DISCUSSION ABOUT HAEMORRHOID- CAUSES, SYMPTOMS, TREATMENT

1. HAEMORRHOID
-Dr Shruti

2.  Greek (haem- blood, rhoos-
flowing)
 Pile (latin, pila- pill/ball)
 Engorgement of the venous
plexus with redundancy of
their coverings

3. ETIOLOGY
 Venous obstruction
Act of straining during defecation
Impedes rapid emptying of cushions
congestion
oedema
Swelling and stretching of tissues
hypertrophy

4. ETIOLOGY
 Prolapse of vascular cushions

5. ETIOLOGY
 Hereditary
 Defecation habits
 Geographical and dietary factors
 Anal sphincter tone

6. EPIDEMIOLOGY
 Sex – 60% operated cases are males
 Age-prevalence increases till 7th decade
 Associated conditions –
 Hernia
 Pregnancy
 Genitourinary prolapse
 Prostatism

7. SYMPTOMS
 Bleeding -Most common
earliest symptom
bright red color
characteristic history

8. SYMPTOMS
 Prolapse
• Patient Complains of protruded mass per anum
• Spontaneous or self digital reduction history
• However, patient may confuse skin tags and perianal
vascular channel thrombosis as pile mass!

9. SYMPTOMS
 Pain, discomfort
 Thrombosed prolapsed internal piles will be
extremely painful
 Or history of dull pain/ discomfort after defecation
which is relieved by reduction of prolapse
 Discharge, pruritis
 Mucous +- blood stained discharge
 pruritis

10. CATEGORIZATION
1st degree Does not descend
below dentate line on
straining
2nd degree Descends below
dentate line on
straining,
Seen at exterior,
disappear again after
straining stops
3rd degree Descends and
remains outside until
digitally replaced
4th degree Permanently outside

11. COMPLICATIONS
 Thrombosis
• Most painful
• Difficulty in sitting/walking/ defecating
 Anemia
 Perianal dermatitis

12. ASSESSMENT OF THE PATIENT
 Inspection
 Discharge
 Rule out rectal prolapse
 Rule out fistula in ano
 Palpation
 Hemorrhoids unless thrombosed are not usually
palpable
 Rule out abscess and anal carcinoma

13.  Proctoscopy
 IMP – to look for other causes of PR bleed
 Sigmoidoscopy
 Rule out inflammatory bowel disease, carcinoma and
ulcer
ASSESSMENT OF THE PATIENT

14. MEDICAL MANAGEMENT
 Changing defecation habits
 Diet manipulation
 Topical anesthetics

15. INVASIVE THERAPY
 Principles
 Prevention of prolapse by fixation
 Prevention of congestion by dividing internal anal
sphincter
 Excision of engorged vascular cushions

16. SCLEROTHERAPY
 Principle- it scars submucosa and fixation of
hemorrhoidal complex in normal location.
 Sodium morrhuate, sodium tetra dryl sulfate,
5%phenol in almond oil, 2ml
 Indication
 Minimally enlarged haemorrhoids where primary complain is
bleeding
 Contraindication
 Associated thrombosis or sepsis
 Active inflammatory bowel disease
 Acute leukemia

17. SCLEROTHERAPY
 Left lateral position
 Anoscope
 25 gauze spinal needle
 Submucosal space
 Start with lowest
hemorrhoid
Complications
Chemical prostatitis and impotence rare but well recognised
complication
Anovaginal fistula

18. BIPOLAR DIATHERMY
 Small bleeding hemorrhoids
 Generates 2 sec pulse
 Coagulates hemorrhoidal tissue, submucosa and
mucosa

19. INFRARED COAGULATION
 15V tungsten halogen lamp
 Temperature at tip reaches 100
degree C
 Coagulator must be placed in firm
contact with base of haemorrhoid
(should not be embedded)
 Circular white eschar will appear
after exposure
 3-5 exposures made in semicircle
around the base

20.  Useful for
 Hep B or HIV positive patients as it doesn’t cause
bleeding or sloughing
 Immunocompromised
 Receiving anticoagulants
 Pregnant
INFRARED COAGULATION

21. HEMORRHOIDAL LIGATION WITH RUBBER
BANDS
 Grade 2 or 3 internal
 Banding should start with biggest hemorrhoid first
 Multiple sessions are required
 Complication - sepsis

22. EXCISIONAL HEMORRHOIDECTOMY
 Indications
 Large 3rd degree
 2nd degree with skin tags
 Banding or sclerotherapy has failed
 Containdications
 Crohn’s or ulcerative colitis assosciated
 Active intestinal or pulmonary TB
 Advanced stage HIV (CDC group 4)
 Associated portal hypertension

23. MILLIGAN MORGAN HAEMORRHOIDECTOMY
Forceps applied over skin component

24. All the hemorrhoids held to retract away from the operating field
MILLIGAN MORGAN HAEMORRHOIDECTOMY

25. MILLIGAN MORGAN HAEMORRHOIDECTOMY
V shaped incision through skin at the base of external component

26. MILLIGAN MORGAN HAEMORRHOIDECTOMY
Dissection deepened

27. Plane developed outside the hemorrhoidal tissue
MILLIGAN MORGAN HAEMORRHOIDECTOMY

28. MILLIGAN MORGAN HAEMORRHOIDECTOMY
Transfixation suture applied or diathermy

29. MILLIGAN MORGAN HAEMORRHOIDECTOMY
Similar for other hemorrhoid mass

30. CLOSED FERGUSON HAEMORRHOIDECTOMY
•Modification
•Mucosa and skin closed with absorbable sutures

31. PARK’S SUBMUCOSAL EXCISION
 Linear radial incision over haemorrhoidal tissue
 Dissected from beneath anoderm and mucosa
 Wound is closed

32. POSTOPERATIVE CARE
 Combination of magnisium hydroxide, liquid paraffin
 Betadine seitz bath after every bowel movement
 Gentle digital examination on 5th postop day, if
impacted feces present, enema
 Pain control
 Bleeding
 Per rectal examination after one month to ensure
that anal stenosis is not developing

33. CIRCULAR STAPLING
OR ANOPEXY
•Mucosal purse string
suture placed 3-5cms
above dentate line
•Tightening this suture
causes drawing in of
mucosa and submucosa
into the stapler
•Stapler is closed

34. CIRCULAR STAPLING OR ANOPEXY
 Too low purse string severe pain
 Too deep purse string potential cause of pelvic
sepsis or rectovaginal fistula

35. HAEMORRHOIDAL ARTERY LIGATION
 Proctoscope containing doppler ultrasound
 Identify site of haemorrhoidal arteries
 Figure of 8 suture
 Often 6-7 vessels are detected and all should be
ligated

36. REFERENCES
 Surgery of the anus, rectum & colon by michael
keighley and norman williams
 Maingot’s abdominal surgery
 Sabiston textbook of surgery
 Farquharson’s textbook of operative general
surgery
 Atlas of general surgery by david carter

37. THANK YOU