HEMORRHOIDAL DISEASE

1. HEMORRHOIDAL
DISEASE
Naveen Chandra Bhatta
MS Resident

2. Introduction
 “Hemorrhoid” (from the ancient Greek word “hema,” blood, and
“rhoos,” flow) meaning flow of blood *(Yang 2014)
 Vascular cushions that underlie the distal rectal mucosa
 15–20% of the resting anal pressure
*(Lestar et al. 2009)
 Symptomatic when enlarged, inflamed, thrombosed, or prolapsed
 About 5% experience hemorrhoids at least once in their lifetime
*(Ganz 2013)

3. History of Hemorrhoids
 First known mention of this disease is from a 1700 BCE Egyptian papyrus
 Celsus (25 BCE – 14 CE) described ligation and excision procedures
 Galen advocated severing the connection of the arteries to veins.

4. Epidemiology
 Higher social class (1.8 times more common)
 Hemorrhoids were causally related to constipation (Burkitt and Graham 1975)
 Prevalence of HD of 4.4% with a peak between 45 and 65 yrs
(Johanson and Sonnenberg, 1990)
 4th leading outpatient digestive system diagnosis in US
 BMI showed significant correlation with risk of developing hemorrhoids
(Van Gelder et al, 2010)
 > 50% of the population over 50 years of age has experienced hemorrhoid
problems (Gencosmanoglu et al. 2002)

5. Applied anatomy of anal canal
 Anal canal : 2.5–4 cm, encircled with anal sphincter complex
 “Anal cushions” also known as hemorrhoidal plexus
 Function: Maintain anal continence
Allow anal distension during defecation
 Fills the gap within the sphincter ring thus resulting in complete fecal continence

6.  Treitz’s muscle(sub epithelial smooth muscle)
 Anorectal vascular plexus formed by direct arteriovenous communication between
the terminal branches of rectal arteries and veins (Aigner et al. 2009)
Fig: Anatomy of anorectal vasculature

7.  3 major cushions: right anterior, right posterior, and left lateral
 Hemorrhoids are referred to abnormally congested and/or downward displacement of
anal cushions (Lohsiriwat 2012)

8. Pathologic changes:
- Markedly dilated vascular channels, venous thrombosis, and fragmented
subepithelial smooth muscle

9. Pathophysiology of Hemorrhoids
 Mean resting anal pressure/ Maximum residual pressure significantly ↑
during rectal distension (Sun et al. 1992)
 Patients with hemorrhoids have lower rectal compliance, and more perineal
descent
 4 groups:
Sliding anal cushions (loss of fixation network)
Vascular abnormality
Rectal redundancy
Increased pressure on anorectal vascular plexus
*(Lohsiriwat 2012)

12. Assessment of Hemorrhoidal Disease
 Outpatient or ambulatory setting
 Performed by General surgeon or with an accredited specialist interest,
in coloproctology
 Thorough history and physical examination to guide assessment
 Consideration of treatment options

13. Patient History
 Most common symptoms described by patients with hemorrhoids are:
• Rectal bleeding
• Perianal pain/discomfort
• Pruritus
• Prolapse
 Other symptoms: perianal swelling, soilage, mucus discharge, or tenesmus .
*(Sanchez and Chinn 2011)
 Full and detailed description of the symptoms to rule out the more
concerning diagnoses *(Garg et al. 2011)

14.  Painless bleeding as the primary symptom.
Bright red in color (often described as “fresh”), and may appear on the paper while
wiping, or can drip into the pan.
 Diet history, history of constipation or diarrhea, prolonged sitting or heavy
lifting, weight loss, abdominal pain, and onset and duration of symptoms
 History regarding medical conditions, coagulation history, and family
history *(Sanchez and Chinn 2011)

16. Patient History
 Mucorrhea, Hygiene, Difficulties, and Pruritus
 Significant prolapse of internal piles: mucous discharge from the anus
 Discomfort to the patients due to the soiling their underclothes and skin
maceration.
 Skin tags: difficulty in anal hygiene, anal discomfort,pruritus

17. Physical Examination
 External examination of the rectum/anus
 Specific signs : skin tags, which may indicate previous hemorrhoids /anal fissure
 Anal fissures or evidence of fistulae ,( perianal sepsis from an abscess or fistula should be ruled
out)
 Digital rectal examination :
 For distal rectal masses, tenderness in the presence of abscesses or fissures, mucus discharge or
blood
 Internal hemorrhoids are not normally palpable unless thrombosed
 Sphincter tone

18.  Pain and Discomfort
 Usually painless
 Pain or significant anal discomfort,
(such as fissure, abscess, or carcinoma) should be excluded
 Thrombosed pile(s), external or internal
 Pain is continuous or subcontinuous,
 Exacerbated by the stool transit through the anal canal.

