1. By Dr. Waqas Munir

2. Haemorrhoids :
Haem=blood
Rhoos = flowing
Piles:
Pila= swelling
The actual term now a days used for this is
Haemorrhoidal disease.

3.  Beneath the epithelium in anal canal there is
rich plexus of vascular tissue called corpus
cavernosi recti, that connect arteries to veins.
 These vessels are normally supported by
longitudinal muscle fibers (muscularis submucosa
ani) which help to retain the vascular cushions in
their position in the upper half of anal canal.
 There are 3 main vascular cushions (primary
sites) in the anal canal(one on the left and
anterior and posterior on the right).
 In 2/3rd of pts these are at primary site and in
1/3rd of pts these are at other site called
secondary sites.

5.  Facors
involved in the development of
haemorhhoidal disease:
 Venous obstruction
 Prolapse of vascular cushions
 Heredity
 Geographical and dietary factors
 Anal sphincter tone
 Anal and rectal sensation
 Defecation habits

6.  Venous obstruction:
 The principal cause of haemorrhoidal disease seems to be the
congestion and hypertrophy of internal anal cushions.
 Cushions congest because
1. They fail to empty rapidly during the act of defecation.
2. They are abnormally mobile.
3. They are trapped by tight internal sphicter.
When the cusions are congested, they bleed and become
edematous.oedema causes stretching of the tissue and
finally hypertrophy.
 Fecal mass in the rectum compress the veins.
 Straining constricts the intermuscular vein so blocks
emptying of veins.
Predisposing fctors of venous obstruction:
 Raised intra abdominal pressure during
pregnancy,from ascites or pelvic tumor, or raised
portal venous pressure with hepatic cirrhosis.
 Piles of pregnancy: These are not necessorily
abnormal.

7.  Prolapse of vascular cushions:
 Submucosal vascular cushions are supported by
 Pectin bands(ligaments of park)
 Muscularis submucosa
 In normal defecation internal sphicter relaxes
and there is outward rotation of vascular tissue
and pectin bands.
 In haemorrhoidal disease this normal rotation is
disturbed due to the decrease in elastic tissue
caused by;
 Increased Age
 Constipation
 Prolonged straining
 Endocrine reasons

8.  Heredity:
 No heredity evidence proved.
 family history is commonly recorded due to same
customs, environment and diet.
 Geographic and dietry factors:
 > western society due to less fiber diet.
 Anal sphincter tone:
 Numerous studies have shown that basal anal pressure
are significantly higher in haemorroidal disease.
 Anal and rectal sensation:
 Anal electro sensitivity and temperature sensations
are reduced in patients with haemorrhoids.
 Defecation habits:
 More than 10-15 min sitting for defecation.

9.  Sex:
 In hospital based studies Men > women
 In community based studies men = women
 Age:
 Increase with age
 Socioeconomic status and occupation:
 > high socioeconomic group
 > heavy laborer and occupations with prolonged sitting
or standing

10. B:First-degree bleeding
without prolapse
C:Second-degree Prolapsed,
reduced spontaneously
D:Third-degree prolapsed,
requiring manual reduction
E:Fourth-degree fibrosed
permanently prolapsed
Reference : Sabiston Textbook of Surgery, 18th Edition

11. 1. Bleeding
2. Prolapse and lump
3. Pain and discomfort
4. Discharge and pruritis

12.  Bleeding:
 Most common and earliest symptom
 Bright red painless bleeding especially at the end of
defecation is pathognomic of the disease.
 Bleeding is similar to anal fissure and
perianal dermatitis but pain and pruritis
differentiate it.
 Bleeding from ulcerative proctitis and rectal
neoplasm is different from haemorrhoidal
disease as it is not fresh bleeding.
 Anemia with haemorrhoids ?

13.  Prolapse or lump:
 Prolapse or lumps protruding through the anus are the real piles.
 Protrusion with the spontaneous or self digital reduction is
characteristic of haemorrhoidal disease.
 Hypertrophid anal papilla and low rectal polyps can
also prolapse and they can be reduced (mistaken for
haemorrhoids)
 Pain and discomfort:
 Haemorrhoids are usually painless.
 If pain is there either think of a complication(thrombosed
prolapsed internal haemorrhoids) or change the diagnosis.
 Discharge and pruritis:
 A constant mucous discharge from the anus with or without
bleeding is characteristic of prolapsed haemorrhoids.

