Friday, October 22, 2010



The pile is exposed and liberated to the vascular pedicle as in the clamp and cauterization method. The pedicle is then ligated or tied with catgut or silk.
The general operative procedure of the ligature operation for ordinary piles is as follows:

Step 1: The patient is placed in the lithotomy position, and the orifice of the anus is thoroughly dilated until it remains open and is easy of access. The rectum is washed out and packed with gauze.

Fig. 9: Operation for piles.

The clamp above grasps the pile in the long axis of the bowel. Interrupted sutures are shown placed in position, the sutures are tied after the pile is removed and the pile clamp released.

Step 2: The piles are seen easily; each one is grasped with forceps [Figure 9]. The mucous membrane of the pedicle of each pile is partly divided with scissors or scalpel; the pile is ligated or tied with stout catgut and then cut off. In the case of large pile, special large clamps are used.

Fig.10: Hemorrhoidectomy. After removing the pile, the crushed base is sutured, as shown in the illustration.

Step 3: When all piles have been removed, the gauze tampon is withdrawn from the rectum. The patient is kept constipated for a day or two.

The complication of operation:

The operation may be followed by hemorrhage, laceration; injury and perforation of the rectum, persistent stricture [narrowing of the rectum], or stenosis [stricture] of the anus

Monday, October 11, 2010



Generally speaking, uncomplicated external and internal hemorrhoids usually are treated by conventional surgery: clamp and cauterization, and ligature operations of hemorrhoids.


This method is used for both internal and external piles [stage 2 and 3 pile] The sphincters are dilated, each pile grasp in turn, the external mucosa-skin folds divided to the vascular pedicle, which is crushed by a clamp applied in the long axis of the bowel. Protecting the skin under the clamp with wet gauze, the pile is slowly burned away by a cauterization at dull red heat. The procedure is repeated with each pile, taking care not to dilate the anus again for fear of hemorrhage. The boric acid ointment is then freely applied on a gauze pad held by a T-bandage.

The steps of Cusach Operation:
Fig.8: Cusach technic of hemorrhoidectomy by the clamp and cautery method.
[a] First step.
[b] Applying the hemorrhoidal clamps. The cautery removes the hemorrhoids.
[c] Eschar following cauterization.

Step 1. Place the patient in the lithotomy position.
Step 2. Grasp the hemorrhoid with a Tuttle forceps. Cut off the skin tabs even with the skin to prevent edema.
Step 3. Place a clamp with the heel directed toward the outer part of the hemorrhoidal tumor. Remove the forceps and excise the pile about ¼ inch from the clamp, leaving a stump which is cauterized thoroughly.
Step 4. Release the clamp gradually and see that stump is not bleeding as it reenters the anus. Apply the same procedure to the other hemorrhoids.
Step 5. Insert into the rectum a small iodoform wick which has been coated with sterile petrolatum; place over this some fluffed gauze.
Step 6. With the patient in proper position, strap the buttocks with adhesive plaster. Permit the end of the wick to project between the two pieces of adhesive plaster. Administer the sedative to the patient before he comes out of the anesthetic. Constipate the patient for 72 hours. At the end of this period give an oil enema and follow with a cathartic.

Ligature and suture operations. [continued]



Like every operation, certain possible complications might occur with the Longo Stapled hemorrhoidectomy.
Minor complications include minor bleeding, mild pulling sensation in the abdomen or in the rectum in the first few days, retention of urine and mild stricture or narrowing of the rectum.
More serious or major complications include infection inside the abdomen, injury and perforation to the rectum. Fortunately such severe complications are extremely rare: 1 or 2 in over 1000 cases.
Nevertheless, this procedure must be performed with care and attention detail to minimize the risk of severe complications.


Because of the procedure is new, widely used in Europe for just over 2 years, it is difficult to know the long-term recurrence rate. Dr Longo had personally performed over 1400 cases, about 500 with 2 to 6 years follow-up, he reported few cases of recurrence. Patients must make sure that they don’t get into the bad habit of being constipated, straining at stools or sitting on toilets for long period of time especially if they have a strong family history of piles

Thursday, September 23, 2010



Generally speaking, external and internal hemorrhoids can be treated by:
• Stapled hemorrhoidectomy treatment
• Clamp and cauterization,
• Ligature operations of hemorrhoids.


