HAEMORRHOIDS management

1. Haemorrhoids
Presented by: Dr. Nandita Doley.
Moderator : Dr. Kabir Rajkhowa
Professor, Dept of General Surgery
Guwahati Medical College & Hospital

2. Introduction
 Haemorrhoid:
Haima= Blood.
Rhoos = Flowing.
What is a “Haemorrhoid”?
Varicosities of the veins of the anal canal are known
Haemorrhoids.

3. Risk Factors For Haemorrhoids
• Common risk factors
 Spinal-cord injuries
 Constipation
 Pregnancy
 Poor bathroom habits/Postponing bowel movements
 Poor-fiber diet
 Liver Cirrhosis – Portal Hypertension
 Hereditary
• Mechanism
 Natural weakening of the blood vessel wall
 Increase in intra-abdominal pressure
 Venous outflow blockade secondary to pregnancy
3

4. How common are Hemorrhoids ?
• One of the most common medical conditions.
• 25% in the adult population, and higher than 50%
for those older than 50.
• Burden in India – It has been projected that 505 of
the population would have hemorrhoids at some
point in their life by the time they reach 50 and
approximately 5% population would suffer from
hemorrhoids at any given point of time.(1)
• The prevalence and the incidence are most
probably higher, considering the fact that, in
certain patients, the illness begins in an 4

5. Anatomy
• They are clusters of vascular tissue, smooth muscle and
connective tissue lined by normal epithelium of anal canal.
•These vessels are normally supported by longitudinal muscle
fibres which help to retain the vascular cushions in their
position in the upper half of the anal canal.
•They are commonly seen in the left lateral, the right anterior
and the right posterior (3,7 and 11 o’clock) positions with a
patient in lithotomy position.

6. Contd..

7. Types of Haemorrhoids
Haemorrhoids originating
above the dentate line are
termed as “Internal
Haemorrhoids”.
Haemorhhoids originating
below the dentate line are
termed as “External
Haemorrhoids”.

8. Grades of Internal Haemorrhoids

9. Symptoms
•Rectal Bleeding.
•Bright red blood in stool.
•Pain during bowel movements.
•Anal Itching.
•Rectal Prolapse.
•Thrombus.

10. Assessment
• History.
•Inspection.
•Palpation.
•Proctoscopy.

11. Treatment
•Conservative:
•Medical
•Invasive therapy
•Injection Sclerotherapy
•Rubber Band Ligation
•Cryotherapy
•Photocoagulation
•Dopler Guided Haemorrhoidal Artery Ligation
•Laser therapy for Piles
•Surgical:
•Open Haemorrhoidectomy
•Closed Haemorrhoidectomy
•Stapler Haemorrhoidectomy

13. Conservative:
•Medical management
•Advice
•For minor symptoms
•High fiber diet.
Thorough perianal lavage after defecation
•Changing defecation habits
•Do not neglect first urge to defecate in the morning.
•Do not insist on trying to pass the last portion of stool from rectum in the
belief that it is not passed
•Diet manipulation
•Bulking agents (high fiber diet) e.g ispaghol husk and methyl cellulose.
•Tropical agents
•Suppositories (shark liver oil, skin respiratory factor)
•Xylocain for pain
•Paraffin as lubricant to avoid rubbing.

14. Conservative:
• Invasive therapy:
•Principles on which invasive therapy is based;
1. Prevention of prolapse by mucosal fixation.
2. Prevention of congestion by stretching or by
dividing the internal sphincter.
3. Excision of the engorged internal vascular
channels.

15. Invasive therapy:
•Injection Sclerotherapy
• Useful in 1st and 2nd degree.
•70% success rate.
•Sclerosant causes aseptic inflammation and fibrosis in
2-3 weeks.
•Gabriel syringe and needle are used.
•5% phenol in almond oil (3ml in each cushion).
•2.4% anhydrous qunine area with pH 2.6.
•Knee chest or left lateral position.
•Right posterior cushion should be injected first.

16. Contd..
Technique:
•The protoscope is passed and obturator is removed.
•The scope is manipulated until the junction between the pink and the
purple mucosa is positioned indicating the base of the cushion.
•The needle of the syringe is introduced obliquely through the
mucosa for 1cm.
•The procedure should be painless.

17. Contd..
Complications:
•Pain.
•Haemorrhage.
•Lower urinary tract sepsis.
•Impotence.
•Oleogranuloma (response to almond oil).
•Bacteremia (8%).

