Haemorrhoids- Dr. VijayalakshmiPresentation Transcript
HAEMORRHOIDS Dr. VIJAYA LAKSHMI L APOLLO BGS HOSPITALS
- The anal canal starts at pelvic diaphragm and ends at anal verge. Approximately 4cm long.
A natomic anal canal extends from anal verge to dentate line.
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.
- The anal verge is the junction between anoderm and perianal skin.
- The dentate line 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.
- 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
- The external sphincter is a voluntary, striated muscle divided into three u-shaped loops (subcutaneous, superficial, 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.
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.
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 SRV IMV Portal vein. The lower rectum and upper anal canal MRV IIV IVC. The Lower anal canal drains into the IRV IVC.
- 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.
- 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.
- The names 'haemorrhoids' and 'piles' are essentially synonymous though differently derived from the two main—and only certain—symptoms, respectively bleeding and protrusion.
- The term ‘Haemorrhoids‘ restricted to abnormal clinical situation
Parts of Haemorrhoid
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.
Distal to dentate line. Covered with anoderm
Cause swelling discomfort & difficult hygiene
Severe pain if thrombosed
Bright red bleeding
Prolapse associated with defecation
- 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
Anal varices in portal hypertension.
Painless bleeding, no Prolapse
Bleeding, Seepage, Prolapse with spontaneous reduction
Bleeding, Seepage, Prolapse requring digital reduction
Prolapsed - Irreducible, Strangulated.
- Single layer of capillary epithelial cells Lamina propria - Trauma
- Lax-textured upper part of the anal cushion.
- Repeated trauma
- Bright red, Drips
Inflamed permanently prolapsed pile
4. Anorectal dysfunction
6. Discomfort and Pain
1. Inflammed, Edematous mucosa
2. Engorgement of the subanodermal veins
oedema contributes to bulk of 'prolapse' Engorgement of the subanodermal veins masquerades as prolapse in some patients
3. Thrombosis and clotting in the vein.
Early venous clotting in an anal cushion Infarction of the pile.
Skin tags A fibrous anal polyp surmounting a pile Sentinel pile at lower end of posterior fissure with perianal dermatitis with punctate excoriations.
6. Perianal hematoma/ Thrombosed external pile
7. Rectal prolapse
8. Rectal tumour
Perianal haematoma - single venous saccule greatly distended with clot.
- Treatment options for internal hemorrhoids 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,sclerotherapy) or surgery.
- Avoidance of prolonged straining at stool
- Increase in dietary fiber
- Stool softeners
- Fiber supplements
- Topical anesthetic gel application - Lidocaine jelly, NTG cream
1. Rubber band ligation
Banding exposed mucosal part of permanently prolapsed pile a. A second banding attempt will occasionally improve on the achievement of the first. b. If the first 'polyp' is insufficient but has been banded too low near the dentate line for enlargement, an adjoining cephalad band can be placed
Rubber band ligation
- Devices – Single operator and assistant-required
Thomson One-man bander used within the Naunton-Morgan anoscope Irvin Moore's nasal conchal forceps for grasping the pile for banding, shown with banding instrument
Rubber band ligation
2. Infrared photocoagulation and bipolar diathermy
5. Laser treatment
Milligan Morgan technique – Gold standard
Sclerotherapy 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.
Advantages of sclerotherapy
1 Easy and inexpensive to administer Technique is simple to perform as an out-patient procedure. No lengthy hospital stay
2 It 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.
Disadvantages of Sclerotherapy
Unsuccessful for larger haemorrhoids
Haemorrhoids 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
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 - success is not good.
2. Severe bleeding or ulceration- accompanying other ano-rectal conditions- IBD,causes severe bleeding or ulcers in the colon’s mucosal tissue.
3. Fissures and Fistula
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
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
Complications & Follow up
3. Injection into vein - too easily injectable or pain in the liver area or unpleasant taste
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 laxatives several weeks after treatment
Anal discharge – Brown offensive fluid
Because of the pain and the anal discharge most patients are unable to return to work for a as a week
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
Patients not capable of tolerating office procedures
Patients with large external hemorrhoidal disease
Patients with grade III or IV mixed hemorrhoidal disease.
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
- 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.
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
Modifications of haemorrhoidectomy :
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 internal haemorrhoid is removed and fixed at the anorectal ring
Procedure for prolapse and haemorrhoids
mechanical hemorrhoidectomy with a circular stapler
Circular stapler hemorrhoidopexy
Stapled circumferential mucosectomy,
- Select grade II hemorrhoids
- Grade III hemorrhoids
- Uncomplicated grade IV hemorrhoids
- Patients for whom other treatment modalities are not successful
- Purely external hemorrhoids
- Fixed prolapse or fibrotic external hemorrhoids
- Abscess, gangrene,
- Anal stenosis,
- Full-thickness rectal prolapse.
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
Management of Infarcted pile
Turbulent flow in sacculated venous plexus
Thrombosis and clotting occurs.
Considerable swelling and discomfort
Invites attempts at immediate amelioration
Conservative and surgical treatment.
Natural thrombolysis restores circulation
Resolution in about 10 days.
Severe – debridement haemorrhoidectomy
A. Short lived
1.Vasovagal - banding of piles, injection
2.Pain post operatively
3.Haemorrhage – Secondary haemorrhage
4.Infection – Rare
5.Urinary – haemorrhoidectomy, Banding
6.Anal cushion thrombosis - Banding
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