Dr Longo is an Italian surgery who introduced his technique to the world in June 1998 in Rome. He reason that since piles are due to prolapse or displacement of enlarged, engorged anal cushions from the upper anus and lower rectum, why not pull them up to their normal positions from the inside instead of cutting them out from the outside.

Fig. 5: Longo hemorrhoidectomy stapling device.

If at the same time, you could cut down the flow of the very rich blood supply, you would reduce the congestion and cause the piles to regress and shrink. The beauty of this approach is that the cutting is on tissues, which carry no sensory nerve endings, so it is totally painless.

Fig. 6: Stapling of hemorrhoids in progress.

Source: Ibid

The Longo hemorrhoidectomy uses a purpose designed staple device to cut a 2 cm circumferential sleeve of lining of the rectum which will pull up the displaced piles to their normal positions, and will also interrupt their blood supply. Over a few days or weeks, the piles will regress to normal. Because of the circumferential cut, all piles are treated, unlike conventional surgery when smaller piles are often left behind to grow giving them a chance to recur.
The bonus of this procedure is once the external piles are fully pulled inside and regress to normal, the anal skin becomes smooth again.

With the conventional operation, skin tags are often formed even though the piles have been completely removed. Patients, especial women, do not like skin tags.

Fig. 7: Final result normal anatomy restored.

Source: op.cit

The other advantage of this procedure is that that patients can be discharged the same day later and return to normal activity much quicker, average 4 days to one week instead of two to three weeks for the conventional operation.
Possible complications. [continued]

Tuesday, September 21, 2010



General measures for stage 1, 2 and 3: Control constipation by laxative drugs such as mineral oil 15-50 ml per oral at bed time; Dulcolax [brand name, generic bisacodyl ] 5 mg /tablet per oral or suppository 10 mg at bed time; Tegaserod 2-4 mg twice per oral daily for chronic constipation.
Local measures: lubricant [petrolatum] to anal region, local anesthetic ointments for pain relief. Warm sit baths, 20-30 minutes twice daily.
Rubber band ligation for internal piles only; if for external piles can effect very severe pain.

The general and local measures can only reduced piles but do not heal the piles.


Injection is applicable for the small internal piles [stage 1 and 2]. Injection of piles with 1 ml of 0.5 % quinine solution or
solution phenol 5 % in vegetable oil through a 22-gauge needle in one day and repeated injections may be necessary
The piles may relief after a few injection.

The complication of schlerosant injection is about 2 % including bleeding, urinary retention and pelvic abscess. Recurrence is
common unless patients alter dietary habits to advisable diet.

3. Surgical treatments [hemorrhoidectomy]:



1. Medication and diet measures.
2. Schlerosant injection
3. Surgical treatment

First stage and second stage treatment usually with medication and diet treatment, or schlerosant injection, usually do not need surgery.
The third and fourth stage need surgery to have cured. Not infrequently third stage patient can be cured with medication and diet treatment.


Since 1982 the writer treated the piles with broad-spectrum antibiotics, antimicrobial and anti-protozoa[ameba, trichomoniasis, giardiasis], and anti anaerobic bacteria. combined with vitamins and diet measures.
This treatment was based on the writer experience and studied on the references about the cause of piles. The writer temporary conclusion that the basic cause of files was mainly multiple infections and inflammations in the rectum and anus had the long run effects on the mucosa and veins circulations to be the caused of piles.
This temporary conclusion need further research and development for confirmation or evidence.

The drugs of choice and available for above criteria for treatment of piles are:

a. Fasigyn [brand name, generic: tinidazole] 500 mg/tablet once 4 tablets [2 gram] daily for 3 days; or
Flagyl [brand name, generic: metronidazole] 500 mg/ tablet-- once 4 tablets daily for 3 days.

b. Terramycin [brand name, generic: oxytetracycline] 250 mg/capsule-- thrice 2 capsules daily for 5-7 days or
doxycycline 100 mg/capsule twice daily for 7 days.

c, Vitamins: vitamin C 500-1000 mg daily; vitamin A 20 000 IU/tablet once daily; vitamin B-complex 2 tablets daily.

