All You Ever Wanted To Know About Piles

What Are Piles?

Piles or haemorrhoids are swellings around the anus caused by enlarged or engorged veins.
Piles 01

Piles Symptoms

Piles may present as a lump at the anus or the lump may come out only when passing motion. Piles may also cause bleeding, typically dripping into the toilet bowl after opening the bowels. If the piles prolapse out and the blood inside clots, the piles become very painful. Patients may have difficulty sitting down. Not all of the above symptoms are caused by piles. I have personally seen many cases where the cause of the lump or bleeding is something else. Common examples include:

  • anal fissures
  • anal polyps
  • mucosal prolapse
  • perianal fistula
  • cancer
What Causes Piles?

Piles are most commonly caused by constipation. When your stools are hard, you have to strain hard during bowel movement. This increases the pressure inside your abdomen and also in the veins. Over time, your veins become swollen and engorged. Sometimes, when the veins get very large, they may prolapse or slip out through the anus. Chronic laxative abuse can also cause excessive straining. Pregnancy causes piles too. As your baby presses on your pelvic veins, this partially obstructs the flow of blood back to your heart and results in rising pressure in your pelvic veins, including the veins around the anus. Piles can also be caused by liver disease like cirrhosis, tumours in the pelvis and abnormal vessels around the anus.

Types of Piles

There are two types of piles: external and internal piles. External piles appear as a bluish lump at the anus. If a clot forms inside, it can become sensitive & painful. Internal piles are usually not visible. They often cause bleeding especially when opening bowels. If they get very large, they can prolapse or slip out as a lump at the anus. When this happens, the piles can become very painful. Often there is a combination of internal and external piles.

Treatment for Piles

If you have been told you have piles, do not delay in seeing a doctor. If you come to me for a check-up, I will conduct a detailed examination to make sure it is really piles and not something else. You’d also be advised in terms of treatment. You can then decide exactly how far you want to go and which treatment to opt for.

4 Common Ways To Treat Piles

If your piles are small and do not cause much trouble, they can be left alone. Small piles which bleed can be helped with medication. This includes medication to deal with constipation if you suffer from constipation. In terms of larger piles, they can be “banded” which means placing a small tight rubber band at the base of the pile. This stops blood flow into the pile so that the pile can shrink down. Later, the rubber band will fall off on its own. Another way to treat piles is by injection. This method has become less and less popular because it causes bleeding and discomfort. If you have very large or multiple piles, I suggest you remove them using surgery.

Using Surgery To Treat Piles

Many people are now opting for stapled haemorrhoidectomy (PPH haemorrhoidectomy) as a treatment method. In this treatment, we use a circular stapler to excise and staple the piles. As the operation is carried out on the inside, you won’t see any visible scars. There is considerably less pain using this method and healing is also faster compared to conventional surgery. However, not everyone can be treated this way. If your piles are not suitable for this method, you can still have them removed using conventional surgery, that is, removing the piles and then suturing the wound. You then have to wash twice daily with salt baths until the wounds heal, which takes about 3 to 4 weeks. Alternatives to stapling include ultrasound guided suture ligation of the piles as well as laser haemorrhoidectomy. Each method has its strengths and weaknesses.

The Mooncake

As I sat in my clinic staring at the newspaper, the phone suddenly rang. It was the Accident & Emergency Unit, and they had an accident case for me. The voice at the other end of the phone sounded urgent, saying it was a bad case, asking if I would accept it.

The day had just gone pear-shaped.

mooncake

 

Broken Glass Everywhere

I hurried over to find Mr Woon, a 26 year old man lying on a stretcher. He was pale and had a large blood soaked pack applied to his neck.

The ambulance person recounted the details – Mr Woon had been involved in a head-on collision with a van. He had been catapulted off his motorcycle and went through the windscreen of the van. That he was wearing a helmet probably saved his brain, but his neck had landed on the jagged glass of the shattered windscreen.

Gingerly, I peeled back the blood soaked pack to be confronted by an absolutely ghastly wound in the neck stretching from ear to ear.

There was some bleeding coming from the wound and he was partly breathing through the wound indicating injury to the windpipe (trachea).

Everywhere there was broken glass.

Hastily I replaced the pack. A quick glance at the monitor showed the blood pressure was holding well though Mr Woon had clearly lost a lot of blood on his way to hospital.

Quickly, I checked to make sure there were no other major injuries elsewhere. I then calmly told Mr Woon that he needed emergency surgery as soon as possible.

Mr Woon weakly nodded and extended a shaky hand to sign the consent.

I then spoke to Dr Wong, the On-Call Consultant Anaesthetist.

In a move of sheer brilliance, Dr Wong instructed me to send Mr Woon straight up to the operating theatre (OT) where he would resuscitate the patient rather than the usual process of admission to the ward first which would have wasted much time.