19.  Prolapse
 Hemorrhoidal (external protrusion of the piles only)
 Muco-hemorrhoidal prolapse (piles protrusion associated to prolapse of the rectal
mucosa/submucosa)
Features Rectal Prolapse Prolapsed
Hemorrhoids
Tissue folds Circumferential Radial
Abnormality
on palpation Double Rectal Wall Hemorrhoidal Plexus
Resting and
Squeezing
pressures
Decreased Normal

20. Investigation
 Anoscopy or proctoscopy completes OPD examination
 Anoscopy more sensitive to flexible sigmoidoscopy as in a prospective
study by Kelly et al.,
-99% of anal lesions were identified on anoscopy whereas 54% were identified on
colonoscopy*
 Endoscopic investigation important to rule out other pathologies
-However it should not be a replacement for ambulatory protoscopy
*Kelly SM, Sanowski RA, Foutch PG et al (2006) A prospective comparison of anoscopy and
fiberendoscopy in detecting anal lesions. J Clin Gastroenterol 8

21. Flexible Sigmoidoscopy and Colonoscopy
 To rule out other serious pathology
 Flexible sigmoidoscopy or colonoscopy is not as accurate in the
identification of hemorrhoids
 Endoanal ultrasound and anorectal manometry-useful in the evaluation of
the sphincter complex
 Important in the assessment prior to intervention for hemorrhoid
 Influences type of intervention the surgeon decides upon, dependent on the risk of
developing incontinence after surgery
*(Kaidar-Person et al. 2007)

23. Anatomical Classification Systems
 Classified by their relation to the dentate line.
Internal, external, or mixed
 Dentate line : 2 cm from the anal verge,
 area of demarcation between the upper anal canal (lined with columnar epithelium) and the lower anal
canal (lined with sensate squamous epithelium)
*(Nisar and Scholefield 2003)
 Internal hemorrhoidal venous plexus above the dentate line: Internal hemorrhoids
 External hemorrhoidal venous plexus below the dentate line:Ext hemorrhoids
*(Lohsiriwat 2012)
 Mixed hemorrhoids (interno-external) : above and below the dentate line.

25. Other classification systems :such as hemorrhoidal position
 Primary (at the sites of the mentioned anal cushions)
 Secondary (between the anal cushions), or circumferential
*(Lunniss and Mann 2004)
 Soiling, anal discomfort, or pruritus not addressed in the traditionally used
classification systems

26. Symptom Severity Classification of Hemorrhoidal Disease

27. Kraemer Proctological Symptom Scale
 Kraemer et al. describe the proctological symptom scale, which
measures the symptoms on visual analogue scales (1–10)
Pain
Itching
 Use to evaluate success of intervention following therapies
 Useful in monitoring disease progression *(Kraemer et al.
2015).
 Following surgical therapies- symptom score improved significantly
Discharge
Bleeding

28. Sodergren Hemorrhoid Symptom
Severity Score
 Symptoms of hemorrhoidal disease that have greatest effect on the quality
of life Pucher et al, 2015
 Frequency/severity of symptoms of pruritus, pain, and prolapse
 With a weighted point allocation assigned for a final score of 0–14
 Cutoff score of ≥ 5,should be considered for operative (nonambulatory)
treatment

30. Treatment of Hemorrhoids

31. Lifestyle Modification
 Recommended in all patients
 Avoid spicy/fatty foods,coffee, alcohol
 Regular exercise, anal hygiene
 High fibre diet and increase oral fluid intake
 Use of sitz baths and the avoidance of straining
 Grade I hemorrhoids treated conservatively in the first instance
with review in 3–6 months

