HAEMORRHOIDS

HAEMORRHOIDS

 Hemorrhoid disease is one of the most common

anorectal conditions
 Hemorrhoid tissue is a normal component of the anal
canal and is composed predominantly of vascular
tissue, supported by smooth muscle and connective
tissue.
 The Diagnosis of hemorrhoids is simple
but often tricky
 HAEMORRHOIDS

The symptomatic enlargement

and distal displacement of the
normal anal cushions
Symptoms: itching,
bleeding, mucosal prolapses,
pain.
World J Gastroenterol 2012 May 7; 18(17): 2009-2017
ANAL CANAL
ANORECTAL JUNCTION

COLLUMNA MORGAGNI

DENTATE LINE

INTERSPHINCTERIC GROVE/
WHITE LINE OF HOUSTON

ANAL VERGE

ANATOMICAL ANAL CANAL (FROM ANAL VERGE TO DENTATE LINE)

SURGICAL ANAL CANAL (FROM ANAL VERGE TO ANORECTAL

JUNCTION
 ANAL CUSHION 11

 Is vascular cushions covered by 3

mucosa & muscularis mucosae
 Discontinuous series of
cushions  3 main cushions: 7
left lateral, right anterior, right
posterior
TREITZ
 Protect canalis analis MUSCLE

& support 20-30% MUSCULARIS

resting continence) MUCOSAE
 Secured by Parks’ ligament PARK
(fibroelastic network coming LIGAMNET
from int. sphincter, muscularis
propia) and Treitz’s muscle
(coming from muscularis
mucosa of the rectum)
Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,
Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002
 PATHOLOGY
 Two major theories:
The Sliding down theory and The Vascular
theory.
 The first: pathological slippage of the normal anal lining, caused by
the deterioration of supportive connective tissue and
increased by the straining during defecation.
 The second: the ‘‘vascular hyperplasia theory’’ supposes
that an abnormal behaviour of the arteriovenous shunt is responsible
for the hypertension of hemorrhoidal plexuses, their consequent
dilatation, and therefore their prolapse and bleeding.
 INCREASE LAXITY OF THE
HEMORRHOIDAL SUPPORT TISSUE
 Chronic straining  weaken and
increase the laxity/ destroys of
hemorrhoidal support tissue
(muscularis mucosae, m Treitz, Lig.
Park  sliding downward of part
of the anal canal lining.
 Anal prolapse  stretching of the
upper and midle hemorroidal
vessels and formation of kinks +
closing pressure of the anal
sphincter creates an obstacle to
the venous flow, creating
predisposition to thrombosis

Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,
Abramowitz et al. Gastroenterologie June-July 2001.
 VASCULAR THEORY
 Hemorrhoids are
varicose dilatations of
the radicles of the
hemorrhoidal veins
Netter FH (1987)
 Internal hemorrhoid:
varicose enlargement of
the veins of superior
hemorrhoidal plexus.
 External hemorrhoid:
varicose enlargement of
the veins of inferior
plexus.
 Following factors suggested contribute to the
development of hemorrhoid

 Heredity  Food and drugs

 Anatomic features  Infection
 Nutrition  Pregnancy
 Occupation  Exercise
 Climate  Coughing
 Psychological problem  Straining
 Senility  Vomiting
 Endocrine changes  Constrictive clothing
 Constipation

Corman et al. Hand book of colon and Rectal Surgery 2002

These activities are associated with Hemorrhoids…

Yang HK. Hemorrhoids, Springer 2014

 PATHOLOGY

 The pathogenesis of the hemorrhoidal disease is

multifactorial and either of the two theories
alone is not sufficient to explain all its aspects
 Several studies have demonstrated “high resting
anal pressure” in patients. It is caused by
increased activity of the internal anal sphincter or
the external anal sphincter or by increased vascular
pressure within the anal cushions .
 INVESTIGATION

 The diagnosis of hemorrhoids is based on

clinical assessment and proctoscopy
 Further investigations should be based on a clinical
index of suspicion
 DEGREE OF INTERNAL HEMORROID

 1st stage: congestive non

prolapsed hemorrhoids
 2nd stage: prolapsing
during defecation,
reducing spontaneously at
the end of defecation,
 3rd stage: prolapsing
during defecation and
requiring manual
reduction
 4th stage: permanently
prolapsed which cannot be
reduced manually

Abramowitz et al. Gastroenterologie June-July 2001.

CLASSIFICATION

Yang HK. Hemorrhoids, Springer 2014

 COMPLICATION

1. Ulceration
2. Gangrene
3. Fibrosis
4. Thrombosis
5. Absces Formation
6. Incontinence
ARTERIO-VENOUS SHUNT IN
HEMORRHOID
 PATHOGENESIS, PATHOLOGY & Rational
treatment of hemorrhoid
OVOID/ TREAT RISK  REDUCE/ TREAT FACTORS INCREASE IAP
FACTORS  FECES SOFTENER

VASCULAR  PLEBOTHROPIC/VENOTONIC
DILATATION &  HEMORRHOID EXCISION
ENGORGEMENT
ABSENT/ NEARLY  LIGATION OF BRANCH OF SUPERIOR
FLAT SPHINCTER RECTAL ARTERY
LIKE CONSTRICTION  EMBOLIZATION OF SUP. RECTAL A.
DESTROYES
SUPPORTING TISSUE  UPWARD LIFTING ANAL CUSHION
 PROLAPS OF  EXCISION
ANAL CUSHION

INFLAMMATION  ANTI-INFLAMMATION

BLEEDING  MEDICAL/ SURGICAL TREATMENT

 TREATMENT

 Treatments are classified into three categories:

