HEMORRHOIDS

•HEMORRHOIDS ARE CUSHIONS OF SUBMUCOSAL

TISSUE CONTAINING VENULES, ARTERIOLES, AND
SMOOTH MUSCLE FIBERS THAT ARE LOCATED IN THE
ANAL CANAL (SEE FIG. 29-4).

•Three hemorrhoidal cushions are found in the left

lateral, right anterior, and right posterior positions.
 EXTERNAL HEMORRHOIDS

• Located distal to the dentate line and are covered

with anoderm.
• The anoderm is richly innervated, thrombosis of an
external hemorrhoid may cause significant pain.
• A skin tag is redundant fibrotic skin at the anal
verge,often persisting as the residua of a
thrombosed external hemorrhoid.
• Treatment of external hemorrhoids and skin tags is
only indicated for symptomatic relief.
 INTERNAL HEMORRHOIDS

• located proximal to the dentate line and covered

by insensate anorectal mucosa.
• Internal hemorrhoids may prolapse or bleed, but
rarely become painful unless they develop
thrombosis and necrosis (usually related to severe
prolapse, incarceration, and/or strangulation).
GRADED OF INTERNAL HEMORRHOIDS

• First-degree hemorrhoids bulge into the anal canal

and may prolapse beyond the dentate line on
straining.
• Second-degree hemorrhoids prolapse through the
anus but reduce spontaneously.
• Third-degree hemorrhoids prolapse through the
anal canal and require manual reduction.
• Fourth-degree hemorrhoids prolapse but cannot be
reduced and are at risk for strangulation.
COMBINED INTERNAL AND EXTERNAL
HEMORRHOIDS

• Straddle the dentate line and have characteristics

of both internal and external hemorrhoids.
• Postpartum hemorrhoids result from straining during
labor, which results in edema, thrombosis, and/or
strangulation.
• Hemorrhoidectomy is often the treatment of
choice, especially if the patient has had chronic
hemorrhoidal symptoms.
• Portal hypertension was long thought to increase
the risk of hemorrhoidal bleeding because of the
anastomoses between the portal venous system
(middle and upper hemorrhoidal plexuses) and the
systemic venous system (inferior rectal plexuses).
• Rectal varices, however, may occur and may
cause hemorrhage in these patients. In general,
rectal varices are best treated by lowering portal
venous pressure.
• Rarely, suture ligation may be necessary if massive
bleeding persists.
TREATMENT
MEDICAL THERAPY

• Bleeding from first- and second-degree hemorrhoids

often improves with the addition of dietary fiber,
stool softeners, increased fluid intake, and
avoidance of straining.
• Associated pruritus often may improve with
improved hygiene. Many over-the-counter topical
medications are desiccants and are relatively
ineffective for treating hemorrhoidal symptoms.
• Rubber band ligation
• Persistent bleeding from first-, second-,and selected third-
degree hemorrhoids
• Infrared Photocoagulation
• small first- and second-degree hemorrhoids
• Sclerotherapy
• first-, second-, and some third-degree hemorrhoids
• Excision of Thrombosed External Hemorrhoids
• Operative Hemorrhoidectomy
• decreasing blood flow to the hemorrhoidal plexuses and
excising redundant anoderm and mucosa.
• Closed Submucosal Hemorrhoidectomy
• The Parks or Ferguson hemorrhoidectomy:
• resection of hemorrhoidal tissue
• closure of the wounds with absorbable suture
• Open Hemorrhoidectomy
• The Milligan and Morgan hemorrhoidectomy
• Whitehead’s Hemorrhoidectomy
• circumferential excision of the hemorrhoidal cushions just
proximal to the dentate line
• risk : ectropion (Whitehead’s deformity)
• Procedure for Prolapse and Hemorrhoids/Stapled
Hemorrhoidectomy
• replaced stapled hemorrhoidectomy
• Because the procedure does not involve excision of
hemorrhoidal tissue,but instead pexes the redundant
mucosa above the dentate line.
• Doppler-Guided Hemorrhoidal Artery Ligation
• Doppler probe is used to identify the artery or arteries
feeding the hemorrhoidal plexus then ligated
 COMPLICATIONS OF
HEMORRHOIDECTOMY
• Postoperative pain
• Urinary retention
• fecal impaction
• Bleeding may also occur 7 to 10 days after
hemorrhoidectomy
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