HEMORRHOIDSHEMORRHOIDS

ANATOMY AND CLASSIFICATIONANATOMY AND CLASSIFICATION

right anterior, right posterior and left lateral right anterior, right posterior and left lateral positions positions

those originating above the dentate line those originating above the dentate line which are termed internal which are termed internal

those originating below the dentate line those originating below the dentate line which are termed external. which are termed external.

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

represent engorgement or enlargement of represent engorgement or enlargement of the normal fibrovascular cushions lining the the normal fibrovascular cushions lining the anal canal. anal canal.

chronic straining secondary to constipation chronic straining secondary to constipation or occasionally diarrhea or occasionally diarrhea

fibrovascular cushions lose their attachment fibrovascular cushions lose their attachment to the underlying rectal wall. to the underlying rectal wall.

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

prolapse of internal hemorrhoidal tissue prolapse of internal hemorrhoidal tissue through the anal canal. through the anal canal.

the overlying mucosa becomes more friable the overlying mucosa becomes more friable and the vasculature increases. and the vasculature increases.

With overlying thinning of the mucosa and With overlying thinning of the mucosa and vascular engorgement, subsequent rectal vascular engorgement, subsequent rectal bleeding occurs. bleeding occurs.

ANATOMY AND CLASSIFICATIONANATOMY AND CLASSIFICATION

classified by history and not by physical classified by history and not by physical examination. examination.

Grade I - bleeding without prolapse. Grade I - bleeding without prolapse.

Grade II - prolapse with spontaneous reduction. Grade II - prolapse with spontaneous reduction.

Grade III - prolapse with manual reduction. Grade III - prolapse with manual reduction.

Grade IV - incarcerated, irreducible prolapse. Grade IV - incarcerated, irreducible prolapse.

SYMPTOMSSYMPTOMS

bright red blood per rectum or a prolapsing bright red blood per rectum or a prolapsing anal mass. anal mass.

with, or following, bowel movements, is with, or following, bowel movements, is almost universally bright red, and very almost universally bright red, and very commonly drips into the toilet water. commonly drips into the toilet water.

Blood may also be seen while wiping after Blood may also be seen while wiping after defecation. defecation.

SYMPTOMSSYMPTOMS

prolapse usually occurs in association with a prolapse usually occurs in association with a bowel movement, bowel movement,

may also prolapse during walking or heavy lifting may also prolapse during walking or heavy lifting as a result of increased intra-abdominal pressure. as a result of increased intra-abdominal pressure.

extreme pain, bleeding and occasionally signs of extreme pain, bleeding and occasionally signs of systemic illness in case of strangulation.systemic illness in case of strangulation.

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Patients should be examined in the left lateral Patients should be examined in the left lateral decubitus position decubitus position

any rashes, condylomata, or eczematous lesions. any rashes, condylomata, or eczematous lesions.

external sphincter function external sphincter function

Any abscesses, fissures or fistulae Any abscesses, fissures or fistulae

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

lubricated finger should be gently inserted into the lubricated finger should be gently inserted into the anal canal while asking the patient to bear down anal canal while asking the patient to bear down

the resting tone of the anal canal should be the resting tone of the anal canal should be ascertained as well as the voluntary contraction of ascertained as well as the voluntary contraction of the puborectalis and external anal sphincter. the puborectalis and external anal sphincter.

masses should be noted as well as any areas of masses should be noted as well as any areas of tenderness. tenderness.

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

internal hemorrhoids are generally not palpable on digital internal hemorrhoids are generally not palpable on digital examination.examination.

anoscopy is performed. anoscopy is performed.

The side viewing anoscope should be inserted with the The side viewing anoscope should be inserted with the open portion in the right anterior then right posterior and open portion in the right anterior then right posterior and finally the left lateral position finally the left lateral position

Hemorrhoidal bundles will appear as bulging mucosa and Hemorrhoidal bundles will appear as bulging mucosa and anoderm within the open portion of the anoscope. anoderm within the open portion of the anoscope.

EVALUATION OF RECTAL EVALUATION OF RECTAL BLEEDINGBLEEDING

rule out rectal cancer. rule out rectal cancer.

young individual with bleeding associated with young individual with bleeding associated with hemorrhoidal disease and no other systemic hemorrhoidal disease and no other systemic symptoms, and no family history, perhaps symptoms, and no family history, perhaps anoscopy and rigid sigmoidoscopy anoscopy and rigid sigmoidoscopy

older individual, with either a family history of older individual, with either a family history of colorectal cancer, or change in bowel habits, a colorectal cancer, or change in bowel habits, a complete colonoscopy should be performed to rule complete colonoscopy should be performed to rule out proximal neoplasia. out proximal neoplasia.

