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About Hemorrhoid

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Hemorrhoids are divided into twotypes, external and internal. External hemorrhoids are located in the distalone-third of the

anal canal, distal to the dentateline, and are covered by anoderm Internal hemorrhoids are located proximal tothe dentate line and are covered by columnar or transitional epithelium.Because this overlying tissue is viscerally innervated, it is not sensitive totouch, pain, or temperature, making it easily amenable to office procedures.Internal hemorrhoids are further subclassified into degrees based on size andclinical symptoms .

Mixed or combined hemorrhoids aredefined as the internal and external hemorrhoids


Patients with anal complaints fromwhatever etiology frequently present at the office complaining of “hemorrhoidsor piles.” Many patients referred or coming into the office complaining of“hemorrhoids” frequently are found to have other anal problems such as pruritusani, anal fissures, fistulas, and skin tags. A careful history and physicalexamination including anoscopy by an experienced individual is mandatory andwill frequently lead to the correct diagnosis. The presence, quantity,frequency, and timing of bleeding and prolapse should be noted. Patients withhemorrhoid disease may complain of bleeding, mucosal protrusion, pain, mucus,discharge, difficulties with perianal hygiene, a sensation of incompleteevacuation, and cosmetic deformity. A thorough dietary and medication historyshould also be done because certain medications, diets, and or dietaryindiscretions cause or exacerbate constipation or diarrhea. Symptoms fromexternal hemorrhoids are usually secondary to thrombosis and physical examinationshows a tender, bluish-colored lump at the anus distal to the dentate line

associated with acute pain.Thrombosed external hemorrhoids can bleed secondary to pressure necrosis andsubsequenthe presence of both internal and external hemorrhoids ulceration ofthe overlying skin. External skin tags are folds of skin that arise from theanal verge. These tags may be the end result of prior episodes of thrombosedexternal hemorrhoids. Enlarged skin tags or external hemorrhoids may interferewith anal hygiene leading to perianal burning or pruritus. Internal hemorrhoidsare painless unless thrombosis, strangulation, gangrene, or prolapse with edemaoccurs. Despite what is written, patients will frequently come to the officecomplaining of “painful hemorrhoids” even when none of these conditions exist.Once other sources of pain are ruled out, careful inquiry regarding thedescription of their pain further elucidates that patients frequently describetheir anal pain as “burning” in nature. This may be secondary to perianalirritation from mucous or fecal leakage leading to secondary pruritus ani.Bleeding from internal hemorrhoids is bright red and associated with bowelmovements. The bleeding usually occurs at the end of defecation. The patientmay complain of blood dripping or squirting into the toilet or blood on thetoilet tissue. Bleeding may also be occult leading to guaiac-positive stools orrarely to anemia. Prolapse of the hemorrhoid cushions may manifest itself as ananal mass, mucous discharge, or a sensation of incomplete evacuation. Theexaminer should ascertain whether the hemorrhoids reduce spontaneously orrequire manual reduction.


Treatment for symptomatic internalhemorrhoids varies from simple reassurance to operative hemorrhoidectomy.Treatments are classified into three categories) dietary and lifestylemodification;  nonoperative/office procedures; and  operativehemorrhoidectomy. In general, less symptomatic hemorrhoids, such as those thatcause only minor bleeding, can be treated with simple measures such as dietarymodification, change in defecatory habits, or office procedures. Moresymptomatic hemorrhoids such as third or fourth degree are more likely torequire operative intervention.

:Dietary and LifestyleModification 

Because prolonged attempts atdefecation, either secondary to constipation or diarrhea, have been implicatedin the development of hemorrhoids, the main goal of this treatment is tominimize straining at stool. This is usually achieved by increasing fluid and fiberin the diet, recommending exercise, and adding supplemental fiber agents(psyllium) to the diet in

patients unable to consumesufficient amounts of fiber in their diets. Despite common teaching, littlegood evidence exists regarding the benefit of fiber in preventing or managinghemorrhoid disease. Reduced hemorrhoidal bleeding has been shown with the useof psyllium in a double-blind, placebo controlled trial; however, other studiesare less favorable.23–26

Psyllium works in conjunction withwater to add moisture to the stool and subsequently decrease constipation.Psyllium may also be therapeutic in treating diarrhea. It may add bulk toliquid stools therefore increasing the consistency and decreasing the volume.Dietary modification with fiber supplementation (psyllium, methylcellulose,calcium polycarbophil) is one of the mainstays of therapy for patients withhemorrhoidal disease. In the majority of cases, symptoms of bleeding and painimprove over a 6-week period. A diet high in fiber (20–35 g/day) including theconsumption of plenty of fruits and vegetables is recommended especially if thepatient has a history of constipation or straining. A common problem with fibersupplementation is noncompliance because of either poor palatability or symptomsof bloating, increased flatus, and abdominal cramps. Compliance is improved bystarting at lower doses and slowly increasing the quantity of fiber ingesteduntil the desired stool consistency is achieved.

If dietary modification fails torelieve symptoms,  then further therapy is indicated.  Frequently, achange in defecatory habits will resolve symptoms. Oftentimes, simply asking anindividual to curtail reading on the commode resolves the hemorrhoidalsymptoms.

