Ch.12 - Hemorrhoids

Question 1

What are the 3 henorrhoidal columns?

Answer 1

Left lateral
Right anterior
Right posterior

Question 2

What are the arterial blood supply to hemorrhoids?

Answer 2

Primarily from terminal branches if the superior henorrhoidal artery

Branches if the middle hemorrhoidal also contribute

Question 3

Where do the muscle fibers in the hemorrhoids arise from?

How do these muscle contribute to hemorrhoids becoming symptomatic?

Answer 3

From the internal sphincter and from conjoined longitudinal muscle

Breakdown of this tissue contribute to hemorrhoids becoming symptomatic

Question 4

How does increased sphincter tone affect hemorrhoids?

Answer 4

Can slow venous return and make hemorrhoids become symptomatic

Question 5

[T/F] somebody can get thrombosed hemorrhoids without much previous history of hemorrhoids at all

Answer 5

True. Can happen all the sudden.

Question 6

What is the recommended dose of dietary fiber for men and women?

Answer 6

Men: 38g
Women: 25g

Question 7

Excessive straining despite having soft BMs. What syndrome could this be?

Does hemorrhoidectomy help?

Answer 7

ODS obstructed defecation syndrome

Hemorrhoidectomy doesn’t help

Question 8

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?

Answer 8

5-7 days

See them back in 2-4 weeks to eval. Success of treatment

1%

Question 9

What are the triad of symptoms for pelvic sepsis after hemorrhoid banding?

How do you confirm the diagnosis?

Answer 9

Pain, fever, urinary retention

In the OR with EUA

Question 10

What are the treatment options for posthemorrhoidectomy pelvic sepsis?

Answer 10

Earlier recognized, mild cases: debridement of the wound with IV Abx

Severe cases: laparotomy with diverting colostomy, pelvic drainage

Question 11

Rubber band ligation is effective for what grades of hemorrhoids?

Answer 11

Grades 1-3

Question 12

What % of ppl who undergo rubber band ligation need long term follow-up and repeat treatment?

Answer 12

18-32%

Question 13

How does infrared radiation work?

How do you do it?

What is the depth of penetration

Answer 13

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

Question 14

Infrared coagulation is most effective for what grades of hemorrhoids?

Answer 14

Grades 1-2

Question 15

Someone has a lot of pain after infrared radiation. Is this normal? What does it mean?

Answer 15

Treatment was done too low or too close to the dentate line

Question 16

With infrared radiation can you treat all 3 columns at once?

Answer 16

Yes

Question 17

Besides the infrared photocoagulation, what other energy treatment are there?

Which one penetrates deeper?

Are they better than infrared?

Answer 17

Bipolar diathermy and direct current monopolar.

Monopolar penetrates deeper.

Infrared is the most popular

Question 18

Sclerotherapy injects what?

Effective for what grades of hemorrhoids?

Best indication for sclerotherapy?

Answer 18

Phenol, carbonic acid and other stuff

Effective up to grade 3

For ppl who require anticoagulation since the bleeding risk is minimal

Question 19

What is the risk of bleeding after banding?

Answer 19

1%

Question 20

Typically, what % of people with hemorrhoidal complaints require an operation?

Answer 20

5-10%

Question 21

Ferguson hemorrhoidectomy is basically peeling the hemorrhoid off the what?

Answer 21

Internal and external sphincter

Question 22

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?

Answer 22

Do locking stitch than just simple running

Question 23

What’s better shit using ligasure?

Answer 23

There may be less post-op discomfort

Question 24

What’s the difference between Ferguson and milligan-morgan?

Answer 24

Milligan-morgan leave it open, not closed other than the suture ligating at the Apex of the hemorrhoidal pedicle

Question 25

What is Whitehead hemorrhoidectomy?

What’s a complication of this?

Answer 25

Circumferential incision, remove all hemorrhoids

Then approximate the remaining proximal rectal mucosa to the anoderm

Whitehead deformity

Question 26

What can you do for post hemorrhoidectomy pain?

Answer 26

Topical nitroglycerin

Oral or topical metronidazole

Question 27

What is PPH?

Does it have higher or lower urinary retention rate?

Answer 27

Procedure for prolapse and hemorrhoids. Stapled henorrhoidectomy

Lower retention rate

Question 28

What are the two time-frames for post hemorrhoidectomy bleed? How frequently do they occur?

Answer 28

Immediate post-op: 1%, technical error

Delayed bleeding: 5.4%, 7-10d post-op.

Question 29

Most likely hemorrhoidectomy scenario that will likely result in anal stenosis?

Treatment?

Answer 29

Emergency hemorrhoidectomy for prolapsed thrombosed hemorrhoid

Bulk laxatives but may require dilation or anoplasty

Question 30

Stapled hemorrhoidectomy. it’s otherwise known as?

What’s an advantage and disadvantage compared to hemorrhoidectomy?

Answer 30

Procedure for prolapse by hemorrhoidopexy

Advantage: less post-op pain
Disadvantage: more recurrence of prolapse and symptoms

Question 31

What is a strangulated hemorrhoid?

Can you enucleate it?

What if the OR is unavailable? Can you do something in the office?

Answer 31

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.