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HAEMORRHOIDSHAEMORRHOIDS
Dr. VIJAYA LAKSHMI LDr. VIJAYA LAKSHMI L
APOLLO BGS HOSPITALSAPOLLO BGS HOSPITALS
AnatomyAnatomy
- The- The anal canalanal canal starts at pelvic diaphragmstarts at pelvic diaphragm
and ends at anal verge...
AnatomyAnatomy
- The- The anal vergeanal verge is the junction betweenis the junction between
anoderm and perianal skin.an...
AnatomyAnatomy
- The- The internal sphincterinternal sphincter is a specializedis a specialized
continuation of the circul...
AnatomyAnatomy
- The- The external sphincterexternal sphincter is a voluntary,is a voluntary,
striated muscle divided into...
AnatomyAnatomy
- Lined in its upper two-thirds by insensibleLined in its upper two-thirds by insensible
mucosa, below by a...
AnatomyAnatomy
- ArterialArterial supply is superior, middle andsupply is superior, middle and
inferior rectal arteries (I...
AnatomyAnatomy
- Three submucosal internal hemorrhoidal- Three submucosal internal hemorrhoidal
plexusesplexuses aboveabov...
PathologyPathology
- The anal cushions are disrupted to produce piles- The anal cushions are disrupted to produce piles
by...
HaemorrhoidsHaemorrhoids
- The names 'haemorrhoids' and 'piles' are- The names 'haemorrhoids' and 'piles' are
essentially ...
Parts of HaemorrhoidParts of Haemorrhoid
Divided into 3 partsDivided into 3 parts
►Pedicle- situated at anorectal ring. Se...
ClassificationClassification
►ExternalExternal
Distal to dentate line. Covered with anodermDistal to dentate line. Covered...
EtiologyEtiology
- Hereditary- Cong. weakness of vein wall- Hereditary- Cong. weakness of vein wall
- Theory : Downward sl...
GradingGrading
First DegreeFirst Degree
- Painless bleeding, no ProlapsePainless bleeding, no Prolapse
Second DegreeSecond...
SymptomsSymptoms
1. Bleeding1. Bleeding
- Single layer of capillary epithelial cells- Single layer of capillary epithelial...
SymptomsSymptoms
2. Prolapse2. Prolapse
3. Itching3. Itching
4. Anorectal dysfunction4. Anorectal dysfunction
5. Soiling5....
SignsSigns
1. Inflammed, Edematous mucosa1. Inflammed, Edematous mucosa
2. Engorgement of the subanodermal veins2. Engorge...
SignsSigns
3. Thrombosis and clotting in the vein.3. Thrombosis and clotting in the vein.
Early venous clotting in an anal...
Differential DiagnosisDifferential Diagnosis
1.1. Anal tagsAnal tags
2.2. Fibroepithelial PolypFibroepithelial Polyp
3.3. ...
Differential DiagnosisDifferential Diagnosis
5. Fissure5. Fissure
6. Perianal hematoma/ Thrombosed external6. Perianal hem...
TreatmentTreatment
- Treatment options for internal hemorrhoids
determined by grade; however, composition
of external tags...
TreatmentTreatment
A.A. ConservativeConservative
- Avoidance of prolonged straining at stool- Avoidance of prolonged strai...
TreatmentTreatment
C.C. InterventionalInterventional
- Aim- Aim
- Techniques- Techniques
1. Rubber band ligation1. Rubber ...
TreatmentTreatment
Rubber band ligationRubber band ligation
- Devices – Single operator and assistant-- Devices – Single o...
Rubber band ligationRubber band ligation
TreatmentTreatment
2. Infrared photocoagulation and bipolar2. Infrared photocoagulation and bipolar
diathermydiathermy
3. ...
SclerotherapySclerotherapy
► Sclerotherapy is commonly used to treat bleedingSclerotherapy is commonly used to treat bleed...
Advantages of sclerotherapyAdvantages of sclerotherapy
11 Easy and inexpensive to administerEasy and inexpensive to admini...
Disadvantages of SclerotherapyDisadvantages of Sclerotherapy
►Unsuccessful for larger haemorrhoidsUnsuccessful for larger ...
