Haemorrhoids

Ronny S,dr,SpOT
Anorectal Anatomy
Arterial Supply Nerve Supply

Inferior rectal A Sympathetic: Superior

middle rectal A hypogastric plexus

Venous drainage Parasympathetic:

Inferior rectal V S234 (nerviergentis
middle rectal V

Pudendal Nerve:
3 hemorrhoidal
Motor and sensory
complexes
L lateral
R antero-lateral
R posterolateral
Anal canal

Lymphatic drainage
Above dentate: Inf. Mesenteric Anal verge
Below dentate: internal iliac
 Pain?
-> painless
Bright red bleeding
Prolapse associated
with defecation

Internal

External
Anoderm
Swell, discomfort,
difficult hygiene

Pain?
-> Thrombosed
Anatomy
 Haemorrhoids
Back Ground
They are part of the normal
anoderm cushions
They are areas of vascular
anastamosis in a supporting stroma
of subepithelial smooth muscles.
The contribute 15-20% of the normal
resting pressure and feed vital
sensory information .
3 main cushions are found
L lateral
R anterior This combination
R posterior is only in 19%
But can be found anywhere in anus
Prevalence is 4%
Miss labelling by referring
physicians and patients is common
Haemorrhoids
Pathogensis
Abnormal haemorrhoids are dilated cushions of arteriovenous
plexus with stretched suspesory fibromuscular stroma with
prolapsed rectal mucosa
3 main processes: 1. Increased venous pressure
2. Weakness in supporting fibromuscular stroma
3. Increased internal sphincter tone
Risk Factors
Pathological Habitual
1. Chronic diarrhea (IBD) 1. Constipation and straining
2. Colon malignancy 2. Low fibre high fat/spicy diet
3. Portal hypertension 3. Prolonged sitting in toilet
4. Spinal cord injury 4. Pregnancy
5. Rectal surgery 5. Aging
6. Episiotomy 6. Obesity
7. Anal intercourse 7. Office work
8. Family tendency
Haemorrhoids
Classification:
Degree of prolapse through anus Origin in relation to Dentate line
1st: bleed but no prolapse 1. Internal: above DL
2nd: spontaneous reduction 2. External: below DL
3rd: manual reduction 3. Mixed
4th: not reducable
 A:Thrombosed external
B:First-degree internal viewed
through anoscope
C:Second-degree internal prolapsed,
reduced spontaneously
D:Third-degree internal prolapsed,
requiring manual reduction
E:Fourth-degree strangulated
internal and thrombosed
external

Reference : Sabiston Textbook of Surgery, 18th Edition

Haemorrhoids
Clinical assessment
Examination History ( Full history required)
Local Haemorrhoid directed:
Inspect for: Pain acute/chronic/
Lumps, note colour and cutaneous
reducability Lump acute/ sub-acute
Fissures Prolapse define grade
Fistulae Bleeding fresh, post defecation
Abscess Pruritis and mucus
Digital: General GI:
Masses Change in bowel habit
Character of blood and mucus Mucus discharge
Perform proctoscopy and Tenasmus/ back pain
sigmoidoscopy Weight loss
Anorexia
Other system inquiry
General abdominal examination
Haemorrhoids
Investigations:
The diagnosis of haemorrhoids is based on
clinical assessment and proctoscopy

Further investigations should be based on a

clinical index of suspicion
Lab: CBC / Clotting profile/ Group and save
Proctography: if rectal prolpse is suspected
Colonoscopy: if higher colonic or sinister pathology is
suspected
Complications
1. Ulceration
2. Thrombosis
3. Sepsis and abscess formation
4. Incontinence

Thrombosed Thrombosed
internal external
haemorrhoids haemorrhoids
Haemorrhoids
Internal H. Treatment :
Grade 1&2 Conservative
Dietary modification: high fibre diet Measures
Stool softeners
Bathing in warm water
Topical creams NOT MUCH VALUE

Indicated in failed medical treatment and grades 3&4 Minimally

injection sclerotherapy invasive
Rubber band ligation
Laser photocoagulation
Cryotherapy freezing
Stapled haemorrhoidectomy
Indications: Surgical
1. Failed other treatments
2. Severely painful grade 3&4
3. Concurrent other anal conditions
4. Patient preference
Haemorrhoids
External H. Treatment :
If presentation less than 72 hours:
Enucleate under LA or GA
Leave wound open to close by secondary intension
Apply pressure dressing for 24 hours post op

If more than 72 hours:

Conservative measures