Piles

There are two types of hemorrhoids: 

Internal Hemorrhoids

Internal hemorrhoids from within the anus beneath the mucus lining. These are usually painless although bleeding is a common symptom. Being painless in nature, you may realize that you have internal hemorrhoids only when you see bright red blood on the toilet paper or oozing in the toilet. Internal hemorrhoids may also prolapse or extend beyond the anus, which can cause complications. When hemorrhoid protrudes or prolapses, it can collect small amounts of mucus and tiny stool particles, which can cause discomfort and itching; trying to relieve the itch by wiping constantly can worsen the problem. A protruding internal hemorrhoid can appear like a small, grape-like mass. Usually, protruding hemorrhoids can be pushed back into the anus with a fingertip.

External Hemorrhoids

External hemorrhoids or external piles develop under the skin around the anus. Since there are many pain-sensing nerves in the skin, external piles cause pain in addition to bleeding. They can also cause difficulty in keeping the anal region clean after bowel movements. External piles can sometimes develop a blood clot inside them (thrombosis), usually after a period of diarrhoea or constipation. In such cases, a sudden, painful swelling or lumps around the rim of the anus can develop. You might notice or feel a lump around the anus. The blood clot usually dissolves, leaving behind an excess of skin (a skin tag), which may cause itching.

Hemorrhoids or piles have four stages or degrees depending on the severity of the symptoms 

First degree (only bleeding, no prolapse)
The nature of the bleeding is characteristically separate from the passage of stools. It may appear on the toilet paper upon wiping or as a splash in the toilet bowl.

Second degree (prolapse present but reduces spontaneously)
There is an appearance of a lump from the anal opening while passing stools. This lump then moves back in on its own.

Third degree (prolapse present and must be manually reduced
Here, the prolapsed or protruding piles do not move back in on their own their passing stools and have to be pushed in manually.

Fourth degree (permanent prolapse)
This is also called permanent prolapse. This means that the piles are protruding permanently outside and it is not possible to push them back manually.

Symptoms of hemorrhoids include:

• Bright red bleeding on the toilet paper after passing stools or a splash of blood in the toilet. This bleeding is usually painless and occurs especially if the stool was very hard or very large.
• Discharge of mucus from the anal opening.
• Itching, redness or soreness of the area around the anus
• Feeling of bowel fullness even after passing stools
• Pain while passing stools
• For hemorrhoids that are prolapsed, a soft, grape-like lump can be felt protruding from the anus.
• External hemorrhoids may also cause intermittent swelling, irritation, and discomfort, especially after diarrhea or constipation.
• If external hemorrhoid has clots, the lump may have a bluish or purple tint and a painful lump, which may discharge blood and may suddenly appear at the rim of the anus.
• In severe cases, there may be excessive anal bleeding, infection, strangulation of hemorrhoids, anal fistula formation, and fecal incontinence.

Painful hemorrhoids must be differentiated from other painful bleeding conditions, such as anal fissure, Crohn's disease, ulcerative colitis, anal fistula, and colorectal cancer.

Causes

The veins around the anus tend to stretch under pressure and may swell or bulge due to which piles can develop. The pressure in the lower part of the rectum increases due to

• Straining while passing stools
• Chronic diarrhea or constipation
• Sitting for long durations of time on the toilet seat

All the above factors interfere with the blood flow to and from the rectal area, cause the blood to pool, thereby enlarging the blood vessels. Also, straining during a bowel movement increases the pressure in the anal canal, pushing the hemorrhoids against the sphincter muscle.

• Advanced age
  The tissues that support and hold hemorrhoids in place can weaken with age, thus causing the hemorrhoids to bulge and prolapse.
• Obesity
  Here, the intra-abdominal pressure is raised causing engorgement of the rectal veins.
• Pregnancy
  Apart from an increase in the intra-abdominal pressure, the enlarging uterus presses on the rectal veins causing them to swell.
• Anal intercourse.

Risk Factors

A risk factor for hemorrhoids is any factor that increases the chance of having hemorrhoids. The factors known to increase the risk of having hemorrhoids are listed below:

• Chronic constipation
  It causes excessive straining while passing stools thus increasing the pressure in the anal canal.
• Low fiber intake
  It is associated with the reduced bulk of stools.
• Sedentary lifestyle 
  It can worsen constipation and cause weight gain, thereby causing the muscles to lose their tone.
• Inadequate water intake 
  Drinking less water can contribute to constipation, increasing the chances of hemorrhoids.

The best way to prevent piles is to keep your stools soft so that they are easy to pass. Apart from regular physical activity, food also plays a major role in maintaining soft stools.

