Haemorrhoids

‡ One of the most common conditions to affect humans.
‡ Incidence of approximately 5% of the population. ‡ First mentioned in the Bible.

What Are Haemorrhoids?
Engorgement of the haemorrhoidal venous plexuses with redundancy of their coverings.

.Anal Cushions ‡ Haemorrhoidal venous plexuses lie in the subepithelial tissues both above and below the Pecinate line.

Left lateral. . . .Right posterior.‡ Haemorrhoidal venous plexuses together with some arteriovenous anastomoses.Right anterior. are surrounded by smooth muscle. ‡ These are found in the following positions: . elastic and fibrous tissue to form 3 anal cushions.

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‡ Vascular cushions contribute 15% of the anal canal¶s pressure.‡ Congest during Valsalva manoeuvre or when increased intra-abdominal pressure. ‡ Shield anal canal and sphincter during the act of evacuation. ‡ It is thought that their function is to complete the closure of the anal canal. ‡ An increase in the size of the cushions is the starting point of haemorrhoids. .

. .Pregnancy.Inadequate fibre intake. ‡ Proposed causes are: . . .Diarrhoea.? Family Hx.Pathophysiology & Aetiology ‡ Not fully understood ± many theories.Straining. .Pelvic Space occupying lesions. . . .Constipation.Prolonged lavatory sitting.Ascites. .

. ‡ Prevalence of approximately 5%. ‡ Peak of prevalence is between 45 and 65. ‡ Caucasians more affected than AfroCaribbeans.Incidence ‡ Difficult to evaluate. ‡ Development before 20 unusual.

Symptoms ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Bleeding Anal swelling Painful anal mass Discomfort Discharge Hygiene problems Soiling Pruritus .

Differential Diagnosis ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Skin tags Condyloma acuminata (anal warts) Hypertrophied anal papilla Rectal prolapse Fissure Abscess Fistula Perianal Crohn¶s Disease Polyps Carcinoma Melanoma. .

Preferably accompanied by Proctoscopy. Flexible sigmoidoscopy (rarely used). ‡ Patients with soiling and incontinence should be investigated with anal manometry. ‡ ‡ ‡ ‡ . Acute pain may require an evaluation under anaesthesia in the operating room.Diagnostic Tests Normally easily made on a physical exam.

. ‡ Above or below the Pecinate line? ‡ Can be mixed.External or Internal? ‡ Classified according to origin of haemorrhoid.

3rd degree ± protrude outside of the anal canal and require manual reduction. .Originates and remains above the Pecinate line. 4th degree ± Irreducible. 2nd degree ± May prolapse beyond the external sphincter on defaecation but spontaneously return within the anal canal.Grading of Internal Haemorrhoids 1st degree . Internal haemorrhoids visible on retro-flexion at Sigmoidoscopy.

Thrombosis Thrombosed Internal Haemorrhoids Thrombosed External Haemorrhoids .

Treatment Options Lifestyle Modifications ‡ Integral part of treatment for all haemorrhoidal disease. . ‡ Improved anal hygiene ‡ Increased dietary fibre ‡ Increased dietary fluids ‡ Avoid constipation or diarrhoea.

Increases lymphatic drainage .Several recent studies have shown it to be effective. .Increases vascular tone .purified flavonoid fraction. ‡ Action: .Anti-inflammatory effects. . ‡ Most common .Oral Medications ‡ Oral vasotopic drugs.

Topical Treatment ‡ Many over the counter medications available. lotions and suppositories. corticosteroids. antiseptics. ointments. creams. astringents and other ingredients. . ‡ Cocktail of local anaesthetics. gels. ‡ Include: Pads.

Method Appropriate For Occludes Blood supply * * * * Fixes Excises Mucosa Tissue Reduces Anal Pressure. Sphincterotomy (lateral) Haemorrhoid -ectomy 1st degree 1st degree 2nd degree 2nd degree 2nd degree * * * * * * * 2nd degree * 2nd + 3rd degree * . Sclerotherapy Infra-red Coag Band Ligation Cryosurgery Manual Dilation of anus.

