Haemorrhoids ~~~~~~~~~~~ Definition Polypoid protrusion of mucosa and or skin through the ano-rectal ring Derivation Pile from the Latin for ball; Pila Haemorrhoid from the association with bleeding Anal cushions Haemorrhoids arise from the normal cushions at the top of the anal canal These cushions provide a continence function They are supplied by the three terminal branches of the superior rectal arteries, the right artery has anterior and posterior parts These terminal braches are typcially seen at the 4, 7 and 11 positions They drain into the haemmoroidal plexus of veins There are two sets of arterio-venous anastamoses, those above and those below the dentate line Internal and External Internal haemmoroids arise above the dentate line and are covered by mucosa External Haemmoroids arise below the dentate line and are covered by skin Pathologically haemorrhoids consist of; Thick submucosa often oedematous Blood vessels often with thrombosis Smooth muscle Connective tissue including Elastin Cause of haemmoroids; Unknown, most popular ideas is chronic straing due to inadequate roughage in the diet. The following may play a role; 1) Poor return of venous blood through the superior rectal veins; Straining to pass water or stool, pregnancy, portal venous hypertension 2) Sphincter dysfunction (hypertonicity); Increased shearing forces on the anal cushions Decreased blood return through the intersphincteric shunts 3) Damage to the connective tissues from repeated swelling; this permits prolapse Grading of haemorrhoids; It is not definite that the patient progresses through these grades. 1) Visible on proctoscopy as bulges, painless bleeding 2) Prolapse on straining and spontaneously reduce, patients may complain of loss of the continence function of the anal cushions, irritation, minor soiling and mucus discharge 3) Prolapse on straining and have to be manually reduced, irritation and discharge and more pain, may thrombose or ulcerate 4) Prolapsed all the time, sclerotic and skin tags Acute complications Thrombosis Ulceration Presentation Discomfort Pain; not usual to cause severely painful defecation Itch Pruritis Ani Prolapse Incontinence, minor soiling Bleeding; typically bright red following defection, comes and goes Differential of acute perianal pain 1) Thrombosed haemorrhoids 2) Perianal haematoma 3) Acute fissure in ano 4) Perianal or rectal abscess (intersphincteric) 5) Proctalgia fugax Examination The Pernieum, for tags and external haemorrhoids, co-existing fissures Proctoscopy to examine the cushions At least a rigid sigmoidoscopy to examine the rectum Indications for colonoscopy or Barium enema Always Bleeding is not the typical bright red post defecation Associated change in bowel habit Age over 50 Bleeding has not ceased after treatment of haemorrhoids Treatment Acute Thrombosis Bed Rest Ice Packs Analgesia Low residue diet Stool Softeners May require haemmoroidectomy Chronic Rule out Rectal Cancer Advice re perianal skin care Operations High fibre diet ? bulk laxatives [ Evidence absent ] Topical agents [ Evidence weak ? lubricant ] Operations Injection sclerotherapy Banding Haemorrhoidectomy Milligan-Morgan Parks Ferguson Whitehead operation for circumferential haemorrhoids PPH (Longo operation) Procedure for Prolapse and Haemmoroids Rubber Band ligation Superior to Injection Sclerotherapy in a randomised trial Does not treat external haemorrhoids Good for grade 1 and 2 haemmoroids Barron's banding apparatus or newer disposable banders One handed and two handed instruments; patient may hold the proctoscope Insert proctoscope and hold cushion with forceps 1.5 cm above the dentate line and slip band down over the forceps Avoid in immunocompromised and anti-coagulated patients Immediate pain indicates misplacement of the band; the band should be removed Pain comeing on after several hours, indicates ischemia of the cushion and should resolve within one week Complications; Misplacement of the band Pain (6%) Haemorrhage (2%) Failure to resolve haemorrhoids or recurrance (3%) Sepsis (rare) Injection sclerotherapy Not as good as banding in a randomised trials Does not treat external haemorrhoids Good for grade 1 and 2 haemmoroids Gabriel's solution, 5% phenol in almond oil, injected at top of haemmoroid above the dentate line The phenol acts to cause thrombosis The almond oil keeps the phenol in solution and stops it diffusing away from the site of injection Gabriel's syringe permits holding of the syringe in one hand while the other holds the proctoscope Gabriel's angled needle to ensure that the phenol in almond oil is injected into the submucosa and not into the muscles or the seminal vesicles or prostate Correct place to inject is at least 1.5 cm above the dentate line, injection of the solution should generate a bump but the mucosa should not blanch Correct volume to inject in each haemorrhoid is 3-5 ml; I favour less Complications; Urethral irritation Perirectal fibrosis Injection into prostate of seminal vesicle may result in impotence Sepsis Advantages; Rapid Well tolerated by the patient Open Haemorrhoidectomy (Milligan-Morgan) Preop preparation; Hi fibre diet Lactulose for 4 days (reduces post operative pain) Antibiotic prophylaxis; Haemmeroidectomy is a clean-contaminated operation, Metronidazole pre and post-op, (reduces pain post op) Position Lithotomy or prone Jack-Knife; prone Jack-Knife best postion but hardest to organise Area of perineum prepped and draped Role of shaving unclear Digital examination using two fingers, small amount of lubrication Anal bivalved speculum inserted Surgery planned with aim to preserve wide muco-cutaneous bridges Haemorrhoids injected with local anaesthetic (long acting, chirocaine or buvipicaine) and adrenaline Wait a few minutes for the injection to work Haemorrhoids are excised (largest first) to leave wide muco-cutaneous bridges (avoid post operative anal stenosis). The excision usually commences on the outside at the apex of the external component, and this is gradually worked upwards into the anal canal. The retractor will need to be re-positioned during this procedure. One of the functions of the retractor is to put the internal sphincter under tension and thus avoid damage to it. Haemostasis is secured with diathermy. At the top end of the cushion the pedicle thins, this is divided and secured with a ligature, if necessary. The tissue is sent for histological examination (malignancy and inflammatory conditions) If it looks like a clover your trouble is over, if it looks like a Dalia, it is sure to be a failure. Wounds are left open and a dressing may be applied into the anal canal; Some surgeons avoid any dressing in the anal canal because they feel that this increases pain This dressing is removed about 1 day post op The patient has been traditionally kept in hospital untill after they pass their first bowel motion; The patient is discharged if they pass a bowel motion without bleeding and their pain is under control Nowadays there is a move to day-case surgery Post op care; Metronidazole (reduces pain) Analgesia Stool softeners Warm bath ? with antiseptic, several times a day and after passing a bowel motion Off work for at least 2 weeks Complications; Immediate; Pain (depends on analgesia) Bleeding (4%) Urinary retention (20% reduced to 0.5% if good pain relief) Medium term; Secondary Haemmorhage (D10-D14 1% of patients) Long term; Anal stenosis (2%) Incontinence (0.4%) Problem areas Portal hypertension Crohn's disease Pregnancy DO NOT ascribe bleeding PR to haemmoroids without checking for rectal cancer % vim: set ai tw=78: