HEMORRHOIDS

Etiology


Hemorrhoids are a common problemseen in the primary care and ambulatory surgery setting. Hemorrhoids are actually vascular cushions located within the anal canal. They occur in three constant positions: Right Anterior, Right Posterior, and Left Lateral. Hemorrhoids can be internal (originating above the dentate line), external (originating below the dentate line), or mixed. Internal hemorrhoids (also known as "piles") are caused by prolapses of rectal mucosa containing the normally dilated veins of the internal venous plexus. External hemorrhoids are thromboses in the veins of the external rectal venous plexus, and as such are covered by skin.

The major precipitator of hemorrhoids is increased rectal pressure (most often due to straining or constipation). Other causes of increased pelvic pressure such as pregnancy, portal hypertension, and excessive diarrhea can exacerbate their development as well.

Because of the differing nervous innervation above and below this line, the clinical presentation will differ as well.
Internal hemorrhoids can be classified into 4 grades:
There is no classification for external hemorrhoids.

Treatment


Treatment of hemorrhoids is based on the severity of symptoms and degree of disease (as above). For asymptomatic disease, conservative management will usually suffice. Bulk-forming agents, the avoidance of constipation, and sitz baths will typically eradicate the problem, or lessen symptoms. Accordingly, first degree, asymptomatic hemorrhoids are treated in this manner. With symptomatic disease, rubber-band ligation or infrared coagulation may be tried. Sclerotherapy (an older therapy), has largely been abandoned. In the banding procedure, a small rubber-band is placed around the base of the hemorrhoid, causing the tissue to die and fall off as a result of lack of blood flow. Likewise, this banding procedure is helpful for second and third degree hemorrhoids as well.
Surgery (in the form of hemorrhoidectomy) is typically reserved for fourth degree hemorrhoids (or some mixed third degree's with a large external component). In these instances, the large vein is removed and gauze packing is inserted to control bleeding. The outcome following surgery is very good in the majority of cases, and the patient should be encouraged to adhere to a high fiber diet and avoid constipation in order to avoid recurrence. In terms of convalescence, patients may experience considerable pain after surgery as the anus tightens and relaxes, but complete recovery is usually seen within two weeks.

External hemorrhoids typically do not cause many problems. Excision is typically reserved for very large hemorrhoids which interfere with good perianal hygiene. Occasionally, patients may present with severe perianal pain and a lump near the anus following severe constipation or prolonged sitting. Visual or rectal exam may reveal a thrombosed external hemorrhoid. A thrombosed external hemorrhoid is one in which blood has pooled and formed a clot. This type of hemorrhoid occurs outside the rectum, around the anal region. It will usually appear as bulging, purple or bluish skin-covered veins, or can be reddish when inflamed. To the touch, it usually feels like a small, hard lump, roughly the size of a pea. With this type of hemorrhoid, most sufferers experience some degree of pain, often quite a lot. A hrombosed external hemorrhoid can cause swelling, itching and/or pain, but it will almost never bleed. The usual treatment is drainage or removal of the clot or the entire hemorrhoid, but only if the condition is acute (<72 hours). Otherwise, expectant management and a high fiber diet is typically all that is needed, as the problem is usually self-limited over 7-10 days.
Pain and the complications are the major issues that bother the patients who were advised surgery In the last 50 years lot had happened in the piles management to prevent complications and pain during and after the procedure. This lead to invention of new techniques like Sclerotherapy Rubber band ligation High macro rubber band ligation Infra red coagulation Stapled haemorroidopexy Cryo surgery Vessel sealer Harmonic scalpel Laser etc Besides regular Open hemorrhoidectomy And closed hemorroidectomy But no single procedure proved to be free from complications and nothing can prevent recurrence COMPLICATIONS AND LIMITATIONS OF THE SURGICAL PROCEDURE TO PILES 1SCLEROTHERAPY : it is advisable only to the 1st an dsecond degree piles It is not useful in 3rd and 4th degree piles Complications include bleeding ,thrombosis, abscess formation and high recurrence rate 2RUBBER BAND LIGATION It is advisable only for internal piles and not suitable for3rd and fourth degree or prolapsed piles Complications include pain ,bleeding, infection ,ulceration,necrosis and peri anal hematoma 3INFRA RED COAGULATION It is again suitable for 1st and 2nd degree piles and not suitable for 3rd or 4th degree piles Complications include proctitis, soiling, recurrence and it needs several sittings 4CRYO SURGERY is limited to 2nd degree piles and complications of this procedure includes pain and bleeding . now it became an outdated procedure 5 STAPLED HEMORROIDOPEXY is limited to 3rd degree piles and not suitable for 4th or 2nd degree piles and main drawback is very expensive Complications include bleeding, rectal stricture,fecal incontinence,severe post op pain,recurrence and rarely RV fistula 6 LASER even though it is a costly issue it doesn’t proved to decrease the pain and complications 7 HEMORRHOIDECTOMY whether it is open or closed is limited to 3rd and 4th degree piles and strangulated piles. Complications include Pain Urinary retention Hemorrhage Local infection and sepsis Anal stenosis Rectal stricture Fissure Fistula Fecal incontinence Anal tags Mucosal prolapsed Pruritis ani recurrence