PRESENTED BY Dr. Mukoro George Duke B.Sc (BGS)UNIPORT MBBS UNIPORT
INTRODUCTION : DEFINITION BRIEF HISTROY PHYSIOLOGIC-ANATOMY/EMBRYOLOGY /HISTOLOGY EPIDEMIOLOGY AETIOLOGY/ RISK FACTORS PATHOLOGY CLINICAL FEATURES MANAGEMENT INVESTIGATIONS TREATMENT Non-operative Operative ,its indications and its complications. COMPLICATIONS of hemorrhoids and prolongation . NEW ISSUES CONCLUSION
CASE PRESENTATIONI present Mr. J.G.A 37 year oldMaleCivil Servant (Bailiff ) and fourth year engineering studentSinglezaramaI jaw by tribeChristian of the RCCG sect.
Pc: Anal protrusions 9yrs duration HPC :Patient presented at general surgery clinicvia OPD with anal protrusions which startedyear 2001 with constipation and passage of hardstools, and later became associated withprotrusion of anal tissue that was spontaneouslyreduceable, 5 years later ,he noticed bright redblood which comes via anus immediately afterpassage of stool. There was associated history ofpain which started a week before admission, thereis no history of passage of mucous ,his diet ,majorly consisted of beverages ,indomine ,breadat home . there is no past history of chronic cough,chronic diarrhea nor abdominal swelling.
Before presentation to the managing team ,he hadused herbal preparations on several occasions forpast 8 years, and two weeks before presentation inthe unit patient was placed on oral methronidazoleand ampicillin , with sitz bath by general surgeryterm A , but he was not relieved of symptom.
PMSH: He had no surgeries in the past.He’s not a known hypertensive , diabetic, sicklecell disease nor bronchial asthmatic patient.Drug Hx: No known drug allergy.FSH: single ,and 2nd among seven siblings in amonogamous setting. Takes alcohol productssparingly and stopped 4years ago, does not taketobacco product of any form.ROS:NOAD.
O/E: A young man, not in obvious painful distress.Not pale, anicteric, acyanossed, not warm to touch.No peripheral lymphadenopathy, nor pedal edema.Abdomen: full and soft, moves with respiration,No scars, male pattern hair distribution.No areas of tenderness,LSK- nilDRE: Good anal hygiene with good sphincteric toneNo fissures ,hemorrhoids present ,small at 6 and 12o’clock positions, tender with bluish distended veins,rectal cavity contained fecal pellets, no masses, rectalmucosal wall is free and mobile prostate not enlarged .
CVS: Pulse rate - 80bpm regular full volume , B.P. – 90/70mmhg. H.S. – 1&2 only. Apex beat - 5th I.C.S. lateral to midclavicular lineRS : RR – 20 cpm Trachea central PN – resonant BS – vesicularCNS: Conscious and alert, oriented in PPT
Summary.A 37 year old male bailiff, with 9 years of analprotrusion, with associated occasional bleeding, a yearhistory of non reducibility , a week history ofassociated pain. on examination had hemorrhoidspresent ,small at 6 and 12 o’clock positions, tender withbluish distended veins.ASSESSMENT: 30 gangrenous hemorrhoids
PLAN: Admitted by consultant from general surgery teamA TO C Book after theatre fee paid , and Prepared for surgery(hemorroidectomy), with ducolax Suppository, consent retrieved, NPOfor 24 hrs. Serum E/U/Cr PCV – 30% FBS Urinalysis (early morning ) Proteinuria 30mg/dl(+) bilirubinuria (+). Noother abnormalities detected . Consultant informed.
