This document discusses hemorrhoids (Buasir/Wasir), including: - Hemorrhoids are dilated veins in the anal canal that can cause bleeding, pain, itching and prolapse. - Risk factors include prolonged standing, genetics, diet low in fiber, constipation, pregnancy, and portal hypertension. - Hemorrhoids are classified by location as internal or external and are examined by inspection, palpation, and anoscopy or proctoscopy. - Treatment depends on severity but may include increased fiber, sitz baths, sclerotherapy, rubber band ligation, or surgery such as hemorrhoidectomy.

1. 痔疮
Buasir/ Wasir
-Refer Manipal pg 792

2. It is 3 cm long, staits as the continuation of rectum, passes
through pelvic diaphragm and ends at the anal verge (skin).

3. Anal canal
Column of
Morgani

11. Dilated plexus of superior haemorrhoidal veins, in relation to
anal canal.

12. Etiology
Primary/ Idiopathic Secondary
 Standing posture
 Thin hemorrhoidal veins and
it branches
 Genetic / familial
 Diet deficient in fibres results
in constipation and small
hard pellet like stools. The
hard stools compress veins
and result in haemorrhoids.
 Rectal CA
 Portal Hypertension
 Pregnancy

13. Location

14. Symptom
 Bleeding: separate from the motion and is seen either
on the paper on wiping or as a fresh splash in the pan
(rarely cause anemia)
 Pain: not common, think of other dx/pain may also
result from congestion of pile masses below a
hypertonic sphincter / secondary to infection and
strangulation
 Constipation usually
 Prolapse
 Mucus discharge,pruritus

15. • External hemorrhoid:
at anal verge, covered
with skin
• Internal hemorrhoid:
above the dentate line,
covered with mucous
membrane.
•Mixed: presence with
both internal and
external hemorrhoids

16. External hemorrhoids
 Distal 1/3 of anal canal
 Distal to dentate line
 Cover by anoderm or by skin
 Somatically innervated
 Sensitive to touch, pain, stretch and temperature

19. Physical Examination
 Inspection:
Look for anal tags, prolapsed, swelling, lumps or bleeding
Prolapse= ask pt to strain and look for any protruded mass
External pile: covered with skin; internal pile covered with
mucous membrane
 Palpation:
Any lumps in perianal region
Digital rectal examination
 Only chronically inflamed and thrombosed hemorrhoid can be
palpated in the anal wall

20. Prolapse hemorrhoid

21. Digital rectal examination
 The resting tone of the anal canal
 Voluntary contraction of the puborectalis and external
anal sphincter.
 Mass / any area of tenderness.
 Int. hemorrhoids are generally not palpable
 Appear as bulging mucosa on anoscopy

22. Investigation
 Proctoscopy
 Sigmoidoscopy

23. Complication
Prolapse
• Impeded venous
return
Strangulation
Gangrene/fibrosis/
Thrombosis/
Ulceration
SuppurationPortal pyemia

24. Thrombosed hemorrhoid Gangrene hemorrhoid
Fibrosed internal hemorrhoid

25. Treatment of hemorrhoid
 Nonoperative: (FIBRES)- Grade I and II
a) Fibre supplementation
b) Increased fluid intake
c) Bulk purgative-laxatives (docusate sodium)-isapgul
husk, etc.
d) Reading in toilet to be discouraged (respond to call and
do not strain)
e) Encourage to lose weight
f) Sitz Bath- warm 40°C
g) Daflon- increase venous tone

26. Office procedures
 Injection of sclerosant- Grade I and II
Contraindication:
a. Acute prolapse thrombosis
b. Severe bleeding and ulceration
c. Fissure and fistula
Produce aseptic thrombosis
5% phenol in almond oil is injected into submucosa
above the dentate line
 Rubberband ligation- Grade I, II and III

27. Haemorrhoidectomy.
 Open method, closed method, stapler haemorrhoidopexy.
Candidates for surgery
 Not respond to office based procedure
 Large external hemorrhoidal dz
 Grade III/IV or mixed hemorrhoidal dz

28. Open method(Milligan-Morgan)
• Leave a bridge of skin in between the excised pile
masses to prevent anal stenosis
• Wound left open
• After haemorrhoidectomy the excised portion should
look like a clover

29. Transfixation
ligature with
nonabsorbable silk
Dissection up to the base (pedicle)
Excision of the piles with skin
•Wound left open
•excised portion should look
like a clover

30. Closed method (Hill- Ferguson)
Haemorrhoidal tissue
excised.
Mucosal wound and skin
sutured completely with a
continuous absorbable
catgut suture.

31. Postop Management
 Analgesic-morphine, pethidine
 Antibiotic+ metronidazole
 Bulk purgative
 Sitz Bath

32. Postop Complication
 Urinary retention
 Hemorrhage
 Wound infection
 Anal stenosis
 Anal fissure
 Anal stricture

33. Stapler hemorrhoidopexy