Piles Management - Dr Dwivedi`s Speciality Ano
Piles Management - Dr Dwivedi`s Speciality Ano
Dr.Amar P. Dwivedi
M.S. (Ayu.) Ph.D.(Sch.)
Associate professor & I/C,
Shalya Tantra Dept.
Dr.D.Y.Patil Medical (Ayu.) college, Navi Mumbai
Contact number: 09323097013/09757445151
Email: [email protected]
• Shri Sai Hospital, Thakkar House
Castle Mill Naka,Thane-W
• Arogyadham Ayurved Hospital
Manpada, Thane- W
• Deerghayu Ayurved Clinic
Devarshi Garden, Majiwada,
Nr. Rutu Park Soc. Thane- W
• Aashray Hospital, Gokuleshdham
Sector 5, Ghansoli, Navi Mumbai
• Asso.Prof. & In Charge
Shalya Tantra Department
Dr. D.Y.Patil College of Ayurved
& Research Institute, Nerul,
Presented by: Dr. Amar P. Dwivedi
•‘Aryabhatta Award’, Las Vegas, USA
•‘Dhanvantari Award’, Rajkot, Gujrat
•‘International Excellence Award’, Malaysia
•‘Panacea Excellence Award’, SriLanka
•‘Best Scientific Research Paper ’ winner at
5th World Ayurved Congress, Bhopal-India &
National Conference-Anusandhan 2010.
• Vice President,NIMA- Thane Branch
VARIOUS CONDITIONS IN
ANO RECTAL REGION
Ischio- rectal Abscess
Rectal Polyps / Warts
Pilo Nidal sinus
Is Called As..
1.These are the dilated veins within the anal canal in the sub-epithelial
region formed by radicals of Superior, Middle and Inferior rectal veins.
2. Piles can be described as masses or clumps ("cushions") of tissue
within the anal canal that contain blood vessels and the surrounding,
supporting tissue (hemorrhoidal cushions).
Haima = blood
Roos = flowing
Pila = ball
Anal cushions :
These are submucus venous plexus containing
arterial twigs, venules, smooth muscles, elastic tissue
& connective tissue. Symptomatic anal cushions are
called as piles / haemorrhoides.
INTRODUCTION & INCIDENCE
• Humans suffer from piles as a
disadvantage of their erect posture.
• 50% of people over 50 yrs age suffer
from some degree of piles.
• 30% of pregnant females suffer from
• Asymptomatic piles are found in
many patients on routine
• Sex ratio approx. 2M : 1F
TYPES OF HAEMORRHOIDS
According to Symptoms1. Bleeding Piles
2. Non Bleeding Piles
• According to Origin1. Hereditary – Pile mass is present by birth
2. Acquired – Pile mass developed after birth
According to etiology1. Primary – Due to indulgence in unsalutary diets & habits
2. Secondary – Due to some other underlying disorders
According to Location-
1. Internal Piles –It is covered with mucous membrane. It arise from Internal
Hemorrhoidal plexus & above dentate line.
2. External piles – It is situated outside the anal orifice & is covered by skin. It arise
from External Hemorrhoidal plexus & below dentate line
3. Internal + External – Combination variety can also co- exist & is known as
Interno- External haemorrhoids.
Degrees of Internal Piles
Projects into anal lumen internally
Protrusion outside anal canal at
Protrusion outside anal canal at
– needs digital repositioning
Positions of Piles
Right anterior ( 11-o’clock)
Right posterior ( 7-o’clock)
Left lateral ( 3-o’clock)
At every o’clock position
Arterial cushions at every
odd o’clock position
i.e. 1 / 3 / 5 / 7/ 9 / 11 o’clock
Congenital – This is due to ‘ Shukra- Shonit beej dosh.
Pile mass is present by birth.
Anatomical – The haemoroidal veins are situated in anal sub-mucosa in
longitudinal direction & does not have support of any other
surrounding tissue. So, being valve less structure (either due to
any pressure/ obstruction on portal vein or due to gravity) they
are always filled with blood which results in its dilatation,
elongation & torsion.
