Medical Articles

Haemorrhoids need not be a pain in the butt!

What is a Haemorrhoid?

  • Definition and Classification
  • Anatomy
  • Pathophysiology

DEFINITION

Haemorrhoids are swellings containing dilated veins within the anal canal in the subepithelial region formed by radicals of the superior, middle and inferior rectal veins.

CLASSIFICATION

  • According to Site of Origin
    • Internal haemorrhoids
    • External haemorrhoids
    • Interoexternal haemorrhoids
  • According to Pathology
    • Primary haemorrhoids
    • Secondary haemorrhoids
  • According to Prolapse
    • First degree
    • Second degree
    • Third Degree
    • Fourth degree

Haemorrhoids

Internal Haemorrhoids

  • Within the anal canal & internal to the anal orifice
  • Commences at the anorectal ring & ends at the dentate line
  • Covered with mucous membrane
  • Bright red or purple in colour
  • Result from varicosity of the internal haemorrhoidal plexus
  • Usually painless

Haemorrhoids

External Haemorrhoids

  • Located at the anal verge, covered with skin & situated outside the anal orifice
  • Results from the varicosity of the external haemorrhoidal plexus.
  • External haemorrhoid swells, becomes firm & turns blue or purple in colour
  • Usually painful

Haemorrhoids

Interoexternal Haemorrhoids

  • Above two varieties together
  • Results from the varicosity of both internal & external haemorrhoidal plexus.

Haemorrhoids

Haemorrhoids

First Degree
Haemorrhoid does not come out of the anus. The veins become congested & bleeding is “splash in the pan” during defecation

Second Degree
Haemorrhoids come out only during defecation & reduce spontaneously after defecation

Third Degree
Haemorrhoids come out only during defecation & do not return by themselves, but need to be replaced manually.

Fourth Degree
Haemorrhoids are permanently prolapsed & proper replacement is not possible. Patients complain of great discomfort & feeling of heaviness in the rectum.

Anatomy

Primary Haemorrhoids

Three positions - 3, 7 & 11 0’Clock positions

Termination of Superior Rectal Artery and vein which divides into right and left main branches

The left branch continues as a single vessel and terminates at 3 0’Clock

The right branch divides into two branches i.e. anterior branch terminates at 11 0’Clock & posterior branch terminates at 7 0’Clock.

Secondary Haemorrhoids

Additional haemorrhoids between the primary haemorrhoids

The anal canal 4 cm long and is directed downward and backward from the rectum to end at the anal orifice.

The middle of the anal canal (dentate line) represents the junction between endoderm and ectoderm

The lower ½ is lined by squamous epithelium and the upper ½ by columnar epithelium

The area above the dentate line is insensate The nerve supply to the upper ½ via autonomic plexus and the lower ½ is supplied by the somatic inferior rectal nerves, a terminal branch of the pudendal nerve.

Hemorrhoidal Disease Epidemiology

  • More than 50%* of the population will develop symptomatic hemorrhoids in their lifetime.
  • The incidence increases with age.
  • Minority of patients will need surgical treatment.

Aetiology

Genetic links
Significant association between haemorrhoids, hernias, genitourinary prolapse and varicose veins
(Selzner 1962, Burkitt 1975; Loder et al 1994)

Environmental factors
Constipation with straining: Low-fiber diet Obesity Sedentary lifestyle
(Stern 1964; Burkitt 1974; Hyams 1970; Thomson 1975, Haas et al. 1984)

Other Conditions
Deterioration of connective supporting tissue: Pregnancy Associated disease
(Gass-Adams 1955, Thomson 1975, Haas et al. 1980. Loder et al.1994)

Physiology

Arteriovenous anastomoses within the submucosa are thought to contribute to the increase in volume of the anal cushions, sealing the anal canal.

The cushions contribute approximately 15%–20% of the resting anal pressure. Perhaps more importantly, they serve as a conformable plug to ensure complete closure of the anal canal.

Pathogenesis

Haemorrhoids

Secondary Causes:

These are due to underlying organic cause such as:

  • pregnancy
  • venous obstruction and congestion
  • straining on micturation/stooling
  • carcinoma of the rectum
  • portal obstruction

Natural history

  • Bleeding
  • Thrombosis
  • Strangulation
  • Gangrene
  • Fibrosis
  • Suppuration
  • Ulceration

Examination and Investigation

Anal and perianal disorders makeup about 20% of all outpatient surgical referall. These conditions are extremely distressiing and embarrasing. Patients often put up with symptoms for long time before seeking medical care.

