Monday, September 7, 2009

Minimally Invasive Procedure for Haemorrhoid (MIPH) Treatment | Piles Treatment | Haemorrhoid Treatment | Aastha Healthcare | Super Speciality Center

What are haemorrhoids?

Haemorrhoids are one of the most commonly occurring ailments, affecting both men and women. One reason people do not talk about haemorrhoid problems with their doctors is because they anticipate a painful, traditional haemorrhoid surgery. But the fact is that better understanding of the disease process along with new technological improvements; have enabled more procedures to be performed as day care procedure.

Piles or Haemorrhoids can occur at any age. Many experts believe that they are caused by continuous high pressure in the veins of the body, which occurs because humans stand upright. The causes of haemorrhoids include constipation and excessive straining during bowel movements. Persistent diarrhoea and loose stool movements are also causes of haemorrhoids, and some people inherit a family tendency to develop piles. Women are more susceptible to haemorrhoids during pregnancy, as pressure from the growing uterus restricts blood flow in the pelvic area. Lifestyle factors can also contribute to haemorrhoid development.


Haemorrhoids may be internal or external. Both types of haemorrhoids can be present at the same time. Internal haemorrhoids are classified further based upon the degree to which they protrude from the anal canal. This grading system is important since the grade in part determines which type of treatment is best. But no widely used grading system exists for external haemorrhoids. According to this grading system:

  • Grade I haemorrhoids may bulge into the anal canal but do not protrude through the anus.
  • Grade II haemorrhoids protrude through the anus during straining and defecation, but return spontaneously.
  • Grade III haemorrhoids protrude through the anus with defecation or straining but do not return spontaneously, requiring the patient to gently push it back into its normal position with a finger.
  • Grade IV haemorrhoids cannot be manually returned to their normal position.

What are the symptoms of piles?
The symptoms of piles can come and go. There are five main symptoms:

  • Itching and irritation
  • Aching pain and discomfort
  • Bleeding
  • A lump, which may be tender
  • Soiling of pants or knickers with slime or faeces ('skid marks').
Itching and irritation probably occur because the lumpy piles stop acting as soft pads to keep the mucus in; instead, a little mucus leaks out and irritates the area around the anus. Pain and discomfort comes from swelling around the pile, and from scratching of the lining of the anal canal by faeces as they pass over the lumpy area. The scratching also causes bleeding, which is a fresh bright red colour and may be seen on faeces or toilet paper or dripping in the pan. A pile that has been pushed down (a second- or third-degree pile) may be felt as a lump at the anus. Internal haemorrhoids cannot cause cutaneous pain, but they can bleed and prolapse. Prolapse of internal haemorrhoids can cause perianal pain by causing a spasm of the sphincter complex. This spasm results in discomfort while the prolapsed haemorrhoids are exposed. The discomfort is relieved with reduction. Internal haemorrhoids can also cause acute pain when incarcerated and strangulated. Again, the pain is related to the sphincter complex spasm. See the table given below to know the symptoms of specific types of haemorrhoids:

Type Symptoms
Internal haemorrhoid symptoms
May protrude
Mucous discharge
Rectal bleeding
Rectal itching
Feeling of incompletely emptying bowels.
External haemorrhoid symptoms Rectal itching uncommon
May protrude
Rectal bleeding
Interferes with anal hygiene.
Thrombosed haemorrhoid symptoms Protrudes
Rectal itching
Rectal pain
Rectal bleeding
Tenderness
Swelling.
Ulcerated haemorrhoid symptoms

Rectal itching
Rectal bleeding
Swelling
Severe rectal pain.



Bulge of Internal Piles

Bleeding of Internal Piles


How is it diagnosed?

Haemorrhoids are diagnosed based upon a history, physical examination and visual inspection of the anal canal and rectum. When the patient reports to the physician with the symptoms of piles, the physician takes detailed case history.

To confirm presence of haemorrhoids, the doctor will do a rectal examination. The doctor will place a gloved and lubricated finger into the rectum to feel for abnormalities. External haemorrhoids can be diagnosed by a visual and/or rectal examination. To diagnose internal haemorrhoids, the doctor will insert a thin tube-like instrument (called an anoscope) into the lower few inches of the rectum. The anoscope has a light at the end and an eyepiece at the front for viewing into the anal canal. The procedure is painless but uncomfortable and lasts about 1 minute and is done in the OPD. Despite the fact that bleeding is common in patients with haemorrhoids, other potential causes of bleeding are excluded. To test for blood that may not be visible, the clinician obtains a small stool sample on a gloved finger. The stool is smeared onto a chemically coated paper and drops of another chemical are added. If blood is present, the colour of the paper will change to blue.

A more detailed look can be done by a procedure called sigmoidoscopy that is done under sedation or anaesthesia and a look upto 25 cm can be done to rule out any sinister disease that may be associated. Occasionally, a barium examination or colonoscopic examination of the large intestine may be required if other diseases are suspected.

What are the treatment options?

Several options are available for the treatment of haemorrhoids. For many, conservative or minimally invasive measures are effective in relieving symptoms. But in many cases, the physician may ask the patient to undergo the surgery.

Conservative Method

Increasing fibre in the diet is one of the best ways to soften and bulk the stool, which can help to reduce bleeding from haemorrhoids. The physician may also prescribe fibre supplementation. These products work by absorbing water and increasing stool bulk, which increases the frequency of bowel movement and softens stool. For grade II piles, Sitz bath will be recommended. The rectal area is immersed in warm water for 10 to 15 minutes two to three times daily. Pain-relieving creams and suppositories are also given to give temporary relief.

