Hemorrhoid

1
1/2548

.
outline
introduction
pathophysiology

classification
evaluation and diagnosis
treatment
Introduction
hemorrhoids are cushions of submucosal
vascular tissue found in the anal canal
muscular fibers, which arise from the
internal anal sphincter : maintain adheren
ce of the mucosal and submucosal layers t
o the underlying internal sphincter and pr
event prolapse
normal hemorrhoidal tissue : anal
continence by acting as a compressible lini
ng that allows the anus to close completel
y
Introduction
this tissue also forms a spongy bolster
that fills with blood and cushions the anal
canal during defecation, preventing damage
to the anal canal and sphincter mechanism
approximately 2-3 cm above the anal verge
is an anatomic landmark known as the
dentate or pectinate line
when this tissue enlarge, the result is
hemorrhoid disease
not dangerous or life threatening
Pathophysiology
exact pathogenesis remains controversial
proposed etiologic factors :

- constipation, diarrhea
- prolonged straining e.g., toilet habit
- pregnancy
- derangement of the internal sphincter
- heredity
- age : elderly weak of anatomy structure
- diet e.g., low-fiber diets
- occupation
- portal hypertension
Pathophysiology
increased pressure causes engorgement of
the hemorrhoids, possibly by interfering wit
h venous return
major theories :

- abnormal dilatation of the veins of the

internal hemorrhoidal venous plexus
- abnormal distention of the arteriovenous
anastamosis of the hemorrhoidal cushions
- downward displacement or prolapse of the
anal cushions
- destruction of the anchoring connective
tissue system
Classification
internal hemorrhoid : above the dentate line
external hemorrhoid : below the dentate line

external hemorrhoid : are covered by skin

- innervated by cutaneous nerves that supply
the perianal area
- sensitive to touch, temperature, stretch,
pain
- acute thrombosis rapid tissue expansion
and edema pain
Classification
- pain lasts 7-14 days and resolves with
resolution of the thrombosis
- with resolution of the thrombosis, the
stretched anoderm persists as excess skin
- external thromboses can occasionally erode
the overlying skin and cause bleeding
Classification
internal hemorrhoid : are covered by mucosa
- not supplied by somatic sensory nerves and
therefore cannot cause pain
- classified by symptoms :
* grade I protudes into the anal canal but
does not prolapse
* grade II prolapses but reduces
spontaneously
* grade III prolapses and requires manual
reduction
* grade IV permanently prolapsed
internal hemorrhoid
Classification

- symptoms typically relate to mucosal

protrusion, bleeding, perianal itching and di
scomfort, difficulties with perianal hygiene
and perianal pain by causing a spasm of the
sphincter complex
- hemorrhoids that remain prolapsed develop
ischemia, thrombosis, or gangrene

complications : stenosis, bleeding, infection,

recurrence, nonhealing wounds, and fistula
formation
Evaluation and diagnosis
history
- color and character of bleeding
- temporal relationships between symptoms
and defecatory patterns
- exacerbating factors
- factors related to relief of symptoms
exclude other common anorectal problems :
fissures, fistulae, condyloma, or pruritus ani
physical examination : visual inspection,
anoscopy
lab test : hematocrit
Treatment
the decision to treat is based on the
frequency and severity of symptoms
nonoperative treatments :

* behavior modification
* stool-bulking agents
* medication treatment
office procedures :

