PILES, FISSURES ANAD FISTULAS

Hemorrhoids also called piles, are swollen and inflamed veins in your anus and lower rectum. Hemorrhoids may result from straining during bowel movements or from the increased pressure on these veins

Types

A] External piles- present as a swelling outside the anus with irritation and itching. These can be painful sometimes and usually do not bleed.

B] Internal piles- Internal piles are usually not painful but these bleed when they are irritated such as during the passage of hard stools. They can be classified into four grades:

• Grade 1 piles are small swellings on the inside lining of the anus. They cannot be seen or felt from outside the anus.

• Grade 2 piles are partly pushed out (prolapse) from the anus when you go to the toilet, but quickly 'retract back' inside again.

• Grade 3 piles hang out (prolapse) from the anus and are felt as one or more small, soft lumps that hang from the anus. However, they can be pushed back inside the anus with a finger.

• Grade 4 piles permanently hang down from within the anus, and cannot be pushed back inside. They can sometimes become quite large

 

    Primary haemorrhoids:  These are three in number seen at 3, 7 & 11 o’clock positions.

Secondary haemorrhoids: Presence of additional haemorrhoids in between the primary piles is known as the secondary piles.

Signs and symptoms

Painless bleeding during bowel movements — you might notice small amounts of bright red blood on your toilet tissue or in the toilet bowl

·         Itching or irritation in your anal region

·         Pain or discomfort

·         Swelling around your anus

·         A lump near your anus, which may be sensitive or painful

·         Leakage of feces

Haemorrhoids symptoms usually depend on the location.

 Internal hemorrhoids lie inside the rectum.You usually can't see or feel these hemorrhoids, and they usually don't cause discomfort.

But straining or irritation when passing stool can damage a hemorrhoid's delicate surface and cause it to bleed. Occasionally, straining can push an internal hemorrhoid through the anal opening. This is

known as a protruding or prolapsed hemorrhoid and can cause pain and irritation.

External hemorrhoids are under the skin around your anus. When irritated, external hemorrhoids can itch or bleed. Sometimes blood may pool in an external hemorrhoid and form a clot (thrombus), resulting in severe pain, swelling and inflammation.

Causes

The veins around your anus tend to stretch under pressure and may bulge or swell. Swollen veins — hemorrhoids — can develop from an increase in pressure in the lower rectum. Factors that might cause increased pressure include:

·         Straining during bowel movements

·         Sitting for long periods of time on the toilet

·         Chronic diarrhoea or constipation

·         Obesity

·         Pregnancy

·         Dietary habits: elimination of cereal fibres from the diet results considerably in the high incidence of chronic constipation and ultimately haemorrhoids

·         Anal inter)      Hereditary:  Some defect in the venous structure has been held responsible. e.g. congenital weakness of the walls of vein.course

·         Constipation: Straining in constipated persons results in the engorgement of internal haemorrhoidal veins, giving rise to the disease piles.

2] Anal Fistula

WHAT IS AN ANAL FISTULA?

Anal fistula, or fistula-in-ano, is an abnormal connection or channel like structure, between the surface of the anal canal and the exterior perianal skin. Anal fistulae originate from the anal glands, which are located between the two layers of the anal sphincters and which drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula. Ancient Ayurveda surgeon, Susruta has described five types of Bhagandara(Sataponak, Ustragriwa, Parisrabi, Sambukawarta, Unmargi). They have been classified according to the vitiation of the three doshas and the shape & site of the fistula tract.

CAUSES OF FISTULA?

Anal fistulas commonly occur due to an anal abscess.

An abscess is a collection of pus and infected fluid. An anal abscess usually develops after a small gland, just inside the anus, becomes infected with bacteria.

A fistula may occur if an abscess has not completely healed, or if the infected fluid has not been entirely drained away.

An anal fistula may also develop as a result of:

·         a growth or ulcer (painful sore)

·         a complication from surgery

·         a congenital abnormality (a health problem that you were born with)

Anal fistulae are also a common complication of conditions that result in inflammation of the intestines. Some of these conditions include:

·         Irritable bowel syndrome (IBS): a chronic (long-term) disorder that affects the digestive system, causing abdominal pain, diarrhoea and constipation.

