Ch.12 - Hemorrhoids Flashcards
What are the 3 henorrhoidal columns?
Left lateral
Right anterior
Right posterior
What are the arterial blood supply to hemorrhoids?
Primarily from terminal branches if the superior henorrhoidal artery
Branches if the middle hemorrhoidal also contribute
Where do the muscle fibers in the hemorrhoids arise from?
How do these muscle contribute to hemorrhoids becoming symptomatic?
From the internal sphincter and from conjoined longitudinal muscle
Breakdown of this tissue contribute to hemorrhoids becoming symptomatic
How does increased sphincter tone affect hemorrhoids?
Can slow venous return and make hemorrhoids become symptomatic
[T/F] somebody can get thrombosed hemorrhoids without much previous history of hemorrhoids at all
True. Can happen all the sudden.
What is the recommended dose of dietary fiber for men and women?
Men: 38g
Women: 25g
Excessive straining despite having soft BMs. What syndrome could this be?
Does hemorrhoidectomy help?
ODS obstructed defecation syndrome
Hemorrhoidectomy doesn’t help
After hemorrhoid band ligation pts can bleed at what timepoint?
When do you see them back? Do you have to?
What’s the incidence of delayed rectal bleeding?
5-7 days
See them back in 2-4 weeks to eval. Success of treatment
1%
What are the triad of symptoms for pelvic sepsis after hemorrhoid banding?
How do you confirm the diagnosis?
Pain, fever, urinary retention
In the OR with EUA
What are the treatment options for posthemorrhoidectomy pelvic sepsis?
Earlier recognized, mild cases: debridement of the wound with IV Abx
Severe cases: laparotomy with diverting colostomy, pelvic drainage
Rubber band ligation is effective for what grades of hemorrhoids?
Grades 1-3
What % of ppl who undergo rubber band ligation need long term follow-up and repeat treatment?
18-32%
How does infrared radiation work?
How do you do it?
What is the depth of penetration
Generates heat that coagulate protein and creates an inflammatory bed.
The radiation is applied to the internal hemorrhoid at 4 different locations of each hemorrhoidal complex. 1-1.5s each
The depth is ~3mm and leads to heat necrosis that caused tissue destruction and eventually fibrosis and scarring
Infrared coagulation is most effective for what grades of hemorrhoids?
Grades 1-2
Someone has a lot of pain after infrared radiation. Is this normal? What does it mean?
Treatment was done too low or too close to the dentate line
With infrared radiation can you treat all 3 columns at once?
Yes
Besides the infrared photocoagulation, what other energy treatment are there?
Which one penetrates deeper?
Are they better than infrared?
Bipolar diathermy and direct current monopolar.
Monopolar penetrates deeper.
Infrared is the most popular
Sclerotherapy injects what?
Effective for what grades of hemorrhoids?
Best indication for sclerotherapy?
Phenol, carbonic acid and other stuff
Effective up to grade 3
For ppl who require anticoagulation since the bleeding risk is minimal
What is the risk of bleeding after banding?
1%
Typically, what % of people with hemorrhoidal complaints require an operation?
5-10%
Ferguson hemorrhoidectomy is basically peeling the hemorrhoid off the what?
Internal and external sphincter
You just finished taking the hemorrhoid off and are closing with victyl. You notice that it’s a bit bloody. What can you do with the suture to help?
Do locking stitch than just simple running
What’s better shit using ligasure?
There may be less post-op discomfort
What’s the difference between Ferguson and milligan-morgan?
Milligan-morgan leave it open, not closed other than the suture ligating at the Apex of the hemorrhoidal pedicle
What is Whitehead hemorrhoidectomy?
What’s a complication of this?
Circumferential incision, remove all hemorrhoids
Then approximate the remaining proximal rectal mucosa to the anoderm
Whitehead deformity
What can you do for post hemorrhoidectomy pain?
Topical nitroglycerin
Oral or topical metronidazole
What is PPH?
Does it have higher or lower urinary retention rate?
Procedure for prolapse and hemorrhoids. Stapled henorrhoidectomy
Lower retention rate
What are the two time-frames for post hemorrhoidectomy bleed? How frequently do they occur?
Immediate post-op: 1%, technical error
Delayed bleeding: 5.4%, 7-10d post-op.
Most likely hemorrhoidectomy scenario that will likely result in anal stenosis?
Treatment?
Emergency hemorrhoidectomy for prolapsed thrombosed hemorrhoid
Bulk laxatives but may require dilation or anoplasty
Stapled hemorrhoidectomy. it’s otherwise known as?
What’s an advantage and disadvantage compared to hemorrhoidectomy?
Procedure for prolapse by hemorrhoidopexy
Advantage: less post-op pain
Disadvantage: more recurrence of prolapse and symptoms
What is a strangulated hemorrhoid?
Can you enucleate it?
What if the OR is unavailable? Can you do something in the office?
Prolapsed and irreducible. +/- thrombosis
Enucleation alone is usually insufficient you have to excise it
In the office, apply local anesthetic, pressure, reduce.bthen rubber ligate vs thrombectomy. Actually a low chance of needing a future surgical henorrhoidectomy.
