about anal fissure and hemorrhoids and its treatment

1. Anal fissure
and
Haemorrhoids
Dr.Preethiya
M.S. General Surgery

2. Anal fissure

3. Definition
– Superficial linear tear in the anoderm (distal to the dentate line )
– Very common and painful condition
– Site
 posterior midline ( 90% )
 Anterior midline (10%)

4. Aetiology
– Constipation
– Spasm of internal sphincter
– Secondary causes
 Ulcerative colitis
 Crohn’s disease
 Syphilis
 Tuberculosis
• Previous anal surgery
• Anal cancer
Predisposing factors
 Hard faeces
 Ischemia
 Haemorrhoidectomy
 Sphincter hypertonia
 Repeated child birth
 Abuse of laxatives

5. Posterior midline is most
common site because….
– Posterior angulation of the anal canal
– Relative fixation of the anal canal
– Divergence of the fibres of external sphincter muscle posteriorly
– Elliptical shape of the anal canal

6. Pathology
– Strained evacuation of hard stool  trauma ( most common )
– Repeated passage of stools – diarrhoea ( less common)
– Anterior anal fissure – most commonly in females occurs following vaginal
delivery .
 Fissure starts proximally at the dentate line , lies in the sensitive skin of the anal
canal – produces pain

7.  Two types
 Acute
 tear of skin of the lower half of the anal canal.
 Hardly any inflammatory induration or oedema
 Anal sphincter spasm is present
 Chronic
 Deep – shaped ulcer with thick oedematous margins .
 Upper end – hypertrophied papilla
 Lower end – skin tag called ‘sentinel pile’ is present
 Characteristic inflammation and induration is present
 Base – scar tissue and internal sphincter muscle .
 They have specific cause
e.g. – crohn’s disease , ulcerative colitis , TB , syphilis

8. Clinical features
– More common in females
– Age – 30 – 50 years
– In Children sometimes cause acquired megacolon
• Symptoms
 Pain starting with and following defection , characterised by sharp ,biting ,
burning
 Bleeding – its variable , usually occurs as a streaks on the outside of the stool or
spots noted on toilet tissue.
 Slight discharge may present
 Pruritis ani

9. Physical examination
Patient in left lateral decubitus position with knees drawn up toward the chest
• Acute fissure – appear similar to laceration , erythematous and bleed easily
• Chronic fissure
 Deep ulcer
 Sentinel pile
 Enlarged anal papillae at dentate line
 Characteristic crater of the vertical fissure is felt
• A tightly closed puckered anus – pathognomonic .

10. Diagnosis
 Adequate clinical examination
 Proctoscopy
 Sigmoidoscopy
 Take biopsy
 Do culture

11. Differential diagnosis
1. Carcinoma of the anus ( early stage)
2. Tuberculous ulcer
3. Proctalgia fugax – characterised by severe pain arising from the rectum and
occurs at irregular intervals .

12. Treatment
– Conservative management
– Surgical management

13. Conservative management
 Helpful in most of the cases
 Main objective to treat constipation
 High fibre diet
 Laxatives to make the stool soft
 Encourage water intake
 Application of local anaesthetic – lignocaine jelly
 Glyceryl trinitrate ointment
 Local application
 It’s a nitric oxide donor produces internal sphincter muscle relaxation

14.  Antibiotics
 Botulinum toxin injection
 Site – internal sphincter
 MOA : inhibits presynaptic release of Ach from cholinergic nerve endings – paresis of
striated muscle and release the spasm
 Hot sitz bath

15. Surgical management
1. ANAL DILATATION - “LORD’S PROCEDURE”
 Simplest method of anal dilatation
 Under GA , patient in lithotomy position , the index and middle
fingers of each hand are inserted simultaneously into the anus
and pulled apart to give maximal dilatation .
 Patient might have faecal incontinence for 10 days
 In case of chronic fissure – anal dilatation could be a failure
because of excessive fibrosis and skin tag.

16. POSTERIOR SPHINCTEROTOMY AND FISSURECTOMY
 Anaesthesia – general anaesthesia
 Position – lithotomy
 Sim’s speculum introduced internal sphincter ( transverse direction ) are divided and floor is
made smooth deep ulcer with fibrotic edges and sentinel pile is
post operatively – liquid diet for 3 days , passage of anal dilator daily till wound is healed .
 Disadvantage - prolonged convalescent period for 7- 10 days.

17. LATERAL ANAL SPHINCTEROTOMY
 Anaesthesia –regional or General
 Position – lithotomy
 Steps
i. Palpate the distal internal sphincter with the help of bivalve
speculum at the inter sphincteric groove
ii. A small longitudinal incision in right or left lateral position
iii. Mucosa is cut
iv. Palpating the submucosa and inter sphincteric planes
v. Internal sphincter is exposed
vi. Internal sphincter is cut up to he apex of the fissure
vii. Wound is left open or closed with absorbable sutures.

