2. HEMORRHOIDS AND ETIOLOGY
• HEMORRHOIDS ARE DILATED SUBMUCOSAL VASCULAR CUSHIONS
WITHIN THE ANAL CANAL. IT IS DOWNWARD SLIDING OF ANAL
CUSHIONS THAT LEADS TO HEMORRHOIDS.
• ETIOLOGY:
• excessive straining (e.g., from chronic constipation, frequent
bowel movements, chronic cough, heavy lifting, diarrhea,
constipation, hard stool, low fiber diet, carcinoma rectum)
• extended periods of sitting (e.g., due to occupation or sedentary
lifestyle)
• pregnancy- enlarged uterus compresses the pelvic vein
• older age
3. ANATOMY OF ANAL CANAL
ANAL CUSHIONS
- Consists of arteriovenous blood vessels, smooth muscle, and fibroelastic tissue (e.g.,
collagen, elastic fibers)
- Located at 11, 7 and 3 o'clock in the lithotomy position (right anterior, right posterior,
and left lateral position)
- maintain continence by enabling tight closure of the rectum.
8. DEGREES OF INTERNAL HEMORRHOIDS
Multiple bleeding, prolapsed
hemorrhoids that were
manually irreducible on
examination are visible,
indicating grade IV
hemorrhoids.
Hemorrhoids are visible
at the posterior and
right and left lateral
positions. There are
multiple anal skin tags,
indicating previous
episodes of inflamed or
thrombosed
hemorrhoids showing III
Hemorrhoids are visible in
the anterior, posterior, and
left lateral positions.
Showing II degree.
9. CLINICAL FEATURES
INTERNAL HEMORRHOIDS:
• Often painless, bright red bleeding at the end of
defecation
• Perianal mass in the event of prolapse
• Pruritus
• Anal discharge (containing mucus or fecal debris)
EXTERNAL HEMORRHOIDS:
• Manifestations are similar to those of internal
hemorrhoids (i.e., bright red bleeding, pruritus,
perianal mass)
• A thrombosed external hemorrhoid manifests with
10. INVESTIGATIONS
• INSPECTION - prolapsed hemorrhoids,
skin tags
• DIGITAL RECTAL EXAMINATION -
thrombosed piles are tender to palpate
• ANASCOPE/PROCTOSCOPY-
-The numbers, degrees and size.
-The surface and appearance of
hemorrhoids.
-chronicity of the prolapse.
• COLONOSCOPY – proximally for any
other cause
• LAB TEST - decrease in hematocrit,
12. CONSERVATIVE TREATMENT
INTERVENTIONS TO REDUCE ANORECTAL PRESSURE AND STRAINING
Lifestyle modifications:
• High fiber diet (20–30 g/day)
• Increased fluid intake
• Avoidance of fatty foods
• Regular physical activity
• Avoidance of excessive straining
INTERVENTIONS TO ALLEVIATE SYMPTOMS (E.G., PAIN, PRURITUS)
• Sitz baths: to reduce pain, edema
• Topical medications for short-term symptomatic relief: topical anesthetics
(e.g., lidocaine), corticosteroids (e.g., hydrocortisone), and/or
vasoconstrictors (e.g., phenylephrine)
13. PARASURGICAL TREATMENT
SCLEROTHERAPY:
Done in 1st degree and early 2nd degree hemorrhoid. Using proctoscope and Gabriel syringe,
3–5 ml of 5% phenol in almond oil is injected into the anorectal ring which helps in fibrosis and
fixation of anal cushion.
BAND LIGATION:
Its done for 2nd degree and is a most commonly used where a two hemorrhoids is banded
through an anoscope and it leads to ischemic necrosis with and the hemorrhoid falls off itself.
INFRARED COAGULATION:
Application of infrared light waves to the base of the hemorrhoid under vision to induce
necrosis and scar formation.
CRYOSURGERY:
Using nitrous oxide (–98°) or liquid nitrogen (–196°), extreme cold temperature is used to
14. SURGICAL TREATMENT
INDICATIONS: Grade III and IV internal hemorrhoids, combined both external
and internal hemorrhoids with prolapse, No recovery even after conservative
and para-surgical treatment.
STAPLED
HEMORRHOIDOPEXY:
Circular stapling
device is used for
excision of the
mucosa and sub-
mucosa 4cm above
the dentate line.
Only effective for
internal hemorrhoids
and prolapsed
hemorrhoids.
15. SURGICAL TREATMENT
HEMORRHOIDECTOMY:
surgical removal of hemorrhoids
• Ferguson approach (closed approach):
The mucosal defect is closed (healing by
primary intention) which is by suturing
after excision of the hemorrhoid.
• Milligan-Morgan approach (open
approach):
The mucosal defect is kept open (healing
by secondary intention) to heal itself after
excision of the hemorrhoid.
DOPPLER-GUIDED HEMORRHOIDAL
ARTERIAL LIGATION:
Identification and ligation of the arteries
supplying hemorrhoids and is used for all
degrees of hemorrhoids. Its just a 20
minutes procedure and is used with
doppler guided ultrasound with the help