32.  Fiber Supplementation
 Two types of fibers :
 water soluble fibers such as pectins, gums, and mucilages,
 insoluble fibers such as cellulose, hemicelluloses, and lignins
 Insoluble fibers significant effect on stool output and are potent stimuli of
colon transit
*(Spiller 1994)
 The general recommendation is to increase fiber intake 20–30 g/day
*(Lembo and Camilleri 2003)
Constipation is a common cause of
hemorrhoids
(Choung et al. 2007)
Chronic straining has been inconsistently
associated
(Johanson and Rimm 1992)

33. Medical Therapy
 Fiber-based laxatives
 Various combinations of local anesthetics,corticosteroids, vasoconstrictors,
antiseptics, and astringents
 Provide short-term symptomatic relief
 Phlebotonics
 Role in the control of acute symptoms
 Useful in reducing symptoms after surgical treatment
*(Perera et al. 2012)

34. 1. Laxatives
 Bulk-Forming Laxatives:
Psyllium seed, methylcellulose, calcium polycarbophil and wheat dextrin
 Natural or synthetic polysaccharides
 Laxative effect by absorbing water and increasing fecal mass
 Used alone or in combination with an increase in dietary fiber

35. 2. Surfactants
 Docusate sodium
 lower the surface tension of stool, water more easily enter the stool
 Less effective than other laxatives

36. 3. Osmotic Agents
 PEG electrolyte solutions for the treatment of chronic constipation
 (intraluminal water secretion and increase in stool frequency)
PEG effective in improving stool frequency and consistency
(Bharucha et al.2013)
 Synthetic disaccharides – Lactulose
 not metabolized by intestinal enzymes
 remain within intestinal lumen due to osmotic effect

37. 4.Prebiotics
 Nondigestible, but fermentable, foods that beneficially affect the host
 Stimulate the preferential growth of health-promoting commensal flora
already residing in the colon
 “good” microbiota, positive effect on stool frequency

38. 5.Probiotics
 Most commonly
 lactic acid bacteria and nonpathogenic yeasts
 Introduction of exogenous bacteria into the human colon
 Ability of probiotics to accelerate colonic transit and stimulate motility*
*Quigley EM (2011) The enteric microbiota in the pathogenesis and management of constipation, Gastroenterol Clin N Am 36: 735–
748

39. 6 .Oral Medications
 Flavonoids: Phlebotonics
 Capable of decreasing capillary permeability
 Facilitating lymphatic drainage in addition to their anti-inflammatory
effects
 Micronized purified flavonoid fraction (MPFF)
 90% diosmin (450 mg) and 10% hesperidin (50 mg), most common flavonoid used in
clinical treatment
A recent metaanalysis of flavonoids for hemorrhoidal treatment:
decreased the risk of bleeding by 67%, persistent pain by 65%, and itching by 35%, and
also reduced the recurrence rate by 47%

40.  Calcium Dobesilate
 Reduction in microvascular permeability, thereby increasing capillary resistance
 Decreases platelet aggregation
 reduces serum viscosity- reduction in tissue edema
 directly as an antioxidant protecting lipids from peroxidation
 Herbal Oral Therapy
 Herbal extracts: Aesculus hippocastanum, Ruscus aculeatus

41. 7.Topical Therapy
A. Local anesthetics
 reduce hemorrhoidal symptoms by exerting a local anesthetic effect
 eliminates the burning/itching associated with hemorrhoids.
 Commonly used formulation is an ointment containing nifedipine 0.3% and
lidocaine 1.5%

42. B. Antispasmodic agents:
 Relieve symptoms associated with anal sphincter spasm and high resting
anal pressures
 Topical GTN 0.2% ointment, in patients with first and second degree hemorrhoids
 Decreased rectal bleeding, improvement in anal pain, throbbing, itching, and irritation
 Side effects include headaches – reported in 43% of patients
 Pharmacological activity: release of nitric oxide
 Vasodilatation of venous vessels
 reducing the muscle tone of the internal anal sphincter (chemical sphincterotomy)
*(Tjandra et al. 2007)

43. C. Nifedipine:
- Treatment of acute thrombosed external hemorrhoids and chronic anal
fissures
- Clinical effect: relaxation on the internal anal sphincter, and predominantly
vasodilatory effect
D. Hydrocortisone Acetate:
 Hydrocortisone acetate 1%, most commonly prescribed topical
corticosteroids, generally combined with lidocaine 3%

44. E. 5-Aminosalicylic Acid
 Reduce the intensity of pain, bleeding, and tenesmus, due to its anti-inflammatory activity
 Decrease the congestion of the hemorrhoidal venous plexus
F. Hyaluronic Acid
- Improve pain during evacuation, pruritus, irritation, and reduces bleeding.