* rubber band ligation

* infrared photocoagulation
* sclerotherapy
surgical managements
Behavior modification
key role in the initial management of
patients with symptomatic hemorrhoidal dise
ase
prevention of straining and avoidance of
precipitating factors
avoid spending prolonged periods of time
sitting on the toilet
perianal hygiene: prevent perianal dermatitis

sit baths and warm soaks : recommended 3

times a day and after each bowel movement
for at least 15 minutes
 Stool-bulking agents

diet alterations (e.g., increasing intake of

fiber) and the addition of stool bulking agen
ts, such as psyllium
produce a soft stool : easy to pass, thus
reducing the requirement to strain with defe
cation
lessons the degree of trauma to the anal
canal epithelium during defecation and reduc
e the likelihood of bleeding and ulceration
 Medication
goal : relieve symptoms as quickly as
possible; maintain remission of symptoms
various topical creams, ointments, lotions,
and suppositories : improve acute symptoms
scientific proof of their efficacy is lacking,
and do not cure the disease
local anesthetics, mild astringents, steroids
continuous application can cause eczema and
sensitisation of the anoderm
rectal absorption : systemic side effects
Local anesthetics

relieve pain, burning, and itching by numbing

the nerve endings
limited to the peri-anal area and lower anal
canal
cause allergic reactions with burning and
itching (similar to hemorrhoids themselves)
examples :
* benzocaine 5-20% enzul alcohol
5-20%
* dibucaine 0.25-1.0% dyclonine
0.5-1.0%
* lidocaine 2-5% pramoxine 1.0%
* tetracaine 0.5-1.0%

Protectants
prevent irritation of the peri-anal area
by forming a physical barrier on the skin
that prevents contact of the irritated ski
n with aggravating liquid or stool from the
rectum
reduces irritation, itching, pain, and
burning
Examples :
* aluminum hydroxide gel cocoa butter
* glycerin kaolin lanolin
* mineral oil white petrolatum zinc oxide
 Astringents

cause coagulation (clumping) of proteins in

the cells of the peri-anal skin or the
lining of the anal canal
promotes dryness of the skin, which in
turn helps relieve burning, itching, and pa
in
examples :

* calamine 5-25%
* zinc oxide 5-25%
Antiseptics
inhibit the growth of bacteria and other
organisms
however, it is unclear whether antiseptics
are any more effective than soap and water
examples :

* boric acid
* phenol
* benzalkonium chloride
* benzethonium chloride
* resorcinol
Keratolytics
cause the outer layers of skin or other
tissues to disintegrate
the disintegration allows medications that
are applied to the anus and peri-anal area
to penetrate into the deeper tissues
two approved keratolytics used in
hemorrhoidal products:
* aluminum chlorhydroxy allantoinate
0.2-2.0%
* resorcinol 1-3%
Medication
Hydrocortisone : topical anti-inflammatory
agent : relieve anal itching
* long-term use : chronic perianal dermatitis
* e.g., Proctosedyl, Doproct
Micronized semisynthetic flavonoids

- improve venous tone and inhibit the

release of prostaglandins
- use for reducing acute symptoms and
secondary hemorrhage after hemorrhoidecto
my
Treatment
e.g., Daflon (500 mg) : active ingredients
are micronized diosmin (450 mg) and
hesperidin (50 mg)
Well absorbed and excreted mainly in the
feces; t1/2 11 hours
- acute hemorrhoid : 6 tabs/day for 4
days then 4 tabs/day for 3 days
chronic hemorrhoid : 2 tabs daily
Other use : treatment of chronic venous
insufficiency, venous leg ulcers
 Office procedures
use in patient who have refractory
symptomatic hemorrhoid
goal : remove excess tissue and produce
fibrosis which fixates the adjacent tissue, r
educing prolapse
rubber band ligation

- most common use in up to 80% of patients

- placement of a tiny rubber band at the
base of each hemorrhoid
Treatment
injection sclerotherapy (injection of a
sclerosing agent such as sodium morrhuate i
nto the tissues) : less efficacy
each treatment modality has relative
advantages and disadvantages
Surgical management :
patient with severe, combined internal and
external hemorrhoids
when repeated attempts at utilization of
nonoperative techniques have failed to allevi
ate symptom
Treatment
Treatment options for symptomatic hemorrhoid

internal (grade) external

treatment I II III IV

diet modification x
sclerotherapy x x
infrared coagulation x x (x)
rubber band ligation (x) x x
hemorrhoidectomy (x) x x x