TREATMENTTREATMENT

varies from simple reassurance to operative varies from simple reassurance to operative hemorrhoidectomy. hemorrhoidectomy.

Treatments are classified into three Treatments are classified into three categories: categories:

1) Dietary and lifestyle modification. 1) Dietary and lifestyle modification. 2) Non operative/office procedures.2) Non operative/office procedures. 3) Operative hemorrhoidectomy. 3) Operative hemorrhoidectomy.

DIETARY AND LIFESTYLE DIETARY AND LIFESTYLE MODIFICATIONSMODIFICATIONS

the main goal of this treatment is to minimize the main goal of this treatment is to minimize straining at stool. straining at stool.

achieved by increasing fluid and fiber in the diet, achieved by increasing fluid and fiber in the diet, recommending exercise, and perhaps adding fiber recommending exercise, and perhaps adding fiber agents to the diet such as psyllium. agents to the diet such as psyllium.

if necessary, stool softeners may be added. if necessary, stool softeners may be added.

"you don't defecate in the library so you shouldn't "you don't defecate in the library so you shouldn't read in the bathroom". read in the bathroom".

Office Treatments Office Treatments RUBBER BAND LIGATIONRUBBER BAND LIGATION

Grade I or Grade II hemorrhoids and, in some Grade I or Grade II hemorrhoids and, in some circumstances, Grade III hemorrhoids.circumstances, Grade III hemorrhoids.

Complications include bleeding, pain, thrombosis Complications include bleeding, pain, thrombosis and life threatening perineal sepsis. and life threatening perineal sepsis.

successful in two thirds to three quarters of all successful in two thirds to three quarters of all individuals with first and second degree individuals with first and second degree hemorrhoids. hemorrhoids.

Office Treatments Office Treatments RUBBER BAND LIGATIONRUBBER BAND LIGATION

Bayer, Myslovaty, and Picovsky followed 2,934 Bayer, Myslovaty, and Picovsky followed 2,934 patients banded over a 12 year period. patients banded over a 12 year period.

Seventy-nine percent required no further therapy, Seventy-nine percent required no further therapy, while eighteen percent required repeat banding while eighteen percent required repeat banding due to recurrence.due to recurrence.

Hemorrhoidectomy was necessary in 2.1% related Hemorrhoidectomy was necessary in 2.1% related to persistent symptoms .to persistent symptoms .

Office TreatmentsOffice TreatmentsINFRARED COAGULATIONINFRARED COAGULATION

generates infrared radiation which generates infrared radiation which coagulates tissue protein and evaporates coagulates tissue protein and evaporates water from cells. water from cells.

is most beneficial in Grade I and small is most beneficial in Grade I and small Grade II hemorrhoids. Grade II hemorrhoids.

Office TreatmentsOffice TreatmentsBICAP ELECTROCOAGULATIONBICAP ELECTROCOAGULATION

It works, in theory, similar to It works, in theory, similar to photocoagulation or to rubber banding. photocoagulation or to rubber banding.

the probe must be left in place for ten the probe must be left in place for ten minutes. minutes.

poor patient tolerance minimized the effect poor patient tolerance minimized the effect of this procedure. of this procedure.

Office TreatmentsOffice TreatmentsSCLEROTHERAPYSCLEROTHERAPY

injection of an irritating material into the injection of an irritating material into the submucosa in order to decrease vascularity submucosa in order to decrease vascularity and increase fibrosis. and increase fibrosis.

Injecting agents have traditionally been Injecting agents have traditionally been phenol in oil, sodium morrhuate, or quinine phenol in oil, sodium morrhuate, or quinine urea. urea.

Office TreatmentsOffice Treatments

Manual anal dilatation was first described by Manual anal dilatation was first described by Lord .Lord .

Cryotherapy was used in the past with the Cryotherapy was used in the past with the belief that freezing the apex of the anal belief that freezing the apex of the anal canal could result in decreased vascularity canal could result in decreased vascularity and fibrosis of the anal cushions. and fibrosis of the anal cushions.

Surgical Treatment of Hemorrhoids Surgical Treatment of Hemorrhoids HEMORRHOIDECTOMYHEMORRHOIDECTOMY

The triangular shaped hemorrhoid is excised The triangular shaped hemorrhoid is excised down to the underlying sphincter muscle. down to the underlying sphincter muscle.

Wound can be closed or left openWound can be closed or left open

stapled hemorrhoidectomy has been stapled hemorrhoidectomy has been developed as an alternative to standard developed as an alternative to standard hemorrhoidectomyhemorrhoidectomy