18. COMPLICATIONS
1. Haemorrhage
2. Hematoma
3. Bruising
4. Perianal abscess
5. Fistula
6. Incontinence

19. ANAL ADVANCEMENT FLAP
 Useful in females and those with normal or low resting anal pressure
 Edge of the fissure are excised and mobilized as full thickness anal skin flap .
 These flaps are slid over the fissure and sutured in place
 Minimal chance of incontinence

20. Haemorrhoids

21. Definition
– Dilated veins within the anal canal in the subepithelial region formed by radicles
of the superior middle and inferior rectal veins.
– Classified according to their anatomic growth within the anal canal
 Internal haemorrhoid
 External haemorrhoid

22. Act of straining during defecation
Impedes rapid emptying of cushions
Congestion
Oedema
Swelling and stretching of tissues
Hypertrophy

23. Aetiology
 Hereditary
 Anatomical
 Absence of valves in superior haemorrhoidal veins
 Veins pass through the rectal musculature 10 cm above the anus will cause
occlusion of veins and congestion during defecation
 Radicles of superior rectal lie unsupported in loose submucous connective
tissue of rectum

24. Physiological cause
Hyperplasia of corpus cavernosum rectum result from failure of mechanism
controlling the arteriovenous shunt producing superior haemorrhoidal veins
varicosity and haemorrhoids.
 Diet
 Secondary haemorrhoids
 Carcinoma of rectum
 Pregnancy
 Chronic constipation
 Difficulty in micturition
 Portal hypertension

25. Internal haemorrhoid
• Haemorrhoid is within the anal canal and
internal to the anal orifice
• Covered with mucous membrane
• Bright red or purple in colour
• Usually commences at the anorectal ring and
end at the dentate line

26. External haemorrhoid
• Haemorrhoid situated outside the anal orifice and is covered by skin
• Internal and external haemorrhoid coexist – “interno-external haemorrhoid”
• Two peculiar condition associated with external haemorrhoid
 Dilatation of veins at the anal verge seen in persons of sedentary life particularly
during straining
 Perianal haematoma or thrombosed external haemorrhoids

27. Thrombosed external haemorrhoid
• Small clot in the perianal subcutaneous tissue seen
superficial to the corrugator cutis ani muscle.
• It is due to back pressure on the anal venule consequent
upon straining at stool , coughing or lifting heavy
weight .
• Appears suddenly and its painful

28. • Present lateral to the anal margin
• Tense and tender swelling
• If untreated – suppurate or may fibroses giving rise to cutaneous tag or may
burst giving rise to bleeding .
TREATMENT
 Incise the haemorrhoid under LA
 Opening in the skin is packed with gauze in light antiseptic solution to
allow the wound to heal by granulation tissue

29. Clinical features
 Bleeding - bright red , painless and occurs along with defection .
 Vascular haemorrhoid – veins become larger and heavier , partial prolapse
occur with each bowel movement gradually stretching the mucosal
suspensory ligament at the dentate line until the 3rd degree haemorrhoid
results .
 Mucosal haemorrhoid – thickened mucous membrane slides downwards .

30.  Prolapse
 First degree – haemorrhoid does not come out of the anus
 Second degree – haemorrhoid come out only during defaecation , reduced spontaneously after defaecation
 Third degree – haemorrhoid come out only during defaecation and do not return by themselves . Need to be
replaced manually and then they stay reduced
 Fourth degree – haemorrhoids that are permanently prolapse . Patient will have great discomfort with a
feeling of heaviness .

31. Pain
Mucous discharge
particular symptom of haemorrhoid
It softens and excoriates the skin of the anus
 mucous discharge is due to engorged mucous membrane
Pruritis ani will be caused
 Anaemia – due to long standing haemorrhoids due to persistent
and profuse bleeding

32. On inspection
 Internal haemorrhoid with out prolapse does not show any
abnormal feature
 Second degree and third degree internal haemorrhoid – seen only
when patient strains , prolapse disappears after the straining is
over .
 Fourth degree – prolapse piles seen in 3 , 7 , and 11’0 clock
position

33. On examination
DIGITAL EXAMINATION
• Cannot feel an uncomplicated internal piles unless it is thrombosed
PROCTOSCOPY
• Proctoscope introduced as far as it does .
• Obturator is then removed and with an illuminator the inside of the canal is
visualized .
• Proctoscope is now withdrawn slowly
• Internal haemorrhoid seen bulging into the proctoscope

34. Complications
1. Bleeding
2. Thrombosis
3. Strangulation
4. Gangrene
5. Fibrosis
6. Suppuration
7. Phylephlebitis ( portal pyaemia)

35. Treatment
 Medical management
 Hanging defecation habits
 Diet modification
 Topical anaesthetics
 Para surgical
 Injection therapy
 Rubber band ligation
 Cryosurgery

36. Infrared coagulation
Laser therapy
Doppler guided haemorrhoidal artery ligation ( DGHAL)
Haemorrhoidectomy
Ligation and excision method

37. Closed haemorrhoidectomy
Submucous haemorrhoidectomy
Circular stapled haemorrhoidectomy
Endo-stapling technique

38. Medical management
1. Bowel regulation
 High residue diet
 Mild laxatives
2. Topical ointments
 Reduces oedema and pruritis
Treatment of haemorrhoid depends in its degree .
Manual dilatation of the anus frequently successful in relieving
symptoms by preventing congestion of haemorrhoidal veins .

