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Hemorrhoids

Nicklaus Rivera
YL8

Hemorrhoids
Cushions of submucosal tissue
containing venules, arterioles,
and smooth muscle fibers that
are located in the anal canal.
Normal part of anorectal
anatomy
Part
of
continence
mechanism
Aid in complete closure of
the anal canal at rest

Cushions

Left Lateral
Right Anterior
Right Posterior

Prolapse

Increased venous engorgement


of hemorrhoidal plexus.
Excessive straining
Increased abdominal pressure
Hard stools

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Types

External
Internal
Combined

External

Distal to dentate line


Covered with anoderm
Thrombosis may cause
significant pain

Anoderm is richly innvervated

External
Skin Tag
Redundant fibrotic skin at the
anal verge
Usually persisting as residua
of a thrombosed external
hemorrhoid
Often confused with
symptomatic hemorrhoids
May cause itching and
difficulty with hygiene

External

Management
Symptomatic relief

Internal

Proximal to dentate line


Covered by insensate
anorectal mucosa
May prolapse or bleed
Not painful unless thrombosis
or necrosis develops

Internal

Grading
First degree
Second degree
Third degree
Fourth

Combined

Straddle the dentate line


Characteristics of both
internal and external
hemorrhoids

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Management
Medical Management
Rubber Band Ligation
Infrared Photocoagulation
Sclerotherapy
Excision of Thrombosed
External Hemorrhoids
Operative
Hemorrhoidectomy
Open Hemorrhoidectomy

Whiteheads Hemorrhoidectomy

Stapled Hemorrhoidectomy

Doppler-guided Hemorrhoidal Artery Ligation

Closed Submucosal Hemorrhoidectomy

Medical
Management

First degree
Second degree

Dietary fiber
Stool softener
Increased fluid intake
Avoidance of straining
Improved hygiene

Rubber Band
Ligation

First degree
Second degree
Select third degree

Rubber Band
Ligation

Mucosa 1-2 cm proximal to


the dentate line
Strangulation scarring
1 or 2 quadrants per visit

Rubber Band
Ligation

Complications
Severe pain
Urinary retention
Infection
Bleeding

Infrared
Photocoagulation

Small first degree


Small second degree

Sclerotherapy

First degree
Second degree
Select third degree

Injection of 1 to 3 mL of a
sclerosing solution into
submucosa
Phenol in olive oil
Sodium morrhuate
Quinine urea

Excision
Thrombosed external
hemorrhoid

Palpable mass 24 to 72 hours


after thrombosis

Intense pain

Elliptical incision

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Excision
Clot resorbs after 72 hours

Pain resolves spontaneously

Excision is unnecessary

Sitz bath and analgesics are


helpful

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Operative
Hemorrhoidectomy

Based on decreasing blood flow


to the hemorrhoidal plexuses
and
excising
redundant
anoderm and mucosa.

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Closed Submucosal
Hemorrhoidectomy
Parks or Ferguson
Resection of hemorrhoidal
tissue and closure of the
wounds
with
absorbable
suture
Elliptical incision
All
three
hemorrhoidal
cushions may be removed

Avoid resecting a large area of


perianal skin to avoid post
operative stenosis

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Open
Hemorrhoidectomy

Milligan and Morgan


Wounds are left open and
allowed to heal

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Whiteheads
Hemorrhoidectomy
Circumferential excision of
cushions just proximal to the
dentate line
Rectal
mucosa
is
then
advanced and sutured to the
dentate line
Not
widely
used
today
because of the risk of
ectropion
(Whiteheads
deformity)

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Procedure for Prolapse and


Hemorrhoids / Stapled
Hemorroidectomy

PPH has been proposed as


alternative surgical approach;
largely
replaced
stapled
hemorrhoidectomy
Does not involve excision of
hemorrhoidal tissue
Instead pexes the redundant
mucosa above the dentate
line
Removes
short
circumferential segment of
rectal mucosa proximal to
dentate line using circular
stapler

Doppler-guided
Hemorrhoidal Artery Ligation

Doppler
probe
identifies
arteries feeding the plexus

Complications
Pain
Urinary retention
10-50%
Minimized by limiting intra- and
perioperative IVF

Fecal impaction
Decreased by preoperative enemas or
limited mechanical bowel prep

Bleeding
7-10 days post op when necrotic mucosa
overlying the vascular pedicle sloughs

Infection

Incontinence

Anal stenosis

Ectropion