Hemorrhoid

. Hemorrhoids are cushions of submucosal tissue

containing venules, arterioles, and smooth-
muscle fibers that are located in the anal canal.
Three hemorrhoidal cushions are found in the
left lateral, right anterior, and right posterior
positions.
Hemorrhoids are thought to function as part of
the continence mechanism and aid in complete
closure of the anal canal at rest
Schwartz's Principles of Surgery, 2010
Colon and Rectal Surgery, 2005
 Functions
contribute to anal continence by forming a
spongy bolster, which cushions the anal canal
and prevents damage to the sphincter
mechanism during defecation. This tissue also
acts as a compressible lining that allows the
anus to close completely

Handbook of Colorectal Surgery, 2003

 Incidence
Age: Most patients who develop hemorrhoids
are between the ages of 30 and 50.
Hemorrhoids occur in both sexes. However,
pregnancy and childbirth are the prime causes of
hemorrhoids in young females.
Medical history: Some patients with leukemia or
bleeding diathesis will have complications from
hemorrhoids.
Excessive straining
 Lack of fiber in diet
Spending hours or reading books on the
bathroom
weight lifters and tennis players
practice anorectal intercourse
Prolonged sitting and lack of activity
 Pathophysiology
chronic straining secondary to constipation or occasionally
diarrhea may result in pathologic hemorrhoids.
Eventually, with repeated straining, the hemorrhoids may
lose their attachment (Treitzs ligaments) to the
underlying rectal wall, leading to the prolapse of the tissue
into the anal canal.
The engorged tissue becomes more friable, which may
contribute to bleeding.
These tissues communicate with the superficial
subcutaneous venules at the anal verge, which may result
in external hemorrhoidal dilation
 Pathophysiology
Current theories : anal "cushions.: aggregations of
blood vessels (arterioles, venules, and arteriolar-
venular communications), smooth muscle, and
elastic connective tissue in the submucosa that
normally reside in the left lateral, right
posterolateral, and right anterolateral anal canal.
disintegration of the anchoring and supporting
connective tissue and the terminal fibers of the
longitudinal muscle above the hemorrhoids allows
these structures to slide distally.
Maingot's, 2007
 Symptoms
Principal : bleeding & prolapse
Secondary : mucus discharge, pain, pruritus,
anemia, fecal incontinence
 Symptoms
Painless bleeding occurs from internal
hemorrhoids, is usually bright red, and is
associated with bowel movements.
The blood will occasionally drip into the commode
and stain the toilet water bright red. After trauma
by firm stools or forceful bowel movements,
bleeding may continue to occur with bowel
movements for severaldays. The bleeding will
often then resolve for a variable period of time.
 Symptoms
Prolapse below the dentate line area can
occur, especially with straining, and may lead
to mucus and fecal leakage and pruritus.
Pain is not usually associated with
uncomplicated hemorrhoids but more often
with fissure, abscess, or external
hemorrhoidal thrombosis.
Gastrointestinal Bleeding, 2010
Manage hemorrhoid complication

If left untreated, the edema progresses to ulceration

and necrosis.
 relieving the pain with analgesics (intravenous
if necessary);
Reducing perianal swelling with either hot
soaks, sitzbaths, or ice packs;
bed rest; and prevention of constipation
Manual reduction, urgent hemorrhoidectomy
 Diagnostic
Rectal examination
Proctoscopy/anoscopy
 It is mandatory that colonoscopy be
performed in high-risk patients to exclude
other sources of bleeding, such as carcinoma
or proctitis (e.g., for patients more than 40
years of age and those with a family history of
colorectal neoplasia or a change in bowel
habits).
 Classification

Grade Ibleeding without prolapse.

Grade IIprolapse with spontaneous
reduction.
Grade IIIprolapse with manual reduction.
Grade IVincarcerated, irreducible prolapse.
 External hemorrhoids are covered with
anoderm and are distal to the dentate line;
they may swell, causing discomfort and
difficult hygiene, but cause severe pain only if
actually thrombosed.
Internal hemorrhoids cause painless, bright
red bleeding or prolapse associated with
defecation.
Treatment
 Treatment
Early disease (Grade I and early Grade II) is often managed
with medications designed to cause vasoconstriction and
treat inflammation for the engorged friable hemorrhoid.
More advanced disease frequently requires operative
management which may include sclerotherapy,
cryosurgery, infrared coagulation, rubber band ligation,
and various modes of surgical excision.
These therapies attempt to remove the redundant tissue
and create cicatrices to fix the remaining mucosa within
the anal canal once again.
 Conservative treatment
there are three mainstays of conservative
management:
1. Bulking agents
2. Sitz baths/warm compresses
3. Local applications
Sclerotherapy
Rubber band ligation
Stapled Hemorrhoidopexy
Open hemorrhoidectomy