Hemorrhoid treatment (2)

Traditional surgery – Hemorrhoidectomy 

 Principles
- Decrease the blood flow to anorectal ring
- Remove 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 defined


 Types
- Excision of hemorrhoids without (open hemorrhoidectomy) or with (closed hemorrhoidectomy) suturing 
- Using different energies for excision
 Diathermy
 Harmonic scalpel
 Bipolar scissors









Reference: psclinic.com.hk/

The information aims to provide educational purpose only. Anyone reading it should consult 
Surgery Specialist before considering treatment and should not rely on the information

above.

Hemorrhoid treatment (1)

Dietary and lifestyle modifications
 Goal: to minimize straining at stool  minimizing constipation
 Diet
- Increase fluid intake
- Stool softeners
 Lifestyle modifications
- Regular defecatory habits


Medications
 Local and oral medications
 Arrests bleeding
 Relieves pain, irritation, and inflammation
 Guard against infection


Outpatient hemorrhoid treatment
 Rubber band ligation, endoscopic ligation
 Ultroid system
 Sclerotherapy
 Infrared coagulation
 Bicap electrocoagulation
 Cryotherapy
 Laser treatment


Banding / Ligation of hemorrhoids
 For Grade 2 and 3 internal hemorrhoids
 Principle: Banding  ischemic necrosis  slough off within few days
 Successful respond rate: 60-70% cured with a single treatment session

http://youtu.be/K7HKrBwuKSw (Video demonstration)




Reference: psclinic.com.hk/

The information aims to provide educational purpose only. Anyone reading it should consult

Surgery Specialist before considering treatment and should not rely on the information above.

Hemorrhoid

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


3. Perianal irritation (itchiness) and discharge (mucus)
4. 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.


 


Reference: psclinic.com.hk/
The information aims to provide educational purpose only. Anyone reading it should consult
Surgery Specialist before considering treatment and should not rely on the information
above.

Procedure for prolapsed and hemorrhoids (PPH)

Stapled hemorrhoidopexy / Procedure for prolapsed and hemorrhoids (PPH) 


 Based on the concept that interruption of the superior and middle hemorrhoidal vessels, and the upward lifting of the prolapsed anorectal mucosa and repositioning of the vascular cushions back into the anal canal cause the hemorrhoidal tissue to atrophy
 For Grade 3 and 4 hemorrhoids
 No incisions are made in the somatically innervated, highly sensitive anoderm  


significantly less postoperative pain
 Side effect: 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

	Staple hemorrhoidopexy	Traditional hemorrhoidectomy
Operative time	Quick, around 30 minutes	40-60 minutes
Postoperative pain	Much less	Painful wound, subsided days to weeks later
Recovery time	Fast, can resume normal activity on next day, avoid strenuous exercise	Slow, requires days to week to resume normal duty
Wound care	No need if not infected	Daily wound dressing, for one to two weeks

Reference: psclinic.com.hk

The information aims to provide educational purpose only. Anyone reading it should consult

Surgery Specialist before considering treatment and should not rely on the information

above.

Procedure for prolapsed and hemorrhoids (PPH)

Stapled hemorrhoidopexy / Procedure for prolapsed and hemorrhoids (PPH) 


 Based on the concept that interruption of the superior and middle hemorrhoidal vessels, and the upward lifting of the prolapsed anorectal mucosa and repositioning of the vascular cushions back into the anal canal cause the hemorrhoidal tissue to atrophy
 For Grade 3 and 4 hemorrhoids
 No incisions are made in the somatically innervated, highly sensitive anoderm  


significantly less postoperative pain
 Side effect: 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

	Staple hemorrhoidopexy	Traditional hemorrhoidectomy
Operative time	Quick, around 30 minutes	40-60 minutes
Postoperative pain	Much less	Painful wound, subsided days to weeks later
Recovery time	Fast, can resume normal activity on next day, avoid strenuous exercise	Slow, requires days to week to resume normal duty
Wound care	No need if not infected	Daily wound dressing, for one to two weeks

Reference: http://psclinic.com.hk/

The information aims to provide educational purpose only. Anyone reading it should consult

Surgery Specialist before considering treatment and should not rely on the information

above.