The side effects of Fasigyn or Flagyl are feeling of mild dry and mild bitter taste in mouth during treatment [3-5 days].
Fasigyn or tinidazol, Flagyl or metronidazole are contraindicated in first trimester pregnant women [the research in animal found fetotoxic effect in first trimester but not in women] , safe is safe it can be given or treated in the third trimester of pregnant women for piles or after delivery.
Terramycin is contraindicated for pregnant women because of fetotoxic effects, it can be replaced with spiramycin 500 mg/tablet-- thrice 2 tablet daily for 5 days.

The vitamin B-Complex effects to prevent side effects of antibiotics
and antimicrobial; vitamin A 20 000 IU daily to strengthen the epithelium of the mucous membrane, and vitamin C 500-1000 mg daily strengthen the collagen structure of connective tissue it necessary plays an important role in the laying-down of the new connective tissue which is essential to healing of mucous membrane and better vascular of blood vessel .
Treatment of multiple infections and inflammations combine with vitamin A, B-complex and C may have effects to heal and to paste the lax mucous membrane in piles to sub-mucous and smooth muscle of anus and rectum .
If the piles with bleeding the additional treatment vitamin K 5 mg once per oral daily and Adona [brand name, generic: carbazochrom sodium sulfonate] 10 mg/tablet per oral 3 times daily.
For itching give anti histamine such as Phenergan 10 mg twice daily.

The children dose : Terramycin for children is 20-25 mg/kg body weight in two divided doses, and the dose of
Fasigyn for children is 50-60 mg/kg body weight as single dose.

d. The diet treatment: Mild food or steam food during treatment. Avoid hard food and hot chili and pepper foods in the period of treatment and one month after treatment. After one month period to prevent recurrent piles, advice to the patients can eat mild hot chili and pepper foods and better no hot chili and pepper food.
Additional diet fruit treatment particularly with papaya and pineapple which contain proteinase enzyme such as papain .The action of papain is proteolytic enzyme activated by present of H2S [hydro sulfide] keratin-ase enzyme which catalyze hydrolytic reactions of keratin proteins to end products polypeptide and amino acids. [Source: Philip B. Hawk et al. 1954, p 157, 306, 317].
The portion of these fruits during treatment: papaya one cup 3-4 times daily, the pineapple the same 1 cup 3-4 times daily for 5 days; and then a half cup twice daily of papaya and pineapple respectively for preventive, other fruits are supplements.
The mechanism action of these fruit are not clear, may be the proteolytic and hydrolysis reactions of proteins by papain in the phlebitis of veins, may open the occlusion and better flow of blood in the veins plexus of hemorrhoids.

Since 1982 the writer had patients stage 1, 2 and 3 [no case stage 4] every year , all were healed or relieved; those only 2 recurrent patients due to eat the very hot chili and peppers food.
And after treated with Fasigyn,Terramycin and diet, both patients relieved. The recurrent piles may be because of large hot chili and peppers eaten by the patients caused inflammations of mucous membrane in rectum and anus, which induced piles.

Symptomatic treatment: [continued]

Friday, September 17, 2010



The stage of pile consists of:
First stage: small protrude of internal mucous of piles or small mass of external piles like polyp, while or after defecation.
Second: protrude of piles larger mass of internal mucous but can reduced spontaneously after defecation; Slight or profuse bright red bleeding, usually at stool with protrusion following defecation, at first reduced spontaneously but later requiring manual replacement; soreness, sense of incomplete evacuation and lumbar discomfort.
Third: protruded or prolapsed of larger mass and can not spontaneously reduced but the piles can be pushed back to above ano-rectal line.
Fourth stage: larger mass protruded and can not be push manually into abdomen above ano-rectal line, it need emergency treatment to prevent strangulation and putrefaction.


Inspection, palpation and proctoscopy for non protruded piles reveal a globular expansible mass covered by mucous membrane. Protruded piles are visible as protuberant purple nodules covered by mucosa.

Fig. 4: Indirect inspection of the rectum and sigmoid.[a and b]. Suitable positions for proctoscopic and sigmoidoscopic examination.