Contraindications of sclerotherapyContraindications of sclerotherapy
1.1. Acute prolapse-thrombosis-Acute prolapse-thrombo...
Sclerotherapy - ProcedureSclerotherapy - Procedure
Preparation – defecation, Lubrication, LA gelPreparation – defecation, ...
Complications - RareComplications - Rare
1.1. BleedingBleeding - accidental puncturing an artery- accidental puncturing an...
Complications & Follow upComplications & Follow up
3.3. Injection into veinInjection into vein - too easily injectable- to...
CryotherapyCryotherapy
Mechanism – tissue after being frozen,Mechanism – tissue after being frozen,
undergoes gradual necr...
CryotherapyCryotherapy
ComplicationsComplications
► PainPain
► Anal discharge – Brown offensive fluidAnal discharge – Brow...
Candidates for SurgeryCandidates for Surgery
- Revised American Society of Colon and
Rectal Surgeons Management of
hemorrh...
Milligan Morgan techniqueMilligan Morgan technique
- Prone Jack-Knife position, butt taped apart.- Prone Jack-Knife positi...
Open HemorrhoidectomyOpen Hemorrhoidectomy
Closed HemorrhoidectomyClosed Hemorrhoidectomy
- Hill-Ferguson retractor in place, grab- Hill-Ferguson retractor in place,...
Closed HemorrhoidectomyClosed Hemorrhoidectomy
TreatmentTreatment
►In closed procedure the patients tend to
experience less pain compared with an
open procedure.
►Howeve...
TreatmentTreatment
Modifications of haemorrhoidectomy :Modifications of haemorrhoidectomy :
- Diathermy dissectionDiatherm...
PPHPPH
Procedure for prolapse and haemorrhoidsProcedure for prolapse and haemorrhoids
- Synonyms- Synonyms
1. mechanical h...
PPH
Indications
- Select grade II hemorrhoids
- Grade III hemorrhoids
- Uncomplicated grade IV hemorrhoids
- Patients for ...
PPHPPH
Contraindications
- Purely external hemorrhoids
- Fixed prolapse or fibrotic external
hemorrhoids
- Abscess, gangre...
PPHPPH
- A specially designed circular stapler is
inserted through a circular anal dilator
- A portion of the prolapsed re...
Management of Infarcted pileManagement of Infarcted pile
- Turbulent flow in sacculated venous plexusTurbulent flow in sac...
ComplicationsComplications
A. Short livedA. Short lived
1.Vasovagal - banding of piles, injection1.Vasovagal - banding of ...
ComplicationsComplications
B. PermanentB. Permanent
1.Impairment of continence – To prevent1.Impairment of continence – To...
HaemorrhoidsHaemorrhoids
THANK YOUTHANK YOU
Haemorrhoids- Dr. Vijayalakshmi
Haemorrhoids- Dr. Vijayalakshmi
Haemorrhoids- Dr. Vijayalakshmi
Haemorrhoids- Dr. Vijayalakshmi
Haemorrhoids- Dr. Vijayalakshmi
Haemorrhoids- Dr. Vijayalakshmi
Haemorrhoids- Dr. Vijayalakshmi
Haemorrhoids- Dr. Vijayalakshmi
Haemorrhoids- Dr. Vijayalakshmi
Haemorrhoids- Dr. Vijayalakshmi
Haemorrhoids- Dr. Vijayalakshmi
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Haemorrhoids- Dr. Vijayalakshmi

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    , your presentation on hemorroids is very good , i will be very thankfull to you if you give your precious knowledge(in the form of this presentation , plz sir i beg your knowledge
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Haemorrhoids- Dr. Vijayalakshmi

  1. 1. HAEMORRHOIDSHAEMORRHOIDS Dr. VIJAYA LAKSHMI LDr. VIJAYA LAKSHMI L APOLLO BGS HOSPITALSAPOLLO BGS HOSPITALS
  2. 2. AnatomyAnatomy - The- The anal canalanal canal starts at pelvic diaphragmstarts at pelvic diaphragm and ends at anal verge. Approximately 4cmand ends at anal verge. Approximately 4cm long.long. - AAnatomic anal canalnatomic anal canal extends from analextends from anal verge to dentate line.verge to dentate line. - Surgical anal canalSurgical anal canal is anal verge tois anal verge to anorectal ring, the circular upper border ofanorectal ring, the circular upper border of puborectalis that is palpable by rectal exam.puborectalis that is palpable by rectal exam. It is 1-1.5 cm from dentate line.It is 1-1.5 cm from dentate line.
