Chairman’s Conference

JI Joshua Garcia

General Objective:

To be able to correctly diagnose and appropriately manage a patient with Hemorrhoids

Specific Objectives:

Discuss the typical symptoms and findings on physical examination of a patient with Hemorrhoids

Discuss the pathophysiology of Hemorrhoids

Discuss the treatment and plan of management of a patient with Hemorrhoids

GENERAL DATA

35 year old Female Married Born Again Filipino Admitted for the 3rd time at DLSUMC on July

22, 2010 at 8:00pm.

CHIEF COMPLAINT

Blood per rectum and anal mass

HISTORY of PRESENT ILLNESS

10 years PTA

(+) anal mass

(+) constipation

(+) feeling of incomplete BM

3 years PTA (7 mos. pregnant)

(+) fresh blood, approx. 1 tsp., not admixed with the stool

(+) anal mass

7 mos. PTC

(+) same symptoms; decreased in amount of blood ( ½ teaspoon)

(+) anal mass

(+) consult surgery; unrecalled meds, cream; hot sitz baths

2 weeks PTC

(+) consult surgery ADMISSION

HISTORY of PRESENT ILLNESS

PAST MEDICAL HISTORY

Unremarkable

FAMILY MEDICAL HISTORY

Unremarkable

OB-GYNE HISTORY

G3P2 (3-0-1-2) VSD

PERSONAL and SOCIAL HISTORY

Communication clerk -16 years Non smoker Occasional alcoholic beverage drinker Diet: fish, less vegetables and fruits

PERTINENT REVIEW of SYSTEMS

(-) weight loss(-) weakness or fatigue(-) anemia(-) fever(-) diarrhea(+) constipation(-) pruritus ani

PHYSICAL EXAMINATION

General Survey:

Awake, conscious, coherent, oriented to 3 spheres, not in apparent cardio-respiratory distress, appears her stated chronological age of 35

Vital Signs:

BP= 120/70 mmHg HR= 96 bpm

RR= 20cpm T= 36.4ºC

Regional Examination

SHEENT:

(-) jaundice (-) pallor, good skin turgor, good capillary refill, (-) lesions/discolorations, normocephalic head, anicteric sclerae, pink palpebral conjunctivae, nose symmetrical with patent nostrils, (-) palpable masses on the neck, (-) CLAD

Chest and Lungs:

Inspection: (-) masses, (-) scars, (-) lesions, (-) subcostal/intercostals/subclavicular retractions

Palpation: symmetrical chest expansion, equal tactile fremitus, (-) tenderness

Percussion: resonant on all lung fields

Auscultation: tracheal sounds over the trachea, bronchovesicular sounds over the large airways, and vesicular sounds over the periphery (-) crackles, (-) wheezes

Cardiovascular System: Inspection: (-) precordial bulge

(-) abnormal contours, (-) superficial dilated veins, PMI 5th ICS LMCL

Palpation: Apex beat 5th ICS LMCL

(-) heave (-) thrills (-) tenderness

Auscultation :normal rate, regular rhythm

S1>S2 at apex, S2>S1 at base (-) S3, S4 (-) murmur

Abdomen:

Inspection: flabby with inverted umbilicus (-) scar (-) visible veins, (-) collaterals, (-) visible pulsations, (-) peristalsis

Auscultation: normoactive bowel sounds (10 bowel sounds per minute), (-) bruit/friction

rubs Percussion: Tympanitic all over Palpation: (-)masses/organomegaly, (-) direct

tenderness

Digital Rectal Examination:

(+) palpable anal mass; good sphincter tone; rectal vault not collapsed ; (+) pararectal tenderness; (-) blood per examining finger

Extremities:

(-) cyanosis (-) edema, full and equal peripheral pulses, full range of motion

Neurologic Exam: E/N

CLINICAL IMPRESSION

Internal Hemorrhoids, Grade III, thrombosed

DIFFERENTIAL DIAGNOSIS

Anal fissures

Anorectal fistulae

Anorectal abscess

Colorectal cancer

PREOPERATIVE DIAGNOSIS

Internal Hemorrhoids, Grade III, thrombosed

OPERATIVE DIAGNOSIS

Internal Hemorrhoids, Grade III, thrombosed

OPERATION PERFORMED

Closed Hemorrhoidectomy

OR FINDINGS

CASE DISCUSSION

HEMORRHOIDS

- cushions of submucosal tissue containing venules, arterioles, and smooth-muscle fibers that are located in the anal canal. Three hemorrhoidal cushions are found in the left lateral, right anterior, and right posterior positions.

Left lateralRight posterior

Right anterior

HEMORRHOIDS

- Thought to function as a part of the continence mechanism and aid in complete closure of the anal canal at rest.

- Excessive straining, increased abdominal pressure, and hard stools increase venous engorgement of the hemorrhoidal plexus and cause prolapse of hemorrhoidal tissue.

- Bleeding, thrombosis, and symptomatic hemorrhoidal prolapse may result.

EXTERNAL HEMORRHOIDS

- Located distal to the dentate line and are covered with anoderm.

- Because anoderm is richly innervated, thrombosis of an external hemorrhoid may cause significant pain.

INTERNAL HEMORRHOIDS

- Located proximal to the dentate line and covered by insensate anorectal mucosa.

- May prolapse or bleed, but rarely become painful unless they develop thrombosis and necrosis (usually related to severe prolapse, incarceration, and/or strangulation).

INTERNAL HEMORRHOIDS

FIRST-DEGREE HEMORRHOIDS bulge into anal canal and may prolapse beyond the dentate line on straining.

SECOND-DEGREE HEMORRHOIDS prolapse through the anus but reduce spontaneously.

