Haemorrhoidal Disease is a Common Presenting Anorectal CoHE,OROIDndition

8/13/2019 Haemorrhoidal Disease is a Common Presenting Anorectal CoHE,OROIDndition

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Haemorrhoidal disease is a common presenting anorectal condition. Although its treatment

dates several hundreds of years, there has been no consensus on an optimal treatment

modality. Advances in the understanding of the pathophysiology of haemorrhoids are aiding

clinicians in providing the most appropriate form of treatment. Once more sinister

pathologies have been excluded management strategies are tailored to the individual patient

depending on the severity of the disease. Clinical classification systems are particularlyuseful as a measure of severity. In many patients conservative measures may prove to be

highly effective, but persistence and progression of symptoms may necessitate more

interventional procedures. This article aims to define and classify haemorrhoids, and review

the efficacy of current treatment modalities including the latest techniues.

Introduction

The word !piles" is derived from the #atin word pila, meaning ball. It has traditionally been

the layman$s term for haemorrhoids, for which treatment dates bac% almost &''' years.

Although there are many well recognised precipitating factors associated with haemorrhoids(such as low fibre inta%e, prolonged straining and pregnancy) the precise aetiology remains

unclear, which is certainly reflected in the number of treatment options available. This review

aims to define haemorrhoidal disease both anatomically and clinically and further explain

how this affects subseuent management strategies. The efficacy of the most popular

modalities of treatment is reviewed and a novel surgical techniue is introduced.

Anatomy and Pathophysiology

The concept of anal cushions being the precursors of haemorrhoids was first introduced in

*+- and described in the classical , and ** o$cloc% positions (*). These cushions lie

predominantly above the dentate line and are separated from the sphincter complex by the

submucosal layer / a combination of blood vessels, muscular and connective tissue0 related

to which is the inferior haemorrhoidal plexus which can become engorged at the anal verge.

This is important in distinguishing prolapsing internal haemorrhoids which are lined by an

insensate covering and whose nec% arises above the dentate line, from external haemorrhoids

which arise below this line. The importance of anal cushions lies in part in the maintenance

of faecal continence0 vascular filling is thought to be responsible for approximately 1'2 of

resting anal pressure (1), and the cushions are able to provide a conformable plug to maintain

complete closure of the anal canal. Theories of the aetiology of haemorrhoids are thought by

some to be related to their vascularity and underlying supportive structure. #ocal changes in

pressure are thought to cause venous dilatation in the anal cushions and (along with avalveless venous system) lead to their engorgement, seen in the increased prevalence of

haemorrhoids in pregnancy. The alternative connective tissue theory suggests that the

underlying support provided by the collagenous fibres of the submucosa degenerates over

time and ultimately leads to a caudal displacement of the anal cushions (), perhaps

explaining the phenomenon of haemorrhoidal prolapse.

Figure 1 - Anatomy of the Anal Canal (4)


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Classification

Improved understanding of local anatomy has led to helpful clinical classifications for

haemorrhoids. The product of underlying pathophysiological and anatomic changes, theyallow examination findings to be standardi3ed, and therefore allow the most appropriate form

of treatment to be offered. One such classification is the 4oligher classification, which

describes & clinical entities (-). 4rade I describes a normal appearance externally with

haemorrhoids which bleed but do not prolapse whereas in grade II the haemorrhoids may

prolapse but reduce spontaneously. 4rade III and I5 describe prolapsing haemorrhoids which

reuire manual digital reduction or remain prolapsed permanently, repectively / figure 1.

However, with the increased availability of endoscopy, haemorrhoids are being able to be

visuali3ed during colonoscopic or sigmoidoscopic examination with a retroflexed scope /

figure . This has led to the development of endoscopic classification systems which again

address and closely correlate to the patient$s symptoms (6).

Although this classification is limited by the assumption of bleeding and prolapse being the

only symptoms attributed by haemorrhoids, it still has an important place in the management

of the condition when used in con7unction with the wider clinical picture.