[c] With the obturator in position the instrument, directed toward the umbilicus, is passed through the sphincter muscles. The obturator now is removed, the rectum inflated [d] and the insertion of the instrument continued under visual control. [e] Shows the usual lateral deviation of the sigmoidoscope when passed from the rectum into the sigmoid.




What are the causes of piles?
The causes include reduced vascular drainage of the pelvic organs such as pregnancy, constipation; repeated trauma to rectum and anus due to sodomy , sexual perversion, large and hard stool which can followed by mucous fissures, sitting on the toiled for a long time. Infection and ruptured blood vessels and increased venous pressure in portal hypertension. Bacterial infection may develop in the venous circulation, producing peri-phlebitis and endo-phlebitis.
Bacterial infection may cause proctitis or rectitis [inflammation of the rectum caused mucosa dilatation] may be due to staphylococcus, streptococcus, pseudomonas aeroginosa, gonorrhea, lymphopathya venereum, amebiasis dysentery, anaerobic bacteria
Thrombosis or rupture of vessels often results in slough and ulceration.

Symptoms and signs

There are 4 principle symptoms:
Pruritus ani: the itching is usually localized anal circle; distressing symptoms of a underlying local or general disorder , it occurs because the sensitive, often moist perinea [pudenda] skin is exposed to irritating fecal material retained in anal recesses. The perinea skin may be erythematous [reddish], moist or bleeding.
Pain: mild or severe pain is the result of constriction, edema, or strangulation of piles; severe pain usually in external piles due to the sensitive of the skin; the internal piles mucosa is less sensitive than the skin.
Bleeding: which may be mild or severe occur with mucous laceration, venous distention, obstruction, or ulceration of prolapsed internal piles as a result of straining or difficult defecation.
Prolapse: protrusion of piles may occur suddenly after sub-mucous rupture of veins, thrombosis or strangulation of internal piles.

The stage of pile consists of: [continued]

Thursday, September 16, 2010


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What is the hemorrhoid?

Hemorrhoids or piles are ano-rectal varicose dilatation involving the hemorrhoids plexus of veins, there are lax pelvic veins and venous stasis Inadequate peri-vascular support and may be the absence of valves permit reversed venous flow in the hemorrhoids plexus.

Figure 1: Anatomy of venous drainage of the rectum and anus showing the superior or internal and the inferior or external hemorrhoid plexuses; these called as "anal cushions."

Figure 2: Prolapsed or protruded piles stage 3 or stage 4.

In the West, it has been estimated that at least 50 percent of individuals over the age of 50 years have at some time experienced piles complaints. A part of women have hemorrhoids, which often develop during pregnancy or delivery, sedentary habits, erect posture, and venous congestion and dilatation accentuate this varicose. Hemorrhoids can occur at any age and affect both sexes female and male.Hereditary factors may predispose to piles.

What types or varieties of piles?

There are external, internal and mixed piles.

External piles are those of the inferior hemorrhoids plexus, are covered by anal skin and arise below the ano-rectal line.

Internal piles implicate the superior hemorrhoids plexus of veins, are covered by mucous membrane and have their origin above the ano-rectal line.

Mixed piles are partly within and partly outside the ano-rectal canal and both are covered by mucosa and skin.

Fig. 3: Cross section of prolapsed internal and external hemorrhoids or mixed hemorrhoids or piles.

Source: Ibid.

There are a few questions about piles or hemorrhoids:

What are the causes, symptoms and signs of hemorrhoids?
How about the examination and diagnose of hemorrhoids or piles?
What are the option of treatments?
What are about the prognosis of the treatments?
What are the potential complication of treatments?

The answers for these questions are as the follows : [continued]

Thursday, January 28, 2010



Picture 1: A girl, shown suffering the effects of severe hunger and malnutrition.

Starvation is the result of a serious lack or deficiency of nutrients need for maintenance of life, it is the most extreme form of malnutrition.


According to FAO [Food and Agriculture Organization] the starvation currently affects more than one billion people or one in six people of the world population 6.7 billion. Prolonged starvation can cause permanent organ change, and eventually death, that is about 20 000 die each day. The WHO [World Health Organization] also states that malnutrition is by far the biggest contributor to child mortality, present in half of all cases.
Picture 2: Starved Vietnamese man,who was deprived of food in Viet Cong prison camp.