  3. 3. AnatomyAnatomy - The- The anal vergeanal verge is the junction betweenis the junction between anoderm and perianal skin.anoderm and perianal skin. - The- The dentate linedentate line is a true mucocutaneousis a true mucocutaneous junction located 1-1.5 cm from anal verge. Ajunction located 1-1.5 cm from anal verge. A 6-12mm transitional zone exists above the6-12mm transitional zone exists above the line where squamous becomes cuboidal,line where squamous becomes cuboidal, then columnar.then columnar. - Anal sphincter mechanism- Anal sphincter mechanism made bymade by internal and external sphincters.internal and external sphincters.
  4. 4. AnatomyAnatomy - The- The internal sphincterinternal sphincter is a specializedis a specialized continuation of the circular smooth musclecontinuation of the circular smooth muscle layer of the rectum. It is involuntary, andlayer of the rectum. It is involuntary, and contracted at rest. Maintains resting analcontracted at rest. Maintains resting anal tone. Innervated by ANStone. Innervated by ANS - The- The intersphincteric planeintersphincteric plane is a fibrousis a fibrous continuation of the longitudinal smoothcontinuation of the longitudinal smooth muscle layer of the rectummuscle layer of the rectum
  5. 5. AnatomyAnatomy - The- The external sphincterexternal sphincter is a voluntary,is a voluntary, striated muscle divided into three u-shapedstriated muscle divided into three u-shaped loops (subcutaneous, superficial, and deep).loops (subcutaneous, superficial, and deep). Acts as a single functional unit.Acts as a single functional unit. - Continuation of the levator ani muscle,Continuation of the levator ani muscle, specifically of thespecifically of the puborectalis musclepuborectalis muscle.. - Innervated by somatic nerve fibersInnervated by somatic nerve fibers - Generates anal squeeze. Key role inGenerates anal squeeze. Key role in maintaining anal continence.maintaining anal continence.
  6. 6. AnatomyAnatomy - Lined in its upper two-thirds by insensibleLined in its upper two-thirds by insensible mucosa, below by a hairless, glandless cuffmucosa, below by a hairless, glandless cuff of highly sensitive squamous epithelium, theof highly sensitive squamous epithelium, the anoderm.anoderm. - The mucosa is seen to be thrown into 8-14The mucosa is seen to be thrown into 8-14 longitudinal folds of Morgagni just abovelongitudinal folds of Morgagni just above dentate line and forming thedentate line and forming the anal cryptsanal crypts atat their distal end.their distal end.
  7. 7. AnatomyAnatomy - ArterialArterial supply is superior, middle andsupply is superior, middle and inferior rectal arteries (IMA, Int. Iliac, int.inferior rectal arteries (IMA, Int. Iliac, int. pudendal artery).pudendal artery). - Venous Drainage- Venous Drainage empties into portal andempties into portal and caval systems. Upper and middle rectumcaval systems. Upper and middle rectum into SRVinto SRVIMVIMV Portal vein. The lowerPortal vein. The lower rectum and upper anal canalrectum and upper anal canal MRVMRVIIVIIVIVC. The Lower anal canalIVC. The Lower anal canal drains into the IRVdrains into the IRV IVC.IVC.
