Hemorrhoids Update Review

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.

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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

Anatomy and Causes of Hemorrhoids

admin — Mon, 07 Dec 2009 03:41:30 +0000

The hemorrhoidal cushions appear predictably in the right anterior, right posterior, and left lateral positions, although there may be intervening secondary hemorrhoidal complexes that blur this classic anatomy. The blood supply is similarly constant, derived from the superior rectal artery, a branch of the inferior mesenteric; from the middle rectal arteries arising from the internal iliac arteries; and from the inferior rectal arteries arising from the pudendal arteries. The venous drainage transitions from the portal venous system above the level of the dentate line to the systemic venous system below this level.

The vascular cushions form the termination of the vascular supply within the anal canal and contribute to the maintenance of anal continence.[6] hemorrhoids occurs as the result of abnormalities within the connective tissue of these cushions, producing bleeding with or without prolapse of the hemorrhoidal tissue.[7] This can occur as the result of excessive straining and chronic constipation.[8] A clear understanding of the pathophysiology is important when considering therapeutic interventions. At the earlier stages of disease progression, when the major manifestation is transudation of blood through thin-walled damaged veins or arterioles, ablation of the vessels should be adequate. Conversely, in late stages of the disease, when there is significant disruption of the mucosal suspensory ligament, fixation of the mucosa to the underlying muscular wall is required for effective therapy.Internal anal sphincter dysfunction may play a role; a number of investigators have demonstrated increased internal anal sphincter tone in patients with hemorrhoids. In reality, a combination of all of these factors is probably important for the ultimate development of large prolapsing internal hemorrhoids.

The standard classification for hemorrhoids is as follows:

Stage 1: bleeding
Stage 2: protrusion but spontaneous reduction
Stage 3: protrusion that requires manual reduction
Stage 4: irreducible protrusion

Although this staging system tends to correlate with the patient’s symptoms, it is unclear whether it can be completely relied on when making therapeutic decisions. As outlined later, it is important to consider the relative role of both internal hemorrhoidal tissue and external hemorrhoidal skin tagging when choosing a modality for complete resolution of all of the patient’s symptoms.

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Hemorrhoids Surgery – Hemorrhoidectomy

admin — Mon, 07 Dec 2009 03:40:00 +0000

The decision to excise the hemorrhoidal plexi requires acceptance by the physician and patient that medical and non-excisional options have either failed or are not appropriate. The usual clinical symptoms that lead to excision are frequent prolapsing of the internal hemorrhoids that results in discomfort and anal seepage. Alternatively, the thickened and prolapsing internal/external hemorrhoidal complexes may make anal hygiene difficult for the patient and may make excision preferable. The final indication for excisional hemorrhoidectomy, although debatable, is the development of acutely thrombosed and gangrenous internal hemorrhoids. It is apparent, however, that hemorrhoidectomy can be performed using standard closed hemorrhoidectomy techniques without undue complications. Specifically, the risk of stenosis appears unwarranted if careful technique is used and the maximum amount of anoderm is preserved with skin bridges between excision sites. In the case of limited external hemorrhoidal thromboses, surgical excision is warranted for more rapid pain relief and avoidance of a residual skin tag.External thromboses are usually easily managed in an office setting with local anesthesia

A, Thrombosed external hemorrhoid in the right lateral quadrant. B, Allis clamp applied to apex of thrombosis and elliptical incision made. C, Thrombosis dissected free of sphincter. D, Appearance of wound after thrombectomy.

Hemorrhoids Update Review

Clinical Evaluation of Hemorrhoids Symptoms

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Bipolar Diathermy in Hemorrhoids Treatment

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Stapled Hemorrhoidectomy, a New Treatment

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Sclerotherapy in Hemorrhoids Treatment

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Non-Excisional Treatment of Hemorrhoids

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History of Hemorrhoids

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Rubber Bands Ligation in Hemorrhoids Treatment

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Type of Hemorrhoidectomy Treatment

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Anatomy and Causes of Hemorrhoids

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