14.  Internal
 External
 Interno-external

15. •Pain?
-> painless
•Bright red bleeding
•Prolapse associated
with defecation
Internal
External
•Anoderm
•Swell, discomfort, diff
icult hygiene
•Pain?
-> Thrombosed

16. 1. Thrombosis and infection of internal
cushions
2. Anemia
3. Perianal dermatitis
4. Thrombosis of external vascular channels

17.  Thrombosis and infection of internal cushions
 Most painful complication
 Thrombosis occurs when cushion is prolapsed and
enlarged.
 If necrosis of the mucous membrane occurs , clot
extrudes and pt is relieved.
 If it is not relieved then give strong analgesics
are given and pt may even need emergency
haemorrhoidectomy to evacuate the clot.
 After rupture of mucous membrane infection can
get through it and pyemia can occur but it is
very rare.

18.  Anemia:
 Rare and look for other causes
 Perianal dermatitis:
 Due to the continuous mucous leakage and
permanently prolapsed cushions.
 Thrombosis of external vascular channels:
 Tense hard and superficial swelling.

19.  History
 Inspection (to rule out other causes)
 Palpation
 Endoscopy(Proctoscopy and sigmoidoscopy)

20.  Conservative;
 Medical
 Invasive therapy
 Injection sclerotherapy
 Rubber band ligation
 Cryotherapy
 Photocoagulation
 Surgical;
 Open haemorrhoidectomy
 Closed haemorrhoidectomy
 White head haemorrhoidectomy
 Laser haemorrhoidectomy
 Diathermy haemorrhoidectomy
 Stapled haemorrhoidopexy

21. GRADE SYMPTOMS AND SIGNS MANAGEMENT
First degree Bleeding; no prolapse Dietary modifications
Second degree Prolapse with spontaneous Rubber band ligation
reduction
Bleeding, seepage Coagulation
Dietary modifications
Third degree Prolapse requiring digital Surgical hemorrhoidectomy
reduction
Bleeding, seepage Rubber band ligation
Dietary modifications
Fourth degree Prolapsed, cannot be reduced Surgical hemorrhoidectomy
Strangulated Urgent hemorrhoidectomy
Dietary modifications
Reference : Sabiston Textbook of Surgery, 18th Edition

22.  Medical management:
 Advice
 For minor symptoms
 High fiber diet
 Thorough perianal lavage after defecation
 Changing defecation habits
 Do not Neglect 1st urge to defecate in morning
 Don’t insist on trying to pass the last portion of stool from
rectum in the belief that it is not passed
 Diet manipiulation
 Bulking agents (high fiber diet) e.g ispaghol husk and
methyl cellulose
 Topical agents
 Suppositories( shark liver oil, skin respiratory factor)
 Xylocain for pain
 Paraffin as lubricant to avoid rubbing

23.  Invasive therapy:
 Principles on which invasive therapy is based;
1. Prevention of Prolapse by mucosal fixation
2. Prevention of congestion by stretching or by
dividing the internal sphincter
3. Excision of the engorged internal vascular
channels

24.  Useful in 1st and 2nd degree
 70% success rate
 Sclerosant causes aseptic inflammation and fibrosis in
2-3 weeks.
 Gabriel syringe and needle
 5% phenol in almond oil (3ml in each cushion)
 2.4% anhydrous qunine urea with ph 2.6.
 Knee chest or left lateral position
 Rt posterior cushion (7oclock) should be injected 1st.

25.  Technique:
 The proctoscope is passed and obturator is removed.
 The scope is manipulated until the junction between pink and
purple mucosa is positioned indicating the base of cushion.
 The needle of syringe is introduced obliquely through the
mucosa for 1 cm.
 The procedure should be painless
 If pain it is either too too dep or too superficial
 Superficial = avascular bleb
 Deep =no swelling
 Must be careful in midline anteriorly
 Complications:
 Pain
 Hemorrhage
 Lower urinary tract sepsis
 Impotence
 Oleogranuloma(response to almond oil)
 Bacteremia(8%)

27.  Used for 2nd degree
 80% success rate
 Principle is mucosal fixation by ulceration.
 Band produces ischemic necrosis with sloughing
and ulceration.
 Ligators
 Barron ligator
 Suction band ligator
 Mc Giveny ligator
 Preparation and position:
 Bowel should be empty
 An assistant to hold proctoscope
 Knee chest position

