Update in Hemorroid

Treatment

Imam Sofii

Workshop Hemorroid PABI; Balikpapan, 19 Maret 2013

Introduction:

Fibrovascular cushions (or hemorrhoids) are part of the

normal anatomy within the anal canal and are believed to be
important in maintaining continence
They are areas of vascular anastomosis in a supporting
stroma of subepithelial smooth muscles.
They contribute 15-20% of the normal resting pressure and
feed vital sensory information.
3 main cushions are found:
L lateral
R anterior
R posterior

But can be found anywhere in anus, prevalence is 4%

Miss labelling by referring physicians and patients is
common
2

Functional anatomy:
Anal canal
Anatomical Surgical
Entoderm (hindgut)
columnar squamous
dentata
pulsated pulseless
line
sensated asensated
proctodeum (ectoderm)
Dentate line
3

Functional anatomy:
The hemorrhoidal cushions
consist of plexuses of large
venous spaces, arterio-venous
communications as corpus
cavernosum recti (CCR) by
Stelzner
The blood supply to the CCR
is provided by the terminal
branches of the superior rectal
artery

1
2
3
4

6
7

It is a functional blood supply that fills this cavernous network

This structure plays an important role in continence by acting as a
conformable plug, in order to ensure the complete closure of the anal
canal.
This mechanism contributes up to 1520% of resting anal pressure
4

Etiopathogenesis:
The etiopathogenesis of the hemorrhoidal disease is multifactorial.
Two major theories: the sliding down theory and the vascular
theory.
The first: pathological slippage of the normal anal lining,
caused by the deterioration of supportive connective tissue
and increased by the straining during defecation.
The second: the vascular hyperplasia theory, supposes that
an abnormal behaviour of the arteriovenous shunt is
responsible for the hypertension of hemorrhoidal plexuses,
their consequent dilatation, and therefore their prolapse and
bleeding.
Several studies have demonstrated high resting anal
pressure in patients.
High pressure is caused by increased activity of the internal
anal sphincter or the external anal sphincter or by increased
vascular pressure within the anal cushions . 5

Etiopathogenesis:
Anchoring tissue (AT)
Internal sphincter (IS)
Internal hemorrhoids (IH)
Parks ligament (PL)
Anal canal (AC)
External hemorrhoids (EH)

Clinical features

Symptoms of hemorhhoids

History ( Full history required)

Haemorrhoid directed:
Pain : acute/chronic/ cutaneous
Lump : acute/ sub-acute
Prolapse; define grade
Bleeding: fresh, post defecation
Pruritis and mucus

Origin in relation to Dentate line

1.
2.
3.

Internal: above DL
External: below DL
Mixed

General GI:
Change in bowel habit
Mucus discharge
Tenesmus/ back pain
Weight loss
Anorexia
Other system inquiry

Degree of prolapse through anus

1st: bleed but no prolapse

2nd: spontaneous reduction
3rd: manual reduction
4th: not reducable

Clinical features
Risk factor:

Pathological
1.
2.
3.
4.
5.
6.
7.

Chronic diarrhea (IBD)

Colon malignancy
Portal hypertension
Spinal cord injury
Rectal surgery
Episiotomy
Anal intercourse

Habitual
1.
2.
3.
4.
5.
6.
7.
8.

Constipation and straining

Low fiber, high fat/spicy diet
Prolonged sitting in toilet
Pregnancy
Aging
Obesity
Office work
Family tendency

Clinical features
Investigation:

The diagnosis of hemorrhoids is based on clinical

assessment and proctoscopy
Further investigations should be based on a
clinical index of suspicion

Lab: CBC / Clotting profile/ Group and save

Proctography: if rectal prolpse is suspected
Colonoscopy: if higher colonic or sinister pathology is
suspected
9

Clinical features
Complication:

1.
2.
3.
4.
5.
6.

Ulceration
Gangrene
Fibrosis
Thrombosis
Sepsis and abscess formation
Incontinence

Thrombosed
internal
haemorrhoids

Thrombosed
external
haemorrhoids

10

Treatment
Varies from simple reassurance to operative
hemorrhoidectomy.
Treatments are classified into three categories:
Dietary and lifestyle modification and medication.
Non (para) operative/office procedures.
Operative hemorrhoidectomy.

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Treatment

Dietary and lifestyle modifications:

The main goal of this treatment is to minimize

straining at stool.
Achieved by increasing fluid and fiber in the diet,
recommending exercise, and perhaps adding fiber
agents to the diet such as psyllium.
If necessary, stool softeners may be added.

"you don't defecate in the

library so
you shouldn't read in the
bathroom".

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Treatment

Office Treatments:

Rubber
Rubber Band
Band Ligation
Ligation

Grade I or Grade II hemorrhoids and, in some

circumstances, Grade III hemorrhoids.
Complications include bleeding, pain, thrombosis and life
threatening perineal sepsis.
Successful in two thirds to three quarters of all
individuals with first and second degree hemorrhoids.

13

Treatment

Office Treatments:
Infrared Coagulation
Generates infrared radiation which coagulates tissue
protein and evaporates water from cells.
It is most beneficial in Grade I and small Grade II
hemorrhoids.

