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Hemorrhoid Normally, do people have anal cushion? Yes Within the normal anal canal exist specialized, highly vascularized “cushions” forming discrete.

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Presentation on theme: "Hemorrhoid Normally, do people have anal cushion? Yes Within the normal anal canal exist specialized, highly vascularized “cushions” forming discrete."— Presentation transcript:

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3 Hemorrhoid

4 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

5 When would we call them ‘hemorrhoids’?
Abnormal Cause symptoms Downward sliding of anal cushions associated with gravity Straining Irregular bowel habits.

6 How do hemorrhoids come?
The cause of hemorrhoids remains unknown

7 How could we diagnose ‘hemorrhoid’?
History Physical examination Endoscopy

8 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

9 History (cont’d) Prolapse Pain?
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

10 Hemorrhoids can be divided to?
External Internal

11 Anatomy The dentate line represents a visually identifiable border between the more distal squamous mucosa and a transitional area of squamous and nonsquamous mucosa. The adjacent nonsquamous lining can consist of either transitional (urothelium-like) or rectal glandular mucosa

12 Internal External Pain? -> Thrombosed Pain? -> painless
Bright red bleeding Prolapse associated with defecation Internal External Anoderm Swell, discomfort, difficult hygiene Pain? -> Thrombosed

13 How are Internal hemorrhoid classified?
Extent of prolapse

14 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 External hemorrhoids are covered with anoderm and are distal to the dentate line; they may swell, causing discomfort and difficult hygiene, but cause severe pain only if actually thrombosed The physical examination should include inspection during straining, preferably on a commode; digital rectal examination; and anoscopy Reference : Sabiston Textbook of Surgery, 18th Edition

15 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

16 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

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18 Treatment Depending on degree of disease, treatment falls into two main categories: nonsurgical and hemorrhoidectomy.

19 Dietary modifications Second degree
GRADE SYMPTOMS AND SIGNS MANAGEMENT First degree Bleeding; no prolapse Dietary modifications Second degree Prolapse with spontaneous reduction Rubber band ligation Bleeding, seepage Coagulation Third degree Prolapse requiring digital reduction Surgical hemorrhoidectomy Fourth degree Prolapsed, cannot be reduced Strangulated Urgent hemorrhoidectomy Seepage(ซึม) Dietary modifications include increasing consumption of fiber, bran(ธัญพืช), or psyllium and water. 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. Even though all patients should be counseled on dietary and fiber recommendations, patients with prolapse and internal plus external hemorrhoids benefit from additional interventions. Reference : Sabiston Textbook of Surgery, 18th Edition

20 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.

21 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 A wide array of fiber supplements are now available over the counter.

22 Suppositories are good?
Over-the-counter suppositories and anal salves, although popular, have never been tested for efficacy

23 In the absence of symptomatic external hemorrhoids, second- and some third-degree internal hemorrhoids can be treated with office procedures that produce mucosal fixation.

24 What is the best? Sclerotherapy Infrared coagulation Heater probe
Bipolar electrocoagulation Rubber band ligation can be performed in the office without sedation through an anoscope using a ligator

25 The band is advanced onto the end of the ligator instrument using a conical attachment (insets). The hemorrhoid is identified at a level proximal to the dentate; this area is tested for sensation before banding. Occluding the suction port of the ligator instrument draws the hemorrhoid into the open end of the ligator, at which time the instrument is fired. The banded hemorrhoid typically sloughs in a week's time. (by permission of Mayo Foundation.)

26 What is the best? The simplest, most effective, and most widely applied office procedure is rubber band ligation Rubber band ligation can be performed in the office without sedation through an anoscope using a ligator

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28 How many sites we can perform this procedure?
Only one site should be banded each time

29 Is there any contraindication?
Taking Antiplatelet Blood-thinning medications Subacute bacterial endocarditis prophylaxis Immunodeficient patientsSubacute bacterial endocarditis prophylaxis

30 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

31 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

32 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

33 Excision of thrombosed external hemorrhoid
Excision of thrombosed external hemorrhoid. The area is infiltrated with local anesthetic, and the thrombosed hemorrhoid is excised sharply. The wound is left open.  (by permission of Mayo Foundation.)

34 To remove complex internal or external hemorrhoids, an open or closed hemorrhoidectomy can be performed as an outpatient procedure

35 Closed hemorrhoidectomy
Closed hemorrhoidectomy. A, Hemorrhoidal tissues are sharply excised starting just beyond the external component and working proximally, finishing with resection of the internal component. B, The sphincter muscles are preserved by dissecting only the tissues superficial to them. C, The pedicle is transfixed and the defect closed with a running absorbable suture.  (by permission of Mayo

36 Postoperative complications
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.

37 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 . Both of the energy application modalities remove the excess hemorrhoidal tissue and coagulate or seal the blood vessels simultaneously with minimal lateral thermal injury to nearby tissue. It is thought that the reduction in trauma to the surrounding anal canal mucosa and the underlying anal sphincter will decrease postoperative edema and pain. A number of small single institutional reports have evaluated both of these new technologies compared to traditional excisional hemorrhoidectomy.[28] These studies all demonstrated decreased postoperative pain and analgesic use in the Harmonic Scalpel or Liga-Sure groups compared with traditional techniques with similar short-term success rates.

38 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 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

39 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 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

40 Figure 51-10 A, Grade 4 hemorrhoid before reduction
Figure 51-10  A, Grade 4 hemorrhoid before reduction. B, Placement of stapling device obturator. Figure 51-11  Stapling device with circumferential excision of anal canal and hemorrhoid mucosa. 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

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43 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. 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.

44 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 In none of the trials was there any significant difference between the two procedures with regard to impairment of continence, which was an initial concern in view of the size of the stapler. In 2003, long-term follow-up of patients in one of the original stapled hemorrhoidopexy trials was reported.[34] At a minimum follow-up of 33 months, there were no significant differences between the two procedures with respect to quality of life, symptoms, or functional outcomes


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