In OT, I encountered Dr Wong getting Mr Woon ready for general anaesthetic. The bleeding in the neck seemed to be under control with the pack in place. Next door, the nurses were busy readying the trolley and instruments. Blood had been ordered from the Lab but it would take some time as the blood had to be cross-matched first.

…Disaster!

As I watched Dr Wong go about his preparations, suddenly Mr Woon coughed violently.

In that instant, something in his neck gave way. A huge amount of blood suddenly erupted forth from his neck, gushing to the floor.

His blood pressure, which had been 120/70 up to that point suddenly plummeted to zero – unrecordable!

For a split second, we stood rooted to the spot, horrified by the disaster unfolding before our eyes.

“O-negative blood! Forget about the cross match. Get me some O-negative blood! NOW!” barked Dr Wong, hastily slapping a new pack over the neck.

(O negative blood is used in desperate situations where there is no time at all for cross match.) All this was bad enough but what really scared me was seeing the normally calm and composed Dr Wong go totally pale.

There wasn’t a moment to lose.

Clamps, Clamps, Clamps!

I sprang through the door into the operating theathre, my mind racing as I went through what I would need and what I was going to do.

“Clamps! Lots of clamps! Vascular clamps. No, not those big ones! Medium sized and small ones. Bring the whole tray! Ties! Vascular sutures! Vascular needle holder! Skin prep! LOTS of it!”

I hastily scrubbed and gowned up, mindful that next door, Dr Wong was going through his own battle to maintain BP and do a crash induction of anaesthesia.

Surgical protocol dictates that at the start of each case, the surgeon carefully prepares the skin with antiseptic solution before carefully draping sterile towels exposing just the operative field to maintain sterility.

No time for that!

I figured all the sterility in the world was useless if the patient died from massive bleeding. If there was wound infection, I can always treat it with antibiotics later.

“Give me that skin prep!” I began pouring the skin prep all over the wound as the nurses looked on, protesting.

“Skin prep – DONE!”

I began clipping and clamping the bleeding vessels. One of the scrub nurses tried to arrange some towels around the wound to give it some semblance of surgical decency.

As I secured the bleeding, I glanced up anxiously from time to time to observe the BP monitor as well as the colour returning to Dr Wong’s face.

The rest of the operation progressed at a more measured pace.

I had to repair the jugular vein and the trachea. Then there was all the debris to clear, not to mention a lot of glass fragments.

The next day, I recounted to Mr Woon in a shaky voice what had happened in OT and how close we had come to losing him. He nodded feebly, understanding and whispered “Thanks”.

By then the hospital had got to hear of my little adventure.

It’s a curious feeling, having looked Death in the face, then having ripped someone from his jaws.

The “Hero Moment”

Years ago I was one of several short-listed candidates for a Registrar post in the UK. One of the other candidates was a smarmy lad with a smug face that looked on others with a patronising smile.

He spent his time in the waiting room telling the other candidates of a stab injury to the chest he had treated as a Casualty officer. The knife had penetrated the heart.

With tremendous courage and presence of mind, he opened up the patient’s chest in Casualty, withdrew the knife, then placed his finger in the wound to control bleeding while he sutured the wound in the heart.

He saved that patient’s life and was the hero of the day. He was known to the interviewers. None of the rest of us had a snowflakes chance in hell of getting that job. I went home dejectedly that day, like a dog with tail between the legs wondering why they had bothered to short-list the rest of us.

But here, right here with Mr Woon, my “hero moment” had arrived, unexpectedly.

What was it like?

Well, it was like walking on air for about a week. Sweet.

By the time I emerged from that state, it was time to send Mr Woon home.

The Mooncake…

I saw Mr Woon many times after that. He needed several minor operations to remove bits of retained glass that had slowly worked its way to the surface over the years.

But he never complained, and we were both glad he was alive. I can honestly say I couldn’t have chosen a nicer person to save.

And I could not have done it without the fantastic nurses at Lam Wah Ee Hospital and Dr Wong.

That is how every year without fail, a box of mooncakes appears at my door at the time of the Mid Autumn Festival. The mooncake followed me, even when I moved to Gleneagles Penang Hospital.

Yes, I do get other larger, more elaborate boxes of mooncakes too.

But it is this box that is, in its own quiet way, the most special one of all.

 

POSTSCRIPT – by Mr Woon
Mr W, his wife and daughter.
Mr Woon, his wife and daughter.

The first time I saw Dr Khoo was the next day after the accident. With a soft spoken voice, he told me what had happened the night before. I believe luck is not the only reason why I’m still living today; the skill and talent of Dr Khoo and all the personnel in the OT had saved me. Thanks Dr Khoo, you have become an integral part of my life.

Thanks for attending my wedding ceremony in 2004.  My wife (then girlfriend) was riding together with me when the accident happened. She was, luckily, unhurt.

My daughter Zi Yi is 7 years old now. One day I’m going to tell her of the adventure I had.

casestudy-drkhoo
Dr Khoo (in blue, seated on the far left) at Mr Woon’s wedding dinner.