2. Greek (haem- blood, rhoos-
flowing)
Pile (latin, pila- pill/ball)
Engorgement of the venous
plexus with redundancy of
their coverings
3. ETIOLOGY
Venous obstruction
Act of straining during defecation
Impedes rapid emptying of cushions
congestion
oedema
Swelling and stretching of tissues
hypertrophy
8. SYMPTOMS
Prolapse
• Patient Complains of protruded mass per anum
• Spontaneous or self digital reduction history
• However, patient may confuse skin tags and perianal
vascular channel thrombosis as pile mass!
9. SYMPTOMS
Pain, discomfort
Thrombosed prolapsed internal piles will be
extremely painful
Or history of dull pain/ discomfort after defecation
which is relieved by reduction of prolapse
Discharge, pruritis
Mucous +- blood stained discharge
pruritis
10. CATEGORIZATION
1st degree Does not descend
below dentate line on
straining
2nd degree Descends below
dentate line on
straining,
Seen at exterior,
disappear again after
straining stops
3rd degree Descends and
remains outside until
digitally replaced
4th degree Permanently outside
12. ASSESSMENT OF THE PATIENT
Inspection
Discharge
Rule out rectal prolapse
Rule out fistula in ano
Palpation
Hemorrhoids unless thrombosed are not usually
palpable
Rule out abscess and anal carcinoma
13. Proctoscopy
IMP – to look for other causes of PR bleed
Sigmoidoscopy
Rule out inflammatory bowel disease, carcinoma and
ulcer
ASSESSMENT OF THE PATIENT
15. INVASIVE THERAPY
Principles
Prevention of prolapse by fixation
Prevention of congestion by dividing internal anal
sphincter
Excision of engorged vascular cushions
16. SCLEROTHERAPY
Principle- it scars submucosa and fixation of
hemorrhoidal complex in normal location.
Sodium morrhuate, sodium tetra dryl sulfate,
5%phenol in almond oil, 2ml
Indication
Minimally enlarged haemorrhoids where primary complain is
bleeding
Contraindication
Associated thrombosis or sepsis
Active inflammatory bowel disease
Acute leukemia
17. SCLEROTHERAPY
Left lateral position
Anoscope
25 gauze spinal needle
Submucosal space
Start with lowest
hemorrhoid
Complications
Chemical prostatitis and impotence rare but well recognised
complication
Anovaginal fistula
18. BIPOLAR DIATHERMY
Small bleeding hemorrhoids
Generates 2 sec pulse
Coagulates hemorrhoidal tissue, submucosa and
mucosa
19. INFRARED COAGULATION
15V tungsten halogen lamp
Temperature at tip reaches 100
degree C
Coagulator must be placed in firm
contact with base of haemorrhoid
(should not be embedded)
Circular white eschar will appear
after exposure
3-5 exposures made in semicircle
around the base
20. Useful for
Hep B or HIV positive patients as it doesn’t cause
bleeding or sloughing
Immunocompromised
Receiving anticoagulants
Pregnant
INFRARED COAGULATION
21. HEMORRHOIDAL LIGATION WITH RUBBER
BANDS
Grade 2 or 3 internal
Banding should start with biggest hemorrhoid first
Multiple sessions are required
Complication - sepsis
22. EXCISIONAL HEMORRHOIDECTOMY
Indications
Large 3rd degree
2nd degree with skin tags
Banding or sclerotherapy has failed
Containdications
Crohn’s or ulcerative colitis assosciated
Active intestinal or pulmonary TB
Advanced stage HIV (CDC group 4)
Associated portal hypertension
31. PARK’S SUBMUCOSAL EXCISION
Linear radial incision over haemorrhoidal tissue
Dissected from beneath anoderm and mucosa
Wound is closed
32. POSTOPERATIVE CARE
Combination of magnisium hydroxide, liquid paraffin
Betadine seitz bath after every bowel movement
Gentle digital examination on 5th postop day, if
impacted feces present, enema
Pain control
Bleeding
Per rectal examination after one month to ensure
that anal stenosis is not developing
33. CIRCULAR STAPLING
OR ANOPEXY
•Mucosal purse string
suture placed 3-5cms
above dentate line
•Tightening this suture
causes drawing in of
mucosa and submucosa
into the stapler
•Stapler is closed
34. CIRCULAR STAPLING OR ANOPEXY
Too low purse string severe pain
Too deep purse string potential cause of pelvic
sepsis or rectovaginal fistula
35. HAEMORRHOIDAL ARTERY LIGATION
Proctoscope containing doppler ultrasound
Identify site of haemorrhoidal arteries
Figure of 8 suture
Often 6-7 vessels are detected and all should be
ligated
36. REFERENCES
Surgery of the anus, rectum & colon by michael
keighley and norman williams
Maingot’s abdominal surgery
Sabiston textbook of surgery
Farquharson’s textbook of operative general
surgery
Atlas of general surgery by david carter