  8. 8. AnatomyAnatomy - Three submucosal internal hemorrhoidal- Three submucosal internal hemorrhoidal plexusesplexuses aboveabove dentate line Lt lateral, Rtdentate line Lt lateral, Rt anterior, Rt posterior quadrants-11,3,7anterior, Rt posterior quadrants-11,3,7 o'clock, drain into the superior rectal vein.o'clock, drain into the superior rectal vein. - Below dentate line, external- Below dentate line, external hemorrhoidhemorrhoid veins drain into pudendal veins.veins drain into pudendal veins. normal Normal Disrupted anal cushion
  9. 9. PathologyPathology - The anal cushions are disrupted to produce piles- The anal cushions are disrupted to produce piles by the forces of defaecation.by the forces of defaecation. - The Valsava effect of excessive straining- The Valsava effect of excessive straining - The anal cushions may be structurally deficient.- The anal cushions may be structurally deficient. - Weakness arising from the influence ofWeakness arising from the influence of progesterone on smooth muscle and elastic tissueprogesterone on smooth muscle and elastic tissue may explain the predisposition to haemorrhoids inmay explain the predisposition to haemorrhoids in pregnancy.pregnancy. - Increase in pelvic vascularity may also contribute.Increase in pelvic vascularity may also contribute.
  10. 10. HaemorrhoidsHaemorrhoids - The names 'haemorrhoids' and 'piles' are- The names 'haemorrhoids' and 'piles' are essentially synonymous though differentlyessentially synonymous though differently derived from the two main—and only certainderived from the two main—and only certain —symptoms, respectively bleeding and—symptoms, respectively bleeding and protrusion.protrusion. - The term ‘Haemorrhoids‘ restricted to- The term ‘Haemorrhoids‘ restricted to abnormal clinical situationabnormal clinical situation
  11. 11. Parts of HaemorrhoidParts of Haemorrhoid Divided into 3 partsDivided into 3 parts ►Pedicle- situated at anorectal ring. SeenPedicle- situated at anorectal ring. Seen through proctoscope. Pink mucosa.through proctoscope. Pink mucosa. ►Internal haemorrhoid- commences belowInternal haemorrhoid- commences below anal ring. Bright red or purple.anal ring. Bright red or purple. ►External associated haemorrhoid- lies b/wExternal associated haemorrhoid- lies b/w dentate line and anal margin. Blue vein candentate line and anal margin. Blue vein can be seen unless fibrosed.be seen unless fibrosed. It is present only in well established cases.It is present only in well established cases.
  12. 12. ClassificationClassification ►ExternalExternal Distal to dentate line. Covered with anodermDistal to dentate line. Covered with anoderm Cause swelling discomfort & difficult hygieneCause swelling discomfort & difficult hygiene Severe pain if thrombosedSevere pain if thrombosed ►InternalInternal Are painlessAre painless Bright red bleedingBright red bleeding Prolapse associated with defecationProlapse associated with defecation
  13. 13. EtiologyEtiology - Hereditary- Cong. weakness of vein wall- Hereditary- Cong. weakness of vein wall - Theory : Downward sliding of anal cushionTheory : Downward sliding of anal cushion associated with gravity, straining andassociated with gravity, straining and irregular bowel habits.irregular bowel habits. - Anatomy- Collecting radicles of SHV lieAnatomy- Collecting radicles of SHV lie unsupported in loose connective tissue ofunsupported in loose connective tissue of anoderm.anoderm. - Rarely Varicosity of the analRarely Varicosity of the anal Vein.Vein. Anal varices in portal hypertension.
  14. 14. GradingGrading First DegreeFirst Degree - Painless bleeding, no ProlapsePainless bleeding, no Prolapse Second DegreeSecond Degree - Bleeding, Seepage, Prolapse withBleeding, Seepage, Prolapse with spontaneous reductionspontaneous reduction Third DegreeThird Degree - Bleeding, Seepage, Prolapse requringBleeding, Seepage, Prolapse requring digital reductiondigital reduction Fourth DegreeFourth Degree - Prolapsed - Irreducible, Strangulated.Prolapsed - Irreducible, Strangulated.
