Haemorrhoids – Lecture Notes on Surgery for Under-Graduates of Homoeopathy

A varicose condition of the haemorrhoidal plexus of veins situated in the loose submucous coat of the anal canal and lower part of the rectum is known as haemorrhoids.

TYPES-

1. Internal – Lies beneath the mucosa
2. External – Similar condition of the external plexus below the dentate line and covered by skin
3. Combined – Intero-external which starts as internal piles then grows downwards to involve the anal skin.

AETIOLOGY:  One of the main tributaries of the superior rectal vein is affected, there is no definite cause except some predisposing factors.

1. Congenital weakness of the wall of anal veins or abnormally increased blood supply in the rectal plexus.
2. In human beings the erect position results in very high pressure on the valve and less rectal venous plexus thus rendering them vulnerable to becoming varicose.
3. Apart from these factors, there may be secondary causes of obstruction like pregnancy, pelvic tumors, neoplasm of the rectum causing thrombosis or obstruction to venous flow.

 THESE ARE FURTHER CLASSIFIED AS

• Primary when no definite causes of obstruction is evident.
• Secondary some definite causes of obstruction is present.

1. Local causes (common)
2. Chronic habitual constipation.
3. Rectal growth or ulceration.

• Pregnancy or pelvic tumor.

1. Chronic straining during micturition.

 

1. B) General causes (rare)

• Cirrhosis of the liver.
• Portal obstruction

 

Anatomical sites  –  3, 7 & 11 O’clock positions involving main tributaries of superior rectal veins.

Primary  –   3, 7 & 11 O’clock positions.

Secondary  – Two associated with piles in the 3 O’clock position and two with that in the 7 O’clock position.

COMPLICATIONS

1. Ulceration
2. Prolapse and strangulation
3. Anaemia from repeated bleeding
4. Thrombosis of the veins
5. Infection (especially after thrombosis)
6. Portal pyaemia.

GRADING OF HAEMORRHOIDS

• First-grade – Haemorrhoids are confined to the anal canal, they bleed but do not prolapse.
• Second grade -Haemorrhoids prolapse on defecation and reduce spontaneously.
• Third-grade – Haemorrhoids remain prolapsed outside the anal margin, usually, infection supervenes and there may be thrombosis of veins.

 

 

EACH HAEMORRHOIDAL MASS CONSISTS OF

• Bunch of varicose veins
• One of the terminal branches of the superior rectal artery lies in loose areolar tissue and is covered by a mucous membrane.

SYMPTOMS

• 1^st Degree

1. a) Painless bleeding per rectum during

defecation.

1. b) Character of blood- fresh blood and

not mixed with motion.

• 2^nd Degree

1. a) Bleeding is more marked
2. b) There is fleshy swelling around the anus during defecation
3. c) Pain is absent or slight discomfort is felt.

• 3^rd Degree

1. Bleeding is slight or absent (which may be due to thrombosis of the vessel)
2. There is constant swelling around the anus
3. There may be mucus discharge or pruritus ani.
4. Painless bleeding may become painful if there is infection or strangulation and at times due to associated fissures in ano.
5. e) Uncomplicated haemorrhoids never produce painful bleeding per rectum.

SIGNS

1. In the first and second degrees no external swelling.
2. In the third degree, there is a fleshy swelling around the anus.
3. The swelling may be tender.

• P/R – In the early stage nothing is felt, but later piles can be felt as an elongated fleshy mass.
• Sigmoidoscopy is done to exclude other rectal lesions.
• In chronic cases anaemia is present.

 

RECTAL BLEEDING

	BLOOD	PAIN
Haemorrhoids	Bright red color blood on paper and in pan. May prolapse	Painless, unless prolapsed and thrombosed.
Fissure in ano	Bright red blood on paper and outside of stool.	Painful, pain lasting long after passing stool.
Colon & rectal cancer.	Blood often mixed in with stool, especially of proximal tumor.	Usually painless, unless distally placed in rectum or anal canal, when causes tenesmus.
Diverticular disease.	Large volume of blood in pan.	Painless.
Ulcerative colitis.	Blood and mucous mixed with loose stool.	Painless, unless coexistent fissure.