  • “Red flags” should be kept in mind
    • Weight loss
    • Change in bowel habit
    • Feeling of incomplete evacuatiion
    • Iron deficiency anaemia (rarely caused by haemorhoids)
    • New onset heartburn
    • Low threshold for colonoscopy especially age >50

Common symptoms

  • Anal bleeding (Bright red especially after defaecation)
  • Anal pain and discomfort (Heavy feeling)
  • Perianal itching and irritation (Pruritis ani)
  • Something coming down
  • Perianal discharge

EXAMINATION

  • Examination of the entire perianal area.
  • Gentle spreading of the buttocks allows easy visualization of distal anal canal
  • Anal fissures & perianal dermatitis
  • Location and size of skin tags indicating prior thrombosis
  • Look for swollen blood vessels
  • External piles seen on the anal margin
  • Internal haemorrhoids sometimes seen during straining and felt if thrombosed
  • Fourth degree prolapsed piles seen in 3, 7 and 11 O’Clocks positions.

Proctoscopy:

  • Proctoscopy to look for internal haemorrhoids & examine the lining of the anal canal
  • Lubricated proctoscope introduced fully with prior intimation to the patient
  • Obturator is removed & with an illuminator the inside the anal canal visualized
  • Proctoscope is slowly withdrawn & pile mass seen bulging into the lumen just below the anorectal ring
  • Position, number, degree of piles and bleeding can be assessed

Haemorrhoids

Sigmoidoscopy

  • To rule out causes of gastrointestinal bleeding above the anal canal to approximatly 30cm

Haemorrhoids

Colonoscopy

  • For cases of bleeding without an identified anal source
  • Suspicion of colonic disorders
  • Screening in patients older than 50

Haemorrhoids

Management

  • History
  • Medical
  • Non operative
  • Operative

HISTORY

'One may cut, resect, suture or burn hemorrhoids. These measures seem to be terrible but they don't cause any damage'
Celsus (30 A.D.): Ligature; Excision
Galenus (138-201 A.D.): Ligature
Ibn-Sina(981-1038 A.D.): Ligature
Guglielmo (1210-1280): Excision + cauterisation

Haemorrhoids and the Most Common Treatments

Haemorrhoids

MEDICAL MANAGEMENT

  • Bed rest
  • Cold / warm sitz baths
  • Soothing agents
  • Topical Anesthetics
  • Creams / Ointments (Steroids)
  • Analgesics
  • Anti-inflammatory agents
  • Suppositories
  • Laxatives
  • Vasoconstrictors
  • Protectants
  • Antiseptics
  • Keratolytics

NON – OPERATIVE MEASURES

  • SCLEROTHERAPY
  • RUBBER BAND LIGATION
  • CRYOSURGERY
  • INFRARED PHOTOCOAGULATION
  • LASER TREATMENT

SCLEROTHERAPY

A sclerosant is injected into the haemorrhoids which causes thrombosis and obliteration by necrosis.

  • ADVANTAGES
    • Quick, relatively painless & O.P.D. procedure.
    • Patient can return to work on the same day
    • High percentage (95%) of cure in first degree haemorrhoids.
  • DISADVANTAGES
    • Recurrence (15%).
    • Faulty technique leads to sloughing and perianal sepsis
    • Not widely practiced

RUBBER BAND LIGATION

A rubber band is placed around the base of the haemorrhoid which cuts off circulation. The hemorrhoid necroses and sloughs within a few days.

  • ADVANTAGES:
    • Simple O.P.D. procedure
    • Band can be placed over larger haemorrhoids
  • DISADVANTAGES:
    • Pain persisting for 24 – 48 hours after ligation
    • Secondary haemorrhage
    • Recurrence 10-15%
    • Perianal sepsis
  • INDICATIONS
    • Large first & second degree haemorrhoids
  • CONTRAINDICATIONS
    • External Haemorrhoids
    • Coagulopathy & Portal hypertension

CRYOSURGERY

Haemorrhoids are frozen with liquid nitrogen for a sufficient period of time to cause necrosis

  • DISADVANTAGES:
    • Profuse watery discharge
    • Equipment is expensive
    • Results not superior to other therapies
  • INDICATIONS:
    • First & Second degree haemorrhoids.
  • CONTRAINDICATIONS:
    • Third & Fourth degree haemorrhoids.
  • ADVANTAGES:
    • P.D procedure
    • Rapid recovery of the patient
    • Minimal or no bleeding
    • Post-operative infection is minimal or absent
    • Interference with bowel movement or urination is minimal

INFRARED AND LASER PHOTOCOAGULATION

  • Energy source is transmitted via a fiber optic cable which terminates in a probe for coagulation.

