Overall description of Piles/ Hemorrhoids causes, types, treatment, pathophysiology

1. HEMORRHOID
S
DR. GAURAV H.
SANGAM
M.S (Ayu)
Consulting Proctologist &
Anorectal Surgeon

2. 1. Introduction
2. Vericosity
3. Anatomy
4. Pathophysiology
5. Causes
6. Clinical features
7. Diagnosis
8. Treatment

3.  Hemorrhoid
 Haema – blood
 Rhoos – flow
 Hemorrhoids means flow of blood.
 Piles – pila (ball)
 Means swelling (round mass)

4. Defination -
 These are dilated veins within the anal
canal in the subepithelial region formed by
radicles of the superior,middle and inferior
rectal veins.
 Hemorrhoids are vericosities of veins in
anal canal

5. 1. Varicosity - varix or varicose
condition in which a vein is swollen
and tortuous. varicose vein - a vein
that is permanently dilated.

6. What causes Varicosities?
 Varicose veins are caused by
increased blood pressure in the veins.

7. Why veins and not
arteries?
Veins
Artery

8. Varicose veins appear in other body,
including:
 Arms
 Legs
 Oesophagus
 Genitals
 Rectum.

9. Alternative Names
Rectal Lump
Piles
Lump in the Rectum
Definition:
Dilated or enlarged veins in the lower
portion of the rectum or anus.

10. Anatomy:- muscles play an imp role

11. Muscles :
 Treitz’s muscle,
 Conjoined longitudinal muscle,
 Internal anal sphincter
 External anal sphincter,
 Mucosa, and the
 Pelvic floor muscles
Submucosa are CUSHIONS
That play an important role in the
formation of prolapsed hemorrhoids.

12. Treitz’s muscle
 Treitz’s muscle passes
through the internal sphincter
and fixes the submucosa
tissue (cushion) to the
conjoined longitudinal
muscle..
 Therefore, it is the most
important muscle in the
formation of hemorrhoids.
Mucosal suspensory ligament
Anal submucosal muscle
Internal sphincte
conjoined longitudinal musc
External sphincter

13. Longitudinal Muscle
 The longitudinal
muscle is
presumed to
perform the same
role as the bone,
as it combines and
supports the
internal and
external sphincter
complex
 It is thought to play
the most important
role together with
treitz’s muscle in
the formation of
Medial longitudinal muscle
Intermediate
longitudinal muscle
Lateral longitudinal muscl
Trietz’s muscle
Corrugator cutis ani

14. What are hemorrhoids?
4 theories:
1. Varicose veins theory
2. Vascular hyperplasia theory
3. Internal anal sphincter
hypertonia
4. The sliding anal theory

15. 4. The Sliding Anal Lining
(Cushion) Theory
 In 1975, Thomson announced that
hemorrhoids result from the sliding
down of the anal cushion (anal
endothelial lining)on the basis of his
anatomical studies which is now
widely accepted.
 Hemorrhoids can develop from the anus
with loose and coarse connective tissue
degradation.

16.  The anal cushion functions as the
continence mechanism and changes the
width of the anal canal.
1. Straining
2. increase venous pressure
3. the anal cushion is dilated and
protrudes out of the anal canal.
4. The Treitz’s muscle stretches and
disintegrates with the force of repeated
straining causing the permanent
prolapse of the anal cushion.
Mechanism

18.  Internal hemorrhoids into
1. Vascular internal hemorrhoids
2. Mucosal prolapses
 External hemorrhoids into
1. Vascular external hemorrhoids and
2. Skin tags.

19. INT AND EXT
HEMORRHOIDS

22.  The three main cushions are located
at left lateral (3o’clock), right anterior
(11 o’clock), and right posterior
(7o’clock) in the anal canal.
 The tissues in the cushion are fixed to
the internal sphincter and the
conjoined longitudinal muscle with
collagen connective tissue and
become weak and loose with age.

23. Causes of Hemorrhoids:
Hemorrhoids are caused by
the disruption of the mucosal
suspensory ligament (Treitz’s
muscle)
The anal cushion protrudes
out of the anal canal by
repetitive straining, resulting in
disintegration of the ligament.

