1. Haemorrhoids

2. 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

3. 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

4. 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.

5. 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.

6. 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

9. 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

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

11. 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

22. 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.

23. 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).

24. 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)..

25. 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.