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Treatment of Piles (Haemorrhoids)

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Grading - The Foundation of Treatment Choice

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1. Conservative (Medical) Management

• Dietary fiber: 20-30 g daily
• Fluid intake: 6-8 glasses of non-alcoholic, non-caffeinated beverages daily
• Stool softeners and bulking agents (e.g., ispaghula/psyllium)
• Defecatory posture: Minimize straining; avoid prolonged sitting on the toilet
• Sitz baths / warm soaks: Provide symptomatic relief
• Topical agents: Proprietary creams applied at night and before defecation (e.g., witch hazel, hydrocortisone-containing creams)
• Phlebotonics (flavonoids): Plant-based flavonoid extracts (e.g., diosmin, hesperidin - brand: Daflon/Vasculara) and synthetic compounds (calcium dobesilate). These improve venous tone, stabilize capillary permeability, reduce bleeding, and have an excellent safety profile. Particularly useful in Grade II-III hemorrhoids. Recent meta-analysis (PMID 38847122) confirms flavonoids improve post-haemorrhoidectomy recovery as well.

• Bailey and Love's Short Practice of Surgery 28th Ed, p. 1452
• Sleisenger and Fordtran's GI and Liver Disease, p. 2671

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2. Office-Based Procedural Treatments

A. Injection Sclerotherapy

• Indication: Grade I and II internal haemorrhoids
• Agent: 5% phenol in arachis (peanut) oil or almond oil (3-5 mL per haemorrhoid)
• Mechanism: Causes submucosal fibrosis, obliterating vascular channels and supporting prolapsing mucosa
• Technique: Inject at the apex of the pedicle, NOT into the haemorrhoid itself; correct placement causes no pain
• Reassess at 8 weeks; repeat if needed
• Warning signs: Pain on injection = needle misplaced; rapid whitening/bulging = too superficial (may cause ulceration)
• Recent meta-analysis (PMID 38261136) confirms sclerotherapy is effective with a good safety profile

B. Rubber Band Ligation (RBL)

• Most common office procedure for haemorrhoids
• Indication: Grade II and III (primarily); can be used in Grade I
• Mechanism: Band placed just proximal to the internal haemorrhoid, above the dentate line - causes necrosis, sloughing, fibrosis, and fixation of mucosa
• IMPORTANT: Never place band distal to the dentate line (causes severe pain)
• Success rate: ~75% for Grade I/II, ~65% for Grade III
• Recurrence: ~20%
• Patients reassessed at 4-6 weeks; most managed with ≤3 procedures
• Post-procedure: Sitz baths, acetaminophen, maintain fiber/water intake
• Complications: Bleeding (1% severe), sepsis, cellulitis (rare but life-threatening - requires urgent attention)
• Local anesthetic injection reduces post-banding pain (confirmed by meta-analysis, PMID 38436741)

C. Infrared Photocoagulation (IRC)

• Suitable for Grade I-II haemorrhoids
• Applied to the apex of the haemorrhoid; causes thermal coagulation and fibrosis
• Office-based, well-tolerated

D. Cryotherapy

• Less commonly used today due to variable results and wound healing issues

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3. Surgical Treatment

• Grade III haemorrhoids failing office procedures
• Grade IV (permanently prolapsed) haemorrhoids
• Haemorrhoids with a significant external/cutaneous component ("mixed haemorrhoids")
• Strangulated/thrombosed haemorrhoids (urgent)

A. Conventional Haemorrhoidectomy

• Milligan-Morgan (Open): Excision of haemorrhoidal complexes leaving wounds open to heal by secondary intention - standard in the UK
• Ferguson (Closed): Wounds closed primarily after excision - standard in the USA
• Both methods have comparable efficacy; meta-analysis (PMID 38762410) shows diode laser hemorrhoidoplasty has fewer complications vs. conventional techniques but similar efficacy

B. Stapled Haemorrhoidopexy (Procedure for Prolapse and Haemorrhoids - PPH)

• Uses a circular stapler to excise a ring of mucosa above the haemorrhoids, reducing prolapse and interrupting blood supply
• Less painful than conventional haemorrhoidectomy
• Higher recurrence rate in the long term
• Less suitable for large external components

