Haemorrhoidal disease, also known as piles, is caused by the distal displacement of normal anal cushions which causes venous dilatation. It is classified into internal or external types depending on whether they are above or below the dentate line. The most common symptom is bleeding. Treatment options include lifestyle changes, medications, injections, rubber banding, surgery, and ablations depending on the grade of haemorrhoids. Proper medical evaluation is important to identify any underlying conditions like cancer that may be causing the symptoms.

1. The Bottom Line:
Haemorrhoidal Disease
Chea Chan Hooi MD
General & Laparoscopic Surgeon
Borneo Medical Centre (Miri)
cheachanhooi@yahoo.com
0149972321

2. Disclosure
• Perform surgeries and clinic procedures for
haemorrhoids and varicose veins
• Use Daflon extensively
• No monetary incentive from Servier
• No shares in Servier

3. Content
• Definition
• Anatomy
• Etiology
• Grades
• Differential diagnoses
• Symptoms
• Investigations
• Treatment
• Conclusion
• Q&A

4. Definition
• Haemorrhoids
– Distal displacement of normal anal cushions causing
venous dilatation
– 痔疮, piles, buasir
– Anal cushions
• Sensory input to differentiate luminal content
• Provides 15 – 20% of resting anal pressure
• Arterio-venous anastomoses

5. Types
• Anatomy
– Internal
• Anal cushion
• Superior to dentate line
• Columnar epithelium
• Grade 1 – 4
– External
• Perianal blood vessels
• Inferior to dentate line
• Anoderm & skin cover

6. Anatomy
Dentate line

7. Etiology
Constant straining
Prolonged sitting on toilet
bowl
Pathological
Iatrogenic

8. Grades of internal haemorrhoids

9. Differential diagnoses

10. Symptoms of haemorrhoids

14. External haemorrhoids

15. Beware
?

16. Cancer

17. Tests
• Colonoscopy
– Over 40 y/o
– Red flags
– Younger patients not improving with phlebotonic
drugs

19. Historical treatment

24. Treatment options
• Lifestyle changes
– Avoid constipation
– Physical activities
– Reduce weight
– Reading in toilet
• Medications
• Interventions

25. Medications
• Symptomatic relief
– Sitz bath
– Topical analgesics
– Systemic analgesics, anti-inflammatory
– Stool softeners
• Phlebotonics
– Flavonoids
– Calcium dobesilate
– Nano-emulsions (diosmin & hesperidin too)
• Osmotics
– Plant-based
– Sugar
Ratto C, Orefice R, Tiso D, Martinisi GB, Pietroletti R. Management of hemorrhoidal disease: new generation of oral and topical treatments. Eur Rev Med
Pharmacol Sci 2020;24:9645-9

27. Flavonoids

32. Injection

33. Rubber band

34. Surgery

35. Plication

36. Dopler-guided haemorrhoidal artery
ligation (DG-HAL)

37. Stapler

38. Anal stenosis – 15%

39. Ablations
Laser
Infra red
Radiofrequency
Cryo

45. Recap
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46. Conclusion
• Haemorrhoids are very common
• Most common symptom is bleeding
• Can mask a cancer
• Proper medical evaluation is important
• The bottom line – vigilant evaluation so as not
to miss other significant diseases

47. Thank you!
Q&A?