Describes the anatomy of anal canal as well as rectum ,also overview of hemorroid and current methods available in treating this pathology.

1. PRESENTED BY
Dr. Mukoro George Duke
B.Sc (BGS)UNIPORT MBBS UNIPORT

2.  INTRODUCTION :
DEFINITION
BRIEF HISTROY
 PHYSIOLOGIC-ANATOMY/EMBRYOLOGY /HISTOLOGY
 EPIDEMIOLOGY
 AETIOLOGY/ RISK FACTORS
 PATHOLOGY
 CLINICAL FEATURES
 MANAGEMENT
INVESTIGATIONS
TREATMENT
Non-operative
Operative ,its indications and its
complications.
 COMPLICATIONS of hemorrhoids and prolongation .
 NEW ISSUES
 CONCLUSION

3. CASE PRESENTATION
I present Mr. J.G.
A 37 year old
Male
Civil Servant (Bailiff ) and fourth year engineering student
Single
zarama
I jaw by tribe
Christian of the RCCG sect.

4. Pc: Anal protrusions 9yrs duration
HPC :Patient presented at general surgery clinic
via OPD with anal protrusions which started
year 2001 with constipation and passage of hard
stools, and later became associated with
protrusion of anal tissue that was spontaneously
reduceable, 5 years later ,he noticed bright red
blood which comes via anus immediately after
passage of stool. There was associated history of
pain which started a week before admission, there
is no history of passage of mucous ,his diet ,
majorly consisted of beverages ,indomine ,bread
at home . there is no past history of chronic cough
,chronic diarrhea nor abdominal swelling.

5. Before presentation to the managing team ,he had
used herbal preparations on several occasions for
past 8 years, and two weeks before presentation in
the unit patient was placed on oral methronidazole
and ampicillin , with sitz bath by general surgery
term A , but he was not relieved of symptom.

6. PMSH: He had no surgeries in the past.
He’s not a known hypertensive , diabetic, sickle
cell disease nor bronchial asthmatic patient.
Drug Hx: No known drug allergy.
FSH: single ,and 2nd among seven siblings in a
monogamous setting. Takes alcohol products
sparingly and stopped 4years ago, does not take
tobacco product of any form.
ROS:NOAD.

7. O/E: A young man, not in obvious painful distress.
Not pale, anicteric, acyanossed, not warm to touch.
No peripheral lymphadenopathy, nor pedal edema.
Abdomen: full and soft, moves with respiration,
No scars, male pattern hair distribution.
No areas of tenderness,
LSK- nil
DRE: Good anal hygiene with good sphincteric tone
No fissures ,hemorrhoids present ,small at 6 and 12
o’clock positions, tender with bluish distended veins,
rectal cavity contained fecal pellets, no masses, rectal
mucosal wall is free and mobile prostate not enlarged .

8. CVS: Pulse rate - 80bpm regular full volume ,
B.P. – 90/70mmhg.
H.S. – 1&2 only.
Apex beat - 5th I.C.S. lateral to midclavicular line
RS : RR – 20 cpm
Trachea central
PN – resonant
BS – vesicular
CNS: Conscious and alert, oriented in
PPT

9. Summary.
A 37 year old male bailiff, with 9 years of anal
protrusion, with associated occasional bleeding, a year
history of non reducibility , a week history of
associated pain. on examination had hemorrhoids
present ,small at 6 and 12 o’clock positions, tender with
bluish distended veins.
ASSESSMENT: 30 gangrenous hemorrhoids

10. PLAN: Admitted by consultant from general surgery team
A TO C
Book after theatre fee paid , and
Prepared for surgery(hemorroidectomy),
with ducolax Suppository, consent retrieved, NPO
for 24 hrs.
Serum E/U/Cr
PCV – 30%
FBS
Urinalysis (early morning )
Proteinuria 30mg/dl(+) bilirubinuria (+). No
other abnormalities
detected .
Consultant informed.

11. INTRA/POST-OPERATIVE MANAGEMENT
Patient was assessed by the anesthesiologist and spinal
anesthesia was administered and failed thereafter placed on
TIVA. He was placed in lithotomy position and draped ,lurch
procedures done , and pellicles of hemorrhoids excised while
haemostasis secured. Rectum was parked with Vaseline gauze
and anal orifice Dressed. During the course of surgery, his vital
signs where monitored.
He was placed on intravenous ciprofloxacin 200mg bd for 5/7
intravenous flagyl 400mg tds for 5/7
I m pentazocine 30mg alternate with im diclophenac 6hrly for 48
hrs then after PRN .
tabs vitamin c T bd for 10/7
NPO to food only for 24 hrs
Iv 5% D/S 8hrly for 24 hrs .
Sitz bath tds +PRN after toileting

12. POST OP COMPLICATIONS NOTICED
Dribbling faeces from anus during sitz bath and at
anal orifice during daily inspections , he was placed on
kegills exercise .
Bleeding from op site on 1st and 3nd , patient was
reassured .
Pain at op site ,he was placed on analgesics
,intramuscular analgesics later oral tramadol 50 mg bd
.
Vital signs were stable throughout his stay in the
hospital.
DISCHARGE :patient was discharge on 5TH day post-
op on the following tabs flagyl 400mg tds, cap
ampiclox 500mg qds and tabs tramadol 50mg bd ,sitz
bath tds and kegills exercise bd all for 7 day to see at
next two Monday clinic for follow-up.

