haemorrhoids are the most common tyoe of gastroenterological disease. it is a nutritive disease. here is a quick review on hemorrhoids, its pathophysiology, clinical features, classification, diagnosis and management.
What are Anal Fissures? Symptoms,causes,Risk Factors & Treatmentjyotinursinghome
Anal Fissures are basically a cut or tearing in the anus part of the body that comes out upwards into the anal canal. Fissures are common situations of the anus and anal canal and are responsible for 6% to 15% of the visits to a colon and rectal (colorectal) surgeon.Get guaranteed fissure treatment in jaipur at jyotinursinghome by leading colorectal & laparoscopic surgeon-Dr Jaya Maheshwari.
Visit us to know more about fissure and its treatment at: http://www.jyotinursinghome.com/fissure-treatment-in-jaipur.html
What are Anal Fissures? Symptoms,causes,Risk Factors & Treatmentjyotinursinghome
Anal Fissures are basically a cut or tearing in the anus part of the body that comes out upwards into the anal canal. Fissures are common situations of the anus and anal canal and are responsible for 6% to 15% of the visits to a colon and rectal (colorectal) surgeon.Get guaranteed fissure treatment in jaipur at jyotinursinghome by leading colorectal & laparoscopic surgeon-Dr Jaya Maheshwari.
Visit us to know more about fissure and its treatment at: http://www.jyotinursinghome.com/fissure-treatment-in-jaipur.html
Please find the power point on Hemorrhoids. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.
Lecture on haemorrhoids for medical students. Encompasses basic sciences, classifications, principles and tips of management of this very common yet potentially complicated disorder.
Fistula is an abnormal condition in which there is a tunnel from the end of bowel movement to the skin around the anus. Healing Hands Clinic is a certified center of excellence for the treatment of fistula having centers at Pune, Chinchwad, Mumbai, Navi Mumbai, Chakan, Nashik, and Bengaluru. It deals with all type of anorectal disorders such as piles, fistula, constipation, fissure, hernia and others.
For more details visit: https://www.healinghandsclinic.co.in/fistula-treatment-centre/
Please find the power point on Hemorrhoids. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.
Lecture on haemorrhoids for medical students. Encompasses basic sciences, classifications, principles and tips of management of this very common yet potentially complicated disorder.
Fistula is an abnormal condition in which there is a tunnel from the end of bowel movement to the skin around the anus. Healing Hands Clinic is a certified center of excellence for the treatment of fistula having centers at Pune, Chinchwad, Mumbai, Navi Mumbai, Chakan, Nashik, and Bengaluru. It deals with all type of anorectal disorders such as piles, fistula, constipation, fissure, hernia and others.
For more details visit: https://www.healinghandsclinic.co.in/fistula-treatment-centre/
Homeopathy is highly scientific, logical, safe, quick and extremely effective method of healing. It offers long lasting to permanent cure, treating the disease from its roots, for most of the ailments.
Homeopathy is the most rational science with respect to its concepts of health, disease and cure. Homeopathy does not treat superficially by just driving away the symptoms but heals the patient from within.
Undoubtedly, homeopathy is the medicine of future.
The remedies are prepared from natural substances to precise standards and work by stimulating the body’s own healing power.
But in case of injuries caused to the body from without, the surgical treatment is necessary only to the extent that the parts injured require mechanical aid whereby the external obstruction to cure is removed mechanically. But in such injuries also the living organism requires active dynamic aid to put it in a position to restore the organism to health and homeopathic treatment is called for.homeopathic remedies can play a vital role in reducing any complications that may arise as well as accelerating healing and recovery.
Hemorrhoids in Women & Men - What You Need to Know.pdfMeghaSingh194
Hemorrhoids in Women and Men can be a common and uncomfortable condition. Hemorrhoids, also known as piles, are a common medical condition that affects both men and women. Swelling and inflammation happen when the veins in the rectum and anus become enlarged. Let's explore more: https://www.southlakegeneralsurgery.com/hemorrhoids-in-women-symptoms-causes-treatment/
The esophagus is a muscular tube that connects the pharynx to the stomach.
