Hemorrhoids-

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HEMORRHOIDS IS A COMPLEX DISEASE WITH COMPLEX MANAGEMENT.THIS POWERPOINT AIMS TO RESOLVE THIS COMPLEXITY IN THE MOST CONVENIENT WAY

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  • Difficult to evaluate due to the fact many do not seek medical advice because of the embarrassment or because of the fear of the pain of treatemnt.. Prevalence of approximately 5%. Peak of prevalence is between 45 and 65. Development before 20 unusual. Caucasians more affected than Afro-Caribbeans.
  • Normally easily made on a physical exam. Preferably accompanied by proctoscopy. Rarely a flexible sigmoidocopy is used but this is less sensitive than a proctoscope at detecting haemorrhoids and is used mainly as part of further investigations exclude inflammatory bowel disease/malignancy. Acute pain may require an evaluation under anaesthesia in the operating room. However in the absence of thrombosis acute anal pain is rare in uncomplicated haemorrhoidal disease and may indicate the presence of another disease such as abscess, o fissure. Patients with soiling and incontinence should be investigated with anal manometry to decide on the type of treatment they receive as they are at increased risk of developing incontinence post-surgery. .
  • Topical Treatment Many over the counter medications available. Include: Pads, ointments, creams, gels, lotions and suppositories. Cocktail of local anaesthetics, corticosteroids, antiseptics, astringents and other ingredients. Treatment of symptoms rather than a cure for the haemorrhoids.
  • These treatments were first described in the treatment of varicose veins, venous ulcers, and edema. Purified flavonoid fraction is a botanical extract from citrus. It exerts its effects on both diseased and intact vasculature, increasing vascular tone, lymphatic drainage, and capillary resistance; it is also assumed to have antiinflammatory effects and promote wound healing. Lately, several randomized controlled studies evaluated the use of oral micronized, purified flavonoid fraction in the treatment of hemorrhoidal bleeding.In all of the studies, bleeding was relieved rapidly, and no complications were reported.
  • These treatments were first described in the treatment of varicose veins, venous ulcers, and edema. Purified flavonoid fraction is a botanical extract from citrus. It exerts its effects on both diseased and intact vasculature, increasing vascular tone, lymphatic drainage, and capillary resistance; it is also assumed to have antiinflammatory effects and promote wound healing. Lately, several randomized controlled studies evaluated the use of oral micronized, purified flavonoid fraction in the treatment of hemorrhoidal bleeding.In all of the studies, bleeding was relieved rapidly, and no complications were reported.
  • Again requires a proctoscope 1 to hold, one to grasp the haemorrhoid. Ligation with a rubber band causes ischaemic necrosis, ulceration and scarring. Fixes connective tissue to the rectal wall. If treating mixed haemorrhoids, analgesia is essential! As the anoderm will be involved which is heavily innervated.
  • Again requires a proctoscope 1 to hold, one to grasp the haemorrhoid. Ligation with a rubber band causes ischaemic necrosis, ulceration and scarring. Fixes connective tissue to the rectal wall. If treating mixed haemorrhoids, analgesia is essential! As the anoderm will be involved which is heavily innervated.
  • Again requires a proctoscope 1 to hold, one to grasp the haemorrhoid. Ligation with a rubber band causes ischaemic necrosis, ulceration and scarring. Fixes connective tissue to the rectal wall. If treating mixed haemorrhoids, analgesia is essential! As the anoderm will be involved which is heavily innervated.
  • During the procedure, a circumferential purse-string suture is placed approximately 2 cm proximal to the dentate line. The stapler is introduced transanally, and the suture is tied around the shaft. On closing and firing the stapler, a circumferential band of excessive rectal mucosa and submucosa proximal to the hemorrhoidal tissue is excised, and the defect in the mucosa is simultaneously closed by the stapler while fixing the mucosa to the underlying rectal wall. This procedure also interrupts the blood supply of the superior hemorrhoidal artery proximal to the hemorrhoidal tissue. So it treats the mucosal prolapse, with concurrent disruption of the blood supply to the hemorrhoidal tissue.
  • During the procedure, a circumferential purse-string suture is placed approximately 2 cm proximal to the dentate line. The stapler is introduced transanally, and the suture is tied around the shaft. On closing and firing the stapler, a circumferential band of excessive rectal mucosa and submucosa proximal to the hemorrhoidal tissue is excised, and the defect in the mucosa is simultaneously closed by the stapler while fixing the mucosa to the underlying rectal wall. This procedure also interrupts the blood supply of the superior hemorrhoidal artery proximal to the hemorrhoidal tissue. So it treats the mucosal prolapse, with concurrent disruption of the blood supply to the hemorrhoidal tissue.
