When you come to see me with rectal bleeding I will spend some time taking a history to try and work out how best to investigate your problem. I will do a rigid sigmoidoscopy (a little telescope that I insert into your rectum to examine the potential causes of your problem) and possibly a proctoscopy (a shorter telescope to look mainly at your anal canal). Depending upon your history I will often recommend that you have further examination called a flexible sigmoidoscopy or a colonoscopy to make sure that the blood is not coming from higher up in the bowel and dripping down.
Haemorrhoids or piles
Piles are little lumps that may come down or “prolapse” when you pass a motion or stool. Most people have them to some extent and usually they cause no problems what so ever. Piles are more common in those that have a tendancy to be constipated or those that strain when they go to the toilet. They can cause bleeding, itchiness, irritation or pain in the area. Generally speaking the worse the haemorrhoids the worse the symptoms.
Piles can be graded according to how bad they are and range from 1 to 4.
Grade 1 Haemorrhoids
These may bleed from time to time but no physical lump is seen or felt. These are relatively minor and can often be treated with simple measures such as improving your diet, increasing your fluid intake and keeping your stools soft to avoid straining or constipation.
Grade 2 Haemorrhoids
These may cause bleeding, irritation or pain. You might notice lumps coming out when you pass a stool. These lumps go back up again on their own after you have finished your bowel movement. I can treat these for you with a simple procedure done in clinic with out any pain killers or anaesthetic. This procedure is called ‘rubber band ligation’. This procedure works very well and sometimes may need to be repeated some weeks afterwards.
Grade 3 Haemorrhoids
These may cause more severe bleeding, irritation or pain. There are lumps that come out when you open your bowels and these don’t go back in by them selves. They need to be pushed back. I may try rubber band ligation for these as it is simple and often works. When rubber band ligation fails I would recommend “haemorrhoidectomy” or the “Rafaello” procedure.
Grade 4 Haemorrhoids
These may cause even worse symptoms still. Here the lumps around your anus are permananetly out. They are often painful and can bleed quite heavily. You might have problems with hygiene and keeping the area clean. Depending on how big they are “rafaello” procedure may an option. Haemorrhoidectomy is the only treatment that works for the very big haemorrhoids.
This is one of the oldest operations that has ever been done and probably the one with the best track record for the treatment of piles. It involves a general anaesthetic or being put to sleep. It is usually a day case operation which means you are home the same day. I will of course explain everything to you in much more detail in clinic but it basically involves cutting the haemorrhoids away and tying off the blood vessel that feeds them.
It is a safe and relatively quick procedure and takes about an hour to do. The biggest down side of this operation is that it is painful and you can expect around 6 weeks of pain whilst the area heals. The reason it takes such a long time to heal is that every time you wipe or wash the area you are undoing the “scab” that is needed to heal. I have done hundreds of these operations with excellent results. I take extreme care to cut away the haemorrhoid and carefully peal it away from your anal sphincter muscle but there is a small chance that the muscle can get damaged, This may mean that there is some disturbance in controlling wind or loose stools but this is usually short lived.
This is a state of the art treatment for piles. I have received special training to be able to offer this procedure. It can usually be done with gentle sedation meaning that you don’t need to be put to sleep. The area is numbed using a local anaesthetic injection and a small needle is inserted into the haemorrhoid. High frequency sound waves are then passed through the needle which causes the haemorrhoid to shrink and shrivel up. The greatest advantage of this procedure is that it is virtually painless and if it does not work haemorrhoidectomy is always still an option. The greatest disadvantage is that it not available on the NHS. I do however offer this procedure at both the BMI Hospitals in Birmingham and Little Aston Spire in Sutton Coldfield.
Case study: A patient with haemorrhoids
Mr B had been suffering for years with haemorrhoids. He had been seen in the NHS and was fully investigated for his symptoms and haemorrhoiods were confirmed as the cause. Due to the size and nature of the haemorrhoids the specialist in the NHS recommended Haemorrhoidectomy. He was correctly councilled that it would be a painful procedure and that he may be in pain for anything up to six weeks. Mr B wanted a less painful alternative. He discussed with some friends from the golf club and wanted to explore the Rafello procedure. Mr B saw Mr Peravali at the BMI Edgbaston Hospital. A few weeks later Mr Peravali performed the procedure. Mr B had an excellent result and is now symptom free. He commented:
“I didn’t even experience 2 minutes of pain!”.
Mr B – West Bromwich
Anal fissure or tear
An anal fissure or tear is reasonably common in people that suffer with constipation. It can also happen during and persist after child birth. It can be linked to certain conditions such as Crohn’s disease. The tear is intensely painful and you will experience pain during passage of the stool and immediately after. It can last several hours and may even be painful without any bowel movement. Some people say it is amongst the worst pains you can experience. The tear itself can be associated with bleeding but the main problem is usually pain. It is important to avoid constipation as this can make the symptoms worse. Once fully investigated and more serious causes of your symptoms have been ruled out it is reasonably easy to treat.
Most people get better with the use of creams for six to eight weeks. A small pea sized amount is placed over the anus, once in the morning and once in the evening for a period of six to eight weeks. If treatment fails with one cream, a stronger cream is used. Most people get better with creams alone but it is very important to address diet, fluid intake and bowel habits to prevent the fissure returning. If creams fail the next step would be a very small operation where you are put to sleep and Botox is injected in to your anus. This is painless. The risks are minimal and the vast majority of people get better with Botox. If Botox fails, the next step would be a slightly bigger operation. We would need to discuss this at length as the risks are increased.
Anal Fistula or Abscess
Another common cause for pain, itching and bleeding from the bottom is an abscess around the anus.
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