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Hemorrhoids - Lower GI Hemorrhage


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HEMORRHOIDS- Lower GI Hemorrhage

Dear Viewers,
Greetings from “Surgical Educator”

In this episode, I am talking about one of the common problems in Genaral Surgery- Hemorrhoids. I have talked on the Etiopathogenesis, Classification, Clinical Features, Investigations, Complications and Treatment. I have also included a Mindmap, a diagnostic algorithm and a treatment algorithm. I hope you will find it very useful and interesting. You can watch this video in the following links:

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Hemorrhoids - Lower GI Hemorrhage

  2. 2. HEMORRHOIDS ✓Causes of Lower GI Hemorrhage ✓Etiopathogenesis ✓Classification of Hemorrhoids ✓Clinical features ✓Investigations ✓Complications ✓Treatment ✓Mindmap ✓Diagnostic algorithm ✓Management Algorithm
  3. 3. Causes for Lower GI Hemorrhage ✓Diverticular disease ✓Angiodysplasia- AV Malformation ✓Colorectal carcinoma ✓Hemorrhoids ✓Fissure-in-ano ✓Ischemic colitis ✓Inflammatory bowel disease ✓Meckel’s diverticulum ✓Upper GI hemorrhage
  4. 4. CLASSICAL CLINICAL VIGNETTE ✓A 72 year old man with H/O chronic constipation presented with BRBPR after straining to pass stools each time, for past 3 months. Bleeding was painless- Painless hematochezia. Colonoscopy six months ago was normal. ✓O/E: BP: 150/70 mms of Hg; HR- 90/min; ✓PT, PTT & INR- Normal; Platelet count- 250,000, INR- 1.1 ✓Proctoscopy- revealed primary hemorrhoids at 3,7 & 11* clock positions ✓Diagnosis: Internal Hemorrhoids ✓Altered scenario: Apart from BRBPR during straining to pass stools, patient presented with anal itching and discomfort, particularly towards the end of the day and has perianal pain when sitting down and finds himself sitting sideways to avoid the discomfort. He is afebrile. ✓Diagnosis: External Hemorrhoids
  5. 5. ETIOPATHOGENESIS ✓ Hemorrhoids are cushions of submucosal tissue containing venules, arterioles, smooth muscle fibers, and elastic connective tissues. ✓Three hemorrhoidal cushions are there at 3, 7, 11 O’clock positions ✓ During defecation, they become engorged with blood, cushion the anal canal, and support the lining of canal. ✓Hemorrhoid is a condition, where there is varicosity in the veins of anorectal region which subsequently leads to hemorrhage.
  6. 6. ETIOPATHOGENESIS ✓ Idiopathic or primary—The predisposing factors are pregnancy, prolonged standing Etc ✓Secondary Causes: ✓Carcinoma of rectum—By blocking the veins, produces back pressure and manifest as piles. ✓Prolonged constipation ✓Persistent straining at micturition, e.g. enlarged prostate
  7. 7. Classification Of Hemorrhoids ✓ Internal hemorrhoids—Situated above the pectinate line. ✓ External hemorrhoids—Situated below the pectinate line. ✓ Internoexternal hemorrhoids— Situated both above and below the pectinate line.
  8. 8. Clinical Features ✓Bleeding per rectum: Bleeding is painless and bright red which usually appears as a fresh smear on the toilet paper. ✓Pain: Pain is not characteristic of hemorrhoid, unless it is associated with fissure in ano or thrombosis. Strangulated piles are extremely painful. ✓Mucus discharge: In 3rd and 4th degree internal haemorrhoids and in all external hemorrhoids ✓Pruritus ani: This results from excessive mucus discharge, secreted from the congested mucosa. ✓Tenesmus: Sensation of incomplete evacuation of bowel
  9. 9. Clinical Features
  10. 10. INVESTIGATIONS ✓Digital Rectal Examination(DRE): A digital examination should always be done. A pile mass cannot be palpated, because it collapses to digital pressure. It can be palpated only when it is thrombosed. ✓Proctoscopy(Anoscopy): As the proctoscope is removed, the piles prolapses into the lumen of proctoscope as cherry red masses. ✓Sigmoidoscopy/Colonoscopy: Do Sigmoidoscopy and Colonoscopy to R/O any colonic pathology
  11. 11. COMPLICATIONS ✓Anemia: Following severe or continued bleeding. ✓Strangulation: This occurs when the prolapsed hemorrhoids are gripped by the internal sphincter and get irreducible. ✓Thrombosis: In strangulated piles, venous return is occluded and thrombosis occurs. The thrombosis is accompanied by considerable pain. ✓Suppuration or ulceration: may occur in a thrombosed hemorrhoids. ✓Fibrosis: After 2 to 3 weeks, thrombosed hemorrhoids become fibrosed, often with spontaneous cure.
  12. 12. TREATMENT ✓Nonoperative ✓a. Sitz bath—The patient is asked to sit inwarm water with the anal region and buttocks dipped in water for about 20 minutes,2 to 3 times a day. This reduces pain edema and promotes healing. ✓b. Antibiotics, laxatives (stool softener) and antiinflammatory drugs are beneficial. ✓c. Regulation of bowel habit with a high fiber diet. ✓d. Local application of astringent ointments. ✓e. Injection of Sclerosant—The agent commonly used is 5 percent phenol in almond oil. This is done in case of first and second degree hemorrhoids.
  13. 13. TREATMENT ✓Operative Treatment: ✓First and second degree hemorrhoids are treated by Lord’s procedure, Barron’s band application and cryosurgery. ✓Third and fourth degree haemorrhoids require hemorrhoidectomy ✓1. Lord’s procedure: Under general anesthesiathe internal sphincter is widely stretched. It results is dilatation and disruption of the fibers of internal sphincter. Thus venous congestion is relieved to improve the hemorrhoids. ✓2. Barron’s Band Ligation: Bands are applied at the neck of hemorrhoids which undergo healing by fibrosis.
  14. 14. TREATMENT
  15. 15. TREATMENT ✓Operative Treatment: ✓3. Cryosurgery: Liquid nitrogen at –196°C is applied to pile masses which coagulate the tissues. The procedure is painless but there will be continuous mucus discharge for 3 to 4 weeks. ✓4. Infrared photocoagulation coagulates tissue protein or evaporates water in the cells. This technique can be used for first-degree and second-degree haemorrhoids. ✓5. Hemorrhoidectomy—This is the ligation and excision of the hemorrhoidal mass under spinal or general anesthesia. -Milligan & Morgan’s Open Hemorrhoidectomy -Farquharsan’s Closed Hemorrhoidectomy
  16. 16. TREATMENT
  17. 17. TREATMENT Farquharsen’s Milligan & Morgan’s CLOSED OPEN
  18. 18. TREATMENT ✓ 6. Stapled Hemorrhoidectomy /Procedure for Prolapsed Hemorrhoid- PPH: 7. UGHAL- ultrasound Guided Hemorrhoidal Artery Ligation:
  19. 19. MINDMAP
  20. 20. Diagnostic Algorithm
  21. 21. Treatment Algorithm