It begins in the neck where it is continuous with the laryngopharynx at the pharyngo-esophageal junction.
The esophagus consists of striated (voluntary) muscle in its upper third, smooth (involuntary) muscle in its lower third, and a mixture of striated and smooth muscle in between.
Hernia is an abnormal swelling and expulsion of tissue. abdominally hernia usually involves groin. groin henias can be either inguinal or femoral. here is a brief review about hernias, types, classification, assessment and management.
importance and scope of space pharmacy. medicines in space. pharmacokinetics and pharmacodynamics in space. drug metabolism. physiological changes in space.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
1. Short review on Hemorrhoids
Dr Anjum Ahamadi
Pharm D
sultan-Ul-Uloom college of pharmacy
2. Introduction
• Hemorrhoids also called piles, are swollen veins in anus and
lower rectum, similar to varicose veins.
• Based on origin they are of two types.
• Internal hemorrhoids: they are usually painless, but tend to
bleed. Internal hemorrhoids develop in the lower rectum.
Internal hemorrhoids may protrude through the anus but most
of the protruted or prolapsed hemorrhoids shrink back inside
the rectum on their own. Severely prolapsed hemorrhoids may
protrude permanently and require treatment.
• External hemorrhoids: they may cause pain. External
hemorrhoids are located under the skin around the anus.
• Haemorrhoids are usually caused by straining during bowel
movements, obesity or pregnancy.
3.
4. Etiology
• Swelling in the anal or rectal veins causes hemorrhoids.
• Factors causeing swelling includes: chronic constipation or
diarrhea, straining during bowel movements, sitting on the
toilet for long periods of time, a lack of fiber in the diet.
• Another cause of hemorrhoids is the weakening of the
connective tissue in the rectum and anus that occurs with
age(age above 45).
• Pregnancy can cause hemorrhoids by increasing pressure in
the abdomen, which may enlarge the veins in the lower
rectum and anus, for most women, hemorrhoids caused by
pregnancy disappear after childbirth.
5. Pathophysiology
• Pathophysiology is based on the theory of sliding anal
canal lining.
• This proposes that hemorrhoids develop when the
supporting tissues of the anal cushions disintegrate or
deteriorate.
• Hemorrhoids are therefore the pathological term to
describe the abnormal downward displacement of the
anal cushions causing venous dilatation.
• There are three major anal cushions, located in the right
anterior, right posterior and left lateral aspect of the anal
canal, and various numbers of minor cushions lying
between them, they undergo various pathological
changes in this condition.
6. • The changes include: abnormal venous dilatation, vascular
thrombosis, degenerative process in the collagen fibers and
fibroelastic tissues, distortion and rupture of the anal
subepithelial muscle.
• In addition to the above findings, a severe inflammatory
reaction involving the vascular wall and surrounding
connective tissue has been demonstrated in hemorrhoidal
specimens, with associated mucosal ulceration, ischemia and
thrombosis.
• Several enzymes were found to be responsible for
degeneration of anal cushion among,which matrix
metalloproteinase (MMP), a zinc-dependent proteinase, is one
of the most potent enzymes, being capable of degrading
extracellular proteins such as elastin, fibronectin, and
collagen.
7. • MMP-9 was found to be over-expressed in hemorrhoids, in
association with the breakdown of elastic fibers.
• Activation of MMP-2 and MMP-9 by thrombin, plasmin or
other proteinases resulted in the disruption of the capillary
bed and promotion of angioproliferative activity of
transforming growth factor β (TGF-β).
• Neovascularization is found in hemorrhoids.
