HAEMORRHOID

S
Dr Aketch Clifford
27th July, 2023
OUTLINE
 INTRODUCTION
 EPIDEMIOLOGY
 ETIOLOGY
 CLASSIFICATION/GRADING
 PATHOPHYSIOLOGY
 CLINICAL PRESENTATION
 WORK UP
 DIFFERENTIAL DIAGNOSES
 MANAGEMENT
INTRODUCTION
 YOU’VE GOT THEM, THEY’RE JUST
ASYMPTOMATIC & VERY IMPORTANT
 Hemorrhoids are normal fibro-vascular structures
underlying the distal rectal mucosa and anoderm.
 Acts as cushions for the sphincters and

 When do they become symptomatic?

 Enlarged
 Inflamed
 Thrombosed
 Prolapsed

 External hemorrhoids develop from ectoderm and

are covered by squamous epithelium, whereas
internal hemorrhoids are derived from embryonic
endoderm and lined with the columnar epithelium of
anal mucosa.
EPIDEMIOLOGY
 A common condition diagnosed in clinical practice, many patients are too embarrassed to seek treatment.
Consequently, the true prevalence of pathologic hemorrhoids is not known.
 Worldwide, the prevalence of symptomatic hemorrhoids is estimated at 4.4% in the general population

 Eighty random patients were examined over a 9-month-period to determine the incidence of asymptomatic
haemorrhoids at the Kenyatta National Hospital (KNH). The incidence of asymptomatic was found to be 21% all being
first degree haemorrhoids, while in the age group 50 years and over, 29% had asymptomatic haemorrhoids. The mean
age calculated as 44.3 years (+/- 18.3), with no statistical difference between the ages of the two sexes. Males however
had a significant greater incidence of asymptomatic haemorrhoids than females. {A STUDY}
AETIOLOGY
 Decreased Venous Return
 Straining and Constipation
 Chronic Diarrhoea
 Pregnancy
 Portal hypertension and anorectal varices
 sitting on the toilet for long periods of
time
 lack of fiber in the diet
CLASSIFICATION
 Related to the location of the enlarged hemorrhoidal tissue relative to the dentate line,
Hemorrhoids located proximally are internal while those distal to the dentate line are external
hemorrhoids.
 INTERNAL HAEMMORRHOIDS
 usually associated with painless bleeding, however can also cause acute pain when incarcerated and
strangulated
 Further graded based on symptomatology (next slide)

 EXTERNAL HAEMMORRHOIDS
 Becomes symptomatic following acute Thrombosis
 Residual enlarged skin tags cause interference with hygiene or appearance
GRADING
CLINICAL PRESENTATION -
SYMPTOMS
 An adequate history should include a
disease-specific history, particularly
focused on the onset, duration, and
degree of the symptoms and risk
factors.
 characterizing any pain, bleeding,
protrusion, or change in bowel habits,
 Attention should be placed on the
patient's coagulation history and
immune status.
 Rectal bleeding is the most common
presenting symptom.
 A patient with a thrombosed external
hemorrhoid may present with
complaints of an acutely painful mass
at the rectum
CLINICAL PRESENTATION -
SIGNS
 General physical examination,

 Perform visual inspection of the anus and rectum

 Digital rectal examination

 Anoscopy or proctosigmoidoscopy when

appropriate.
 SIGNS TO NOTE
• Redundant tissue
• Skin tags from old thrombosed external
hemorrhoids
• Fissures
• Fistulas
• Signs of infection or abscess formation
• Rectal or hemorrhoidal prolapse, appearing as a
bluish, tender perianal mass
INVESTIGATIONS
 HAEMATOLOGY
 CBC
 Coagulation Studies

 ANOSCOPY
 FLEXIBLE SIGMOIDOSCOPY
 FURTHER IMAGING (In suspicion of other conditions, ca etc)
 HISTOLOGY (Strictly for suspicious tissues after proper gross examination.)
MANAGEMENT
 It is hard to make an asymptomatic patient better
 Treat only if symptomatic
 Treat underlying acute disease (abscess|
 Treatment variable depending on type and grade of haemorrhoid.
 Modalities Include
 NON OPERATIVE
 OPERATIVE
 NON OPERATIVE
 CONSERVATIVE MANAGEMENT
 Warm Baths
 High Fibre Diet
 Stool softeners
 Antidiarrhoeal agents
 Toilet habit Retraining
 Topical agents & Oral Agents
 Anesthetics, astringent, antipruritic,
Analgesic, Vasoconstrictors, protectants
 NON SURGICAL PROCEDURES
 Rubber band ligation
 Coagulation, electrocautery, and
electrotherapy
 Sclerotherapy and cryotherapy
 Laser therapy and radiofrequency
ablation
OPERATIVE
 Excision of thromboses
 Surgical Haemorrhoidectomy
 Stapled hemorrhoid surgery/procedure for prolapsing hemorrhoids (PPH)
 Doppler-guided transanal hemorrhoidal dearterialization
 Hemorrhoidal artery ligation and rectoanal repair
ANY QUESTIONS