  • Hemorrhoids-

    1. 1. Surgery Haemorrhoids Presenter: Dr. Sachin
    2. 2. Haemorrhoids ?Engorgement of the haemorrhoidal venous plexuses with redundancy of their coverings.
    3. 3. Haemorrhoids haimorrhoides bleedinghaima=blood rhoos=flowing
    4. 4. Piles pila (a ball)swelling in anal canal which may or may not bleed
    5. 5. Anal sphincters  Internal  Involuntary  Circular muscle layer  Upper ¾ of anal canal  Upto to white line of hilton  External  Voluntary  Striated muscle layer  Inferior rectal nerve & sacral nerve  Three parts:  Subcut., superficial, deep
    6. 6. above dentate lineArterial   superior rectal A.supply  below dentate line  inferior rectal A.
    7. 7. Venous drainage Internal haemorrhoidal plexus  in submucosa  drain in superior rectal vein  Communicate with external plexus  Site of communication between portal and systemic veins  Veins at 3,7 and 11 o’clock position are large  Potential site for primary haemorrhoid
    8. 8. Venous drainage External haemorrhoidal plexus  Lies outside muscular coat of anal canal  Communicate freely with internal plexus
    9. 9. Potential sites forPrimary Haemorrhoids
    10. 10. Anal veins Arrange radially around anal margin Communicates with internal plexus & IRV Straining rupture these vein Ruptured vein present  as subcutaneous perianal hematoma
    11. 11. Venous SRVdrainage MRV IRV
    12. 12. Aetiology Straining Constipation Prolonged lavatory sitting Trauma Ageing Diarrhoea Lack of fibre rich diet hereditary
    13. 13. Secondary causes Local anorectal deformity, hypotonic sphincter Abdominal ascites gravid uterus, Pelvic uterine neoplasm, ovarian neoplasm, Pregnancy Portal hypertension paraplegia, Neurological multiple sclerosis
    14. 14. Pathogenesis Various theories are :1. Portal hypertension and varicose veins2. Upright posture of human beings3. Hyperplasia of corpus cavernosum recti4. Erosion and weakening of wall of veins due to infection secondary to trauma5. Hard faecal matter obstructing venous return6. Raised anal canal resting pressure
    15. 15. CURRENT VIEW Shearing forces acting on anus Caudal displacement of anal cushions and mucosal trauma Fragmentation of supporting structures Loss of elasticity of anal cushions Loss of retraction of cushions
    16. 16. Anal Cushions Haemorrhoidal venous plexuses together withsome arteriovenous anastomoses surrounded by smooth muscle, elastic and fibrous tissuein the subepithelial space both above & below the pecinate line.
    17. 17.  Shield anal canal and sphincter during evacuation. Complete the closure of the anal canal. Contribute 15% of the anal canal’s pressure. Congest during Valsalva manoeuvre or increased intra-abdominal pressure. Increase in the size is the starting point of haemorrhoids.
    18. 18. 11 o’clock 3 o’clock7 o’clock
    19. 19. Incidence  Difficult to evaluate.  Prevalence ~ 5%.  Peak of prevalence is between 45 and 65.  unusual before the age of 20.  Caucasians > Afro-Caribbeans.
