Haemorrhoids

Hemorrhoids

Haemorrhoids are dilated submucosal veins within the internal or external anal canal that are usually inflamed or thrombosed. They usually occur at the 3 o’clock, 7 o’clock and 11 o’clock positions. A digital rectal examination is diagnostic for haemorrhoids. Haemorrhoids can be classified as internal, external and combined. Combined haemorrhoids most often require hemorrhoidectomy. Grading of haemorrhoids is based on reducibility (not on appearance).

Internal vs external haemorrhoids

	Internal hemorrhoid	External hemorrhoid
Location	Proximal to dentate line	Distal to dentate line
Causes	Increased intra-abdominal pressure (local, pelvic, abdominal and neurological causes)	Extension of internal hemorrhoids (interno-external hemorrhoids), straining, cooughing, lifting heavy weight
Innervation	Autonomic	Somatic
Pain	Not painful	Often painful
Bleed	often bleeds	usually does not bleed

Causes of hemorrhoids

Classification	Causes
Local	Anorectal deformity, hypotonic anal sphincter, anorectal carcinoma
Pelvic	Gravid uterus, fibroids, carcinoma of the uterus or cervix, ovarian neoplasm, bladder carcinoma
Abdominal	Ascites
Neurological	Paraplegia, multiple sclerosis

Classification (Grading) of internal hemorrhoids

Grade	Finding on DRE	Treatent
Grade I	No prolapse outside anal canal. Only associated with bleeding.	Conservative medical treatment and lifestyle modifications
Grade II	Prolapse outside anal canal with valsava, spontaneously reduces at rest	Rubber band ligation, Sclerotherapy
Grade III	Prolapse outside anal canal with valsava, manually reducable	Rubber band ligation, Sclerotherapy, coagulation, hemorrhoidectomy if symptomatic
Grade IV	Prolapse outside anal canal without valsava, cannot be manually reduced. May be strangulated, thrombosed, or ulcerated.	Hemorrhoidectomy

• Risk factors for hemorrhoids
  • Excessive straining (chronic constipation, chronic cough, heavy lifting, BPH)
  • Extended sitting (sedentary lifestyle)
  • Pregnancy (third trimester)
  • Older age (due to laxity of veins)
  • Connective tissue disorders (Ehlers-Danlos, Scleroderma)
  • Portal hypertension
  • Colon cancer
  • Inflammatory bowel disease
  • Spinal cord injury
  • Rectal surgery
  • Episiotomy
  • Anal intercourse
• Patient history (increased abdominal pressure)
  • Constipation
  • Athletes
  • Inflammatory bowel disease
  • Pregnant
  • Manual work
  • Liver disease
  • Anybody can get haemorrhoids
• Signs and symptoms
  • Painless bright red blood per rectum (small in amount, seen on the toilet paper after bowel movement)
  • Perianal mass (in case of prolapse)
  • Perianal pruritus (due to bleeding and prolapse)
  • Severe perianal pain (in case of external hemorrhoid and prolapse)
  • Anal discharge (mucoid and contains fecal debris)
• Investigations
  • Anoscopy
• Differentials
  • Anal fissure: younger women with tight rectum. Painful BRBPR.
  • Anal skin tags
  • Proctitis
  • Rectal prolapse
• Conservative treatment
  • Increase fibre in the diet
  • Increase fluid intake
  • Avoid fatty foods
  • Exercise regularly
  • Treat constipation with stool softeners (docusate) or laxatives (polyethylene glycol)
• Indications for hemorrhoidectomy
  • Third and fourth degree hemorhroids
  • Secondary degree hemorrhoids not cure by non-operative treatment
  • Fibrosed hemorrhoids
  • Interno-external hemorrhoids with well defined external hemorrhoids

Treatment options for hemorrhoids

Treatment	Description
Symptomatic treatment	Advise on defectaory habits, diet, stool softeners and bulking agents
Injection sclerotherapy	Submucosal injection of 5% phenol in arachis oil or almond oil. Complications may include sepsis, prostatitis, impotence and rectovaginal fistula.
Rubber band ligation	Using a Barron’s bander, elastic bands are applied on the base of the pedicle of each hemorrhoid proximal to the dentate line leading ot ischaemic necrosis and sloughing within 10 days
Open hemorrhoidectomy (Milligan-Moragn operation)	Ligation and excision of the hemorrhoid. The anal mucosa and skin are left open to heal by seondary intention
Closed hemorrhoidectomy (Ferguson operation)	Ligation and excision of the hemorrhoid. The mucosal defect is closed with continuous sutture after undermining the anoderm on each side
Stapled hemorrhoidopexy	Removal of a strip of rectal mucosa and submucosa proximal to the dentate line then closing the defect using a stapling gun. This causes the hemorrhoids to move up (fixation) and reduces blood flow to hemorrhoids. Has a higher recurrence rate than conventional hemorrhoidectomy.
Transanal-Hemorrhoidal deearterialisation (THD) or Haemorrhoid artery ligation operation (HALO)	Use transanal doppler to guide ligaiton of vessels feeding the hemorhroid. Recurrence rates for fourth degree hemorrhoids is high but has better complication rate and post-operative pain

Treatment of complications of hemorrhoids

Complications	Treatment
Thrombosis, ulceration and strangulation	Conservative approach for pain and pruritus with sitz baths, topical anaesthetic (lidocaine), corticosteroids (hydrocortisone) or vasoconstrictors (phenylephrine). Subtototal hemorrhoidectomy can be performed emergently
Bleeding	Local compress containing adrenaline, resuscitation, rubber band ligation and hemorrhoidectomy

• Contraindications to hemorrhoidectomy and band-ligation
  • Rectal varices: present in patients with portal hypertension. There is a risk of massive bleeding post-operatively
  • Coagulopathy (cirrhosis or on anticoagulants)
• Complications of hemorrhoids
  • Strangulation and thormbosis
  • Ulceration
  • Gangrene
  • Portal pyaemia
  • Fibrosis

Complications of hemorrhoidectomy

Classification	Complications
Early	Pain (requires opiate analgesia), acute urinary retention (especially in men), reactionary hemorrhage (more common than secondary hemorrhage)
Late	Secondary hemorrhage (uncommon), anal stricture, anal fissure, submcous abscesses, incontinence (due to damage of the underlying internal sphincter)