Piles/Hemorrhoids
What are Piles/Hemorrhoids?
These are three spongy pads positioned inside the anal canal, also known as anal cushions. They are vascular in nature. They swell and fit together depending upon the physiological needs, thereby maintaining the continence mechanism. They sometimes swell or dilate and when you pass hard stools, they get injured and cause bleeding. These are commonly known as bleeding internal piles. This bleeding is usually painless.
They cause another problem when they swell and come out of the anal canal. They are known as prolapsed piles. Initially, they return to the anal canal spontaneously but in later stages, they need to be pushed by hand into the anal canal. In the last stage, they become irreducible and can’t be pushed back into the anal canal.
When they are associated with the prolapse of the rectal mucosa along with the increased anal tone, they often get thrombosed due to congestion and cause severe pain. These episodes, generally recurrent, and defined as “acute hemorrhoidal crisis” or “hemorrhoidal strangulation”, are very painful and disabling.
During these crises, hemorrhoids do not re-enter the anus until the thrombosis and edema heal in about a week.
This is often accompanied by constipation and the formation of the anal fissure. An anal fissure is a very painful wound in the anus that causes anal burning for many hours after evacuation.
These patients are not able to retain the stools properly and are often suffering from “wet anus”. The mucus that escapes often causes an itchy, annoying, and not easy to cure bacterial dermatitis.
Are there any medical therapies for patients in whom it is believed that surgery is not necessary?
Medical therapies are recommended particularly in thrombosed piles. Almost all bleeding piles will require surgery in the future. Locally, creams containing anesthetic substances can be used for short periods to relieve pain. But oral pain relievers are more effective along with sitz bath and stool softeners.
Sometimes thrombosed piles need evacuation of the hematoma or the collected blood through a small surgery. No medical treatment is needed for non-symptomatic prolapsed piles. Surgery is the only option for prolapsed piles.
What are the indications for surgery?
The most important indication for the intervention is related to the severity of the symptoms, their impact on the quality of life, the age, and the general condition of the patients.
There are effective and painless solutions to the treatment of piles. It is now well known that the prolapse of piles is due to the internal prolapse of the rectum, therefore removing the piles does not cure the cause but only one of the effects of the internal prolapse. The traditional hemorrhoidectomy, which involves only removal of the piles, (Milligan Morgan operation), causes intense post-operative pain that lasts for a few weeks and requires daily medications. The surgery does not cure the internal prolapse of the rectum, it does not cure any associated constipation therefore there is a high possibility of recurrence. Removal of piles causes an inevitable weakening of continence given the physiological role that they play.
Based on the principle that the prolapse of hemorrhoids is caused by an internal prolapse of the rectum, a newer technique has been developed by Professor Antonio Longo to resect the internal prolapse of the rectum through the anal orifice using a tool (PPH), invented by him. Various modifications of this instrument have been developed by different manufacturers.
The instrument can simultaneously resect and sew rectal prolapse. Depending on the extent of the prolapse, one PPH (mucosectomy with a stapler) or two PPH (STARR surgery) can be used.
This operation is practically painless because the residual suture is inside the rectum where there are no nerve fibers that cause pain; the hemorrhoids are repositioned in the anal canal and therefore the anal continence is not compromised; only needs epidural anesthesia and one night of hospitalization; no dressings are required and work resumes in 3-4 days. A very important fact is that the technique also improves obstructed defecation or constipation. There are practically no complications or very few insignificant ones.
Many recommendations are made, but practically none of them are effective. Studies say that hemorrhoidal prolapse is more frequent in countries where nutrition is low in vegetables and fruit and where life is more hectic and stressful. Diet low in water content and fibres can cause hard stools that require effort to evacuate. Stress increases the closing tone of the anal sphincters and therefore the effort to evacuate. Both these factors cause internal prolapse of the rectum and subsequently of hemorrhoids.
Are there people who are predisposed to have piles?
The most predisposed people are those who have a sedentary lifestyle or are stressed for work or family reasons or those who sit and strain for long hours on the toilet seat.
Hemorrhoid surgery
Stapled Hemorrhoidectomy or the minimally invasive procedure for hemorrhoids
It was performed for the first time in 1993 by Professor Antonio Longo from Italy.
The principle of the surgery is simple. Since the prolapse of hemorrhoids is a consequence of the internal prolapse of the rectum, with the stapler, the prolapse is removed and at the same time, the mucosa is rejoined with titanium micro clips.
Therefore, no incision is made in the anus which regains normal anatomy and normal physiological functions.
What are the benefits of this procedure?
The operation is virtually painless if well performed and no complications arise. 80% of patients do not need any analgesic therapy. Besides, patients do not need any postoperative medication and normally resume their normal activities after 3 days. Is it indicated in all grades and types of hemorrhoids?
All hemorrhoids that need surgical therapy can be treated with this technique.
Anal fistula
What is an anal abscess?
An anal abscess is an infected, pus-filled cavity, located near the anus or rectum.
What is an anal fistula?
An anal fistula, often the result of a previous abscess, is a small tunnel that connects the anal gland, from which the abscess originated, to the skin around the anus.
What causes an abscess?
An abscess arises from an acute infection of a small gland just inside the anus, due to the entry of bacteria or foreign material into the gland. Certain conditions, such as colitis or other intestinal inflammation, can sometimes make these infections more frequent.
What causes a fistula?
After an abscess has been drained, a canal that connects the anal gland from which the abscess originated to the skin may persist. If this happens, the persistence of secretion from the external opening may indicate the formation of the fistula. If the external opening of the canal heals, a recurrent abscess may develop.