13. INTRODUCTION :
 DEFINITION : Pathological presentation of
hemorroidal venous cushions characterized by distention
and sliding down of anal cushions containing varicose
veins.
 BRIEF HISTROY:if bile or phlegm be determined
to the veins in the rectum ,it heats the blood in the
veins :and these veins becoming heated attract blood
from nearest veins ,and been gorged the inside of the
gut swells outwardly, and the heads of the veins are
raised up, and being at the same time bruised by the
faeces passing out ,and injured by the blood collected
in them ,they squirt blood, most frequently along with
faeces , but sometimes without faeces. ----------
Hippocrates (460-375 BC)

15. PHYSIOLOGIC-ANATOMY/EMBRYOLOGY/
HISTOLOGY
The anal canal is the terminal part of the large
intestine.]
The anal canal is 3-4 cm long

16. In humans, it extends from the anorectal junction to
the anus. It is directed downwards and backwards. It is
surrounded by inner involuntary and outer voluntary
sphincters which keep the lumen closed in the form of an
anteroposterior slit.
Internal anal sphincters (smooth), external anal sphincter
(striated),
Upper two-third(mucosal) ,lower one-third (skin) .
The embryonic origin is lower anorectal part of the
cloacae which is lined by derivative of endoderm
(upper2/3) and lower 1/3 by ectoderm from anal
pit(proctodeum), indicated anatomicly by relative
avascularised Hiltons white line(pectinate line).It is
situated between the rectum and anus, below the level of
the pelvic diaphragm. It lies in the anal triangle of
perineum in between the right and left ischiorectal fossae.

17.  The anal canal is divided into three parts.
The zona columnaris is the upper half of the canal,
terminating at the annulus hemorroidalis(zona hemorroidalis)
, and is lined by simple columnar epithelium.
The lower half of the anal canal, below the pectinate line, is
divided into two zones separated by Hilton's white line. The
two parts are the zona hemorrhagica(pecten) and zona
cutanea, lined by stratified squamous non-keratinized and
stratified squamous keratinized, respectively. the margin of the
anus is guided by corrugators cutis ani muscle.
Blood supply :superior ,middle and inferior hemorroidal
vessels. It’s part of the porto-caval anastomosis.
Lymphatic drainage: inguinal group of lymph nodes and iliac
groups of lymph nodes. Watershed line serves as land mark.
Nerve supply ;inferior rectal nerve and inferior hypogastric
plexuse.

18. EPIDEMIOLOGY
Symptomatic hemorrhoids affect at least 50% of the
American population at some time during their lives,
with around 5% of the population suffering at any
given time, and both sexes experiencing the same
incidence of the condition. They are more common in
Caucasians. The exact incidence in the population of
developing countries has not been determined but in
spite of assertions to the contrary the condition is
frequently encountered in most developing countries.

19. AETIOLOGY/RISK FACTOR
The predisposing factors include
heredity, age, sex, pregnancy ,obesity, the puerperal state
and even temperament,morphology,intraabdominal
mass.
The precipitating factors comprise cathartic
abuse, diarrhoea, enemata, constipation, infection, anal
spasm or atony of the anal sphincter, obesity and rise in
intraabdominal pressure,portal hypertension,anal sex.
EXTERNAL :associated with anal fissure, anal tags

20. PATHOPHYSIOLOGY
Varicose submucosal branches of the superior and
inferior hemorroidal veins constituting the internal and
external haemorrhoidal plexuses are congregated into 3
primary positions - right anterior, right posterior and left
lateral - depending on the pattern of termination of the
superior rectal artery, as repeated pressure occur with engorgement
of the submucosal venous plexus, there is contraction and closure
of intramuscular venous plexus, impeding venous return, by the
sphincteric muscle while intra-arterial pressure increase ,combine
with the valvulessity of the vein there is initial distention, while the
dentate ligament remain intact ,after a while, the ligament are
stretched and there is prolapsed. Prolonged reduction in nutrient
supply of the prolapsed lead to dead mucosal tissue ,which
ruptures and bleeds.

