Medical and surgical treatment of piles

  
Medical and surgical treatment of piles

Treatment of piles can be divided into

 conservative medical

Treatment indicated in first and early second degree piles as well as in long term management after treatment of other degree this relies mainly on avoiding constipation and straining as well as increase dietary fiber intake local application of astringent creams like xyloproct give moderate symptommatic relief to  symptoms also give analgesics laxatives and antibiotics and rest in bed those in case of prolapsed piles also use lead subacetate lotion applied to piles 2 hourly for 24 hours to relieve the edema manual dilatation of the anus under anaesthesia (lord) can be used for patient with prolapsed
thrombosed piles and anal spasm as sever stretching of anal sphincter relieves pain

 Injection sclerotherapy 

Indicated for uncomplicated first degree bleeding internal piles five per cent phenol in almond oil or 5% ethanolamine oleate solution is used for injection three ml are injected sub mucosally into the root of each major haenorrhoid well above the dentate line two or three sites can be injected per session injection can be repeat after 4 week but it is not recommended to repeat it more than 2 or 3 times it is usually gives good short term results rarely injection may cause ulceration when done superficially or pain abscess and oleo granuloma

 Rubber band ligation 

This is indicated in bleeding and prolapsed second degree  and early third degree internal piles it is contraindicated in patients on anticoagulants bleeding disorders or immune deficiency up to three sites can be treated in the same session and it can be repeated after 4-6 weeks

 Infrared photo coagulation

 Indicated for first and second degree piles  the probe is inserted by an anoscope and is applied to haemorrhoids above the dentate line for 1-2 seconds it is applied to 3 or 4 sites over the apex and sids of each major haemorrhoid this produce a cicular burn about 2-5 mm in depth results are comparable to sclerotherapy and banding

 Operative treatment of piles

Haemorrhoidectomy is associated with less need for further future therapy surgery is usually indicated in third and fourth degree piles there are now two main competing techniques traditional excisional haemrrhoidectomy and stapled haemorrhoidectomy 

Open haemorrhoidectomy(milligan - morgan ,st. marks

Haemorrhoidectomy which the prolapsed piles are excised by scissors or diathermy usually at three main sites leaving three mucocutaneous bridges at least 1 cm in width each and leaving the resultant wound open this is still the most widely practical transfixing excision
haemorrhoidectomy 

Closed haemorrhoidectomy (ferguson

This is a similar technique but it ends with closure of the wound it is more popular in the united states

Laser haemorrhoidectomy

Laser may be used either for vaporization of the tissues overlying the piles resulting in an ulcer and fixation (non-contact laser) usually in second degree piles or used as knife for performing a milligan-morgan haemorrhoidectomy either the CO2 or ND-YAG is used but these claims are not yet substantiated

 Stapled haemorrhoidectomy (LONGO PROCEDURE ,PPH PROCEDURE FOR PROLAPSE AND HAEMORRHOIDS

This new procedure aims at pulling the prolapses cushions back
into place rather than resceting them this is done by excising a cylinder of the lower rectal mucosa and submucosa and re anastomosing them using a specially designed circular
stapling instrument it is indicated in third degree not in fourth degree and seems to be associated with less postoperative pain and faster return to normal activity however long term result are not known yet postoperative management this should be include adequate analgesia stool softeners and frequent sitz baths give antibiotics and metronidazole may be done as a day case surgery NB,the degree of pain in individual patient is unpredictable

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