47. Ambulatory Procedures
 Injection sclerotherapy and RBL: most widely practiced
 Rubber band ligation appears to be the most effective of these
treatments *(Macrae and Mcleod 1995)
 Indicated in failed conservative management of grade I disease, or grade II–
III hemorrhoids
 Mechanism
 producing a scar at the base of the hemorrhoid
 reducing the vascular supply
 fixing the hemorrhoid cushion to the upper part of the anal canal

48. Rubber Band Ligation
 Blaisdel described RBL of Int hemorrhoids in 1954
 Popularized by Barron in 1963
 now among TOC for symptomatic internal hemorrhoids
(Iyer et al. 2004)
 Safe, effective, low-cost, and easy-to-use method
 can be performed without anesthesia in the outpatient clinic

49.  Indications for RBL
 Symptomatic Grade II and III hemorrhoids
 Contraindications:
 First- and fourth-degree hemorrhoids
 Thrombosed hemorrhoids
 Anorectal pathologies (fissures, fistulas, and abscess)
 Colitis
 Colorectal malignancies
 Pregnancy
 Coagulation disorders: unless it appears to be safe to stop antiplatelet and anticoagulant therapy
before the procedure

50. Rubber Band Ligation Application Technique
 Sims or modified knee chest position
 A device that applies a rubber band to each hemorrhoid via a proctoscope
 constricts the blood supply, causing ischemia 1–2 weeks later
 scar is fixed to the rectal wall
*(Chaundhry and Abscarian, 2016)

51. •No bowel preparation is recommended
•Procedure performed without sedation

52. Complications of RBL (3-8%):
 Thrombosis of external hemorrhoids
 Postband bleeding: <1%
 Pain within 24 h of the procedure
 Urinary retention
 Pelvic sepsis is a very rare (1: 15,000) but life threatening complication
The reported long-term success rate of RBL (with long-term defined as 6 months minimum) is
approximately 90% in patients with grade II-III hemorrhoidal disease
*(Marques et al. 2006)
If >4 banding sessions required for symptom control, a conventional hemorrhoidectomy required
*(Cocorulloet al.2017)
RBL has lower recurrence rates than than either sclerotherapy or infrared coagulation
*(MacRae and McLeod 1997)
Outcomes

55. Laser Coagulation
 CO2 or Nd-YAG and diode lasers
 Laser beam applied to submucosal layer
 shrinkage and degeneration
 Minimal bleeding, less pain, short time *(Yang,2014)
 Use of diode laser, 2007
 Has low penetration depth(2mm), no anal sphincter injury

56. Ultroid (Direct current probe)
 Dispositive device , uses low voltage monopolar current
 Generates sodium hydroxide
 coagulation of hemorrhoidal tissue
 Long time, post procedural pain
Cryosurgery
 Popularized in 1980s
 Liquid nitrogen applied to hemorrhoidal tissue
 necrotizing effect

57. Surgical Procedures
 Formal excisional surgery
 Stapled hemorrhoidopexy or procedure for prolapsed hemorrhoids (PPH),
 Hemorrhoidal artery ligation (HAL)/Doppler guided hemorrhoidal artery ligation (DGHAL),
in combination with sutured mucopexy
 Excisional surgery
 excising the external component of the hemorrhoid along with itsvascular pedicle
Open (Milligan et al. 1937)
closed (Ferguson and Heaton 1959) technique
 Stapled hemorrhoidopexy
 circular stapling device to resect a ring of redundant mucosa above the hemorrhoidal
bundle
*(Longo 1998)

