Hemorrhoids Update Review

Thrombosed external hemorrhoids

admin — Sun, 06 Jun 2010 02:48:11 +0000

Thrombosis is a fairly common complication of hemorrhoids disease. Most patients give no history of straining or physical exertion and do not have histories of hemorrhoids disease. The complication develops with an abrupt onset of anal mass,hemorrhoids and pain that peaks within 48 hours. Usually, the pain becomes minimal after the fourth day. Occasionally, the skin overlying the hematoma becomes necrotic, causing bleeding and discharge or infection, which causes further necrosis and more pain. Treatment should be aimed at relief of severe pain, prevention of recurrent clot, and prevention of residual skin tags. If the patient is experiencing severe pain of hemorrhoids at the time of examination, excision should be performed. Conversely, if the pain is already subsiding and the clot is starting to shrink, thrombosis may be managed conservatively with warm sitz baths for comfort, proper anal hygiene, and bulk-producing agents such as bran or psyllium seed. The procedure can often be performed with the use of local anesthesia, and the wound can be left open without packing. Relief of pain is usually immediate. Postoperative care is simple and is aimed at keeping the wound clean with warm sitz baths and washing. An analgesic drug may be required during the first 24 hours. Patients must be warned of a relatively high recurrence rate about 6% after excision and 25% with noninvasive treatment.

Hemorroids overview

admin — Sun, 06 Jun 2010 02:33:10 +0000

In the upper anal canal, the hemorrhoids cushions are composed of three submucosal pillars of sinusoids within connective tissue, generally in the left lateral, right anterior, and right posterior. During the act of defecation, the hemorrhoids cushions become engorged with blood, cushioning the anal canal and supporting the anal canal lining. The pathologic term hemorrhoids is used to describe the downward displacement of the cushion along with dilation of the contained sinusoids and sometimes bleeding from the arteriole, venule, or sinusoidal portion.Hence, hemorrhoids develop when the supporting tissues of the anal cushion deteriorate or with extensive downward pressure, as in prolonged straining at stool or pregnancy.

The most common complaints of burning, itching, swelling, and pain usually are not from hemorrhoids but result from pruritus ani, anal abrasion, anal fissure, thrombosed external hemorrhoids, or prolapsed anal papilla. Symptoms are aggravated by constipation and diarrhea. The most common manifestation of hemorrhoids is painless, bright red rectal bleeding associated with bowel movement. With severe hemorrhoids,the patient commonly describes the bleeding episode as blood dripping into the toilet bowl. A feeling of incomplete evacuation is also common. In chronic prolapse, exposed rectal mucosa often causes perianal irritation and mucus staining on the underwear. Congestion of external hemorrhoids or skin tags can cause discomfort. Except in the presence of thrombosis, pain is rarely an early symptom of hemorrhoidal disease and other diagnoses should be excluded.

According to modern concepts, prolapse of anal cushions is initiated by the shearing effect of the passage of a hard stool or by excessive downward pressure as with constipation, pregnancy, or childbirth, or by the precipitous act of defecation as in urgent diarrhea. If prolapse of the vascular cushions can be prevented or if the congesting effect of a tight anal canal can be abolished, the anal cushions return to their normal state and symptoms are ameliorated without necessitating removal of the cushions themselves. Therefore, the rationale of giving bulk in the diet is to eliminate straining at defecation by producing soft, bulky stool. A high-fiber diet usually reduces symptoms of hemorrhoids and is ideal for first- and second-degree hemorrhoids.

Clinical Evaluation of Hemorrhoids Symptoms

admin — Mon, 07 Dec 2009 03:47:58 +0000

Bleeding and protrusion are among the most common symptoms of hemorrhoids. However, Mazier reported on a series of 500 patients with complaints of “hemorrhoids” and found that only one third had any significant hemorrhoids (personal communication). hemorrhoids bleeding typically results in bright red blood that drops into the toilet or is noted on the toilet. It is generally painless. More vigorous bleeding can occur as the hemorrhoids enlarge. Usually, prompt reduction of the protruding mass will cause this bleeding to abate. Acute thromboses of internal or external hemorrhoids are usually associated with severe pain that occurs with a palpable perianal mass. These patients are generally very uncomfortable, and the diagnosis is immediately obvious on clinical examination.

Examination of the patient with hematochezia, although dictated largely by the age of the patient, should include sufficient investigations to rule out a proximal source of bleeding, such as inflammatory bowel disease or neoplasia. Moreover, hemorrhoids bleeding is rarely a cause of iron-deficiency anemia.