28.  Technique:
 Rubber band is equipped by the help of loading cone.
 Pass proctoscope
 Visualize the cushion,the base of cushion lies 1.5-2cm above the
dentate line
 Long shaft of the suction band equipment is introduced through
the proctoscope.
 Hemorrhoid is sucked into the lumen of the inner drum.
 Handle is squeezed to advance the outer drum that releases the
rubber band and applies it to the neck of haemorrhoid.
 Volume of strangulated tissue should not be larger
than 1cm diameter and at least 1cm prior to dentate
line.
 Barron stated 1 band each time but latest research
showed that all 3 bands can be applied at 1 time
(time saving and economical)

30.  Complications:
1. Pain (most common)
1. If severe pain then removal of band and treatmeent with
photocoagulation
 Removal of the rubber band: Grasp the strangulated
mucosa with forceps and attempt to rotate it so that the
rubber band or at least the constricting groove is seen
clearly then a small triangular blade is used to cut directly
until the band snaps and mucosa returns to the normal
tissue.
 Alternatively the band can be removed by conventional
suture removal scissors or application of crochet hook.
2. Bleeding.
3. Pelvic cellulitis (clostridial infection common )
 Measures to avoid:
 Screening for immunodeficiency
 Rectal washout prior banding
 Prophylactic antibiotics

31.  Principle: when tissue freezes , intracellular
water crystalizes,cell membranes are destroyed
and tissue death occurs.
 Tissue freezes at -20c and permanent
destruction at -22c.
 Liquid Nitrous oxide is used which boils at -90c
 Technique:
 With bivalved speculum anal cushions are exposed.
 Apply lubricant
 The probe is laid along the length of the cushion and
pressed laterally while trigger is squeezed. Nitrous oxide
evaporates in the tip that become frosted. This is
continued for 3 minutes.

33.  The technology includes infrared radiation
generated by tungsten halogen lamp which is
focused on the tissue from a gold plated
reflector housing through a polymer tubing.

35.  Indications:
 3rd degree haemorrhoids
 2nd degree haemorrhoids which have not been cured by
non operative methods
 Fibrosed haemorrhoids
 Interno- external haemorrhoids when the external
haemorrhoids are well defined.
 Preparation:
 1 enema night before surgery another 1 hour before
surgery
 Pts with severly prolapsed haemorrhoids should be spared
from enema.
 Anesthesia:
 Any type of anesthesia
 If L/A 0.25% bupicain with 1:200,000 adrenalin

36.  Benefits:
 Less post op discomfort
 Minimum in patient and virtually no out patient care
 No loss of continence
 No need of subsequent anal dilation
 Relative contra indications:
 Crohn’s disease
 Portal hypertention
 Lymphoma
 Leukemia
 Bleeding diathesis

37.  Technique:
 Prone jack knife position/left lateral
 Adhesive tape to retract the buttocks
 Anal canal examined by Pratt bivalved speculum.
 After inspection replace bivalved speculum with Fansler operating anoscope.
 Anoscope is adjusted so that the operating channel is in line with the
haemorrhoidal tissue.
 The skin tag or anal epithelium adjacent to haemorrhoidal tissue is grasped with
the pair of Aliss forceps and retracted toward the center of anal canal.
 Scissors with its curve toward anal canal is used to incise beneath the tissue
forceps from the perianal skin upwards along the haemorrhoidal tissue.
 Most prominent region of haemorrhoidal tissue is excised 1st to minimize the
subsequent loss of anoderm.
 Bleeding submucosal vessels are controlled with cautry.
 After complete excision of the haemorrhoidal tissue to a point above the internal
sphincter the wound is closed using a running 3/0 suture.
 Stiching is begun at the apex and mucosa is fixed with submucosa and muscle.

41.  Technique:
 Lithotomy position
 1st the left lateral haemorrhoid is excised, then right posterior
and then right anterior.
 Skin covered component of each pile is seized with the artery
forceps and retracted outward.
 The purple anal mucosal component of each pile is grasped
with another artery forceps and drawn downward and
outward.this indicates pile have been drawn to max extent so
that ligature can be applied at their upper pole.
 A V- shaped incision is made in the anal and peri anal skin so
that the limbs of the V cross the mucocutaneous junction but
do not extend into the mucosa.The point of V should lie 3 cm
away from anal verge.
 Venous plexus is dissected from internal sphincter while
preserving this sphincter.
 The apex of the pedicle is transfixed with 1/0 chromic catgut.
 The isolated haemorrhoid is then excised with the scissors a
few mm below the ligature.

45.  Early:
 Pain
 Acute retention of urine
 Reactionary hemorrhage
 Late:
 Secondary hemorrhage
 Anal stricture
 Anal fissure
 Incontinence