Piles, medically called as hemorrhoid is a very common disease. It occurs more in female than male. It is probably the award to human race for adaption of erect posture, as quadrupeds do not suffer from this disease. Piles, as such occurs due to various local factors, mainly a cushion defect in the vascular bed of rectum and anal canal. But, there are some diseases which present as piles. Common amongst those are:
Cancer Rectum and Colon
Portal Hypertension
Cancer of rectum and colon: Many times the clinicians avoid digital rectal examination and presume that the bleeding from anus is from the simple piles. That is why, it is said that” If the clinician has not put his finger inside, he may put his foot in it”. This shows how much vexing it is, if not carried out. Many great surgeons have missed the diagnosis and operated as simple piles leaving the underlying disease intact. Rectal cancer may present as painless bleeding from anus. As the tumor grows there occurs some obstruction to the venous flow resulting in engorged anal veins, apart from it there may be direct bleeding from the tumor itself. Multiple polyposis is a predisposing cause among many others. Non-vegetarian diet, especially meat consumption is associated with colon cancer. Vegetarian diet, fiber in diet, aspirin, metformin and regular exercise may have some protective effect.
Portal Hypertension: This disease is rather a complication of cirrhosis of liver. Here, there is obstruction to free flow of blood from lower extremities through the liver; and alternative channels open up for the flow of blood to the heart. In that way an alternative channel opens up in the rectum and anal canal, in addition to other sites; the veins become engorged resulting in bleeding from the anus. Cirrhosis of liver may result from chronic hepatitis, commonly hepatitis B and C; amongst other causes alcoholic cirrhosis, biliary cirrhosis and aflatoxin poisoning are some of the common causes.
Hemorrhoid
So, for any bleeding from anus a simple examination like digital examination should not be skipped.
There is pain of varying degree in the anus during passing of motions, compelling the patient to hold stool. The pain lasts for sometimes after the act. Most of the sufferers are ladies. It may follow after passing of hard stool in the recent past.
It is called Fissure-in-Ano. Non-vegetarian food of animal origin is responsible for it as that causes constipation. A life style change with more protein intake has increased it many fold. Some patients have an inherent problem of high sphincter tone. Fissure is a linear ulcer seen in the external anal region. It may occupy either front or back side of anal canal, or sometimes both the sides. In female, it is usally seen in the anterior (front) side whereas in male in the posterior side (back). Usually always, covered by a skin fold in the out side. As the skin fold guards the fissure like a sentry, called sentinel pile, is always painful to touch. The fissure sometimes bleeds and blood comes as a streak attached to the stool.
Fiber in diet prevents it. Most commonly treated in a conservative manner keeping in view to make the stool soft. So, stool softeners paly a major role. Liguid paraffin containing liquids are avoided, as they delay healing. To get ride of pain anesthetic gels are prescribed. A warm bath to anus, called sitz bath is advised after defaecation. An antibacterial gel is also advised. A smooth muscle relaxant gel is also prescribed. If conservative treatment fails a sphincter cutting surgery is contemplated. But, such surgery has the problem of anal incontenence. Most of my patients get relief from dietary modification and conservative treatment.
An old lady in her seventies came with prolonged blood and mucusdysentery.She was anaemic,her body swollen and has a her rectum out.This sort of complication of dysentery is commonly seen in children.There was a co-existing lax anal sphincter.Geriatric people are generally neglected more so in India.Otherwise this sort of complications of dysentery should not have been seen.My medicine specialist colleague has treated her dysentery and anaemia. Now it is my term to treat the prolapse of rectum.She is frail.The rectum is out for about 15 cms. and not self reducing.The anal sphincter is lax.In this case a surgery though indicated for prolapse a sphincter tightening surgery is also indicated.But she is not fit for a general anaesthesia.So I went for a palliative procedure .Here though it will contain the prolapsing rectum,some times may give way.If the patient strains much during defaection the rectum may plug the anal opening preventing passage of stool out side.The patient has been advised to practice an exercise to tune up the sphincter.Let us seen what happens.Hopefully if she does not strain after cure of dysentery the simple procedure done will help her.
This is a very nasty disease to me.Somehow I am not comfortable to treat this one.Patient comes with a painful swelling near to anus,fever and prostration .On examination a painful swelling will be found near the anal opening.Once drained a large amount of foul swelling pus will come out and relief the patient to a considerable extent. And this cycle goes on unless the patient is not throughly investigated for possibility of Fistula-In-Ano. It is a condition where there is build up of a tunnelled connection ,of course small in caliber between interior of lower gut and the exterior i.e. skin.This occurs from an infection of anal glands located inside the anus and rectum and gradually enlarge to burst to the out side.With passing of time the inside of the fistula or tunnel matures and continuously discharges pus.That is why I call a nasty disease. Fistula may also manifestation of some diseases like TB,Ulcerative Colitis,Chron’s Disease ,A rectal cancer and some other diseases.These are of various types and classified in various manner. Most accepted being superficiel,deep,intershincteric,transphencteric and high etc.which is required for the treating doctors.Treatment of more complex fistulas are not very much satisfactioy.A fistulogram gives good idea of it’s extension to help in operation.Besides trans rectal ultrasonogram is helpful.Tuberculosis if suspected should be searched for the primary site of infection .A simple per rectal examination is helpful to supect a cancer inside. Surgery is the option for most of fistulas except TB and some other diseases.Here the whole tract is excised leaving a raw area to heal from the depth. And if dressing done properly and wound heals fromthe depth probably the surgeon should be able to sleep cmfortably.The excised specimen is to be subjected to histopathological study to exclude associated cancer and TB in the tract.And in that case furhter treatment for the specific disease to be taken up.
Most common complication of surgery is inardverent injury to the anal sphincture making the patient incompetent to hold faecal matter.And the next is recurrance. So this surgey many times brings down the ranking of the surgeon’s popualrity.People taking non-veg diet and suffering fron constipation are prone for this disease.
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