Figure 2 oligher Classification of !aemorrhoids"


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Figure # $etrofle%ed colonoscope sho&ing internal 'ie& of haemorrhoids


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he Clinical Picture

Haemorrhoids affect between &2 and 62 of the general population (), however this figure

is indicative only of symptomatic haemorrhoids and may well be an under8estimate. Hospital8

based proctoscopy studies have shown prevalence rates of up to 962 with the ma7ority of

patients being asymptomatic. (9) :ymptoms are widely variable, but haemorrhoids are

responsible for the ma7ority of cases of rectal bleeding. The most common symptoms after

bleeding include pain, mucous discharge and pruritus with or without associated

haemorrhoidal prolapse (+). The colour of the bleeding is attributed to the arterial oxygen

tension caused by arteriovenous communications within the anal cushions (*'), while pruritis

and associated discomfort is thought to be due to prolapse of the rectal mucosa leading to

deposition of mucus on the perianal s%in. The combination of type and severity of symptoms

in addition to examination findings, allows the most appropriate treatment modality to be

offered.

It is paramount not to attribute all cases of bright red rectal bleeding to haemorrhoids0Conditions from anal fissure to colorectal malignancy may all produce similar symptoms and

concurrent pathology must be excluded with investigation of the proximal colon, which in

most cases is performed by sigmoidoscopic or colonoscopic investigation. Also,

haemorrhoids are rarely responsible for anaemia (**).

he reatment adder

Classification systems, such as the one described above, allow standardisation of the

condition and can also monitor progression. Once a patient has been satisfactorily

investigated, the surgeon is in a position to offer the most appropriate treatment. As

haemorrhoids are essentially a benign condition, treatment is directed at alleviating symptoms

rather than to necessarily halt progression. ;ost surgeons have traditionally adopted a step8

wise approach in treatment depending on the severity of symptoms and clinical grading of the

haemorrhoids, with escalation if necessary. /


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Conser'ati'e +anagement

Conservative management is usually reserved for the minimum of symptoms and grade I orgrade II haemorrhoids. >y addressing some of the precipitating factors, they may well

prevent the need for further intervention. It essentially involves lifestyle modification and

dietary advice as well as medical treatment. :ome have suggested that constipation may be a

precipitating factor in the development and progression of haemorrhoids and the lower

incidence of the condition in populations with high dietary fibre inta%e may add weight to

this theory (*1), although this is never been proven definitively, and others have eually

proposed that haemorrhoids may actually lead to constipation (*). Adeuate fluid and fibre

inta%e may reduce straining effort during defaecation, along with laxatives, but may well also

prevent recurrence of haemorrhoids. A recent meta8analysis of fibre supplementation showed

that the ris% of bleeding was lower with an increased fibre inta%e, along with the rate of

recurrence (*&). #) and in7ection sclerotherapy, although cyrotherapy and


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photocoagulation are potential options.

Figure .on-conser'ati'e reatments

?># has been modified over the years from >laisdell$s original description (*6) which

advocated the application of a single band alone. Currently, surgeons may apply up to

bands at a time and can repeat this every 6 wee%s or so. The techniue involves the direct

visualisation of the haemorrhoidal pedicle through a proctoscope, with application of a band

around it using either forceps or a suction device. This results in ischaemic necrosis of the

haemorrhoidal tissue which subseuently auto8amputates. It is important to warn patients that

they may experience some bleeding after *'8*& days when the banded tissue sloughs off.

:uccess rates of between 6+2 and +&2 have been shown (*) with low complication rates,

although there have been potentially life8threatening complications reported. =ith higher

success rates than other office procedures, it is still deemed to be less efficient than

haemorrhoidectomy in the long term, albeit with less pain and fewer complications.(*9)

?ecent evidence suggests that in fact most patients complain of moderate or worse

discomfort after banding (*+).

In7ection sclerotherapy is a widely available techniue, the most common sclerosant being

-2 phenol in almond oil, and is particularly useful for bleeding piles. The sclerosant induces

an inflammatory reaction causing changes both in the haemorrhoidal mass and affecting the

underlying architecture. Haemorrhoids are again identified by proctoscopy and then in7ected

well above the dentate line. As long as the in7ections are appropriately directed there is no

pain experienced by the patient. Although this is a seemingly easy, reproducible procedure,there are as many reported problems with it as advantages. High failure rates accompanied by

misplaced in7ections have led many surgeons to abandon this office procedure.

