Nonoperative treatment
- It is recommended when the haemorrhoids are a symptom of some other condition or disease except of course when a carcinoma is present.
- The bowels are regulated by hydrophyllic colloids (lsogel etc.), and if necessary a small dose of purgative at night.
- Various proprietary creams can be inserted into the rectum at night and before defecation.
- Suppositories are also useful.
Active treatment.
- This consists of injection or elastic band applications to the base of each haemorrhoid or formal operation, each with specific indications.
Injection Treatment (Sclerotherapy) is for first degree bleeding haemorrhoids, as a whole not an ideal treatment because it causes temporary relief, with frequent recurrence and it further increases the anal canal tone/ stenosis which further complicate the problem. - With the help of a proctoscope the upper end of haemorrhoid at anorectal ring is injected in submucosal plain 3 to 5 ml of 5 % phenol in almond oil.
- Rubber band ligation is half hearted treatment, success is rare unless one is expert in it. Only internal piles can be banded. The rubber band is applied on the internal pile by means of a band ligature well above the pectinate line to prevent any pain or discomfort.
- Cryosurgery. Coagulation necrosis of piles with extreme cold applicator (cryoprobe) is not under full control and routinely good results are not obtain, tends to cause troublesome mucus discharge.
- Infrared coagulation (Photocoagulation) Infrared irradiation, occasionally used for treating first- and second-degree piles, is delivered through a probe, the tip of which is firmly applied to the mucosal surface at the upper pole of the ‘ pile.
- Laser is used by some to destroy the piles. The pain is much less.
Operative treatment
- HAEMORRHOIDECTOMY Operation. Ligation and excision.
- Indications. Failed non operative treatment, second and third-degree haemorrhoids, fibrosed haemorrhoids, thrombosed haemorrhoids, and for haemorrhoids associated with fissure, fistula.
- Patient is operated under saddle, spinal, epidural, or local anaesthesia in lithotomy position.
- Re examine the anal area, than anal sphincter is widely stretched in young, moderately in old, a maneuver which greatly reduces postoperative pain.
- The internal haemorrhoids are then prolapsed by traction on the skin tags and grasped with artery forceps.
- A V- shaped cut is given on the external pile and dissection is done to the pedicle avoid damaging the sphincter then with chromic one pedicle is transfixed and haemorrhoidectomy done.
- Each haemorrhoid having been dealt with in this manner they are excised 1·25 cm distal to the ligature, the ends of which are cut about 1 cm from the knot.
- After securing the hemostasis a small gauze socked with pyodine and lignocain gel is tucked in the anal canal and above it a pad of gauze is held firmly with T-bandage.
- The pile sloughs out in 7 to 10 days, and the raw area heals with secondary intention within 30 days.
- In modifications of the haemorrhoidectomy operation (Closed Haemorrhoidectomy), the anal wound is closed completely or partly to reduce pain and healing time.
- The internal pile is transfixed at its apex with one chromic catgut, the entire pile mass is excised in such manner that sufficient skin, anoderm, and mucosa are preserved to suture with a running suture.
Postoperative treatment.
- Apply locally lignocaine gel three / four times daily.
- Frequent wash the anal canal with plenty of water.
- Prescribed flagyl and antibiotic for three to four days.
- Give routine pain killer for five days than SOS.
- No need of dressing simple use the under weir.
- The patient can be discharged after 06 hours.
- The wounds heal in 3 to 6 weeks.
Postoperative complications
- Pain Immediate after operation or in the early postoperative period required good analgesia and xylocaine jelly introduced through a fine nozzle into the rectum, as necessary, is of considerable value.
- A good anal dilatation done as an initial part of surgery will be very helpful in reducing postoperative pain and the pain during early bowel evacuation.
- Retention of urine is not unusual after haemorrhoidectomy in male patients, and frequently it is precipitated by the presence of a rectal pack.
- Before resorting to catheterisation, the patient should be reassured, given an analgesic, allowed to stand at the side of the bed in privacy or be assisted to a hot bath into which he may be able to void urine.
- Haemorrhage Primary hemorrhage on the table can occur.
- Reactionary haemorrhage can also sometimes occur and may require the patient to be rushed to the OT and for resuturing of the bleeding area.
- A secondary haemorrhage occurring after 7th day has become rare in this era of antibiotics.
- The haemorrhage may be mainly or entirely concealed, but will become evident on examining the rectum.
- If the haemorrhage is severe, an anaesthetic should be given and a catgut stitch inserted to occlude the bleeding vessel, if mild it is best managed by proper packing, effective antibiotics, intravenous fluids, and blood transfusion.
- Anal stenosis or stricture is a rare but a troublesome complication mainly due to over dissection or over treatment of haemorrhoids and must be prevented at all costs.
- A rectal examination at the 1Oth day will indicate if stricturing is to be expected then under general anaesthesia dilate the anus to take four fingers, after that daily use of the dilator should give a satisfactory result, if late then anoplasty.
- Infection and submucous abscesses are not frequent complications despite the potentially infective operative site.
Treatment of Complications of Haemorrhoids
- In cases of severe haemorrhage, role out bleeding diathesis or the use of anticoagulants, transfuse the blood if necessary, ligation and excise the piles is recommended.
- In cases of strangulation, thrombosis, gangrene, inflamed and permanently prolapsed haemorrhoids surgery offers the only hope of permanent cure under antibiotic cover.
External Haemorrhoids
- External haemorrhoids consist of distinct clinical entities.
- External Thrombosed Pile (perianal haematoma). This is a small subcutaneous perianal haematoma due to the rupture of an underlying vein consequent upon straining at stool, coughing, or lifting a heavy weight. It appears as sudden painful swelling which is tense and tender. If small, it resolves in due course. Large haematomas require excision or evacuation, relief of pain is immediate and a permanent cure is certain. Left alone, they may rupture spontaneously and extrude the clot, or continue bleeding.
- Prolapsed Thrombosed Piles.
- When prolapsing piles get infected or strangulated due to sphincter spasm, the whole pile mass becomes irreducible. This is a very painful condition and presents as a painful mass protruding through the anus which is in severe sphincter spasm.
- Conservative treatment consists of local application of anaesthetic ointment with antiseptics, oral antibiotics with metronidazole, emollient laxatives, and a sitz bath but surgical treatment is of choice and consists of excision of the entire pile mass.
- Interoexternal haemorrhoids Associated with internal haemorrhoids.
- Dilatation of the veins of the anal verge becomes evident only if the patient strains, when a bluish, cushion-like ring appears. This variety of external haemorrhoid is almost a perquisite of those who lead a sedentary life. The only treatment required is an adjustment in habits of the patient.
- A ‘sentinel’ pile It is a skin tag placed in the midline at the distal end of the chronic anal fissure.
- Genital warts.