• Terminal branches of the superior rectal artery supplying the
anal cushion in patients with hemorrhoids and it has
significantly larger diameter, greater blood flow, higher peak
velocity and acceleration velocity, compared to those of
healthy volunteers. Moreover, an increase in arterial caliber
and flow was well correlated with the grades of hemorrhoids.
8. • A sphincter-like structure, formed by a thickened tunica
media containing 5-15 layers of smooth muscle cells,
between the vascular plexus within the subepithelial space
of the anal transitional zone in identified.
• Unlike this the hemorrhoids contain remarkably dilated,
thin-walled vessels within the submucosal arteriovenous
plexus, with absent or nearly-flat sphincter-like constriction
on the vessels.
• This concludes that a smooth muscle sphincter in the
arteriovenous plexus helps in reducing the arterial inflow,
thus facilitating an effective venous drainage.
• Then it was proposed that, if this mechanism is impaired,
hyperperfusion of the arteriovenous plexus will lead to the
formation of hemorrhoids.
9. • Based on the histological findings of abnormal venous
dilatation and distortion in hemorrhoids, it is understood that
dysregulation of the vascular tone might play a role in
hemorrhoidal development.
• Basically, vascular smooth muscle is regulated by the
autonomic nervous system, hormones, cytokines and overlying
endothelium.
• Imbalance between endothelium-derived relaxing factors (such
as nitric oxide, prostacyclin, and endothelium-derived
hyperpolarizing factor) and endothelium-derived
vasoconstricting factors (such as reactive oxygen radicals and
endothelin) causes several vascular disorders.
• In hemorrhoids, nitric oxide synthase, an enzyme which
synthesizes nitric oxide from L-arginine, was reported to
increase significantly.
10.
11.
12. Classification and grading
• Some authors proposed classifications based on anatomical
findings of hemorrhoidal position: described as primary (at the
typical three sites of the anal cushions), secondary (between
the anal cushions), or circumferential.
• Based on symptoms: described as prolapsing and non-
prolapsing. However, these classifications are in less
widespread use.
• Based on location: Internal hemorrhoids originate from the
inferior hemorrhoidal venous plexus above the dentate line and
are covered by mucosa. external hemorrhoids are dilated
venules of this plexus located below the dentate line and are
covered with squamous epithelium. Mixed (interno-external)
hemorrhoids arise both above and below the dentate line.
• Internal hemorrhoids are further graded.
13. Grading of internal hemorrhoid
• Internal hemorrhoids are further graded based on their appearance
and degree of prolapse.
• This classification is known as Goligher’s classification:
• (1) First-degree hemorrhoids (grade I): The anal cushions bleed but do
not prolapse;
• (2) Second-degree hemorrhoids (grade II): The anal cushions prolapse
through the anus on straining but reduce spontaneously;
• (3) Third-degree hemorrhoids (grade III): The anal cushions prolapse
through the anus on straining or exertion and require manual
replacement into the anal canal; and
• (4) Fourth-degree hemorrhoids (grade IV): The prolapse stays out at all
times and is irreducible.
• Acutely thrombosed, incarcerated internal hemorrhoids and
incarcerated thrombosed hemorrhoids involving circumferential rectal
mucosal prolapse are also fourth-degree hemorrhoids.
14. Clinical features
• Hemorrhoids are not dangerous or life threatening.
• Symptoms usually go away within a few days, and some people with
hemorrhoids never have symptoms.
• Internal hemorrhoids: The most common symptom of internal
hemorrhoids is bright red blood in stool after a bowel movement.
Internal hemorrhoids that are not prolapsed are usually not painful.
Prolapsed hemorrhoids often cause pain, discomfort, and anal itching.
• External hemorrhoids: Blood clots may form in external hemorrhoids. A
blood clot in a vein is called a thrombosis. Thrombosed external
hemorrhoids cause bleeding, painful swelling, or a hard lump around
the anus. When the blood clot dissolves, extra skin is left behind. This
skin can become irritated or itch.