Hemorrhoid treatment (2)

Traditional surgery – Hemorrhoidectomy 
 Principles
- Decrease the blood flow to anorectal ring
- Remove 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 defined

 Types
- Excision of hemorrhoids without (open hemorrhoidectomy) or with (closed hemorrhoidectomy) suturing 
- Using different energies for excision
 Diathermy
 Harmonic scalpel
 Bipolar scissors









Reference: http://psclinic.com.hk/

The information aims to provide educational purpose only. Anyone reading it should consult

Surgery Specialist before considering treatment and should not rely on the information

above.

Hemorrhoid treatment (1)

Dietary and lifestyle modifications
 Goal: to minimize straining at stool  minimizing constipation
 Diet
- Increase fluid intake
- Stool softeners
 Lifestyle modifications
- Regular defecatory habits


Medications
 Local and oral medications
 Arrests bleeding
 Relieves pain, irritation, and inflammation
 Guard against infection


Outpatient hemorrhoid treatment
 Rubber band ligation, endoscopic ligation
 Ultroid system
 Sclerotherapy
 Infrared coagulation
 Bicap electrocoagulation
 Cryotherapy
 Laser treatment


Banding / Ligation of hemorrhoids
 For Grade 2 and 3 internal hemorrhoids
 Principle: Banding  ischemic necrosis  slough off within few days
 Successful respond rate: 60-70% cured with a single treatment session

http://youtu.be/K7HKrBwuKSw (Video demonstration)





Reference: http://psclinic.com.hk/

The information aims to provide educational purpose only. Anyone reading it should consult

Surgery Specialist before considering treatment and should not rely on the information

above.

Diagnosis & Management

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


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


Four categories
1) Dietary and lifestyle modification  prevention
2) Medications  relieve symptoms
3) Outpatient hemorrhoid treatment
4) Operation


Treatment according to severity 

	Dietary and lifestyle modifications	Medications	Outpatient procedures	Operations
Grade 1	Ö	Ö	+/-	x
Grade 2	Ö	Ö	Ö	+/-
Grade 3	x	x	Ö	Ö
Grade 4	x	x	x	Ö

Reference: http://psclinic.com.hk/

The information aims to provide educational purpose only. Anyone reading it should consult

Surgery Specialist before considering treatment and should not rely on the information

above.

Hemorrhoid - Clinical features

Clinical features

l  Many patient with hemorrhoids are asymptomatic, therefore, no need for treatment

l  Symptomatic

1)       Rectal bleeding – fresh, after defecation, stain toilet paper, separated from stool; anemia if prolonged bleeding

2)       Prolapse

Ø  Grade 1 – bleeding without prolapse

Ø  Grade 2 – prolapse with spontaneous reduction

Ø  Grade 3 – prolapse with manual reduction

Ø  Grade 4 – incarcerated, irreducible prolapse

3)       Perianal irritation (itchiness) and discharge (mucus)

4)       Pain if the external hemorrhoid thrombosed

l  Hemorrhoids in pregnancy

-          Usually occur in third trimester

-          Resulted from:

1)       Hormonal changes

2)       Obstruction of venous return by the gravid uterus

3)       Chronic straining secondary to constipation

-          Majority of symptoms resolve after delivery

-          Treated with conservative measures

-          Intervention rarely indicated

Reference: http://psclinic.com.hk/

The information aims to provide educational purpose only. Anyone reading it should consult

Surgery Specialist before considering treatment and should not rely on the information

above.

Hemorrhoid - Introduction

Introduction

l  Very common disease, affecting more than 80% of adult at sometimes in their life

l  In the past, hemorrhoid was considered as varicose vein

l  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

l  Resulted from chronic straining, leading to local congestion

-          Chronic constipation, diarrhea, prolonged attempts at defecation, prolonged sitting and standing, lack of fibers in diet, etc

-          Local congestion à anal cushions lose their attachment to the underlying rectal wall à prolapse of internal hemorrhoidal tissue through the anal canal

-          As these hemorrhoids engorge à overlying mucosa becomes more friable and the vasculature increases à rectal bleeding

l  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

-          Interno-external hemorrhoids are extended from above to below the dentate line 

Reference: psclinic.com.hk/ 

The information aims to provide educational purpose only. Anyone reading it should consult

Surgery Specialist before considering treatment and should not rely on the information

above.