What are piles (hemorrhoids)?

Piles (or hemorrhoids) are actually engorged blood vessels around the anus that occurs due to excessive straining at stools or after pregnancy in women. These engorged vessels can be easily traumatized by passage of stools, leading to bleeding during defecation. Excessive straining at stools also causes these engorged anal cushions to be pushed out during defecation. Over long periods of time, the elasticity of the supporting tissues is weakened and the prolapsed elements become increasingly difficult to return to the anal canal after bowel movements. They become painfully incarcerated outside the anus, leading to formation of painful pile(s) externally.

What are the different grades of piles?

Piles can be external (outside) or internal (inside the anus). They are divided into 4 grades of severity, based on their sizes and the symptoms that they produced:

• Grade I: Enlarged internal piles that usually presents with bleeding during defecation. These can be easily treated with medications.
• Grade II: These larger piles tend to protrude out during straining at stools but are able to spontaneously return back into the anal canal after bowel movement.
• Grade III: These large piles protrude during defecation causing significant bleeding and remain painfully outside the anus, requiring finger pressure to push it back inside the anus.
• Grade IV: These piles are persistently outside the anus and the blood in the engorged vessels is usually clotted, leading to an extremely painful and swollen lump that requires surgery to achieve relieve.

Do piles turn cancerous?

Piles often present with bleeding during bowel movements. Cancers of the colon or rectum can also present with blood in stools. It is not always easy to differentiate bleeding arising from a benign condition such as piles, from other more sinister conditions like cancer. Therefore, it is important to perform diagnostic evaluations in patients with persistent bleeding to make an accurate diagnosis.

What are the methods for treating piles?

There are many medical and surgical options for managing piles. Please click here to know more about the different treatment options.

What is the best method for treating piles?

Treatment for piles should be tailored to the extent of the problem and the symptoms that the piles produced to ensure that the outcomes are the most optimal without taking unnecessary risks. It is difficult to determine which treatment option is the most suitable without an examination, as small piles (grades I or II) will not require surgery and can be easily treated with simple medications or rubber-band ligation in the clinic on the same day with minimal discomfort and no downtime from work or activities, while larger prolapsing ones (grades III or IV) will usually require surgery in the operating theatre for better symptom control. Surgery is advocated only for the treatment of larger symptomatic piles.

Why is surgery sometimes needed for piles?

The aim of surgery is to remove the grade III or IV piles to relieve the symptoms of pain, swelling and/or bleeding. These symptomatic piles have progressed to such a stage where treatment with medication alone or with less invasive procedures will not be enough to treat and alleviate the symptoms.

These less invasive procedures which may not work for grade III or IV hemorrhoids include:-

1. rubber-band ligation (application of an elastic band on enlarged piles, thereby cutting off the blood flow to the  piles, causing them to shrink and then fall off); or
2. Injection sclerotherapy (involves injecting a chemical that scars the enlarged piles, reducing the blood-flow and thereby shrinking them and alleviating symptoms)

What is the cost of surgery for piles? Can it be reimbursed by Medisave?

For Singaporeans, surgery for piles can enjoy payment by Medisave, subjected to the amount claimable imposed by CPF Board (Central Provident Fund Board).
The cost of treatment will depend on what modalities are used for treatment, whether hospitalization is needed and whether any disposable equipment (e.g. stapling device) is used. A consultation and physical examination is required to determine the mode of treatment. Sometimes, simple medications may just be all that is necessary.

How much time is required for piles surgery? Do I need to stay in the hospital?

Surgery, if needed, can be arranged on the same day or the following day after consultation. Surgery should take less than 30 minutes. You will only need Day Surgery and hospitalization for just a few hours with no need for an overnight stay.

Is piles surgery painful? How long is the recovery period?

The extent of discomfort and recovery period varies depending on the method used to treat the piles. Newer methods of piles treatment are less painful, with faster recovery time and less time off work. Use of better and more effective painkillers further reduce any discomfort.

Conventional Hemorrhoidectomy

In Conventional Hemorrhoidectomy, an instrument delivering a high-energy electrical current that cuts tissues and stops bleeding at the same time is used to cut out the enlarged piles. This is the usual method employed for grade III or IV piles. It is usually performed under general or regional anaesthesia and may require hospitalisation. This procedure can be performed as a day-case and patients can be discharged the same evening.

The wound is usually left open to heal on its own over 4 - 6 weeks. The wound can be also closed with sutures to shorten the healing time.

Ligasure Hemorrhoidectomy

Ligasure Hemorrhoidectomy is a recent modification of the Conventional Hemorrhoidectomy method in which a special vessel sealing device is used to cut off the piles and seal off the engorged blood vessels, thus achieving the intention of removing redundant tissue while minimizing the chances of bleeding. It is also performed under general or regional anaesthesia as a day-case and patients can be discharged the same evening. The wound can be closed with sutures to shorten the healing time.

Stapled Hemorrhoidectomy

Stapled Hemorrhoidectomy is a more advanced procedure usually performed under general or regional anaesthesia. The piles are pushed back into their normal positions within the anal canal. A stitch is then placed around the anal canal, and then used to pull the hemorrhoid tissue into the stapler. The stapler is fired and the piles are removed, while the remaining tissue is simultaneously stapled together. This interrupts the blood supply to the piles, and the loose anal skin is also pulled back up into the anal canal. Because it leaves no open wound on the sensitive skin, Stapled Hemorrhoidectomy is generally less painful and has a shorter recovery time compared to Conventional Hemorrhoidectomy. Most patients will be fairly comfortable within 1 – 2 weeks, as opposed to the 4 – 6 weeks healing time using the Conventional method.