24. What are hemorrhoids?
4 theories:
1. Varicose veins theory
2. Vascular hyperplasia theory
3. Internal anal sphincter
hypertonia
4. The sliding anal theory

25. 1. Defecation with
Prolonged Straining
 Everyone’s anal cushion descends on
defecation.
 Posture for defecation is held for a
long time,
 The mucosal suspensory ligament
relaxes and does not return to its
original
 Defecation should be completed in a
short time, within 3 min, if possible.

26. 2. Constipation with a
Low-Fiber Diet
 With constipation or a low-fiber diet,
hemorrhoids will develop as a result of
prolonged straining
 During defecation, reading a
newspaper or books which prolongs
defecation time is also not
recommended.

27. 3. Diarrhea
 Diarrhea also is apt to descendent of
anal cushion resulting in prolapse,
because the frequency of bowel
movement increases.

28. 4. Pregnancy
 Abdominal distension and backward
posture of the buttocks - abdominal
pressure increases
 The enlarged uterus tends to
compress the vena cava, which
disturbs venous circulation - cause the
engorgement and aggravate
hemorrhoids.

29. 5. Occupation
 Hemorrhoids are frequent for those
who sit for a long period of time while
working,
 Such as drivers, or
 Those who work in a squatting
position.

30. 6. Psychological
Problems and Spinal
Paralysis
 The frequency of hemorrhoids is also
high in those with psychological
problems or spinal paralysis

31. 7. Hereditary
 Failure of the mucosal suspensory
ligament to return after relaxation
causes hemorrhoids to prolapse
easily.
 These can be hereditary factors
contributing to the development of
hemorrhoids.

32. 8. Alcohol
 Diuretic
 Dehydration
 Body needs water to make stools soft
 Liver cirrhosis - leads to swollen and
engorged veins within the rectum
called varicose veins.
 Liver cirrhosis – Ascitis – increase
intra abdominal pressure –
hemorrhoids.

33. SUP RECTAL
VEIN
A.D OF
INTERANL
ILIAC VEIN
INTERAL
PUDENDAL
VEIN
MIDDLE
RECTAL VEIN
INF RECTAL
VEIN
SPLENIC VEIN
INF
MESENTRIC
VEIN
PORTAL VEIN
IVC
COMMON ILIAC
VEIN
INTERAL ILIAC
VEIN
PORTA VACAL
ANASTOMOSIS
MEDIAN
SACRAL VEIN
LEF
T
VENOUS
DRAINAGE

34. 9. Sports and Leisure
Activities
 Golf,
 Cycling,
 Horse riding,
 Climbing,
 Weight lifting,
 Being
 The catcher in baseball,
 Wrestling,
 Fishing,
 Card playing,
 Driving,
 Sitting for a long period of time

35. SYNPTOMS

36. Bleeding
 Bleeding is the most frequent
symptom
 Fresh red colour
 spurting and dripping to just
staining on the toilet paper.
 Dark Red-colored Blood,- Colon
Disease, Such As Colon Cancer
Or Ulcerative Colitis, Can Be
Suspected.

38. Prolapse
 Relaxation and
disruption of
treitz’s ligament
and the conjoined
longitudinal
ligament due to
the squatting or
defecation
position.

39. Anal Pain
 Internal hemorrhoids usually do not
cause pain.
 Anal disorders distal to the dentate
line of the anal canal,
Thrombosed external hemorrhoids or
Anal fissures,
 In the internal hemorrhoids, the
incarcerated form can cause severe
anal pain.

40. Discharge
 Mucoid discharge is from the mucosa
proximal to the dentate line.
 It can appear with prolapsed
hemorrhoids.
 Can also occur in other conditions such
as
 Rectal polyps,
 Anal fistula,
 Ulcerative colitis,
 Crohn’s disease, and
 Irritable bowel syndrome.

41. Itching Sensation
 With mucosal
prolapse, the
amount of
perianal
discharge
increases
 This stimulates
perianal skin
with itching
sensation.