  15. 15. SymptomsSymptoms 1. Bleeding1. Bleeding - Single layer of capillary epithelial cells- Single layer of capillary epithelial cells Lamina propria - TraumaLamina propria - Trauma - Lax-textured upper part of the anal cushion.- Lax-textured upper part of the anal cushion. - Repeated trauma- Repeated trauma - Bright red, Drips- Bright red, Drips Inflamed permanently prolapsed pile
  16. 16. SymptomsSymptoms 2. Prolapse2. Prolapse 3. Itching3. Itching 4. Anorectal dysfunction4. Anorectal dysfunction 5. Soiling5. Soiling 6. Discomfort and Pain6. Discomfort and Pain Prolapsed piles
  17. 17. SignsSigns 1. Inflammed, Edematous mucosa1. Inflammed, Edematous mucosa 2. Engorgement of the subanodermal veins2. Engorgement of the subanodermal veins oedema contributes to bulk of 'prolapse' Engorgement of the subanodermal veins masquerades as prolapse in some patients
  18. 18. SignsSigns 3. Thrombosis and clotting in the vein.3. Thrombosis and clotting in the vein. Early venous clotting in an anal cushion Infarction of the pile.
  19. 19. Differential DiagnosisDifferential Diagnosis 1.1. Anal tagsAnal tags 2.2. Fibroepithelial PolypFibroepithelial Polyp 3.3. Sentinel PileSentinel Pile 4.4. DermatitisDermatitis Skin tags A fibrous anal polyp surmounting a pile Sentinel pile at lower end of posterior fissure with perianal dermatitis with punctate excoriations.
  20. 20. Differential DiagnosisDifferential Diagnosis 5. Fissure5. Fissure 6. Perianal hematoma/ Thrombosed external6. Perianal hematoma/ Thrombosed external pilepile 7. Rectal prolapse7. Rectal prolapse 8. Rectal tumour8. Rectal tumour Perianal haematoma - single venous saccule greatly distended with clot.
  21. 21. TreatmentTreatment - Treatment options for internal hemorrhoids determined by grade; however, composition of external tags considered. - Lower grades can be treated with nonsurgical methods such as sitzbaths, stool softeners, and fiber supplements - Higher grades with either office-based procedures (infrared coagulation therapy, banding,sclerotherapy) or surgery.
  22. 22. TreatmentTreatment A.A. ConservativeConservative - Avoidance of prolonged straining at stool- Avoidance of prolonged straining at stool - Increase in dietary fiber- Increase in dietary fiber B.B. MedicalMedical - Stool softeners- Stool softeners - Fiber supplements- Fiber supplements - Topical anesthetic gel application -- Topical anesthetic gel application - Lidocaine jelly, NTG creamLidocaine jelly, NTG cream
  23. 23. TreatmentTreatment C.C. InterventionalInterventional - Aim- Aim - Techniques- Techniques 1. Rubber band ligation1. Rubber band ligation Banding exposed mucosal part of permanently prolapsed pile a. A second banding attempt will occasionally improve on the achievement of the first. b. If the first 'polyp' is insufficient but has been banded too low near the dentate line for enlargement, an adjoining cephalad band can be placed
  24. 24. TreatmentTreatment Rubber band ligationRubber band ligation - Devices – Single operator and assistant-- Devices – Single operator and assistant- requiredrequired Thomson One-man bander used within the Naunton-Morgan anoscope Irvin Moore's nasal conchal forceps for grasping the pile for banding, shown with banding instrument
  25. 25. Rubber band ligationRubber band ligation
  26. 26. TreatmentTreatment 2. Infrared photocoagulation and bipolar2. Infrared photocoagulation and bipolar diathermydiathermy 3. Sclerotherapy3. Sclerotherapy 4. Cryotherapy4. Cryotherapy 5. Laser treatment5. Laser treatment 6. Haemorrhoidectomy6. Haemorrhoidectomy Milligan Morgan technique – Gold standardMilligan Morgan technique – Gold standard
  27. 27. SclerotherapySclerotherapy ► Sclerotherapy is commonly used to treat bleedingSclerotherapy is commonly used to treat bleeding internal hemorrhoid. In this procedure, ainternal hemorrhoid. In this procedure, a sclerosant is injected into the base of thesclerosant is injected into the base of the hemorrhoids.hemorrhoids. ► There are many types of sclerosants- chemicalThere are many types of sclerosants- chemical ► Mechanism - low-grade, long-standingMechanism - low-grade, long-standing inflammation which scars the vein, mucosal tissue,inflammation which scars the vein, mucosal tissue, collapse the vein walls, and cause to shrivel.collapse the vein walls, and cause to shrivel.
