CONTENT
NO PARTICULAR PAGES
1. Introduction 2
2. Problem statement 3
3. Literature review 4-6
4. Discussion 7-13
5. Conclusion 14
6. Reference list 15
7. Attachment 16-17
INTRODUCTION
1
Haemorrhoids (piles) are extremely common, affecting nearly half of the
population at some time. Men tend to suffer more often and for longer periods,
whereas women are particularly susceptible in late pregnancy and the puerperium.
Haemorrhoids is a condition in which the veins around the anus or lower rectum
are swollen and inflamed. There are two types of haemorrhoids which is external and
internal haemorrhoids.
External haemorrhoids is located outside of the anus. The swollen veins cause a
soft lump around the anal opening. These lumps can turn hard if blood clot develops
and become painful thrombosed haemorrhoids. Since the anus has many nerve
endings, external haemorrhoids can be very painful or itchy. Sometimes the clot may
even break out of the haemorrhoids by itself or dissolve back into normal blood
circulation.
Internal haemorrhoids are located inside the rectum or anal canal and usually not
painful. This is because the anal canal does not have many nerve endings. Indeed,
most people are not aware that they have internal haemorrhoids until a hard stool
rubbing against them cause these haemorrhoids to rupture and bleed. Left untreated,
some internal haemorrhoids can prolapse or be pushed out of the anal opening.
Sometimes the sphincter muscle can close shut in a spasm and trap this prolapsed
haemorrhoids outside the anus. This cuts off the blood circulation and creates a
strangulated hemorrhoid. Some prolapsed haemorrhoids can be manually pushed back
inside the anus. Advanced cases of prolapsed haemorrhoids must be surgically
treated. Prolapsed and strangulated haemorrhoids is a serious medical condition that
requires immediate attention. Also, bleeding of any amount should be checked by a
doctor since it may be an indication of more serious conditions such as colorectal
cancer.
Haemorrhoids are classified into first, second, third and fourth degrees according
to the extent of prolapse through the anal canal. First degree (grade 1) piles never
prolapse, second degree (grade 2) piles prolapse during defecation and then return
spontaneously, third degree (grade 3) piles remain outside the anal margin unless
replaced digitally, fourth degree (grade 4) piles prolapse and cannot be manually
reduced.
2
PROBLEM STATEMENT
Patient profile
NAME : Muhammad Ali Bin Tambi
AGE : 36 years old
SEX : Male
RACE : Malay
On 7 February at 6:45 pm, Mr. Ali came to emergency department Hospital
Sultanah Aminah with chief complain of per rectal swelling and on off bleeding for
past 1 year. Patient claimed the swelling over perianal region was reducible
previously and turned into irreducible since 2 days ago. The pain score at that time is
5/10. Patient came with background history of constipation and heavy weight lifting.
Otherwise, no chest pain, no short of breath (SOB), no anemic symptoms such as
palpitation, dizziness and giddiness. Social history of patient is non smoker and non
alcohol drinker. Previously worked in army and currently is jobless. Patient was
divorced 2 years ago. Patient denied multiple sexual partner and denied of IVDU. On
admission, patient was alert, conscious and full GCS. Vital sign taken is blood
pressure 121/74 mmHg , pulse rate 88 bpm, SPO2 98% under room air and
temperature 37.0’C .Physical examination was done and result from per rectal
examination was single 3x4cm mass at perianal region with skin erosion, no contact
bleeding, no pus discharge. Patient was diagnosed with thrombosed grade 4
haemorrhoids by Medical Officer and admitted to Surgical Ward Barat 4 for further
treatment and observation.
LITERATURE REVIEWS
3
WHF Thomson 1975, British Journal of Surgery
An anatomical and clinical study aimed at uncovering factors likely to be helpful
in understanding the true nature of haemorrhoids is described. The main finding
was of specialized “cushions” of submucosal tissue lining the anal canal; it is
argued that piles are merely the result of their displacement.
AG Acheson, JH Scholefield 2008
Haemorrhoids or “piles” are enlarged vascular cushions within the anal canal that
have been described for many centuries and continue to form a large part of a
colorectal surgeon's workload. The exact incidence of this common condition is
difficult to estimate as many people are reluctant to seek medical advice for
various personal, cultural, and socioeconomic reasons, but epidemiological
studies report a prevalence varying from 4.4% in adults in the United States to
over 30% in general practice in London.