• Excessive straining, rubbing, or cleaning around the anus may make
symptoms, such as itching and irritation, worse. Hemorrhoids are not
dangerous or life threatening. Symptoms usually go away within a few
days, and some people with hemorrhoids never have symptoms.
15.
16. Diagnosis
• Anal and rectal examination.
• Physical examination to look for visible hemorrhoids.
• A digital rectal exam with a gloved, lubricated finger and an anoscope(a
hollow, lighted tube) may be performed to view the rectum.
• Other tests include:
• Colonoscopy: A flexible, lighted tube called a colonoscope is inserted
through the anus, the rectum, and the upper part of the large intestine,
called the colon. The colonoscope transmits images of the inside of the
rectum and the entire colon.
• Sigmoidoscopy: This procedure is similar to colonoscopy, but it uses a
shorter tube called a sigmoidoscope and transmits images of the rectum
and the sigmoid colon, the lower portion of the colon that empties into
the rectum. •
• Barium enema x ray: A contrast material called barium is inserted into the
colon to make the colon more visible in x-ray pictures.
18. Dietary modification and lifestyle
changes
• Since shearing action of passing hard stool on the anal
mucosa may cause damage to the anal cushions and lead to
symptomatic hemorrhoids, increasing intake of fiber or
providing added bulk in the diet might help eliminate straining
during defecation.
• In clinical studies of hemorrhoids, fiber supplement reduced
the risk of persisting symptoms and bleeding by
approximately 50%, but did not improve the symptoms of
prolapse, pain, and itching.
• Fiber supplement is therefore regarded as an effective
treatment in non-prolapsing hemorrhoids; however, it could
take up to 6 wk for a significant improvement to be manifest.
19. • As fiber supplements are safe and cheap, they remain an
integral part of both initial treatment and of a regimen
following other therapeutic modalities of hemorrhoids.
• Lifestyle modification should also be advised to any
patients with any degree of hemorrhoids as a part of
treatment and as a preventive measure.
• These changes include increasing the intake of dietary fiber
and oral fluids, reducing consumption of fat, having regular
exercise, improving anal hygiene, abstaining from both
straining and reading on the toilet, and avoiding medication
that causes constipation or diarrhea.
20. Pharmacotherapy
• Oral flavonoids: also known as venotonic agents were first
described in the treatment of chronic venous insufficiency and
edema.
• They appeared to be capable of increasing vascular tone, reducing
venous capacity, decreasing capillary permeability, and facilitating
lymphatic drainage as well as having anti-inflammatory effects.
• Although their precise mechanism of action remains unclear, they
are used as an oral medication for hemorrhoidal treatment,
particularly in Europe and Asia.
• Micronized purified flavonoid fraction (MPFF), consisting of 90%
diosmin and 10% hesperidin, is the most common flavonoid used in
clinical treatment.
• The micronization of the drug to particles of less than 2 μm not only
improved its solubility and absorption, but also shortened the onset
of action.
21.
22. • Oral calcium dobesilate: This is another venotonic drug commonly
used in diabetic retinopathy and chronic venous insufficiency as well
as in the treatment of acute symptoms of hemorrhoids.
• It was demonstrated that calcium dobesilate decreased capillary
permeability, inhibited platelet aggregation and improved blood
viscosity; thus resulting in reduction of tissue edema.
• A clinical trial of hemorrhoid treatment showed that calcium
dobesilate, in conjunction with fiber supplement, provided an
effective symptomatic relief from acute bleeding, and it was
associated with a significant improvement in the inflammation of
hemorrhoids.
• Topical agents: it provide only syptomatic cure.
• various topical agents are available in the form of suppositories,
ointments, creams etc.
• These topical medications can contain various ingredients such as
local anesthesia, corticosteroids, antibiotics and anti-inflammatory
drugs.
23. • Topical glyceryl trinitrate 0.2% ointment is used for relieving
hemorrhoidal symptoms in patients with low-grade hemorrhoids
and high resting anal canal pressures.