• Dietary and lifestyle modification and
medication.
• Non Surgical Intervention /Non operative/
office procedures.
• Surgical Intervention (Operative)
 DIETARY AND LIFESTYLE
MODIFICATIONS

 The main goal of this treatment is to minimize straining at

stool.
 Achieved by increasing fluid, fiber in the diet, and
recommending exercise.
 MEDICATION: Purified flavonoid fraction is a botanical
extract from citrus. Oral micronized purified flavonoid
fraction (hesperidin  diosmin  hidrosmin) It increasing
vascular tone, lymphatic drainage, and capillary resistance;
also assumed to have anti inflammatory effects and
promote wound healing.
NON SURGICAL INTERVENTION

 Non Surgical Intervention include: Rubber band

ligation, Sclerotherapy, Bicap electrocoagulation,
Laser therapy and Infra red coagulation can be
performed in an out patient setting and are
considered to be primary option in treatment of
grade I-III Hemorrhoid

Middleton SB, Lovegrove RE, Reece Smith H. Management of

Hemorrhoids: Symptoms govern treatment. BMJ 2008:336:461
 RUBBER BAND LIGATION

 Grade I or Grade II hemorrhoids and (in some

circumstances) Grade III hemorrhoids.
 Complications include bleeding, pain, thrombosis
and life threatening perineal sepsis.
 Successful in two thirds to three quarters of all
individuals with first and second degree
hemorrhoids.
SCLEROTHERAPY
 Symptomatic gr I to II hemorrhoid
 Submucosa injection at the base of the hemorrhoid with 5
mL of 5% phenol oil, vegetable oil etc.
 creates submucosal fibrosis and scarring, which prevents
or minimizes the extent of the mucosal prolapse
 Numerous studies: compare different treatment
modalities the results inconsistent  sclerotherapy
seems to be a less effective option.
 Complication: periprostatic parasympathetic
nerves injury  erectile dysfunction, pain etc

J Am Coll Surg Vol. 204, No. 1, January 2007

 SURGICAL INTERVENTION

 Surgical Intervention is ussually the treatment of choice

for grade III-IV hemorrhoids.
 Hippocrates (460 BC): “One may Cut, Resect, Suture or
Burn Hemorrhoids. These Measures seem to be terrible
but they don’t cause any damage”.
 Sir Astley Cooper (1836): Ligation and Excision
 White Head’s (1882): Removing the pile bearing area of
anal canal and restoring mucosal continuity by suturing
of rectal mucosa to anal skin
 SURGICAL INTERVENTION

 The Milligan Morgan Procedure is the most widely

practiced technique and is considered the current
‘Gold Standard’ for surgical management
 The Closed Technique is more popular in USA
 Both Operations have been demonstrated to be
equally effective and safe, However the close
technique demonstrated to result in faster wound
healing
 Significant Morbidity: Extremely Painfull

Shanmugam V, Campbell KL, Steel RJ: Hemorrhoidectomy for Hemorrhoid. Cochrane data base.Systemic Review.
2005;3;CD005034
 SURGICAL INTERVENTION

 Modifications to the original Milligan Morgan:

Diathermy, Ultrasonic Scalpel, Laser and Ligasure.
 Goal: To reduce post operative pain, blood loss and
faster woud healing.
 Literatur Review: There was no evidence support the
practice of laser, ligasure and diathermy achieve
good hemostatis and reduce post operative pain.

Cheetham MJ, Phillips RK. Evidence-based practice inhemorrhoidectomy. Colorectal Dis

2001;3:126-134
 CIRCULAR HEMORRHOIDECTOMY

GRADE III & IV

DO NOT SPARRING ANAL CANAL MUCOSA
MANY COMPLICATION: Stricture, constipation,
incontinence, wet anal syndrome.
EXCISIONAL OF THREE MAIN PILE

FERGUSSON METHOD
(CLOSED METHOD)

INTACT MUCOSAL
BRIDGE

MORGAN-MILLIGAN METHOD
(OPEN METHOD)
 Sub-mucosal
HEMORRHOIDECTOMY (park)
 SURGICAL INTERVENTION

 Hemorrhoidal Artery ligation (HAL) is a novel non

invasive surgical traetment for hemorrhoids that
was developed by Morinaga (1995)
 Transanal Hemorrhoid Dearterialization (THD)
 Doppler Guided Hemorrhoid Arterial Ligation
(DGHAL)
 DOPLER GUIDED HEMORRHOID
ARTERY LIGATION (HAL)
HAL: first reported by
Morinaga (Japan) 1995
Because the arteries
carrying the blood inflow
are ligated, internal
pressure of the plexus of
hemorrhoid is decreased,
shrink and become
smaller.
The American Journal of Surgery, 2006
Step for Recto-Anal Repair (RAR)
STAPPLER HEMORRHOIDOPEXY

o PECK 1986, DEVELOPED BY

LONGO
o BASED ON THE THEORY OF
INCREASE LAXITY OF
HEMORRHOIDAL SUPPORT TISSUE
o CIRCULAR REMOVAL OF THE
RECTAL MUCOSA PROXIMAL TO
HEMORRHOIDAL TISSUE 
UPWARD MOVEMENT OF THE
PROLAPSING HEMORRHOID
o TARGET TO CUT THE RECTAL
ARTERY IS NOT ALWAYS
ACHIEVED
 CONCLUSION

 Hemorrhoid is a normal vascular cushion

 Post operative pain following hemorrhoidectomy
appears to be the most important motivating factor
in the drive to
acquire better tratment options
 To provide the most effective surgical treatment it is
necessary to choose the appropriate technique
tailored to the individual patients clinical symptoms