HAEMORRHOIDSBy Dr. Waqas Munir

INTRODUCTIONHaemorrhoids :

Haem=bloodRhoos = flowing

Piles:

Pila= swellingThe actual term now a days used for this is Haemorrhoidal disease.

ANATOMY Beneath the epithelium in anal canal there is

rich plexus of vascular tissue called corpus cavernosi recti, that connect arteries to veins.

These vessels are normally supported by longitudinal muscle fibers (muscularis submucosa ani) which help to retain the vascular cushions in their position in the upper half of anal canal.

There are 3 main vascular cushions (primary sites) in the anal canal(one on the left and anterior and posterior on the right).

In 2/3rd of pts these are at primary site and in 1/3rd of pts these are at other site called secondary sites.

ANATOMY

PATHOPHYSIOLOGY Facors involved in the development

of haemorhhoidal disease:Venous obstructionProlapse of vascular cushionsHeredityGeographical and dietary factorsAnal sphincter toneAnal and rectal sensationDefecation habits

Venous obstruction: The principal cause of haemorrhoidal disease seems to be the

congestion and hypertrophy of internal anal cushions. Cushions congest because

1. They fail to empty rapidly during the act of defecation.2. They are abnormally mobile.3. They are trapped by tight internal sphicter.

When the cusions are congested, they bleed and become edematous.oedema causes stretching of the tissue and finally hypertrophy.

Fecal mass in the rectum compress the veins. Straining constricts the intermuscular vein so blocks

emptying of veins.

Predisposing fctors of venous obstruction: Raised intra abdominal pressure during pregnancy,from

ascites or pelvic tumor, or raised portal venous pressure with hepatic cirrhosis.

Piles of pregnancy: These are not necessorily abnormal.

PATHOPHYSIOLOGY(FACTORS)

PATHOPHYSIOLOGY(FACTORS) Prolapse of vascular cushions: Submucosal vascular cushions are supported

by Pectin bands(ligaments of park) Muscularis submucosa

In normal defecation internal sphicter relaxes and there is outward rotation of vascular tissue and pectin bands.

In haemorrhoidal disease this normal rotation is disturbed due to the decrease in elastic tissue caused by;

Increased Age Constipation Prolonged straining Endocrine reasons

PATHOPHYSIOLOGY(FACTORS) Heredity:

No heredity evidence proved. family history is commonly recorded due to same

customs, environment and diet. Geographic and dietry factors:

> western society due to less fiber diet. Anal sphincter tone:

Numerous studies have shown that basal anal pressure are significantly higher in haemorroidal disease.

Anal and rectal sensation: Anal electro sensitivity and temperature sensations are

reduced in patients with haemorrhoids. Defecation habits: More than 10-15 min sitting for defecation.

EPIDEMIOLOGY Sex:

In hospital based studies Men > women In community based studies men = women

Age: Increase with age

Socioeconomic status and occupation:

> high socioeconomic group > heavy laborer and occupations with prolonged

sitting or standing

DEGREES

B:First-degree bleeding

without prolapse

C:Second-degree Prolapsed, reduced spontaneously

D:Third-degree prolapsed, requiring manual reduction

E:Fourth-degree fibrosed permanently prolapsed

Reference : Sabiston Textbook of Surgery, 18th Edition

SYMPTOMS1. Bleeding2. Prolapse and lump3. Pain and discomfort4. Discharge and pruritis

SYMPTOMS Bleeding:

Most common and earliest symptom Bright red painless bleeding especially at the

end of defecation is pathognomic of the disease.

Bleeding is similar to anal fissure and perianal dermatitis but pain and pruritis differentiate it.

Bleeding from ulcerative proctitis and rectal neoplasm is different from haemorrhoidal disease as it is not fresh bleeding.

Anemia with haemorrhoids ?

SYMPTOMS Prolapse or lump:

Prolapse or lumps protruding through the anus are the real piles.

Protrusion with the spontaneous or self digital reduction is characteristic of haemorrhoidal disease.

Hypertrophid anal papilla and low rectal polyps can also prolapse and they can be reduced (mistaken for haemorrhoids)

Pain and discomfort: Haemorrhoids are usually painless. If pain is there either think of a complication(thrombosed

prolapsed internal haemorrhoids) or change the diagnosis.

Discharge and pruritis: A constant mucous discharge from the anus with or

without bleeding is characteristic of prolapsed haemorrhoids.

