External hemorrhoids are covered with anoderm and are distal to the dentate line; they may swell, causing discomfort and difficult hygiene, but cause severe pain only if actually thrombosedThe physical examination should include inspection during straining, preferably on a commode; digital rectal examination; and anoscopy
Seepage(ซึม)Dietary modifications include increasing consumption of fiber, bran(ธัญพืช), or psyllium and water. 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.Even though all patients should be counseled on dietary and fiber recommendations, patients with prolapse and internal plus external hemorrhoids benefit from additional interventions.
By Dr. Waqas Munir
Haemorrhoids : Haem=blood Rhoos = flowingPiles: Pila= swellingThe actual term now a days used for this isHaemorrhoidal disease.
Beneath the epithelium in anal canal there is rich plexus of vascular tissue called corpus cavernosi recti, that connect arteries to veins. These vessels are normally supported by longitudinal muscle fibers (muscularis submucosa ani) which help to retain the vascular cushions in their position in the upper half of anal canal. There are 3 main vascular cushions (primary sites) in the anal canal(one on the left and anterior and posterior on the right). In 2/3rd of pts these are at primary site and in 1/3rd of pts these are at other site called secondary sites.
Facors involved in the development of haemorhhoidal disease: Venous obstruction Prolapse of vascular cushions Heredity Geographical and dietary factors Anal sphincter tone Anal and rectal sensation Defecation habits
Venous obstruction: The principal cause of haemorrhoidal disease seems to be the congestion and hypertrophy of internal anal cushions. Cushions congest because 1. They fail to empty rapidly during the act of defecation. 2. They are abnormally mobile. 3. They are trapped by tight internal sphicter. When the cusions are congested, they bleed and become edematous.oedema causes stretching of the tissue and finally hypertrophy. Fecal mass in the rectum compress the veins. Straining constricts the intermuscular vein so blocks emptying of veins.Predisposing fctors of venous obstruction: Raised intra abdominal pressure during pregnancy,from ascites or pelvic tumor, or raised portal venous pressure with hepatic cirrhosis. Piles of pregnancy: These are not necessorily abnormal.
Prolapse of vascular cushions: Submucosal vascular cushions are supported by Pectin bands(ligaments of park) Muscularis submucosa In normal defecation internal sphicter relaxes and there is outward rotation of vascular tissue and pectin bands. In haemorrhoidal disease this normal rotation is disturbed due to the decrease in elastic tissue caused by; Increased Age Constipation Prolonged straining Endocrine reasons
Heredity: No heredity evidence proved. family history is commonly recorded due to same customs, environment and diet. Geographic and dietry factors: > western society due to less fiber diet. Anal sphincter tone: Numerous studies have shown that basal anal pressure are significantly higher in haemorroidal disease. Anal and rectal sensation: Anal electro sensitivity and temperature sensations are reduced in patients with haemorrhoids. Defecation habits: More than 10-15 min sitting for defecation.
Sex: In hospital based studies Men > women In community based studies men = women Age: Increase with age Socioeconomic status and occupation: > high socioeconomic group > heavy laborer and occupations with prolonged sitting or standing
1. Bleeding2. Prolapse and lump3. Pain and discomfort4. Discharge and pruritis
Bleeding: Most common and earliest symptom Bright red painless bleeding especially at the end of defecation is pathognomic of the disease. Bleeding is similar to anal fissure and perianal dermatitis but pain and pruritis differentiate it. Bleeding from ulcerative proctitis and rectal neoplasm is different from haemorrhoidal disease as it is not fresh bleeding. Anemia with haemorrhoids ?
Prolapse or lump: Prolapse or lumps protruding through the anus are the real piles. Protrusion with the spontaneous or self digital reduction is characteristic of haemorrhoidal disease. Hypertrophid anal papilla and low rectal polyps can also prolapse and they can be reduced (mistaken for haemorrhoids) Pain and discomfort: Haemorrhoids are usually painless. If pain is there either think of a complication(thrombosed prolapsed internal haemorrhoids) or change the diagnosis. Discharge and pruritis: A constant mucous discharge from the anus with or without bleeding is characteristic of prolapsed haemorrhoids.
