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Understanding Haemorrhoids: Diagnosis, Symptoms & Treatment Options

Learn about haemorrhoids, a common condition causing rectal bleeding, protrusion, and discomfort, often treated by non-specialists. Discover how to assess bleeding per rectum and why proper evaluation is crucial. Explore conservative and surgical treatment options, including banding and sclerotherapy. Understand the importance of rectal examination and the risks of delayed diagnosis. Find out about innovative techniques like CO2 laser and harmonic knife for advanced cases.

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Understanding Haemorrhoids: Diagnosis, Symptoms & Treatment Options

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  1. Haemorrhoids

  2. Essentials of diagnosis • Rectal bleeding, protrusion, discomfort • Mucoid discharge from rectum • Secondary anaemia • Characteristic findings on anal inspection and anuscopic examination

  3. THE PROBLEM • Nobody likes them: patients and doctors • Very frequent • Major discomfort • Treated often by non-specialists • Well treated=good results

  4. Sensitive area

  5. DEFINITION • Normal structures of the rectal wall which are displaced from the original position • Normal histological structures • Plenty vascularization: both arterial (inferior haemorrhoidal artery) and venous lakes which may be distended. • Chrinic constipation + straining on defecation + increased anal tonus – favor the development of haemorrhoids.

  6. Symptomatic classification • Grade 1 – bleeding • Grade 2 – prolaps with spontaneous reduction • Grade 3 – prolaps that needs digital replacement • Grade 4 – Prolaps - permanent TRATAMENT – depending on symptoms

  7. Anatomic classification

  8. Symptoms • Painless bleeding • Pruritus • Prolaps • Pain (asociated with a complication – thrombosis or inflamation) • Incontinence

  9. BLEDDING PER RECTUMHow to evaluate!!! • Small drops of blood on toilet paper • Clinical examination + rectal + rectoscopy • Blood dropping in the toilet • Rigid recto-sygnoidoscopy • Blood mixed with feces • Rigid recto-sygnoidoscopy + barium enema OR colonoscopy = complete examination of the colon • Dark blood • Complet examination of the colon

  10. Massive OR Chronic • May be massive and presents as an emergency • May be a cause of chronic anaemia • May explain • Severe iron deficiency anaemia • Ischaemic cardiac disease due to low levels of oxygen transporter

  11. NEVER • NEVER treat haemorrhoidal disease without clinical and digital examination of the rectum MALPRAXIS = patients life and your money

  12. PRURITUS ANI • Frequently associated with haemorrhoids • Minute incontinence with local irritation of the skin • Aggressive local cleaning may produce small lesions that will generate pruritus • Tags • Local edema

  13. PAIN • External thrombosed haemorrhoids • Round blue lesions (perianal haematoma) with significant edema and very tender • Internal thrombosed haemorrhoids • Pain is less severe • Major pain in cases of strangulated prolaps of haemorrhoids

  14. EXAMINATION • Speaking with the patient will create trust • Offer an intimate room 

  15. RECTAL EXAMINATION • Blind – use a hydro soluble gel • Forts evaluate visually the perianal region • Evaluate the tonicity of the sphincter in non contracting status and during contraction • Prostate • Content

  16. RECTOSCOPYANUSCOPY SYGMOIDOSCOPY

  17. RECTOSCOPY + ANUSCOPY • Masses that prolaps in the tube of the scope • Stigmata of recent bleeding

  18. WHY COMPULSORY TO EVALUATE • Colonic cancer is frequently missed due to obvious haemorrhoidal disease • Main diagnosis is delayed for a long time – too late

  19. CONSERVATIV TRATAMENT Bleeding • Dietary suplements with fibers (larger volume + softer) • Increase vascular tonus • Ginko Biloba • Flavonoids (Detralex)

  20. CONSERVATIV TRATAMENT PRURITUS • Hot bath – decreasing muscular tonus • Fibers in food • Analgetic creams • Corticoids locally (supositories or cream) but no more then 7 days • Changed local hygiene

  21. CONSERVATIV TRATAMENT THROMBOSIS OF HAEMORRHOIDS • Surgical thrombectomy – first 48 hours • Analgetics • Dietary changes • Hot bath

