If you just had a streak of blood, you are possibly questioning yourself on Piles, Fissures, and Fistula. To help you better grasp the conceptual differences between them, we have summarised them below.
Additionally, we have quoted everything you seek to know about each of them with an in-depth analysis that will help you understand the contrasting features individually.
Piles vs Fissures vs Fistula
| Features | Piles | Fissures | Fistula |
|---|---|---|---|
| Definition | Swollen veins near the anal canal | Ulcers near the anal canal that are extremely painful | Tracks that run from the outside skin to internal parts |
| Features | Painless bleeding (pain can occur if external or complication occurs) | Blood streaks and sharp intense pain | Discharge is a prominent feature |
| Types | Internal and External | None | Low-level and High-level (additionally, simple and complex) |
| Causes | Constipation, Straining, Lower fiber diet, Genetic | Hard stools, anatomical curvature, previous surgery, Crohn’s disease, Ulcerative colitis, and TB | Mostly explained by Cryptoglandular Hypothesis. Other causes include Tuberculosis, Cancer, Crohn’s disease, Ulcerative colitis, Trauma |
| Diagnosis | Clinical, Digital rectal examination and Proctoscopy | Mostly clinical | MRI/MRI Fistulogram, Colonoscopy if IBD suspected |
| Treatment | Conservative- Fiber-rich diet and fluids, Non-operative such as Sitz bath, and Operative- Banding, Laser, Sclerosant injection, etc. | High fiber diet, Stool softeners, Lactulose, Analgesics | Fistulotomy/Fistulectomy, Seton technique |
Piles
What are Piles?
Piles, also known as Hemorrhoids, are swollen veins of the anal canal. It occurs when there is an abnormal downward sliding of anal cushions caused by straining or other factors.
The term “Haemorrhoids” is derived from two Greek words- haima (bleed) and rhoos (flowering), which indicate bleeding.
On the other hand, the word “Pile” is derived from the Latin word- “Pila”, which means ball.
Why do Piles occur?
Over 4.4% population suffers from hemorrhoids. That is a number above 10 million! Although it can occur at any age, it still has predominance in the age group between 30-65 years.
And despite the common myth that it occurs mostly in men, there is equal prevalence in both sexes.
There are a number of reasons why one can suffer hemorrhoids in their life. The prominent ones are mentioned below:
- Genetical
- Straining
- Diarrhoea
- Constipation
- Hard stools
- Low fiber diet
- Over purgation
- Cancer of Rectum
- Pregnancy- Increased progesterone relaxes and lowers the tone of the venous wall, a larger uterus compresses the pelvic vein, and constipation is prevalent.
- Liver problems- Portal Hypertension (rare)
- Idiopathic reason: It is quite difficult to determine the cause of piles.
What are the Signs and Symptoms?
People suffering from piles can show a number of symptoms apart from bleeding. These are:
- Bleeding– This is classical “Splash in the pan”. It is typically bright red and fresh and often occurs during defecation.
- Protrusion from the anal canal
- Anemia– This can occur due to persistent blood loss
- Discharge– mucous-like discharge
- Pain– Usually hemorrhoids are not painful. But it can occur if they are an external type or there is an infection, spasm, or co-existing prolapse.
What are the Types of Piles?
There are two types of Piles. These can be internal or external. The landmark point is called Hilton’s line. This is a line that joins the upper two halves of the anal canal with the lower one-third.
If the piles are above this Hilton’s line, they are called Internal Hemorrhoids. However, if they are present below the line, they are called External Hemorrhoids.
While the internal hemorrhoids are protected by mucous membranes, the external hemorrhoids are protected by the skin.
A better understanding of the internal and external types of piles can be made by the following image:
Grading
Piles can be graded based on Prolapse (bulging or spilling out of a bodily portion) and whether it reduces by itself or not. There are four grades of hemorrhoids which are as follows:
| Grade | Symptoms |
|---|---|
| Grade 1 | Bleeds but does not come out |
| Grade 2 | Prolapse after defecation but spontaneously rebound |
| Grade 3 | Prolapsed during defecation may only be replaced manually. |
| Grade 4 | Prolapse cannot be reduced at all |
Classifications based on Location
This classification follows primary sites- 3, 7, and 11’o clock positions. Depending on the three, it can be categorized as:
Primary Piles
Located at 3, 7, and 11 o’clock positions, these are the branches of the superior hemorrhoidal vessel, which separates into two on the right side and one on the left.