Bicap Electrocoagulation
It works, in theory, similar to photocoagulation or to
rubber banding.
The probe must be left in place for ten minutes.
Poor patient tolerance minimized the effect of this
procedure.
14

Treatment

Office Treatments:

Sclerotherapy
Sclerotherapy

Injection of an irritating material into the submucosa in

order to decrease vascularity and increase fibrosis.
Injecting agents have traditionally been phenol in oil,
sodium morrhuate, or quinine urea.
Other Office Treatments:
Manual anal dilatation was first described by Lord .
Cryotherapy was used in the past with the belief that
freezing the apex of the anal canal could result in
decreased vascularity and fibrosis of the anal cushions.

15

Treatment

Surgical Treatments:
Hemorrhoidectomy

Milligan-Morgan
Ferguson
Parks
Whitehead-Toupet
Ligasure

Milligan-Morgan
16

Treatment

Surgical Treatments:

Ferguson
Ferguson

Ferguson

17

Parks

Treatment

Surgical Treatments:
Ligasure

Diatermy
(Loder-Phillips, 1993)

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Treatment

Surgical Treatments:

Stapled hemorrhoidopexy
Terminology:
Stapled hemorrhoidectomy
Circular stapled
hemorrhoidectomy
Circular stapled anoplasty
PPH
Stapled prolapsectomy
Transverse mucosal
prolapsectomy
Longo procedure

19

Stapled hemorrhoidopexy

Surgical rationale
Excision of cylinder of rectal mucosa replacement of
hemorrhoids in
anal canal
Vascular interruption shrinkage of prolapsed component
Avoidance of anal wound reduces pain

20

Treatment

Surgical Treatments:
Transanal Hemorrhoid Dearterialization (THD)
Hemorrhoid Arterial Ligation (HAL)
Doppler Guided Hemorrhoid Arterial Ligation (DGHAL)
Close to anorectal jungtion (+ 2
cm).
Almost 6 sectors there are artery
(99,3-99,7%).
The artery are into the
submucosa (98,3-100%).
The artery are very superfisial
(2.4-1.9 cm)

21

Rasionale:
Increased arterial inflow and/or a decreased venous outflow
Hypertension of CCR
Dilatation of the hemorrhoidal cushions favors
prolapse during defecation or straining

kening and the subsequent tearing of the Parks and Treitz ligam
Further dilatation and increasing of the prolapse
Rupture of artero-venous shunts
Bleeding (spontaneous or during defecation)
22

Evaluation:
Every procedure could be
postoperative evaluation
i.e:

Pain
Pruritus
Bleeding
Soiling
Incontinence to gas
Oedema
Thrombosis
Pile/prolaps
Spingter tone

23
The American Journal of Surgery 183 (2002) 519524

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Rational decition:

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Hemorrhoidal Disease: A Comprehensive

Review

26

J Am Coll Surg Vol. 204, No. 1, January 200

27
The ASCRS Textbook of Colon and Rectal Surgery

28

29

Arch Surg. 2009;144(3):266-272

30

Arch Surg. 2009;144(3):266-272

Comparison of operative outcomes and postoperative complications in patients

31

32

33
The American Journal of Surgery (2012) 204, 684688

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Symptom questionnaire

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38

SH vs Convs (Cochrane review)

All RCT from 1998-2006: SH vs Convs.
SH patients significantly more like to have recurrent in longterm followup 1year or more (7 trials, 537 pts; OR=3,85;
95%CI=1,47-10,07; p=0,006).
SH was associeted higher recurrence rate (5 trials; 417 pts;
OR=3,60; 95%CI=1,24-10,49; p=0,02).
A significantly complained prolapse symptom (8 trials; 798
pts; OR=2,96; 95%CI=1,33-6,58; p=0,008).
Giordano et al: SH was associeted higher recurrence rate (14
trials; 1063 pts; OR=5,5; p<0,001) and undergo to correct
recurrent prolapses (10 trials; 824 pts; OR=1,9; p<0,002).
All other clinical parameters showed trends favoring SH.
Fasten et al: recurrent prolapses can be successfully treated
with redo PPH more than 90%.
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Hemorrhoids; Shackelfords surgery of the Alimentary Tract;2013:

HAL
Giardano et al: 16 (17) met inclusion creteria were
observasional study (low-very low study).
Of the 1996 pts involved (majority grade II or III disease):
early postoperative pain 18,5%;
residual protrusion, bleeding, and fever incidence > 3%.
Folloup of 1year or more 6 (17):
prolapse incidence 10,8%;
bleeding 9,7%;
pain on defecation 8,7%.

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Hemorrhoids; Shackelfords surgery of the Alimentary Tract;2013:

Conclusion:
Hemorrhoids are part of the normal anatomy within the anal
canal.
Multifactorial etiopathogenesis: pathological slippage of the
normal anal lining, vascular hyperplasia theory, high resting
anal pressure.
The diagnosis of haemorrhoids is based on clinical
assessment and proctoscopy.
Three categories treatment:
1) Dietary and lifestyle modification and medication
2) Non (para) operative/office procedures.
3) Operative haemorrhoidectomy.
Pain is the most frightening complication for the most
patient.
41

Conclusion:
Early diagnosis and prompt treatment can reduce the
complication and recurrence.
The management of symptomatic haemorrhoid should be
directed at the symptom complex of the individual patient.
For many specific cases, more than one procedure and
modification is needed.
Recently, Stapled haemorrhoidectomy and Hemorrhoid
Arterial Ligation with or without mucosopexy may prove to
be an effective, less painful technique to manage
prolapsed hemorrhoid.

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makasih
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