There are certain contraindications for banding and in7ecting piles such as patients being on

formal anticoagulant medication and coagulopathies, but there are no guidelines discouraging

the use of a combination of procedures under these circumstances. One large study has shown

that by using a combination of sclerotherapy, rubber band ligation and infrared coagulation

over a period of 1 months on average, satisfaction rates of around +'2 were achieved with

less than *'2 reuiring surgical intervention. (1')

Cyrotherapy appears to have fallen out of favour. =ith the use of a specialised probe, thehaemorrhoidal mass is ablated, and can be repeated over time. @otential problems include


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ulceration and discharge as a conseuence of impaired healing following application of the

cyro8probe. (1*)

@hotocoagulation reuires the use of specific infrared optical euipment. The procedure is

similar to sclerotherapy in that direct visualisation of the haemorrhoid with a procotscope is

reuired. Once the coagulator device is primed, the base of the haemorrhoidal tissue istargeted and necrosis ensues. The subseuent healing of the mucosa leads to shrin%age of the

piles and ulcer formation. It has been most commonly used for internal haemorrhoids and has

been shown to be a superior techniue to sclerotherapy with fewer complications (11).

*urgical ,ptions

/%cision !aemorrhoidectomy

Haemorrhoidectomy has remained the centre of all the surgical procedures for symptomatic

haemorrhoids of high grade or those failing office procedures. Although the exact details ofthe operation and its variants are beyond the scope of this review, haemorrhoidectomy has

been shown to be the most effective treatment for haemorrhoids (1). Originally described by

=hitehead in the late part of the *+th century, its modification, the ;illigan8;organ

operation (1&) was later reserved for prolapsing haemorrhoids of grade III and I5. This

involves excision of the internal and external components of each haemorrhoid, leaving the

s%in open in a 8leaf clover pattern and allowing healing to occur by secondary intention.

Over the years newer, more efficient surgical procedures have been developed with the

operation being performed with either an open (as described above) or closed techniue

where the haemorrhoid component is excised and the wounds closed primarily (1-). The

theory behind the closed or oulder) haemorrhoidectomy are also varieties of operation

which have the common theme of excising haemorrhoidal tissue, the latter using a specialised

surgical instrument to minimise tissue trauma and confer faster wound healing. At present the

#iga:ureT; haemorrhoidectomy has been shown to more efficacious than conventional

haemorrhoidectomy (1).

Bnfortunately, complication rates have traditionally been higher in surgery than office

procedures with post8operative pain being the most common, though this is not necessarilythe case with newer techniues (19). A number of trials have attributed this to be the main

factor preventing patients from an early return to normal life, and have suggested time8frames

of between 1 and & wee%s before patients return to wor% (1+8*). Other complications include

urinary retention, sepsis, incontinence and anal stenosis (1, ).

Figure 0 Photograph of +illigan-+organ !aemorrhoidectomy (#4)


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*tapled Anope%y

This procedure has recently gained a reputation for being the 4old8standard for prolapsed

haemorrhoids (grade III and I5) with encouraging results regarding postoperative recovery

and comparable complication to traditional haemorrhoidectomy (-).


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3oppler-uided !aemorrhoidal Artery igation (3-

!A)

The newest treatment modality which is gaining considerable popularity is oppler8guided

haemorrhoidal artery ligation. Although essentially a surgical procedure, it is far lesstraumatic than traditional surgical options and does not involve the excision of haemorrhoidal

tissue and their associated complications. This techniue was first described more than

decade ago and involves the use of a specialised proctoscope coupled with a oppler probe

(&-). It can be performed with or without general anaesthesia depending on the patient and

clinical circumstances. It has been performed on grades II8I5, but is thought to be most

useful for grades II and III. The procedure wor%s on the principle that arterial flow through

local arteriovenous anastamoses maintains the haemorrhoidal mass. #igating these vessels

ultimately leads to haemorrhoid shrin%age with conseuent reduction and cessation of

bleeding.