INTRA/POST-OPERATIVE MANAGEMENTPatient was assessed by the anesthesiologist and spinalanesthesia was administered and failed thereafter placed onTIVA. He was placed in lithotomy position and draped ,lurchprocedures done , and pellicles of hemorrhoids excised whilehaemostasis secured. Rectum was parked with Vaseline gauzeand anal orifice Dressed. During the course of surgery, his vitalsigns where monitored.He was placed on intravenous ciprofloxacin 200mg bd for 5/7intravenous flagyl 400mg tds for 5/7I m pentazocine 30mg alternate with im diclophenac 6hrly for 48hrs then after PRN .tabs vitamin c T bd for 10/7NPO to food only for 24 hrsIv 5% D/S 8hrly for 24 hrs .Sitz bath tds +PRN after toileting
POST OP COMPLICATIONS NOTICEDDribbling faeces from anus during sitz bath and atanal orifice during daily inspections , he was placed onkegills exercise .Bleeding from op site on 1st and 3nd , patient wasreassured .Pain at op site ,he was placed on analgesics,intramuscular analgesics later oral tramadol 50 mg bd.Vital signs were stable throughout his stay in thehospital.DISCHARGE :patient was discharge on 5TH day post-op on the following tabs flagyl 400mg tds, capampiclox 500mg qds and tabs tramadol 50mg bd ,sitzbath tds and kegills exercise bd all for 7 day to see atnext two Monday clinic for follow-up.
INTRODUCTION : DEFINITION : Pathological presentation ofhemorroidal venous cushions characterized by distentionand sliding down of anal cushions containing varicoseveins. BRIEF HISTROY:if bile or phlegm be determinedto the veins in the rectum ,it heats the blood in theveins :and these veins becoming heated attract bloodfrom nearest veins ,and been gorged the inside of thegut swells outwardly, and the heads of the veins areraised up, and being at the same time bruised by thefaeces passing out ,and injured by the blood collectedin them ,they squirt blood, most frequently along withfaeces , but sometimes without faeces. ----------Hippocrates (460-375 BC)
PHYSIOLOGIC-ANATOMY/EMBRYOLOGY/HISTOLOGYThe anal canal is the terminal part of the largeintestine.]The anal canal is 3-4 cm long
In humans, it extends from the anorectal junction tothe anus. It is directed downwards and backwards. It issurrounded by inner involuntary and outer voluntarysphincters which keep the lumen closed in the form of ananteroposterior slit.Internal anal sphincters (smooth), external anal sphincter(striated),Upper two-third(mucosal) ,lower one-third (skin) . The embryonic origin is lower anorectal part of thecloacae which is lined by derivative of endoderm(upper2/3) and lower 1/3 by ectoderm from analpit(proctodeum), indicated anatomicly by relativeavascularised Hiltons white line(pectinate line).It issituated between the rectum and anus, below the level ofthe pelvic diaphragm. It lies in the anal triangle ofperineum in between the right and left ischiorectal fossae.
The anal canal is divided into three parts.The zona columnaris is the upper half of the canal,terminating at the annulus hemorroidalis(zona hemorroidalis), and is lined by simple columnar epithelium.The lower half of the anal canal, below the pectinate line, isdivided into two zones separated by Hiltons white line. Thetwo parts are the zona hemorrhagica(pecten) and zonacutanea, lined by stratified squamous non-keratinized andstratified squamous keratinized, respectively. the margin of theanus is guided by corrugators cutis ani muscle.Blood supply :superior ,middle and inferior hemorroidalvessels. It’s part of the porto-caval anastomosis.Lymphatic drainage: inguinal group of lymph nodes and iliacgroups of lymph nodes. Watershed line serves as land mark.Nerve supply ;inferior rectal nerve and inferior hypogastricplexuse.
EPIDEMIOLOGY Symptomatic hemorrhoids affect at least 50% of theAmerican population at some time during their lives,with around 5% of the population suffering at anygiven time, and both sexes experiencing the sameincidence of the condition. They are more common inCaucasians. The exact incidence in the population ofdeveloping countries has not been determined but inspite of assertions to the contrary the condition isfrequently encountered in most developing countries.
AETIOLOGY/RISK FACTORThe predisposing factors includeheredity, age, sex, pregnancy ,obesity, the puerperal stateand even temperament,morphology,intraabdominalmass.The precipitating factors comprise catharticabuse, diarrhoea, enemata, constipation, infection, analspasm or atony of the anal sphincter, obesity and rise inintraabdominal pressure,portal hypertension,anal sex. EXTERNAL :associated with anal fissure, anal tags
PATHOPHYSIOLOGY Varicose submucosal branches of the superior andinferior hemorroidal veins constituting the internal andexternal haemorrhoidal plexuses are congregated into 3primary positions - right anterior, right posterior and leftlateral - depending on the pattern of termination of thesuperior rectal artery, as repeated pressure occur with engorgementof the submucosal venous plexus, there is contraction and closureof intramuscular venous plexus, impeding venous return, by thesphincteric muscle while intra-arterial pressure increase ,combinewith the valvulessity of the vein there is initial distention, while thedentate ligament remain intact ,after a while, the ligament arestretched and there is prolapsed. Prolonged reduction in nutrientsupply of the prolapsed lead to dead mucosal tissue ,whichruptures and bleeds.
