Transcript Piles Management - Dr Dwivedi`s Speciality Ano

MANAGEMENT
OF
Haemorrhoids (piles)
Presented by:
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]
[email protected]
Website: www.amarayurved.com
Attachments:
• 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,
Navi Mumbai
Haemorrhoids
Presented by: Dr. Amar P. Dwivedi
Profile :
Awarded with:
•‘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
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Imperforate Anus
Piles
Fistula
Fissure
Ischio- rectal Abscess
Proctitis
Enlarged Pappila
Rectal Polyps / Warts
Pilo Nidal sinus
Carcinoma
Pruritis
Any Problem
Around The
Anus
Is Called As..
Piles
HAEMORROIDS (PILES)
Definition :
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).
Haemorrhoides
Piles
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
piles
• Asymptomatic piles are found in
many patients on routine
examination
• Sex ratio approx. 2M : 1F
TYPES OF HAEMORRHOIDS
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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
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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
1st-degree
Projects into anal lumen internally
2nd-degree
Protrusion outside anal canal at
defecation with
spontaneous reduction
3rd-degree
Protrusion outside anal canal at
defecation straining
– needs digital repositioning
4th-degree
Permanently prolapsed
irreducible piles
Positions of Piles
• PRIMARY
Right anterior ( 11-o’clock)
Right posterior ( 7-o’clock)
Left lateral ( 3-o’clock)
• Accessory
At every o’clock position
• DGHAL
Arterial cushions at every
odd o’clock position
i.e. 1 / 3 / 5 / 7/ 9 / 11 o’clock
ETIOLOGICAL FACTORS
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Congenital – This is due to ‘ Shukra- Shonit beej dosh.
Pile mass is present by birth.
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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 .
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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.
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Asthma:
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.
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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)
SYMPTOMS
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Bleeding
Swelling / Prolapse
Straining / Pain / Discomfort
Constipation
Itching, Irritation
Incomplete evacuation
Digital evacuation /
instrumentation
Abdominal bloating = GAS
TROUBLE
Lethargy/ Wt. Loss
Black-out episodes
Symptoms of ANAEMIA
Pathogenesis of Bleeding
Hard stools
Disruption of sinusoids
by straining / irritation
Straining at defecation
Bleeding from pre-sinusoidal arteries
Bruising of engorged venous
cushions
Constipation+Straining+IAS spasm
De epithelization
Venous back flow
Ulceration
Mucosal strech
Bleeding
Tear & Bleed
Bleeding
• 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)
Examination
• Gain the Confidence
of the Patient
• Position
• Light (Angle- Poise Lamp)
• Instruments required likeGloves, Jelly, Torch, Guaze,
Proctoscopes ,Forecep
Position of patient
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SIM’S position
Lithotomy position
Knee-Chest position
Prone position
What else is to be kept ready??
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Ears open
Eyes open
MIND open
Gentleness
Respect towards patient
Soft words & politeness
Understanding the patient
What thing to keep away
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Arrogance
Mobile phones
Sharp instruments
Ego
Inspection
• Spread buttocks apart gently
• Focus the light source
• Observe the peri-anal region
& anal verge
Skin discoloration
Scars, Pruritus, Sinuses,
Soiling, Discharge = Pus, Blood etc.
External Tag, Swellings (Boil/Induration)
? Sphincter Tone/Spasm (Refluxes)
Other Pathologies
Physical examination
• INSPECTION:
 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
INSPECTION
(Most neglected but most informative)
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Fissure
Hematoma
Wart
Pilonidal sinus
Pruritis ani
Prolapsed Piles
Sentinal pile / tag
Bleeding / Discharge
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External opening of fistula
Abscess
Sphincter tone
Soiling
Prolapse during valsalva
Stricture / Stenosis
Sphincter spasm
Worm infestations
D.R.E
(DIGITAL RECTAL EXAMINATION)
P/R examination
Physical 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 :
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Anal tone
Ano-rectal sling level
Anal canal length
.Squeeze pressure
Inspect the finger for blood / mucus / feces
Exclusion of other diseases esp. Ca’
PALPATION &
DIGITAL RECTAL EXAMINATION (DRE)
Anal Canal
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Sphincter tone
Ano-rectal sling
Fibrosis
Internal opening of Fistula
Induration
Tenderness.
Peri anal Tenderness,
Induration
Rectum
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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
blood/mucus/pus/stools
 P.V. examination with separate gloves
ANOSCPOY / PROCTOSCOPY
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Proper instruments and lighting
Position
Technique
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
Bleeding points
Rectal mucosa status
Other lesions
MANAGEMENT
• 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.
Conservative Management
• 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,
Bisacodyl
• Suppository- Bisacodyl,Glycerene
• Analgesics / Antibiotics / Prokinetics
• Oral preparations- Sodium picosulphate, Calcium dobesilate,
Tranexamic acid
• Iron supplement
• Seitz’ Bath
Ayurvedic Management
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
Hingavasthak churna
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
after food
• 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.
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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
peripheral tissues.
• 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
NON-SURGICAL
SURGICAL
(office procedures)
BANDING
SCLEROTHERAPY
I.R.C
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LASER
**
HAL
STAPLER
M.I.P.H
OPEN
**
CLOSED
**
Harmonic
INJECTION SCLEROTHERAPY
HISTORY
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
1) Encasement,
which prevents defecatory trauma & thus prevents bleed
2) Blockage of hemorrhoidal vessels,
which do not bulge on straining
3) Fibrosis,
which fixes mucosa to muscle & prevents prolapse.
INDICATIONS FOR SCLEROTHERAPY
• INTERNAL PILES ONLY
BEST =
for Grade – I, Bleeding Piles
GOOD =
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
• Pregnancy
• Crohn’s / Ulcerative colitis
Solutions used for Injection:
Phenol
Various vegetable oils eg. Almond /
olive / coconut
STD (sodium tetradecyl sulphate)
Carbolic acid
Sodium morrhuate
Quinine & urea hydrochloride
Glycerine
Polidocanol
Dosage per pile mass
5 – 7ml (max = 10 ml)
1 – 2ml
Site of Injection
-In submucosa
-Into pile mass
- At the pedicle of the pile mass at anorectal ring (ALBRIGHT’S method)
Post-procedure Instructions
• Mild discomfort
• Tenesmus
• 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
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Cost – effective
Office procedure so early return to work
Painless
Can be repeated
Complications of Sclerotherapy
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Fainting / Giddiness
Necrosis
Re-Bleed
Abscess
Stricture
Urine retension
Burning & itching
Fistula formation
Injection ulcer
Paraffinoma
13/41
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)
or
BANDING
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
Contra-indications
• Bleeding diathesis (???)
• Infection ( fistula / abscess)
• Fissure
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
• Pain
Immediate / delayed
• Bleeding
Immediate / delayed
• Thrombosis
• Fissure
• Slippage of band
• Sepsis
I.R.C.
INFRA - RED COAGULATION
(Modified ‘Agnikarm’)
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
Trigger
15volt tungstenhalogen lamp
Light energy
Heat energy
Contact
teflon tip
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)
Pre-op instruction
Patient may feel slight warmth
ADVANTAGES
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No operation
No bleeding
No pain
No anesthesia
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
Principle :
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
Procedures Recommended
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.
• REMOVE
FEAR
Open Surgery for Piles
There are two established methods of haemorroidectomy
1. Open haemorroidectomy
2. Closed haemorroidectomy
Pre-operative piles
Post - operative
Haemorroidectomy
Breakthrough in Haemorroid Surgery
Stapler M.I.P.H
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.
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 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