What are the symptoms of an abscess or a fistula?
Symptoms of both ailments include pain, sometimes accompanied by swelling, not necessarily related to evacuations. Other symptoms are irritation of the skin around the anus, secretion of pus (which often relieves pain), fever, and generally feeling unwell.
Does an abscess always become a fistula?
No. A fistula develops in 50% of all abscess cases, and there is no way to predict whether this will happen or not.
How is an abscess treated?
An abscess is treated by draining the pus of the infected cavity, creating an opening in the skin near the anus relieves tension. Antibiotics are usually not an alternative to pus drainage, because antibiotics are carried by the blood and do not penetrate the liquids into the abscess.
Should a fistula always be operated on?
Fistula always needs surgery because it could become deeper and more complex over time and, therefore, more difficult to cure because sometimes cancer can occur on a chronic fistula.
How is fistula treated?
Fistulectomy or Fistulotomy is the surgery needed for an anal fistula. Fistula often develops four to six weeks after the drainage of an abscess and sometimes, months or years later. Surgery usually involves opening the fistula tract and excise it till the other end. Sometimes this tract is laid open and fulgurated. In complex fistulas, sometimes a Seton is required which is a thread of nylon or silk. For fistulas that involve the sphincter muscle apparatus, a flap surgery might be required to maintain the mechanism of continence. In most cases, fistula surgery can be performed on a daycare basis or with a short hospital stay.
How long does it take before the patient can resume their office?
Fistulas usually take 2 to 4 weeks to heal. Initially, pain killers are required for a few days. Usually, patients resume their work after a week.
What are the post-operative precautions and recommendations?
After the surgical treatment of an abscess or fistula, baths in warm water three or four times a day are recommended. Stool softeners (fiber, mucilage) can help prevent loose stools from traumatizing wounds. Bowel movements do not affect healing so there is no need to use contracting drugs. Even normal physical activity does not interfere with wound healing. During the healing period, a periodic check by the surgeon is important to verify the correct evolution of the wounds.
What are the chances of the recurrence of a fistula?
If it has healed properly, the problem will not usually return, though it can form in a different site. In any case, it is important to follow the surgeon’s directions to prevent a recurrence.
Anal fissure
What is an anal fissure?
The anal fissure is a tear in the lining of the anal canal, almost always located in the midline mostly on the outer side. This wound tends to heal spontaneously in most of the cases. It can become chronic in some cases where it doesn’t heal. Therefore, it needs a little surgical treatment to heal, i.e. removal.
The skin that lines the anal canal has very rich sensory innervation that includes nerve corpuscles, called receptors, which are very sensitive: towards acidity or other chemical characteristics of the stool, mucus, or exudate (chemoreceptors); towards pressure (pressure sensors); towards heat (thermoreceptors).
The passage of stool causes intense pain because it stimulates the chemoreceptors, especially if the stool is acidic, and the pressure sensors, if the stool is hard. The pain can persist for many hours, because the fissure, inflamed with acid stool, induces a persistent spasm of the anus. Sometimes the pain is associated with an annoying itch due to secondary peri-anal dermatitis.
What are the causes of an anal fissure?
There are some types of fissures that result from different causes.
The fissure can be due to traditional hemorrhoidectomy surgery, which could cause tightening of the anus that is easily torn with the passage of Hard stool. Internal rectal prolapse can cause constipation due to the mechanical obstruction of the anal canal and hemorrhoidal prolapse. An excessive effort to evacuate hard stools results in more anal dilation due to the simultaneous passage of hard stools and hemorrhoids, which results in an anal tear.
Psychophysical stress and fissure – Cause and effect
There is muscle hypertonia in patients with an anxiety disorder. It can result in hypertonia of puborectalis muscle as well as perianal muscles also. This condition induces some alterations that contribute to the formation of the anal fissure. Anal hypertonicity also induces partial ischemia of the anal canal as it compresses the arteries that supply the anal canal. Also, anal hypertonicity creates ischemia by compression. The ischemic anal skin is much more fragile and therefore can “split” forming the fissure.
Treatment of Anal Fissure
A correct diagnosis of the cause causing inflammation of the anus must be made. The treatment aims to cure the cause of inflammation and/or infection of the anus.
Fissures secondary to hemorrhoidal prolapse need surgery for hemorrhoidal prolapse. It is a painless, minimally invasive technique that, through the anal orifice, removes the internal rectal prolapse using a specially created instrument. In these cases, the fissure, if chronic, is removed to promote healing.
When there is a narrowing of the anal orifice as a consequence of traditional hemorrhoid surgery, or as a consequence of chronic inflammation, the most appropriate treatment is surgical therapy. The fissure is covered with a flap from the adjacent normal skin. Anal fissure due to hypertonia of the sphincter and peri-anal muscles tends to heal spontaneously. Local treatments are of very little use, including creams based on muscle relaxants such as nifedipine, botulinum toxin, nitroglycerin, etc. In fact, the sphincter relaxation obtained with these substances is very minimal and can cause a headache. Considering that hypertonicity is of psychosomatic origin, psychiatry consultation must be taken.
Surgical treatment of anal fissure
Surgical treatment is indicated only in chronic anal fissures, i.e. after any medical treatment failure of at least 30 days. The excision of the fissure is accompanied by lateral internal sphincterotomy, where a part of the anal sphincter is divided to decrease the anal tone and promote healing.