• Sedentary lifestyle – Long term sitting job, daily traveling
for long distance, engaged in driving or abstinence
from any kind of physical exercise may result in
overfilling in the haemoroidal veins.
• Alcohol – Excessive alcohol intake can cause Hepatitis
resulting in portal hypertension which
ultimately exert pressure on the haemoroidal
veins resulting in protrusion of pile pedicle .
Suppression of urge of daefication/ micturation:
Suppression of urge of daefication vitiates vat which
may result in constipation & further straining while
daefication, exerting pressure on the haemoroidal
veins. Similarly, frequent IBS or diarrhea may
cause mucosal irritation & inflammation resulting
in protrusion of pile mass.
Asthma or COPD is associated with vigorous
& frequent coughing which increases the intra
abdominal pressure, thus ultimately exerts
pressure on the haemoroidal veins.
Similarly, lifting heavy weight can also cause
pressure on anal veins.
Enlargement of Prostate:
The male suffering from BPH usually strains
while micturation & this forceful micturation exerts
pressure on the haemoroidal veins. Similarly,
patients suffering from urinary calculus & frequent
UTI are also prone to such conditions.
• Other factors causing Piles:
In females1) During pregnancy the intra abdominal pressure is
increased (due to the foetus) resulting in portal hypertension.
2) At the time of labour (delivery) there is tremendous pressure
on the anal canal causing anal fissure and prolapsed piles.
3) Fibroid in uterus may cause pressure on anal veins.
Some other factors mentioned in Sushrut samhita –
1) Straineous work (Balvad vigrah)
2) Anger or sorrowful emotions (Shok)
3) Contradictory food consumption (Adhyashan)
4) Over sex indulgence (Stri prasang)
5) Squatting posture (Utkatasan)
6) Horse riding (or long drive)
7) Suppression of natural urge (veg dharan)
8) Diminished Appetite (Mandagni)
Swelling / Prolapse
Straining / Pain / Discomfort
Digital evacuation /
Abdominal bloating = GAS
Lethargy/ Wt. Loss
Symptoms of ANAEMIA
Pathogenesis of Bleeding
Disruption of sinusoids
by straining / irritation
Straining at defecation
Bleeding from pre-sinusoidal arteries
Bruising of engorged venous
Venous back flow
Tear & Bleed
• Occasional to regular / recurrent
• Bright red ( from presinusoidal arterial twigs)
• Initally Streaks specially with hard stools
• Later Steady drip
• Advanced Squirts / stream / drip with defecation &
Also apart from defecation
(blood spotting on undergarments)
• Gain the Confidence
of the Patient
• Light (Angle- Poise Lamp)
• Instruments required likeGloves, Jelly, Torch, Guaze,
Position of patient
What else is to be kept ready??
Respect towards patient
Soft words & politeness
Understanding the patient
What thing to keep away
• Spread buttocks apart gently
• Focus the light source
• Observe the peri-anal region
& anal verge
Scars, Pruritus, Sinuses,
Soiling, Discharge = Pus, Blood etc.