  28. 28. Advantages of sclerotherapyAdvantages of sclerotherapy 11 Easy and inexpensive to administerEasy and inexpensive to administer Technique is simple to perform as an out-patientTechnique is simple to perform as an out-patient procedure. No lengthy hospital stayprocedure. No lengthy hospital stay 22 It works fast and last longIt works fast and last long After 7 to 10 days, the shriveled hemorrhoid fall offAfter 7 to 10 days, the shriveled hemorrhoid fall off during normal bowel movement. Patient symptomsduring normal bowel movement. Patient symptoms free at least 12 months.free at least 12 months. 33 Can be performed in elderly patientsCan be performed in elderly patients The method of choice for treating in elderlyThe method of choice for treating in elderly patients, who have fragile veins.patients, who have fragile veins. 44 Multiple hemorrhoids can be treated atMultiple hemorrhoids can be treated at onceonce Up to 3 hemorrhoids can be injected.Up to 3 hemorrhoids can be injected.
  29. 29. Disadvantages of SclerotherapyDisadvantages of Sclerotherapy ►Unsuccessful for larger haemorrhoidsUnsuccessful for larger haemorrhoids ►Haemorrhoids return after treatment –Haemorrhoids return after treatment – although not within 12 months of treatmentalthough not within 12 months of treatment Indications for sclerotherapyIndications for sclerotherapy -First-degree,even those which bleed-First-degree,even those which bleed profuselyprofusely -Second-degree hemorrhoid, in which the-Second-degree hemorrhoid, in which the prolapse is slight or barely noticeable, alsoprolapse is slight or barely noticeable, also responds well to this procedureresponds well to this procedure
  30. 30. Contraindications of sclerotherapyContraindications of sclerotherapy 1.1. Acute prolapse-thrombosis-Acute prolapse-thrombosis- Third-degreeThird-degree hemorrhoids not be treated because the risk ofhemorrhoids not be treated because the risk of acute prolapse-thrombosisacute prolapse-thrombosis Large second-degree also not treated - success isLarge second-degree also not treated - success is not good.not good. 2. Severe bleeding or ulceration-2. Severe bleeding or ulceration- accompanying other ano-rectal conditions-accompanying other ano-rectal conditions- IBD,causes severe bleeding or ulcers in theIBD,causes severe bleeding or ulcers in the colon’s mucosal tissue.colon’s mucosal tissue. 3. Fissures and Fistula3. Fissures and Fistula
  31. 31. Sclerotherapy - ProcedureSclerotherapy - Procedure Preparation – defecation, Lubrication, LA gelPreparation – defecation, Lubrication, LA gel Position - left lateral position,buttocks at tablePosition - left lateral position,buttocks at table edgeedge Injection – base of hemorrhoid, above dentateInjection – base of hemorrhoid, above dentate line. Needle 1-2 cm deep,parallel to analline. Needle 1-2 cm deep,parallel to anal canal.3-5 ml of sclerosant is injectedcanal.3-5 ml of sclerosant is injected slowly. After procedure needle held inslowly. After procedure needle held in place for about two minutes, then slowlyplace for about two minutes, then slowly withdrawn.withdrawn. Max. 3 separate injections Given at theMax. 3 separate injections Given at the basesbases
  32. 32. Complications - RareComplications - Rare 1.1. BleedingBleeding - accidental puncturing an artery- accidental puncturing an artery Delayed bleeding- too much solution or atDelayed bleeding- too much solution or at wrong site-causes an ulcer to developwrong site-causes an ulcer to develop Bleeding after 7-14 days - hospitalization.Bleeding after 7-14 days - hospitalization. 2.2. PainPain - improper selection of injection site- improper selection of injection site Done above dentate line.Pain stop procedureDone above dentate line.Pain stop procedure Short-lived.Short-lived. ManagedManaged by topical pain killersby topical pain killers