Trans-anal Hemorrhoidal De-arterialization (THD)

During Trans-anal Hemorrhoidal De-arterialization (THD), a special device is inserted through the anus and the blood vessels supplying the piles are precisely located using Doppler ultrasound, and then tied off using surgical stitches. This will interrupt the blood supply to the engorged piles and is suitable if the piles are not too large or prolapsing, with bleeding as the predominant symptom. Since this does not involve cutting any tissue, there is generally minimal post-operative discomfort and no need to be off work after the day of the procedure.

Rubber-band Ligation

Ligation of piles is an outpatient treatment that can be performed in the clinic without anaesthesia. In this procedure, a small rubber-band is applied to the base of the piles, stopping the blood supply to the piles. The piles will then shrivel and die within 3-5 days. The shrivelled pile will fall off during normal bowel movement 3 – 5 days later. It is usually not possible for the patient to discern the shedding of the shrivelled piles, although some mild bleeding during defecation in the 1st week is expected and should not be persistent or massive. The scarring that forms will prevent further prolapse and bleeding. Because it is only possible to 'pinch' off a small portion of the pile at any one time, a large prolapsing pile may sometimes require 2 – 3 repeat ligations 6 weeks apart to achieve the desirable effect. Most patients should be able to return to work the day following the ligation procedure.

Why should we consider genetic testing?

A strong family history of colorectal cancer or colorectal cancer occurring in an individual younger than 50 years old may imply an increased risk of colorectal cancer in the family due to an underlying hereditary trait. The Colorectal Cancer Genomic Health Service at Capstone Colorectal Surgery Centre offers integrated genetics-based management of hereditary colorectal cancers. Understanding your risks of genetically-related cancer can be life saving for you, your relatives, and your future generations.

Working closely with a patient’s physician and other distinguished specialists, we provide comprehensive management of healthcare issues in patients who have, or are at risk to have, inherited colorectal conditions. This takes colorectal cancer care to a new, personalized level. Our recommendations are tailored specifically to an individual’s risk profile, based on the unique family characteristics to provide the most current standard of care.

How is gene testing conducted?

The decision to pursue genetic testing is personal. At Capstone Colorectal Surgery Centre, you have access to professionals who can help guide your decisions. Dedicated Colorectal specialist will explain the details of genetic testing, provide you with accurate, up-to-date information about your specific genetic condition, and inform you of your medical management options, while providing supportive counseling. The need and appropriateness of genetic testing is normally determined during the genetic counseling consultation. The test itself is non-invasive and involves just a simple blood sampling.

Who will benefit from genetic testing?

An individual should consider a genetics consultation if:

1. there is a strong family history of 3 or more colorectal cancers affecting 2 or more generations, especially if one of the affected is a first degree relative (such as a parent or sibling)
2. there is a personal or family history of colorectal cancer diagnosed before 50 years old
3. you had multiple polyps in the colon, rectum or the rest of the gastrointestinal tract
4. you are from a family known to have hereditary conditions such as:
1. Familial Adenomatous Polyposis (FAP)
2. Lynch Syndrome (LS)
3. Puertz-Jegher’s Syndrome (PJS)
4. Cowden’s Syndrome (CS)
5. your managing physician believes there is a possible hereditary component to your colorectal cancer.

What does a genetic consultation involve?

A high-risk family consultation typically involves:

• Review of family history and construction of a family tree
  
• Review of medical history & physical examination
  
• Genetic testing, if appropriate, with pre-test genetic counseling
  
• Education about a patient’s specific diagnosis and any associated health risks
  
• Health planning for the future that details appropriate medical management strategies
  
• Discussion of the health risks to family members
  
• Recommendations and help with genetic testing for at-risk family members

What is a genetic test?

Every human being is born with a unique set of genes. Sometimes a person’s genes may cause a disease or birth defect. Genes can also cause an increased chance of developing certain medical conditions. Genetic tests are usually performed using blood samples or tissues of the patient.

There are many different types of genetic tests. A genetic test is a laboratory test that is performed to analyze an individual’s genetic makeup.

The test may examine a person’s DNA (deoxyribonucleic acid), RNA (ribonucleic acid), proteins, or other chemicals in cells that can indicate a genetic condition. There are different reasons or indications for a genetic test to be performed - they can be used to confirm a diagnosis or to predict the chance that a person will develop a specific disease or condition in the future. Genetic tests can also be used for carrier screening to find out if a person has specific genes that increase the chances of a disease or birth defect occurring in his children or other members of his family.

What are the limitations of a genetic test?

There is no single genetic test that detects all genetic diseases. Most genetic tests detect specific conditions. Your attending doctor will advise you on the genetic tests most suitable for you.

What are the benefits and risks of genetic testing?

Benefits:

A person found to have an increased risk of certain medical conditions would be better informed about the choices of preventive or therapeutic medical treatments for himself. Having the knowledge can empower a person and his affected family members to make significant life planning decisions that may affect the overall disease outcome, prognosis and the future health status of himself and his family.

Knowing about a certain disease gene may provide vital health/ medical information that could assist your doctor in more effectively planning for your clinical care or initiate preventive measures for at-risk individuals.

Risks:

The physical risk of undergoing a genetic test is usually minimal, typically similar to that of providing a blood sample. If your test involves any other type of sample, the doctor performing the procedure, or a designated representative would explain the risks and complications to you before you decide to have the genetic test.