2. Definitions
• Hemorrhoids
Dillated vascular channel in 3 constant locations
Normal part of human anatomy
• Hemorroidal Disease
Manifeted by prolapse, bleeding, & itching
• Internal hemorrhoids
Originate above dentate line
Covered with transitional mucosa
• External hemorrhoids
Located close to the verge
Covered with transitional mucosa
3. Usual sites of internal hemorrhoids
Knee-chest position
Left lateral
Right posterior
Right anterior
4. Incidence of hemorrhoidal disease
• Exact incidence is not known
• 10 - 25 % of adult population thought to be
affected
5. Pathogenesis of hemorrhoids
Normal vascular cushions present at birth
Downward pressure during defecation
Muscle fibers that anchor cushions attenuated
Hemorrhoids: slide, congested, bleed, prolapse
High resting anal pressure (unclear?)
6. Classification of internal hemorrhoids
• First degree Project a short way into the anal canal
The only symptom is bleeding
• Second degree Prolapse during defecation
Return spontaneously
• Third degree Must be returned manually
• Fourth degree Hemorrhoids are irreducible
7. Symptoms of hemorrhoids
Intermittent symptoms
• Painless bleeding
Seen on toilet tissue
Dripping into toilet at end of defecation
Accumulate in rectum with dark blood or clots
• Prolapsed hemorrhoids
Blood & mucus stain patient’s underwear
Mucus against anal skin lead to itching
23. Sites of sclerosing injections
1 Superficial
2 Good (submucosa)
3 Deep (intramuscular)
24. Sclerosing injections
• Substances
1 ml is sufficient to create raise area
Phenol 5 % – Quinine Chlorhydrate & urea 5%
• Number of injections
2 injections per week
4 – 6 injections in total
• Results
Success in 75 % of first & second degree
29. Number of bands in one session
Disagreement
• 1 band by session
Many authorities believe that severity of pain & risk
of complictions are less
• 2 – 3 bands by session
Safe & effective at one setting
• 8 – 10 bands in one session
30. Retroflexed endoscopic multiple band ligation
Extensive ligations of internal hemorrhoids & normal rectal mucosa
immediately proximal to internal hemorrhoids
weeks after8 – 10 elastic bands
in one session
Before band ligation
Gastrointest Endosc 2004 ; 59 : 380 – 4 .
31. Rubber band ligation is probably the
most common fixation method in use
worldwide today
32. Rubber band ligation
Complications
Pain Moderate 5 - 85% – analgesic
Severe near dentate line – ablation
Bleeding Minimal 1 – 15 %
Severe: 0.5 - 2% – Transfusion – suture
Cellutitis Severe complication (50% mortality)
15 cases reported between 1980 – 1988
Anaerobic – Gram negative bacteria
Early symptoms: anorectal pain & urinary troubles
Early treatment ameliorate prognosis (antibiotics)
Dysuria & urine retention
39. Treatment of acute hemorrhoidal disease
Medical
Direct injection of 9 ml bupivacaine 0.25% + 1 ml hyaluronidase
Gentle massage followed by reduction of the mass
NSAIDs parenterally
Surgical
Emergency hemorrhoidectomy occasionally