Operative Management

Haemorrhoids

HAEMORRHOIDECTOMY

  • Traditionally the method of choice
  • Open method:
    • Milligan Morgan ligature and excision
  • Closed method:
    • Hill-Ferguson
  • Submucosal haemorrhoidectomy.
  • Indications:
    • Grade II - IV haemorrhoids

Complications of haemorrhoidectomy

  • Local
    • stenosis
    • faecal leakage
    • recurrence
    • bleeding
    • retention of urine
  • Severe perineal sepsis (esp IDDM & immunosuppressed)
  • Prolonged painful healing

The future of haemorrhoid surgery

  • Transanal haemorrhoidal dearterialisation (THD)
  • Procedure for prolapse and haemorrhoids (PPH)

Transanal haemorrhoidal dearterialisation (THD)

  • Doppler device is used to accurately locate one of the 6 feeding arteries of the haemorrhoidal cushions.
  • Device guides needle to ligate artery thus interrupting inflow and decompressing the haemorrhoidal cushion
  • Pexis of cushion into anatomical position with absorbable suture

Technique

Haemorrhoids

THD

Haemorrhoids

THD Surgical Approach

Haemorrhoids

Pexy of prolapsed cushion

Haemorrhoids

Advantages of THD

Advantages:
Absent or minimal post-op pain
No major post-op complications
Resolutive (>90%) for bleeding and prolapse
Day case surgery
Immediate return to normal activity
Can be repeated

Disadvantages:
Cost
Learning curve

DATA - THD

Haemorrhoids

Procedure for prolapse and haemorrhoids (PPH)

  • PPH involves the repositioning of the internal and external hemorrhoids to their anatomical position through the excision of a strip of excess prolapsed mucosa above the dentate line.
  • PPH is not a hemorrhoidectomy in principle. It is a hemorrhoidopexy.
  • However, part of the internal hemorrhoids may be excised along with the prolapsed rectal mucosa.

PRINCIPLES OF PPH

Haemorrhoids

Haemorrhoids

Haemorrhoids

Haemorrhoids

Haemorrhoids

Indications and Contraindications

  • Indications:
    • 2nd, 3rd and 4th degree hemorrhoids
    • Rectal mucosal prolapse
  • Contraindications:
    • Absolute:
      • Abscess
      • full thickness rectal prolapse
    • Relative:
      • non-reducible prolapsed hemorrhoids on the perianal skin
      • acute thrombosed internal hemorrhoids
      • previous rectal surgery (because scarring may cause difficulties in various stages of the procedure)

Advantages of PPH

  • Less Pain
    • No painful wounds
    • The haemorrhoidal cushions are not destroyed
    • Sensation of the anoderm is not disturbed
  • Quicker recovery
  • No stenotic scaring
  • Reduced theatre time

Complications of PPH

  • Post operative urine retention
    • 2% needed to be catherized
  • Post-op bleeding demanding surgical therapy
    • 1% on day of procedure
    • 6% on day after procedure
    • 3% days after procedure
  • Urgency
    • 30% (resolves within 48h)
  • Recurrence 2% (Milligan 2%)

PPH Technique - Steps

  • Fixating of purse-string
  • Insertion of the stapler

Haemorrhoids

Haemorrhoids

The PPH Effect

Haemorrhoids

History of PPH

  • 250,000 procedures have been carried out to date.
  • Over 13,000 procedures have been performed in the U.S. since September 2001.
  • 80%of haemorrhoid procedures in Italy are performed using PPH.

Haemorrhoids

Less Pain

Haemorrhoids

Quicker Recovery

Haemorrhoids

PPH Risks and Complications

As with any surgical procedure, there are risks that accompany PPH:

  • If too much muscle tissue is drawn into the device, it can result in damage to the rectal wall, resulting in inflammation or infection.
  • The internal muscle of the sphincter may be damaged, resulting in short-term dysfunction, such as severe pain or incontinence.
  • With the launch of the PPH03 a proctoring program was introduced to help with the learning curve

PPH DATA

Haemorrhoids