• local application of nifedipine ointment in treatment of acute
thrombosed external hemorrhoids was known to be effective.
• Apart from topical medication influencing tone of the internal anal
sphincter, some topical treatment targets vasoconstriction of the
vascular channels within hemorrhoids,
• such as Preparation-H® (Pfizer, United States), which contains
0.25% phenylephrine, petrolatum, light mineral oil, and shark liver
oil.
• Phenylephrine is a vasoconstrictor having preferential vasopressor
effect on the arterial site of circulation, whereas the other
ingredients are considered protectants.
• Preparation-H is available in many forms, including ointment,
cream, gel, suppositories, and medicated and portable wipes.
• It provides temporary relief of acute symptoms of hemorrhoids,
such as bleeding and pain on defecation.
24. Non pharmacological(non operative)
therapy
• Sclerotherapy: This is currently recommended as a treatment option for
first- and second-degree hemorrhoids.
• It involves administration of chemical agents to create a fixation of mucosa
to the underlying muscle by fibrosis.
• The solutions used for injecting are 5% phenol in oil, vegetable oil,
quinine, and urea hydrochloride or hypertonic salt solution.
• The solution shouk be injected into submucosa at the base of the
hemorrhoidal tissue and not into the hemorrhoids themselves; otherwise,
it can cause immediate transient precordial and upper abdominal pain.
• Misplacement of the injection may also result in mucosal ulceration or
necrosis, and rare septic complications such as prostatic abscess and
retroperitoneal sepsis.
• Antibiotic prophylaxis is indicated for patients with predisposing valvular
heart disease or immunodeficiency because of the possibility of
bacteremia after sclerotherapy.
25. • Rubber band ligation: Rubber band ligation (RBL) is a simple, quick, and
effective means of treating first- and second-degree hemorrhoids and
selected patients with third-degree hemorrhoids.
• Ligation of the hemorrhoidal tissue with a rubber band causes ischemic
necrosis and scarring, leading to fixation of the connective tissue to the rectal
wall.
• Placement of rubber band too close to the dentate line may cause severe
pain due to the presence of somatic nerve afferents and requires immediate
removal.
• RBL is safely performed in one or more than one place in a single session with
one of several commercially available instruments, including hemorrhoid
ligator rectoscope and endoscopic ligator which use suction to draw the
redundant tissue in to the applicator to make the procedure a one-person
effort.
• The most common complication of RBL is pain or rectal discomfort, which is
usually relieved by warm sitz baths, mild analgesics and avoidance of hard
stool by taking mild laxatives or bulk-forming agents.
26. • Other complications include minor bleeding from mucosal ulceration, urinary
retention, thrombosed external hemorrhoids, and extremely rarely, pelvic
sepsis. The patients should stop taking anticoagulants for one week before and
two weeks after RBL.
• Infrared coagulation: The infrared coagulator produces infrared radiation which
coagulates tissue and evaporizes water in the cell, causing shrinkage of the
hemorrhoid mass.
• A probe is applied to the base of the hemorrhoid through the anoscope and the
recommended contact time is between 1.0-1.5 s, depending on the intensity
and wavelength of the coagulator.
• The necrotic tissue is seen as a white spot after the procedure and eventually
heals with fibrosis.
• Compared with sclerotherapy, infrared coagulation (IRC) is less technique-
dependent and avoids the potential complications of misplaced sclerosing
injection.
• Although IRC is a safe and rapid procedure, it may not be suitable for large,
prolapsing hemorrhoids.
• Radiofrequency ablation: it is a new technique of hemorrhoidal treatment.
• A ball electrode connected to a radiofrequency generator is placed on the
hemorrhoidal tissue and causes the contacting tissue to be coagulated and
evaporized.