58. Traditional Hemorrhoidectomy:
 Technique: Open Hemorrhoidectomy
 Milligan and Morgan in 1937
 remained the standard by which all hemorrhoid surgeries are compared.
 Lithotomy position
 With a complete anal block limited sedation is required with Propofol

59. Technique
 Local anesthetic/epinephrine
 relax the anal sphincter, induce vasoconstriction thereby improving hemostasis
 postoperative pain control
 Clamps under tension, pink rectal mucosa exposed
 Curved mayo scissors incise perianal skin, tissue dissected off the internal sphincter
 3-0 polyglycolic acid ligate the apex and hemorrhoid excised
 The skin edges remain open to heal by secondary intention
An old adage states: “If it looks like a clover your troubles are over. If it looks like a dahlia it’s
a failure” *(Ferguson and Heaton,1959)

60. Closed Hemorrhoidectomy
 First described by Ferguson and Heaton , 1959
 A prone jackknife position is used
 buttocks are retracted with adhesive tape on both sides
 Wound is closed
 with continuous
 simple over-and-over suture of 5-0 polyglycolic acid
 beginning at the apex
 No drainage tubes, or hemostatic packs are inserted, no compression dressing.

61. A Comparison of Open Hemorrhoidectomy (MilliganMorgan) vs.
Closed Hemorrhoidectomy (Ferguson)
 Milligan-Morgan hemorrhoidectomy is performed almost exclusively in Europe and the
rest of the world
 Closed technique is performed predominantly in the United States
 They concluded closed hemorrhoidectomy to be superior to open in these
measures

62. Modern Hemorroidectomy
 The LigaSure is a bipolar electrothermal device
 seals blood vessels through combination of pressure and radiofrequency.
 The completion of coagulation
 signaled by the feedback sensors
 tissue can be excised along the line of coagulum.
 Complete coagulation of arteries and veins
 up to 7 mm in diameter with minimal surrounding thermal spread
 Decrease in thermal injury at the surgical site reduce anal spasm and pain
 Safe and simple method to improve surgical outcomes

63. What kind of hemorroidectomy be performed
 Patient Information
 Excisional procedures
 rate of recurrences is low,
 treat additional anorectal pathology,
 main disadvantage is pain
 Stapled hemorrhoidopexy and THD
 reduce postoperative pain
 no need of wound care
 higher recurrence rates on long term

64. Stapled Hemorrhoidopexy (SH)
 Circular excision of the prolapsing rectal mucosa and submucosa proximal to the
dentate line using a circular stapling device
 Painless
 The stapling technique does not create any external wounds
 It is more a hemorrhoidopexy than a hemorrhoidectomy
 Also been known as stapled anopexy, procedure for prolapse and hemorrhoids
(PPH), stapled mucoprolaxectomy or Longo procedure
*(Rowsell et al. 2000; Longo 1998)

65. Transanal Hemorrhoidal Dearterialization (THD):
 Mucopexy associated to a Doppler-guided dearterialization
 of the terminal branches of the superior hemorrhoidal artery
 It lowers the postoperative pain
 Provides low rate of complications
 Increased recurrence on the long term( 11% to 59%)
*Giordano et al. 2009

66. Doppler guided hemorrhoidal artery ligation
 Morinaga et al. (1995) (HAL) procedure for internal hemorrhoids in 1995
 Principle
 ligation of the terminal branches of the superior rectal artery
 reduction of the blood flow
 shrinkage of the hemorrhoidal cushions
 Advantages
 preservation of the anatomy and physiology of the anal canal
 absence of external wounds, better tolerance
 less painful postoperative period
 Disadvantages
 high recurrence rates of up to 30% after DH
 too high above the hemorrhoidal zone
o missing the targeted submucosal branches of the superior rectal artery

67. Intra- and Postoperative Management
 Prophylactic Antibiotics
 Preemptive Analgesia
 Anesthesia and Intraoperative Care
 Total IV sedation (propofol) and local anesthetic (Argov et al. 2012)
 Postoperative Pain Management
(NSAID, Liposomal Bupivacaine, Gabapentin)
 Topical agents
 Sitz baths
 Bowel Regimens

