Haemorrhoids

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Classification
External
Distal to dentate line. Covered with anoderm
Cause swelling discomfort & difficult hygiene
Severe pain if thrombosed
Internal
Are painless
Bright red bleeding
Prolapse associated with defecation
Complications
B. Permanent
1.Impairment of continence -To prevent
important criteria is intact 'corpus
cavernosum recti".
2.Edema and tags
3,Stricture and Stenosis - Due to excessive
excision
4.Anal Fissure
Anorectal anatomy
of Longitudinal muscle
Circular rectum-
rectum muscle of
Muscularis Mucosa mucosae
Puborectalis
muscle
Anorectal Rectal columns. ring.
plexus Internal hemorrhoidal
sphincter. Deep external
plane Intersphincteric
Anal Internal
Anal crypt sphincter.
gland (lies in
intersphincteric
sphincter Superficial into crypt). plane,
opens external
Dentate
plexus External line hemorrhoidal
sphincter. Subcutaneous external
6
Closure, firing, and withdrawal of the stapler
Repositioned mucosae and hemorrhoids
The stapler is then closed of the
The completaly, ana-canal fired in Succossful
completion procedure for prolapse and hem-
and withdrawn gently. wallis one fluid motion,
reconnected and orrhoids corects the prolapse, restores
internal hemorrhoids
restored, and the hemorthoidal artery's terminal
branches, their normal anatomic position, and alleviates
the patient's
which feed internal hemorthoids, to
are interrupted. symptoms.
Treatment
Rubber band ligation
- Devices - Single operator and assistant-
required
o-E
Irvin Moore's nasal conchal forceps for grasping
the pile for banding, shown with banding
instrument
Thomson One-man bander used within
the Naunton-Morgan anoscope
Closed Hemorrhojdectomy
- Hill-Ferguson retractor in place, grab
Cushion, place suture at apex 4cm above
dentate line, elliptical excision down to
sphincter. Close from ligated pedicle out to
skin.
- Complications: urinary retention, bleeding
stenosis, incontinence, infection.
Anatomyy
The external sphincter is a voluntary,
striated muscle divided into three u-shaped
loops (subcutaneous, supericial, and deep).
Acts as a single functional unit.
Continuation of the levator ani muscle,
specifically of the puborectalis muscle,
Innervated by somatic nerve fibers
Generates anal squeeze. Key role in
maintaining anal continence
Sclerotherapy Procedure
Preparation defecation, Lubrication, LA gel
Position - left lateral position,buttocks at table
edge
Injection - base of hemorrhoid, above dentate
line. Needle 1-2 cm deep,parallel to anal
canal.3-5 ml of sclerosant is injected
slowly. After procedure needle held in
place for about two minutes, then slowly
withdrawn.
Max. 3 separate injections Given at the
bases
Treatment
Treatment options for internal hemorrthoids
determined by grade; however, composition
of external tags considered.
Lower grades can be treated with
nonsurgical methods such as sitzbaths,
stool softeners, and fiber supplements
Higher grades with either office-based
procedures (infrared coagulation therapy,
banding.scleroth era py) or surgery.
Candidates for Surgery
Revised American Society of Colon and
Rectal Surgeons Management of
hemorrhoids by surgical treatment
Patients who do not respond to office-
based procedures
2. Patients not capable of tolerating office
procedures
3. Patients with large external hemorrhoidal
disease
4. Patients with grade Ill or IV mixed
hemorrhoidal disease.
Cryotherapy
Complications
Pain
Anal discharge - Brown offensive fluid
Recurrent haemorrhoids
Skin tags
Because of the pain and the anal discharge
most patients are unable to return to work
for a as a week
Ssymptomns
2. Prolapse
3. Itching Prolapsed piles
4. Anorectal dysfunction
5. Soiling
6. Discomfort and Pain
Sclerotherapy
Sdlerotherapy is commonly used to treat bleeding
internal hemorrhoid. In this procedure, a
sclerosant is injected into the base of the
hemorrhoids.
There are many types of sclerosants- chemical
Mechanism - low-grade, long-standing
inflammation which scars the vein, mucosal tissue,
collapse the vein walls, and cause to shrivel.
Contraindications of sclerotherapy
1. Acute prolapse-thrombosis- Third-degree
hemorrhoids not be treated because the risk of
acute prolapse-thrombosis
Large second-degree also not treated - successis
not good.
2. Severe bleeding or ulceration-
accompanying other ano-rectal conditions-
BD,causes severe bleeding or ulcers in the
colon's mucosal tissue.
