Haemorrhoids

• One of the most common conditions to affect humans.

• Incidence of approximately 5% of the population.
• First mentioned in the Bible.
 What Are Haemorrhoids?
Engorgement of the haemorrhoidal venous
plexuses with redundancy of their
coverings.
 Anal Cushions
• Haemorrhoidal venous plexuses lie in the
subepithelial tissues both above and below the
Pecinate line.
• Haemorrhoidal venous
plexuses together with some
arteriovenous anastomoses, are
surrounded by smooth muscle,
elastic and fibrous tissue to form
3 anal cushions.

• These are found in the

following positions:

- Left lateral.
- Right posterior.
- Right anterior.
• Congest during Valsalva manoeuvre or when
increased intra-abdominal pressure.
• Shield anal canal and sphincter during the act of
evacuation.
• It is thought that their function is to complete the
closure of the anal canal.
• Vascular cushions contribute 15% of the anal
canal’s pressure.
• An increase in the size of the cushions is the
starting point of haemorrhoids.
 Pathophysiology & Aetiology
• Not fully understood – many theories.
• Proposed causes are:

- Straining, - Pregnancy,
- Inadequate fibre intake, - Ascites,
- Prolonged lavatory sitting, - Pelvic Space occupying
- Constipation, lesions,

- Diarrhoea, - ? Family Hx,

 Incidence
• Difficult to evaluate.
• Prevalence of approximately 5%.
• Peak of prevalence is between 45 and
65.
• Development before 20 unusual.
• Caucasians more affected than Afro-
Caribbeans.
 Symptoms
• Bleeding
• Anal swelling
• Painful anal mass
• Discomfort
• Discharge
• Hygiene problems
• Soiling
• Pruritus
 Differential Diagnosis
• Skin tags
• Condyloma acuminata (anal warts)
• Hypertrophied anal papilla
• Rectal prolapse
• Fissure
• Abscess
• Fistula
• Perianal Crohn’s Disease
• Polyps
• Carcinoma
• Melanoma.
 Diagnostic Tests
• Normally easily made on a physical exam.
• Preferably accompanied by Proctoscopy.
• Flexible sigmoidoscopy (rarely used).
• Acute pain may require an evaluation
under anaesthesia in the operating room.
• Patients with soiling and incontinence
should be investigated with anal
manometry.
 External or Internal?
• Classified according to origin of haemorrhoid.
• Above or below the Pecinate line?
• Can be mixed.
Grading of Internal Haemorrhoids
1st degree - Originates and remains above the Pecinate line.
2nd degree – May prolapse beyond the external sphincter on
defaecation but spontaneously return within the anal canal.
3rd degree – protrude outside of the anal canal and require
manual reduction.
4th degree – Irreducible.

Internal haemorrhoids visible

on retro-flexion at
Sigmoidoscopy.
Thrombosis

Thrombosed
Internal
Haemorrhoids

Thrombosed
External
Haemorrhoids
 Treatment Options
Lifestyle Modifications

• Integral part of treatment for all

haemorrhoidal disease.
• Improved anal hygiene
• Increased dietary fibre
• Increased dietary fluids
• Avoid constipation or diarrhoea.
Oral Medications
• Oral vasotopic drugs.
• Most common - purified flavonoid fraction.
• Action:
- Increases vascular tone
- Increases lymphatic drainage
- Anti-inflammatory effects.
- Several recent studies have shown it to be
effective.
Topical Treatment
• Many over the counter medications available.
• Include: Pads, ointments, creams, gels, lotions
and suppositories.
• Cocktail of local anaesthetics, corticosteroids,
antiseptics, astringents and other ingredients.
 Appropriate Occludes Fixes Excises Reduces
Method Blood Mucosa Tissue Anal
For
supply Pressure.