68. Postoperative Complications
 Minor complications (4.6%)
 Pain, slippage of bands, mild rectal bleeding, and micturition disturbances
 Major complications (2.5%)
 delayed massive rectal bleeding
 urinary retention
 Pain
 prolapsed thrombotic hemorrhoids
 perianal abscess followed by a perianal fistula

69. Other Factors Influencing treatment Choice
 Choice of treatment
 depend firstly on the degree of symptoms
 Asymptomatic hemorrhoids should not be treated
 Thorough history of the nature of the symptoms and how the patient is
affected by them
 Patient choice and expectation
 Comorbidities and medical factors

70. Evidence for Efficacy of Treatments According to Grade of
Hemorrhoids
 Grade I Hemorrhoids
 Only conservative measures in most cases.
 cheap and safe, commonly recommended
A Cochrane review of seven randomized controlled trials in 2005 found
47% reduction in prolapse, pain, and itching and a 50% reduction in bleeding in patients taking additional
fiber (Alonso-Coello et al. 2006)

71. Grade II–III Hemorrhoids
 Office-based procedures
 RBL most effective ,lower risk of long-term recurrence than injection
sclerotherapy and infrared coagulation
*(Macrae and Mcleod 1995; Johanson and Rimm 1992)
Hubble trial, (Brown et al,2016) open label multicenter RCT, 49% recurrence at 12 months with
RBL, compared with 30% recurrence with HAL ,recurrence with RBL treated with repeated session
of RBL
 For large grade III hemorrhoids stapled hemorrhoidopexy
 reserved for circumferential hemorrhoids not amenable to excision

72.  Excisional hemorrhoidectomy
 more successful treatment for grade II and III hemorrhoid than office-based procedures
 Higher complication rate
 higher degree of postoperative pain
*(Macrae and Mcleod 1995)

73. Grade IV Hemorrhoids
 Symptomatic grade IV hemorrhoids
 require excisional surgery
 Success of HAL reported combined with plication sutures (also termed mucopexy or
rectoanal repair (RAR)) in grade IV disease
*(Faucheron et al. 2011; Festen et al.
2009)
 Excisional hemorrhoidectomy:
Open (Milligan-Morgan), closed (Ferguson), and sutureless techniques using an
advanced energy device such as LigaSure, Harmonic, or bipolar diathermy scissors.
 The sutureless techniques
 less blood loss and lower postoperative pain scores
 but are more expensive due to the cost of disposable equipment
*(Chung and Wu 2003)

74. Management of Treatment Failure and Recurrent
Symptoms
 Less invasive office-based procedure more than once rather than proceed to
formal surgery (*Hubble Trial)
 Stepwise management plan, least invasive treatment options first

75. Recommended Classification Based
Algorithm for Treatment of Hemorrhoids
 No “one size fits all” approach to the management of hemorrhoids
 Patient preference, medical factors, comorbidities, and surgical expertise
taken into account

76. New Therapeutic Horizons for Hemorrhoidal
Disease
 Malva Silvestris
 Allium ampeloprasum subsp. iranicum (Leek)
 Catechins and Epicatechins
 Streptokinase Suppositories
 Intra-Anal Iferanserin
 Diltiazem Gel

77. Special considerations
 Thrombosed or Strangulated Hemorrhoids
 Severely painful, swollen, irreducible
 Conservative management
 with laxatives, topical anesthetic ointment, analgesics, icepack, avoidance of
straining
 Pain period slowly subside after 48-72 hrs
 Risk of anal stenosis and portal pyemia who undergone emergency
hemorrhoidectomy

78. Hemorrhoids in Pregnancy
 Upto 40% pregnant affected
 Majority during last trimester and 1 month postpartum
 Simple conservative measures
Hemorrhoids in Immunocomprised patients
 Increased risk of sepsis and poor wound healing
 Conservative management usually
 Injection sclerotherapy when intervention is warranted
 Antibiotic prophylaxis to be considered

79. Hemorrhoids and Patients requiring Anti coagulation
 Minor bleeding symptoms: no need to stop
 Usual conservative measures suffice
 Stop anticoagulation for required no of days when intervention is required
 Need of bridging anticoagulation in high risk cases requiring anticoagulation
 RBL is not recommended

80. New Therapeutic Agents