21. CLINICAL FEATURES
Bleeding ,first symptoms, either as splash in the pan or
as streak.
Mass per rectum
Discharge (mucoid)
Pruritus
Pain(prolapsed,infection,spasm, thrombosed.
Complicated; Complicated; Profuse
bleeding,strangulation,thrombosis,ulcerated,gangrene
,fibrosis,stenosis,suppuration,pylephlebitis(rare)
Anal swelling ,(visual,proctoscope).

22. Types are: Anatomical boundary.
internal ;above dentate line, covered with
mucosa. varicosity of superior rectal vein
tributaries
External ;below dentate line ,covered with
skin. Varicosity of inferior rectal veins tributaries
Interno-external;together occurs.
Vascular origin
Primary :located at 3’,7’,and 11 o’clock
positions, related to branches of the superior
hemorroidal vessel which divides into two ;left side it
continues as one .
Secondary: One which occurs between the
primary sites.

23. Severity
First degree
Second degree
Third degree
Fourth degree
Others :arterial pile which is an hematogiomatous
condition of superior rectal artery entering the pedicle of
internal hemorroidal which will bleed profusely.
DEFFERENTIAL DIAGNOSIS
Carcinoma
Rectal prolapsed
Perianal warts
Bleeding ;fissure in ano,polyps,ulcerative and amoebic
colitis, fistula in ano,diverticulitis ,intussusceptions

24. MANAGEMENT
INVESTIGATIONS
Proctoscopy
Hematocrit /Full blood count
Colonoscopy
Barium enema
TREATMENT
Non operative ;
Sitz bath
Antibiotics
Fiber diet 35gram/day,plenty of water.
Daflon
Ducolax suppository
Liquid paraffin

25. Operative
Lord dilatation
Complication;incontinence,infection,hemorrhage/hae
matoma,prolapsed rectum.
Injection sclerosant therapy /Super freeze;luer-lock or
Gabriel syringe

26. Barrons banding

27. cryosurgery
infra-red coagulation
Laser therapy
Stapled haemorrhoidopexy(Antonio lango):
 Also known as Procedure for Prolapse &
Hemorrhoids (PPH), Stapled Hemorrhoidectomy,
and Circumferential Mucosectomy.

28. OPEN –OPERATIVE METHODS
Indications :
3rd degree piles
Failure of non-operative methods
Fibrosed piles
 Ligation and excision(Milligan-Morgan):
Developed in the United Kingdom by Drs. Milligan
and Morgan, in 1937.
 Submucosal hemorroidectomy of ‘Park
 Hill-Ferguson closed method : Developed in
the United States by Dr. Ferguson, in 1952
.

29. Special consideration :management of
strangulated/thrombosed/gangrenous pile ,initial management include
conservative treatment to reduce edema
COMPLICATIONS
Early Complications Include:
1) Severe postoperative pain, lasting 2-3 weeks. This is mainly due to
incisions of the anus, and ligation of the vascular pedicles.
2) Wound infections are uncommon after hemorrhoid surgery. Abscess
occurs in less than 1% of cases. Severe necrotizing infections are rare.
3) Postoperative bleeding.
4) Swelling of the skin bridges.
5) Major short-term incontinence.
6) Difficult urination. Possibly secondary to occult urinary retention,
urinary tract infection develops in approximately 5% of patients after
anorectal surgery. Limiting postoperative fluids may reduce the need
for catheterization (from 15 to less than 4 percent in one study).
7)Reactionary hemorrhage

30. Late Complications Include:
1) Anal stenosis.
2) Formation of skin tags.
3) Recurrence.
4) Anal fissure.
5) Minor incontinence.
6) Fecal impaction after a hemorrhoidectomy is associated
with postoperative pain and narcotic use. Most surgeons
recommend stimulant laxatives, or stool softeners to
prevent this problem. Removal of the impaction under
anesthesia may be required.
7) Delayed hemorrhage/secondary, probably due to
sloughing of the vascular pedicle, develops in 1 to 2 percent
of patients. It usually occurs 7 to 16 days postoperatively.
No specific treatment is effective for preventing this
complication, which usually requires a return to the
operating room for one or more stitches.

31. NEW ISSUES
Harmonic Scalpel Hemorroidectomy
HAL-RAR Method Hemorroidectomy(DG) HAL (Doppler
Guided Hemorrhoidal Artery Ligation) and (DG) RAR
(Doppler Guided Recto Anal Repair Proctoplasty). Developed
in 2001.93-96% success rates.first to utilise MIS.

32. CONCLUSION :
Hemorrhoids are one of
the most common
causes of anal
pathology, the deeper
your knowledge, the
more equipped you
would be to manage
them , the more likely
you will seek to handle
more.
Thanks
for
listenin
g