·         Diverticulitis: the formation of small pouches that stick out of the side of the large intestine (colon), which become infected and inflamed.

·         Ulcerative colitis: a chronic condition that causes the colon to become inflamed and can cause ulcers to form on the lining of the colon.

·         Crohn's disease: a chronic condition that causes inflammation of the lining of the digestive system.

SYMPTOMS OF FISTULA

Anal fistulae can present with many different symptoms such as:

·         Pain

·         Discharge - either bloody or purulent

·         Pruritus ani– itching around the anus

·         Systemic symptoms if abscess becomes infected

DIAGNOSIS OF FISTULA

Diagnosis is by examination, either in an outpatient setting or under anaesthesia. The examination can be an Anoscopy.

Possible findings:

·         The opening of the fistula onto the skin may be seen

·         The area may be painful on examination

·         There may be redness

·         A discharge may be seen

·         It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula

ANAL FISSURES

What is a fissure?

An anal fissure is a small tear in the skin that lines the anus. An anal fissure may occur when you pass hard or large stools during a bowel movement. An anal fissure typically causes pain and bleeding with bowel movements.

Anal fissures most often affect people in middle age, but fissures also are the most common cause of rectal bleeding in infants. Most anal fissures heal within a few weeks with treatment for constipation, but some fissures may become chronic

COMMON CAUSES OF ANAL FISSURES

Anal fissures can be caused by trauma to the anus and anal canal. The cause of the trauma can be one or more of the following:

·         Chronic constipation

·         Straining to have a bowel movement, especially if the stool is large, hard, and/or dry

·         Prolonged diarrhea

·         Anal stretching

·         Insertion of foreign objects into the anus

Other causes of anal fissures (other than trauma) include:

·         Longstanding poor bowel habits

·         Overly tight or spastic anal sphincter muscles (muscles that control the closing of the anus)

·         Scarring in the anorectal area

·         Presence of an underlying medical problem: such as Crohn’s disease and ulcerative colitis; anal cancer; leukemia; infectious diseases (such as tuberculosis); and sexually transmitted diseases (such as syphilis, gonorrhea, Chlamydia, chancroid, HIV)

·         Decreased blood flow to the anorectal area

SYMPTOMS OF ANAL FISSURE

Signs and symptoms include:

·         Pain during, and even hours after, a bowel movement

·         Constipation

·         Blood on the outside surface of the stool

·         Blood on toilet

·         A visible crack or tear in the anus or anal canal

·         Burning and itch that may be painful

·         Discomfort when urinating, frequent urination, or inability to urinate

·         Foul-smelling discharge

·          

RISK FACTORS FOR ANAL FISSURES

Factors that may increase your risk of developing an anal fissure include:

·         Infancy. Many infants experience an anal fissure during their first year of life, although experts aren't sure of the reason.

·         Aging. Older adults may develop an anal fissure partly because of slowed circulation, resulting in decreased blood flow to the rectal area.

·         Constipation. Straining during bowel movements and passing hard stools increase the risk of tearing.

·         Childbirth. Anal fissures are more common in women after they give birth.

·         Crohn's disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract, which may make the lining of the anal canal more vulnerable to tearing

PREVENTION OF ANAL FISSURES

For fissures in adults:

·         Keep the anorectal area dry

·         Wipe the area with soft materials, a moistened cloth, or cotton pad; avoid rough and scented toilet paper

·         Promptly treat all occurrences of constipation and diarrhea

·         Avoid irritating the rectum

COMPLICATIONS OF ANAL FISSURES

Complications of anal fissure can include:

·         Anal fissure that fails to heal. An anal fissure that doesn't heal can become chronic, meaning it lasts for more than six weeks.

·         Anal fissure that recurs. If you've experienced anal fissure once, you have an increased risk of another anal fissure.

·         A tear that extends to surrounding muscles. An anal fissure may extend into the ring of muscle that holds your anus closed (internal anal sphincter). This makes it more difficult for your anal fissure to heal. An unhealed fissure may trigger a cycle of discomfort that may require medications or surgery to reduce the pain and repair or remove the fissure.