Haemorrhoids and Haemorrhoidectomy

Question 1

Define haemorrhoids.

Answer 1

Displacement and dilatation of one or more anal cushions (vascular tissue)

Haemorrhoidal cushions are normal anatomical structures located within the anal canal, usually occupying the left lateral and right anterior and posterior positions. As they enlarge, they can protrude outside the anal canal causing symptoms.

Question 2

Where do anal cushions lie?

Answer 2

Proximal to the dentate line within the anal canal

At 3 o’clock.
At 7 o’clock.
At 11 o’clock.
As viewed form the lithotomy position.

NB: anal cushions are anal VEINS

Question 3

How common are haemorrhoids?

Answer 3

• US prevalence is 4% - more common in white population
• Presents usually between 45-65yrs
• Since 1950 there is an unexplained decrease in the prevalence of symptomatic haemorrhoidal disease.
• Haemorrhoids affect 50% of the population over the age of 50.

Question 4

What is the aetiology of haemorrhoids?

Answer 4

• Straining with defaecation/constipation
• Pregnancy.- increased abdominal pressure

Other : hepatic insufficiency - There is little evidence that hepatic insufficiency or portal hypertension contributes to the formation of haemorrhoids, but these conditions can result in rectal varices.

Question 5

What is the pathophysiology of haemorrhoids?

Answer 5

• Normal anatomical and functional components of the anal canal and only when symptomatic are termed haemorrhoidal disease
• When patient strains, haemorrhoids are pulled into anal canal
• As vascular tissues engorge the thin epithelial lining is easily torn → bleeding which is seen as bright blood on cleansing
• Haemorrhoids can enlarge to the point of protrusion through the anal canal → sensation of incomplete evacuation.
• External haemorrhoids commonly cause pruritus or feeling of inadequate cleaning following a bowel movement
• Thrombosed external haemorrhoids can form after period of excessive straining → sudden onset perianal pain → tender palpable lesion adjacent to anal canal

Question 6

What is the classification of haemorrhoids?

Answer 6

• External
• Internal (graded)

Grade 1 - protrusion is limited to within the anal canal.

Grade 2 - protrudes beyond the anal canal but spontaneously reduces on cessation of straining.

Grade 3 - protrudes outside the anal canal and reduces fully on manual pressure.

Grade 4 - protrudes outside the anal canal and is irreducible.

Question 7

What is the difference in location of external and internal haemorrhoids?

Answer 7

External - located in the distal anal canal, distal to the dentate line, and covered by sensate anoderm or skin.

Internal - originate proximal to the dentate line and covered by insensate transitional epithelium.

Question 8

What is a grade 1 haemorrhoid?

Answer 8

A grade one haemorrhoid will only bleed.

Question 9

What is a grade 2 haemorrhoid?

Answer 9

A grade two haemorrhoid will prolapse, but will spontaneously reduce.

Question 10

What is a grade 3 haemorrhoid?

Answer 10

A grade three haemorrhoid will prolapse and require manual replacement.

Question 11

What is a grade 4 haemorrhoid?

Answer 11

A grade 4 haemorrhoid will be permanently prolapsed.

Question 12

What are the symptoms of haemorrhoids. (4)

Answer 12

• Painless red PR bleeding (usually after defecation).
• Perianal lump.
• Mucous discharge.
• Pruritus ani.

Question 13

What are the signs of haemorrhoids? (2)

Answer 13

Visible prolapsed haemorrhoids.
Anaemia. (if the bleeding is brisk)

Question 14

What investigations should you do?

Answer 14

• Colonoscopy/flexible sigmoidoscopy - usually normal but checks for IBD, cancer
• FBC - ?microcytic/hypochromic anaemia
• Stool for occult haem

Question 15

How do you manage haemorrhoids?

Answer 15

Conservative:

• Lifestyle and dietary modification - specifically increased fibre (25-30g/day) intake and adequate fluids. Clean and dry perineum after defecation
• Simple analgesia - paracetamol only preferred
• Local anaesthetic creams/ointments e.g. Anusol - these usually contain astringent, lubricants, antiseptic, local anaesthetic, and/or corticosteroids.
• GTN/botulinum toxin injections - reduces spasm of internal anal sphincter

Grade 1 + 2 -

1. rubber band ligation
2. sclerotherapy

OR infrared photocoagulation or haemorrhoid arterial ligation or stapled haemorrhoidopexy

Grade 3 -

1. rubber band ligation
2. staples haemorrhoidopexy
3. haemorrhoid arterial ligation

OR surgical haemorrhoidectomy

Grade 4 -

1. Surgical haemorrhoidectomy

Question 16

What is surgical haemorrhoidectomy? What are the indications and complications?

Answer 16

Indications - grade 3 and 4 haemorrhoids

Excision of the haemorrhoid under general/regional anaesthetic

Complications -

• Pelvic sepsis - rectal pain, urinary retention, abdominal pain, and pyrexia
• Faecal incontinence usually to flatus (52%) and liquid stool (40%) has been reported following surgical haemorrhoidectomy
• Bleeding
• Anal stenosis - risk with circumferential excision

Question 17

What is rubber band ligation?

Answer 17

Indication - grade 2 and 3 haemorrhoids

• Anoscopy is used
• Rubber band is placed on redundant haemorrhoidal tissue with care being taken to place the bands above the dentate line.
• Tissue contained in the band necroses and sloughs in approximately 1 week

Complications - transient bleeding (anticoags should be withheld before surgery) or rarely septic events

Question 18

What is sclerotherapy/infrared coagulation for haemorrhoids?

Answer 18

Indications - grade 1 or 2 haemorrhoids that are too small for rubber band ligation

Scleotherapy -

• injection of a chemical agent directly into the haemorrhoid to cause local tissue destruction and scarring
• with aid of anoscope, 2-3mL sclerosant
• typically needs to be done a couple of times in order to treat all haemorrhoids

Complications - bleeding, mild pain, pressure, tenesmus, swelling, infection, recurrence, thrombus in anal region

Infrared photocoagulation

• infrared radiation applied directly to the haemorrhoid –> coagulation, scarring and subsequent fixation of the internal haemorrhoidal tissue

Complications - pain, thrombosis, sepsis, necrosis of pile

Question 19

What is haemorrhoid arterial ligation?

Answer 19

Indications - grade 2 or 3 haemorrhoids

AKA Transanal haemorrhoidal de-arterialisation

• Uses a custom proctoscopy with a Doppler transducer to identify and ligate terminal branches of the superior rectal artery above the dentate line –> haemorrhoidal shrinkage
• Typically done under short general anaesthetic and multiple ligations may be required
• Fewer recurrences at 1 year than with rubber band ligation

Complications - rectal bleeding, urinary retension, dysuria, anal pain, faecal urgency, haematoma.

Question 20

What is stapled haemorrhoidopexy?

Answer 20

Indications - grade 3 or small grade 4 haemorrhoids

• Prolapsing haemorrhoids are relocated within the anal canal, rather than excised
• Complications - pain, bleeding etc

Question 21

What are the complications of haemorrhoids?

Answer 21

• Anaemia from cotinuous/excessive bleeding
• Thrombosis - sudden onset perianal pain with tender nodule at anal canal often after vigorous activity
• Incarceration - if can no longer be reduced into anal canal

Question 22

What is the prognosis with haemorrhoids?

Answer 22

• Treatment results in resolution/improvement of symptoms with low recurrence rates
• Surgical haemorrhoidectomy offers best long-term effect with less than 20% recurrence

Question 23

What is the management of thrombosed haemorrhoids?

Answer 23

Reduction or excision