What is the cause of starvation ?
What are the symptoms and signs of starvation?
How to treat starvation ?
How to prevent starvation ?
What is the prognosis of starvation ?


The basic cause of starvation is the imbalance between energy of intake and energy expenditure. In other words: the body expends more energy that it takes is as food.
The starvation is caused by a number of factors. They include: Anorexia nervosa, fasting, coma, stroke, severe gastrointestinal disease, famine and extreme poverty. The poverty where half of the world’s population lives on less than $ 2 a day.
Picture 3: Adult,shown suffering of starvation is dying


1. Chronic diarrhea, decreased ability to digest of food because of lack of digestive acid production in the stomach.
2. Shrinkage of vital organs such as heart, lungs, ovaries or testes and their functions.
3. Reduction in muscle mass and weakness because of it.
4. Low body temperature.
5. Irritability.
6. Immune deficiency, less of resistance to infections.
7. Decrease sex drive.
8. The signs of specific nutrient deficiency may occur such as deficiency of vitamins.


It is necessary to treat the cause of starvation. Nutrients feeding rich in protein, energy and adequate vitamins and minerals. If the degree of malnutrition is severe, the intravenous feeding must begin the treatment and then the treatment with liquid nutrients. Gradually, solid foods are introduced with high protein and energy.


For the individual, prevention obviously consists of ensuring they eat plenty of food, varied enough to provide a nutritionally complete diet. Supporting farmer in areas of food insecurity through such measures as free or subsidized fertilizers and seeds increases food harvest and reduces food prices.


People can recover from severe diagnosis of starvation to a normal stature and function. Children may suffer from permanent mental retardation or growth defects of their deprivation was long and extreme.
Cecil & Loeb A Textbook of Medicine.W.B.Saunders Company,Philadelphia,USA,1959,p 537-540.
Waldo E.Nelson,M.D., D.Sc. Texbook of Pediatrics.W.B.Saunders Company,Philadelphia,USA,1959,p 358-369.

Friday, January 22, 2010



Marasmus is a form of severe malnutrition, dominated by energy deficiency of nutrients or foods intake. Probably combine with protein, vitamins and minerals deficiency. Marasmus occurrence increases prior to age one to under five year age.

The syndrome of marasmus:
1. Clinically, there is failure to gain weight, later followed by weight less and finally emaciation [to cause to lose flesh so as to become very thin] and dry skin.
2. There is loss of adipose tissue from normal areas for deposits like buttocks and tights.
3. There is extensive tissue and muscle wasting and weakness.
4. Other common symptoms include loose skin folds hanging over the axillary skin and gluteal skin.
5. The abdomen may be concave or flat; if there is distention of the abdomen, usually it is due to parasitic diseases such as ascariasis [roundworm], schistosoma, oxyuriasis [enterobius vermicularis or seatworm] combines with mild edema.
6. Vitamins deficiency vitamin B-complex and C are common often leading to anemia, pellagra, dry beriberi and scurvy.
7. The afflicted patients are often fretful and irritable.

Picture: Child suffering with marasmus in India.

It seems, the child is about under five years old.

Marasmus is caused by a severe deficiency of nearly all nutrients or foods intake particularly energy or calories and protein.

It is necessary to treat the cause of marasmus with adequate nutrients feeding rich in energy or calories, protein, vitamins and minerals. Treatment in the uncomplicated case requires temporarily a high energy, high protein diet, with much of the nutrients derived from milk, eggs and meat.
The maintenance diet should be an average one according to age and weight of the patient.

Others treatment for anemia, pellagra, dry beriberi and scurvy can be administered with vitamin B-complex and vitamin C; and the treatment of any coexisting infections with antibiotics.
Parasitic diseases treatment with combantrin [pyrantel pamoate] syrup for children.
Treatment of dry skin and dehydration, administer the Ringer's lactate solution or Dextran 6 % in saline intravenous infusion.