C. Doppler-Guided Haemorrhoidal Artery Ligation (DGHAL / THD)

• Uses a Doppler probe to identify and ligate terminal branches of the superior rectal artery
• Minimally invasive, less pain, suitable for Grade II-III
• May be combined with mucopexy (RAR - recto-anal repair)

D. Diode Laser Haemorrhoidoplasty

• Emerging technique; delivers laser energy to shrink haemorrhoidal tissue
• Meta-analysis (2024, PMID 38762410) shows fewer post-op complications and less pain vs. Milligan-Morgan/Ferguson but comparable symptom resolution

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4. Treatment of Complications

Strangulated / Thrombosed Haemorrhoids

• Conservative: Bed rest, adequate analgesia, cold saline compresses, laxatives - resolution in 3-4 days
• Surgical: Urgent haemorrhoidectomy if there is impending mucosal necrosis (risk of anal stenosis if not careful)
• Antibiotics: Systemic antibiotics to reduce risk of portal pyaemia

External Haemorrhoidal Thrombosis

• Incision and evacuation of clot within 72 hours of onset gives excellent relief
• After 72 hours, conservative management (sitz baths, analgesia) is preferred as the thrombus begins to resolve

Severe Haemorrhoidal Bleeding

• Local adrenaline (epinephrine) compress
• Blood transfusion if required
• Examination under anaesthesia + ligation/excision if conservative measures fail

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5. Treatment by Grade - Quick Reference

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Recent Evidence Highlights (2024-2025)

• Sclerotherapy is effective with low complication rates across all office-based techniques (PMID 38261136)
• Local anaesthetic at RBL significantly reduces post-banding pain (PMID 38436741)
• Diode laser haemorrhoidoplasty: fewer complications vs. open surgery, similar efficacy (PMID 38762410)
• Flavonoids/phlebotonics reduce bleeding duration and improve post-haemorrhoidectomy recovery (PMID 38847122)
• Surgical vs. conservative meta-analysis (2025): Surgery provides better long-term symptom control for Grade III-IV but higher complication risk (PMID 40596934)

Sources: Bailey and Love's Short Practice of Surgery 28th Ed | Sleisenger and Fordtran's Gastrointestinal and Liver Disease | PubMed systematic reviews 2024-2025

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Medicines Treatment Chart - Fever Patient

Note: 100°F (37.8°C) is classified as a low-grade fever. True fever is generally defined as ≥100.4°F (38°C). At this level, antipyretic medicines may not always be necessary if the patient is comfortable - treating the underlying cause is the priority. However, for symptomatic relief, the following applies.

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First-Line Antipyretic Medicines

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Supportive / Adjunct Medicines

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Detailed Drug Profile

1. Paracetamol (Acetaminophen) - PREFERRED FIRST CHOICE

2. Ibuprofen - SECOND CHOICE (if no contraindications)

3. Diclofenac

4. Naproxen

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Non-Pharmacological Measures (Equally Important)

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When to Escalate / Seek Immediate Medical Attention

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Summary Prescription at a Glance

Rx:
1. Tab. Paracetamol 500 mg      - 1 tab every 6 hours (if temp > 100°F) 
                                    with water, after food
                                    Max: 4 tabs/day
                                    Duration: 3 days or until fever resolves

2. Tab. Ibuprofen 400 mg        - 1 tab every 8 hours (if inflammation present)
                                    ONLY after food  
                                    Duration: 3 days (avoid if peptic ulcer/kidney issues)

3. ORS Sachet                   - 1 sachet in 200 mL water, 3x/day

Advice:
- Drink 2-3L fluids daily
- Rest adequately
- Tepid sponging if uncomfortable
- Return if fever > 103°F or persists > 3 days
- Investigate cause if fever does not settle

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Sources: Morgan & Mikhail's Clinical Anesthesiology 7e | Rosen's Emergency Medicine | Lippincott Illustrated Reviews: Pharmacology

Disclaimer: This chart is for general educational reference. Always tailor treatment to the individual patient and identify the underlying cause of fever. Consult a licensed physician before prescribing.