Figure Cast of haemorrhoid &ith arterial supply displayed (40)

Bsing the proctoscope to identify terminal branches of the superior rectal artery and

haemorrhoidal artery, the vessels are subseuently ligated by placing haemostatic sutures

(


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An even newer techniue which aims to act on grade I5 haemorrhoids with rectal mucosaprolapse is the 48HA# recto8anal repair (?A?). It uses the same method as 48HA# but

additionally applies a vertical running suture which retracts the prolapsed mucosa. There are

no large series$ published on this treatment, however it could be potentially a rival to stapled

anopexy.

he Future

The resurgence in the treatment of haemorrhoids has led to the introduction of more efficient

variants of traditional techniues and novel surgical procedures all aimed to increase efficacy,

reduce complications and promote better healing and higher satisfaction. =ith greater

understanding of the anatomy and pathophysiology of the condition, it may be possible to

limit treatment to a few interventions relating directly to an appropriate classification system.

It is highly improbable that there will be one all8encompassing optimal treatment modality

for haemorrhoids, as the condition represents a spectrum of severity. However, the important

message is that whichever treatment is used, it must be safe and efficient.

?D, @enninc%x


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and in vitro study in man. Int E Colorectal is. *+9+F &0 **98*11.

/ Haas @A, 4. Dvaluation of anaemia caused by hemorrhoidal bleeding. is

Colon ?ectum. *++&F 0 *''68.

*1 / >ur%itt @. 5aricose veins, deep vein thrombosis and haemorrhoidsF Dpidemiology and

suggested aetiology. >;E. *+1Fii0 --68-6*.

* / Eohanson Elaisdell @C. Office ligation of internal haemorrhoids. American E. of :urg. *+-9F +60

&'*8&'&.

* / >at #, ;el3er D, Goler ;, re3nic% . Complications of rubber band ligation of

symptomatic internal haemorrhoids. iseases of Colon and ?ectum. *++F 60 1981+'.

*9 / :hanmugam 5, Thaha ;A, ?abindranath G:, Campbell G#, :teele ?EC, #oudon ;A.

?ubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane

atabase of :ystematic ?eviews 1''-. Issue *, Art oF C''-'&.

*+ / =atson


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operative treatment of haemorrhoids. #ancetF *+0 10 ***+8**1&.

1- / occasanta @, Capretti @4, 5enturi ;, Cioffi B, e :imone ;, :alamina 4, Contessini8

Avesani D, @eracchia A. ?andomised controlled trial between stapled circumferential

mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with

external mucosal prolapse. Am E :urg. 1''*F *910 6&869.

1 / :enagore A, ;a3ier =@, #uchtefeld ;A, ;acGeigan E;, =engert T. Treatment of

advanced hemorrhoidal diseaseF a prospective, randomised comnparison of cold scalpel vs.

contact dFLA4 laser. is Colon ?ectum. *++F 60 *'&18*'&+.

/ evien C5, @u7ol E@. Total circular hemorrhoidectomy. Int :urg. *+9+F &0 *-&8.

& / Appearance immediately after pile removal. Eeremy #ivingstone$s :urgical @age, 1''.

JOnlineK Available at www.livingstone.demon.co.u%Mimg1+.7pg. Accessed 'M'*M1''

- / :utherland #;, >urchard AG, ;atsuda G, :weeney E#, >o%ey D#, Childs @A. A

systematic review of stapled hemorrhoidectomy. Arch :urg 1''1F *0 *+-8*&'6.

6 / #ongo A. Treatment of hemorrhoidal disease by reduction of mucosa and hemorrhoidal

prolapse with a circular stapling deviceF a new procedure. @roceedings of the 6th =orld

Congress of Dndoscopic :urgery, Eune , *++9. ;undo33i Dditore, *++9.

/ g G8H, Ho G8:, Ooi >:, Tang C#, Du G=. Dxperience of ** stapled

haemorrhoidectomy operations. >r E of :urg. 1''6F +0 11681'.

