Hemorrhoid

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Hemorrhoid
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Normally, do people have anal cushion?

• Yes
• Within the normal anal canal exist specialized,
  highly vascularized cushions forming discrete
  masses of thick submucosa containing blood
  vessels, smooth muscle, and elastic and
  connective tissue
• These structures aid in anal continence

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When would we call them hemorrhoids?

• Abnormal
• Cause symptoms
• Downward sliding of anal cushions associated with
  gravity
• Straining
• Irregular bowel habits.

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How do hemorrhoids come?

• The cause of hemorrhoids remains unknown

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How could we diagnose hemorrhoid?

• History
• Physical examination
• Endoscopy

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History

• Dripping or even squirting of blood in the toilet
  bowl
• Chronic occult bleeding leading to anemia is
  rare, and other causes of anemia must be excluded

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History (contd)

• Prolapse
• below the dentate line area can occur, especially
  with straining, and may lead to mucus and fecal
  leakage and pruritus
• Pain?
• is not usually associated with uncomplicated
  hemorrhoids but more often with fissure, abscess,
  or external hemorrhoidal thrombosis

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Hemorrhoids can be divided to?

• External
• Internal

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Anatomy
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• Pain?
• -gt painless

• Bright red bleeding
• Prolapse associated with defecation

Internal

• External

• Anoderm
• Swell, discomfort, difficult hygiene

• Pain?
• -gt Thrombosed

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How are Internal hemorrhoid classified?

• Extent of prolapse

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• AThrombosed external
• BFirst-degree internal viewed through anoscope
• CSecond-degree internal prolapsed, reduced
  spontaneously
• DThird-degree internal prolapsed, requiring
  manual reduction
• EFourth-degree strangulated internal and
  thrombosed external

Reference Sabiston Textbook of Surgery, 18th
Edition
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Usefulness

• Digital examination -gt assess
• internal and external hemorrhoidal disease
• anal canal tone
• exclusion of other lesions, especially low rectal
  or anal canal neoplasms
• Virtually all anorectal symptoms are ascribed to
  hemorrhoids , anorectal pathologies be
  considered and excluded

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Anoscopy

• Definitive examination
• Flexible proctosigmoidoscopy should always be
  added to exclude proximal inflammation or
  neoplasia
• Colonoscopy or barium enema should be added if
  the hemorrhoidal disease is unimpressive, the
  history is somewhat uncharacteristic, or the
  patient is older than 40 years or has risk
  factors for colon cancer, such as a family
  history

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Treatment

• Depending on degree of disease, treatment falls
  into two main categories nonsurgical and
  hemorrhoidectomy.

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Reference Sabiston Textbook of Surgery, 18th
Edition
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Dietary modifications

• Dietary modifications are always appropriate for
  the management of hemorrhoids, if not for acute
  care then for chronic management, and for
  prevention of recurrence after banding and/or
  surgery.

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Nonsurgical Rx

• Simple measures
• better local hygiene
• avoidance of excessive straining
• better dietary habits supplemented by medication
  to keep stools soft, formed, and regular
• Symptoms of bleeding but not prolapse can be
  significantly reduced over a period of 30 to 45
  days with the use of fiber supplements

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Suppositories are good?

• Over-the-counter suppositories and anal salves,
  although popular, have never been tested for
  efficacy

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• In the absence of symptomatic external
  hemorrhoids, second- and some third-degree
  internal hemorrhoids can be treated with office
  procedures that produce mucosal fixation.

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What is the best?

• Sclerotherapy
• Infrared coagulation
• Heater probe
• Bipolar electrocoagulation

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What is the best?

• The simplest, most effective, and most widely
  applied office procedure is rubber band ligation

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How many sites we can perform this procedure?

• Only one site should be banded each time

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Is there any contraindication?

• Taking
• Antiplatelet
• Blood-thinning medications
• Subacute bacterial endocarditis prophylaxis
• Immunodeficient patientsSubacute bacterial
  endocarditis prophylaxis

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Any advice for patients?