42. Positions to examine
patients:
Left lateral position
Lithotomy position
Knee-chest position

43. Diagnosis:
1. History.
2. Interview
Bleeding
Prolapse
Anal pain
Itching sensation
Discharge
Change of bowel habit

44. Inspection:
 A comfortable
atmosphere is
needed to relax
the patient
 A well-equipped
side lamp and
 A height
controllable bed.
The treatment procedure, including
operation, is decided after inspection

46. First Step
 Palpate the anus by
inserting up to the distal
joint of the index finger
 To check from the anal
verge to the dentate line.
1. Internal sphincter tone,
2. External hemorrhoids,
3. Anal fissure,
4. Perianal abscess,
5. Anal cancer
6. The thumb is
sometimes used
together to palpate to
confirm the existence of

47. Second Step
 Insert the index
finger up to the
middle joint.
 Palpate 2–3 cm
upward from the
dentate line.
 By rotating the finger
360°, the
hemorrhoid is
palpated - degree of
prolapse.
 If a fistula is present
internal opening are
also palpated.

48. Third Step
•This step involves
inserting the full
length of the index
finger.
•If it were not
performed properly,
rectal cancer may not
be noticed.

49. Anoscopic Examination
 Cylindrical
anoscope
1. Insert the anoscope
2. Insert the gauze through
the anoscope and
remove the anoscope
only
3. Pressure as usual on
defecation and observe
the site and degree of
the prolapse while
withdrawing the
previously inserted

50. Specular Anoscope
 The specular
anoscope is used to
inspect the anal canal
by inserting and
opening the anoscope
sideways.
 Then withdraw the
anoscope widening
slowly.
 This makes the
hemorrhoid to be
pushed out of anal
canal.
Colonoscopic Examination

51. Differential Diagnosis
 Hypertrophied
Anal Papillae
 It is considered
normal
 Usually there are
no symptoms
 But if it grows
excessively
large, it
protrudes below
the dentate line
which is called a
fi brous anal

52.  Rectal Prolapse
 When the entire
layer of the
rectal wall
prolapsed
circumferentially,i
t is called a
complete rectal
prolapse.

53. Rectocele
 the suspensory
tissue of anterior
rectal wall is relaxed
and distended
toward the vagina
which results in
defecation
difficulties and
bleeding problem.

54. D & D
 Rectal Polyp and Cancer
 Skin Tag

55. Classification :

60. Conservative Treatment
of Hemorrhoids
 Conservative treatment is basic
treatment that should be performed,
regardless of their severity.
 Early internal or external hemorrhoids
can be treated with the conservative
method including the following:
1. Hot sitz bath
2. Medication
3. Diet
4. Defecation counseling

61. Hot Sitz Bath
 For the conservative treatment,
postoperative management, and
prevention
 40–42 °c
 5-10mins
 Relieves pain by lowering anal
pressure,
 Helps to keep anus clean, and
 Improves anal blood circulation that
relieves congestion and edema.

62. Medical Treatment of
Hemorrhoids
 Oral medications for hemorrhoids
include the following:
1. Agent to improve circulation by
strengthening the vein and capillary
like, DAFLON (compounds help blood
circulation around the anus to settle
edema and relieve congestion.)
1. Anti-inflammatory agent, and
2. Stool softener

63.  Medicine for bleeding.
1. Tranexamic Acid is an anti-fibrinolytic
2. Ethamsylate is a haemostatic medication. It works by
increasing the ability of platelets to stick together and
form blood clots.

64. Ointment
 Applied around the anus
 Anti inflammatory agent to relieve
1. Inflammation and
2. Itching sensation.
Mostly Steroidal Preparation

65. Suppositories
 Suppositories are inserted into lower
rectum
 It acts like an ointment but also has
the effect of oral medication.
 Suppositories have a lasting effect

66. Dietary Treatment:
High Fibers
 For hemorrhoid patients, fluid and fiber
intake should be increased for the stool
to be soft and easy defecation.
Bowel Movement Education

67. 1. SCLEROTHERAPY
Injecting chemical agent on the
hemorrhoidal plexus
submucosally.
 Phenol In Almond Oil (PAO)
 Polidocanol Injection
INDICATIONS:
First, second and early third
degree internal hemorrhoids.

68.  2 TYPES OF SCLEROSING AGENT:
1. Oil based
2. Water soluble
 Previously the chemical used to be
oil-based which has its own
advantage, limitation and
complications.
 Nowadays water-soluble chemicals
have minimized the complications
and have results on table.