19. Invasive therapy:
Rubber Band ligation:
•Used for 2nd degree.
•80% success rate.
•Principle is mucosal fixation by ulceration.
•Band produces ischemic necrosis with sloughing and
ulceration.
•Ligators
•Barron ligator
•Suction band ligator
•Mc Giveny ligator.

20. Contd..
Technique:
•Rubber band is equipped by the help of the loading cone.
•Pass proctoscope.
•Visualize the cushion, the base of cushion lies 1.5-2cm above the
dentate line.
•Long shaft of the suction band equipment is introduced through the
proctoscope.
•Haemorrhoid is sucked into the lumen of the inner drum.
•Handle is squeezed toadvance the outer drum that releases the rubber
band and applies it to the neck of haemorrhoid.

22. Complications:
•Pain (If severe pain then removal of band
and treatment with photocoagulation).
•Bleeding.
•Pelvic cellulitis (clostridial infection
common).

23. Invasive therapy:
Cryotherapy:
When tissue freezes, intracellular water crytalizes, cell membranes are
destroyed and tissue death occurs. Tissue freezes at -20ºC and permanent
destruction occurs at -22ºC . Liquid Nitrous oxide is used in this process.
Technique:
•With bivalved speculum anal cusions are exposed.
•Apply lubricant.
•The probe is laid along the length of the cushion and pressed laterally
while the trigger is squeezed. Nitrous oxide evaporates in the tip that
become frozen. This is continued for 3 minutes.

25. Invasive therapy:
Photocoagulation:
The technology includes infared
radiation generated by tungsten halogen lamp
which is focused on the tissue from a gold
plated reflector housing through a polymer
tubing.

27. Invasive therapy:
Dopler Guided Haemorrhoidal Artery
Ligation:
DGHAL is a non-excisional surgical technique for
the treatment of haemorrhoidal disease, consisting of the
ligation of the distal branches of the superior rectal artery,
resulting in a reduction of blood flow and decongestion of
haemorrhoidal plexus resulting in fibrosis.

28. Technique:
•The proctoscope consists of a Doppler transducer on the
tip.
•There is an opening slightly distally from the transducer
through which the ligature can be placed in the tissue.
•The proctoscope connects to the Doppler device and
produces easily recognizable acoustic signals.
• After an arterial signal is detected, it is ligated.

29. •After ligation, the absence of an arterial signal on that
spot is confirmed with the Doppler transducer.
•Three full circles with the proctoscope are performed in
the rectal canal.
•The ligations are performed with a vicryl stitch especially
made for this procedure (AMI HAL suture, 2/0 vicryl,
tapered needle, 5/8 circumference, reinforced needle-
thread connection).
Contd…

30. Disposable proctoscope with the Doppler transducer on the tip.

31. The proctoscope connects to the Doppler device and produces
easily recognizable acoustic signals.

33. a. Before DGHAL.
b. After DGHAL.

34. Surgery: Haemorrhoidectomy
•Indications:
•3rd degree haemorrhoids.
•2nd degree haemorrhoids which have not been cured by non-
operative methods.
•Fibrosed haemorrhoids.
•Interno-external haemorrhoids when the external haemorrhoids
are well defined.
•Preparation:
•1 enema night before the surgery, another enema 1 hour before
the surgery.
•Points with severely prolapsed haemorrhoids should be spared
from enema.

35. Open haemorrhoidectomy
(Milligan- Morgan):
•Technique:
•Lithotomy position.
•1st the left lateral haemorrhoid is excised, them the right posterior and
then the right anterior.
•Skin covered component of each pile is seized with the artery forceps and
retracted outward.
•The purple anal mucosal component of each pile is grasped with another
artery forceps and drawn downward and outward. This indicates the pile
has been drawn to the maximum extent so that ligature can be applied at the
upper pole.

36. Contd..
•A V-shaped incision is made in the anal and peri-anal skin
so that the limbs of the V cross the mucocutaneous
junction but do not extend into the mucosa.
•Venous plexus is dissected from the internal sphincter
while preserving the sphincter.
•The apex of the pedicle is transfixed with 1/0 chromic
catgut.
•The asolated haemorrhoid is then excised with the
scissors a few millimetre below the ligature.

