What are Piles?

Piles or hemorrhoids is an anorectal disease characterized by the enlargement

and the distal displacement of the anal cushions situated at the end of the rectum. Anal cushions are normal connective tissue and smooth muscle formations, filled with blood vessels. They are involved with the anal sphincter in the control of bowel movement.

Hemorrhoids is a very common disease presenting an increased prevalence over time. Currently, It is estimated that 75% of American people will experience hemorrhoids symptoms at some point in their life, whereas in 1990 epidemiological studies showed a hemorrhoids prevalence of 4.4% in the American population.

Clinically, hemorrhoids are mostly characterized with painless rectal bleeding during defecation. This symptom can be accompanied with mucus discharge, a burning sensation, and itching.

According to their severity, hemorrhoids are classified into four grades:

• Grade 1 are slightly enlarged internal hemorrhoids.
• Grade 2 are larger hemorrhoids which prolapse and become external during defecation or certain physical activities. They reduce spontaneously.
• Grade 3 are external hemorrhoids which require manual reduction.
• Grade 4 are non-reducible external hemorrhoids.

The main risk factors for hemorrhoids are obesity, pregnancy, aging, and any condition causing increased intraabdominal pressure such as constipation.

Additionally, food and lifestyle, for instance low-fiber diets and alcohol intake, can influence the development and severity of hemorrhoids.

Hemorrhoids diagnosis is conducted through physical examination which includes digital rectal examination, and anoscopy. When rectal bleeding is present, colonoscopy  is used to confirm the diagnosis and exclude other conditions such as colorectal cancer.

The choice of treatment depends on the severity of the symptoms and the type of hemorrhoids.

Dietary and lifestyle changes are usually sufficient to effectively treat low graded internal hemorrhoids. More complicated conditions can be treated with office-based procedures such as sclerotherapy and rubber band ligation.

Sclerotherapy consists of injecting a chemical solution in order to reduce the blood supply to the hemorrhoids. Rubber band ligation is a painless procedure consisting of tying the hemorrhoids at their base.

High graded and complicated hemorrhoids require surgical removal. 

What is a fissure?

Anal fissure is a linear or oval-shaped tear in the skin in the distal anal canal. It is a very common anorectal condition affecting persons from all age groups, with an equal incidence in both sexes.

Every year, 235000 new cases of anal fissure are reported in the United States alone.

Symptoms of an anal fissure include severe pain and spasm during or after defecation. Modest  bleeding can be also present. The pain may last for several hours after defecation.  Some persons also experience pruritus or itching.

Anal fissure can become a chronic condition when it’s present for more than six to eight weeks. In this case, the tear in the skin is deeper with exposed fibers of the anal sphincters and hypertrophied papilla.

The causes of anal fissure are still unclear, however anal trauma is considered to be a major risk factor. Anal trauma can result from constipation, irritation after diarrhea, anoreceptive intercourse, or anorectal surgery.

Trauma during pregnancy and delivery also increases the risk for fissure. Up to 11% of patients develop chronic fissure following childbirth.

Hypertonicity of the internal anal sphincter and the increased resting anal pressure are often observed in patients with anal fissure in comparison to healthy controls, and can be associated with the etiology of anal fissure.

Another risk factor is local ischaemia due to the compression of blood vessels in the hypertonic sphincter. Lowering the resting anal pressure and increasing blood flow in the local tissue can heal up to 90 % of fissure cases.

Diagnosis of anal fissure is straightforward through physical examination. The fissure is usually visible. When pain recedes, the diagnosis is confirmed by a digital rectal examination and anoscopy.

90% of acute fissures heal spontaneously. An increased intake of water and a high-fiber diet are recommended.

In the case of chronic fissure, either pharmacological agents or surgery through sphincteretomy are used in order to reduce the spasm and the resting anal canal pressure, to restore the blood flow in the anal tissue, and therefore to heal the fissure. 

Difference between piles and fissure 

1. Definition of piles and fissure

Piles or hemorrhoids are an enlargement of the anal cushions at the end of the rectum, whereas an anal fissure is a linear or oval-shaped tear in the skin of the anal canal.

2. Symptoms of piles and fissure

Symptoms of hemorrhoids include painless bleeding, mucus discharge, a burning sensation, and itching. Hemorrhoids can aggravate and become external.

Anal fissure is characterized by acute pain and spasm during or after defecation. Bleeding may occur but is less severe than with hemorrhoids. 

3. Causes of piles and fissure

Hemorrhoids are caused by obesity, aging, pregnancy, increased intraabdominal pressure, and lifestyle such as alcohol intake and low-fiber diets.

Anal fissure is mainly caused by anal trauma due to pregnancy or surgery for instance, high resting anal pressure, and local ischaemia.

4. Diagnosis of piles and fissure

Diagnosis of hemorrhoids is conducted through a physical examination, digital rectal examination, and anoscopy. Colonoscopy helps ruling out other existing conditions such as colorectal cancer.

In the case of anal fissure, a simple physical examination is enough. Digital rectal examination and anoscopy can only be conducted to confirm the diagnosis when the patient is free of pain.

5. Treatment of piles and fissure

Hemorrhoids can be treated with simple dietary changes. Severe cases require sclerotherapy, rubber band ligation, or even surgical removal.

Anal fissure mostly resolves on its own. When chronic it’s treated with pharmacological agents or surgical sphincteretomy. 

Piles versus Fissure: Comparison table

Summary of piles and fissure 

Piles and fissure are two different anorectal diseases:

• Piles are an enlargement of anal cushions at the distal rectum, while fissure is a tear in the skin in the lower anal canal.

• Piles are characterized with painless bleeding, while fissure presents severe pain and modest bleeding.

• Piles and fissure have different causes: Piles mostly occur after increased intraabdominal pressure resulting from obesity, age, or pregnancy, while fissure is mainly caused by anal trauma, and increased pressure in the anal canal.

• Severe piles and chronic fissure are treated with different procedures: sclerotherapy, rubber band ligation, and surgical removal are used to treat piles, while sphincteretomy and pharmacological agents are used to treat fissure.

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