  33. 33. Complications & Follow upComplications & Follow up 3.3. Injection into veinInjection into vein - too easily injectable- too easily injectable or pain in the liver area or unpleasant tasteor pain in the liver area or unpleasant taste 4.4. Injection into prostate -Injection into prostate - Urinary retention – Most commonUrinary retention – Most common Infertlity – sol. -> seminal vessel-> testicleInfertlity – sol. -> seminal vessel-> testicle Prostitis – no treatment, antibioticsProstitis – no treatment, antibiotics Abscess – surgery. Painful blood clotAbscess – surgery. Painful blood clot formation – anal dilation/surgeryformation – anal dilation/surgery Analgesics – Stool softeners - Follow upAnalgesics – Stool softeners - Follow up
  34. 34. CryotherapyCryotherapy Mechanism – tissue after being frozen,Mechanism – tissue after being frozen, undergoes gradual necrosis, due partly toundergoes gradual necrosis, due partly to thrombosis of microcirculation. Cryoprobethrombosis of microcirculation. Cryoprobe Agents – Liquid nitrogen, Nitrous oxide gasAgents – Liquid nitrogen, Nitrous oxide gas Procedure - Increasing margin of tissueProcedure - Increasing margin of tissue around probe turns white, max. width ofaround probe turns white, max. width of about 6-7 mm.Necrosis of the freezedabout 6-7 mm.Necrosis of the freezed hemorrhoid occurs over several days-ahemorrhoid occurs over several days-a week. Slough separates in 2-3 weeks.week. Slough separates in 2-3 weeks. complete healing often requiring additional 2complete healing often requiring additional 2 weeks or more. Patient-analgesics andweeks or more. Patient-analgesics and laxatives several weeks after treatmentlaxatives several weeks after treatment
  35. 35. CryotherapyCryotherapy ComplicationsComplications ► PainPain ► Anal discharge – Brown offensive fluidAnal discharge – Brown offensive fluid ►Recurrent haemorrhoidsRecurrent haemorrhoids ►Skin tagsSkin tags ►Because of the pain and the anal dischargeBecause of the pain and the anal discharge most patients are unable to return to workmost patients are unable to return to work for a as a weekfor a as a week
  36. 36. Candidates for SurgeryCandidates for Surgery - Revised American Society of Colon and Rectal Surgeons Management of hemorrhoids by surgical treatment 1. Patients who do not respond to office- based procedures 2. Patients not capable of tolerating office procedures 3. Patients with large external hemorrhoidal disease 4. Patients with grade III or IV mixed hemorrhoidal disease.
  37. 37. Milligan Morgan techniqueMilligan Morgan technique - Prone Jack-Knife position, butt taped apart.- Prone Jack-Knife position, butt taped apart. - Bridges must be left between excisions- Bridges must be left between excisions - Clover leaf shaped defect in anal canal &- Clover leaf shaped defect in anal canal & perianal skin. Wounds are left open.perianal skin. Wounds are left open. - Healing with scar contracture draws tissue- Healing with scar contracture draws tissue back into anal canal and reattaches it toback into anal canal and reattaches it to muscle coatmuscle coat
  38. 38. Open HemorrhoidectomyOpen Hemorrhoidectomy
  39. 39. Closed HemorrhoidectomyClosed Hemorrhoidectomy - Hill-Ferguson retractor in place, grab- Hill-Ferguson retractor in place, grab cushion, place suture at apex 4cm abovecushion, place suture at apex 4cm above dentate line, elliptical excision down todentate line, elliptical excision down to sphincter. Close from ligated pedicle out tosphincter. Close from ligated pedicle out to skin.skin. - Complications: urinary retention, bleeding,- Complications: urinary retention, bleeding, stenosis, incontinence, infection.stenosis, incontinence, infection.
