HAEMORRHOIDS, also known as piles, are very common in Jamaica. It is one of the commonest causes of bleeding from the lower gastrointestinal tract. It mainly affects persons whose diet lack fibre and it doesn’t show a predilection for either males or females; both genders are affected equally.

Piles are cushions of blood vessels within the submucosa of the anal canal.

There are three main cushions in the anal canal. They contain blood vessels, connective and elastic tissue, and smooth muscle. These tissues contribute up to 20 per cent of resting pressure within the anal canal and surround the artery or vein communications between the ending branches of the superior and middle rectal arteries and the superior middle and inferior rectal veins.

These cushions become filled with blood and cause closure of the anal canal, contributing to anal continence and prevention of stool leakage during straining, sneezing, coughing, or blowing ones nostrils. They also protect the anal sphincters during stooling and help with sensation to differentiate liquids, solids and gas to assist with the decision to pass which one at a convenient time.

These cushions can be affected by prolonged straining (childbirth), constipation, exercise, low fibre diet, genetics, pregnancy, age, and the absence of valves in the haemorrhoidal veins. Increased pressure within the submucosal artery or vein plexus of the anus can cause these cushions to swell and with reduced support of tissues they protrude through the canal. They are then felt as fleshy material at the anus called haemorrhoids or piles.

Piles can be internal or external based on their placement secondary to an area called the dentate line. External haemorrhoids are below the dentate line and are richly supplied by nerves, so they are extremely painful when they thrombose or form clots. Internal piles are lined differently and are not sensitive to pain or temperature.

Internal piles are graded into first to fourth degree. First degree haemorrhoids do not protrude outside the anus and are present only in the anal canal. They are not seen on rectal exam, only by a proctoscope, but they may bleed during stooling. Second- degree piles prolapse outside the anal canal during stooling but reduce right after. Third-degree piles protrude and have to be pushed back up by the patient or doctor and fourth-degree piles are prolapsed and cannot be reduced.

Haemorrhoids may occur by themselves or accompanying other diseases such as cancers, inflammatory bowel diseases, abscesses, or cirrhosis of the liver. Patients should see their doctor who will take a thorough history and do a complete physical examination.

SIGNS AND SYMPTOMS

The patient may present with bleeding without pain, tissue protrusion, mucous secretion, or a feeling to stool after stooling if they have internal piles. While external piles will cause painful bleeding, thrombosis and itching and poor hygiene around the anus. The attack may be just after straining, stooling or sitting for long periods.

TREATMENT

Management of these patients with piles that are affecting them involve conservative treatment such as diet – increasing roughage by eating foods high in fibre such as vegetables and fruits; lifestyle modifications like drinking more water and using mineral oil to produce soft, bulked stools to decrease straining; using drugs such as daflon and creams such as topical corticosteroids, topical anaesthetics and sitz bath, which is sitting in warm water that reduces tissue swelling and relaxes the anal tissue. There are also nonoperative procedures such as placing a rubber band around the haemorrhoids, using sclerotherapy, diathermy, phlebotonics or photocoagulation, and operative removal or haemorrhoidectomy, by the surgeon.

If there is a painful swelling outside the anus called a thrombosed haemorrhoid, it can be treated by complete removal by the surgeon. If surgery is declined, the texture of stool can be modified by, for example, using mineral oil, increasing fibre and hydration; analgesics such as NSAIDS, sitz baths and rest. The body then absorbs or releases the clot over a period of time.

Dr Romayne Edwards is a consultant emergency physician at the University Hospital of the West Indies and an associate lecturer at the University of the West Indies.