Haemorrhoids [Piles]
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon Essex.

1. What are haemorrhoids?

Haemorrhoids or piles are small lumps inside or around the anus caused by distention of small blood vessels underneath the lining of the bottom passage. They may be present in up to 15% of the population but in most cases cause no problems. According to their location they are called internal or external. The internal piles may prolapse after defecation.

3. What symptoms do they cause?

In most cases they cause no symptoms at all, however, they may cause anal irritation and discharge of mucus. They may also bleed without pain; it is usually a streak of blood on the sides of the stool. Pain is usually associated with anal fissure [crack] or acute thrombosis of an external pile. They may also prolapse through the anus and give a sensation of discomfort, until they are pushed in.

5. What are the treatment options?

.  Conservative.

    Piles may be treated with simple measures, such as attention to your diet, particularly increasing the amount of fibre and bran in your diet to make your motions softer and avoid straining. Medicated suppositories and cool sitz baths after each motion are also helpful. Conservative treatment is effective in about three quarters of the patients and there is no need for further treatment.

.  Injection sclerotherapy.

    A special liquid [phenol] is injected into the pile; it causes inflammation and thrombosis of the vessels. As a result the piles shrivel and shrink. Injections are usually done in the outpatient clinic and are not normally painful. You should be aware that there may be some bleeding or discomfort over the next two or three days. You may need to take an analgesic, such as aspirin or paracetamol.

   Several injections may be required to treat your piles and these are normally done at about six weekly intervals. You will be given a further appointment if the doctor feels that this is appropriate. Although a cause of injection should cause the piles to disappear completely, they may recur in the future [40%], especially if you continue to be constipated and continue to strain.

.  Banding of piles.

Small piles, which do not respond to medical treatment or injection, and remain a constant concern for the patient, may be treated by placing a tiny rubber band around them. These bands constrict the piles, which will eventually separate and be expelled through the anus a week later. Banding is usually done at the outpatient clinic. One or two piles are treated in one session. If others need treatment, this will be done at a further session.

·  After banding, it is important not to strain to pass a bowel motion even if you feel you must. This may push the bands out.

· Some patients [10-20%] experience some discomfort and pain [like a toothache]. This usually lasts for 2-3 days and -if necessary- can be relieved by taking a pain killer such as paracetamol. In a few cases the pain may be more severe, in which case more powerful pain killer will be required [consult your doctor], as well as regular hot baths.

·   Bleeding may also occur for some days, especially when the piles separate, after 5-7 days. This stops without treatment in almost all cases. If it persists, then further treatment of the piles may be necessary.

.  Surgery [haemorrhoidectomy]

Following adequate removal of haemorrhoidal tissue, recurrence after surgery is uncommon.

Surgery is performed under general anaesthesia and in most cases you will have to stay in the hospital for one or two nights. As the first motion after surgery may be painful, you should start taking lactulose [15ml twice a day] 2 days before surgery to ensure that the bowel content will be soft and bulky.

You will be discharged after you open your bowels. Some pain and discomfort is normal, but usually settles within one or two weeks. Bleeding may also occur during the first two days but requires no further treatment in almost all cases.

·   Stappling haemorrhoidectomy. This is new technique that developed recently, using the same method as in rectal prolapse. It is indicated in specific cases. Although it causes less discomfort, the long-term results are still to be assessed.

However, you should be informed that you would feel miserable for a fortnight, before you recover completely, and some lumps in the area may appear following surgery, due to inflammatory skin changes. They usually settle within 4-6 weeks. You must ensure that you modify your diet and increase the amount of fibre and bran in order to have a smooth recovery and avoid any future episodes of constipation.

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Please note:
A written referral from a general practitioner is helpful but is not essentially required in order to make an appointment to see a consultant specialist.