This document provides information on haemorrhoids (also known as hemorrhoids), including: - Anatomy of the anal canal and haemorrhoidal tissue - Epidemiology of symptomatic haemorrhoids, affecting around 4.4% of the global population - Common causes like straining, pregnancy, obesity, and familial tendency - Grading of internal haemorrhoids from first to fourth degree based on degree of prolapse - Treatment options like rubber band ligation, sclerotherapy, excisional or stapled haemorrhoidectomy depending on severity

1. HAEMORROIDS (lecture)
DR.BEZAN BALOCH
ASSISTANT PROFESSOR OF SURGERY
U-11

2. Anatomy
The anal canal is about 3–4cm long. It passes slightly posteriorly,
starting at the anorectal angle and ending at the anal verge. In
the male, the anal canal is related to the bulb of the urethra
anteriorly, and in the female to the perineal body and the vagina
anteriorly. Laterally, it is related to the ischiorectal fossa containing
the inferior haemorrhoidal vessels and pudendal nerve posteriorly lie
the coccyx and the puborectalis muscle, the anal canal is surrounded by
the internal
and external sphincter muscles.
The epithelium of the anal canal is columnar above the anal
valves and squamous below them; the site of the anal valves is
also known as the dentate or pectinate line and this indicates
the mucocutaneous junction.

5. The anal valves
that represent the openings of the anal glands, and the glands
themselves lie in the plane between the internal and external
sphincters, helping to lubricate the anal canal. The mucosa
above the dentate line is arranged in longitudinal columns
covering the internal haemorrhoidal plexus. The internal anal
sphincter is a downward, thickened
extension of the circular muscle fibres of the rectum and extends
approximately 1›cm below the anal canal. It consists entirely
of smooth muscle and is innervated by the pelvic autonomic
plexus. The external sphincter, on the other hand, is made up
of skeletal muscle that is arranged around the anal canal outside
the internal sphincter

6. the dentate line
The dentate line is surrounded by longitudinal
mucosal folds, known as the columns of
Morgagni, into which
the anal crypts empty. These crypts are the source
of cryptoglandular
abscesses . In contrast to the anatomic anal
canal, the surgical anal canal begins at the
anorectal junction
and terminates at the anal verge.

7. Ano rectal Vascular Supply
The superior rectal artery arises
from the terminal branch of the inferior mesenteric artery
andsupplies the upper rectum. The middle rectal artery arises
from
the internal iliac; the presence and size of these arteries are
highly variable. The inferior rectal artery arises from the internal
pudendal artery, which is a branch of the internal iliac artery.
A rich network of collaterals connects the terminal arterioles of
each of these arteries, thus making the rectum relatively resistant
to ischemia

9. Hemorrhoids
Hemorrhoids are cushions of submucosal
tissue containing,venules, arterioles, and
smooth muscle fibers that are located
in the anal canal . Three hemorrhoidal
cushions are found in the
left lateral,
right anterior,
right posterior positions.

11. Epidemiology
Worldwide, the prevalence of symptomatic
hemorrhoids is estimated at 4.4% in the general
population. In the United States, up to one third
of the 10 million people with hemorrhoids seek
medical treatment, resulting in 1.5 million related
prescriptions per year.

12. Etiology
• Straining &Constipation
• Pregnancy
• Portal Hypertension
• Lack of erect posture
• Familial tendency
• Obesity
• Colorectal malignancy

13. Clinical Presentation and Evaluation
symptoms of hemorrhoidalprotrusion or bleeding.
In cases of protrusion, the hemorrhoids are graded
according to the level of prolapse. First-degree internal
hemorrhoids do not prolapse; the anoscope must be used
to visualize them. Second-degree internal hemorrhoids
prolapse with defecation and return spontaneously to
their anatomic position. Third-degree internal
hemorrhoids prolapse with defecation and require manual
reduction.
Fourthdegree
hemorrhoids are not reducible .

14. Bleeding may be minimal, appearing only on toilet
paper,or it may occasionally be severe enough to
cause anemia. Itis usually bright red, coats the stool
(rather than being mixed
with it),
and is painless, unless there
is
thrombosis,
ulceration,
gangrene.

15. Investigations
• anal inspection and digital rectal examination
• Blood investigations.
Anoscopy(proctoscopy)
Sigmoidoscopy

17. External hemorrhoids
are located distal to the dentate line
and are covered with anoderm. Because the anoderm is richly
innervated, thrombosis of an external hemorrhoid may cause
significant pain. It is for this reason that external hemorrhoids
should not be ligated or excised without adequate local
anesthetic.
A skin tag is redundant fibrotic skin at the anal verge,often
persisting as the residual of a thrombosed external
hemorrhoid.
Skin tags are often confused with symptomatic hemorrhoids.
External hemorrhoids and skin tags may cause itchingand
difficulty with hygiene if they are large.

19. Internal hemorrhoids
are located proximal to the dentate
line and covered by insensate anorectal
mucosa. Internal hemorrhoids
may prolapse or bleed, but rarely become
painful unless
they develop thrombosis and necrosis (usually
related to severe
prolapse, incarceration, and/or strangulation).

22. DEGREE ■ DESCRIPTION
First Hemorrhoids bleed but do not prolapse
Second Hemorrhoids prolapse on straining but
reduce spontaneously
Third Hemorrhoids prolapse and require
manual reduction
Fourth Prolapsed hemorrhoids cannot be
manually
reduced

24. Complications of haemorrhoids
Strangulation and thrombosis
Ulceration
Gangrene
Portal pyaemia
Fibrosis

25. Treatment
Medical Therapy.
Bleeding from first- and second-degree
hemorrhoids often improves with the addition of dietary
fiber,stool softeners, increased fluid intake, and avoidance of
straining, warm bath,topical ointments.
Associated pruritus often may improve with improved
hygiene. Many over-the-counter topical medications are
relatively ineffective for treating hemorrhoidal
symptoms.