TYPES Internal External Interno-external

External

Internal

•Anoderm•Swell, discomfort, difficult hygiene

•Pain?-> Thrombosed

•Pain?-> painless

•Bright red bleeding•Prolapse associated with defecation

COMPLICATIONS1. Thrombosis and infection of internal

cushions2. Anemia3. Perianal dermatitis4. Thrombosis of external vascular

channels

COMPLICATIONS Thrombosis and infection of internal

cushions Most painful complication Thrombosis occurs when cushion is prolapsed and

enlarged.

If necrosis of the mucous membrane occurs , clot extrudes and pt is relieved.

If it is not relieved then give strong analgesics are given and pt may even need emergency haemorrhoidectomy to evacuate the clot.

After rupture of mucous membrane infection can get through it and pyemia can occur but it is very rare.

COMPLICATIONS Anemia:

Rare and look for other causes

Perianal dermatitis: Due to the continuous mucous leakage and

permanently prolapsed cushions.

Thrombosis of external vascular channels:

Tense hard and superficial swelling.

ASSESSMENT History Inspection (to rule out other causes) Palpation Endoscopy(Proctoscopy and

sigmoidoscopy)

TREATMENT Conservative;

Medical Invasive therapy

Injection sclerotherapy Rubber band ligation Cryotherapy Photocoagulation

Surgical; Open haemorrhoidectomy Closed haemorrhoidectomy White head haemorrhoidectomy Laser haemorrhoidectomy Diathermy haemorrhoidectomy Stapled haemorrhoidopexy

TREATMENT

Reference : Sabiston Textbook of Surgery, 18th Edition

GRADE SYMPTOMS AND SIGNS MANAGEMENT

First degree Bleeding; no prolapse Dietary modifications

Second degree Prolapse with spontaneous reduction

Rubber band ligation

  Bleeding, seepage Coagulation

    Dietary modifications

Third degree Prolapse requiring digital reduction

Surgical hemorrhoidectomy

  Bleeding, seepage Rubber band ligation

    Dietary modifications

Fourth degree Prolapsed, cannot be reduced Surgical hemorrhoidectomy

  Strangulated Urgent hemorrhoidectomy

    Dietary modifications

CONSERVATIVE Medical management:

Advice For minor symptoms

High fiber diet Thorough perianal lavage after defecation

Changing defecation habits Do not Neglect 1st urge to defecate in morning Don’t insist on trying to pass the last portion of stool

from rectum in the belief that it is not passed Diet manipiulation

Bulking agents (high fiber diet) e.g ispaghol husk and methyl cellulose

Topical agents Suppositories( shark liver oil, skin respiratory factor) Xylocain for pain Paraffin as lubricant to avoid rubbing

CONSERVATIVE Invasive therapy: Principles on which invasive therapy is

based;1. Prevention of Prolapse by mucosal fixation2. Prevention of congestion by stretching or by

dividing the internal sphincter3. Excision of the engorged internal vascular

channels

INJECTION SCLEROTHERAPY

Useful in 1st and 2nd degree 70% success rate Sclerosant causes aseptic inflammation and

fibrosis in 2-3 weeks. Gabriel syringe and needle 5% phenol in almond oil (3ml in each cushion) 2.4% anhydrous qunine urea with ph 2.6. Knee chest or left lateral position Rt posterior cushion (7oclock) should be

injected 1st.

INJECTION SCLEROTHERAPY

Technique: The proctoscope is passed and obturator is removed. The scope is manipulated until the junction between pink and

purple mucosa is positioned indicating the base of cushion. The needle of syringe is introduced obliquely through the mucosa

for 1 cm. The procedure should be painless If pain it is either too too dep or too superficial

Superficial = avascular bleb Deep =no swelling

Must be careful in midline anteriorly Complications:

Pain Hemorrhage Lower urinary tract sepsis Impotence Oleogranuloma(response to almond oil) Bacteremia(8%)

RUBBER BAND LIGATION Used for 2nd degree 80% success rate Principle is mucosal fixation by ulceration. Band produces ischemic necrosis with

sloughing and ulceration.

Ligators Barron ligator Suction band ligator Mc Giveny ligator

Preparation and position:Bowel should be emptyAn assistant to hold proctoscopeKnee chest position

Technique: Rubber band is equipped by the help of loading cone. Pass proctoscope Visualize the cushion,the base of cushion lies 1.5-2cm above the

dentate line Long shaft of the suction band equipment is introduced through

the proctoscope. Hemorrhoid is sucked into the lumen of the inner drum. Handle is squeezed to advance the outer drum that releases the

rubber band and applies it to the neck of haemorrhoid.

