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Monday, May 14, 2007


It is a disease that affects fully 50% of people above 30 years of age. A disease on which thrives a cottage industry of quacks and Madrasi daktars. It is a disease resting on many a myth among its sufferers. It is also a disease that has doctors trying hard to do good, but often ending up doing harm to the patient. This disease is called piles, or hemorrhoids.
Excepting an occasional old dog, man is the only animal that suffers from piles. Once thought to be just a collection of dilated veins arising out of man’s erect posture and chronic constipation, things have changed considerably. Without going into the old misconcepts let us go into the current perspectives and how they have changed the treatment of piles.
First things first, piles are present in ALL human beings. They are normal. Obviously, they are there for a reason. In all individuals, in the anal canal there are three protrusions called anal cushions. They keep the anus closed, grip the stools when they pass and are therefore helpful in the control of defecation. In some people, they come out with the rectal lining and pass through the anus. As the rectal lining comes out of the anus, the stretched veins and arteries break and cause the characteristic bleeding, which is so shocking to the average person. The rectal lining that is out of the anus (a condition known as mucosal prolapse) gets irritated and secretes mucus, causing the anus to be wet and itchy. At a particular stage the protruded mass gets squeezed by the anal sphincter muscle (the ring of muscle that helps us to hold the urge to pass stools at odd places and times), causing a blockage of its blood supply. This is known as gangrenous piles.
The whole concept of piles has changed from it being a problem of abnormal anal blood vessels to a problem of rectal lining. So what, you ask?
Look at it this way: if you have a problem due to a bunch of abnormal veins, you would remove them. If you have a problem because the rectal lining slides down you could set the patient okay by fixing the slide, not by removing the anal cushions or piles. On this rests the whole new development of the latest treatment modalities of hemorrhoids.

When the bleeding occurs silently from the internal cushions without them coming out, it is known as Grade I piles. They are treated by prescribing laxatives like Isabgul, or by a procedure called banding, where the vessels to the piles are pinched by placing rubber bands at their roots. This is essentially a painless outdoor procedure and requires little time, cost or hospitalization. An alternate approach is to inject a chemical into the piles to scar its vessels, thereby stopping the blood loss. This is called sclerotherapy or injection treatment.
Both these are simple and painless quick methods but may need repetition to give better results.
When the piles come out of the anus and also go back, they fall in Grade II category. These are also similarly treated. Avoiding surgery in either of these grades could prevent the bulk of the post-operative complications of piles surgery.
When the pile mass becomes large enough to come out of the anus and stays out permanently, it is in the last stage, called Grade III. These are the surgical cases. The traditional surgery has involved operative removal, with its resultant pain, slow healing and need for dressings.
Since the 1990s the concept of piles has changed. It was proposed by Antonio Longo of Italy that it was the sliding of the rectal lining that was the cause of the patient’s symptoms. Longo invented a device along with Ethicon Endosurgery, a division of the giant Johnson and Johnson of the USA, to create a device that removed the excess rectal mucosa from inside the rectum, sealing the cut edges with rows of staples (tiny metal pins) at the same time. This procedure was called Procedure for Prolapsed Hemorrhoids, or PPH, in short. The operation is low on postoperative pain because it is done higher up in the painless rectal lining, and has no external wounds for the same reason. As a result the patient has a smooth post operative recovery and can join work much more quickly than after the conventional operation. The device has become hugely popular all around the world, with the company touting it as one of its most successful products. Today, even patients know of the ‘staples’ procedure for piles as the latest in treatment.
According to renowned colorectal specialist, Dr. PO Nystrom of Karolinska Hospital, Stockholm, Sweden, “ The problem of hemorrhoids is essentially one of mucoanal prolapse. We do not give importance to the presence of the pile masses themselves, and ignore them. If the slide of the excess rectal lining is prevented by fixing it, then the patient’s symptoms are resolved.”
In other words, what Nystrom is saying is that there has been a major shift in the philosophy of treatment from the old concept of surgical removal (hemorrhoidectomy) to a newer one of fixing the lining (anopexy). This is giving results equivalent to the old operation, but causing less pain and problems of wound healing.


I. The piles (PPH) stapler:
This is the big boy on the block. Manufactured by Johnson and Johnson, it is marketed in aggressive style, with myriad workshops and seminars arranged for both doctors and patients, creating a market for an unheard of price. The stapler, for all the benefits it offers, is priced at around Rs. 15,000 only! The costs of the hospitalization are separate, of course.
Its success can be gauged from the fact that around three hundred staplers are fired annually in Eastern India alone. Today, patients demand the surgery even if they are not suitable candidates, a tribute to the marketing success of the PPH and its company!
The stapler works like this: the gun pushes up the pile masses into the rectum, and it removes a ring of excess rectal tissue at the root of the piles, essentially pulling up the piles towards the rectum.
If external piles are present they may need to be removed separately or ignored.
The procedure, marketed as a bloodless removal of piles, can have disastrous consequences in certain cases. A stapler misfiring can result in severe, life-threatening bleeding. It may also result in infections and narrowing of the rectum in the late post-operative phase. However, these are rare instances seen more in the hands of the inexperienced surgeon.

II. Hemorrhoidal Arterial Ligation (HAL):
In this new procedure, a Doppler (a form of ultrasound machine) locates the artery that feeds the piles and the area is stitched, causing shrinkage in the size and reducing the bleeding.
It has not been launched in India as of now.

III. Transanal Hemorrhoidal Dearterialisation (THD):
This is another recent procedure that not only seals the arteries of the pile masses at the root, but also uses stitches on the excess rectal lining to result in a pull up of the entire pile mass. The results seem to be promising.

IV. Infra Red Coagulation (IRC):
Here an infrared light comes out of a probe and is focused on the pile mass to cause it to coagulate and shrink. It is not really a new procedure, and is, at best equivalent to banding for early stages of piles. Those with large, prolapsed piles are not suitable candidates for this.

V. Botox (Botulinum Toxin) injection:
The new wonder drug called Botox, so much a favorite of the cosmetologist for treating wrinkles and deep creases, is useful in some cases of fissure and piles. Injection reduces the pain after operation, and it may be used in combination with any of the above procedures. Botox, as users know, is expensive and a shot can make you poorer by several thousand rupees, plus the cost of the procedure.

1. Adopt a healthy lifestyle, eating enough portions of vegetables and fruits avoiding chronic constipation.
2. Avoid surgery unless there is the piles come out of the anus. Surgery for bleeding alone is not advisable.
3. For the prolapsing, large piles a newer fixation operation is better than a conventional cutting operation.

Many of our so-called ‘piles’ cases suffer from some other disease; make sure your diagnosis is correct:
1. Rectal/colon cancer or polyp: Elderly patients often suffer from a growth as a cause of bleeding per rectum. They also have piles. Merely operating on the piles without ruling out a growth is dangerous! A colonoscopy would give the diagnosis easily.
2. Fissure: a tear in the anus is a fissure. Most patients who suffer from this have anal pain, especially at the time of passing stools. Though some patients respond to non-operative treatment, many require a small operation that weakens the anal muscle (sphincter).
3. Fistula: a small hole outside the anus with a history of discharge of fluid, blood or pus is a fistula. It may be cured by operation. Recently, fibrin glue has been tried to cure it without operation, with questionable results.

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