Haemorrhoids

Introduction
1. extremely common
2. affecting nearly half of the population at some time in their lives
3. Gender Differences
  1. Men
    1. suffer
      1. more often
      2. longer periods
  2. Women
    1. susceptible
      1. late pregnancy
      2. puerperium
Pathogenesis
1. heredity
  1. predisposition
    1. pregnancy
    2. constipation
    3. diarrhoea
2. probably initiated by
  1. straining to pass small hard stools
    1. raises intra-abdominal pressure
      1. obstructs venous return
      2. venous plexuses become engorged
      3. bulging mucosa dragged distally by the hard stool
3. Haemorrhoids may
  1. bleed
    1. arterial component of the anal cushion
      1. characteristic bright red rectal bleeding
    2. venous component
      1. causes problem ONLY if it becomes thrombosed
      2. thrombosed external venous saccule
  2. prolapse
  3. cause slight
    1. mucus
    2. faecal
    3. leakage
4. Located at
  1. When viewed
    1. supine
    2. lithotomy
    3. position
  2. 3
  3. 7
  4. 11
  5. o'clock positions
    1. correspond to the positions of the anal cushions
Classification
1. degree
  1. 1st
    1. never prolapse
  2. 2nd
    1. prolapse through defaecation
    2. return sponaneously into the anal canal
  3. 3rd
    1. remain outside the anal margin
      1. unless replaced digitally
2. Most haemorrhoids can be described as internal because they are covered by glandular mucosa
3. Large neglected haemorrhoids may extend beneath the stratified squmaous epithelium so that their lower part becomes covered by skin
4. intero-external piles
Symptoms and Signs
1. intermittent symptoms
2. attacks last from a few days to a few weeks
3. precipitating factor
  1. episodes of constipation
4. bleeding
  1. stool trauma
5. prolapse
  1. large haemorrhoids
    1. then thrombose
6. small skin tags
7. common chronic or intermittent
  1. perianal irritation
  2. Itching(pruritus ani)
  3. rectal bleeding
    1. on the paper
    2. seperate from the stool
  4. haemorrhoidal prolapse
  5. mucus leakage
  6. Mild incontinence of flatus
  7. imperfect closure of anal cushions
8. Digital Examination
  1. essential
  2. exclude carcinoma
  3. useful measure of anal tone
9. Investigation
  1. Proctoscopy
    1. demostrate internal piles
  2. Sigmoidoscopy
    1. important in patient over 40 years
    2. occassionally rectal polyp is diagnosed this way
Acute Presentations
1. Thrombosed
  1. on inspection
  2. mass
    1. oedematous
    2. congested
    3. purplish
    4. seen @ the anal margin
  3. tight spasm of the anal sphincter
    1. digital rectal exam - VERY PAINFUL !
2. Both thrombosed and strangulated present with acute pain
3. Strangulated
  1. even more painful
  2. mass
    1. can become
      1. necrotic
      2. ulcerated
  3. symptomatic relief
    1. several days of bed rest
    2. application of
      1. ice packs
      2. topical anaesthetic gel
4. Surgeons prefer for urgent haemorrhoidectomy
  1. slightly higher risk of complications
  2. more rapid return to normal life
  3. prophylactic antibiotics
  4. hospital stay and recovery period
    1. generally shorter
    2. Subtopic 2
Conservative Management and Prevention of Haemorrhoids
1. most important means of prevention
  1. avoiding constipation
  2. ensuring a bulky stool
2. best achieved by
  1. diet high in fibre
  2. pt advised to always heed the call to evacuate
  3. pt strongly encouraged to
    1. avoid straining
    2. spend minimal time defaecating
3. repititive straining
  1. leads to the formation of a solitary ulcer
  2. posterior wall of of the proximal anal canal
4. 3rd degree haemorrhoids
  1. symptoms can often be relieved by the patient replacing the prolapsing haemorrhoids digitally after defaecation
5. treatment
  1. creams
  2. suppositories
  3. topical preparations
  4. contain local anaesthetic agents or steroids
    1. useful as temporary measure
    2. do nothing to treat the underlying condition
    3. may even cause local allergic reactions
    4. overuse
      1. maceration of the perianal skin
      2. predisposes to secondary infection
Surgical Treatment
1. Injection of Sclerosants
  1. which?
    1. 1st degree which
      1. do not regress by
      2. dietary change
      3. avoiding straining
    2. most 2nd degree
  2. what?
  3. Sclerotherapy
    1. outpatient basis
    2. does not require any anaesthetic
    3. how?
2. Banding
  1. application of rubber bands
    1. to obliterate the haemorrhoidal vessels
    2. How?
    3. not placed around the stalk
      1. unbearably painful
    4. Result
      1. haemorrhoid gradually shrinks
3. Haemorrhoidectomy
  1. indicated for 3rd degree haemorrhoids
  2. operation most commonly performed
    1. Milligan and Morgan
      1. leaves
      2. skin & mucosal defects
      3. heal by
      4. secondary intention
      5. wound contraction
  3. Stapled Haemorrhoidectomy
    1. gained popularity for
      1. large grade II
      2. grade III
    2. mucosal prolapse
    3. aims to restore the anatomy of the anal cushions
      1. excising an entire ring of low rectal mucosa
      2. including the engorged neck of the piles
    4. less painful & gives equivalent results
    5. Before Operation
      1. stool softeners
      2. gentle laxatives
    6. Post-Operative
      1. Painful Early Period
      2. caudal analgesia
Thrombosed External Haemorrhoids
1. acutely painful
2. onset
  1. sudden
  2. if untreated
    1. persistent pain lasting 1-2 weeks
    2. worse on defaecation
  3. on examination
    1. blue-black hemispherical bulge
3. most
  1. subside over a few days
  2. patients need only oral analgesia
  3. thrombosis may be incised and drained under local anaesthesia
4. Subtopic 4