Hemorrhoids

Ginesha Hafidzy Garishah

Definition

• Hemorrhoids are swollen blood vessels of the

rectum. The hemorrhoidal veins are located in the
lowest area of the rectum and the anus. Sometimes
they swell so that the vein walls become stretched,
thin, and irritated by passing bowel movements.
• They are among the most common causes of anal
pathology, and subsequently are blamed for
virtually any anorectal complaint by patients and
medical professionals alike.
 Epidemiology
• Many individuals experience this condition without
seeking medical consultation; patients are often
reluctant to seek medical help because of
embarrassment or the fear, discomfort, and pain
associated with the treatment, so the exact incidence of
this disease cannot be estimated.
• In both genders, a peak in prevalence is noted between
45 and 65 years of age; development of hemorrhoids
before the age of 20 is unusual, and Caucasians are
affected more frequently than are African
and Americans
Anatomy
• The rectum is the lower 10 to 15 cm of the large intestine.
• The anatomic anal canal is the outlet of the digestive system.
It is a tube about 3.8 cm long running from the perianal skin
of the buttocks to the mucosal lining of the rectum.
TISSUE SPACE AROUND THE RECTUM

1-Ishiorectal
space 2-
pelviorectal
space
3-perianal
space
 VIEW OF THE ANAL CANAL
m. levator ani

Internal sphincter ani

m. puborectalis

Profundus pars of the

external sphincter ani

Superficialis pars of
the external sphincter
ani
Subcutaneous pars of Morgagni’s
m. corrugator cutis
the external sphincter columna
ani
ani
Anatomy

• Its external opening is the anus, which is tightly

shut except during stool evacuation by two strong
but sensitive rings of muscles: the internal sphincter
and external sphincter.
• The action of the internal sphincter is controlled
subconsciously (it is always contracted to prevent
accidental loss of stool), whereas the action of the
external sphincter is voluntary.
Anatomy
• The sphincters are well supplied with blood vessels and
nerves.
• Where the anal canal meets the rectum there is a ring of
folds called the dentate line.
• Among these folds are the anal crypts, small tube-like
depressions opening into the anal canal.
• The dentate line delineates where nerve fibers end.
• Above this line, this area is relatively insensitive to pain.
• Below the dentate line, the anal canal and anus are
extremely sensitive.
Etiology
• Most common cause - constipation
• Prolonged straining
• Pregnancy
• Heredity
• Increased intra-abdominal pressure
• Aging (due to thinning of supportive tissue)
 Classification
• Internal Hemorrhoid
– Whenever the internal hemorrhoidal plexus is enlarged, there
is associated increase in supporting tissue mass with resultant
venous swelling
• External Hemorrhoid
– The veins in the external hemorrhoidal plexus become
enlarged or thrombosed, the resultant bluish mass is called an
external hemorrhoid
Both types of hemorrhoids are very common and are associated
with increased hydrostatic pressure in the portal
venous system such as during pregnancy, straining
at stool, or with cirrhosis
Internal / External Hemorrhoid
Classification of Internal Hemorrhoids

• Grade I
– Seen on anoscopy, may bulge a short way into anal canal;
does not extend below dentate line
• Grade II
– Prolapses out of anal canal with straining or defecation;
reduces spontaneously
• Grade III
– Prolapses out of anal canal with straining or defecation;
reduces manually
• Grade IV
– Irreducible;may strangulate
Generalized Symptoms

• Bleeding on stool or in toilet

• Mucosal protrusion
• Discharge
• Soiled underwear - due to internal
• Sensation of incomplete evacuation
• Hemorrhoids are painless unless thrombosed
• Bleeding from internal hemorrhoids is bright red -
from external - darker
Symptoms - Internal Hemorrhoids

• When internal hemorrhoids enlarge pain is

not a usual feature until complicated by
thrombosis, infection, or erosion of the
overlying mucosal surface

• Most persons complain of bright red blood

on the toilet tissue, or coating the stool, with
a feeling of vague anal discomfort
Symptoms - Internal Hemorrhoids
• The discomfort is increased when the hemorrhoid
enlarges or prolapses through the anus
• Prolapse is often accompanied by edema and
sphincteric spasm
• Prolapse, if not treated, usually becomes chronic as the
muscularis stays stretched - the patient c/o constant
soiling of underwear and very little pain
• Prolapsed hemorrhoids may become infected or
thrombosed; the overlying mucous membrane
may bleed profusely as the result of trauma
of defecation
Prolapsed Hemorrhoid
Symptoms - external hemorrhoids
• External hemorrhoids, because they lie under the
skin are usually very painful

• Result in tender blue swelling at the anal verge due

to thrombosis of a vein in the external plexus - need
not be associated with enlargement of the internal
veins