40. LASE THERAPY FOR LASER
 Nd- YAG, diode and carbon dioxide lasers can be used
in the treatment of third degree piles.
 The intense beam of light interacts with tissue and can
be used to cut, coagulate and abalate the tissue,
sealing off nerves and tiny blood vessels. By sealing
superficial nerve endings patients have minimum
postoperative discomfort.
 In a study to evaluate Diode laser for treatment of
haemorrhoid, the results show zero recurrence and
stricture after one year and very lowtotal complication
such as edema and haemorrhage.(2)

41. Closed haemorrhoidectomy
•Technique:
•Prone jack knife position/left lateral.
•Adhesive tape to retract the buttocks.
•Anal canal examined by Pratt bivalved speculam.
•After inspection, replace bivalved speculum with Fansler operating
anoscope.
•Anoscope is adjusted so thet the operating channel is in line with the
haemorrhoidal tissue.

42. Contd..
•The skin tag or anal epithelium adjacent to haemorrhoidal
tissue is grasped with the pair of Aliss forceps and retracted
toward the centre of the anal canal.
•Sciccors with its curve toward the anal canal is used to
incise beneath the tissue forceps from thr perianal skin
upwards along the haemorrhoidal tissue.
•Most prominent region of the haemorrhoidal tissue is
excised 1st to minimize the subsequent loss of anoderm.
•Bleeding submucosal vessels are controlled with cautry.

43. Contd..
•After complete excision of the haemorrhoidal tissue to a
point above the internal sphincter the wound is closed
using a running 3/0 suture.
•Stiching is begun at the apex and mucosa is fixed with
submucosa and muscle.

47. Stapler haemorrhoidectomy
•Technique:
•A circular, hollow tube is inserted into the anal canal.
•Through this tube, a suture (a long thread) is placed,
actually woven, circumferentially within the anal canal
above the internal hemorrhoids.
•The ends of the suture are brought out of the anus
through the hollow tube.
•The stapler (a disposable instrument with a circular
stapling device at the end) is placed through the first
hollow tube and the ends of the suture are pulled.

48. Contd…
•Pulling the suture pulls the expanded hemorrhoidal
supporting tissue into the jaws of the stapler.
• The hemorrhoidal cushions are pulled back up into their
normal position within the anal canal.
The stapler then is fired. When it fires, the stapler cuts off the
circumferential ring of expanded hemorrhoidal tissue trapped
within the stapler and at the same time staples together the
upper and lower edges of the cut tissue.

49. Internal haemorrhoids in
anal canal

50. Hollow tube inserted into the anal canal and
pushing up the haemorrhoids.

51. Suturing the anal canal through the hollow
tube

52. Bringing the expanded haemorrhoidal supporting
tissue into the hollow tube by pulling on suture

53. Haemorrhoids pulled back above the anal
canal after stapling and removal of
haemorrhoidal supporting tissue

54. Postoperative care:
•Advice to take Sitz bath twice/day using warm saline solution.
•Bulk laxative, twice daily.
•Appropriate analgesia.
•Antibiotics.
•Dry dressing.
•Follow up after 3-4 weeks.

55. Postoperative Complications:
•Early
•Pain.
•Acute retention of urine.
•Reactionary haemorrhage.
•Late
•Secondary haemorhage.
•Anal stricture.
•Anal fissure.
•Incontinence.

56. Prevention
 Eat high fiber diet.
 Drink Plenty of Liquids.
 Fiber Supplements.
 Exercise.
 Avoid long periods of standing or sitting.
 Don’t Strain while defecation.
 Go as soon as you feel the urge.

57. Conclusion
• In most instances, haemorrhoids are treated conservatively,
using many methods such as lifestyle modification, fiber
supplement, suppository-delivered anti-inflammatory drugs
and administration of venotonic drugs.
• Non-operative approaches include sclerotherapy and
preferably rubber band ligation.
• An operation is indicated when non-operative approaches
have failed or complications have occurred.

58. Conclusion
• Conventional haemorrhoidectomy is the gold standard
operation against which other haemorrhoidal procedures
should be compared.
• Nonetheless, it has its own postoperative morbidity,
including pain, bleeding and infection.
• This has led to the application of more recent techniques
to improve the treatment of this very common disease.

59. References
 Phlebolymphology: 2004: 268-297.
 World J Gastroenterol. 2015 Aug 21; 21(31): 9245–9252.
 Advances in Therapy. 2018;35(11):1979-1992.
 Bailey nd love’s short practice of surgery:26th edition.
 A Manual of Clinical Surgery, S das 15th edition
 SRB’s manual of surgery: 6th edition.
 (1)Agarwal Niranjan, Singh Kumkum. Indian journal of Surgey 2017
 (2)Abdolhadi et al 2012(Iran)
 medicinenet.inc

60. THANK YOU