27. • By this method, vascular components of hemorrhoids are reduced and
hemorrhoidal mass will be fixed to the underlying tissue by subsequent
fibrosis.
• RFA can be performed on an outpatient basis and via an anoscope similar to
sclerotherapy.
• Complications include acute urinary retention, wound infection, and perianal
thrombosis.
• Even though RFA is a virtually painless and safe procedure, it is associated
with a higher rate of recurrent bleeding and prolapse.
• Cryotherapy: it ablates the hemorrhoidal tissue with a freezing cryoprobe.
• It has been claimed to cause less pain because sensory nerve endings are
destroyed at very low temperature.
• However, several clinical trials revealed that it was associated with prolonged
pain, foul-smelling discharge and a high rate of persistent hemorrhoidal mass.
• It is therefore rarely used.
• Hence, RBL could be recommended as the initial non-operative modality for
treatment of grade I-III hemorrhoids.
• In a British survey of almost 900 general and colorectal surgeons, RBL was the
most common procedure performed, following by sclerotherapy and
hemorrhoidectomy.
28. Operative therapy
• Hemorrhoidectomy: Excisional hemorrhoidectomy is the
most effective treatment for hemorrhoids with the lowest
rate of recurrence compared to other modalities.
• It can be performed using scissors, diathermy or vascular-
sealing device such as Ligasure and Harmonic scalpels.
• Excisional hemorrhoidectomy can be performed safely under
perianal anesthetic infiltration as an ambulatory surgery.
• Indications for hemorrhoidectomy include failure of non-
operative management, acute complicated hemorrhoids such
as strangulation or thrombosis, patient preference, and
concomitant anorectal conditions such as anal fissure or
fistula-in-ano which require surgery.
• In clinical practice, the third-degree or fourth-degree internal
hemorrhoids are the main indication for hemorrhoidectomy.
29.
30. • Plication: Plication is capable of restoring anal cushions to their normal position
without excision.
• This procedure involves oversewing of hemorrhoidal mass and tying a knot at the
uppermost vascular pedicle(first image).
• However, there are still a number of potential complications following this
procedure such as bleeding and pelvic pain
• Dogler guided arterial ligation: Doppler-guided hemorrhoidal artery ligation
(DGHAL) is a nonexcisional surgical technique for the treatment of hemorrhoidal
disease, consisting of the ligation of the distal branches of the superior rectal
artery, resulting in a reduction of blood flow and decongestion of hemorrhoidal
plexus resulting in fibrosis(second image).
31. • Stapled hemorrhoidopexy: A circular stapling device is used to excise a ring of
redundant rectal mucosa proximal to hemorrhoids and resuspend the hemorrhoids
back within the anal canal.
• Apart from lifting the prolapsing hemorrhoids, blood supply to hemorrhoidal tissue
is also interrupted.
• Stapled hemorrhoidopexy involves stapling the last section of the large bowel,
which reduces the supply of blood to the hemorrhoids and causes them to
gradually shrink.
32.
33. Pregnancy hemorrhoids
• Hemorrhoids are very common during pregnancy especially in the third
trimester.
• Acute crisis such as profound bleeding and irreducible prolapsing may be found
in pregnant women with pre-existing hemorrhoids.
• Since hemorrhoids and its symptoms will gradually resolve after giving birth, the
primary goal of treatment is to relief acute symptoms related to hemorrhoids by
means of dietary and lifestyle modification.
• Kegel exercises, lying on left side, and avoidance of constipation could reduce
the episode and severity of bleeding and prolapse.
• Fiber supplement, stool softener and mild laxatives are generally safe for
pregnant women.
• Topical medication or oral phlebotonics may be used with special caution
because the strong evidence of their safety and efficacy in pregnancy is lacking.
• In case of massive bleeding, anal packing could be a simple and useful
maneuver.
• Hemorrhoidectomy is reserved in strangulated or extensively thrombosed
hemorrhoids, and hemorrhoids with intractable bleeding.