Rozhl Chir 2014 , Czech
The most common and serious complications of haemorrhoids include perianal
thrombosis and incarcerated prolapsed internal haemorrhoids with subsequent
thrombosis. They are characterised by severe pain in the perianal region possibly
with bleeding. In a short history of the perianal thrombosis, acute surgical
incision or excision is indicated, which can result in rapid relief of the painful
symptoms. In incarcerated prolapsed internal haemorrhoids, emergency
haemorrhoidectomy may also be indicated. Segmental haemorrhoidectomy in the
most affected quadrants followed by further elective surgery for haemorrhoids in
the next stage is preferred.
4
Varut Lohsiriwat 2012, World J Gastroenterol
Hemorrhoids are defined as the symptomatic enlargement and distal displacement
of the normal anal cushions. The most common symptom of hemorrhoids is rectal
bleeding associated with bowel movement. The abnormal dilatation and
distortion of the vascular channel, together with destructive changes in the
supporting connective tissue within the anal cushion, is a paramount finding of
hemorrhoids. It appears that the dysregulation of the vascular tone and vascular
hyperplasia might play an important role in hemorrhoidal development, and could
be a potential target for medical treatment. In most instances, hemorrhoids are
treated conservatively, using many methods such as lifestyle modification, fiber
supplement, suppository-delivered anti-inflammatory drugs, and administration
of venotonic drugs. Non-operative approaches include sclerotherapy and,
preferably, rubber band ligation. An operation is indicated when non-operative
approaches have failed ocomplications have occurred. Several surgical
approaches for treating hemorrhoids have been introduced including
hemorrhoidectomy and stapled hemorrhoidopexy, but postoperative pain is
invariable. Some of the surgical treatments potentially cause appreciable
morbidity such as anal stricture and incontinence.
JF Johansan, A Sonnenberg 1990, Gastroenterology
Hemorrhoids are a frequently occurring disorder widely believed to be caused by
chronic constipation. In the present study, the epidemiology of hemorrhoids was
evaluated and compared with the epidemiology of constipation. The analysis was
based on 4 data sources: from the United States, the National Health Interview
Survey, the National Hospital Discharge Survey, and the National Disease and
Therapeutic Index; from England and Wales, the Morbidity Statistics from
General Practice.
PJ Morgado, 1998 Diseases of the colon and rectum- Springer
5
The present classification of first, second, and third grade hemorrhoids only
reflects variation in size of a normal human tissue and does not relate to
“hemorrhoidal disease”. Cross-sections and coronal sections of the anal canal in
32 fetuses, with ages ranging from 28 and 38 weeks of development, were studied
and the following fundamental facts were found: in the lumen of the anal canals
of fetuses, there are prominences of mucosa formed by conjunctive and
muscular tissue, arterial and venous vessels and glands.
JS Chen 2010, Chang Gung Med J
Hemorrhoids are one of the most common anorectal disorders.
Conventional hemorrhoidectomy is the most commonly practiced surgical
technique. Stapled hemorrhoidectomy (procedure for prolapse and hemorrhoids
[PPH]) and Ligasure hemorrhoidectomy are newly developed methods for the
surgical management of hemorrhoids. The objective of this study was to compare
the effectiveness and safety of these two novel techniques with that of
conventional hemorrhoidectomy.
J Sayfan 2001, Digestive surgery
Based on a retrospective review of a personal experience with 500 modified
Milligan-Morgan hemorrhoidectomies, technical suggestions for avoiding early
and late complications are presented. The problems of early and delayed
bleeding, anal verge and mucosal stenosis, pain and prolonged healing due to
persistent anal ulcer
DISCUSSIONS
6
SIGN AND SYMPTOMS OF HAEMORRHOIDS
Haemorrhoids often procedure symptoms intermittently. Attacks last from a
few days to a few weeks, often with complete freedom from trouble between
times.
Any haemorrhoids may bleed from stool trauma during defecation. Bleeding
from the arterial component of the anal cushion results in the characteristics
bright red rectal bleeding. Large haemorrhoids may prolapse and then thrombose
causing acute severe pain if venous return is obstructed by sphincter zone.
Longstanding haemorrhoids eventually atrophy, probably by thrombosis and
fibrosis, leaving small skin tags at the anal margin.
The common chronic or intermittent symptoms of haemorrhoids are :
Pain on defecation
Perianal iritataion and itching (pruritis ani) caused by mucus leakage.
