Haemorrhoids

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