• Be aware of severe perineal sepsis and even
  deaths after rubber band ligation
• Return to the emergency department if delayed or
  undue pain, inability to void, or a fever develops

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Surgical Rx

• Hemorrhoidectomy is the best means of curing
  hemorrhoidal disease
• Considered when
• patients fail to respond satisfactorily to
  repeated attempts at conservative measures
• hemorrhoids are severely prolapsed and require
  manual reduction
• hemorrhoids are complicated by strangulation or
  associated pathology, such as ulceration,
  fissure, fistula
• hemorrhoids are associated with symptomatic
  external hemorrhoids or large anal tags

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Surgical Rx (contd)

• Simple thrombosed external hemorrhoids
• excision in the office is best performed early in
  the course of the disease, during the period of
  maximum pain

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• To remove complex internal or external
  hemorrhoids, an open or closed hemorrhoidectomy
  can be performed as an outpatient procedure

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• Three bundles are identified in the right
  anterior, right posterior, and left lateral
  positions
• Be careful, sufficient anoderm is preserved to
  avoid the long-term complication of anal stenosis
• Postoperative complications
• Fecal impaction
• Infection
• Urinary retention
• Patients typically recover sufficiently to return
  to work within 1 to 2 weeks
• As an alternative to the closed technique, the
  surgical wounds can be left open to reduce
  postoperative pain, but at the expense of longer
  healing times.

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Newer technology

• Goal to decrease postoperative pain
• The two main categories
• Ultrasonic or controlled electrical energy such
  as the Harmonic Scalpel and Liga-Sure
• Longos technique

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Stapled hemorrhoidopexy

• Longo's technique, commonly referred to as the
  stapled hemorrhoidectomy or stapled
  hemorrhoidopexy
• Excises a circumferential portion of the lower
  rectal and upper anal canal mucosa and submucosa
  and performs a reanastomosis with a circular
  stapling device
• As a result, the prolapsed anal cushions are
  retracted into their normal anatomic positions
  within the anal canal. In addition, the terminal
  branches of the inferior hemorrhoidal artery are
  disrupted, and blood flow into the cushions is
  thereby decreased. The primary physiologic appeal
  of this operation is that it leaves the richly
  innervated anal canal tissue and perianal skin
  intact, thus reducing the pain usually associated
  with excisional hemorrhoidectomy

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• Initially, stapled hemorrhoidopexy was performed
  with a large standard end-to-end anastomosis
  (EEA) stapler. Recently, however, a dedicated
  stapling device specifically designed for this
  operation was introduced into clinical practice.
  The stapled hemorrhoidopexy consists of five
  steps
• Reduce the prolapsed tissue
• Gently dilate the anal canal to allow it to
  accept the instrument.
• Place a purse-string suture
• Place and fire the stapler
• Control any bleeding from the staple line

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• Most important technical consideration is proper
  placement of the purse-string suture
• The suture should be at least 3 to 4 cm above the
  dentate line if it is too low, a portion of the
  dentate line may be excised, which could lead to
  a severe prolonged pain syndrome or to persistent
  fecal urgency. In addition, the purse-string
  suture must be placed so as to incorporate all of
  the redundant tissue circumferentially failure
  to do so may lead to incomplete excision and
  predispose to recurrent prolapse
• Finally, extreme care must be exercised in
  placing the purse-string suture in women so that
  the vagina is not entrapped anteriorly.

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Stapled hemorrhoidopexy

• Vs. excisional hemorrhoidectomy
• Significantly less postoperative pain overall
• Less pain with the first bowel movement
• Earlier resumption of normal activities
• has been associated with a number of serious
  complications, including anastomotic dehiscence
  necessitating colostomy, rectal perforation,
  severe pelvic infection, and acute rectal
  obstruction and therefore training before use is
  strongly recommended