3. Fissures and Fistula
Symptoms
1. Bleeding
Single layer of capillary epithelial cells
Lamina propria Trauma
- Lax-textured upper part of the
- Repeated trauma
- Bright red, Drips
Inflamed permanently prolapsed pile
Anatomy
Lined in its upper two-thirds by insensible
mucosa, below by a hairless, glandless cuff
of highly sensitive squamous epithelium, the
anoderm.
The mucosa is seen to be thrown into 8-14
longitudinal folds of Morgagni just above
dentate line and forming the anal crypts at
their distal end.
External hemorrhoid Internal hemorhoid Mized
hemorrhoid
Origin
Origin internal above rectal dentate plenus) line
(esternal below rectal dent plemus) ate line Origin
internal above and esternal and below rectal dentate
plemus) line
Hevrtis
Anatomy
Arterial supply is superior, middle and
inferior rectal arteries (IMA, Int. Iliac, int.
pudendal artery).
Venous Drainage empties into portal and
caval systems. Upper and middle rectum
into SRVIMV> Portal vein. The lower
rectum and upper anal canal
MRVIIV>IVC, The Lower anal canal
drains into the IRV IVC.
Closed Hemorrhojdectomy
Jl
Right posterior anal cushion
Left lateral anal oushion
Enlarged an al eushions
Right anal cushion anterior
Usual of prolapse position for of internal anal cushions
hemorrhoids and sites
Prolapsed "rosette" of internal hemorrhoids Hvortis
@tesartis RAGNG
Rubber band ligation
Rubber bands
Internal
hemorrhoid
Ligator
Etiology
- Hereditary- Cong. weakness of vein wall
Theory: Downward sliding of anal cushion
associated with gravity, straining and
irregular bowel habits.
Anatomy- Collecting radicles of SHV lie
unsupported in loose connective tissue of
anoderm.
Rarely Varicosity of the anal
Vein.
Anal varices in portal hypertension.
Open Hemorrhojdectomy
PPH
Indications
Select grade ll hemorrthoids
- Grade ll hemorrhoids
- Uncomplicated grade IV hemorrhoids
- Patients for whom other treatment
modalities are not successful
Signs
1. Inflammed, Edematous mucosa
2. Engorgement of the subanodermal veins
Engorgement of the subanodermal veins
masquerades
oedema contributes to bulk of prolapse' patients as
prolapse in some
Superior rectal vein
Right branch
Left branch
Anterior branch
Posterior branch ((O)
Fig.
are classically 61.25 Disposition of
sited at 3, 7 anal and vasculature 11 o'clock. illustrating
why haemorrhoids
Anatomy
The anal canal starts at pelvic diaphragm
and ends at anal verge. Approximately 4cm
long
Anatomic anal canal extends from anal
verge to dentate Iine.
Surgical anal canal is anal verge to
anorectal ring, the circular upper border of
puborectalis that is palpable by rectal exam.
It is 1-1.5 cm from dentate line.
Externall Terior
iliac vein mesenteric
Inferior
plexus Internal Internal hemorrhoidal iliac vein artery
mesenteric
Middle rectal vein vein
Inferior rectal vein
External
Vascular supply plexus hemorrhoidal
Intenal iliac vein
Internal iliac artery
Superior rectal
artery
vein Superior rectal
Middle rectal artery
Middle rectal vein
Internal pudendal artery
Internal pudendal vein
Inferior rectal artery
Signs
3. Thrombosis and clotting in the vein.
Early venous clotting in an anal cushion Infarction of the
pile.
Treatment
In closed procedure the patients tend to
experience less pain compared with an
open procedure.
However, occasionally a closed incision
may open up after surgery - If the external
skin is tight following a closed procedure
Treatment
C. Interventional
0O
- Aim
-Techniques
1. Rubber band ligation
a. A second banding
attempt wil occasionally
improve on the
achievement of the first.
b. If the first 'polyp' is
insufficient but has
been banded too loww
near the dentate line for
enlargement,
adjoining an
cephalad
Banding exposed mucosal part
of pemanently prolapsed pile band can be placed
Anatomy
- The internal sphincter is a specialized
continuation of the circular smooth muscle
layer of the rectum. It is involuntary, and
contracted at rest. Maintains resting anal
tone. Innervated by ANS
- The intersphincteric plane is a fibrous
continuation of the longitudinal smooth
muscle layer of the rectum
Differential Diagnosis
5. Fissure
6. Perianal hematoma/ Thrombosed extermal
pile
7. Rectal prolapse
8. Rectal tumour
Perianal haematoma
saccule greatly distended - single venous
with clot.