Secondary Piles
This is the one that happens between the three major clock sites mentioned above.
What are the Possible Complications?
There are rare cases of life-threatening complications occurring if prompt management and emergency care are given timely. However, these can occur and include:
- Excessive bleeding- may require an urgent blood transfusion
- Strangulation- when the anal sphincter grips the piles
- Ulceration
- Gangrene
- Fibrosis
- Stenosis
- Infection (abscess which requires antibiotics)
- Thrombosis- when piles turn dark purple/black in color and feel substantial and sensitive.
All Possible Treatment Options for Piles
There are over 9 treatment options one can have. However, this depends on various factors and is ultimately decided by the surgeon himself. These are:
Please note, according to guidelines, all asymptomatic hemorrhoid cases are not required to be treated.
1. Non-Operative
- Sitz-bath– This implies that the patient must sit in warm water for 20 minutes, with the anal area immersed in water, 2-3 times each day. This decreases edema and discomfort while also promoting recovery.
- Local treatments can be used to relieve pain, irritation, and edema.
- Drink plenty of water and consume 35 g of fiber every day. Fibre substitutes (bulk-building substances, such as ispaghula husk, sterculia, and methylcellulose) can be used to augment a high-fiber diet; squats may minimize the occurrence of piles. Drinking plenty of fluids is also advised.
- Laxatives such as Lactulose are often prescribed to reduce constipation and therefore, prevent bleeding from hemorrhoids.
2. Piles Injection- Sclerosant therapy
This is an OPD procedure that is done for first and second-grade hemorrhoids. This involves injecting 3-5 ml of 5% phenol in almond oil into the submucosal plane just above the anorectal ring to the pedicle.
This procedure can be repeated after 6 weeks and is relatively quick and painless. however, they are not popular because the oily solution is difficult to handle.
3. Banding
Barron’s banding is done for second-degree piles. This is a fairly cheap procedure and simple to perform.
The physician will use a proctoscope to visualize the hemorrhoids and band them to stop the bleeding. Two piles can be banded in one single sitting. The procedure is difficult in terms of visualization but easier to perform though.
4. Cryosurgery
Hemorrhoids are exposed to extreme cold temperatures using Nitrous oxide or Liquid nitrogen. It is painless, safe, and can be done on an OPD basis too.
5. Infrared Coagulation
This is the opposite of cryosurgery and heat is used instead. Often, three or four sittings at one-month intervals are required.
6. Laser Therapy
This is done for third-degree piles and involves laser usage. Advantages include- Less operational time; less intraoperative and postoperative bleeding and discomfort; faster healing; quicker recovery; performed under LNSA; fewer problems; less pain, constipation, and urine retention.
7. DGHAL- Doppler-Guided Hemorrhoidal Artery Ligation
This is under trial and requires further evidence for its efficacy.
8. Stapled haemorrhoidopexy
This involves circumferential excision. It is less painful, causes less blood loss, promotes faster recovery, requires a shorter hospital stay, and is as effective.
9. Open Surgery
Hemorrhoidectomy is the most effective therapy for piles. This involves ligation and removal of hemorrhoids.
Summary of Treatment Plans
| Preventive | Therapeutic |
|---|---|
| Fiber-rich diet and plenty of fluids | Medical– Sitz bath, Laxatives, Pain killers |
| Laxatives | Conservative Surgery– Banding, Sclerotherapy, Cryotherapy, DGHAL, Laser, IRC |
| Surgical– Open and Closed hemorrhoidectomy, Stapled and Anal stretching |
What happens when Piles are Inflamed, Edematus, and Permanently prolapse?
A physician with an MBBS degree or higher may try manual stretching of the anal canal initially. This reduces anal cushion congestion and relaxes the anal sphincter, resulting in a reduction in prolapsed piles-dilatation Lord’s (8 fingers).
The official surgery is performed in 1-2 weeks after the edema has subsided.
What are the possible Complications of Surgery for Piles?