Sclerotherapy 1st degree * *

Infra-red Coag 1st degree * *
Band Ligation 2nd degree * * *
Cryosurgery 2nd degree * * *
Manual Dilation 2nd degree *
of anus.
Sphincterotomy 2nd degree *
(lateral)
Haemorrhoid 2nd + 3rd degree *
-ectomy
 Sclerotherapy
• Treatment option for symptomatic
non-prolapsing grades I to II
haemorrhoids.
• Haemorrhoid injected with phenol,
vegetable oil, quinine, and urea
hydrochloride.
• Causes oedema, inflammatory
reaction, & intravascular thrombosis.
•Submucosal fibrosis & scarring
minimises the extent of mucosal
prolapse and potentially shrinks the
haemorrhoid as well.
Band Ligation
• Ligation with a rubber band
causes ischaemic necrosis,
ulceration and scarring.
• Fixes connective tissue to the
rectal wall.
• If treating mixed haemorrhoids,
analgesia is essential!
 Surgical Treatment
Offered when:

- Other procedures unsuccessful.

- For patients who cannot tolerate other
procedures.
- Large external haemorrhoids.
- Grade III to IV mixed haemorrhoidal disease.
• Many different techniques practiced.
• Conventional methods includes excision of
internal and external haemorrhoidal tissue.
• Multiple instruments can be employed.
• All of these techniques require specialist
training, because the complications can be
severe.
 Milligan-Morgan (open)
Haemorrhoidectomy
• First described over 2 centuries ago.
• Haemorrhoidal pedical mobilised.
• Absorbable suture placed at the pedicle
site.
• Haemorrhoidal tissue excised.
• Wound left open.
• Often used because of location, technical
difficulties or extensive/gangrenous
haemorrhoidal tissue.
Final Operative Aspect in a Haemorrhoidectomy.
 Ferguson’s (Closed)
Haemorrhoidectomy
• Developed in 1952
• Haemorrhoidal pedical mobilised.
• Absorbable suture placed at the pedicle
site.
• Haemorrhoidal tissue excised.
• Mucosal wound and skin sutured
completely shut with a continuous suture.
 Harmonic Scalpel
• Allows excision of haemorrhoids with
sutureless technique
• Offers shorter operative time and less
post-op pain.
• Can be performed in O/P setting and
hospital stay is generally not required.
• Increased cost comparative to other
techniques.
 PPH (the procedure for prolapse and
hemorrhoids) or Haemorrhoidopexy

• Longo introduced the technique in 1995.

• Stapler introduced trans-anally.
• Circumferential band of excessive rectal mucosa
and submucosa proximal to the haemorrhoidal
tissue is excised.
• Fixes mucosa to rectal
Wall.
• Interrupts blood supply.
 References
• M. Hulme-Moir and D.C. Bartolo, Hemorrhoids, Gastroenterol Clin North Am 30
(2001), pp. 183–197.
• J.F. Johanson and A. Sonnenberg, The prevalence of hemorrhoids and chronic
constipation An epidemiologic study, Gastroenterology 98 (1990), pp. 380–386.
• T.C. Sardinha and M.L. Corman, Hemorrhoids, Surg Clin North Am 82 (2002),
pp. 1153–1167
• P.B. Loder, M.A. Kamm, R.J. Nicholls and R.K. Phillips, Haemorrhoids:
pathology, pathophysiology and aetiology, Br J Surg 81 (1994), pp. 946–954
• V. Shanmugam, M.A. Thaha and K.S. Rabindranath et al., Systematic review of
randomized trials comparing rubber band ligation with excisional
haemorrhoidectomy, Br J Surg 92 (2005), pp. 1481–1487.
• S.Y. Kwok, C.C. Chung, K.K. Tsui and M.K. Li, A double-blind, randomized trial
comparing Ligasure and Harmonic Scalpel hemorrhoidectomy, Dis Colon
Rectum 48 (2005), pp. 344–348.
• A. Longo, Stapled anopexy and stapled hemorrhoidectomy: two opposite
concepts and procedures, Dis Colon Rectum 45 (2002), pp. 571–572.
• Orit Kaidar-Person, Hemorrhoidal Disease: A Comprehensive Review. Journal
of the American College of Surgeons 204 (2007), pp. 102-117
• Michael Henry, Clinical Surgery (2002) W.B.Saunders pp 367 -371
Indications For Complete Colon Evaluation
In Patients With Haemorrhoidal Symptoms