Colonoscope 160 cm
60 Flexible cmn sigmoidoscope
Sigmoidoscopee 18 cm
Finger 12 cm
proctoscope
8 crm
Fig.
the rectum 6o.5
asked rectum reach llustration
to "strain can different showing
down' be felt levels.
(courtesy vith the Note how
of index that the various
C. finger. even cancers methods
Mann) especially in the of examining
if the upper patient part the of is
Endoscopic image of
internal hemorrhoids seen
on retroflexion of the
1exible sigmoidoscope at
the ano-rectal junction.
Pathology
The anal cushions are disrupted to produce piles
by the forces of defaecation.
- The Valsava effect of excessive straining
-The anal cushions may be structurally deficient.
Weakness arising from the influence of
progesterone on smooth muscle and elastic tissue
may explain the predisposition to haemorrhoids in
pregnancy.
Increase in pelvic vascularity may also contribute.
Geographic anatomy of ancorectum
Restosigmoid
junction
rectal Superior valve
Rectal
Middle Valves ampulla
rectal valve Houston bf
Inferior
rectal valye
1.0-15 Anorectal
ring
Dentate
cm 1.0-1.5 line Surgical
Anatomic
anal
Anal (anoderm) canal anal canal
verge
Cryotherapy
Mechanism - tissue after being frozen,
undergoes gradual necrosis, due partly to
thrombosis of microcirculation. Cryoprobe
Agents - Liquid nitrogen, Nitrous oxide gas
Procedure Increasing margin of tissue
around probe turns white, max. width of
about 6-7 mm.Necrosis of the freezed
hemorrhoid occurs over several days-a
week. Slough separates in 2-3 weeks.
complete healing often requiring additional 2
weeks or more. Patient-analgesics and
axatives several weeks after treatment
Anatomy
Three submucosal internal hemorrhoidal
plexuses above dentate line Lt lateral, Rt
anterior, Rt posterior quadrants-11,3,7
o'clock, drain into the superior rectal vein.
- Below dentate line, external hemorrhoid
veins drain into pudendal veins.
Normal
Disrupted
anal cushion
Complications
A. Short lived
1.Vasovagal - banding of piles, injection
2.Pain post operatively
3.Haemorrthage - Secondary haemorrhage
4.Infection Rare
5.Urinary - haemorrhoidectomy, Banding
6.Anal cushion thrombosis - Banding
HAEMORRHOIDS
Dr. VIJAYA LAKSHMI L
APOLLO BGS HOSPITALS
Complications & Follow up
3. Injection into vein - too easily injectable
or pain in the liver area or unpleasant taste
4. Injection into prostate -
Urinary retention- Most common
Infertlity -sol. > seminal vessel-> testicle
Prostitis- no treatment, antibiotics
Abscess- Surgery. Painful blood clot
formation - anal dilation/surgery
Analgesics Stool softeners - Follow up
Treatment
A. Conservative
Avoidance of prolonged straining at stool
- Increase in dietary fiber
B Medical
-Stool softeners
- Fiber supplements
- Topical anesthetic gel application
Lidocaine jelly, NTG cream
Advantages of sclerotherapy
1 Easy and inexpensive to administer
Technique is simple to perform as an out-patient
procedure. No lengthy hospital stay
2It works fast and last long
After 7 to 10 days, the shriveled hemorrhoid fall off
during normal bowel movement. Patient symptoms
free at least 12 months.
3 Can be performed in elderly patients
The method of choice for treating in elderly
patients, who have fragile veins.
4 Multiple hemorrhoids can be treated at
Once
Up to 3 hemorrhoids can be injected.
Complications Rare
-
1. Bleeding - accidental puncturing an artery
Delayed bleeding- too much solution or at
wrong site-causes an ulcer to develop
Bleeding after 7-14 days - hospitalization.
2. Pain -improper selection of injection site
Done above dentate line. Pain stop procedure
Short-lived. Managed by topical pain killers
Differential Diagnosis
1 Anal tags Skin tags
2 Fibroepithelial Polyp
3 Sentinel Pile
4 Dermatitis
Sentinel pile at lower end of posterior
A fibrous anal polyp fissure with perianal dermatitis with
surmounting a pile punctate excoriations.
Haemorrhoids
The names 'haemorrhojds' and 'piles' are
essentially synonymous though differently
derived from the two main-and only certain
-symptoms, respectively bleeding and
protrusion.