Lifestyle and dietary modificationsalong with ruling out proximal sources of bleeding are all that is required forthe majority of patients complaining of hemorrhoidal disease.

:Office Treatments 

Rubber Band Ligation

Rubber band ligation is a method oftissue fixation and one of the most widely used techniques in the UnitedStates. It can be used to treat first-, second-, and third-degree internalhemorrhoids. The most common method currently in use for the outpatienttreatment for hemorrhoids was originally described The rubber band is placed onthe redundant mucosa a minimum of 2 cm above the dentate line which causesstrangulation of the blood supply to the banded tissue, which sloughs off in5–7 days leaving a small ulcer that heals and fixes the tissue to theunderlying sphincter. Rubber band ligation is frequently recommended forindividuals with first- or second-degree hemorrhoids and, in somecircumstances, third-degree hemorrhoids.

Several commercially available typesof hemorrhoid ligators are available including a suction ligator. simplify thebanding procedure for both patient and surgeon This single-operator ligator,with its own suction mechanism, was designed for use without the need of anassistant or an anoscope. By pointing the ligator directly toward theappropriate site and by measuring the distance from the anal margin usingreference markings on the ligator, the bands can be placed accurately in ablind manner inside the rectum for the treatment of symptomatic internalhemorrhoids.

O’Regan reported a 97% success ratewith two major complications (one episode of bleeding and one of perianalsepsis) in 480 patients.

Rubber band ligation can beperformed safely with the patient in various positions; however, the pronejackknife position provides the best exposure. Anesthesia is not required forthis procedure. Rectal preparation with enemas is not required but may be usedif desired.

Infrared Photocoagulation, Bipolar Diathermy,

and Direct-Current Electrotherapy are other modalities ofoffice used techniques for therapy of hemorrhoids

External Hemorrhoids:

Acute Thrombosis

Patients with a thrombosed externalhemorrhoid typically present with complaints of a painful mass in the perianalregion. The pain is frequently described as burning in nature. The painassociated with the abrupt onset of an anal mass usually peaks at around 48hours and subsides significantly after the fourth day.The skin overlying thethrombosed hemorrhoid may necrose and ulcerate, resulting in bleeding,discharge, or infection.


Hemorrhoidectomy is indicated forpatients with symptomatic

combined internal and externalhemorrhoids who have

failed or are not candidates fornonoperative treatments. This

would include patients withextensive disease, patients with

concomitant conditions such asfissure or fistula, and patients

with a preference for operativetherapy. Only about 5%–10% of

patients need surgicalhemorrhoidectomy. Recurrence with

operative hemorrhoidectomy isuncommon and hemorrhoidectomy

is the most effective treatment forhemorrhoids, especially

those that are third degree.Hemorrhoidectomy can be

performed using a variety oftechniques or instruments; however,

most are variants of either a closedor open technique.

The Milligan-Morgan technique (open)is widely used in the

United Kingdom. It involves excisionof the

external and internal hemorrhoidcomponents leaving the skin

defects open to heal by secondaryintention over a 4- to 8-week

period. The Fergusonhemorrhoidectomy (closed) involves

excision of the external andinternal hemorrhoid components

with closure of the skin defectsprimarily

:Stapling Technique

The stapling procedure can be donewith the patient in the

prone jackknife, lithotomy, or leftlateral position while under

local, spinal, or generalanesthesia. A circular anal dilator is

introduced into the anal canal,which reduces the prolapsed tissues.

The obturator is removed, and theprolapsed tissue falls

into the lumen of the dilator. Acircumferential pursestring

suture is placed 4–6 cm above thedentate line into the submucosa.

The circular stapler is opened andthe head is introduced

proximal to the pursestring. Thepursestring sutured is tied and

the suture threader is used to pullthe free ends of the pursestring

suture through a pair of holes onthe lateral sides of the

stapler. Traction is applied to thepursestring while the stapler

is being closed, which causes theprolapsed mucosa and some

hemorrhoidal tissue to be drawn intothe casing. The stapler is

fully tightened and then fired. Theinstrument should be left

closed for 20 seconds after firingto enhance hemostasis. The

staple line should be carefullyexamined for hemostasis and

any bleeding areas should beoversewn. Anoscopic examination

will reveal persistent internalhemorrhoids. It is important

to remember that this technique doesnot completely excise the

hemorrhoids; rather, it returns thetissues to their physiologic

location. The circular specimen willcontain the excised tissue

and the pursestring suture.

: PosthemorrhoidectomyHemorrhage

occurring in approximately 2%.Traditionally, sepsis of the ligated pedicle has

been considered an importantetiological factor, although this

has been challenged by a recentstudy by Chen et al. who

found male patients and operatingsurgeon as risk factors. The

majority of patients will respond topacking or tamponade

with a Foley catheter balloon.Approximately 15%–20% of

Severe hemorrhage afterhemorrhoidectomy is a rare complication

patients may need suture ligation tocontrol the postoperative

bleed. Initial rectal irrigation hasbeen suggested as a technique

to separate patients that havestopped bleeding from

those that need to go to theoperating room. Another helpful

technique is to irrigate the rectumfree of clots and blood

at the initial hemorrhoid operation,to prevent postoperative

passage of old clots that couldcause clinical confusion.  

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