  40. 40. Closed HemorrhoidectomyClosed Hemorrhoidectomy
  41. 41. TreatmentTreatment ►In closed procedure the patients tend to experience less pain compared with an open procedure. ►However, occasionally a closed incision may open up after surgery - If the external skin is tight following a closed procedure
  42. 42. TreatmentTreatment Modifications of haemorrhoidectomy :Modifications of haemorrhoidectomy : - Diathermy dissectionDiathermy dissection - Park’s submucosal excisionPark’s submucosal excision - Radial clamps or staples or PPH - Less pain.- Radial clamps or staples or PPH - Less pain. Learning curve. Rectal wall injury,Learning curve. Rectal wall injury, rectovaginal fistula. Only a portion of therectovaginal fistula. Only a portion of the prolapsed rectal mucosa and internalprolapsed rectal mucosa and internal haemorrhoid is removed and fixed at thehaemorrhoid is removed and fixed at the anorectal ringanorectal ring
  43. 43. PPHPPH Procedure for prolapse and haemorrhoidsProcedure for prolapse and haemorrhoids - Synonyms- Synonyms 1. mechanical hemorrhoidectomy with a circular stapler 2. Stapled hemorrhoidectomy 3. Circular stapler hemorrhoidopexy 4. Stapled circumferential mucosectomy, 5. Stapled anopexy 6. Stapled hemorrhoidopexy.
  44. 44. PPH Indications - Select grade II hemorrhoids - Grade III hemorrhoids - Uncomplicated grade IV hemorrhoids - Patients for whom other treatment modalities are not successful
  45. 45. PPHPPH Contraindications - Purely external hemorrhoids - Fixed prolapse or fibrotic external hemorrhoids - Abscess, gangrene, - Anal stenosis, - Full-thickness rectal prolapse.
  46. 46. PPHPPH - A specially designed circular stapler is inserted through a circular anal dilator - A portion of the prolapsed rectal mucosa and internal hemorrhoids removed - The remaining hemorrhoidal tissue drawn back into correct anatomic position - Hemorrhoidal swelling is reduced following PPH because hemorrhoidal artery blood flow is disrupted
  47. 47. Management of Infarcted pileManagement of Infarcted pile - Turbulent flow in sacculated venous plexusTurbulent flow in sacculated venous plexus - Thrombosis and clotting occurs.Thrombosis and clotting occurs. - Considerable swelling and discomfortConsiderable swelling and discomfort - Invites attempts at immediate ameliorationInvites attempts at immediate amelioration - Conservative and surgical treatment.Conservative and surgical treatment. - Natural thrombolysis restores circulationNatural thrombolysis restores circulation - Resolution in about 10 days.Resolution in about 10 days. - Nitroglycerin ointmentNitroglycerin ointment - Severe – debridement haemorrhoidectomySevere – debridement haemorrhoidectomy
  48. 48. ComplicationsComplications A. Short livedA. Short lived 1.Vasovagal - banding of piles, injection1.Vasovagal - banding of piles, injection 2.Pain post operatively2.Pain post operatively 3.Haemorrhage – Secondary haemorrhage3.Haemorrhage – Secondary haemorrhage 4.Infection – Rare4.Infection – Rare 5.Urinary – haemorrhoidectomy, Banding5.Urinary – haemorrhoidectomy, Banding 6.Anal cushion thrombosis - Banding6.Anal cushion thrombosis - Banding
  49. 49. ComplicationsComplications B. PermanentB. Permanent 1.Impairment of continence – To prevent1.Impairment of continence – To prevent important criteria is intact 'corpusimportant criteria is intact 'corpus cavernosum recti' .cavernosum recti' . 2.Edema and tags2.Edema and tags 3.Stricture and Stenosis – Due to excessive3.Stricture and Stenosis – Due to excessive excisionexcision 4.Anal Fissure4.Anal Fissure
  50. 50. HaemorrhoidsHaemorrhoids THANK YOUTHANK YOU

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