69. Technique: (water soluale)
1. Dilute in 1:1 ratio with normal
saline.
2. With 26/27 long 1 1/2 inch
needle.
3. It is to be injected in aseptic
precaution
4. Above the dentate line,
parallel to anal canal,
submucosally above the

70.  Technique: (water
soluale)
5.Till up to the whole mass
converted from pinkish
to whitish colour
6. Inject 1-2 pile masses
only.
7. Repeated after 15 to 20

71.  Technique: (in short)
1. Above the dentate line
2. Parallel to anal canal
3. Lift the mucosa
4. Gentally inject till sunshine
phenomenon and avoid trauma
to mucosa

73. MODE OF ACTION:
IT
CREATES
FIBROSIS
CALCIFICATION
WHICH STOPS
BLEEDING
SCARRING
REGRESSION
OF
HEMORRHOIDS

74.  COMPLICATION:
1. It has only one complication, if you
inject more than 1 ml solution in
veins, it can lead to deep vein
thrombosis, cirrhosis of the liver,
chemical reaction and very rare
infection.
 RESULTS:
1. The success rate is very quiet and
painless. It is been known as cure for
hemorrhoids without pain and
surgery.

75. 2. RUBBER BAND
LIGATION:
 INDICATION:
 This technique is usually indicated in
pedunculated first, second and early third
degree internal hemorrhoids

76.  RUBBER BAND LIGATION INSTRUMENTS
REQUIRED:

77. Technique:
1. Position comfortable to surgeon
and patient.
2. Introduce split anoscope with light
source.
3. Place 1 or 2 elastic bands at a
time.
4. Catch the pile mass with a
instrument and confirm the
pedunculated hemorrhoids and fire

78. • Technique:
6. Strangulation of the blood
vessel, cut off the blood supply,
necrosis and slough out to the
hemorrhoids.
7. In 5 to 7 days it falls off
eventually.
8. It leaves small ulcer which
heals by its own.
9. Maximum you can ligate 2 &

79. 0

82.  MODE OF ACTION:
LIGATION
WITH
ELASTIC
RINGS.
SLOUGH OUT
TO THE
HEMORRHOID
NECROSIS
STRANGULATION

83. COMPLICATIONS:
1. Sometimes one can
get vagal symptoms
2. Inadequate fixation
3. Severe pain On table
Bleeding
4. Thrombosis

84.  COMPLICATIONS:
6. Urinary retention
7. Secondary bleeding from ulcer
due to infection
8. Pelvic and perineal sepsis
9. About 2.5 % patients require
hospitalization due to massive
hemorrhage, severe pain and
perineal sepsis.

85. RESULTS:
Result is 70-80% by experts
with proper protocol.
Within 1 – 10 years patient
requires repeat of the
procedure.
After 5 to 10 years it requires
new modalities of treatment.

86. 3. INFRARED
COAGULATION:
 Infrared coagulation is also known as
coagulation therapy.

87. INDICATIONS:
It is recommended for
internal bleeding piles and
small mucosal ulcer.

88. Technique:
1.Position comfortable to
the patient & surgeon
2.Requires special
computerized control
photo coagulation
instrument

89.  Technique:
4. Time set – 1 – 1.5 sec
5. 2 hemorrhoids at a
time, repeat after 15 –
21 days
6. 5 – 6 sittings required
for prolapse

91.  MODE OF ACTION:
CONVERTING
INFRARED LIGHT
INTO HEAT
SCARRING AND
FIBROSIS
WATER EVAPORATION
& ESCHAR FORMATION
COAGULATION
OF TISSUE
PROTEIN

92. Complications:
1. Ulceration
2. Proctocolitis
3. Bleeding
Result:
1. In acute emergency to stop
bleeding, results are good. (If the
bleeder is small and from the mucosa it
stops immediately)
2. Long standing results are
unsatisfactory.

93. 4. CRYOTHERAPY:
 Cryotherapy, is use of low temperatures
in medical therapy.
 Also known as cryosurgery or
cryoablation.