9 / ;ehigan >E, ;onson E?, Hartley ED. :tapling procedure for haemorrhoids versus

;illigan8;organ haemorrhoidectomyF randomised controlled trial. #ancet. 1'''F --0 918

9-.

+ / ?owsell ;, >ello ;, Hemingway ;. Circumferential mucosectomy (stapledhaemorrhoidectomy) versus conventional haemorrhoidectomyF randomised controlled trial.

#ancet. 1'''F --0 +89*.

&' / Ho LH, Cheong =G, Tsang C, et al. :tapled hemorrhoidectomy / cost and

effectiveness. ?andomised controlled trial including incontinence scoring, anorectal

manometry, and endoanal ultrasound assessments at up to months. is Colon ?ectum.

1'''F &0 *6668*6-.

&* / Dsser :, Ghubchandani I, ?a%hmanine ;. :tapled hemorrhoidectomy with local

anaesthesia can be performed safely and cost8efficiently. is Colon ?ectum. 1''&F &0 **6&8

**6+.

&1 / ?ipetti 5, Caricato ;, Arullani A. ?ectal perforation, retropneumoperitoneum, and

pneumomediastinum after stapling procedure for prolapsed hemorrhoidsF report of a case andsubseuent considerations. is Colon ?ectum. 1''1F &-0 1698'.


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& / ;aw A, Du G=, :eow8Choen , :hetty , #indsey I, ;ortensen E, =arren >ritish Haemorrhoid Centre 1''. Cast of a haemorrhoid. JOnlineK Available at

www.halocentre.comMwhatishalo.html. Accessed 'M'*M'

& /


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Mandi di bak mandi dengan air hangat,biasanya dapat mengurangi rasa sakit

di perianal.0al ini mungkin karena air hangat dapat merelaksasai meksnisme

spinkter dan spasme.1ebuah literatur menyebutkan, kompres es dapat

menguragi nyeri akibat thrombosis akut.1ebagian besar pasien melihat adanya

perbaikan atau resolusi komplit dari gejala-gejala yang mereka alam, dengan

tindakan konservasi! di atas. Pengobatan diarahkan hanya pada gejala dan

bukan penampakan hemoroid.

"ika pasien mengeluhkan nyeri hebat, kemugkinan ia menderita hemoroid

ekternal akibat thrombosis.2ni biasanya membaik dalam 3-)* hari, tetapi jika

tetap terasa sakit da luar periode tersebut, bisa di lakukan eksisi untuk

menghilangkan thrombus. Penggunaan dressing penekan, bisa menjadi pilihan

pengobatan.

Pengobatan Farmakologis

Pengobatan !armakologis non spesi!ik meliputi laksati!, analgesik,

antiin!lamasi dan obat-obatan topikal#mengandung anatesi local dan

steroid$.1ementara obat-obatan spesi!ik untuk hemoroid #agen phlebotropik$

yang ada saat ini adalah !lavonoid, mencakup micronised diosmin dan

hesperidin dan hidrosomin. Obat-obatan ini secara signi!ikan menurunkan gejala

dan mencegah terjadinya rekurensi.%ahkan sebuah studi menemukan,

pemberian diosmin dan hesperidin sama e!ekti! dengan rubber band ligation,

dengan e!ek samping yang lebih kecil.

Laksatif

4aksati! dalam bentuk serat dapat membantu menguragi gejala hemoroid,

terutama perdarahan. 1ebuah tinjauan dilakukan P.&lonso dan ka(an-ka(an

terhadap tujuan hasil penelitan melibatkan 35 pasien, yang secara acak dibrri

serat atu non serat.Meta analisa ini menunjukan, laktasi! dalam pengobatan

hemoroid simtomatik.

Diosmin-Hesperidin

Keduanya biasa di!omulasi sebagai micronized purified flavonoid fraction

#MP66$ unik, yang mengandumg 7*8 diosmin dan )*8 hesperidin. 0esperidindiektrak dan genus citrusdengan spesies Rutaceae aurantieae,suatu tipe jeruk

kecil yang biasa ditemukan di daratan 1panyol, &!rika tara dan

9hina,sementara diosmin yang merupakan senya(a !lavonoid diperoleh melalui

proses sintesa, mulai dari bahan baku.