•Pain? -> painless •Bright red bleeding •Prolapse associated with defecation Internal External •Anoderm •Swell, discomfort, diff icult hygiene•Pain?-> Thrombosed
1. Thrombosis and infection of internal cushions2. Anemia3. Perianal dermatitis4. Thrombosis of external vascular channels
Thrombosis and infection of internal cushions Most painful complication Thrombosis occurs when cushion is prolapsed and enlarged. If necrosis of the mucous membrane occurs , clot extrudes and pt is relieved. If it is not relieved then give strong analgesics are given and pt may even need emergency haemorrhoidectomy to evacuate the clot. After rupture of mucous membrane infection can get through it and pyemia can occur but it is very rare.
Anemia: Rare and look for other causes Perianal dermatitis: Due to the continuous mucous leakage and permanently prolapsed cushions. Thrombosis of external vascular channels: Tense hard and superficial swelling.
History Inspection (to rule out other causes) Palpation Endoscopy(Proctoscopy and sigmoidoscopy)
Conservative; Medical Invasive therapy Injection sclerotherapy Rubber band ligation Cryotherapy Photocoagulation Surgical; Open haemorrhoidectomy Closed haemorrhoidectomy White head haemorrhoidectomy Laser haemorrhoidectomy Diathermy haemorrhoidectomy Stapled haemorrhoidopexy
GRADE SYMPTOMS AND SIGNS MANAGEMENT First degree Bleeding; no prolapse Dietary modifications Second degree Prolapse with spontaneous Rubber band ligation reduction Bleeding, seepage Coagulation Dietary modifications Third degree Prolapse requiring digital Surgical hemorrhoidectomy reduction Bleeding, seepage Rubber band ligation Dietary modifications Fourth degree Prolapsed, cannot be reduced Surgical hemorrhoidectomy Strangulated Urgent hemorrhoidectomy Dietary modificationsReference : Sabiston Textbook of Surgery, 18th Edition
Medical management: Advice For minor symptoms High fiber diet Thorough perianal lavage after defecation Changing defecation habits Do not Neglect 1st urge to defecate in morning Don’t insist on trying to pass the last portion of stool from rectum in the belief that it is not passed Diet manipiulation Bulking agents (high fiber diet) e.g ispaghol husk and methyl cellulose Topical agents Suppositories( shark liver oil, skin respiratory factor) Xylocain for pain Paraffin as lubricant to avoid rubbing
Invasive therapy: Principles on which invasive therapy is based; 1. Prevention of Prolapse by mucosal fixation 2. Prevention of congestion by stretching or by dividing the internal sphincter 3. Excision of the engorged internal vascular channels
Useful in 1st and 2nd degree 70% success rate Sclerosant causes aseptic inflammation and fibrosis in 2-3 weeks. Gabriel syringe and needle 5% phenol in almond oil (3ml in each cushion) 2.4% anhydrous qunine urea with ph 2.6. Knee chest or left lateral position Rt posterior cushion (7oclock) should be injected 1st.