CLINICAL FEATURESBleeding ,first symptoms, either as splash in the pan oras streak.Mass per rectumDischarge (mucoid)PruritusPain(prolapsed,infection,spasm, thrombosed.Complicated; Complicated; Profusebleeding,strangulation,thrombosis,ulcerated,gangrene,fibrosis,stenosis,suppuration,pylephlebitis(rare)Anal swelling ,(visual,proctoscope).
Types are: Anatomical boundary. internal ;above dentate line, covered with mucosa. varicosity of superior rectal veintributaries External ;below dentate line ,covered withskin. Varicosity of inferior rectal veins tributaries Interno-external;together occurs. Vascular origin Primary :located at 3’,7’,and 11 o’clockpositions, related to branches of the superiorhemorroidal vessel which divides into two ;left side itcontinues as one . Secondary: One which occurs between theprimary sites.
Severity First degree Second degree Third degree Fourth degree Others :arterial pile which is an hematogiomatouscondition of superior rectal artery entering the pedicle ofinternal hemorroidal which will bleed profusely. DEFFERENTIAL DIAGNOSIS Carcinoma Rectal prolapsed Perianal wartsBleeding ;fissure in ano,polyps,ulcerative and amoebiccolitis, fistula in ano,diverticulitis ,intussusceptions
cryosurgeryinfra-red coagulationLaser therapyStapled haemorrhoidopexy(Antonio lango): Also known as Procedure for Prolapse &Hemorrhoids (PPH), Stapled Hemorrhoidectomy,and Circumferential Mucosectomy.
OPEN –OPERATIVE METHODSIndications :3rd degree pilesFailure of non-operative methodsFibrosed piles Ligation and excision(Milligan-Morgan):Developed in the United Kingdom by Drs. Milliganand Morgan, in 1937. Submucosal hemorroidectomy of ‘Park Hill-Ferguson closed method : Developed inthe United States by Dr. Ferguson, in 1952 .
Special consideration :management ofstrangulated/thrombosed/gangrenous pile ,initial management includeconservative treatment to reduce edemaCOMPLICATIONSEarly Complications Include:1) Severe postoperative pain, lasting 2-3 weeks. This is mainly due toincisions of the anus, and ligation of the vascular pedicles.2) Wound infections are uncommon after hemorrhoid surgery. Abscessoccurs in less than 1% of cases. Severe necrotizing infections are rare.3) Postoperative bleeding.4) Swelling of the skin bridges.5) Major short-term incontinence.6) Difficult urination. Possibly secondary to occult urinary retention,urinary tract infection develops in approximately 5% of patients afteranorectal surgery. Limiting postoperative fluids may reduce the needfor catheterization (from 15 to less than 4 percent in one study).7)Reactionary hemorrhage
Late Complications Include:1) Anal stenosis.2) Formation of skin tags.3) Recurrence.4) Anal fissure.5) Minor incontinence.6) Fecal impaction after a hemorrhoidectomy is associatedwith postoperative pain and narcotic use. Most surgeonsrecommend stimulant laxatives, or stool softeners toprevent this problem. Removal of the impaction underanesthesia may be required.7) Delayed hemorrhage/secondary, probably due tosloughing of the vascular pedicle, develops in 1 to 2 percentof patients. It usually occurs 7 to 16 days postoperatively.No specific treatment is effective for preventing thiscomplication, which usually requires a return to theoperating room for one or more stitches.
NEW ISSUESHarmonic Scalpel HemorroidectomyHAL-RAR Method Hemorroidectomy(DG) HAL (DopplerGuided Hemorrhoidal Artery Ligation) and (DG) RAR(Doppler Guided Recto Anal Repair Proctoplasty). Developedin 2001.93-96% success rates.first to utilise MIS.
CONCLUSION :Hemorrhoids are one ofthe most commoncauses of analpathology, the deeperyour knowledge, themore equipped youwould be to managethem , the more likelyyou will seek to handlemore.Thanks forlistening