Hemorrhoids:Its current management

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

1. HEMORRHOIDS 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 2 nd 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 - 80 bpm regular full volume , B.P. – 90/70 mmhg. H.S. – 1&2 only. Apex beat - 5 th 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 : 3 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 1 st and 3 nd , 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 5 TH 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)

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

15. 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 .

16. 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 .

17. 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.

18. 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

19. 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.  

20. 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).

21. 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.

22. 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

23. 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

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

25. Barrons banding

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

27. OPEN –OPERATIVE METHODS Indications : 3 rd 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 .

28. 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

29. 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.

30. 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.

31. 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 listening