26. Rubber Band Ligation.
Persistent bleeding from first-, second-,and selected third-
degree hemorrhoids may be treated by rubberband
ligation.Mucosa located 1 to 2 cm proximal to the dentate
lineis grasped and pulled into a rubber band applier. After
firingthe ligator, the rubber band strangulates the
underlying tissue, causing scarring and preventing further
bleeding or prolapse

29. complications of rubber band ligation include urinary
retention, infection, and bleeding. Urinary retention occurs in
approximately 1% of patients and is more likely if the ligation
has inadvertently included a portion of the internal sphincter.
Necrotizing infection is an uncommon, but life-threatening
complication. Severe pain, fever, and urinary retention are early
signs of infection and should prompt immediate evaluation of
the patient usually with an exam under anesthesia. Treatment
includes débridement of necrotic tissue, drainage of associated
abscesses, and broad-spectrum antibiotics. Bleeding may occur
approximately 7 to 10 days after rubber band ligation, at the
time when the ligated pedicle necroses and sloughs. Bleeding
is usually self-limited, but persistent hemorrhage may require
exam under anesthesia and suture ligation of the pedicle.

30. Sclerotherapy.
The injection of bleeding internal hemorrhoids
with sclerosing agents is another effective office
technique for
treatment of first-, second-, and some third-degree
hemorrhoids.
One to 3 mL of a sclerosing solution (phenol in olive oil,
is injected into the submucosa of
each hemorrhoid. Few complications are associated with
sclerotherapy,
but infection and fibrosis have been reported

33. Operation
Indications
The indications for haemorrhoidectomy include:
• third- and fourth-degree haemorrhoids;
• second-degree haemorrhoids that have not been
cured by
non-operative treatments;
• fibrosed haemorrhoids;
• interoexternal haemorrhoids when the external
haemorrhoid
is well defined.

34. Operative Hemorrhoidectomy. A number of
surgical procedures
have been described for elective resection of
symptomatic
hemorrhoids. All are based on decreasing
blood flow to
the hemorrhoidal plexuses and excising
redundant anoderm and
mucosa.

35. Closed Submucosal Hemorrhoidectomy
The Parks or Ferguson
hemorrhoidectomy involves resection of
hemorrhoidal tissue and closure of the wounds
with absorbable suture. The
procedure may be performed in the prone or
lithotomy position.The hemorrhoid cushions and
associated redundant mucosa are identified and
excised

36. using an elliptical incision starting just distal to the
anal vergeand extending proximally to the
anorectal ring. It is crucial toidentify the fibers of
the internal sphincter and carefully brushthese
away from the dissection in order to avoid injury to
thesphincter. The apex of the hemorrhoidal plexus
is then ligatedand the hemorrhoid excised. The
wound is then closed with arunning absorbable
suture.

38. Open Hemorrhoidectomy
. This technique, often called the
Milligan and Morgan hemorrhoidectomy, follows
the same
principles of excision described earlier, but the
wounds are left
open and allowed to heal by secondary
intention.

42. Procedure for Prolapse and
Hemorrhoids/Stapled Hemorrhoidectomy
Procedure for prolapse and hemorrhoids (PPH)
has been proposed as an alternative surgical
approach.
The term
PPH has largely replaced stapled hemorrhoidectomy
because
the procedure does not involve excision of
hemorrhoidal tissue,
but instead pexes the redundant mucosa above the
dentate line.

44. PPH removes a short circumferential segment
of rectal mucosa proximal to the dentate line
using a circular stapler.
fixes redundant mucosa higher in the anal
canal.
Several studies suggest that this procedure is
safe and effective, is associated
with less postoperative pain and disability,

45. Doppler-Guided Hemorrhoidal Artery Ligation.
recent approach to treating symptomatic
hemorrhoids is Dopplerguided
hemorrhoidal artery ligation (also called transanal
hemorrhoidal
dearterioalization).
In this procedure, a Doppler probe is
used to identify the artery or arteries feeding the
hemorrhoidal
plexus.
These vessels are then ligated. Early reports have
shown
promise, but long-term durability remains to be
determined.

46. Complications of Hemorrhoidectomy
Postoperative pain
following excisional hemorrhoidectomy requires
analgesia usually with oral narcotics. Nonsteroidal
anti-inflammatory drugs,
muscle relaxants, topical analgesics, and comfort
measures,including sitz baths, are often useful as
well.
Urinary retentionis a common complication following
hemorrhoidectomy andoccurs in 10% to 50% of
patients.

47. The risk of urinary retention can be minimized by
limiting intraoperative and perioperativeintravenous
fluids and by providing adequate analgesia.
Pain can also lead to fecal impaction. Risk of
impaction maybe decreased by preoperative enemas
or a limited mechanical
bowel preparation, liberal use of laxatives
postoperatively, andadequate pain control.
While a small amount of bleeding, especiallywith
bowel movements, is to be expected, massive
hemorrhagecan occur after hemorrhoidectomy.

48. Long-term sequelae of hemorrhoidectomy
incontinence,
anal stenosis,
Many patients experience transient incontinence to
flatus, but
these symptoms are usually short-lived, and few
patients have permanent fecal incontinence.
Anal stenosis may result from
scarring after extensive resection of perianal skin.

49. Long term advises
Avoid constipation
Weight loss
Avoid prolonged sitting on the toilet
Avoid prolonged sitting at work
Improved anorectal hygiene