This document discusses the various causes of rectal bleeding, focusing on hemorrhoids. It defines internal and external hemorrhoids, explaining their locations and causes. Symptoms of internal hemorrhoids include painless bleeding during defecation and possible prolapse. Complications can include strangulation, thrombosis, and gangrene. Treatment options are discussed, including non-operative approaches like injection sclerotherapy, banding, and infrared coagulation, as well as operative techniques like open or closed hemorrhoidectomy and stapled hemorrhoidopexy. External hemorrhoids and related conditions are also briefly mentioned.

1. Dr. Dinesh. M.G
Professor of Surgery
J.J.M.M.C.
Davangere

2. Causes of rectal bleeding
 Haemorrhoids
 Fissure in ano
 Polyps
 Colorectal carcinoma
 Ulcerative colitis
 Diverticulosis
 Angiodysplasia
 Infection (bacillary dysentery)
 Upper GI tract and Meckel’s diverticulum

3. Haemorrhoids

4. Internal haemorrhoids
 Internal haemorrhoids are dilated veins that occur in
prolapsing anal cushions that characteristically lie in the
3, 7 and 11 o’clock positions
 Haemorrhoids generally cause symptoms when they
become enlarged, inflamed, thrombosed or prolapsed

5. Types
 Internal
 Occurs internal to dentate line and is covered by mucous
membrane
 External
 Occurs below the dentate line and is covered by skin
 Internoexternal
 Internal and external occurring together

6. Internal haemorrhoids-Aetiology
 Hereditary
 Congenital weakness of vein wall
 Abnormally large arterial supply to rectal plexus
 May be associated with varicose veins of legs
 Anatomical
 High venous pressure due to absence of valves in portal
circulation leading to dilatation of veins
 Rectal plexus of veins pass through muscular layer and develop
high pressure during contraction of muscles during defaecation
 Exacerbating factors
 Straining in constipation
 Enteritis, colitis or the dysenteries aggravate latent haemorrhoids

7. Pathology-internal haemorrhoids
 Primary haemorrhoid are seen at 3, 7 & ll o’clock
positions
 Secondary haemorrhoids may occur in between these
primary haemorrhoids
 Parts of primary haemorrhoids
 Pedicle at the anorectal ring
 Internal haemorrhoid above the dentate line appearing
purple
 External associated haemorrhoid covered by skin below the
dentate line

8. Clinical features
 Bright red painless bleeding during defaecation
 Prolapse
 I0 haemorrhoids bleed but do not prolapse
 II0 haemorrhod prolapse during defaecation and return on
their own
 III0 haemorrhoid prolapse during defaecation and need to be
manually replaced
 IV0 haemorrhoids permanently remain prolapsed
 Mucous discharge
 Pain seen in complications
 Anaemia

9. Clinical features and investigations
 Anorectal examination
 Proctoscopy
 Digital rectal examination
 Sigmoidoscopy

10. Complications
 Strangulation
 Thrombosis
 Ulceration
 Gangrene
 Fibrosis
 Suppuration
 Portal pyaemia and liver abscesses

11. Prolapsed haemorrhoids

12. Treatment
 Non operative treatment
 Active treatment
 Injection treatment
 Banding treatment(Baron)
 Cryotherapy
 Photocoagulation
 Haemorrhoidectomy
 Open technique
 Closed technique
 Stapled haemorrhoidopexy

13. Injection sclerotherapy
Gabriel’s syringe

14. Baron’s banding

15. Infrared coagulation

16. Open haemorrhoidectomy

17. Closed haemorrhoidectomy

18. Stapled hemorrhoidopexy

19. External haemorrhoids
 Thrombosed external haemorrhoid
 Internoexternal haemorrhoid
 Sentinel pile
 Dilatation of the veins at the anal verge

20. Thank you