EXAMINATION AND INVESTIGATION

1. Examination of the abdomen to exclude palpable lesions of the colon or aggravating factors for haemorrhoids.
2. Rectal examination – Internal haemorrhoids are not palpable but prolapsing piles are immediately obvious.
3. Proctoscopy will visualize the internal haemorrhoids.
4. Sigmoidoscopy is performed routinely, again to eliminate a lesion higher in the rectum proctitis, polyp and cancer.
5. A barium enema is carried out in any case where symptoms such as alteration in bowel habits or to find some more sinister condition than internal haemorrhoids.
6. Colonoscopy may be indicated to visualize and take a biopsy of any lesion thus revealed

 

HOMOEOPATHIC MANAGEMENT

• AESCULUS HIPP.
• ALOE
• GRAPHITES
• NUX VOMICA
• PULSATILLA
• CARBO VEG
• SULPHUR
• ARNICA MONTANA
• CALCAREA FLUORICA.
• MURIATIC ACID
• LYCOPODIUM

 

AESCULUS HIPPOCASTANUM

• The action of this drug is most marked on the lower bowel, producing engorged haemorrhoidal veins, with characteristic backache, with absence of actual constipation.
• Dry, aching in anus feels full of small sticks.
• Anus raw, sore, and much pain after stool.
• Haemorrhoids, with sharp shooting pains up the back.
• Both blind and bleeding haemorrhoids; worse during climacteric; if they bleed it gives relief.
• Burning in anus with chills up and down back.
• There is a pain like burning and stitching pain in the anus that persists for a long hour after the stool.
• Feeling of something stuck inside the anus because of inflammation of piles.
• There is a constipation tendency.
• Haemorrhoids associated with backache.
• Several large piles seem to block up the rectum, with little or no bleeding, great suffering & constipation.

ALOES SOCRATINA

• Aloe Socotrina is a medicine used to treat external piles that are sore and tender.
• Sharp or burning pain in the rectum and a constant feeling of bearing down in the rectum may be felt.
• The application of a cold compress may help relieve the pain or burning sensation.
• Haemorrhoids that are swollen and protrude “like a bunch of grapes” and are soothed by cold soaks or compresses may be helped with this remedy.
• Haemorrhoids may alternate with diarrhoea, and the person may have a lot of flatulence.
• Heaviness, heat, pressing and burning in the rectum.
• Want of confidence in sphincter ani, rectum seems full of fluid which feels heavy, as if it would fall out.
• When passing the wind, feeling as if stool would escape with it.
• Itching, burning, pulsations, pain as if from fissures, at the anus, preventing sleep.
• A lot of mucus, with pain in the rectum after stool.
• Burning in the anus and rectum.
• Constipation, with heavy pressure in the lower part of the abdomen.
• Diarrhoea from beer.

GRAPHITES

• Burning haemorrhoids.
• Prolapse, diarrhoea, stools of brown fluid, mixed with undigested substance, very fetid, sour odour.
• Smarting, sore anus, itching.
• Lump stool, conjoined with threads of mucus.
• Varices of the rectum.
• Itching, a sensation of excoriation, and swelling of the anus.
• Large haemorrhoidal excrescences in the anus, with pain as from excoriation, esp. after a stool.
• Painful and burning cracks between the haemorrhoidal tumours.
• Prolapse of the rectum with the varices, as if the rectum was paralyzed.
• Graphites is a medicine used to treat painful piles that get worse during sitting.
• Cutting pains and swelling with cracks at the anus are present.
• The stool tends to be hard, knotty and scanty.

NUX VOMICA

• Nux Vomica is a medicine used to treat blind piles where there is pronounced burning and itching around the anus.
• Haemorrhoids are caused by a sedentary lifestyle, overeating and drinking, especially spicy and rich foods and alcohol.
• Constriction of the rectum.
• Irregular, peristaltic action, hence frequent ineffectual desire, or passing but small quantities at each attempt.
• The absence of all desire for defecation is a contra-indication.
• Alternate constipation and diarrhoea after abuse of purgatives.
• Urging for passing stool felt throughout the abdomen.
• Itching, blind haemorrhoids, with ineffectual urging to stool, very painful, after drastic drugs.
• Diarrhoea after a debauch, worse, morning.
• Frequent small evacuations.
• Scanty stool, with much urging.
• Dysentery and stools relieve pains for a time.
• Constant uneasiness in the rectum.

PULSATILLA

• Haemorrhoids are itchy and uncomfortable, with sticking pains.
• They are likely to protrude, with improvement after lying down.
• Warmth often aggravates the symptoms.
• This is a very helpful remedy for haemorrhoids that appear during pregnancy or around the menstrual period.
• Constipation and difficult evacuations, sometimes with painful pressure on the rectum and pains in the back.
• Blind haemorrhoids, with itching and sticking pains.
• Involuntary and unperceived evacuations during sleep.
• Protrusion of haemorrhoids.
• Stools frequent, soft, diarrheic, consisting of yellow mucus or mixed with blood, preceded by cutting in the abdomen, or with pains in the small of back.
• Blind and bleeding haemorrhoids, with itching, smarting, and pain as from excoriation.
• Haemorrhoidal tumours with great soreness.

