Hemorrhoides

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Hemorrhoides

  1. 1. Hemorrhoidal disease Samir Haffar M.D.
  2. 2. Definitions • Hemorrhoids Dillated vascular channel in 3 constant locations Normal part of human anatomy • Hemorroidal Disease Manifeted by prolapse, bleeding, & itching • Internal hemorrhoids Originate above dentate line Covered with transitional mucosa • External hemorrhoids Located close to the verge Covered with transitional mucosa
  3. 3. Usual sites of internal hemorrhoids Knee-chest position Left lateral Right posterior Right anterior
  4. 4. Incidence of hemorrhoidal disease • Exact incidence is not known • 10 - 25 % of adult population thought to be affected
  5. 5. Pathogenesis of hemorrhoids Normal vascular cushions present at birth Downward pressure during defecation Muscle fibers that anchor cushions attenuated Hemorrhoids: slide, congested, bleed, prolapse High resting anal pressure (unclear?)
  6. 6. Classification of internal hemorrhoids • First degree Project a short way into the anal canal The only symptom is bleeding • Second degree Prolapse during defecation Return spontaneously • Third degree Must be returned manually • Fourth degree Hemorrhoids are irreducible
  7. 7. Symptoms of hemorrhoids Intermittent symptoms • Painless bleeding Seen on toilet tissue Dripping into toilet at end of defecation Accumulate in rectum with dark blood or clots • Prolapsed hemorrhoids Blood & mucus stain patient’s underwear Mucus against anal skin lead to itching
  8. 8. Third degree internal hemorrhoids
  9. 9. Forth degree internal hemorrhoids
  10. 10. Knee-chest position
  11. 11. Anal & rectal palpation
  12. 12. Normal anal canal
  13. 13. Internal hemorroids Seen with the proctoscope
  14. 14. Localized hemorrhoidal prolapse
  15. 15. Prolapse of 3 mains hemorrhoidal piles
  16. 16. External hemorroids (skin tags)
  17. 17. Hypertrophic papillae
  18. 18. Protruding hypertrophied papilla
  19. 19. Treatment of internal hemorrhoids Reduce downward pressure Diet Bulk agents Veinotonic agents Avoid prolonged sitting at stool Fix cushions to sphincter Sclerosing injections Rubber band ligation Cryotherapy Photocoagulation: infrared - laser Electrocoagulation: bipolar - heater probe Excise hemorrhoids Hemorrhoidectomy
  20. 20. Preferences for treatment of hemorrhoids Degree or Grade Treatment 1 Sclerosing injections Infrared coagulation 2 Infrared coagulation Rubber band ligation 3 Rubber band ligation 4 Hemorrhoidectomy
  21. 21. Sclerosing injection Instruments
  22. 22. Sclerosing injection
  23. 23. Sites of sclerosing injections 1 Superficial 2 Good (submucosa) 3 Deep (intramuscular)
  24. 24. Sclerosing injections • Substances 1 ml is sufficient to create raise area Phenol 5 % – Quinine Chlorhydrate & urea 5% • Number of injections 2 injections per week 4 – 6 injections in total • Results Success in 75 % of first & second degree
  25. 25. Infrared photocoagulation
  26. 26. Infrared photocoagulation • Coagulation proximal to internal hemorrhoids • Applied for 1.5 sec in 2 – 3 sites • Success in 75 % of 1st & sd degree • Rare complications
  27. 27. Rubber band ligation
  28. 28. Rubber band ligation
  29. 29. Number of bands in one session Disagreement • 1 band by session Many authorities believe that severity of pain & risk of complictions are less • 2 – 3 bands by session Safe & effective at one setting • 8 – 10 bands in one session
  30. 30. Retroflexed endoscopic multiple band ligation Extensive ligations of internal hemorrhoids & normal rectal mucosa immediately proximal to internal hemorrhoids weeks after8 – 10 elastic bands in one session Before band ligation Gastrointest Endosc 2004 ; 59 : 380 – 4 .
  31. 31. Rubber band ligation is probably the most common fixation method in use worldwide today
  32. 32. Rubber band ligation Complications Pain Moderate 5 - 85% – analgesic Severe near dentate line – ablation Bleeding Minimal 1 – 15 % Severe: 0.5 - 2% – Transfusion – suture Cellutitis Severe complication (50% mortality) 15 cases reported between 1980 – 1988 Anaerobic – Gram negative bacteria Early symptoms: anorectal pain & urinary troubles Early treatment ameliorate prognosis (antibiotics) Dysuria & urine retention
  33. 33. External hemorroidal thrombosis
  34. 34. Thrombectomy Instruments
  35. 35. Thrombectomy Local anesthesia Incision Enucleation
  36. 36. Edematous external hemorroidal thrombosis
  37. 37. Sebaceous cyst Not painful After puncture
  38. 38. Thrombosed hemorrhoidal prolapse Acute hemorrhoidal disease
  39. 39. Treatment of acute hemorrhoidal disease Medical Direct injection of 9 ml bupivacaine 0.25% + 1 ml hyaluronidase Gentle massage followed by reduction of the mass NSAIDs parenterally Surgical Emergency hemorrhoidectomy occasionally
  40. 40. Only about 10% of patients should undergo operation
  41. 41. Thank You

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