The patient is examined in the left lateral position (or in the “head-down” position on the proctoscopy table) with the knees drawn up toward the chest as high as possible. This approach allows relative patient comfort and the ability to clearly inspect the perianal skin and to perform anoscopy and proctosigmoidoscopy. A careful digital examination of the anal canal and distal rectum should be performed, and the prostate should also be examined in male patients. An anoscope is essential to clearly inspect the hemorrhoidsal tissue and anal canal. The three common locations for hemorrhoids should be inspected, and the size, friability, and ease of prolapse of these areas should be recorded. After this, the decision regarding the need for more proximal colorectal evaluation should be considered, although rigid proctoscopy is a minimum. It cannot be emphasized enough that the examination must also be performed while the patient is seated on the toilet. The patient is asked to strain. Prolapsing hemorrhoidsal tissue in then sought. If none is found, but blood is present on the anal verge or examining finger, the patient has stage I disease. If the tissue prolapses, but reduces when the patient stops straining, the patient has stage II disease. If the prolapse must be reduced by the patient, it is stage III disease. Stage IV disease is obvious: an edematous nonreducing mass of internal and external hemorrhoidsal tissue is present at the anal verge. After the hemorrhoids are appropriately staged, treatment options should be explored.

Hemorroids overview

Bipolar Diathermy in Hemorrhoids Treatment

admin — Mon, 07 Dec 2009 03:47:07 +0000

Bipolar diathermy involves the use of electrical current to coagulate the hemorrhoids, including the mucosa and submucosa. The machine generates a 2-second pulse of energy to accomplish the treatment. This approach is applicable for small bleeding hemorrhoids and probably has no greater efficacy than sclerosing.

Other variations on the use of energy to scarify internal hemorrhoids and fix them to underlying tissues includes infrared coagulation and direct current therapy or Ultroid (Microvasive, Boston, MA) therapy. Infrared coagulation uses a tungsten halogen lamp that generates heat energy for 1.5 seconds, resulting in destruction of the mucosa and submucosa at the application site . The depth of penetration of this injury is usually 3 mm. Conversely, the Ultroid uses electrical current that is applied for up to 10 minutes per complex treated. Ultimately, these new modalities are a variation on the theme of local tissue destruction and fixation of the hemorrhoids at the appropriate level.

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Stapled Hemorrhoidectomy, a New Treatment

admin — Mon, 07 Dec 2009 03:46:28 +0000

A new entry into the arena of excisional hemorrhoidectomy is the circular stapled hemorrhoidectomy .The technique uses a circular, transanally placed pursestring suture 4 cm from the dentate line and within the enlarged internal hemorrhoids. A 31-mm stapler is then placed transanally to perform a circumferential excision of the hemorrhoidal tissue and a repositioning and fixation of the anoderm to its proper location in the anal canal. The results appear promising, with decreased postoperative pain, shorter periods of convalescence, and similar complication rates compared with other forms of excisional hemorrhoidectomy.

Sclerotherapy in Hemorrhoids Treatment

admin — Mon, 07 Dec 2009 03:45:53 +0000

Although sclerotherapy, first advocated by Mitchell in 1871, has been used often in hemorrhoids, it is rarely performed in the United States.The purpose of sclerotherapy is to scar the submucosa, resulting in atrophy of the tissue injected and scarification with fixation of the hemorrhoidal complex within its normal location in the anal canal. A variety of solutions have been advocated, although it appears that sodium morrhuate and sodium tetradechol sulfate predominate. This modality is most effective in situations with minimal enlargement of hemorrhoidal complexes where the primary complaint is bright red rectal bleeding.

The procedure is performed with the patient in the left lateral decubitus position. An anoscope is inserted to clearly identify the symptomatic complex, and a 25-gauge spinal needle is used to instill the sclerosant into the submucosal space . The syrine should be aspirated before injection to avoid a direct intravascular injection. Typically, 1 to 2 ml of sclerosant is adequate. The surgeon can inject as many locations as desired because the procedure is essentially painless. It is important, however, not to circumferentially inject the anal canal, because this may induce stricture formation.

Non-Excisional Treatment of Hemorrhoids

admin — Mon, 07 Dec 2009 03:45:11 +0000

The majority of patients evaluated for hematochezia that ultimately proves to be hemorrhoidal in origin can be and should be managed with fiber supplementation. Although it is not clearly proved that constipation contributes to hemorrhoidal symptoms, it is certainly reasonable to improve bowel function to reduce hemorrhoidal complaints in the majority of early-stage patients. The remaining nonoperative and operative interventions should be reserved for patients with advanced hemorrhoids and patients who are unresponsive to this simple but effective medical management routine.