‡ Haemorrhoid injected with phenol. . vegetable oil. quinine.Sclerotherapy ‡ Treatment option for symptomatic non- prolapsing grades I to II haemorrhoids. and urea hydrochloride. ‡ Causes oedema. ‡Submucosal fibrosis & scarring minimises the extent of mucosal prolapse and potentially shrinks the haemorrhoid as well. & intravascular thrombosis. inflammatory reaction.

Band Ligation ‡ Ligation with a rubber band causes ischaemic necrosis. ‡ Fixes connective tissue to the rectal wall. ‡ If treating mixed haemorrhoids. analgesia is essential! . ulceration and scarring.

.For patients who cannot tolerate other procedures. .Surgical Treatment Offered when: .Grade III to IV mixed haemorrhoidal disease.Other procedures unsuccessful. .Large external haemorrhoids. .

‡ All of these techniques require specialist training. ‡ Conventional methods includes excision of internal and external haemorrhoidal tissue.‡ Many different techniques practiced. because the complications can be severe. . ‡ Multiple instruments can be employed.

‡ Often used because of location.Milligan-Morgan (open) Haemorrhoidectomy ‡ First described over 2 centuries ago. ‡ Wound left open. . ‡ Haemorrhoidal pedical mobilised. ‡ Haemorrhoidal tissue excised. ‡ Absorbable suture placed at the pedicle site. technical difficulties or extensive/gangrenous haemorrhoidal tissue.

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.Final Operative Aspect in a Haemorrhoidectomy.

. ‡ Mucosal wound and skin sutured completely shut with a continuous suture. ‡ Haemorrhoidal tissue excised. ‡ Absorbable suture placed at the pedicle site.Ferguson¶s (Closed) Haemorrhoidectomy ‡ Developed in 1952 ‡ Haemorrhoidal pedical mobilised.

‡ Can be performed in O/P setting and hospital stay is generally not required. ‡ Increased cost comparative to other techniques. .Harmonic Scalpel ‡ Allows excision of haemorrhoids with sutureless technique ‡ Offers shorter operative time and less post-op pain.

PPH (the procedure for prolapse and hemorrhoids) or Haemorrhoidopexy ‡ Longo introduced the technique in 1995. ‡ Circumferential band of excessive rectal mucosa and submucosa proximal to the haemorrhoidal tissue is excised. ‡ Fixes mucosa to rectal Wall. ‡ Interrupts blood supply. . ‡ Stapler introduced trans-anally.

Shanmugam. M. Tsui and M. Kwok. Hemorrhoids. Thaha and K. pp. 183±197. Loder. Phillips. 1153±1167 P. Surg Clin North Am 82 (2002). S. Johanson and A.B. Rabindranath et al. Orit Kaidar-Person. pp.. Corman.A. Longo. 344±348. Hemorrhoids.J. pp. pp. K.B. M. J. Sardinha and M.S. pp. Dis Colon Rectum 48 (2005). R.A. Br J Surg 81 (1994). 946± 954 V. A double-blind. Nicholls and R. Systematic review of randomized trials comparing rubber band ligation with excisional haemorrhoidectomy. Clinical Surgery (2002) W. pathophysiology and aetiology. Bartolo. Haemorrhoids: pathology.K. Chung. Gastroenterology 98 (1990).C. Journal of the American College of Surgeons 204 (2007).F. Gastroenterol Clin North Am 30 (2001). 1481±1487. Br J Surg 92 (2005). Hulme-Moir and D. pp. randomized trial comparing Ligasure and Harmonic Scalpel hemorrhoidectomy. 380±386. C.C.C. pp. Hemorrhoidal Disease: A Comprehensive Review. Li.References ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ M. pp. Stapled anopexy and stapled hemorrhoidectomy: two opposite concepts and procedures.K.L. The prevalence of hemorrhoids and chronic constipation An epidemiologic study.K.Y. Dis Colon Rectum 45 (2002). T. 102-117 Michael Henry. Kamm. 571±572.Saunders pp 367 -371 . A. Sonnenberg.

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Indications For Complete Colon Evaluation In Patients With Haemorrhoidal Symptoms .

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