Haemorroids www.medshortnotes.

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DR.K.PRATHAPAN MD

DEFINITION

Distened anal cushion

@ positions of 3' , 7' , 11' Clock

Most common in Elders

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Primary
no definitive underlying cause Increased intraabdominal pressure Obesity pregnancy constipation

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Secondary
Definitive cause is present

eg: Ca.rectum

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C/F:
Bleeding - 1st symptom ( splash in the pan/bright red and fresh)
Lump @ anus - persistent and appear while defecation haemorroids are painless unless complicated. pain may be due to prolapse, infection or spasm Pruritus

Anaemia - secondary

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Ex:
DRE - CAN NOT FELT ; but thrombosed piles can be felt.
Protoscopy Haemorroids can be associated with rectal carcinoma which sometimes can be missed by PRE. therefore, Sigmoidosopy is needed. In elders it must be done. Sigmoidoscopy or colonoscopy or barium enema should be done if there is any suspicion of associated malignancy.(SRB'S Manual of Surgery)
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Degrees
1st degree - only bleeding + no lump
2nd degree - Lump appears on defecation and disappears spontaneously (soon after defecation) 3rd degree - Lump appear on defecation But Lump is reduced by manually by patient 4th degree - persistent lump (manual reduction is not possible!)

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DD
Rectal ca

Rectal prolapse Perianal warts

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Complications:
Prolapsed haemorroids
Strangulation (because due to anal sphincter constriction)

Ulceration
Gangrene

Portal pyaemia- rare

Sometimes blood transfusion is required in case of profuse hemorrhage
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Mx:
Conservative Mx decreased strain/ avoid straining stool softners/stool bulking agents If 1st and 2nd degree Sclerotherapy Banding Haemorroidal artery ligation (HAL)
in sclerotherapy - 5% phenol missed with oil (arachids oil / armand oil)

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 Surgical Mx

If 3rd and 4th degree or 1st/2nd that not resolved with conservative Mx -Haemorroidectomy and HAL

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Complication after Sx
Early: Reactionary or secondary Bleeding Acute retention of urine - commonest Late: Anal Stenosis/Anal stricture Anal fissure

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EXAM POINTS:
3' clock position - Left lateral 7' clock position - right posterior 11' clock position -right anterior

Internal - above the dentate line, covered with mucous membrane External - below the dentate line, covered with skin Interno -external - together occur
Portal hypertension rarely cause haemorroids (SRB'S MANUAL OF SURGERY) Complication of external piles pruritus ani Perianal hematoma Perianal abscess formation

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