94. PROCEDURE:
1. Position comfortable to the patient
& surgeon
2. without anesthesia
3. Requires special cold temperature
control photo coagulation
instrument
4. Time set – 1 – 1.5 sec till mucosa
becomes white
5. 2 hemorrhoids at a time, repeat
after 15 – 21 days

95.  MODE OF ACTION:
BURNS THE MUCOSA
CREATE FIBROSIS
WHICH STOPS BLEEDING
AND REGRESSION OF PILE
MASS

96. COMPLICATIONS:
1. Pain
2. Bleeding
3. Purulent mucisal discharge
4. Electrolyte imbalance

97. 7. RADIOFREQUENCY
 Coagulation of hemorrhoids using
a radio- frequency device, frequency
of 4MHz

98.  INDICATION:
1. Early - stage bleeding, non prolapsing
hemorrhoids

99. TECHNIQUE:
1. Under local anaesthetic, with
or without sedation.
2. A lubricated proctoscope is
inserted into the
3. Local anaesthetic is injected
into tissue surrounding the
haemorrhoid

100.  TECHNIQUE:
4. Probe connected to a radiofrequency
generator is inserted into the
haemorrhoid, or a ball electrode is
rolled over the surface of the
haemorrhoid.
5. The tissue within the haemorrhoid
heats up and the haemorrhoid
shrinks.
6. The haemorrhoids may be treated in
several sessions,each taking up to
20 minutes.

101. MODE OF ACTION:
FREQUENCY IS RELEASED FROM
GENERATOR
FOCUSED ON AFFECTED
AREA
TISSUE RESISTANCE IN THE PATH
OF WAVE
MAKE INTRACELLULAR
FLUID BOIL
INTURN PRODUCES COAGULATION AND
SHRINKAGE OF TISSUE

102. COMPLICATION:
Bleeding (5-10 days)
Discharge
Urinary retension
RESULTS:
More or less similar to that of
rubber band ligation

103. 5. DG-HAL – DOPPLER
GUIDED HEMORRHOIDAL
ARTERY LIGATION
This procedure is a non-
invasive procedure for the
treatment of hemorrhoids.
Ligation of terminal branches
of Superior Hemorrhoidal
Artery under Doppler
guidance is known as DG-

106. INDICATION:
2nd and 3rd degree
hemorrhoids or any
procedure for plexus
ligation.

107.  TECHNIQUE:
1. Doppler ultrasound mounted to a
specially designed proctoscope is
inserted in the anal canal.
2. After this identification of the branches
of superior hemorrhoidal artery with
the help of readings on a specially
designed monitor.
3. After identification of the hemorrhoidal
artery, put a stitch with absorbable
material and then sound disappears.

108. 0

109.  TECHNIQUE:
4. All the branches should be ligated
about 2-3 cms above dentate line.
5. Ligation of all the hemorrhoidal
artery results in reduced blood
pressure inside the plexus with
subsequent reduction of bleeding
and swelling of tissue.
6. Maximum 6 ligatures can be taken
at 11, 12, 2, 5, 7, 9 o clock
position.

111.  COMPLICATIONS:
 If procedure is not done properly results in
1. Pain
2. Bleeding
3. Stricture
 RESULTS:
1. Complaints of bleeding stops in 95 % of
cases with no pain.
2. In 78% improvement in prolapsed related
symptoms.
3. Procedure is cost effective, expertization is
required to perform this procedure.

112. 6. LASER IN
HEMORRHOIDS:
This procedure produce good
coagulation, it is relatively easy
with less bleeding and pain.
This is because of specific wave
length of this type of laser.
Carbon dioxide laser is the most
adequately used laser in
surgical proctology.

114. INDICATION:
Early 3rd degree and 4th
degree internal hemorrhoids.

115.  TECHNIQUE:
1. In lithotomy position, under local
anesthesia or general anesthesia or
spinal anesthesia this procedure can
be performed.
2. The laser beam light is applied with a
dedicated handle and is slowly moved
on the area to be treated, until total
tissue destruction.
3. It can be done on all hemorrhoids in
one sitting.
4. Procedure can be performed in 20-30
mins.

117.  COMPLICATIONS:
1. Pain
2. Hematoma
3. Secondary bleeding
4. Very rare infection
 RESULTS:
1. Long standing results are awaited.
2. It is a costly procedure.
3. Nowadays computerized special
proctology software and machines are
widely used.

118. HEMORRHOIDECTOMY
MILLIGAN MORGN METHOD

119. MILLIGAN MORGAN HEMORRHOIDECTOMY

120. THANK YOU:
MUMBAI – DADAR, PRABHADEVI, CHEMBUR, TILAKNAGAR,
GHATKOPAR, KHARGHAR, KAMOTHE, ULWE