Hemorrhoid Hemorrhoid Normally do by ert554898


Normally, do people have anal
 Yes
 Within the normal anal canal exist specialized, highly
  vascularized “cushions” forming discrete masses of thick
  submucosa containing blood vessels, smooth muscle,
  and elastic and connective tissue
 These structures aid in anal continence
When would we call them
 Abnormal
 Cause symptoms
  Downward sliding of anal cushions associated
   with gravity
  Straining
  Irregular bowel habits.
How do hemorrhoids come?
 The cause of hemorrhoids remains
How could we diagnose
 History
 Physical examination
 Endoscopy
 Dripping or even squirting of blood in
 the toilet bowl
 Chronic occult bleeding leading to anemia
 is rare, and other causes of anemia must
 be excluded
History (cont’d)
 Prolapse
  below the dentate line area can occur,
  especially with straining, and may lead to
  mucus and fecal leakage and pruritus
 Pain?
  is not usually associated with uncomplicated
  hemorrhoids but more often with fissure,
  abscess, or external hemorrhoidal
Hemorrhoids can be divided to?
 External
 Internal
         -> painless
         •Bright red bleeding
         •Prolapse associated
         with defecation


         •Swell, discomfort,
         difficult hygiene

-> Thrombosed
How are Internal hemorrhoid
 Extent of prolapse
                                                         A:Thrombosed external
                                                         B:First-degree internal
                                                           viewed through anoscope
                                                         C:Second-degree internal
                                                           prolapsed, reduced
                                                         D:Third-degree internal
                                                           prolapsed, requiring
                                                           manual reduction
                                                         E:Fourth-degree strangulated
                                                           internal and thrombosed

Reference : Sabiston Textbook of Surgery, 18th Edition
 Digital examination -> assess
  internal and external hemorrhoidal disease
  anal canal tone
  exclusion of other lesions, especially low
   rectal or anal canal neoplasms
 Virtually all anorectal symptoms are
 ascribed to “hemorrhoids” , anorectal
 pathologies be considered and excluded
 Definitive examination
 Flexible proctosigmoidoscopy should always
  be added to exclude proximal
  inflammation or neoplasia
 Colonoscopy or barium enema should be
  added if the hemorrhoidal disease is
  unimpressive, the history is somewhat
  uncharacteristic, or the patient is older
  than 40 years or has risk factors for colon
  cancer, such as a family history
 Depending on degree of disease, treatment
 falls into two main categories: nonsurgical
 and hemorrhoidectomy.
         GRADE                           SYMPTOMS AND SIGNS             MANAGEMENT
         First degree                    Bleeding; no prolapse          Dietary modifications
         Second degree                   Prolapse with spontaneous      Rubber band ligation
                                         Bleeding, seepage              Coagulation
                                                                        Dietary modifications
         Third degree                    Prolapse requiring digital     Surgical hemorrhoidectomy
                                         Bleeding, seepage              Rubber band ligation
                                                                        Dietary modifications
         Fourth degree                   Prolapsed, cannot be reduced   Surgical hemorrhoidectomy
                                         Strangulated                   Urgent hemorrhoidectomy
                                                                        Dietary modifications