Aim for 25-30 grams or more of high fibrous food every day. High-fiber food usually has a mix of soluble and insoluble fiber both. If you are not used to it, gradually increase fiber in your diet as having too much too fast can cause flatus and bloating.

Here are some ways by which you can decrease the chances of developing piles or hemorrhoids: 

• Avoid sitting on the pot for long durations
  The more time you spend sitting on the pot, the more likely are you to strain for passing stools. Also, the seated position exerts additional stress on the blood vessels of the anal region. Keep the stack of magazines and the smartphones out of the loo! See bathroom time as a necessity and not as an extended escape time!
   
• Drink more water
  Step up your water intake as water is essential for soft stools. Softer stools mean less straining.
   
• Do not delay your need to go 
  If you have a habit of delaying your bowel movement, it can cause your stools to become hard and dry, which in turn causes strain in passing stools, eventually causing pressure on the anal venous cushion.
  Also, do not unnecessarily force a bowel movement when u do not get the urge to pass stools naturally.
   
• Have fiber-rich foods
  Include leafy vegetables, fresh fruits, whole grains, and cereals in your diet. You may also add a natural fiber, such as psyllium husk, in your diet. However, be careful to incorporate it slowly into your daily diet as it may cause gas and bloat in some people.
   
• Exercise regularly
  Being physically active stimulates bowel movements. If you have never exercised before, do not jump into an intense exercise regimen, such as abdominal crunches or lifting heavy weights. Also, do not try to cram exercises at the weekend if you do not exercise throughout the week. Go slow and follow a simple and effective exercise routine. Even as little as a 20-minute walk every day can help in having regular and good bowel movements.
   
• Stay Active
  If you have a desk job or a sedentary lifestyle, make sure you get up from your desk every hour or so for a 2-3 minute break. Incorporate short walks around your office space. Opt for stairs instead of the elevator. Park your car at the farthest parking slot to allow you more time to walk.

Diagnosis

Hemorrhoids or piles can usually be diagnosed from a simple medical history and a physical examination of the anal region.

External hemorrhoids are usually apparent only by examination of the anal region by the doctor. 
To diagnose internal hemorrhoids, your doctor may perform some tests and examine your anal canal and rectum. These include;

• Digital examination
  During a digital rectal exam, your doctor inserts a gloved and lubricated finger into your rectum and feels for anything unusual, such as growths. The digital examination suggests to your doctor whether further testing is needed.
   
• Visual inspection
  Your doctor may also examine the lower portion of your colon and rectum with an anoscope, proctoscope, or sigmoidoscope to rule out any other causes of bleeding, such as colorectal cancer or colorectal polyps, especially in people over 45 years of age.

Non-invasive treatment options

If you have only mild discomfort due to your hemorrhoids, your doctor may suggest over-the-counter creams, ointments, suppositories, or pads. These products contain ingredients, such as hydrocortisone and lidocaine, which can temporarily relieve pain and itching.

Minimally invasive treatment options
For persistent bleeding or painful hemorrhoids, your doctor may recommend one of the following minimally invasive procedures. These procedures usually do not require anesthesia and can be done in the doctor's office only.

• Rubber band ligation
  One or two small rubber bands are placed around the base of internal hemorrhoid to ensure that the rubber bands cut off the circulation of engorged hemorrhoid. Hemorrhoid then withers and falls off within a week or so. This procedure usually works very well for many people. However, hemorrhoid banding can be uncomfortable and may cause bleeding, which might actually occur 2-4 days after the procedure is performed. It is rarely severe but occasionally serious complications can occur.
   
• Injection (sclerotherapy)
  In this procedure, your doctor injects a chemical solution into the affected hemorrhoids. This helps in shrinkage of the hemorrhoidal tissue. This procedure causes minimal or no pain but may be less effective than rubber band ligation.
   
• Coagulation (infrared, laser, or bipolar)
  This procedure uses laser or infrared light or heat. It causes the small, bleeding, internal hemorrhoids to harden and shrivel up. Coagulation has few side effects but is associated with a higher rate of hemorrhoids recurrence compared to the rubber band treatment.

Surgical treatment options

Surgery for hemorrhoids is called as haemorrhoidectomy. Indications for haemorrhoidectomy are:

• Third- and fourth-degree hemorrhoids.
• Second-degree hemorrhoids that have not been cured by non-operative procedures.
• Fibrosed hemorrhoids.
• Intero-external hemorrhoids when the external hemorrhoid is well defined.

The surgery may be performed under local (combined with sedation), spinal, or general anesthesia. Surgery is the most effective treatment modality to treat severe or recurring hemorrhoids. The patient can go back home the same day and can get back to his routine in about 7-10 days.
Complications from surgery may include temporary difficulty in emptying your bladder and may result in urinary tract infections.