Melalui mikronisasi, kedua bahan akti! tersebut mengalami proses

penggilingan dengan teknologi tinggi. 1ebuahjet of air at supersonic velocities

mampu mengurangi ukuran partikel standar dari 3:m, hingga kurang dari

;:m.&kibatnya, penyerapan keduanya jadi lebih cepat dan lebih baik, sehingga

bisa meningkatkan bioavailabilitas. 2mplikasinya tentu mengarah pada e!ikasi

klinis yang lebih cepat dan superior.


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Kedua senya(a tersebut memiliki mekanisme kerja yang unik. 4ayaknya

noradrenalin, obat ini mengakibatkan kontraksi vena,menurunkan ekstravasasi

dari kapiler dan menghambat reaksi in!lamasi terhadap prostaglandin terhadap

prostaglandin #P


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%anyak obat bebas yang bisa di gunakan untuk mengobati hemoroid. 2ni

biasanya obat yang sama yang digunakan untuk mengatasi gejala anal, seperti

gatal atau tidak nyaman. %eberapa penelitian menunjukkan, obat-obatan ini

tidak berdampak pada hemoroid, hanya menurunkan gejala hemoroid.

Produk-produk yang digunakan untuk pengobatan hemeroid tersedia dalambentuk ointments, creams, gels, suppositories, !oams dan pads.1aat digunakan

pada anal canal, produk-produk ini dimasukkan dengan jari atau suatu pipa.

1ebelum dimasukkan, pipa harus diberi pelumas.

Protektan

Proktetan mencegah iritasi daerah perianal dengan membentuk barier !isik

pada kulit, yang mencegah kontak kulit yang teriritasi dengan cairan atau

kotoran yang berpotensi memperburuk kondisi.%arier tersebut menurunkan

iritasi, rasa gatal, sakit dan rasa terbakar.

Protektan meliputi@

&luminium

9ococa buter

inc oide atau calamine #yang mengandung Ainc oide$ dalam konsentrasi

sampai ;+8

Astrigents

&strigents menyebabkan koagulasi protein dalam sel kulit perianal ataulapisan kanal anal. 0al ini menyebabkan kulit kering, yang pada akhirnya

membantu mengurangi rasa terbakar, gatal dan sakit.

&strigents meliputi@


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9alamine +-;+8

>inc oide +-;+8

Witch haAel )*-+*8

Antiseptik

&ntiseptik menghambat perkembangan bakteri dan organisme lain. %elum jelas,

apakah antiseptik lebih e!ekti! dari sabun dan air.

9ontoh antiseptic meliputi@

%oric acid

0ydrastis

Phenol

%enAalkonium chloride

9etylpyridinium chloride

%enAenthorium choloride

Resorcinol

Keratolitis

Keratolitik adalah kimia yang menyababkan lapisan terluar kulit atau jaringan

lain mengelupas.&lasan digunakan obat ini, agar obat-obatan yang digunakan

pada anus dan daerah perianal dapat masuk ke jaringan yang lebih dalam. 'ua

agen keratolitik yang disetujui 6'& adalah@

&lumunium chlorhydroy allantoinate *,;-;,*8

Resoncinol )-8

Anlgesik

Produk-produk analgesik, seperti produk anatesi, menguragi rasa sakit, gatal

dan terbakar dengan menekan reseptor dari sara! rasa sakit.

9ontoh analgesik@

Menthol *,) B ),*8 #lebih besar dari ),*8 tidak dianjurkan$

9amphor *,) B 8 #lebih besar dari 8 tidak dianjurkan$


18/18

"uniper tar ) B +8

Kortikosteroid

Kortikosteroid menentukan in!lamasi dan mengurangi rasa gatal. "ika

digunakan berkepanjangan , bisa menyebabkan kerusakan permanen pada kulit.

Documents

Haemorrhoidal Disease is a Common Presenting Anorectal CoHE,OROIDndition