The term 'Haemorrhojds' restricted to
abnormal clinical situation
Treatment
Modifications of haemorrhoidectomy
Diathermy dissection
Park's submucosal excision
Radial clamps or staples or PPH - Less pain.
Learning curve. Rectal wall injury,
rectovaginal fistula. Only a portion of the
prolapsed rectal mucosa and intemal
haemorrhoid is removed and fixed at the
anorectal ring
Milligan Morgan technique
- Prone Jack-Knife position, butt taped apart.
- Bridges must be left between excisions
- Clover leaf shaped defect in anal canal &
perianal skin. Wounds are left open.
- Healing with scar contracture draws tissue
back into anal canal and reattaches it to
muscle coat
Anatomy
The anal verge is the junction between
anoderm and perianal skin.
- The dentate linę is a true mucocutaneous
junction located 1-1.5 cm from anal verge. A
6-12mm transitional zone exists above the
line where squamous becomes cuboidal,
then columnar.
Anal sphincter mechanism made by
internal and external sphincters.
PPH
Contraindications
- Purely external hemorrhoids
- Fixed prolapse or fibrotic external
hemorrhoids
- Abscess, gangrene,
- Anal stenosis,
- Full-thickness rectal prolapse.
Parts of Haemorrhojd
Divided into 3 parts
Pedicle- situated at anorectal ring. Seen
through proctoscope, Pink mucosa,
Internal haemorrhoid- commences below
anal ring. Bright red or purple.
External associated haemorrhoid- lies b/w
dentate line and anal margin. Blue vein can
be seen unless fibrosed.
It is present only in well established cases.
PPH
Procedure for prolapse and haemorrhojds
- Synonyms
1. mechanical hemorrhoidectomy witha
circular stapler
2 2 Stapled hemorrhoidectomy
3. 3 Circular stapler hemorrhoidopexy
4. Stapled circumferential mucosectomy,
5 Stapled anopexy
6 6. Stapled hemorrhoidopexy.
Management of Infarcted pile
Turbulent flow in sacculated venous plexus
Thrombosis and clotting occurs.
Considerable swelling and discomfort
Invites attempts atimmediate amelioration
Conservative and surgical treatment.
Natural thrombolysis restores circulation
Resolution in about 10 days.
Nitroglycerin ointment
Severe -debridement haemorrhoidectomy
Treatment
2. Infrared photocoagulation and bipolar
diathermy
3. Sclerotherapy
4. Cryotherapy
5. Laser treatment
6 Haemorrhoidectomy
Milligan Morgan technique Gold standard
PPH
A specially designed circular stapler is
inserted through a circular anal dilator
A portion of the prolapsed rectal mucosa
and internal hemorrhoids removed
The remaining hemorrhoidal tissue drawn
back into correct anatomic position
- Hemorrhoidal swelling is reduced following
PPH because hemorrhoidal artery blood
flow is disrupted
A Insertion The Preparation
prepared intemal
from the dontate in the hemorhoids of the purse-string
rectal line. mucosasubmucosa are held back suture
to circuler while opproximately4-5 a purse string cm is
placo. push the anal of the
prolapse dilator/obdurator anal dilator/obdurator
back and lit is the inserted hemorrhoidal into the anal
tissue canal into
3
Initial A After Insertion
is
prolapse traction tightoned the ands of the
on is drawn the and of
purse-string gently the stapler retraction into
pushed suture the
into the staplor must into
casin be the are anal
maintained anal knotted, canal
canal. tho
so Mocdorate stapler
the bayond fully placement
threader, anvil the opened
to purso-string homorrholdal of the circular
that the
nel of the oach secure
instrument. limb the of the excess suture.
suture mucosal The circular stapler
purse stapler
is brought tissuo. string
through With is tied is insertod
the around
the suture chan
Disadvantages of Sclerotherapy
Unsuccessful for larger haemorrhoids
Haemorrhojds return after treatment
although not within 12 months of treatment
Indications for sclerotherapy
-First-degree,even those which bleed
profusely
-Second-degree hemorrhoid, in which the
prolapse is slight or barely noticeable, also
responds well to this procedure
1 Later effe cts of clotting of thee sacoulated venous
plexus with infarction of the pile.
Grading
First Degree
Painless bleeding, no Prolapse
Second Degree
Bleeding, Seepage, Prolapse with
spontaneous reduction
Third Degree
Bleeding, Seepage, Prolapse requring
digital reduction
Fourth Degree
Prolapsed Strangulated
- Ireducible,