Scratching exacerbates the problem
Rectal bleeding (fresh blood, on the paper or separate from the stool)
Mucus leakage due to imperfect closure of the anal cushions
Mild incontinence of flatus also due to imperfect closure of the anal cushions
Perianal discharge
Haemorrhoidal prolapse
ETIOLOGY AND PATHOPHYSIOLOGY OF HAEMORRHOIDS
7
Constipation and pregnancy are the most common triggers for development of
haemorrhoids. Lack of fiber in the modern Western diet is likely a factor. Straining
during constipation raises intra abdominal pressure which obstructs venous return,
causing the venous plexuses to engorge. The bulging mucosa is then dragged distally
by the hard stool. Furthermore, persistent straining causes the pelvic floor to sag
downwards, extruding the anal mucosa and causing a small degree of prolapse.
Haemorrhoids are usually located in the 3, 7 and 11 o’clock positions when viewed
with the patient in the supine lithotomy positions. These correspond to the anatomical
positions of the anal cushions. The venous component causes a problem only if it
becomes thrombosed to form a thrombosed external venous saccule. In pregnancy-
related haemorrhoids, venous engorgement and mucosal prolapse are probably the
main mechanisms. Progesterone mediates venous dilatation and the fetus obstructs
pelvic venous return. There are several diseases that can lead to haemorrhoids such as
enlargement of liver that often found in alcohol abuser. Prolonged sitting or standing
and lack of exercise also can lead to haemorrhoids.
8
INVESTIGATION OF HAEMORRHOIDS
Blood investigation
1. Full Blood Count : to measure the Hb, platlet count, haematocrite and total white
differential count (infection)
2. Liver Function Test : to check the condition health of liver
3. Renal Profile : to measure the health state of kidney
4. Blood Urea Serum Electrolytes : to measure the balancing of electrolytes in body
Digital Examinations
On examinations, external piles or skin tags may be visible in the anal area.
Digital examinations (per rectal) is essential to exclude carcinoma and provides a
useful measure if anal tone. Haemorrhoids are not palpable unless they are large since
the contained blood empties with finger pressure.
Scope
Proctoscopy : needed to demonstrate internal piles which are seen bulging
into the lumen
Sigmoidoscopy : important in patients over 40 years old if there is a history
of bleeding or any symptoms suspicious of malignancy.
9
CONSERVATIVE TREATMENT FOR HAEMORRHOIDS
1. Take a warm sitz bath
A sitz bath of warm water for 10 to 15 minutes, either in the bathtub or in a special
basin to provide a quick relief from the swelling and pain of haemorrhoids.
2. Apply ice finger
Apply ice on anus for 15 to 20 minutes every hour. Use an ice pack or put crushed ice
in a plastic bag and cover it with towel before apply it. Ice will helps prevent tissue
damage and decreases swelling and pain.
3. Take medications
Medicines can help decrease pain (analgesic such as Tab Paracetamol, Capsule
Tramal) and swelling (Tab Papase). Suppositories and Syrup Lactulose can soften the
bowel movement.
10
SURGICAL TREATMENT FOR HAEMORRHOIDS
Haemorrhoidal Artery Ligation Operation (HALO)
It involves locating the artery supplying each haemorrhoids using ultrasound, then
encircling it with stitch via the insensitive lower rectal mucosa to cut off its blood
supply. Over the following few days the haemorrhoids shrink, bleeding and local
symptoms abate, although skin tags remain.
Stapled haemorrhoidetomy
This is the newest surgical treatment for haemorrhoids. It aims to restore the anatomy
of the anal cushion by excising a ring of low rectal mucosa, including the engorged
necks of the piles. The metal staple line remains permanently in situ, palpable
digitally and sometimes causing pain.
Rubber banding
A cone of mucosa just above the haemorrhoidal necks is drawn into a banding tissue
instrument, often by suction and tight elastic bands released around the base of the
cone, constricting the haemorrhoidal vessels. The bands are not placed around the
stalks of prolapsing haemorrhoids. The result of banding is that the haemorrhoids
gradually shrinks. The bands separate with time and are passed.
Sclerotherapy
With the aid of proctoscope, 1-3 ml of a midly irritant solution of 5% phenol in oil is
injected submucosally around the pedicles of the three major haemorrhoids in the
insensitive upper anal canal. This provokes a fibrotic reaction, effectively obliterating
the haemorrhoidal vessels and causing atrophy of the haemorrhoids.
11
COMPLICATIONS OF HAEMORRHOIDS
Anemia
Chronic blood loss from haemorrhoids may cause anemia in which don’t have enough
healthy red blood cells to carry oxygen to cells.
Strangulated haemorrhoids
If the blood supply to an internal haemorrhoids is cut off, the haemorrhoids may be
strangulated which can cause pain.