Nutrients should be planned to avoid dietary deficiency by feeding rich in protein, adequate in energy, vitamins and minerals. Nutrients derived from milk, eggs, meat, whole grain, fruit, and vegetables.
Good hygienic habit and immunization to prevent infectious diseases.

Thursday, January 14, 2010




Pluri-deficiency means more than one deficiency or multiple deficiency of nutrient. Syndrome is from the Greek word meaning “run together” diseases and symptoms. Clinical pluri-deficiency syndrome [PDS] which results from more than one deficiency such as deficiency of calories [energy], protein and probably other nutrients such as vitamins and minerals.
PDS is the most extreme form of malnutrition [under nourished].
The basic cause of PDS is an imbalance between energy, protein, and vitamins intake and expenditure. In other words: the body expends more energy, protein and vitamins than it takes in as food. The imbalance can come from one or more medical condition causes and socio-economic condition causes.
Medical causes: Anorexia nervosa, digestive diseases, depression and coma.
Socio-economic causes: famine, poverty, uneducated, deprivation and observed in various countries, especially in war-torn areas where starvation is common.
We can identify 3 types of extreme PDS:
2. Marasmus
3. Starvation.


Kwashiorkor is the term applied to a clinical syndrome which results from an extreme deficiency of protein, and probably deficiency of other nutrients, especially those of vitamins B-complex and vitamin A, , C and K.
The term “kwashiorkor is said to mean “red boy” in the language of Gold Coast Africa. Another interpretation is the “syndrome of the changeling”
The syndrome of kwashiorkor as it has been described signs among the children consist of :

Picture 1: A. Kwashiorkor in a two year-old boy. Note the generalized edema and the skin lesions.B. Close-up of the same child the showing hair changes ; the edema of the face and the skin lesions can be seen more clearly.

Source: Waldon E.Nelson,M.D.,D.Sc.
Textbook of PEDIATRICS. Seven Edition,W.B.SaundersCompany,Philadelphia,USA,1959, p 358.
1. Retarded growth in the weaning and post-weaning under 3 years old children.
2. Edema usually associated with hypo-proteinemia [low protein in the plasma of the blood].

Picture 2: Left, infant with "sugar-baby" kwashiorkor,showing stunting, edema of feet and hands,moon face and depigmentation of the hair.
Right, normal infant of same age and racial group.Source: Ibid, p 360
3. Alteration in skin and hair pigmentation.
4. The frequent association of a variety of dermatoses [skin disorders] such as pellagra.
5. Gastrointestinal disorders, including anorexia, vomiting, and diarrhea.
6. Irritability and apathy.
7. Fatty infiltration, cellular necrosis or fibrosis of the liver.
8. A high mortality rate.

Some combinations of these signs is essential for diagnosis.
Edema usually starts in the feet, but soon involves the face, hands, arms and genitals; ascites [accumulation of fluid in the abdominal cavity] is rare.
The hair loses its luster and in Negro tends to lose its curl and become straight and fine; it becomes pale or almost reddish.
If there is vitamin A deficiency with symptoms of night blindness, xerophthalmia [ocular disease] appear late in the disease.

Picture 3: Recovery from xerophthalmia, showing permanent eye lesion.
Source : Opcit, p 361

Vitamin B-complex deficiency is a common , often leading to anemia, beri-beri and pellagra.

Vitamin C deficiency there may be a "rosary" at the costochondral junctions and a depression of the sternum.Rickets due to vitamin D deficiency. Hemorrhagic jaundice of vitamin K deficiency.
Picture 4: Vitamin C deficiency scorbutic rosary,depression of sternum and the so-called frog position. Source: Opcit, p 369

Kwashiorkor is usually treated with the diet rich in proteins of high biological value, vitamins and minerals, adequate energy ; and the treatment of the coexisting infections.

It can be accomplished by feeding an adequate diet during the post-weaning phase. Nutrient diet rich in source of protein such as dried milk, skim milk, fish meal and legume [soy beans]; adequate energy, vitamins and minerals

Picture 5: Hemorrhagic jaundice due to vitamin K deficiency.Source: Cecil & Loeb. A Textbook of MEDICINES. W.B.Saunders Company, Philadelphia,USA,1959, p 540