There are reported difficulties that can occur after surgical procedures. Some of these are as follows:
- Pain
- Urinary retention
- Bleeding- requires immediate IV Fluids initially followed by Blood Transfusion
- Stricture formation
- Unwanted discharge
- Fecal incontinence or flatulence
- Whitehead deformity
Piles Pictures
Anal Fissures
Also known as Fissure-in-ano, these are ulcers that are extremely painful. One peculiar feature about them in practice is that it lies above the dentate line.
Why do people get Anal Fissures?
- Due to the curvature of the sacrum and rectum, hard fecal matter going down produces a rupture in the anal valve, resulting in a posterior anal fissure.
- An anterior anal fissure is frequent in females owing to a lack of pelvic floor support.
- Hard stools, diarrhea, increased sphincter tone, local ischemia, trauma, and sexually transmitted illnesses are all symptoms of hard stool.
- Hemorrhoidectomy, Crohn’s disease, venereal disease, ulcerative colitis, and TB are some of the other reasons.
What are the Symptoms?
There are three classical features in people who have fissures. They are:
- Extremely painful especially on defecation
- Blood streaks on the stool
- Sharp intense pain while defecating
The diagnosis is often made clinically by physicians. There is no requirement for a proctoscopy.
How are they Treated?
Fissures usually require conservative management. The steps employed depend on the severity and acuteness of the illness:
- Adequate fluid consumption (6-8 glasses of liquids)
- Diet high in fiber (vegetables, fruits, brown rice)
- Agents for bulk formation (psyllium husk, bran)
- Softeners for stools (lactulose)
- Local anesthetics (5% lignocaine)
- Constipation can be avoided by taking a Sitz bath.
- Regular anal dilation after recovery
NICE guidelines for Fissure (UK)
This is the quickest summary of the protocol for treatment:
- <6 weeks- Lactulose> Topical Anaesthetics
- >6 weeks- Topical GTN> Secondary Care Referral for Sphincterotomy/Botulinum
Difference between Piles and Fissure
Piles or hemorrhoids are usually not painful and present as a “Splash” of blood on defecation. On the other hand, fissures present as an extremely painful condition and “Streaks” of blood.
Fistula
Fistula is sometimes confused with fissures and piles. But they are entirely different from both.
What is a Fistula?
In layman’s terms, Fistula is like a tunnel that opens outside from the skin and goes deep inside to different areas.
In clinical terms, a fistula-in-ano is a granulation tissue-lined channel that links the perianal skin superficially to the anal canal; anorectum, or rectum deeper.
Why do people get them?
There are two hypotheses for the causes. One is the Cryptoglandular Hypothesis which states that most of them begin as a single main tract, but recurrent infection eventually leads to the creation of extensions (secondary tracts).
The other simply incorporates the remaining causes which are as follows:
- Tuberculosis
- Carcinoma
- Crohn’s disease
- Ulcerative colitis
- Lymphogranuloma venereum
- Hiradenitis suppurativa
- Traumatic
What are the Types of Fistula?
There are two types- Low level and High level:
- Low-level fistulas are those that enter into the anal canal beneath the internal ring.
- High-level fistulas are those that enter into the anal canal at or near the internal ring.
These can further be divided as Simple or Complex depending on the addition of extensions.
What are the Features and Treatment Plans?
The clinical features as well as the curative options are listed for each as follows:
Low-Level Fistula
- They exhibit seropurulent discharge (65%), as well as skin irritation, and one or more external openings may be present in the surrounding skin.
- It may heal superficially, but pus may gather under the skin, causing an abscess that drains from the same or a new orifice.
- Usual investigations include MRI/ MRI Fistulogram. A colonoscopy may be advised if Ulcerative colitis or Crohn’s disease is suspected.
- Treatment involves Fistulotomy and Fistulectomy.
High-Level Fistula
- Its top aperture is located at or near the anorectal ring and is much more challenging to treat as compared to the Low-level.
- Investigations required include Barium enema X-ray, colonoscopy, chest X-ray, and biopsy.
- Initially, colostomy (the surgical operation that generates a big intestinal hole) is followed by a definitive approach. Seton Technique is the preferred method for treating this type.
Difference between Piles and Fistula
While Piles present as blood loss on defecation, Fistula are associated with discharges from the tracks. These tracks connect external skin to different areas within the anal canal.