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hemorrhoids

  • Introduction
Hemorrhoid is a very common disease, which affects more than 80% of adults. In the past, hemorrhoid was considered as varicose vein. Recently, it is defined as a vascular cushion resulted from downward displacement of anal cushion, which are blood-filled spaces supported by a matrix of fibrous tissue and smooth muscle located in lower rectum. It is resulted from chronic straining, leading to local congestion due to various reasons such as chronic constipation, diarrhea, prolonged attempts when defecation, prolonged sitting and standing, lack of fibers in diet, etc. Local congestion will cause anal cushions to lose their attachment to the underlying rectal wall, leading to prolapse of internal hemorrhoidal tissue through the anal canal. As these hemorrhoids engorge, vasculature increases and the overlying mucosa become more friable. As a result, rectal bleeding occurs.
Hemorrhoid is classified as internal, external or internoexternal in relation to dentate line at lower rectum. Internal hemorrhoids are located above the dentate line, external hemorrhoids are located below the dentate line, while interno-external hemorrhoids are extended from above to below the dentate line
  • Clinical features
Hemorrhoids in many patients are found to be asymptomatic, and therefore no treatment is needed.
For symptomatic hemorrhoids, symptoms include:
1. Rectal bleeding – fresh bleeding is found after defecation that stain toilet paper and is separated from stool. Anemia will be results if prolonged bleeding occurs.
2. Prolapse – According to severity, prolapse is divided into different grading:
Grade 1 – bleeding without prolapse
Grade 2 – prolapse with spontaneous reduction
Grade 3 – prolapse with manual reduction
Grade 4 – incarcerated, irreducible prolapse


Perianal irritation (itchiness) and discharge (mucus)
Pain due to thrombosis of external hemorrhoid

Hemorrhoids in pregnancy
Hemorrhoids can also be found usually in the third trimester during pregnancy. It can be due to hormonal changes, obstruction of venous return by the gravid uterus and chronic straining secondary to constipation. Majority of symptoms can be resolved after delivery. These can be treated with conservative measures and intervention is rarely being indicated.

Diagnosis 
Hemorrhoids are diagnosed by carrying out prompt clinical examination. Although the most common cause of rectal bleeding is hemorrhoids, we must exclude the most important cause, which is colorectal cancer. Colonsocopy examination is required if clinically indicated.

Varies from simple reassurance to surgery
Treat symptomatic disease only
Depends on grading

It is divided into four categories:
1.Dietary and lifestyle modification to prevent hemorrhoids formation
2.Medications to relieve symptoms
3.Outpatient hemorrhoid treatment
4.Operation 

  • Treatment of hemorrhoids

Treatment is according to severity of hemorrhoids



  • Dietary and lifestyle modification

Dietary and lifestyle modification
The goal is to minimize straining at stool by minimizing constipation. Increase fluid intake which acts as stool softeners is encouraged in diet. Moreover, regular defecatory habits should be developed.

Medications
There are two kinds of medications, local and oral medications. This helps to:

arrest bleeding

relieve pain, irritation, and inflammation

guard against infection

Outpatient hemorrhoid treatment

Rubber band ligation, endoscopic ligation
Sclerotherapy
Infrared coagulation
Bicap electrocoagulation
Cryotherapy
Laser treatment

  • Surgery

1.Banding / Ligation of hemorrhoids
It is carried out for Grade 2 and 3 internal hemorrhoids. The principle of it is to cause ischemic necrosis by banding, which will slough off within a few days. 60-70% successful response rate is found when cured with a single treatment session

2.Traditional surgery – Hemorrhoidectomy
The principle of the surgery is to decrease the blood flow to anorectal ring, which is followed by the removal of redundant hemorrhoidal tissue.Indications
Grade II, III and IV hemorrhoids
Failure of non-operative treatment of 2nd degree pile
Thrombosed hemorrhoid
Interoexternal pile when the external pile is well definedTypes
Excision of hemorrhoids with (closed hemorrhoidectomy) or without (open hemorrhoidectomy) suturing
Excision by using different energies
Diathermy
Harmonic scalpel
Bipolar scissors

3.Stapled hemorrhoidopexy / Procedure for prolapsed and hemorrhoids (PPH)
Based on the concept of interruption of the superior and middle hemorrhoidal vessels, and the upward lifting of the prolapsed anorectal mucosa, followed by repositioning of the vascular cushions
back into the anal canal, causing atrophy of hemorrhoidal tissue
For Grade 3 and 4 hemorrhoids
No incisions are made in the somatically innervated, highly sensitive anoderm, which cause significantly less postoperative pain
Side effects include rectal perforation, sphincter dysfunction and sepsis
Advantages:
1.Simple and quick procedure
2.Less postoperative pain, shorter hospital stay and earlier return to normal activity
3.Similar complication rate as conventional procedure








  • Hemorrhoidal artery ligation (HAL) and Transanal hemorrhoid dearterialization (TAH)

These are for treatment of bleeding and Grade 2 to 3 prolapsed hemorrhoids. Dearterialization is to apply Doppler-USG for identification and selective ligation of the branches of rectal artery, thereby correcting the arterial hyperinflux, which is the main cause of bleeding and swelling of the haemorrhoidal plexus. Mucopexy or rectoanal repair is the reposition of the cushions in their anatomical site by folding the muco-hemorrhoidal prolapsed


Benefits
Minimally invasive and atraumatic
Marginal post-operative pain
No grave complications

*All surgical procedures are performed in the day procedure centre registered under Private Healthcare Facilities Register, Department of Health