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					HEMORRHOIDS
Hemorrhoid (heme = blood; rhoos = flowing), derives from the Greek adjective, haimorrhoides. One of the most encountered 'surgical' complaint. Anatomy: series of 3 discontinuous submucosal vascular cushions.

The three main cushions: Left lateral, right anterior, and right posterior positions. The submucosal layer of these cushions is rich in blood vessels and muscular fibers arise from the internal sphincter and the conjoined longitudinal muscle, and are responsible for maintaining adherence of mucosal and submucosal tissues to the internal sphincter and blood vessels of the submucosa. These vascular cushions may protect the anal canal from injury by filling with blood during defecation. Blood supply superior, middle, inferior hemorrhoidal vessels Pathophysiology: Unknown. The deterioration of supporting tissue to the vascular cushions in the anal canal produces venous distension, erosion, bleeding, and thrombosis. Possible theories: venous obstruction secondary to congestion and hypertrophy of the anal cushions, prolapse or downward displacement of the anal cushions, destruction of anchoring connective tissue, and abnormal dilatation of the veins of the internal hemorrhoidal plexus. Other factors, such as heredity, age, anal sphincter tone, diet, occupation, constipation, diarrhea and pregnancy, have also been implicated in the cause of hemorrhoids. • • • • First degree: cushion that doesn’t descend on defecation, may bleed. Second degree: protrudes below pectinate line, return spontaneously. Third degree: Protrudes to external canal, requires manual reduction. Forth degree: Irreducible.

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Diagnosis: • Pattern of bleeding • painless unless thrombosed or congested, gangrene, ulcerated • anemia rare but can be significant. Differential Diagnosis: • perianal Crohn’s • rectal prolapse • tumor or abscess • fissure Treatments: Depends on symptoms, degree of prolapse Nonoperative/minor procedures: • stool softeners, bulk forming agents, o sitz bath or ice packing for acute swelling, o topical agents may relieve some irritation (?). • Sclerotherapy: NOT for external hemorrhoids, thrombosed, ulcerated internal hemorrhoids (1st, 2nd degree) • Infrared coagulation for 1st, 2nd degree who is not candidate for banding, (esp bleeding) • Rubber band ligation: replace 80% of surgical hemorrhoids, low morbidity (2%) vaso-vagal, secondary thrombosed external, delayed bleeding after necrosis (3-4 days). • Endoscopic ligation: new technique, high success rate reported, grade II has better results than grade III Operative procedures: Hemorrhoidectomy:. • Suture ligature performed. • The incidence of urinary retention varies (avoid too much IV, rectal packing, pain control), bleeding 2-4%. • Must be sent to pathology. Special considerations: • Thrombosed external hemorrhoids usually present as a painful, tender mass in the anus, frequently following an episode of constipation or diarrhea. If the patient presents with severe pain, ulceration, rupture, or onset of the condition within 48 hours, excision is the preferred treatment. Conversely, if the discomfort is mild or if the problem is present for greater than two or three days, and the discomfort seems to be dissipating, sitz baths, stool softeners, and analgesics may be the best therapeutic options. The use of topical nifedipine is suggested by some authors. • Acute thrombosed internal hemorrhoids: treatment is usually nonoperative, because pain is not a frequent complaint. • Prolapse gangrene internal hemorrhoids: reduction under anesthesia, sedation follow by hemorrhoidectomy later.

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AIDS patients have higher post op complications. Crohn’s disease: AVOID procedures.

Bibliography: • Corman M: Hemorrhoids. In: Colon and Rectal Surgery. Philadelphia, Pa, LippincottRaven; 1998: 154-156. • Haas PA, Fox TA Jr, Haas GP: The pathogenesis of hemorrhoids. Dis Colon Rectum 1984 Jul; 27(7): 442-50. • Moesgaard F, Nielsen ML, Hansen JB: High-fiber diet reduces bleeding and pain in patients with hemorrhoids: a double-blind trial of Vi-Siblin. Dis Colon Rectum 1982 Jul-Aug; 25(5): 454-6. • Parks AG: The surgical treatment of homorrhoids. Br J Surg 1956; 43: 337-351. • Saleeby RG Jr, Rosen L, Stasik JJ: Hemorrhoidectomy during pregnancy: risk or relief? Dis Colon Rectum 1991 Mar; 34(3): 260-1. • Sun WM, Peck RJ, Shorthouse AJ: Haemorrhoids are associated not with hypertrophy of the internal anal sphincter, but with hypertension of the anal cushions. Br J Surg 1992 Jun; 79(6): 592-4. • Thompson WHF: The nature of hemorrhoids. Br J Surg 1975; 62: 542-552. • Thorton SC: Sclerotherapy of hemorrhoids. In: Selected topics in Colon & Rectal Surgery, Norwalk: Konsyl Pharmaceutic 1992, 5, 72-75. Yair Edden, MD February 10, 2005

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