Treating haemorrhoids (piles)
An introduction to haemorrhoids: what they are, how they're caused, and how they can be prevented and treated.
Investigation of Haemorrhoids
- History and duration of symptoms and examination including rectal examination is important to exclude bowel cancer or inflammation which can present with very similar symptoms to those arising from haemorrhoids.
- To exclude serious conditions such as bowel cancer and inflammatory bowel disease which can sometimes present with symptoms similar to those related to piles, it is very important to examine the rectum and left colon with a special flexible camera about 60cm long and the width of a finger (performed under sedation or no sedation depending upon the patient request).
- Finally a very small telescope is inserted into the anal canal to fully assess the haemorrhoids.
- View a PowerPoint slide showing the classification of haemorrhoids.
Treatment of early Haemorrhoids (grade 1 and 2)
Dependent on the severity of haemorrhoids, symptoms arising from very early haemorrhoids can be treated by adopting a high fibre diet. If symptoms donít resolve then banding or injection of the haemorrhoids may be advised.
1. Banding of haemorrhoids
This treatment works by a rubber band cutting through tissue and causing an ulcer which heals by fibrosis, "fixing" the haemorrhoid in its normal anatomical position.
- Performed as an outpatient procedure, and sedation is unnecessary.
- Involves the placement of a small telescope called a proctoscope inside the anal canal and a rubber band is applied to tissue above the haemorrhoid.
- This results in pulling the haemorrhoid into its normal anatomical position.
- Up to three haemorrhoids can be treated at one time using banding.
- This treatment is effective in 70% of patients with early haemorrhoids.
- Pain, mild in 20% but severe in 5% often the result of a misplaced rubber band requiring its immediate removal.
- Fainting can result on standing after treatment.
- Blood loss, usually slight but in rare instances can be severe requiring hospital admission.
- Very rare cases of necrotising faciitis reported.
2. Injection Sclerotherapy
The rational of injecting chemical agents into haemorrhoids is to create fibrosis so that prolapse cannot occur.
- Phenol in oil is the commonest chemical agent used.
- Less effective than banding in treatment of early haemorrhoids.
- Sclerotherapy normally produces dull pain lasting up to 48 hours.
- Very effective in 70% of patients with very early haemorrhoids.
- Pain from injecting into wrong place or too deep
- Bleeding from puncture point
- Prostatis, urinary tract infection and blood in seamen
Treatment of advanced Haemorrhoids (grade 3 and 4)
This is a radical surgical treatment for grade 3 and 4 haemorrhoids and is performed under general or spinal anaesthetic. The operation involves cutting out the haemorrhoids and is an effective treatment but is associated with considerable pain on opening bowels on the first few occasions. Pain can sometimes persist for several weeks.
- Variable stay in hospital depending on the degree of pain and when bowels are opened.
- This surgery can occasionally result in damage to anal muscles resulting in seepage and soiling.
- Haemorrhoidectomy is associated with 10% treatment failure rate.
- Post-operative haemorrhage
- Inability to empty rectum requiring hospital admission and manual evacuation
- Minor incontinence but occasionally severe
- Anal stenosis
- Fistula formation
- Anal fissure
2. Stapled Haemorrhoidectomy
This technique involves the removal of excess prolapsing tissue above the haemorrhoids resulting in the restoration of the haemorrhoids to their normal anatomical position.
- The operation is performed under general or spinal anaesthetic and involves the insertion of a circular stapling devise which removes a cylinder of excess tissue and staples the ends together.
- Since the tissue removed is above the area of normal sensation it is relatively pain-free.
3. Haemorrhoidal Artery Ligation Operation (HALO)
A relatively new technique first devised by a Japanese surgeon in 1995 and now becoming increasingly popular in various parts of the world.
Mr Saeed performing the HALO procedure
The basis of the operation is to restore the haemorrhoids back to their anatomical position, and occlude the blood supply to the vascular cushions forming the haemorrhoids, resulting in them shrinking. The operation is best performed under general or spinal anaesthesia. However smaller haemorrhoids in some patients can be treated under sedation and local anaesthesia using this technique.
A miniature Doppler ultrasound device locates branches of arteries supplying the haemorrhoids. These blood vessels are tied off, and the haemorrhoid shrinks over the subsequent days and weeks.
This cast of a haemorrhoid clearly shows the feeding artery (white arrow) which is carefully located with this procedure
Because the stitch is placed in the lower rectum where there are virtually no sensory nerves the procedure is pain-free.
View a PowerPoint slide showing a diagram of the HALO procedure
New developments to this technique now means that in addition, an Anopexy to return the prolapsing haemorrhoids back into rectum can now be performed.
- The new modified instrument allows the placement of stitches internally to lift the prolapsing tissue.
- This technique offers a real choice to treat a variety of stages of haemorrhoids including stage 4 haemorrhoids without the need to cut any tissue and therefore avoids any complications associated with those techniques.
- It is relatively painfree and 85% of patients have complete resolution of their symptoms and over 90% are thoroughly pleased with the results even if there are minor residual symptoms.
- View a PowerPoint slide showing a diagram of the Anonpexy procedure.