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Haemorrhoids

  • Affect 50% of population over the age of 50 years
  • Usually presents with:
    • Painless bright red rectal bleeding
    • Prolapsing perianal lump
    • Acute pain due to thrombosis
    • Faecal soiling or pruritus ani

Pathogenesis

  • The following factors appear important:
    • Dilatation of venous plexus
    • Distension of AV anastomoses
    • Displacement of anal cushions
  • 80% of patients have high resting anal pressure

Classification

  • Haemorrhoids are often classified as internal or external
  • Internal haemorrhoids arise above the dentate line and can be sub-classified as
    • First degree - bleeding only
    • Second degree - prolapse, reduce spontaneously
    • Third degree - prolapse, pushed back
    • Fourth degree - permanently prolapsed

haemorrhoids

Picture provided by J M Enriques-Navascies, Hospital Donostia, San Sebastian, Spain.

Thrombosed haemorrhoids

Picture provided by Michael Rudd, Royal Brisbane Hospital, Brisbane, Australia

Treatment

  • All should have high residue diet
  • Local preparations rarely produced long-term clinical benefit

Outpatient

  • Treatment options for first and second degree haemorrhoids include:
    • Injection with 5% phenol in arachis or almond oil
    • Rubber band ligation
  • Randomised trial of rubber band ligation and sclerotherapy have shown
  • 90% success with rubber band ligation
  • 70% success with sclerotherapy

Inpatient

  • Treatment options include:
    • Dilatation and banding
    • Haemorrhoidectomy
  • Haemorrhoidectomy is usually performed as an open procedure (Milligan-Morgan)
  • It is the treatment of choice for third-degree haemorrhoids
  • Secondary infection and postoperative pain may be reduced with oral metronidazole
  • Botulinum toxin injection may also reduce postoperative pain
  • Complications include bleeding (3%), urinary retention (10%)
  • Anal stenosis may develop adequate skin bridges are not maintained
  • Other haemorrhoidectomy techniques include closed or stapled procedures
  • The recently described stapled technique is associated with:
    • Reduced operating time
    • Less postoperative pain
    • Shorten hospital stay
    • More rapid return to normal activity

Stapled haemorhoidectomy

Stapled haemorrhoidectomy

Pictures provided by Reda Saad, El Demerdash University Hospital, Cairo, Egypt

Bibliography

Brisinda G.  How to treat haemorrhoids.  Br Med J 2000:  321:  582-583.

Davies J,  Duffy D,  Boyt N et al.  Botulinum toxin reduces pain after haemorrhoidectomy:  results of a double-blind, randomized trial.  Dis Colon Rectum 2003;  46:  1097-1102.

Fazio V W.  Early promise of stapling techniques for haemorrhoidectomy.  Lancet 2000;  355:  768-769.

Mehigan B J,  Monson J R T,  Hartley J E.  Stapling procedures for haemorrhoids versus Milligan-Morgan haemorrhoidectomy:  randomised controlled trial.  Lancet 2000;  355:  782-785.

Roswell M,  Bello M,  Hemmingway D M.  Circumferential mucosectomy (staple haemorrhoidectomy) versus conventional haemorrhoidectomy :  randomised controlled trail.  Lancet 2000;  355:  779-781.

Shalaby R,  Desoky A.  Randomised clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy.  Br J Surg 2001;  88:  1049-1053.

Shanmugam V,  Thaha M A,  Rabindranath K S.  Systematic review of randomized trials comparing rubber band ligation with excisional haemorrhoidectomy.  B J Surg 2005;  92:  1481-1487.

Sutherland L M,  Burchard A K,  Matsuda K et al. A systematic review of stapled hemorrhoidectomy. Arch Surg 2002;  137:  1395-1406
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