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Slide 1 :
Hemorrhoid BY: Dr M.Rafi.B.Sina
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OBJECTIVE INTRODUCTION ANATOMY CLASSIFICATION PATHOGENESIS CLINICAL MANIFESTATIONS DIFFERENTIAL DIAGNOSIS TREATMENT
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INTRODUCTION Hemorrhoids are normal vascular structures in the anal canal. However, they are often the source of a variety of problems. The cardinal features of hemorrhoidal disease include bleeding, anal pruritus, prolapse, and pain due to thrombosis.
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ANATOMY Hemorrhoids arise from a plexus of dilated arteriovenous channels and connective tissue with the veins arising from the superior and inferior hemorrhoidal veins. They are located in the submucosal layer in the lower rectum and may be external or internal based upon whether they are below or above the dentate line. Both types of hemorrhoids often coexist.
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ANATOMY Internal hemorrhoids arise from the superior hemorrhoidal cushion. Their three primary locations (left lateral, right anterior, and right posterior) correspond to the end branches of the middle and superior hemorrhoidal veins. The overlying mucosa is rectal, and innervation is visceral.
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ANATOMY External hemorrhoids arise from the inferior hemorrhoidal plexus and are located beneath the dentate line. They are covered with squamous epithelium, which contains numerous somatic pain receptors Intern& external hemorrhoids communicate with one another& drain into internal pudendal veins & ultimately to VCI.
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External Internal Anoderm Swell, discomfort, difficult hygiene Pain? -> Thrombosed Pain? -> painless Bright red bleeding Prolapse associated with defecation
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Classification Grade I hemorrhoids are visualized on anoscopy and may bulge into the lumen but do not extend below the dentate line. Grade II hemorrhoids prolapse out of the anal canal with defecation or with straining but reduce spontaneously. Grade III hemorrhoids prolapse out of the anal canal with defecation or straining, and require the patient to reduce them into their normal position. Grade IV hemorrhoids are irreducible and may strangulate.
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A:Thrombosed external B:First-degree internal viewed through anoscope C:Second-degree internal prolapsed, reduced spontaneously D:Third-degree internal prolapsed, requiring manual reduction E:Fourth-degree strangulated internal and thrombosed external
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PATHOGENESIS Age, diarhea, pregnancy, pelvic tumors, Prolonged sitting, straining, chronic constipation. Three predominant theories have been advanced With advancing age or aggravating conditions, the connective tissue which anchors hemorrhoids to the underlying sphincter mechanism deteriorates eventually, the weakly anchored hemorrhoids begin to bulge, and "slide" into the anal canal leading to progressive symptoms
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PATHOGENESIS The second theory suggests that symptomatic hemorrhoids arise from hypertrophy or increased tone of the internal anal sphincter . during defecation, the fecal bolus forces the hemorrhoidal plexus against the internal sphincter, which causes them to enlarge and become symptomatic.
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PATHOGENESIS The third theory attributes the development of symptoms to swelling of the hemorrhoidal cushions. This theory assumes that the anatomic properties of the hemorrhoidal plexus are similar to those of erectile tissue
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CLINICAL MANIFESTATIONS painless bleeding Prolapse pain associated with a thrombosed hemorrhoid pruritus
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CLINICAL MANIFESTATIONS Bleeding — Painless bleeding is usually associated with a bowel movement. Bright red blood typically coats the stool at the end of defecation. Blood may also drip into the toilet or stain toilet paper. Chronic blood losses from hemorrhages can be substantial enough to induce iron deficiency anemia .
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CLINICAL MANIFESTATIONS Pruritus Prolapse of internal hemorrhoids may permit leakage of rectal contents .Skin tags associated with external hemorrhoids may be difficult to clean, resulting in prolonged contact of fecal material with the perianal skin and leading to local irritation.
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CLINICAL MANIFESTATIONS Pain usually results from thrombosis, which can occur in both internal and external hemorrhoids. Thrombosis of external hemorrhoids may be associated with excruciating pain
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Differential diagnosis Patients with a variety of other anorectal disorders may present with a presumed diagnosis of hemorrhoids. Examples include anal fissures, rectal prolapse, anal cancer, and Crohn's disease
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Treatment GRADING OF INTERNAL HEMORRHOIDS Grade I: The hemorrhoids do not prolapse Grade II: The hemorrhoids prolapse upon defecation but reduce spontaneously Grade III: The hemorrhoids prolapse upon defecation and must be reduced manually Grade IV: The hemorrhoids are prolapsed and cannot be reduced manually
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CONSERVATIVE TREATMENT Conservative measures are successful for most patients with symptomatic hemorrhoids and bleeding, irritation, pruritus, or thrombosis.
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CONSERVATIVE TREATMENT Bleeding Adding fiber to the diet. psyllium or methylcellulose. Irritation and pruritus can be treated with a variety of analgesic creams, hydrocortisone suppositories, and warm sitz baths.
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Treatment OFFICE BASED PROCEDURES The principle of most of these therapies is to remove or to cause sloughing of excess hemorrhoidal tissue. Healing and scarring fixes the residual tissue to the underlying anorectal muscular ring.
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OFFICE BASEDPROCEDURES Rubber band ligation Infrared coagulation Bipolar diathermy (Bicap) Laser photocoagulation Sclerotherapy Cryosurgery
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SURGICAL THERAPY Continued symptoms despite conservative or minimally invasive measures usually requires surgical intervention Initial treatment of choice in patients with symptomatic grade IV hemorrhoids Strangulated internal hemorrhoids
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SURGICAL THERAPY Techniques for the operative treatment of hemorrhoids include: Closed hemorrhoidectomy Open hemorrhoidectomy with excision ligationStapled hemorrhoidectomy Whitehead hemorrhoidectomy Lateral internal sphincterotomy
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Complications of hemorrhoidectomy Urinary retention Urinary tract infection Fecal impaction Delayed hemorrhage.
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POSTOPERATIVE PAIN MANAGEMENT Perianal infiltration with a long-acting local anesthetic provided significant pain relief, whether given alone or with oral analgesics Topical diltiazem ointment (2 percent) applied to the perianal region three times daily for seven days
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POSTOPERATIVE PAIN MANAGEMENT Botulinum toxin Nonsteroidal antiinflammatory drugs and/or acetaminophen
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HEMORHOID ANATOMY,CAUSE,PATHOGENESIS,CLINICAL FEAUTURES,DDX,TREATMENT
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