39. Injection therapy
Sclerotherapy
• Principle – it scars submucosa and fixation of haemeorrhhoidal
complex in normal location
• Sclerosant
 Albright solution – 5 % phenol in almond or archis oil with 140
mg of menthol to make 30 ml solution .
 Sodium morrhuate
 Sodium tetradryl sulphate

40. ADVANTAGE
 Method is quick
 Relatively painless
 Comparatively free from complications
 First degree haemorrhoidal results
DISADVANTAGE
• Asscoiated thrombosis or sepsis
• Active inflammatory bowel disease
• Acute leukaemia
COMPLICATION
• Chemical prostatitis and impotence rare
• Anovaginal fistula

41. Rubber band ligation
 Done for 2nd degree haemorrhoids .
 “BARRON’S “ bander is commonly available
 Causes ischemic necrosis and piles fall off , which slough off with
in 10 days Asscoiated with bleeding
 Bands should be placed for pile mass to take care of breakage
 Three haemorrhoidal mass can be taken care in one session
 Repeat banding can be done only after 3 weeks

42. Equipment is inexpensive , simple to perfom
Can be done without anesthesia
Contraindicated – fissure / fistula
Complications :
 If applied low into skin – severe pain
 Discomfort
 Secondary haemorrhage
 Ulceration

43. Cryosurgery
 Extreme cold temperature used to coagulate and cause necrosis of piles which
gets separated and falls of subsequently
 Used agent – nitrous oxide (-98 degree) or liquid nitrogen ( -196 degree)
 Procedure
 Pt in lithotomy position
 Cryoprobe applied in longitudinal axis of internal pile above the dentate line
 Pressure maintained above 700 lb continuously

44. Traction and slight rotation in both directions to draw entire
pile mass
Entire tissur is frozen for 20 -30 secs .
Probe detached from mass
Procedure repeated on other pile mass
 Advantage
 Painless
 Simple
 Safe
 Less bleeding
 Disadvantage
 Profuse watery discharge
 Itching .
 Incontinence occasionally

45. Infrared coagulation
 Includes by tungsten halogen lamp which is focused on the tissue from a gold plated
reflector through a polymer tubing
 Discrete area of necrosis which heals to form a scar , reduces or eliminate blood flow
through haemorrhoid
 3 or 4 sittings are needed at 1 month intervals .

46. Laser therapy
– For 3 degree piles
– Agent used – Nd – YAG laser , diode and carbon
dioxide laser
– Advantage
 Less operative time
 Less intraoperative and post op bleed
 Rapid healing
 Quick recovery
•Disadvantage
Need skill , sphincter to be
taken care of
Secondary haemorrhage

47. Doppler guided haemorrhoidal
artery ligation ( DGHL)
– Advanced instrument that works under doppler
guided ultrasound .
– Cures all degree of haemorrhoid
– Causes choking and blocking of blood supply of
piles
– Painless
– 20 –minute procedure that cures all degree of
haemorrhoids .

48. Haemorrhoidectomy
INDICATIONS
 2nd degree haemorrhoids not cured by non-surgical management
 Fibrosed haemorrhoids
 Interno – external haemorrhoids
TECHNIQUE
– Open technique – Milligan-Morgan operation
– Closed technique

49. 1. Ligation and excision of piles ( Milligan –Morgan )
 Procedure
 Under anaesthesia , in lithotomy position
 Sphincter dilated
 Skin held with forceps
 Internal sphincter separated and pushed up
 Pedicle is transfixed with vicryl or catgut and distal
part is excised
 Post operatively
 Sitz bath
 Antibiotics
 Laxatives ‘analgesics
 Local applications

50. 2. Submucous haemorrhoidectomy of ‘Parks’ (
submucous haemorrhoidectomy )
3 . Hill – Ferguson closed method
Procedure
 Patient in prone position
 Under GA/ caudal anaesthesia
 Retraction is done using Hill – Ferguson
retractor
 Incision made around pile mass , pedicle is
dissected to its proximal base
 Ligated with trans-fixation using 2-0 vicryl or
silk
 Mucosa and skin sutured

51. Management of strangulated or thrombosed or gangrenous pile
• Initially conservative management
• Warm water saline sitz bath
• Antibiotics
• Elevation
• Bed rest
• Saline compression dressing and analgesics
• Haemorrhoidectomy after 4 -5 days , once oedema reduces

52. Endo –Stapling haemorrhoidectomy
• Recently introduced
• Stapling gun is used
Procedure
• Stapling gun introduced through anus
• Strip of mucosa and submucosa just above the
dentate line is excised circumferentially
• Gun is activated which repairs the cut mucosa and
submucosa by stapling the edges together