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Definition:

  • Haemorrhoids are referred to the condition in which the anal and perianal venous plexus is inflamed and dilated in and around the anus and lower abdomen. 
  • They are described as the varicosities of the anal veins.

 Other names: 

    • Piles (Latin – meaning balls)
    • And also Haemorrhoids (hem uh roids)

Anatomy :

    • Anal vein is terminated as internal and external venous plexus.
    • The Hemorrhoidal plexus is also called as Internal rectal venous plexus.

Haemorrhoids

    • Both the internal and external venous plexus are thin-walled and dilated, when these dilated vessels protrude beneath the anal or rectal mucosa it is called Hemorrhoids

Haemorrhoids or Piles

Types:

    • There are two types of hemorrhoids based on the region of inflammation either above or below the pectinate line (also called a dentate line).

    • They are;
        • Internal hemorrhoids

        • External hemorrhoids

    • Internal haemorrhoids are present above the pectinate line.
    • External haemorrhoids are present below the pectinate line.

Piles

Internal haemorrhoids :

    • Synonym – true piles.
    • They are present above the pectinate line.
    • Moreover the main cause is dilatation of the internal rectal venous plexus.
    • Overcoat – mucosa, and these bleeds.
    • These do not cause pain, because regions above the pectinate line are endodermic in origin.

    • These are grouped as primary piles and secondary piles
        • Primary haemorrhoids:
            • The primary piles occur in three positions, they are
                • 3 ‘o’clock – left lateral position

                • 7 ‘o’clock – right posterior position

                • 11 ‘o’clock – right anterior position.

                • Enlargement of the three main radicles of the superior rectal vein at respective regions causes primary piles.

        • Secondary haemorrhoids:
            • Varicosities in the other than these three positions of the lumen refers to secondary piles.
                • Stage 1 – slight enlargement in the internal Haemorrhoid plexus

                • Stage 2 – the Haemorrhoid finger passes the pectinate line

                • Stage 3 – further protruding down where it is visible in the anal sphincter.

                • Stage 4 – fully protruded out.

Internal haemorrhoids position

 

Internal haemorrhoids position

External Haemorrhoids :

    • Synonym – False piles
    • They are present below the pectinate line.
    • Cause – dilatation of the external rectal venous plexus.
    • Overcoat – skin
    • Location – below the anal skin -these skin stretch and form the skin tags.
    • This type causes pain because regions below the pectinate line are ectodermic in origin.
    • In external hemorrhoids, the Haemorrhoid protruded below the white line of Hilton.

Clinical features of Haemorrhoids:

    • Bleeding – first shown symptom, bleeds in bright red.
    • Moreover occurs during defecation.
    • Bleeding occurs as drops of red blood at the end of defecation.

    • Prolapse – 1⁰ hemorrhoids: bleeds but does not prolapse
        • 2⁰ Haemorrhoids: prolapse on defecation but return spontaneously

        • 3⁰ Haemorrhoids: bleeds and prolapse on defecation, it has to be replaced manually.

        • 4⁰ Haemorrhoids: bleeds and permanently prolapsed.

    • Discharge – frequent mucoid discharge
    • Anemia – in case of severe chronic bleeding
    • Sudden painful condition along with discomfort.
    • Tender swelling is seen
    • Pain on defecation.
    • Constipation.

Causes of Haemorrhoids:

    • Firstly, Portal hypertension
    • Chronic constipation and straining in stool
    • Cardiac failure
    • Venous status of pregnancy
    • Hereditary predisposition
    • And also tumors of the rectum.

Risk factors:

    • First;y, Portal hypertension
    • Increased intra-abdominal pressure
    • Severe constipation and straining during defecation.
    • Pregnancy
    • Obesity
    • And also heavy lifting

Diagnosis:

    • Microscopically – In internal piles thin-walled and also dilated tortuous veins are seen under the rectal mucosa.
    • External piles are seen under the anal skin. In prolapsed piles, thrombosis, hemorrhage, inflammation, scarring, and strangulation are seen.
    • Investigation – digital examination, ano – proctoscopy examination and also sigmoidoscopy. 

Treatment of Haemorrhoids :

    • Firstly, Constipation – Treatment modality is to prescribe laxatives.
    • Pain – Application of 5% xylocaine jelly per rectally to ease pain. 
    • On server bleeding – to maintain intravascular volume by fluids and blood transfusion to resuscitate shock and to maintain hemodynamic stability. 1⁰ and 2⁰ hemorrhoids- to give injection or tablet of tranexamic acid .
    • For the 1⁰ Haemorrhoids which bleeds, injection of phenol – in a specially designed syringe – Gabriel’s syringe, injecting around 3-5 ml above the Anorectal ring, 3 sessions at the 6-week interval .
    • Moreover for 3piles laser therapy is usually prescribed.

    • Based on the stages:
      •  
        • Stage 1: Recommendation of high fibre diet and also Sitz bath.

        • Stage 2: To use Steroid creams like hydrocortisone . And also to use Pramoxine as anti-itching cream

        • Stage 3 and 4: Rubber band ligation

    • For external hemorrhoids,
      •  
        • Cryosurgery (application of liquid nitrogen)

        • Hemorrhoidectomy (surgical removal)                    

        • And also photocoagulation (application of infrared coagulation)

    • MEDICAL :
      •  
        • Local applications, Sitz bath, Diet, Laxatives, Drugs, Analgesics.

    • PARASURGICAL :
      •  
        • Sclerotherapy

        • Banding

        • Cryotherapy

        • Infrared coagulation

        • Laser therapy

        • Doppler – Guided Haemorrhoidal artery ligation

    • SURGICAL :
      •  
        • Open haemorrhoidectomy

        • Closed haemorrhoidectomy

        • Stapled haemorrhoidopexy

        • Anal stretching – Recamier, Lord’s


Postoperative complications :

  • Pain- due to spasms, nerve irritation and also muscle injury.
  • Retention of urine – Commenest
  • Reactionary or secondary haemorrhage
  • Anal fissure
  • Anal stricture
  • Recurrence
  • Anal discharge for sometimes
  • Incontinence for faeces or gas
  • And also Ectropion ( Whitehead deformity )

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