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.

Investigations 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

Treatment Symptomatic Injection of sclerosant Banding Stapling - endostapler Photocoagulation Haemorrhoidectomy Cryosurgery - abandoned

Indications for haemorrhoidectomy third-degree haemorrhoids Failure of nonoperative treatments of second-degree 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.