  22. Surgical treatment 1 – Milligan - Morgan

  23. Surgical treatment 2 – Ferguson

  24. Surgical treatment 3 – Stappler haemorrhoiedctomy

  25. NEW TECHNIQUES

  26. BANDING • Principles: • Elastic ligatures on the base of haemorrhoid followed by necrosis • Detachment of necrotic area • Scar formation + sclerosis will fix the mucosa

  27. SCLEROTHERAPY • Irritative substances (Almond oil + phenol) • Slerosis + fixation of mucosa • Injection only around vessels

  28. ANAL DILATION • Hypertony is a major cause of pain • Unde rgeneral anaesthesia • Make banding easier and better • Decreased the tonus of the sphincter – mechanism of hemorrhoid formation • Not in cases with low tonus

  29. FOTOCOAGULATION • Infrared radiation directly over the hemorrhoid • Therncauterisation followed by sclerosis • In stages

  30. CRIOCOAGULATION and ELECTROCOAGULATION • Criotherapt forceps – rapid cooling at -36 degree • Similar effects with infrared thermocoagulation • Lesions will shrink • More efficient for large hemorrhoids

  31. CO2 LASER • Hemorrhoidectomy by vaporisation of tissue • Similar with surgical excision • Very expensive and difficult to use

  32. Harmonic knife • Ultrasonic energy • Very little effects on the tissue around the area treated • No smoke, low temperatures (50-100 degrees) • Seals vessels and coagulates proteins

  33. Harmonic knife • No burned tissue (doesn’t coagulate via dessictaion) • Coagulates even large vessels • Low chances for postoperative bleeding

  34. Ligation of haemorrhoidal artery HAL • New technoque • Ligation of feeding artery • Good results

  35. COMPLICATIONS OF ALL METHODS • Stenosis • Tags • Recurencies • Fissure • Incontinence • Impactation with feces • Postop bleeding

  36. RESULTS • Very good • Dependeing on the tpe of hemorrhoids and clnical signs • Rational choice of therapy • Better in the hands of a proffesional

  37. FISSURA IN ANOANAL FISSURE

  38. General considerations • Denuded epithelium of the anal canal overlying the internal sphincter • Painful – highly sensitive area • Typically single ulcerations • Hypertrophic papilla – chronic inflammation • Sentinel pile

  39. Diagnosis • 3 ELEMENTS • Ulcer • Hypertrophic pappila • Sentinel tag

  40. Clinical findings • Symptoms and signs: • Painful bowel movement associated with bright red bleeding • Pain severe: after movement and sensation is described like burning • Constipation

  41. Clinical examination • With anaesthesia • Rectal: • Tag • Ulcer – in the middle • Pappila • Increased tonus • Sigmoidoscopy should be deffered

  42. Differential diagnosis • Other ulcers: • Syphilis • Carcinoma • TBC • Granulomatous enetritis with ulcers • NOT TYPICAL • Biopsy • Association with haemorrhoids

  43. TREATMENT • Medical: • Softening of the stool • Topical cream with myorelaxant • Hot bath • Flavonoids • Surgical: • Lateral internal shpyncterotomy • Anal dilation

  44. PROGNOSIS • Very good if good care • Tend to become chronic • The do not become malignant

  45. ANORECTAL ABSCESS

  46. ESSENTIALS OF DIAGNOSIS • Persistent throbbing rectal pain • External evidence of absecss • Systemic manifestations of infection

  47. General considerations • Invasion of pararectal spaces by pathogenic microorganisms (mixed infection + frequent anaerobs) • Infection starts from an infected cript • Classification is anatomical according to the spaces invaded

  48. Classification • Perianal – bellow levator ani • Ischiorectal – ischiorectal fossa • Retrorectal • Submucous • Marginal – in the anal canal beneath the anoderm • Pelvirectal • Intermuscular

  49. Clinical Findings • The more superficial, the more painful • PAIN – related to sitting and walking • Infection: swelling, redness, induration, tenderness • Deep abscess – limited local signs + sepsis

  50. Complications • Spreading to adjacent spaces • Pelvic gangrene or necrotizing fasciitis when anaerobic infections spread without concern for anatomic bariers • Fistula formation

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