OPD / Alternate Procedure

Patients who have bothersome haemorrhoid symptoms, despite trying conservative measures, may consider a minimally invasive procedure. Most procedures are performed as a day surgery, allowing a patient to go home in the afternoon or evening. The following procedures are intended for treatment of internal haemorrhoids:

Rubber band ligation - Rubber band ligation is the most widely used procedure, and is best suited for grade I, grade II, and certain grade III internal haemorrhoids. Rubber bands or rings are placed around the base of an internal haemorrhoid. As the blood supply is restricted, the haemorrhoid shrinks and degenerates over several days. Many patients report a sense of "tightness" after the procedure, which may improve with warm sitz baths.

Laser, infrared, or bipolar coagulation - These methods involve the destruction of internal haemorrhoids with laser or infrared light or heat. Coagulation causes the haemorrhoidal tissue to harden and degenerate, and to form scar tissue as the area heals. Coagulation is generally effective for grade I and grade II internal haemorrhoids. In a technique called Haemorrhoidolysis, therapeutic galvanic waves are applied directly to the haemorrhoid, to shrink and dissolve the tissue.

Sclerotherapy - During sclerotherapy, a chemical solution is injected into haemorrhoidal tissue, causing inflammation, degeneration, and scar formation.

Cryosurgery- This freezes the pile to destroy it. It is not used much, because it causes a watery discharge afterwards.

Surgical Method

Patients who continue to experience symptoms despite conservative or minimally invasive therapies typically require surgical removal of haemorrhoids (haemorrhoidectomy). Surgery is the treatment of choice for patients with symptomatic grade IV internal haemorrhoids or strangulated internal haemorrhoids. Now under this, there are again two ways for doing it:

Conventional or open method
New method or MIPH method

Conventional method

Surgery to remove haemorrhoids is called haemorrhoidectomy. During this, the doctor makes incisions around the anus to cut away the haemorrhoids. It involves the surgical removal of excess haemorrhoidal tissue and anal canal lining. Most anal surgeries are being done under general or regional anaesthesia. Most patients experience some degree of pain following the surgery. It is painful for 7-10 days afterwards.

While surgery usually relieves the pain, swelling, bleeding, and itching caused by haemorrhoids, a drawback to this procedure is that the incisions are made in a highly sensitive area and might require stitches, which can cause the area to be tender and painful. In addition, patients might have some trouble urinating because the pain following surgery makes it difficult to relax and allow urine to flow.

New Method or stapler haemorrhoidectomy

In the past, open surgery was the only option available to surgeons when they needed to see inside a patient's body or remove or repair and organ. But today, minimally invasive technology is completely changing the way doctors approach patient care. While conventional surgical haemorrhoidectomy is a safe and reliable procedure, it is often associated with significant postoperative pain. A new procedure for removing large haemorrhoids, the stapler haemorrhoidectomy, is less painful and allows patients to return to work and other normal activities much earlier than with the conventional procedure. Stapled Piles Surgery is also known as PPH (procedure for prolapse and haemorrhoids) or MIPH (Minimally invasive procedure for haemorrhoids). The PPH procedure was first introduced in Italy in 1997 and in the last four years has become very popular all over the world.


This technique uses a stapling device and takes advantage of the fact that pain-sensing nerve fibres are absent higher in the anal canal. In this procedure, the mucosa above the dentate line, which contains part of the pile mass, is excised and stapled with the stapler gun, thus taking care of bleeding and prolapse - the two major components of piles. The pile masses are compressed into a cup like cavity inside the stapler. When fired, the titanium staples cut and seal simultaneously, thus causing minimal bleeding and as the cut line is above the nerves, there is reduction in post operative pain. Additionally there is no incision on the perianal skin or lower part of anal canal and the wound in the anal mucosa is also primarily closed with a stapler, thus, there is no need to do any post operative dressing. It can be done as an outpatient, using local anaesthesia with intravenous (IV) sedation. Routine preoperative workup for these techniques is required. Simple distal rectal evacuation is required for a clean operative field. Distal rectal evacuation is best achieved by small-volume saline enemas. But it should be done by a surgeon who is especially trained in doing stapler surgery. This is because there are few risks associated with the unskilled hands. The risks include: damage to the rectal wall, overstretching of sphincter muscles. etc.


Benefits and drawbacks

Studies suggest that Stapled Piles Surgery (also known as PPH - procedure for prolapse and haemorrhoids or MIPH - Minimally invasive procedure for haemorrhoids) is an effective treatment. This technique potentially provides a tool for reducing some of the problems associated with conventional surgery. It considerably reduces operative bleeding, postoperative pain, the length of hospital stay, and encourages a rapid return to normal activities when compared with conventional piles surgery. So the clear advantages of the modern methods for outpatient treatment of internal piles are that they are quick and relatively painless. Patients lose little if any time from work, the complications are minor, and the cure rates are high. So to summarise, given below are the advantages of MIPH in points:

Smaller incisions resulting in reduced pain and discomfort
Minimal scarring
Greater surgical precision
Fewer complications
Less blood loss and a decreased need for blood transfusions
Reduced risk of infection
Shorter hospital stays
Faster recoveries

Care to be taken at home

While no strategy completely removes the risk of haemorrhoids occurring again, following these suggestions can lower the risk:

Avoid straining during bowel movements.
Avoid constipation
Drink enough liquid for proper hydration.
Eat a diet high in fibre.
Exercise regularly.

For more information, kindly visit :
http://www.aasthahealthcare.com/Minimally-Invasive-procedure-for-Haemorrhoid-MIPH-Treatment.htm

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