• Spasm often occurs since the thrombus usually lies at

the level of the sphincteric muscles
Diagnosis
• The diagnosis of internal or external hemorrhoids is made by
– inspection
– digital exam
– direct vision through the anoscope & proctosocpe
Diagnosis
• Exam-
– Prone, jack-knife position or lateral Sim’s position
– Location of the hemorrhoids should be described
according to their anatomic position
– Visual inspection
– DRE- digital rectal exam
DIGITAL EXAMINATION OF THE RECTUM
How hemorrhoids causes bleeding?
 DIFFERENTIAL DIAGNOSIS
CONDITIONS THAT CAUSE THE SAME SYMPTOMS):
• Inflammatory bowel disease (Crohn’s and Ulcerative Colitis)
• Polyps (bleeding)
• Colon cancer (bleeding)
• Rectal cancer (bleeding)
• Anal Cancer -Squamous Cell Carcinoma or Anal Melanoma-
(pain and or bleeding)
• Rectal prolapse (the whole rectal lining protrudes from the anus)
• Anal fissure - a tear of the skin around the anus
(pain and bleeding)
 Hemorrhoids Treatment Principles

• Thorough physical exam to determine severity and

rule out other pathology
– Refer for surgical evaluation if white or
discolored, firm or fixed
• Determine if the problem is internal, external or
both
• Assess the symptom complex
 TREATMENT OF HEMORRHOIDS
• Non-Surgical Treatment
a. Dietary Measures
b. Sitz Baths
c. Ointments and Suppositories
• Preparation-H
• Steroids
• Pramoxine HCL
d. Stool Softeners
e. Office Procedures (internal hemorrhoids only!)
• Hemorrhoid injections (Sclerotherapy)
• Rubber Band Ligation
• Infrared Coagulation
Surgical Treatment For Internal
Hemorrhoids
• Excisional hemorrhoidectomy
• Doppler Guided Hemorrhoid Artery Ligation
and Rectoanal Repair (DGHAL/RAR)
• Stapled Hemorrhoidectomy
 Surgical Treatment For Thrombosed
Hemorrhoids
• For external thrombosed hemorrhoids two surgeries are available:
o Enucleation: For the acute phase of the swollen lump, removing the clot
(enucleation) is performed if patients are having severe pain. In the office the
hemorrhoid is injected with Lidocaine. A small incision is made over the lump
and the clot is removed. The swelling persists for 3-4 weeks, however; the acute
pain is gone.
o External hemorrhoid excision: If the hemorrhoid persists for longer than 5
weeks or recurs in the same spot I suggest excising the whole external
hemorrhoid in the office. Lidocaine is injected in the hemorrhoid and the
hemorrhoid is excised completely. The recovery is 3-5 days for most patients but
may require a full week to recover.
Treatment of Hemorrhoid

1st degree
Conservative
• Dietary advise
• Bulk laxatives
• Sitz bath
• Treatment will be effective at 6 month
Treatment of hemorrhoids

2nd degree
• Rubber band ligation.
• Complication of band separates
–Hemorrhage
–Sepsis
–Pain
Treatment of hemorrhoids
• 3rd degree
– Hemorrhoidectomy
Complication of hemorrhoidectomy
• Acute urinary retention
• Secondary hemorrhage
• Anal stenosis
Thrombosed hemorrhoid
• Conservative (laxative, analgesic, ice packs)
• Operative manual dilatation of the anus and
hemorrhoidectomy
Hemorrhoid Prevention

• The risk of hemorrhoids can be decreased by

eating a high fiber diet, staying well hydrated,
getting regular exercise, and trying to have a
bowel movement as soon as possible after
the urge arises
Hemorrhoid Prognosis

• Most people with hemorrhoids have an

excellent prognosis. While symptoms of
bleeding or discomfort may flare from time
to time, they don't last long and can be
relieved with symptomatic care at home.
 Complications

• The blood in the enlarged veins may form

clots and the tissue surrounding the
hemorrhoids can die (Necrosis)
• This causes painful lumps in the anal area.
• Severe bleeding can occur causing iron
deficiency anemia.
 CONCLUSION
• Haemorrhoids is a common anorectal disorder that hampers the daily activity
of suffered people and ultimately imposes sever burden on society. It has such
a common occurrence is very rarely talked about due the embarrassing nature
of the disease. If the treatment is delayed it gets worse day by day.
• Exact cause is still unknown, some modifiable and non modifiable risk factors
are found to be the reason for the development of the disease upto some
extent.
• Many treatments are available in both modern and unani system, but the best
treatment is prevention. Haemorrhoids can be reduced by changes in life style
and dietary habits. Unani therapy is also beneficial in treating the
haemorrhoids as it is cheap and almost free from side effects.