External Tag, Swellings (Boil/Induration)
? Sphincter Tone/Spasm (Refluxes)
1ST-degree = Nil evidence
2nd-degree = Bogginess at anal verge at affected side, gentle
traction on bogginess reveals mucosa
3rd-degree = Inner red/purplish mucosa & outer skin covered
bogginess with linear furrow in between
4th-degree = Evident irreducible prolapse
• White Pannus
• Pruritic signs
• Soiled perineum
(Most neglected but most informative)
Sentinal pile / tag
Bleeding / Discharge
External opening of fistula
Prolapse during valsalva
Stricture / Stenosis
(DIGITAL RECTAL EXAMINATION)
D.R.E. (Digital Rectal Examination)
• Ask patient to bear down & gently insert lubricated gloved finger inside
• Early piles = Soft, easily collapsible venous swellings
• Late piles = Fibrosis of connective tissue
Piles are palpable as soft longitudinal folds
Also appreciate :
Ano-rectal sling level
Anal canal length
Inspect the finger for blood / mucus / feces
Exclusion of other diseases esp. Ca’
DIGITAL RECTAL EXAMINATION (DRE)
Internal opening of Fistula
Peri anal Tenderness,
Collapsed , ballooned
Loaded / empty
Wall irregularity & nodularity
Stenosis / stricture
Polyp / mass
Cervix & uterus in females
Prostate & seminal vesicles in males
Blummer shelf deposits
Examine the finger after P/R for
P.V. examination with separate gloves
ANOSCPOY / PROCTOSCOPY
Proper instruments and lighting
Many things can be diagnosed
Physical Examination –
With scope inside anal canal, ask patient to bear down
& inspect while withdrawing the scope.
Look for = bulge – site / covering mucosa colour
Rectal mucosa status
• Acute stage Conservative Treatment:
In Allopath, the line of treatment is as follows –
1. In Acute stage i.e. if the patient comes with symptoms like
severe pain with haematoma, then Analgesics+ Anti inflammatory
+ Anaesthetic agent like Xylocaine oint. / jelly is prescribed.
Also, patient is asked to take Hot Seitz bath with KMNO4. Haemostatic drugs
like Stredron or Ethamsilate can be given to arrest bleeding
Generally, the swelling resolves itself. But if the condition do not improved,
then it may suppurate or may fibrose giving rise to cutaneous tag or may
burst giving rise to bleeding.
2. If haematoma do not resolve, then it is Incised under local anesthesia & the
wound is allowed to heal by granulation tissue.
• Diet – Fiber rich, balanced (easy to digest) diet
• Ointments - Hydrocortesone acetate,Heparin sodium,
Aminobenzoate,Lignocaine hydrochloride, Zinc oxide
• Laxatives - Liquid paraffin, Lactulose, Isabgol, Senna,Castor oil,
• Suppository- Bisacodyl,Glycerene
• Analgesics / Antibiotics / Prokinetics
• Oral preparations- Sodium picosulphate, Calcium dobesilate,
• Iron supplement
• Seitz’ Bath
Sushruta has mentioned four fold regimen for piles:
1. Aushadhi Chikitsa i.e Internal medicine effective in I and
II grade piles
2. Kshar chikitsa i.e application of kshar locally or internally
effective in I and II grade piles
3. Agni Karma i.e Excision of pile pedicle by Cauterization
4. Shalya Karma i.e Ligation and Excision of Pile pedicle
effective in III grade and prolapsed pile mass.
Ayurvedic Conservative treatment
– Deepan and pachan chikitsa
The main objective is to restore the digestive
power ( Jatharagni) by:
1. Ajmodadi churna or
2. Chitrakadi or ampachak vati
3. Shankha vati ( form of mild kshar)
- Vata anuloman chikitsa
For this purpose Avipatikar churna or Panchasakar churna can be prescribed
- Mal Sarak chikitsa-(To treat constipation)
- Haritaki churna
- Abhaya arishta
- Triphala churna
To arrest bleeding Nagkeshar Churna, Bolbaddha ras or
Kutaj Churna can be given.
Bhalatak kalp in non bleeding piles and kutaj churna
for bleeding piles is choice of drug mentioned in Sushrut.
Various combination for local application
is advocated for initial stage like :
a. Latex of snuhi+ turmeric powder
b. Kasisadi taila
c. Turmeric podwer + Pippli churna+ Gomutra
d. Nimbadi malhara etc.
• Specific guidelines mentioned in Sushrut Samhita
– In initial stage of piles local application of inform of lep is mentioned which
may promote frbrosis and delay the protrusion of pile pedicle
• Snuhi latex + Turmeric powder can be tried
• Turmeric + Pippali churna + Gomutra can be applied
– Specific instruction regarding Diet
• Shali, Shasti, Jau or wheat grain mixed
with ghrit and milk and gruel is made.
