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).

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
called as piles / haemorrhoides.
 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

 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.
 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
 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.

• 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 .
• 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.

• Enlargement of Prostate:

The male suffering from BPH usually strains

while micturation & this forceful micturation exerts
pressure on the haemoroidal veins. Similarly,
patients suffering from urinary calculus & frequent
UTI are also prone to such conditions.
• 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)
4) Over sex indulgence (Stri prasang)
5) Squatting posture (Utkatasan)
6) Horse riding (or long drive)
7) Suppression of natural urge (veg dharan)
8) Diminished Appetite (Mandagni)
 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
 Pathogenesis of Bleeding
Hard stools Disruption of sinusoids
by straining / irritation
Straining at defecation
Bleeding from pre-sinusoidal arteries
Bruising of engorged venous
cushions Constipation+Straining+IAS spasm

De epithelization Venous back flow

Ulceration Mucosal strech

Bleeding Tear & Bleed

 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)
 Examination
• Gain the Confidence
of the Patient

• Position

• Light (Angle- Poise Lamp)

• Instruments required like-

Gloves, Jelly, Torch, Guaze,
Proctoscopes ,Forecep
Position of patient

• 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:

 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
 INSPECTION
(Most neglected but most informative)

• Fissure • External opening of fistula

• Hematoma • Abscess
• Wart • Sphincter tone
• Pilonidal sinus • Soiling
• Pruritis ani • Prolapse during valsalva
• Prolapsed Piles
• Stricture / Stenosis
• Sentinal pile / tag
• Sphincter spasm
• Bleeding / Discharge
• Worm infestations
 D.R.E
(DIGITAL RECTAL EXAMINATION)

P/R examination
 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’
 PALPATION &
DIGITAL RECTAL EXAMINATION (DRE)

Anal Canal Rectum

 Collapsed , ballooned
 Sphincter tone
 Loaded / empty
 Ano-rectal sling
 Wall irregularity & nodularity
 Fibrosis  Stenosis / stricture
 Internal opening of Fistula  Polyp / mass
 Induration  Cervix & uterus in females
 Tenderness.  Prostate & seminal vesicles in males
Peri anal Tenderness,  Blummer shelf deposits
 Examine the finger after P/R for
Induration blood/mucus/pus/stools
 P.V. examination with separate gloves
 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
 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.
 Conservative Management
• Diet – Fiber rich, balanced (easy to digest) diet

• Ointments - Hydrocortesone acetate,Heparin sodium,

Aminobenzoate,Lignocaine 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
 Ayurvedic Management

Sushruta has mentioned four fold regimen for piles:

1. Aushadhi Chikitsa i.e Internal medicine effective in I and

II grade piles
2. Kshar chikitsa i.e application of kshar locally or internally
effective in I and II grade piles
3. Agni Karma i.e Excision of pile pedicle by Cauterization
4. Shalya Karma i.e Ligation and Excision of Pile pedicle
effective in III grade and prolapsed pile mass.
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
 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.
• 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
 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
 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.
 TREATMENT OPTIONS FOR PILES

NON-SURGICAL
SURGICAL
(office procedures)

I.R.C OPEN
** **
LASER STAPLER
BANDING SCLEROTHERAPY CLOSED
** M.I.P.H
**
HAL Harmonic
 INJECTION SCLEROTHERAPY
HISTORY

1869= Jhon Morgan of Dublinintroduced this procedure using

persulphate of iron

1871= Mitchell of Clinton-Illionis, USA, used carbolic acid (27–

95%) & olive oil

HE SOLD THE SECRET TO QUACKS BEFORE HIS DEATH

1879= Andrews of Chicago, discovered the secret from Quacks and

gave it to the world.
 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.
 INDICATIONS FOR SCLEROTHERAPY

• INTERNAL PILES ONLY

BEST = for Grade – I, Bleeding Piles

GOOD = for Grade – II bleeding piles

PALLIATIVE = for Grade – III bleeding piles

 Contra – Indications for Sclerotherapy

• External Piles

• Associated Anal Lesions eg; fissure, fistula, skin tags

• Attack of thrombosed internal piles

• Pregnancy

• Crohn’s / Ulcerative colitis

Solutions used for Injection: Dosage per pile mass

Phenol
Various vegetable oils eg. Almond / 5 – 7ml (max = 10 ml)
olive / coconut

STD (sodium tetradecyl sulphate) 1 – 2ml

Carbolic acid

Sodium morrhuate

Quinine & urea hydrochloride

Glycerine

Polidocanol
Site of Injection

-In submucosa

-Into pile mass

- At the pedicle of the pile mass at ano-

rectal ring (ALBRIGHT’S method)
Post-procedure Instructions

• Mild discomfort

• Tenesmus

• Follow – up after 3 wks

• Watch for fever / pain / bleeding.& inform sos

 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
 Complications of Sclerotherapy

• 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%

• Overall 77% successful

• Especially in stopping bleeding
• But has less effect on prolapsing element of pile
RUBBER BAND LIGATION (RBL)
or
BANDING
 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

 Indication for RBL

• Ideal for Grade – II internal piles

• Early Grade -- III internal piles

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

• Fissure
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

 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 )
 Complication of RBL

• Pain Immediate / delayed

• Bleeding Immediate / delayed

• Thrombosis

• Fissure

• Slippage of band

• Sepsis
 I.R.C.
INFRA - RED COAGULATION
(Modified ‘Agnikarm’)
INDICATION FOR I.R.C.

• INTERNAL PILES ONLY

BEST = Bleeding Piles of Grade – I,

GOOD = Bleeding piles of Grade – II

 24 K Gold Plated Reflector

Solid Quartz Light Guide

Trigger
Contact
15volt tungsten- teflon tip
halogen lamp

Light energy Heat energy

 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
 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

 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.
 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.
 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

 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
 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
 Open Surgery for Piles
There are two established methods of haemorroidectomy
1. Open haemorroidectomy
2. Closed haemorroidectomy

Pre-operative piles Post - operative

Haemorroidectomy
Breakthrough in Haemorroid Surgery
Stapler M.I.P.H
 DO’S & DON’T’S (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.
.
 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.
Beware of these Quacks