Volume of strangulated tissue should not be larger than 1cm diameter and at least 1cm prior to dentate line.

Barron stated 1 band each time but latest research showed that all 3 bands can be applied at 1 time (time saving and economical)

RUBBER BAND LIGATION

RUBBER BAND LIGATION Complications:

1. Pain (most common)1. If severe pain then removal of band and treatmeent with

photocoagulation

Removal of the rubber band: Grasp the strangulated mucosa with forceps and attempt to rotate it so that the rubber band or at least the constricting groove is seen clearly then a small triangular blade is used to cut directly until the band snaps and mucosa returns to the normal tissue.

Alternatively the band can be removed by conventional suture removal scissors or application of crochet hook.

2. Bleeding.3. Pelvic cellulitis (clostridial infection common )

Measures to avoid: Screening for immunodeficiency Rectal washout prior banding Prophylactic antibiotics

CRYOTHERAPY Principle: when tissue freezes , intracellular

water crystalizes,cell membranes are destroyed and tissue death occurs.

Tissue freezes at -20c and permanent destruction at -22c.

Liquid Nitrous oxide is used which boils at -90c

Technique: With bivalved speculum anal cushions are exposed. Apply lubricant The probe is laid along the length of the cushion and

pressed laterally while trigger is squeezed. Nitrous oxide evaporates in the tip that become frosted. This is continued for 3 minutes.

PHOTOCOAGULATION The technology includes infrared

radiation generated by tungsten halogen lamp which is focused on the tissue from a gold plated reflector housing through a polymer tubing.

HEMORRHOIDECTOMY Indications:

3rd degree haemorrhoids 2nd degree haemorrhoids which have not been cured

by non operative methods Fibrosed haemorrhoids Interno- external haemorrhoids when the external

haemorrhoids are well defined.

Preparation: 1 enema night before surgery another 1 hour before

surgery Pts with severly prolapsed haemorrhoids should be

spared from enema.

Anesthesia: Any type of anesthesia If L/A 0.25% bupicain with 1:200,000 adrenalin

CLOSED HAEMORRHOIDECTOMY Benefits:

Less post op discomfort Minimum in patient and virtually no out patient

care No loss of continence No need of subsequent anal dilation

Relative contra indications: Crohn’s disease Portal hypertention Lymphoma Leukemia Bleeding diathesis

CLOSED HAEMORRHOIDECTOMY Technique:

Prone jack knife position/left lateral Adhesive tape to retract the buttocks Anal canal examined by Pratt bivalved speculum. After inspection replace bivalved speculum with Fansler operating

anoscope. Anoscope is adjusted so that the operating channel is in line with the

haemorrhoidal tissue. The skin tag or anal epithelium adjacent to haemorrhoidal tissue is

grasped with the pair of Aliss forceps and retracted toward the center of anal canal.

Scissors with its curve toward anal canal is used to incise beneath the tissue forceps from the perianal skin upwards along the haemorrhoidal tissue.

Most prominent region of haemorrhoidal tissue is excised 1st to minimize the subsequent loss of anoderm.

Bleeding submucosal vessels are controlled with cautry. After complete excision of the haemorrhoidal tissue to a point above the

internal sphincter the wound is closed using a running 3/0 suture. Stiching is begun at the apex and mucosa is fixed with submucosa and

muscle.

OPEN HAEMORRHOIDECTOMY(MILLIGAN- MORGAN)

Technique: Lithotomy position

1st the left lateral haemorrhoid is excised, then right posterior and then right anterior.

Skin covered component of each pile is seized with the artery forceps and retracted outward.

The purple anal mucosal component of each pile is grasped with another artery forceps and drawn downward and outward.this indicates pile have been drawn to max extent so that ligature can be applied at their upper pole.

A V- shaped incision is made in the anal and peri anal skin so that the limbs of the V cross the mucocutaneous junction but do not extend into the mucosa.The point of V should lie 3 cm away from anal verge.

Venous plexus is dissected from internal sphincter while preserving this sphincter.

The apex of the pedicle is transfixed with 1/0 chromic catgut. The isolated haemorrhoid is then excised with the scissors a few

mm below the ligature.

COMLICATIONS OF HAEMORRHOIDECTOMY

Early:Pain Acute retention of urineReactionary hemorrhage

Late:Secondary hemorrhageAnal strictureAnal fissure Incontinence

THANKS