorrhoids (piles)
Presented by:
Dr.Deepak Nayak
M.S. (Ayu.) Ph.D.
Associate professor
Shalya Tantra Dept.
Govt dhanwantri ayurveda Medical college, ujjain[M.P]
Haemorrhoids
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
Any Problem
Around The
Anus
Is Called As..
Piles
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).
Anal cushions :
These are submucus venous plexus containing
arterial twigs, venules, smooth muscles, elastic tissue
& connective tissue. Symptomatic anal cushions are
called as piles / haemorrhoides.
INTRODUCTION & INCIDENCE
• Humans suffer from piles as a
disadvantage of their erect posture.
• 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.
Degrees of Internal Piles
1st-degree 3rd-degree
Projects into anal lumen internally Protrusion outside anal canal at
defecation straining
– needs digital repositioning
2nd-degree
Protrusion outside anal canal at 4th-degree
defecation with Permanently prolapsed
spontaneous reduction irreducible piles
Positions of Piles
• PRIMARY
Right anterior ( 11-o’clock)
Right posterior ( 7-o’clock)
Left lateral ( 3-o’clock)
• Accessory
At every o’clock position
• DGHAL
Arterial cushions at every
odd o’clock position
i.e. 1 / 3 / 5 / 7/ 9 / 11 o’clock
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.
• Asthma:
• Enlargement of Prostate:
• Position
• SIM’S position
• Lithotomy position
• Knee-Chest position
• Prone position
What else is to be kept ready??
• Ears open
• Eyes open
• MIND open
• Gentleness
• Respect towards patient
• Soft words & politeness
• Understanding the patient
What thing to keep away
• Arrogance
• Mobile phones
• Sharp instruments
• Ego
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
Physical examination
• INSPECTION:
• White Pannus
• Pruritic signs
• Soiled perineum
INSPECTION
(Most neglected but most informative)
P/R examination
Physical examination
D.R.E. (Digital Rectal Examination)
• Ask patient to bear down & gently insert lubricated gloved finger inside
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’
PALPATION &
DIGITAL RECTAL EXAMINATION (DRE)
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.
Conservative Management
• Diet – Fiber rich, balanced (easy to digest) diet
• Suppository- Bisacodyl,Glycerene
• Iron supplement
• Seitz’ Bath
Ayurvedic Management
• 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.
• This may cause fibrosis of the tissues which prevents the pile pedicle from
protrusion. Also to some extend it works similar to sclerosing therapy
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.
NON-SURGICAL
SURGICAL
(office procedures)
I.R.C OPEN
** **
LASER STAPLER
BANDING SCLEROTHERAPY CLOSED
** M.I.P.H
**
HAL Harmonic
INJECTION SCLEROTHERAPY
HISTORY
This results in
1) Encasement,
which prevents defecatory trauma & thus prevents bleed
3) Fibrosis,
which fixes mucosa to muscle & prevents prolapse.
INDICATIONS FOR SCLEROTHERAPY
• External Piles
• Pregnancy
Phenol
Various vegetable oils eg. Almond / 5 – 7ml (max = 10 ml)
olive / coconut
Carbolic acid
Sodium morrhuate
Glycerine
Polidocanol
Site of Injection
-In submucosa
• Mild discomfort
• Tenesmus
• Fainting / Giddiness
• Necrosis Injection ulcer
• Re-Bleed
• Abscess Paraffinoma
• Stricture
• Urine retension
• Burning & itching
• Fistula formation
13/41
Results after Sclerotherapy
• Grade – I piles == 98 %
• Grade – II piles == 68%
• Grade – III piles == 31%
Contra-indications
• Bleeding diathesis (???)
• Infection ( fistula / abscess)
• Fissure
Post – procedure Instructions
DISADVANTAGE OF RBL
Has no effect on skin covered component
Complications present ( avoidable )
Complication of RBL
• Thrombosis
• Fissure
• Slippage of band
• Sepsis
I.R.C.
INFRA - RED COAGULATION
(Modified ‘Agnikarm’)
INDICATION FOR I.R.C.
Trigger
Contact
15volt tungsten- teflon tip
halogen lamp
• Results in scarring
Site of application:
Pre-op instruction
• REMOVE FEAR
Open Surgery for Piles
There are two established methods of haemorroidectomy
1. Open haemorroidectomy
2. Closed haemorroidectomy
No heavy exercise.