Technique: The proctoscope is passed and obturator is removed. The scope is manipulated until the junction between pink and purple mucosa is positioned indicating the base of cushion. The needle of syringe is introduced obliquely through the mucosa for 1 cm. The procedure should be painless If pain it is either too too dep or too superficial Superficial = avascular bleb Deep =no swelling Must be careful in midline anteriorly Complications: Pain Hemorrhage Lower urinary tract sepsis Impotence Oleogranuloma(response to almond oil) Bacteremia(8%)
Used for 2nd degree 80% success rate Principle is mucosal fixation by ulceration. Band produces ischemic necrosis with sloughing and ulceration. Ligators Barron ligator Suction band ligator Mc Giveny ligator Preparation and position: Bowel should be empty An assistant to hold proctoscope Knee chest position
Technique: Rubber band is equipped by the help of loading cone. Pass proctoscope Visualize the cushion,the base of cushion lies 1.5-2cm above the dentate line Long shaft of the suction band equipment is introduced through the proctoscope. Hemorrhoid is sucked into the lumen of the inner drum. Handle is squeezed to advance the outer drum that releases the rubber band and applies it to the neck of haemorrhoid. Volume of strangulated tissue should not be larger than 1cm diameter and at least 1cm prior to dentate line. Barron stated 1 band each time but latest research showed that all 3 bands can be applied at 1 time (time saving and economical)
Complications: 1. Pain (most common) 1. If severe pain then removal of band and treatmeent with photocoagulation Removal of the rubber band: Grasp the strangulated mucosa with forceps and attempt to rotate it so that the rubber band or at least the constricting groove is seen clearly then a small triangular blade is used to cut directly until the band snaps and mucosa returns to the normal tissue. Alternatively the band can be removed by conventional suture removal scissors or application of crochet hook.2. Bleeding.3. Pelvic cellulitis (clostridial infection common ) Measures to avoid: Screening for immunodeficiency Rectal washout prior banding Prophylactic antibiotics
Principle: when tissue freezes , intracellular water crystalizes,cell membranes are destroyed and tissue death occurs. Tissue freezes at -20c and permanent destruction at -22c. Liquid Nitrous oxide is used which boils at -90c Technique: With bivalved speculum anal cushions are exposed. Apply lubricant The probe is laid along the length of the cushion and pressed laterally while trigger is squeezed. Nitrous oxide evaporates in the tip that become frosted. This is continued for 3 minutes.
The technology includes infrared radiation generated by tungsten halogen lamp which is focused on the tissue from a gold plated reflector housing through a polymer tubing.
Indications: 3rd degree haemorrhoids 2nd degree haemorrhoids which have not been cured by non operative methods Fibrosed haemorrhoids Interno- external haemorrhoids when the external haemorrhoids are well defined. Preparation: 1 enema night before surgery another 1 hour before surgery Pts with severly prolapsed haemorrhoids should be spared from enema. Anesthesia: Any type of anesthesia If L/A 0.25% bupicain with 1:200,000 adrenalin
Benefits: Less post op discomfort Minimum in patient and virtually no out patient care No loss of continence No need of subsequent anal dilation Relative contra indications: Crohn’s disease Portal hypertention Lymphoma Leukemia Bleeding diathesis
Technique: Prone jack knife position/left lateral Adhesive tape to retract the buttocks Anal canal examined by Pratt bivalved speculum. After inspection replace bivalved speculum with Fansler operating anoscope. Anoscope is adjusted so that the operating channel is in line with the haemorrhoidal tissue. The skin tag or anal epithelium adjacent to haemorrhoidal tissue is grasped with the pair of Aliss forceps and retracted toward the center of anal canal. Scissors with its curve toward anal canal is used to incise beneath the tissue forceps from the perianal skin upwards along the haemorrhoidal tissue. Most prominent region of haemorrhoidal tissue is excised 1st to minimize the subsequent loss of anoderm. Bleeding submucosal vessels are controlled with cautry. After complete excision of the haemorrhoidal tissue to a point above the internal sphincter the wound is closed using a running 3/0 suture. Stiching is begun at the apex and mucosa is fixed with submucosa and muscle.
Technique: Lithotomy position 1st the left lateral haemorrhoid is excised, then right posterior and then right anterior. Skin covered component of each pile is seized with the artery forceps and retracted outward. The purple anal mucosal component of each pile is grasped with another artery forceps and drawn downward and outward.this indicates pile have been drawn to max extent so that ligature can be applied at their upper pole. A V- shaped incision is made in the anal and peri anal skin so that the limbs of the V cross the mucocutaneous junction but do not extend into the mucosa.The point of V should lie 3 cm away from anal verge. Venous plexus is dissected from internal sphincter while preserving this sphincter. The apex of the pedicle is transfixed with 1/0 chromic catgut. The isolated haemorrhoid is then excised with the scissors a few mm below the ligature.