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Hemorrhoids
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  • 1. BY DR.VEENA INTERNEE
  • 2.  Symptomatic anal cushions.  Haemorrhoidal venous cushions are normal structures of anorectum and universally present in all persons unless previous intervention has taken place.  It is a common anal pathology but many patients are embarrassed to seek medical attention.
  • 3.  Straining and constipation.  Pregnancy.  Obesity.  Prolonged sitting.  Portal hypertension and anorectal varices.  Chronic diarrhea.  familial
  • 4.  Colon malignancy.  Loss of rectal muscle tone.  Spinal cord injury.  Rectal surgery.  High socioeconomic status.  Episiotomy.  Anal intercourse.  IBD
  • 5. STRAINING AND CONSTIPATION Low fibre diet Less bulky stools Straining at defecation Increased intraanal pressure Decreased venous return Enlarged hemorrhoidal venous cushions
  • 6.  They are clusters of vascular tissue, smooth muscle and connective tissue lined by normal epithelium of anal canal.  They are commonly seen in left lateral, right anterior and right posterior(3,7,11’o clock) position with patient in lithotomy position.
  • 7.  Depending on anal origin within analcanal and relation to dentate line haemorrhoids divided in to I. internal haemorroids. II. external haemorrhoids. III. mixed haemorrhoids.
  • 8. INTERNAL  Lie above dentate line.  Develops from embryonic endoderm.  Covered by columnar epithelium of anal canal.  Not supplied by somatic sensory nerves.so cannot cause pain. EXTERNAL  Lie below dentate line.  Develops from embryonic ectoderm.  Covered by sqamous epithelium.  Innervated by cutaneous nerves that supply perianal area.
  • 9.  GRADE I painless bleeding, no prolapse.  GRADE II prolapse on defecation that reduces spontaneously.  GRADE III prolapse that has to be reduced mannually.  GRADE IV permanent prolapse.
  • 10.  Painless bleeding- color, timing, quantity.  Prolapse.  Perianal pruritus and irritation.  Discomfort.  Acute pain when incarcerated/strangulated.
  • 11.  Thrombosed external hemorrhoid may present with acutely painful mass at rectum.  Skin tags.
  • 12.  P/R-done in Sim’s position.  Anoscopy.  Proctosigmoidoscopy.
  • 13.  Anoscopy.  Flexible sigmoidoscopy.  Colonoscopy.  CBP.  Proctoscopy.  Coagulation profile.
  • 14.  Treat only symptomatic haemorrhoids I. Conservative II. Nonsurgical III. surgical
  • 15.  TOC in grade I internal and nonthrombosed external haemorrhoids.  Warm baths(sitz bath)-bid/tid.  High fibre diet.  Adequate fluid intake.  Stool softeners.  Topical analgesics.  Proper anal hygiene.
  • 16.  To destroy internal haemorrhoids.  Rubber band ligation.  Sclerotherapy.  Coagulation.  Electrocautery, electrotherapy.  Cryotherapy.  Laser therapy and radio wave ablation.
  • 17.  GRADE I,II haemorrhoids not improved by conservative procedures.  Pt. kept in left lateral position.  5ml of sclerosant is injected submucosally in to apex of pile pedicle.  5% phenol in arachis oil/almond oil.  Patient is reassessed after 8weeks.  Too deep injection has disastrous consequences like pelvic sepsis,prostatitis,impotence,rectovaginal fistula.
  • 18.  Barron's bander is used to slip tight elastic bands on to base of pedicle of each haemorrhoid.  Bands cause ischemic necrosis of piles,which slough off in 10days.  Side effect is bleeding.
  • 19. HAEMORRHOIDECTOMY  INDICATIONS-  Grade III,IV haemorrhoids with severe symptoms.  Conservative or nonsurgical treatment fails.  Patient preference.  Presence of anorectal conditions requiring surgery. (fistula,fissure,large skin tags).  Fibrosed haemorrhoids.  Intero-external haemorrhoids when external haemorrhoid is well defined.
  • 20.  Open and closed techniques.  Open technique also called milligan- morgan operation.  Both involve ligation and excision of the haemorrhoid but in open technique the anal mucosa and skin are left open to heal by secondary intention,and in closed technique the wound is sutured.  Stapled haemorrhoidopexy.
  • 21. EARLY  Pain.  Acute retension of urine.  Reactionary hemorrhage. LATE  Secondary hemorrhage.  Anal fissure.  Anal stricture.  Incontinence.
  • 22. THROMBOSED EXTERNAL HAEMORRHOIDS  Safely exiced when patient present within 48 to 72 hours of symptoms onset.  If present after 72 hours from symptom onset, conservative therapy preferred. SKIN TAGS excision when hygiene problem exists
  • 23.  Strangulation and thrombosis.  Ulceration.  Gangrene.  Portal pyemia.  Fibrosis.
  • 24.  Rectal prolapse.  Colorectal cancer.  Condylomata acuminata.  Proctitis.  Pruritus ani.  IBD.  Pedunculated polyps.  Perianal abcess.  Anal fissure,fistula.  Varicosities.