This is to taken as diet regularly
• Lot of green leafy vegetables
• Shatavari mula kalka along with milk
• Apamarga mula cooked with rice
• Butter milk should be taken regularly
• Jaggery with haritaki
Kshar Karma in Piles
• This is indicated for II Grade internal piles. The kshar is applied to the
dilated pile pedicles with the help of specially designed probe known as
“Jambaushatha shalaka” under the guidence of proctoscope (Arsho
darshan yantra) having slit on its side.
After mild kshar application the pile pedicle is washed with sour gruel
(Dhanyaamla) or water and followed by local application of yashtimadu
ghrita at the site.
• Each pile pedicle is treated differently at the interval of one week.
• This may cause fibrosis of the tissues which prevents the pile pedicle from
protrusion. Also to some extend it works similar to sclerosing therapy
Use of Kshar sutra in Piles
• Some Ayurvedic surgeons prepare a separate kshar sutra which is mild in
nature and have less coatings for the ligation of internal pile pedicle.
According to them this medicated Kshar sutra simultaneously necroses
the pile pedicle, and at the same time they promote fibrosis over the
• This technique is practiced in few places
northern India and is not popular enough.
• However this mild kshar sutra can
be effectively used in external piles
and external sentinel tags.
TREATMENT OPTIONS FOR PILES
1869= Jhon Morgan of Dublinintroduced this procedure using
persulphate of iron
1871= Mitchell of Clinton-Illionis, USA, used carbolic acid (27–
95%) & olive oil
HE SOLD THE SECRET TO QUACKS BEFORE HIS DEATH
1879= Andrews of Chicago, discovered the secret from Quacks and
gave it to the world.
Principle of Sclerotherapy
Injection of irritant solution evokes inflammatory
reaction in submucosa where haemorrhoidal vessels lie.
This results in
which prevents defecatory trauma & thus prevents bleed
2) Blockage of hemorrhoidal vessels,
which do not bulge on straining
which fixes mucosa to muscle & prevents prolapse.
INDICATIONS FOR SCLEROTHERAPY
• INTERNAL PILES ONLY
for Grade – I, Bleeding Piles
for Grade – II bleeding piles
PALLIATIVE = for Grade – III bleeding piles
Contra – Indications for Sclerotherapy
• External Piles
• Associated Anal Lesions eg; fissure, fistula, skin tags
• Attack of thrombosed internal piles
• Crohn’s / Ulcerative colitis
Solutions used for Injection:
Various vegetable oils eg. Almond /
olive / coconut
STD (sodium tetradecyl sulphate)
Quinine & urea hydrochloride
Dosage per pile mass
5 – 7ml (max = 10 ml)
1 – 2ml
Site of Injection
-Into pile mass
- At the pedicle of the pile mass at anorectal ring (ALBRIGHT’S method)
• Mild discomfort
• Follow – up after 3 wks
• Watch for fever / pain / bleeding.& inform sos
Advantage of Sclerotherapy
• Easily learned procedure
• Stops bleeding in 24 - 48 hrs in majority of cases
Cost – effective
Office procedure so early return to work
Can be repeated
Complications of Sclerotherapy
Fainting / Giddiness
Burning & itching
Results after Sclerotherapy
• Grade – I piles == 98 %
• Grade – II piles == 68%
• Grade – III piles == 31%
• Overall 77% successful
• Especially in stopping bleeding
• But has less effect on prolapsing element of pile
RUBBER BAND LIGATION (RBL)
Principle of RBL
• Rubber ring ligature applied to the mucosal covered part
of the Internal Pile through a proctoscope
• This strangulates the feeding vessel to the pile and
gradually cuts through the mucosa
• The pile thus sloughs off after 7 – 14days
Indication for RBL
• Ideal for Grade – II internal piles
• Early Grade -- III internal piles
• Bleeding diathesis (???)
