If the vascular lining of a patient's anal canal becomes swollen and starts to protrude, he has piles. These are common in the industrial world, but are less often seen in patients on high-residue traditional diets. They usually form in the 3, 7, and 11 o'clock positions (when he is in the lithotomy position), and although they usually cause no symptoms, they can bleed and make him severely anaemic; they can prolapse, and they can thrombose and become very painful. Untreated, they eventually shrink to form harmless skin tags.

He may complain of bleeding, of ''something coming down', of a mucus discharge, or of pruritus. If he has diagnosed himself, and says that he has piles, enquire how they affect him. Piles are the commonest cause of rectal bleeding, which is usually painless, bright red, and either streaks the stool, or follows after it. Carcinoma of the colon is the most important differential diagnosis, so exclude this by always sigmoidoscoping anyone with rectal bleeding, even in the developing world where carcinoma is uncommon; even if he has piles[md]he may have both!

Piles are reversible in their early stages, and may respond to a high-residue diet, or to dilatation of his anal sphincter. If they are very large and have been present for a long time, you will have to excise them. Never fail to examine him, and remember that ointments are seldom a sufficient treatment.

PILES EXAMINATION. You can see piles through a proctoscope, but only the patient can tell you if they bleed, or prolapse on defecation, if they retract spontaneously, or if he has to replace them. There are 3 degrees of piles.

First degree piles usually only cause bleeding, and don't prolapse from his anus, so you cannot see them merely by looking at it.

Second degree piles prolapse on defecation, but return spontaneously afterwards. They form distinct swellings at the three main positions. If you pull gently, you may be able to draw them down.

Third degree piles prolapse on defecation, and don't return spontaneously, so that he has to push them back. They form large projecting lumps, their outer parts covered with skin, and their inner parts with purple anal mucosa, separated by a groove.

DIGITAL EXAMINATION is not enough by itself for diagnosing piles, because you cannot usually feel them with your finger. If, however, a pile has been present for some time, you may feel it as a soft longitudinal projection, as you sweep your finger round his anus.

PROCTOSCOPY is the only satisfactory way to diagnose piles. They bulge into a proctoscope like grapes, as you withdraw it and ask him to bear down. Withdraw it just to his anus, and then ask him to continue straining.

If no red mucosa projects beyond his anal verge, his piles are first degree.

If they do project, they are second or third degree.

If they remain prolapsed when he stops straining, and you have to push them back, they are third degree.

SIGMOIDOSCOPY must be done routinely to look for carcinoma, especially if he is over forty and from the industrial world; it is desirable in the developing world. If he presented with bleeding, and you cannot see any piles, it is essential!!

INTERNAL PILES If his symptoms are mild, or merely consist of bleeding, simple measures are usually enough. If he is not already on a high-residue diet, persuade him to eat one. Treat constipation with stool-softeners. If his piles have appeared in association with an attack of diarrhoea, they will probably go as his diarrhoea resolves. If necessary, treat it.

CAUTION ! Don't treat piles, unless they cause symptoms (anaemia for example) that need treating. They often remain asymptomatic for many years. One patient may have classical third degree piles, but no symptoms. Another may collapse from hypovolaemic shock with only first degree piles.

If piles prolapse, the above measures are unlikely to be adequate, so see below for the indications for Lord's anal stretch (22.5), and ligation and excision (22.6).

If he has acutely painful, bluish, fixed swellings at his anus, which make sitting or defecation painful, his piles have probably been squeezed by his internal sphincter, so that they have thrombosed, ulcerated, strangulated, or become gangrenous. Digital examination is painful, and proctoscopy impossible. He may refer to his symptoms as ''an attack of piles'. One differential diagnosis is a ''thrombosed external pile', see below.

If the symptoms from his prolapsed piles are mild, give him a rubber glove and some analgesic ointment, and ask him to return them to his anus himself. This, combined with baths, may enable him to overcome his acute attack.

If the symptoms from his prolapsed piles are severe, bath him and wash the mass. A warm bath is remarkably soothing. Put him to bed, raise its foot steeply, and give him morphine. Apply a large moist gauze dressing to his anus, and hold it with firm pressure in a T[nd]bandage. Some surgeons apply an ice pack. Don't worry about his bowels for a few days.

Lord's anal stretch under anaesthesia is very good for the early painful stages, and relieves pain, even though his piles remain prolapsed; it may make them resolve more quickly.

The mass will shrink over about a week. Thrombosis leading to fibrosis may cure his symptoms, so that he needs no further treatment. If it does not, excise his piles (22.6) when his oedema has settled.

CAUTION ! Don't: (1) Try to incise thrombosed internal piles, or (2) try to excise them immediately.

If a thrombosed pile fibroses, it may present as a pedunculated fibrous polyp (unusual). Excise it.

If a thrombosed pile becomes infected, treat him with antibiotics, if necessary (rare). Tie and excise his piles as soon as the infection has subsided.

If he is admitted because of severely bleeding piles, exclude a bleeding diathesis (measure his bleeding and clotting time) or anticoagulant treatment. Put him to bed, give him morphine, and transfuse him. Many bleeding piles are cured by Lord's anal stretch alone, if they are of first degree, or small second degree. The patients who bleed severely are usually the younger ones with tight anal sphincters.

EXTERNAL PILES If he presents with a painful anus, and you find a small (0.5 to 1 cm), tense, black, acutely tender swelling just outside his anal verge, it is a thrombosed external pile. First, make sure it is an external pile, and not a thrombosed internal pile, which has prolapsed from higher up. It will probably resolve spontaneously in a week, and eventually become a skin tag.

If you see him within 36 hours, use a fine needle to infiltrate the skin around it with lignocaine, bisect it, squeeze out the clot, and excise it together with 1.25 cm of his adjacent skin. His pain will go immediately. Apply vaseline gauze, and let the pear-shaped wound granulate.