History of Hemorrhoids

admin — Mon, 07 Dec 2009 03:43:53 +0000

About hemorrhoids ,there are few diseases that are more chronicled in human history than symptomatic hemorrhoidal disease.References occur in ancient texts dating back to Babylonian, Egyptian, Greek, and Hebrew cultures. Included in many of these writings are multiple recommended treatment regimens such as anal dilatation, topical ointments, and the intimidating red-hot poker. Although few persons have died of hemorrhoidal disease, many patients have wished they had, particularly after therapy; this fact led to the beatification of St. Fiacre, the patron saint of gardeners and hemorrhoidal sufferers. This discussion should guide the practitioner in a more humane approach to hemorrhoidal disease with an emphasis on cost effectiveness and minimal complications.

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Rubber Bands Ligation in Hemorrhoids Treatment

admin — Mon, 07 Dec 2009 03:43:21 +0000

Barron was the first to describe hemorrhoidal banding with rubber bands in 1963.Since this original description, there have been a number of reports that have documented the efficacy banding offers for the management of the majority of patients with bleeding stage II and III internal hemorrhoids.The procedure is generally well tolerated without the need for prescription analgesia if the band is placed above the level of the dentate line. The technique is demonstrated in the picture below . It is important to ask the patient if he or she experiences any pain during placement of the bander, before deployment of the band. Discomfort immediately after band placement may be reduced by the injection of a local anesthetic agent, but this does not appear to be a long-lasting benefit. Banding is associated with the rare but frequently fatal complication of postbanding sepsis, which is heralded by the symptoms of increasing rectal pain, fever, and inability to void.It is essential to treat these symptoms early and aggressively with early antibiotic treatment coupled with surgical drainage

Bayer et al. reported a series of 2934 patients in whom 79% of patients achieved complete relief of symptoms after a single session of banding at only one or two locations. With this approach, patients required multiple sessions for control of symptoms (two sessions, 32%; three sessions, 17%; four sessions, 25%; and five or more sessions, 20%). Only 2% of patients required hemorrhoidectomy. It may be possible to achieve a similar outcome with a shorter duration of therapy, albeit at the expense of greater post-treatment pain, by banding all symptomatic hemorrhoidal sites at the initial visit.Banding techniques appear to be durable after initial control of symptoms, with 69% of patients maintaining long-term relief and only 8% ultimately requiring excisional hemorrhoidectomy.

Type of Hemorrhoidectomy Treatment

admin — Mon, 07 Dec 2009 03:42:14 +0000

Options for hemorrhoidectomy include the techniques of Milligan-Morgan hemorrhoidectomy, closed Ferguson hemorrhoidectomy, Whitehead hemorrhoidectomy, and the stapled hemorrhoidectomy. The procedures are usually performed in the operating room after minimal preoperative preparation of the bowel. Lasers have no role to play in excisional hemorrhoidectomy, and in fact they cause delayed healing, increased pain, and increased cost.Anesthetic management is usually left to the anesthesiologist and patient; however, local anesthesia supplemented by the administration of intravenous narcotics and propofol is very effective. The use of spinal anesthesia, although effective, may increase the risk of postoperative urinary retention.

The Milligan-Morgan hemorrhoidectomy, which is widely practiced in Europe, was originally described in 1937, and its efficacy has been subsequently documented in many series.This technique includes resection of the entire enlarged internal hemorrhoid complex, ligation of the arterial pedicle, and preservation of the intervening anoderm.[33] The distal anoderm and external skin is left open to minimize the risk of infection in the wounds. This technique is safe and effective. However, the fact that the external wounds are left open can be a cause of considerable discomfort and prolonged morbidity.

The closed Ferguson hemorrhoidectomy was proposed as an alternative to the Milligan-Morgan technique and has a similar large body of reported experience. This technique involves an hourglass-shaped (centered at the midportion of the anoderm) excision of the entire internal/external hemorrhoidal complex, preservation of the internal and external anal sphincters, and primary closure of the entire wound. Occasionally, it is necessary to undermine flaps of anoderm and perianal skin to allow removal of intermediate hemorrhoidal tissue while preserving the bridges of anoderm between pedicles. This technical adjustment avoids postoperative strictures.

The Whitehead hemorrhoidectomy, described in 1882, was devised to eradicate the enlarged internal hemorrhoidal tissue in a circumferential fashion and to relocate the prolapse dentate line, which is often a component of prolapsing hemorrhoids. Although this technique was used widely, it was subsequently largely abandoned because of the high rates of mucosal ectropion and anal stricture.The technique has had renewed support, with several authors who documented minimal stricture rates and no occurrences of mucosal ectropion.Despite these promising reports, the Whitehead procedure is technically demanding because of the need to accurately identify the dentate line and relocate it to its proper position

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