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Haemorrhoids

Section: Colorectal Sub-section: Proctology Curriculum: Curriculum, page 18

Definition

Haemorrhoids

  • Normally occurring arteriovenous plexuses within the anal canal also known as anal cushions

Internal Haemorrhoids plexus

  • above dentate line
  • Columnar epithelium - insensate
  • Mucous deposition (if prolapsing - itch)
  • Provide fine control over continence of gas and liquid

External Haemorrhoids plexus

  • below dentate line
  • Squamous epithelium - sensate
  • external haemorrhoidal plexus is a venous plexus encircling the anal verge.

Epidemiology

Incidence

  • Very common
  • 4%, M=F

Anatomy

Anal Anatomy

  • 4cm long
  • Begins as the rectum pass back between the levator ani muscles
  • Upper limit is the pelvic floor
  • Lower limit is the anal opening
  • Proximal rectum is lined by columnar epithelium which changes in the lower rectum to be lined by stratified squamous epithelium. This change takes place in the

Pathophysiology

Aetiology → factors that increase straining and increase

  • Intraabdominal pressure
  • Constipation
  • Pregnancy

Pathophysiology

  • Chronic straining leads to weakened suspensory fibromuscular ligs
  • Impaired venous drainage and stasis engorgement
  • Transudation
  • Venous thromobosis
  • Normally anal cushions (internal) are fixed by fibromuscular ligaments
    • Treitz ligaments which are a continuation of the longitudinal muscle of muscularis propria of the rectum
  • Weakening of these ligaments results in
    • Prolapse, bleeding, pain and anal spasm
      • Impaired venous drainage and venous engorgement
      • Draining veins block and feeding arteries continue feeding
      • Local stasis and transudation of fluids (seepage and itch)
      • Venous thrombosis causing stretching of overlying mucosa - pain

Classification

Goligher’s Classification 1 - Prominent vasculature without prolapse 2 - Prolapsing haemorrhoids that spontaneously reduce 3 - Prolapsing haemorrhoids that require manual reduction 4 - Prolapsing haemorrhoids that are unable to be reduced

Clinical

  • Painless rectal outlet type bleeding
  • Prolapse
  • Mucous discharge and itch
  • Thrombosed and prolapsed internal haemorrhoid vs thrombosed “external haemorrhoid” - perianal haematoma
  • DRE, rigid sigmoidoscopy, proctoscopy
  • Describe location
    • Most common = left lateral, right antero and posterolateral
    • Describe based on ant/post and laterality
    • Not clockface

Investigations

  • If history consistent for significant bleeding - Hb
  • Flexible sigmoidoscopy in absence of red flag symptoms
  • NEED TO LOOK UP LGIB AUSTRALASIAN GUIDELINES FOR MANAGEMENT
  • Colonoscopy most likely

Treatment

Goals of Treatment

  • Reduction of causative factors
  • Reinstitution of normal anal anatomy
  • Symptom control

Lifestyle

  • Increased dietary fibre
  • Reduce straining when defecating
  • Exercise and low fat diet to reduce obesity
  • Sitz bath
  • Reduction of constipating medications

Medical/Non-operative

  • Metamucil
  • Proctosedyl (steroid hydrocortisone and LA)
    • Steroid - hydrocortisone
    • LA - cinchocaine
    • Reduce inflammation and sodium channel blocker
    • Ointment or suppository - TDS 1/52, BD 1/52 then OD 1/52 (TAPER)
    • SE local irritation
  • Ultraproct (stronger steroid Fluocortolone and LA)
    • Steroid - fluocortolone
    • LA - cinchocaine
    • Same as above but less duration and quicker taper
  • Rubber-band haemorrhoidal ligation
    • Fibrotic reaction
    • Risk - post-procedure pain, bleeding, urinary retention
  • Sclerotherapy for haemorrhoid
    • (5% oily phenol) injected submucosally
      • Fibrotic reaction
      • Risk - pain, bleeding, prostatitis, haematuria, severe infection (fourniere’s)
  • Infrared photocoagulation

Surgical Haemorrhoidectomy - grade 2-4 For large haemorrhoidal disease that has failed conservative measures Adequate mucocutaneous skin bridges to prevent anal stenosis Painful post-procedure Stapled haemorrhoidopexy - grade 3-4 For predominantly prolapsing haemorrhoidal disease Too high - remnant disease Too low - pain High risk - intraabdominal/anastomotic leak Meta-anaylsis suggested higher long-term risk of recurrence and the symptoms of prolapse HAL-RAR - grade 3-4 For large circumferential haemorrhoidal disease Higher risk of recurrence but less pain

Post-operative risks

  • pain
  • bleeding (associated with infeciton)
  • Infection
  • Stricture 3% (6 weeks post-op)

Graph View

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