Haemorrhoids

Throwback to colorectal clinic, when I was super excited at the prospect of seeing real haemorrhoids and the doctor just looked at me like I had been dropped too much as a kid.


Haemorrhoids (Piles)

Definition: a.k.a piles. Disrupted and dilated anal cushions, which are prone to protrusion, bleeding and prolapse into the anal canal.

The anus is lined mainly by discontinuous masses of spongy vascular tissue- the anal cushions- which contribute to anal closure.

Image result for hemorrhoids

Internal haemorrhoids = arise from superior haemorrhoidal plexus and lie above dentate line

External haemorrhoids = arise from inferior haemorrhoidal plexus, below dentate line

Classification

1st degree- remain in rectum

2nd degree- prolapse through the anus of defecation but spontaneously reduce

3rd degree- prolapse through the anus on defecation and require digital reduction

4th degree- remain persistently prolapsed

Aetiology/risk factors:

-constipation with prolonged straining is a key factor

-congestion from a pelvic tumour, pregnancy, congestive cardiac failure, or portal hypertension are important in only a minority of cases

Epidemiology: common, prevalence = 4-5%

Peak age = 45-65 years

Symptoms:

-commonly asymptomatic

-bright red rectal bleeding (bright red = blood from capillaries of underlying lamina propria)

-bleeding often coats stools, on the tissue, or dripping into the pan after defecation

-there may be mucous discharge and pruritus ani (itching)

-anal lumps or prolapsing tissue

As there are no sensory fibres above the dentate line (squamomucosal junction), piles are not painful unless they are external haemorrhoids, which thrombose when they protrude and are gripped by the anal sphincter, blocking venous return. These can cause severe pain.

Signs:

-severe anaemia may occur = pallor

Examinations

-abdominal exam to rule out other diseases

-PR exam: prolapsing haemorrhoids are obvious, internal haemorrhoids are not palpable

Investigations:

Proctoscopy- see the internal hemorrhoids (allows visual examination of anus and rectum)

Image result for proctoscope Sigmoidoscopy- to identify and rule out pathology higher up, such as co-existing rectal tumours

Management:

Medical (for 1st degree)

increase fluid and fibre intake

-topical analgesics (cream)

-stool softener

-topical steroids for short periods only

Non-operative (2nd and 3rd degree and 1st degree with failed medical therapy- may remove need for surgery)

Rubber band ligation– banding produces an ulcer to anchor the mucosa as the bands are applied just proximal to the haemorrhoid incorporating tissue that falls away after 2-3 days. It has the lowest recurrence rate.

Image result for rubber band ligation

Image result for haemorrhoid sclerotherapy
Sclerosants- (for 1st or second degree), 2mL of 5% phenol in almond/ arachis oil is injected into the haemorrhoid above the dentate line, inducing inflammation and subsequent fibrosis resulting in mucosal fixation. Recurrence higher.

Infra-red coagulation- applied to localised areas of haemorrhoids, works by coagulating vessels and tethering mucosa to subcutaneous tissue. As successful as banding and may be less painful.

Cryotherapy-freezing, has a high complication rate and is not recommended.

Surgery- (symptomatic 3rd or 4th degree)

Haemorrhoidectomy

Definition:

Excisional haemorrhoidectomy most effective treatment = excision of haemorrhoids +/- ligation of vascular pedicles. Scalpel, electrocautery or laser may be used.

Day case surgery, about 2 weeks recovery.

Stapled haemorrhoidopexy/ haemorrhoidectomyfor prolapsing haemorrhoids

Involves mucosectomy 2cm proximal to the dentate line to ‘hitch up’ the prolapsing anal lining and disrupting proximal blood flow.

May result in less pain, shorter hospital stay, quicker recovery. Used when there is a large internal component, but higher recurrence and prolapse rate than excisional surgery.

Indications: symptomatic 3rd or 4th degree haemorrhoids

Complications: constipation, infection, anal stricture, bleeding, recurrence, incontinence (rare)

Prolapsed, thrombosed haemorrhoids:

analgesia

-ice pack

-stool softener

-some advocate early surgery

-pain usually subsides after 2-3 weeks

Complications:

-bleeding, prolapse, thrombosis of haemorrhoids

Complications of intervention:

Rubber band ligation- bleeding, infection, pain

Sclerosants- impotence, prostatitis, perineal sepsis, retroperitoneal sepsis, hepatic abscess

Surgery- constipation, infection, anal stricture, bleeding, recurrence, incontinence (rare)

Prognosis: often a chronic problem, with recurrence of symptoms necessitating repeat local treatments. Surgery can provide long-term relief for severe symptoms.

References: Cheese & Onion, Rapid Surgery
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