HAEMORRHOIDS


INTRO
Haima = blood, Rhoos = flowing (Greek).
Haemorrhoids are a common perianal problem in the West, whereby fibrovascular cushions in the anus engorge and enlarge, possibly bleeding, prolapsing or incarcerating.
See perianal haematoma for 'thrombosed external haemorrhoid'.
- external are covered in anoderm; internal with endoderm with no sensory innovation.
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EPIDEMIOLOGY

Very common, increasing with age.
Almost everyone will have an episode of first degree haemorrhoid.

Geography

Common in West

Risk Factors
Low fibre diet
Constipation
Family history
Pregnancy
Occupation / straining.
May be severe in spinal patients
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AETIOLOGY

Degenerative
See below

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BIOLOGICAL BEHAVIOUR

Anatomy & Physiology
Submucosa at anus forms a continuous ring of tissue, like vascular cushions.
- main at left lateral, right anterior and right posterior portions (3,7,11 o'clock)
- rich in blood and muscular fibres, like lips.
- contribute 15% to resting anal pressure.
- muscle arises from internal sphincter & conjoined longitudinal muscle
Fill with blood when intra-abdominal pressure increases, to help maintain continence.
- blood from superior haemorrhoidal artery and branches of middle & inf haemorrhoidal.
- drain to superior, middle & inferior haemorrhoidal veins.

Pathophysiology

One or combination of:

1. Elevated anal sphincter pressure.

2. Degeneration of supporting tissue to vascular cushions
- may relate to chronic straining, hard stool, weakening of pelvic floor support.

3. Venous distension

4. Prolapse of cushions and surrounding tissue.


Classification
Internally, 4 degrees of severity.

1st No prolapse but bleeding
- bulge into anal lumen, can be crushed as a hard stool descends

2nd Prolapse through sphincter, returning after strain.


3rd must be manually repositioned.


4th thrombosed irreducible

- strangulation and gangrene possible.

Complications
Thrombosis may occur (4th degree).
Note these are not the same as rectal varicosities from porto-caval shunting.
- those are located more proximally in the anal canal and rectum
- treated by reducing portal hypertension.

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MANIFESTATIONS

Symptoms

Local
Itch, bleed, prolapse, irritate, hurt, hygiene.

First degree

Spotting or frank blood on toilet paper / covering stool or in bowl.
As they are above the dentate line (internal), there is no pain.

Second degree

Feeling of a mass coming out during motion.
A dragging discomfort may be associated.
Usually do not bleed.

Third degree

Mass comes out and stays out.
Causes unpleasant faecal soiling (covered with mucous and shite).
Dragging discomfort, anal tenderness, and a dull pain.
Itchiness.

Fourth degree

Large thrombosed mass protruding from the anus.
Pain is excruciating.
If ulcerating vein, frank haemorrhage (rare).

Signs
Observe
Proctoscopy
Note redundant skin folds if past resolution.
Internal are larger, and more circumferential, covered with mucosa not squamous epithelium.
May encompass part or all of anus.
Differentiate from prolapse - quite firm and non-compressible.
Investigate incontinence as unlikely to be caused by the haemorrhoids; just soiling.
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INVESTIGATIONS
Not really needed.
Flex sigmoidoscopy, colonoscopy should be done if bleeding / anaemia to ensure no tumour.
Defecography may prove no prolapse.
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MANAGEMENT

1. Lifestyle Changes
Fibre, stool softeners (e.g. mucilax).
- fibre laxatives associated with 53% reduction in symptoms and bleeding.
Perianal hygiene; sitz baths and baby wipes.
Less time on toilet.
Drink more fluid.
Warm baths and bed rest if thrombosed veins (often resolve after 48-72 hours).

2. Topical Agents
E.g. scheriproct (steroid, analgesic)
Rectogesic (analgesic)
Relieve symptoms; not proven to alter course of disease or bleeding.
- avoid prolonged use of topical steroids; thin skin.

3. Surgical
See operative procedure

Principles
First Degree

Sclerotherapy - see below
This excites fibrosis and fixes the cushion to the anal canal wall.
Alternatively banding

Second Degree

Similarly as for first degree.
Some are removed surgically.

Third Degree

Haemorrhoidectomy indicated.
Varicosed veins dissected out, tied off, removed.
Very painful operation.

Fourth Degree
Admit for analgesia.
Haemorrhoidectomy indicated

Emergency haemorrhoidectomy?
E.g. for acute strangulated internal haemorrhoids?
Options are non-operative Rx, anal dilation, and emergency haemorrhoidectomy.
When performed correctly there is no higher morbidity than for elective haemorrhoidectomy.
However, the risk here is that swelling leads to excessive excision of anal mucosa and subsequent development of anal stenosis.
- a few residual skin tags is better than over-zealous excision.
Anal dilation is an option, done gently, to reduce prolapsed piles back to where they belong.
Non-operative?
- yes, preferred.
- analgesia, bed rest, until spontaneous resolution.
- ice is an option, but a generous coating of sugar is also good: hygroscopic and rapidly reduces tissue oedema encouraging resolution.

Sclerotherapy
Grade I and II internal haemorrhoids.
Injection of irritant
- causes inflammation, scarring.
Must be directed at the perivascular tissue around the upper pole of each pile.
1. Take note of the situation of the haemorrhoid as the prolapse over the withdrawing scope.
- that is 3,7,11 in lithotomy.
2. As the scope is withdrawn, the piles will prolapse such that they obscure your view of the base.
- remove, replace, reintroduce
- withdraw until a rim appears and the anus tries to extrude your scope.
- resist extrusion, and hold a position showing the upper pole of the piles; if prolapse occurs you are too low.
3. With a shouldered needle, jab and aspirate at base.
- if blood returns, to not inject; fully withdraw and reinsert.
4. Inject ~2ml of 5% phenol in almond oil at the base of the pile.
- it will swell a little and blanch.
Indications
Easy, effective and quick.
Office procedure.
Inject 1 or 2 per visit.
Little discomfort.
Safe in the immunocompromised; less risk than surgery even grade III.
Serious complications are rare.
Discomfort for 48h possible.
Do no inject vessels -- can be systemic problems; chest and upper abdo pain.
If injected into parasympathetic nerves, can cause erectile dysfunction.
Local infections and abscesses are rare.
- pelvic sepsis rare; 5d after procedure; fever, perianal pain, urinary retention etc.


Banding
Simple and effective
Best for grade 1 with minimal prolapse.
Effective for grade 2
Success rate >75%
Office procedure.
One or two bands to base just proximal to the anal cushion.
Insert proctoscope.
Deliver bands just proximal to the internal anal cushion; constrict blood supply, creating a zone of necrosis.
Causes inflammation, scarring, ulceration, fibrosis.
Can cause discomfort.
- do not place below dentate line or will result in pain.
Can cause minor bleeding
- severe bleeding uncommon but can occur when necrotic ulcer sloughs, up to 1-2 weeks after procedure.
- avoid blood thinners.
- uncommon critical bleeding can be compressed with an inflated Foley catheter balloon tight against anal ring until definitive operative treatment achieved.
Pelvic sepsis is a rare complication
- few recorded cases of death.
Usually should do 1 or 2 at a time; repeat banding 4 weeks apart.

Infrared Coagulation
Newer modality used in some centres
Grade I-III
Infrared beam at haemorrhoidal apex; superficial tissue destruction.


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