Reference : Sabiston Textbook of Surgery, 18th Edition
Dietary modifications
 Dietary modifications are always
 appropriate for the management of
 hemorrhoids, if not for acute care then for
 chronic management, and for prevention of
 recurrence after banding and/or surgery.
Nonsurgical Rx
 Simple measures
  better local hygiene
  avoidance of excessive straining
  better dietary habits supplemented by
   medication to keep stools soft, formed, and
  Symptoms of bleeding but not prolapse can
   be significantly reduced over a period of 30
   to 45 days with the use of fiber supplements
Suppositories are good?
 Over-the-counter suppositories and anal
 salves, although popular, have never been
 tested for efficacy
 In the absence of symptomatic
 external hemorrhoids, second- and
 some third-degree internal
 hemorrhoids can be treated with office
 procedures that produce mucosal fixation.
What is the best?
 Sclerotherapy
 Infrared coagulation
 Heater probe
 Bipolar electrocoagulation
What is the best?
 The simplest, most effective, and most
 widely applied office procedure is
 rubber band ligation
How many sites we can perform
this procedure?
 Only one site should be banded each time
Is there any contraindication?
 Taking
  Antiplatelet
  Blood-thinning medications
  Subacute bacterial endocarditis prophylaxis
  Immunodeficient patientsSubacute bacterial
   endocarditis prophylaxis
Any advice for patients?
 Be aware of severe perineal sepsis and
  even deaths after rubber band ligation
 Return to the emergency department if
  delayed or undue pain, inability to void, or
  a fever develops
Surgical Rx
 Hemorrhoidectomy is the best means of
  curing hemorrhoidal disease
 Considered when
  patients fail to respond satisfactorily to
   repeated attempts at conservative measures
  hemorrhoids are severely prolapsed and
   require manual reduction
  hemorrhoids are complicated by
   strangulation or associated pathology, such
   as ulceration, fissure, fistula
  hemorrhoids are associated with
   symptomatic external hemorrhoids or large
   anal tags
Surgical Rx (cont’d)
 Simple thrombosed external hemorrhoids
  excision in the office is best performed early
   in the course of the disease, during the
   period of maximum pain
 To remove complex internal or external
 hemorrhoids, an open or closed
 hemorrhoidectomy can be performed as an
 outpatient procedure
 Three bundles are identified in the right anterior,
  right posterior, and left lateral positions
 Be careful, sufficient anoderm is preserved to avoid
  the long-term complication of anal stenosis
 Postoperative complications
   Fecal impaction
   Infection
   Urinary retention
 Patients typically recover sufficiently to return to
  work within 1 to 2 weeks
 As an alternative to the closed technique, the
  surgical wounds can be left open to reduce
  postoperative pain, but at the expense of longer
  healing times.
Newer technology
 Goal to decrease postoperative pain
 The two main categories
  Ultrasonic or controlled electrical energy such
   as the Harmonic Scalpel and Liga-Sure
  Longo’s technique
Stapled hemorrhoidopexy
 Longo's technique, commonly referred to as the stapled
  hemorrhoidectomy or stapled hemorrhoidopexy
 Excises a circumferential portion of the lower rectal and
  upper anal canal mucosa and submucosa and performs a
  reanastomosis with a circular stapling device
 As a result, the prolapsed anal cushions are retracted
  into their normal anatomic positions within the anal
  canal. In addition, the terminal branches of the inferior
  hemorrhoidal artery are disrupted, and blood flow into
  the cushions is thereby decreased. The primary
  physiologic appeal of this operation is that it leaves the
  richly innervated anal canal tissue and perianal skin
  intact, thus reducing the pain usually associated with
  excisional hemorrhoidectomy
 Initially, stapled hemorrhoidopexy was
 performed with a large standard end-to-end
 anastomosis (EEA) stapler. Recently, however,
 a dedicated stapling device specifically
 designed for this operation was introduced into
 clinical practice. The stapled hemorrhoidopexy
 consists of five steps:
   Reduce the prolapsed tissue
   Gently dilate the anal canal to allow it to accept
    the instrument.
   Place a purse-string suture
   Place and fire the stapler
   Control any bleeding from the staple line
 Most important technical consideration is proper
  placement of the purse-string suture
 The suture should be at least 3 to 4 cm above the
  dentate line; if it is too low, a portion of the
  dentate line may be excised, which could lead to a
  severe prolonged pain syndrome or to persistent
  fecal urgency. In addition, the purse-string suture
  must be placed so as to incorporate all of the
  redundant tissue circumferentially; failure to do so
  may lead to incomplete excision and predispose to
  recurrent prolapse
 Finally, extreme care must be exercised in placing
  the purse-string suture in women so that the
  vagina is not entrapped anteriorly.
Stapled hemorrhoidopexy
 Vs. excisional hemorrhoidectomy
 Significantly less postoperative pain overall
 Less pain with the first bowel movement
 Earlier resumption of normal activities
 has been associated with a number of
 serious complications, including
 anastomotic dehiscence necessitating
 colostomy, rectal perforation, severe pelvic
 infection, and acute rectal obstruction and
 therefore training before use is strongly

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