    20. 20. Earliest symptom Bleeding { A splash in the pan } Discharge Prolaps H’oids Haemorrhoids & Pruritus Pain ( If complication ) Symptoms
    21. 21. Physical Examination Left lateral decubitus position Any rashes, condylomata, or eczema Any abscesses, fissures or fistulae
    22. 22. Digital Rectal Examination The resting tone of the anal canal voluntary contraction of the puborectalis and external anal sphincter. mass / any area of tenderness. Int. hemorrhoids are generally not palpable Appear as bulging mucosa on Anoscopy
    23. 23. Diagnostic Tests Physical examination. Proctoscopy. Flexible sigmoidoscopy Evaluation under anaesthesia in acute pain Anal manometry  if h/o soiling & incontinence
    24. 24. • Classified according to origin of haemorrhoid.• Above or below the Pecinate line? External or Internal
    25. 25. External hemorrhoid Internal hemorrhoid Below dentate line Above dentate line Varicosities of veins Varicosities of veins draining draining inferior rectal artery superior rectal artery Lined by Lined by squamous epithelium columnar epithelium Painful Pain insensitive Prone to thrombosis if May prolapse outside vein ruptures anal canal (Thrombosed pile) (prolapsed hemorrhoid)
    26. 26. Gr I Gr II Gr III Gr IVnot prolapse returns spontaneously manually returned remains prolapsed Grading of hemorrhoids (on history)
    27. 27. Complications of hemorrhoids prolapse Gripped by Ext. sphincter Impeded venous return Gangrene Strangulation Fibrosis Ulceration Thrombosis Suppuration Portal pyaemia
    28. 28. ThrombosedExternal haemorrhoids
    29. 29. ProlapsedInternal haemorhoids
    30. 30. TREATMENT Conservative Dietary and lifestyle modification. Non operative/office procedures. Operative hemorrhoidectomy Minimal invasive procedures
    31. 31. Dietary & Lifestylemodifications Minimize straining at stool. and Prevention of constipation
    32. 32. Dietary & Lifestylemodifications Drinking Fluids High-fiber diet Use of Fiber supplements Stool softeners Exercise Local hygiene
    33. 33. Dietary & Lifestylemodifications “you dont defecate in the library so you shouldnt read in the bathroom”
    34. 34. Dietary & Lifestylemodifications  Ifprolapses, gently push back into anal canal  Use moist towelettes or wet toilet paper instead of dry toilet paper.
    35. 35. Topical Treatment Include:  Pads,  Ointments,  Creams,  Gels,  Lotions  Suppositories.
    36. 36.  Used now a days includes  Calcium dobesilate .25%  Anhydrous lignocaine 3%  Hydrocortisone acetate .25%  Zinc 5%
    37. 37. Sitz bath Sitz mean to sit Used in treatment of Gr. IV hemorrhoids Duration:15-20 minutes Cold water is used  Draw heat out of sore piles  Reduce blood flow in them  Reduce pressure inside swollen piles
    38. 38. Sitz bath Postoperative Warm water is used  Dialatation of blood vessels  Allow blood to pass through swollen piles more quickly  Relaxes muscles so ease anal sphincter tone
    39. 39. Oral Medications Oral vasotopic drugs. Most common - purified flavonoid fraction. Actions:  Increases vascular tone  Increases lymphatic drainage  Anti-inflammatory effects.  Several recent studies have shown it to be effective.
    40. 40. Topical medications Commonaly used is Combination of Calcium dobesilate & docusate sodium
    41. 41.  Calcium dobesilate:  Decrease capillary permeablity,  Decrease platelet aggregation  Stops bleeding  Reduce thrombus formation  Improves mucosal inflammation
    42. 42.  Docusate sodium:  Stimulant laxative,  makes bowel movement softer and easier to pass  Reduces pain or rectal damage caused by hard stools or straining
    43. 43. Office procedures Sclerotherapy Infra-redCoag Band Ligation Cryosurgery Manual Dilation of anus. Sphincterotomy (lateral) Bicap electrocoagulation haemorrhoidolysis
    44. 44. Sclerotherapy(Mitchell) For Gr I to II haemorrhoids. phenol, vegetable oil, quinine, and urea hydrochloride. Albright solution:  5% phenol  in almond or arachis oil  with 140 mg of menthol  to make 30 ml Injected in submucosa around pedicle
    45. 45. Sclerotherapy Causes  oedema,  inflammatory reaction  & intravascular thrombosis. Submucosal fibrosis & scarring  minimises the extent of mucosal prolapse  and potentially shrinks the haemorrhoid as well. Injected in submucosa around pedicle
    46. 46. Sclerotherapy Quick painless Follow up after 6 weeks 2-3 further injections may be required Free from major complications Injected in submucosa around pedicle