Blood clot
Occasionally, a clot can form in a haemorrhoids. It can be extremely painful and need
to be lanced or drained.
Infection
Bacteria can get into hemorrhoids that are bleeding and infect the tissue. Untreated
infections can sometimes cause serious complications, such as tissue death, abscesses,
and fever.
Prolapse
Prolapsed hemorrhoids can cause pain or discomfort when you sit or pass a bowel
movement.
12
PREVENTION OF HAEMORRHOIDS
The best way to prevent hemorrhoids is to keep your stools soft, so they pass
easily. To prevent hemorrhoids and reduce symptoms of hemorrhoids, follow these
tips:
Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so
softens the stool and increases its bulk, which will help you avoid the
straining that can cause hemorrhoids. Add fiber to your diet slowly to avoid
problems with gas.
Drink plenty of fluids. Drink six to eight glasses of water and other liquids
(not alcohol) each day to help keep stools soft.
Consider fiber supplements. Most people don't get enough of the
recommended amount of fiber 20 to 30 grams a day in their diet. Studies
have shown that over-the-counter fiber supplements, such as psyllium
(Metamucil) or methylcellulose (Citrucel), improve overall symptoms and
bleeding from hemorrhoids.
If you use fiber supplements, be sure to drink at least eight glasses of water
or other fluids every day. Otherwise, the supplements can cause or worsen
constipation.
Don't strain. Straining and holding your breath when trying to pass a stool
creates greater pressure in the veins in the lower rectum.
Go as soon as you feel the urge. If you wait to pass a bowel movement and
the urge goes away, your stool could dry out and be harder to pass.
Exercise. Stay active to help prevent constipation and to reduce pressure on
veins, which can occur with long periods of standing or sitting. Exercise can
also help you lose excess weight that might be contributing to your
hemorrhoids.
Avoid long periods of sitting. Sitting too long, particularly on the toilet, can
increase the pressure on the veins in the anus.
13
CONCLUSION
In conclusion, haemorrhoids are a very common anorectal condition defined as
the symptomatic enlargement and distal displacement of the normal anal cushions.
They affect millions of people around the world, and represent a major medical and
socioeconomic problem. Multiple factors have been claimed to be the etiologies of
hemorrhoidal development, including constipation and prolonged straining,
pregnancy and also lack of fiber in diet. The abnormal dilatation and distortion of the
vascular channel, together with destructive changes in the supporting connective
tissue within the anal cushion, is a paramount finding of hemorrhoidal diseases.
Besides that, there are two types of haemorrhoids which is internal and external
haemorrhoids. Haemorrhoids also divided into four degree according to its own grade
of prolapse. Internal or external hemorrhoids that don’t prolapse or thrombose are
more likely to heal without causing any symptoms or complications. Prolapsed and
thrombosed hemorrhoids are much more likely to cause discomfort or increase risk of
complications.
There are two types of treatment to treat haemorrhoids which are conservative
and surgical treatment. Conservative treatment can be done without operation such as
take medication to prevent swelling and to reduce pain. Furthermore, take a sitz bath
for 15 to 20 minutes to help reduce swelling at anal region and also apply ice finger at
anus to prevent tissue damage. Surgery treatment required patient to do surgery such
as stapled haemorrhoidectomy and rubber band ligation.
In a nutshell, seek emergency medical attention if haemorrhoids cause pain and
discomfort or if notice any symptoms such as bleeding or prolapse. Haemorrhoids that
are treated quickly have a better chance of healing without causing any further
complications
14
REFERENCE
1. Thomson WH. The nature of haemorrhoids. Br J Surg. 1975;62:542–552.
2. Acheson AG, Scholefield JH. Management of
haemorrhoids. BMJ. 2008;336:380–383.
3. Rozhl [Link] of haemorrhoids. 2014 Apr;93(4):223-5. Czech.
4. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic
constipation. An epidemiologic study. Gastroenterology. 1990;98:380–386
5. Morgado PJ, Suárez JA, Gómez LG, Morgado PJ. Histoclinical basis for a
new classification of hemorrhoidal disease. Dis Colon Rectum. 1988;31:474–
480.
6. Sayfan J. Complications of Milligan-Morgan hemorrhoidectomy. Dig
Surg. 2001;18:131–133.
7. Chen JS, You JF. Current status of surgical treatment for hemorrhoids--
systematic review and meta-analysis. Chang Gung Med J. 2010;33:488–500.
ATTACHMENT
15
Pictures of stapled haemorrhoidectomy procedure
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