Transcript Hemorrhoid
Hemorrhoid Normally, do people have anal cushion? Yes Within the normal anal canal exist specialized, highly vascularized “cushions” forming discrete masses of thick submucosa containing blood vessels, smooth muscle, and elastic and connective tissue These structures aid in anal continence When would we call them ‘hemorrhoids’? Abnormal Cause symptoms Downward sliding of anal cushions associated with gravity Straining Irregular bowel habits. How do hemorrhoids come? The cause of hemorrhoids remains unknown How could we diagnose ‘hemorrhoid’? History Physical examination Endoscopy History Dripping or even squirting of blood in the toilet bowl Chronic occult bleeding leading to anemia is rare, and other causes of anemia must be excluded History (cont’d) Prolapse below the dentate line area can occur, especially with straining, and may lead to mucus and fecal leakage and pruritus Pain? is not usually associated with uncomplicated hemorrhoids but more often with fissure, abscess, or external hemorrhoidal thrombosis Hemorrhoids can be divided to? External Internal Anatomy •Pain? -> painless •Bright red bleeding •Prolapse associated with defecation Internal External •Anoderm •Swell, discomfort, difficult hygiene •Pain? -> Thrombosed How are Internal hemorrhoid classified? Extent of prolapse 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 Reference : Sabiston Textbook of Surgery, 18th Edition Usefulness Digital examination -> assess internal and external hemorrhoidal disease anal canal tone exclusion of other lesions, especially low rectal or anal canal neoplasms Virtually all anorectal symptoms are ascribed to “hemorrhoids” , anorectal pathologies be considered and excluded Anoscopy Definitive examination Flexible proctosigmoidoscopy should always be added to exclude proximal inflammation or neoplasia Colonoscopy or barium enema should be added if the hemorrhoidal disease is unimpressive, the history is somewhat uncharacteristic, or the patient is older than 40 years or has risk factors for colon cancer, such as a family history Treatment Depending on degree of disease, treatment falls into two main categories: nonsurgical and hemorrhoidectomy. GRADE SYMPTOMS AND SIGNS MANAGEMENT First degree Bleeding; no prolapse Dietary modifications Second degree Prolapse with spontaneous reduction Rubber band ligation Bleeding, seepage Coagulation Dietary modifications Third degree Prolapse requiring digital reduction Surgical hemorrhoidectomy Bleeding, seepage Rubber band ligation Dietary modifications Fourth degree Prolapsed, cannot be reduced Surgical hemorrhoidectomy Strangulated Urgent hemorrhoidectomy Dietary modifications Reference : Sabiston Textbook of Surgery, 18th Edition Dietary modifications Dietary modifications are always appropriate for the management of hemorrhoids, if not for acute care then for chronic management, and for prevention of recurrence after banding and/or surgery. Nonsurgical Rx Simple measures better local hygiene avoidance of excessive straining better dietary habits supplemented by medication to keep stools soft, formed, and regular Symptoms of bleeding but not prolapse can be significantly reduced over a period of 30 to 45 days with the use of fiber supplements Suppositories are good? Over-the-counter suppositories and anal salves, although popular, have never been tested for efficacy In the absence of symptomatic external hemorrhoids, second- and some third-degree internal hemorrhoids can be treated with office procedures that produce mucosal fixation. What is the best? Sclerotherapy Infrared coagulation Heater probe Bipolar electrocoagulation What is the best? The simplest, most effective, and most widely applied office procedure is rubber band ligation How many sites we can perform this procedure? Only one site should be banded each time Is there any contraindication? Taking Antiplatelet Blood-thinning medications Subacute bacterial endocarditis prophylaxis Immunodeficient patientsSubacute bacterial endocarditis prophylaxis Any advice for patients? Be aware of severe perineal sepsis and even deaths after rubber band ligation Return to the emergency department if delayed or undue pain, inability to void, or a fever develops Surgical Rx Hemorrhoidectomy is the best means of curing hemorrhoidal disease Considered when patients fail to respond satisfactorily to repeated attempts at conservative measures hemorrhoids are severely prolapsed and require manual reduction hemorrhoids are complicated by strangulation or associated pathology, such as ulceration, fissure, fistula hemorrhoids are associated with symptomatic external hemorrhoids or large anal tags Surgical Rx (cont’d) Simple thrombosed external hemorrhoids excision in the office is best performed early in the course of the disease, during the period of maximum pain To remove complex internal or external hemorrhoids, an open or closed hemorrhoidectomy can be performed as an outpatient procedure Three bundles are identified in the right anterior, right posterior, and left lateral positions Be careful, sufficient anoderm is preserved to avoid the long-term complication of anal stenosis Postoperative complications Fecal impaction Infection Urinary retention Patients typically recover sufficiently to return to work within 1 to 2 weeks As an alternative to the closed technique, the surgical wounds can be left open to reduce postoperative pain, but at the expense of longer healing times. Newer technology Goal to decrease postoperative pain The two main categories Ultrasonic or controlled electrical energy such as the Harmonic Scalpel and Liga-Sure Longo’s technique Stapled hemorrhoidopexy Longo's technique, commonly referred to as the stapled hemorrhoidectomy or stapled hemorrhoidopexy Excises a circumferential portion of the lower rectal and upper anal canal mucosa and submucosa and performs a reanastomosis with a circular stapling device As a result, the prolapsed anal cushions are retracted into their normal anatomic positions within the anal canal. In addition, the terminal branches of the inferior hemorrhoidal artery are disrupted, and blood flow into the cushions is thereby decreased. The primary physiologic appeal of this operation is that it leaves the richly innervated anal canal tissue and perianal skin intact, thus reducing the pain usually associated with excisional hemorrhoidectomy Initially, stapled hemorrhoidopexy was performed with a large standard end-to-end anastomosis (EEA) stapler. Recently, however, a dedicated stapling device specifically designed for this operation was introduced into clinical practice. The stapled hemorrhoidopexy consists of five steps: Reduce the prolapsed tissue Gently dilate the anal canal to allow it to accept the instrument. Place a purse-string suture Place and fire the stapler Control any bleeding from the staple line Most important technical consideration is proper placement of the purse-string suture The suture should be at least 3 to 4 cm above the dentate line; if it is too low, a portion of the dentate line may be excised, which could lead to a severe prolonged pain syndrome or to persistent fecal urgency. In addition, the purse-string suture must be placed so as to incorporate all of the redundant tissue circumferentially; failure to do so may lead to incomplete excision and predispose to recurrent prolapse Finally, extreme care must be exercised in placing the purse-string suture in women so that the vagina is not entrapped anteriorly. Stapled hemorrhoidopexy Vs. excisional hemorrhoidectomy Significantly less postoperative pain overall Less pain with the first bowel movement Earlier resumption of normal activities has been associated with a number of serious complications, including anastomotic dehiscence necessitating colostomy, rectal perforation, severe pelvic infection, and acute rectal obstruction and therefore training before use is strongly recommended