Dr McGregor is an expert in Haemorrhoid Surgery.
WHAT ARE HAEMORRHOIDS / PILES
Haemorrhoids are a common problem and affect up to 50% of people at some time in their life.
Haemorrhoids, also known as piles are rather like varicose veins in the canal of the anus. Piles develop from three pads or cushions of tissue that line the anal canal or back passage.
Here, just under the mucous membrane inner lining, is a considerable network of veins extending upwards for an inch or so from the level of the skin to just above the anal canal, where it joins the rectum.
This tissue is normal - it acts as a compressible lining that allows the anus to close completely, so avoiding leakage. If the veins become dilated and swollen, they may then project into the anal canal and even out of the back passage (this is called prolapse) to form visible swellings. These swellings are the ‘piles’.
Although uncomfortable and embarrassing, it is not normally a serious condition. Piles are usually painless. Piles may be completely symptomless, especially if they are small, and many people don't realise they have them. But they can also cause a range of problems:A swelling protruding from the anus.
Piles may be felt as small soft lumps at the opening of the back passage, sometimes compared to a 'bunch of grapes'. They are usually soft and fleshy but may become hard if thrombosis occurs. The piles may only appear after straining at the toilet.
Protruding haemorrhoids can lead to skin irritation and discomfort and there is usually mucus discharge from the irritated mucous membrane.Bleeding from the back passage. The lining that covers the piles is quite delicate and if it is damaged, for example as you open your bowels, there may be bleeding which is usually seen as small amounts of bright red blood on the toilet paper or on the surface of the motions. Occasionally piles cause severe bleeding.Mucus discharge and itching.
Piles can cause intense itching of the skin around the back passage.Haemorrhoids can become inflamed and swollen, but are rarely very painful, unless associated with an actual splitting of the anus (anal fissure).
CONVENTIONAL TREATMENT OPTIONS
There is no guaranteed way of preventing piles, but a high fibre diet is a good place to start. This will reduce the risk of constipation and the straining to pass a stool that can cause haemorrhoids.
General recommendations are:
- Eat plenty of fresh fruit and vegetables (at least five portions every day)
- Cut down on fat (especially animal fat), sugary food, refined and processed food
- Eat plenty of pulses (eg peas, beans, lentils)
- Eat plenty of wholegrain foods (use the wholemeal varieties of bread, pasta and breakfast cereals)
- Drink alcohol in moderation
A high-fibre diet is also best if you already have haemorrhoids. This helps to prevent constipation and avoid the straining to pass a stool that can make haemorrhoids worse.For most people with haemorrhoids, the condition is mild and can be treated with over the counter (OTC) medicines that tackle the symptoms, usually in the form of ointments or suppositories. Haemorrhoids caused by pregnancy may go away after the baby has been born.Various preparations and brands are commonly used. They do not 'cure' haemorrhoids. However, they may ease symptoms such as discomfort and itch. A bland soothing cream, ointment, or suppository may ease discomfort. They can be used as often as you like. Several brands are available without a prescription. One that contains an anaesthetic may ease pain better. You should only use these for short periods at a time (5-7 days). If you use it for longer, the anaesthetic may irritate or sensitise the skin around the anus. One that contains a steroid may be prescribed by a doctor if there is a lot of inflammation around the haemorrhoids.
Steroids reduce inflammation and may help to reduce any swelling around a haemorrhoid. This may help to ease itch and pain. You should not normally use these for longer than one week at a time.Very painful prolapsed haemorrhoids are uncommon. The pain may be eased by an ice pack (or bag of frozen peas) pressed on for 15-30 minutes. Strong painkillers may be needed.
Haemorrhoids of pregnancy usually settle after the birth of the child. Treatment is similar to the above.
Injection of a 'sclerosing' (shrinking) chemical into the haemorrhoid, may be successful but the benefit is sometimes only short lived and may need to be repeated a few times.
This procedure is usually done by a surgeon in an outpatient clinic. A pile is grasped by the surgeon with forceps or a suction device. A rubber band is then placed at the base of the pile. This cuts off the blood supply to the pile which then 'dies' and drops off after a few days. The tissue at the base of the haemorrhoid heals with some scar tissue.
Banding is a common treatment for large internal and early prolapsing haemorrhoids. It may also be done to smaller piles which have not settled with the measures described above (increase in fibre etc).
Banding of haemorrhoids is often painless as the base of the haemorrhoid originates above the anus opening - in the very last part of the gut where the gut lining is not sensitive to pain. A small number of people have complications following banding such as urinary problems, or infection or ulcers forming at the site of a treated haemorrhoid. If the band is accidentally placed too low it can be very painful until the band drops off. Rarely, the band erodes through one of the arteries supplying a haemorrhoid and can result in a large haemorrhage requiring hospital treatment.
Generally banding is more successful than injection therapy but may at times be painful, and in more advanced cases, can require multiple applications and numerous visits to your specialist.
FORMAL SURGICAL REMOVAL (HAEMORRHOIDECTOMY)
An operation to cut away the haemorrhoid(s) is an option to treat very large internal piles and prolapsing piles not successfully treated by banding or other methods. This is done under general anaesthetic and is usually successful at removing the piles.
It is however very painful for up to six weeks after the surgery whilst the wounds heal and patients may not return to work for many weeks. Problems with healing may also occur and many people who have undergone this operation describe the immediate post-operative period as ‘misery’.
WHAT IS HAL-RAR ?
The Haemorrhoidal Artery Ligation - Recto Anal Repair (HAL-RAR) operation is a new operation designed to eradicate piles without the need for cutting or a general anaesthetic.
Dr McGregor is one of a handful of Australian Surgeons trained in this technique.
The Haemmorrhoid Artery Ligation
operation uses a miniature Doppler ultrasound device to locate all the arteries supplying the haemorrhoids as they come down from the rectum under the lining of the bowel. The device also has a small window which allows a stitch to be placed around the artery thus cutting off the blood supply to the pile. During the course of the procedure all the arteries supplying the piles are located (up to 6) and tied off.
Over the next few days and weeks the pile shrinks away and the symptoms resolve. Because the stitch is placed in the lower rectum, where there are virtually no pain nerves, rather than in the anus the procedure is much less painful than conventional treatments with pain only lasting a few days. The procedure is performed under general anaesthetic. Because all of the blood vessels to the piles are accurately located the operation is more successful than injection; and as the blood vessels are properly ligated rather than just looped with a band they will not dislodge, producing a better response with far less risk of bleeding after the procedure.
Most patients are back to work after 72 hours with only a minimum of discomfort. Some patients can have significant discomfort but this is only for a couple of days and is treated with strong pain killers.
This procedure has been performed in Europe and North America now for many years with excellent results. 85% of patients have a complete resolution of their symptoms and over 90% are thoroughly pleased with the result even if there are some very minor residual symptoms . This is due to the relative ease of recovery from the operation compared to more conventional treatment options.