    47. 47. Sclerotherapy Contraindications  Prolapsed pile  Infection Complications  retroperitoneal sepsis,  portal pyemia  necrotising fascitis  Prostatitis  Impotence  Rectovaginal fistula Injected in submucosa around pedicle
    48. 48. Barron’Band Ligation Large Gr I & Gr II witout external component 2 bands Not >2 hemorrhoids at a time Follow up after 1 month Success rate:50-100% occlude base of hemorrhoid above dentate line
    49. 49. Barron’Band Ligation Band causes ischemic necrosis ulceration and scarring Fix connective tissue to rectal wall necrosis in 24-48 hrs & slough off in 7 days May cause pain for 24-48 hrs and secondary hemorrhage occlude base of hemorrhoid above dentate line
    50. 50. Barron’Band Ligation Complications:  anal stenosis  Inclusion of dentate line cause pain  vasovagal shock  sepsis occlude base of hemorrhoid above dentate line
    51. 51. cryosurgery Freezing of hemorrhoidal tissue  liquid Nitrogen probe at -160oC for 3 minutes Applied for 10-15 minutes  Over upper part of hemorrhoidal area Profusewatery discharge is most common complication (in first 3 hrs)
    52. 52. Cryosurgery Painless Causes necrosis of hemorrhoidal tissue Healing completes in 4-6 wks Little efficacy in prolapsed hemorrhoids
    53. 53. Infrared photocoagulation High intensity infra red light 3-6 pulses of 1.5 sec each appllied to mucosa
    54. 54. Infrared photocoagulation Coagulate vessels & fix underlying mucosa Useful for actively bleeding piles Painless and uncomplicated
    55. 55. BICAP Electrocoagulation Theoretically similar to photocoagulation Probe must be left in place for ten minutes. Poor patient tolerance minimizes the effect of this procedure.
    56. 56. Lord’s Maximal anal dilatation Spasmof int sphincter responsible for many symptoms of hemorrhoids Reserved for large Gr II & Gr III hemorrhoids NOT eliminate redundant tissue Risk of incontinence
    57. 57. Haemorrhoidolysis Therapeutic galvanic waves Produce chemical reaction Shrink and dissolve hemorrhoidal tissue Most effective on internal hemorrhoids
    58. 58. Indications of surgery Mainly driven by impact of symptoms on quality of life 3rd and 4th degree piles 2nd degree not cured by conservative means Fibrosed hemorrhoid Interno-external hemorrhoid Bleeding sufficient to cause anemia Soiling Ulceration,thrombosis,gangrene
    59. 59. Milligan-Morgan (open)Haemorrhoidectomy First described over 2 centuries ago.
    60. 60. Milligan-Morgan (open)Haemorrhoidectomy
    61. 61. Milligan-Morgan (open)Haemorrhoidectomy
    62. 62. Final Operative Aspect in a Haemorrhoidectomy. Wound left open
    63. 63. Ferguson’s (Closed)Haemorrhoidectomy Developed in 1952 Haemorrhoidal tissue excised. Mucosal wound and skin sutured completely with a continuous absorbable suture.
    64. 64. Harmonic Scalpel sutureless technique shorter operative time less post-op pain. hospital stay not required. Comparative Increased cost to other techniques.
    65. 65. MIPHLongo introduced the technique in 1995.
    66. 66. MIPHStappler haemorrhoidopexy
    67. 67. Advantages Lesser pain Quick return to normal activity Lesser mean hospital stayRisks Higher chances of recurrence and prolapse May be unsuccessful in large hemorrhoids Pelvis sepsis and sphincter dysfunction
    68. 68. Laser surgery of hemorrhoid Pile mass excised or vaporised using laser beam Allow precision and accuracy Rapid and unimpaired healing Lesser bleeding and pain as laser seal off tiny blood vessels and nerves Can be combined with other modalities
    69. 69. HAL-RAR Hemorrhoidectomy HAL - Doppler guided haemorrhoidal artery ligation RAR - Recto anal repair proctoplasty (mucopexy) Combine two methods Artery ligated 3-4 cm proximal to dentate line Reducing blood flow to inner hemorrhoidal plexus Mucopexy combined for grade 3-4 hemorrhoid
    70. 70. A.M.I. (DG) HAL/RAR®System
    71. 71. Complications of surgery Early complications  Post operative pain lasting 2-3 weeks  Wound infection rarely  Post op bleeding  Swelling of skin bridges  Short term incontinence  Difficult urination
    72. 72. Complications of surgery Late complications  Anal stenosis  Anal fissure  Fecal impaction  Mild incontinence  Submucous abscess  Delayed bleeding  Skin tags  Recurrence
    73. 73. Prevention Eat high fiber diet Drink Plenty of Liquids Fiber Supplements Exercise Avoid long periods of standing or sitting Don’t Strain Go as soon as you feel the urge
    74. 74. Thank you for your patience

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