• Infection ( fistula / abscess)
Post – procedure Instructions
• Dull ache / fullness of rectum may be present
• Urge to defecate may be there
• Bleeding may occur ----- clots = 1-2days
----- spots = 5 – 14days
Follow-up after 2 weeks
Advantage of RBL
• No learning curve
• Effective symptomatic relief in 80 – 90% cases
• Safe procedure
• Virtually painless if done properly
• Can band all 3 piles in one sitting
• Can be repeated after 3 weeks
• Cost – effective
DISADVANTAGE OF RBL
Has no effect on skin covered component
Complications present ( avoidable )
Complication of RBL
Immediate / delayed
Immediate / delayed
• Slippage of band
INFRA - RED COAGULATION
INDICATION FOR I.R.C.
• INTERNAL PILES ONLY
BEST = Bleeding Piles of Grade – I,
GOOD = Bleeding piles of Grade – II
24 K Gold Plated Reflector
Solid Quartz Light Guide
15volt tungstenhalogen lamp
Principle of I.R.C.
• It causes actual burn upto the submucosa
• Light energy converted to heat energy
• Causes tissue destruction
• Evokes inflammatory reaction
• Results in scarring
Site of application:
Above the pile mass, At or just below A/R sling
( same as for sclerotherapy)
Patient may feel slight warmth
No admission to hospital
No need to take leave from work
Safe for patients with Diabetes
Safe for patients with High Blood Pressure
Safe for patients with Heart Problems
Safe for Pregnant patients suffering from piles.
Cryo - Therapy
Freezing the pile mass with cryo-probe to subzero
temperature of upto -700C with Nitrous oxide /
-1800C with Liquid Nitrogen Causing thrombosis of microcirculation & gradual necrosis and sloughing off of the pile.
• When cryoprobe is placed on the tissue the ice ball forms a
visible white area which will eventually slough
• The procedure usually takes 10-15 min. and the patient is
observed for 30 min.
Disadvantage of Cryo - Therapy
• Needs Local anesthesia / sedation
• Post-op pain present
• Copious foul smelling browny discharge for
wks till the would sloughs & heals
• Secondary haemorrhage
• Delayed return to work
Thus it use is abandoned in current era
Grade – I piles :
I.R.C. / Sclerotherapy
Grade – II piles:
I.R.C. / R.B.L. / scleroRx
Grade – III piles:
Palliative Rx with
R.B.L. / scleroRx
Important Instruction to Doctors
• Piles has a multifactorial causative etiology
• “CURE” should never be promised to any patient
• Just mention that this is the right treatment for your
patient under his current circumstances.
Open Surgery for Piles
There are two established methods of haemorroidectomy
1. Open haemorroidectomy
2. Closed haemorroidectomy
Post - operative
Breakthrough in Haemorroid Surgery
DO’S & DON’T’S (Pathyapathya)
After Kshar sutra procedure patient is asked to follow the below mentioned
instructions To have balanced (easy to digest) diet.
To avoid Heavy meals.
To avoid suppression of urge and Constipation.
To regularize the food and bowel habits.
To avoid cold beverages, Alcohol and Smoking
Note: All the above mentioned factors are
Responsible for Agnimandya and can vitiate the vaat dosh.
To avoid Ratri- jagaran & Day time sleep.
No heavy exercise.
No (over) sex indulgence.
No horse riding (or motor bike/ car- long drive).
To control anger or emotions.
To maintain the local hygiene.
To avoid long time or awkward sitting posture.
• Anal Exercises :- Contraction & relaxation of
anus for 5 to 10 minutes in a day will give more
strength to anal canal.
• Yogasanas :- Practise of specific yogasanas like
Shirshasana, Uttanpadasan will reduce the
pressure over the anal mucosa.
Beware of these Quacks
shri vyankateshwar Balaji