CARBO VEGETABILIS

• Large painful haemorrhoidal tumours of a deep blue colour at the anus.
• Fluent haemorrhoids.
• Shooting, itching and burning pain in the anus.
• Discharge from varices.
• Discharge of a viscous and corrosive serum from the anus and rectum, esp. at night.
• Excoriation and oozing at the perineum.
• Constipation, hard, tough, scanty stool.
• Insufficient evacuations, difficult evacuations, without being hard, with straining, burning pain in the anus, and pains similar to those of parturition, in the abdomen.
• Flatus hot, moist, offensive.
• Itching, gnawing and burning in the rectum.
• Acrid, corrosive moisture from the rectum.
• A musty, glutinous moisture exudes, soreness, and itching moisture in the perineum at night.
• Painful diarrhoea of old people.
• Discharge of blood from the rectum, burning at the anus, burning varices.
• Frequent, involuntary cadaverous-smelling stools, followed by burning.
• White haemorrhoids, excoriation of the anus.
• Bluish, burning piles, painafter stool.

SULPHUR

• Constitutions disposed to haemorrhoids, with constipation or morning diarrhoea.
• There is itching of the anus always.
• The person is having a tendency to early morning stool just after waking from bed.
• Itching and burning of anus; piles dependent upon abdominal plethora.
• Frequent, unsuccessful desire; hard, knotty, insufficient.
• Redness around the anus, with itching.
• Morning diarrhoea, painless, drives out of bed, with prolapse of rectum.
• Haemorrhoids, oozing and belching.
• Haemorrhoids where there is a soreness and tenderness at the anus along with a hard, knotty stool.
• Weakness after passing stool, excessive rectal pain, and a biting sensation at the anus that gets better upon lying down.
• The anus is inflamed and red and may protrude significantly.
• The person may feel worse from warmth, and bathing and have flatulence with a strong, offensive odour.

ARNICA MONTANA

• Sore, bruised-feeling in haemorrhoids, especially when straining or over-exertion (for instance, childbirth or heavy lifting) has brought on the haemorrhoids.
• Stools in the form of pap, of an acid odour.
• Flatus, smelling like rotten eggs.
• Diarrhoea, with tenesmus, frequent, scanty, small, mucous stools.
• Involuntary stools, chiefly during the night, thin, brown, or white.
• Stools of undigested matter.
• Purulent, bloody stools, with haemorrhoids.
• Pressure in the rectum.

CALCAREA FLUORICA

• This remedy may be indicated for haemorrhoids with bleeding and itching in the anal region, or internal haemorrhoids causing soreness in the very low back and sacrum.
• Bleeding haemorrhoids.
• Itching of the anus as from pin-worms.
• Internal or blind piles frequently, with pain in the back, generally far down on the sacrum and constipation.
• Much wind in the lower bowels, worse during pregnancy.
• Slight diarrhoea with painful urging before stool.
• Constipation with dizziness and dull headache.
• Itching in their anus awakening him at night.
• Bleeding piles, Fissures & fistula.

MURIATIC ACID

• Tendency to involuntary evacuations while urinating.
• Haemorrhoids are most sensitive to all touch, even a sheet of toilet paper is painful.
• Anal itching and prolepses ani while urinating.
• Haemorrhoids during pregnancy, bluish, hot with violent stitches.
• Involuntary evacuation of liquid and serous faeces when urinating.
• Discharge of blood during stools.
• Prolapse of the rectum, when urinating.
• Itching in the anus.
• Haemorrhoids protrude like a bunch of grapes.
• Swollen and bluish haemorrhoidal excrescences, with burning pain as from excoriation < by touch.
• Bleeding haemorrhoids.

LYCOPODIUM

• Pains in the anus after a meal and after an evacuation.
• Itching and tension in the anus.
• Incisive pains, shootings and pain from excoriation in the rectum.
• Spasms in the rectum, contraction of the rectum so that it protrudes during a hard stool.
• Piles swollen, protruding, burning protruding during soft stool, painful on touch and when sitting.
• Haemorrhoidal excrescences in the anus and in the rectum, with prolapse of the rectum.
• Itching eruption in the anus, itching and tension at the anus (evening in bed).
• Painful closing of the anus.
• Protrusion of the varices.
• Distension of the varices of the rectum.
• Inactive intestinal canal.
• Ineffectual urging, stool hard, difficult, small, incomplete.
• Haemorrhoids are very painful to touch and aching.

Bibliography:-

• Essential Orthopaedics by J. Maheshwari 5^th Edition
• Hand Book of Surgery by S. C. Basu. 2^nd Edition reprinted in 2005 Pocket Manual Of Homoeopathic Materia Medica, Boericke William, M.D
• Clinical Materia Medica. Farrington. E.A., M.D.
• A Dictionary of practical materia medica Clarke Henry John, M.D.
• Homoeopathic Therapeutics. Samuel Lilienthal. M.D.