• Hemorrhoid stapling (stapled hemorrhoidectomy or stapled hemorrhoidopexy)
  An alternative to hemorrhoidectomy, this procedure blocks blood flow to the hemorrhoidal tissue and is used only for internal hemorrhoids. It generally involves less pain than hemorrhoidectomy, although it has been associated with a greater risk of recurrence and rectal prolapse compared to a hemorrhoidectomy. Complications can also include bleeding, urinary retention, and pain and rarely a life-threatening blood infection (sepsis). Talk to your doctor about the best options for you.

Self-care

• Try Sitz Bath
  A Sitz ("sitzen" means "to sit" in German) bath is a warm water bath for the buttocks and hips, which can relieve irritation and itching in the anal region and relax the anal sphincter muscle. You can use a small plastic tub that fits over the toilet seat or you can sit in a regular bathtub filled with few inches of warm water. A 20-minute Sitz bath after each bowel movement, 2-3 times a day helps. Thereafter, gently pat the anal area dry; do not wipe hard or try to rub.
   
• Apply ice pack
  Keeping an ice pack at the anal region can help in reducing swelling and pain.
   
• Use a cushion/soft surface
  Sitting on a cushion or a soft surface rather than a hard surface helps in reducing the swelling of the existing piles. It also prevents new hemorrhoids from forming.
   
• Try topical medications
  Over-the-counter hemorrhoid ointments containing a local anesthetic can temporarily relieve pain and have no harmful effects.
   
• Elevate your feet
  When you sit on the western commode, try elevating your feet a bit by placing a step stool. This changes the position of the rectum and it allows easier passage of stools.

Prognosis

• Hemorrhoids generally need treatment if they are bothersome.
• Hemorrhoids that occur during pregnancy and usually spontaneously reduce after childbirth.
• For hemorrhoids related to constipation, the prognosis is good if necessary changes are made in the diet and lifestyle.
• For hemorrhoids that require surgical intervention or minimally invasive procedures, the results are usually very good.

Complications

Hemorrhoids if untreated may cause the following complications:

• Profuse bleeding from the hemorrhoids usually occurs in cases of external piles.
• Strangulation and thrombosis.
• Ulceration can occur due to tissue death from pressure (tissue necrosis)
• Gangrene can occur if the blood supply to a hemorrhoid is cut off.
• Portal infection.
• Fibrosis-thickening and scarring of the affected tissue can occur.

Any food with little or no fiber can cause or aggravate constipation. So, avoid or limit their intake as much as possible. These include:

• Refined carbohydrates, including white bread.
• Dairy products, including cheese.
• Meat.
• Processed foods, such as frozen meals and fast food.
• Spicy food.
• Alcohol.
• Caffeine.
• Salt
  Excess salt intake can cause water retention, which puts more pressure on your blood vessels, including the veins in the anal region.
• Iron supplements can cause constipation. So, talk to your doctor before you take them.

• Add or substitute beans for meat in soups, as beans and nuts are high in fiber. Include legumes in your diet.
   
• Grains, cooked oats, and barley will give you soluble fiber. Substitute white bread, pasta, and crackers with their whole grain counterparts.
   
• Whenever possible, try to have fruits and vegetables whole, without peeling the skin on the apples, plums, potatoes, and pears, since the skin is a rich source of insoluble fibers. Avoid cooking green vegetables to the point that their color fades. A cup of greens, such as broccoli, green peas, or Brussels sprouts provides 4-5 grams of fiber. Vegetables and fruits, such as celery, cucumber, and watermelon, have fiber plus a lot of water. Add such vegetables into your diet. Snack on dried fruits, such as figs, apricots, and dates.

Hemorrhoids are a very common health problem. They are usually not serious but can be very unpleasant and cause discomfort, thereby affecting the quality of life. The prevalence of piles is not selective for age or sex. However, old age is a risk factor for piles. Piles are less prevalent in the underdeveloped countries. The typical low-fibre, high-fat diet usually that is a norm in western countries is associated with straining and constipation, which consequently leads to the development of hemorrhoids.

Piles mean swollen and distended veins of the lower rectum and the anus. It is essential to understand that hemorrhoids are part of the normal human anatomy. The hemorrhoids form an anal cushion of veins present under the mucous membranes that line the lowermost part of the rectum and the anal canal. It is only when these veins are swollen and distended and may cause symptoms, we say a person has developed piles or hemorrhoids. The blood vessels involved must continuously fight gravity to get blood back up to the heart.