Transcript Haemorrhoids

Haemorrhoids
Haemorrhoids
Definition
Haemorrhoids are dilated veins occurring in relation to
the anus.
Types of haemorrhoids:• external
• internal
External variety is
covered by skin
The internal variety is
covered by mucous membrane.
When both are present together
called intero-external haemorrhoids.
Pathophysiology:Pile mass descends – gripped by the sphincters – more engorgement
• Mucosal gathering in relation to the three branches
of superior rectal arteries – called anal cushions –
necessary for completer continence
• They slide down and internal haemorroids develop
in the prolapsing tissues.
Aetiology:Heredity – congenital weakness of
vein walls or an abnormally large
arterial supply to the rectal plexus.
Varicose veins of the legs and
haemorrhoids often occur concurrently
Most are idiopathic
Carcinoma rectum
Pregnancy
Straining at micturition
Thesuperior rectal veins being tributaries of
the portal vein have no valves.
Straining accompanying constipation or that
induced by overpurgation
Diarrhoea of enteritis, colitis or the
dysenteries agravates the latent
haemorrhoids
Internal Haemorrhoids
Commonest. It is the dilatation of the
internal venous plexus with an enlarged
displaced anal cushion.
Communication between the internal and
external plexuses of the veins – when
the internal plexus is engorged the external
plexus is also is likely to be involved.
• Internal haemorrhoids are arranged in three groups at 3,7, and
11 O’clock positions during lithotomy position.
• Each principal haemorrhoid can be divided into three parts:
• The pedicle – at the anorectal ring.
• The internal haemorrhoid, commences just below the anorectal
ring. It is bright red or purple
• An external haemorrhoid lies between the dentate line and the
anal margin. It is covered by skin, through which blue veins
can be seen.
Clinical features
Symptoms of haemorhhoids
• bright red painless
bleeding
• Mucus discharge
• Prolapse
• Pain only on prolapse
• Anaemia
Investigations
External haemorrhoid is visible on inspection itself
Redundant folds or tags of skin
On straining the internal haemorrhoids may become visible
transiently
Digital examination – if thrombosed felt
Sigmoidoscopy :should be done as a precaution in every case
to rule out any cause higher above.
Complications
Strangulation
Thrombposis
Ulceration
Gangrene
Fibrosis
Suppuration
pylephlebitis
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Treatment
Symptomatic
Injection of sclerosant
Banding
Stapling - endostapler
Photocoagulation
Haemorrhoidectomy
Cryosurgery - abandoned
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Indications for haemorrhoidectomy
third-degree haemorrhoids
Failure of nonoperative treatments of seconddegree haemorhoids
Fibrosed haemorrhoids
Interoexternal haemorrhoids when the external
haemorrhoids is well defined
• Procedure: STEP 1
• HAL Doppler - A novel therapy for the treatment of
hemorrhoids
• Before proceeding to the ultrasound guided hemorrhoidal
artery ligation, the doctor accurately locates the terminal of
all different branches of the superior rectal artery considering
the vessels depth. Firstly, the xylocaine jelly is applied to the
tip of the instrument and to the anus. The HAL Doppler is
slowly inserted into the anus and rotated to locate the artery
to be ligated (as shown in the Figure). The arterial sound is
clearly audible when the Doppler transducer is directly over
the hemorrhoidal artery.
• Procedure: STEP 2
• HAL Doppler - A novel
therapy for the
treatment of
hemorrhoids
• The needle (2-0 Vycryl,
strong curved with
forceps) is inserted into
the HAL Doppler (as
shown below).
• Procedure: STEP 3
• HAL Doppler - A
novel therapy for the
treatment of
hemorrhoids
• The needle passes
beneath the artery and
is withdrawn (as
shown in the Figure
below)..
• Procedure: STEP 4
• HAL Doppler - A novel therapy for
the treatment of hemorrhoids
• A knot is tied externally, which is
then pushed down into the mucosa
with the knot pusher (as shown in the
Figure), thus ligating the artery. The
Doppler sound disappears as soon as
the ligation is successfully
performed. The suture is cut with
scissors inside of the instrument.
After completion of the ligation, a
second assessment with the HAL
Doppler system should confirm
disappearance of sound. Thereby,
successfully ligating branches of the
superior rectal artery.