This document discusses hemorrhoidal disease, including definitions, incidence, pathogenesis, classification, symptoms, and treatment options. It defines hemorrhoids as dilated vascular channels located in three constant locations in the anus. Hemorrhoidal disease is manifested by prolapse, bleeding, and itching. Treatment options discussed include sclerosing injections, infrared photocoagulation, rubber band ligation, and hemorrhoidectomy. The preferences for treatment are outlined based on the degree of hemorrhoids.

1. Hemorrhoidal disease
Samir Haffar M.D.

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. Usual sites of internal hemorrhoids
Knee-chest position
Left lateral
Right posterior
Right anterior

4. Incidence of hemorrhoidal disease
• Exact incidence is not known
• 10 - 25 % of adult population thought to be
affected

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. 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. 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. Third degree internal hemorrhoids

9. Forth degree internal hemorrhoids

10. Knee-chest position

11. Anal & rectal palpation

12. Normal anal canal

13. Internal hemorroids
Seen with the proctoscope

14. Localized hemorrhoidal prolapse

15. Prolapse of 3 mains hemorrhoidal piles

16. External hemorroids (skin tags)

17. Hypertrophic papillae

18. Protruding hypertrophied papilla

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. 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. Sclerosing injection
Instruments

22. Sclerosing injection

23. Sites of sclerosing injections
1 Superficial
2 Good (submucosa)
3 Deep (intramuscular)

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. Infrared photocoagulation

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. Rubber band ligation

28. Rubber band ligation

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. 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. Rubber band ligation is probably the
most common fixation method in use
worldwide today

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. External hemorroidal thrombosis

34. Thrombectomy
Instruments

35. Thrombectomy
Local anesthesia Incision
Enucleation

36. Edematous external hemorroidal thrombosis

37. Sebaceous cyst
Not painful After puncture

38. Thrombosed hemorrhoidal prolapse
Acute hemorrhoidal disease

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. Only about 10% of patients should
undergo operation

41. Thank You