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Hemorrhoides
 

Hemorrhoides

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    Hemorrhoides Hemorrhoides Presentation Transcript

    • Hemorrhoidal disease Samir Haffar M.D.
    • Definitions • Hemorrhoids Dillated vascular channel in 3 constant locations Normal part of human anatomy • Hemorroidal Disease Manifeted by prolapse, bleeding, & itching • Internal hemorrhoids Originate above dentate line Covered with transitional mucosa • External hemorrhoids Located close to the verge Covered with transitional mucosa
    • Usual sites of internal hemorrhoids Knee-chest position Left lateral Right posterior Right anterior
    • Incidence of hemorrhoidal disease • Exact incidence is not known • 10 - 25 % of adult population thought to be affected
    • Pathogenesis of hemorrhoids Normal vascular cushions present at birth Downward pressure during defecation Muscle fibers that anchor cushions attenuated Hemorrhoids: slide, congested, bleed, prolapse High resting anal pressure (unclear?)
    • Classification of internal hemorrhoids • First degree Project a short way into the anal canal The only symptom is bleeding • Second degree Prolapse during defecation Return spontaneously • Third degree Must be returned manually • Fourth degree Hemorrhoids are irreducible
    • Symptoms of hemorrhoids Intermittent symptoms • Painless bleeding Seen on toilet tissue Dripping into toilet at end of defecation Accumulate in rectum with dark blood or clots • Prolapsed hemorrhoids Blood & mucus stain patient’s underwear Mucus against anal skin lead to itching
    • Third degree internal hemorrhoids
    • Forth degree internal hemorrhoids
    • Knee-chest position
    • Anal & rectal palpation
    • Normal anal canal
    • Internal hemorroids Seen with the proctoscope
    • Localized hemorrhoidal prolapse
    • Prolapse of 3 mains hemorrhoidal piles
    • External hemorroids (skin tags)
    • Hypertrophic papillae
    • Protruding hypertrophied papilla
    • Treatment of internal hemorrhoids Reduce downward pressure Diet Bulk agents Veinotonic agents Avoid prolonged sitting at stool Fix cushions to sphincter Sclerosing injections Rubber band ligation Cryotherapy Photocoagulation: infrared - laser Electrocoagulation: bipolar - heater probe Excise hemorrhoids Hemorrhoidectomy
    • Preferences for treatment of hemorrhoids Degree or Grade Treatment 1 Sclerosing injections Infrared coagulation 2 Infrared coagulation Rubber band ligation 3 Rubber band ligation 4 Hemorrhoidectomy
    • Sclerosing injection Instruments
    • Sclerosing injection
    • Sites of sclerosing injections 1 Superficial 2 Good (submucosa) 3 Deep (intramuscular)
    • Sclerosing injections • Substances 1 ml is sufficient to create raise area Phenol 5 % – Quinine Chlorhydrate & urea 5% • Number of injections 2 injections per week 4 – 6 injections in total • Results Success in 75 % of first & second degree
    • Infrared photocoagulation
    • Infrared photocoagulation • Coagulation proximal to internal hemorrhoids • Applied for 1.5 sec in 2 – 3 sites • Success in 75 % of 1st & sd degree • Rare complications
    • Rubber band ligation
    • Rubber band ligation
    • Number of bands in one session Disagreement • 1 band by session Many authorities believe that severity of pain & risk of complictions are less • 2 – 3 bands by session Safe & effective at one setting • 8 – 10 bands in one session
    • Retroflexed endoscopic multiple band ligation Extensive ligations of internal hemorrhoids & normal rectal mucosa immediately proximal to internal hemorrhoids weeks after8 – 10 elastic bands in one session Before band ligation Gastrointest Endosc 2004 ; 59 : 380 – 4 .
    • Rubber band ligation is probably the most common fixation method in use worldwide today
    • Rubber band ligation Complications Pain Moderate 5 - 85% – analgesic Severe near dentate line – ablation Bleeding Minimal 1 – 15 % Severe: 0.5 - 2% – Transfusion – suture Cellutitis Severe complication (50% mortality) 15 cases reported between 1980 – 1988 Anaerobic – Gram negative bacteria Early symptoms: anorectal pain & urinary troubles Early treatment ameliorate prognosis (antibiotics) Dysuria & urine retention
    • External hemorroidal thrombosis
    • Thrombectomy Instruments
    • Thrombectomy Local anesthesia Incision Enucleation
    • Edematous external hemorroidal thrombosis
    • Sebaceous cyst Not painful After puncture
    • Thrombosed hemorrhoidal prolapse Acute hemorrhoidal disease
    • Treatment of acute hemorrhoidal disease Medical Direct injection of 9 ml bupivacaine 0.25% + 1 ml hyaluronidase Gentle massage followed by reduction of the mass NSAIDs parenterally Surgical Emergency hemorrhoidectomy occasionally
    • Only about 10% of patients should undergo operation
    • Thank You