THIRD-DEGREE HEMORRHOIDS prolapse through the anal canal and require manual reduction.

FOURTH- DEGREE HEMORRHOIDS prolapse but cannot be reduced and are at risk for strangulation.

Hemorrhoids: (A), internal; (B), external; (C), mixed; (D), thrombosed.

Internal hemorrhoids occur higher up in the anal canal, out of sight. Bleeding is the most common symptom of internal hemorrhoids, and often the only one in mild cases.

External hemorrhoids are visible-occurring out side the anus. They are basically skin-covered veins that have ballooned and appear blue. Usually they appear without any symptoms. When inflamed, however, they become red and tender.

Sometimes, internal hemorrhoids will come through the anal opening when straining to move your bowels. This is called a prolapsed internal hemorrhoid; it is often difficult to ease back into the rectum, and is usually quite painful.

When a blood clot forms inside an external hemorrhoid, it often causes Severe pain. This thrombosed external hemorrhoid can be felt as a firm, tender mass in the anal area, about the size of a pea.

External hemorrhoid  one in a vein of the inferior rectal plexus, below the pectinate line and covered with modified anal skin.

Internal hemorrhoid  one in a vein of the superior rectal plexus, originating above the pectinate line and covered by mucous membrane.

Prolapsed hemorrhoid  an internal hemorrhoid that has descended below the pectinate line and protruded outside the anal sphincter.

Strangulated hemorrhoid  a prolapsed hemorrhoid, whose blood supply has become occluded by constriction of the anal sphincter.

Thrombosed hemorrhoid  one containing clotted blood.

COMBINED INTERNAL and EXTERNAL HEMORRHOIDS straddle the dentate line and have characteristics of both internal and external hemorrhoids.

POSTPARTUM HEMORRHOIDS result from straining during labor, which results in edema, thrombosis, and/or strangulation.

Typical Hemorrhoids Symptoms:

Chronic intermittent bright red bleeding with bowel movements, on tissue, in commode, or streaked on stool surface.

Feeling of fullness, swelling, extra tissue and incomplete BM.

Irritation or itching from seepage of mucus, fecal soiling or dermatitis from hemorrhoid creams causes rash.

Pain may occur with prolapse, associated external hemorrhoids or anal fissure.

Typical Hemorrhoids Symptoms:

Bulge of tissue on anal skin Blood on toilet tissue. Thrombosis of external hemorrhoids leading to

a hard painful lump. Skin tags left over after dilated external

hemorrhoids, hemorrhoidectomy, or resolved thrombosis. Can trap stool and cause dermatitis and itching.

Physical Examination External findings important to note include any

of the following: Redundant tissue Skin tags from old thrombosed external

hemorrhoids Fissures Fistulas Signs of infection or abscess formation Rectal or hemorrhoidal prolapse, appearing

as a bluish, tender perianal mass

During the digital rectal examination, assess for any masses, tenderness, mucoid discharge or blood, and rectal tone. Internal hemorrhoids are usually not palpable unless thrombosed.

TREATMENT

MEDICAL THERAPY

Addition of dietary fiber, stool softeners, increased fluid intake, and avoidance of straining

Improve hygiene

RUBBER BAND LIGATION

- Persistent bleeding from first-, second-, and selected third- degree hemorrhoids

- Mucosa located 1 to 2 cm proximal to the dentate line is grasped and pulled into a rubber band applier. After firing the ligator, the rubber band strangulates the underlying tissue, causing scarring and preventing further bleeding or prolapse.

Rubber band ligation of internal hemorrhoids. The mucosa just proximal to the internal hemorrhoids is banded.

INFRARED PHOTOCOAGULATION

- Is an effective office treatment for small first- and second-degree hemorrhoids.

- The instrument is applied to the apex of each hemorrhoid to coagulate the underlying plexus. All three quadrants may be treated during the same visit.

- Larger hemorrhoids and hemorrhoids with a significant amount of prolapse are not effectively treated with this technique.

SCLEROTHERAPY

- Injection of bleeding internal hemorrhoids with sclerosing agents is another effective office technique for treatment of first-, second-, and some third-degree hemorrhoids.

- One to 3 mL of a sclerosing solution (phenol in olive oil, sodium morrhuate, or quinine urea) are injected into the submucosa of each hemorrhoid.

EXCISION of THROMBOSED EXTERNAL HEMORRHOIDS

Acutely thrombosed external hemorrhoids generally cause intense pain and a palpable perianal mass during the first 24 to 72 hours after thrombosis.

The thrombosis can be effectively treated with elliptical excision performed in the office under local anesthesia

After 72 hours, the clot begins to resorb, and the pain resolves spontaneously. Excision is unnecessary, but sitz baths and analgesics often are helpful.

OPERATIVE HEMORRHOIDECTOMY

CLOSED SUBMUCOSAL HEMORRHOIDECTOMY

(Parks or Ferguson hemorrhoidectomy) Involves resection of hemorrhoidal tissue and closure of the

wounds with absorbable suture.

The procedure may be performed in the prone or lithotomy position under local, regional, or general anesthesia.

The anal canal is examined and an anal speculum is inserted. The hemorrhoid cushions and associated redundant mucosa are identified and excised using an elliptical incision starting just distal to the anal verge and extending proximally to the anorectal ring.

The apex of the hemorrhoidal plexus is then ligated and the hemorrhoid excised. The wound is then closed with a running absorbable suture.

Technique of closed submucosal hemorrhoidectomy. A. The patient is in prone jackknife position. B. A Fansler anoscope is used for exposure. C. A narrow ellipse of anoderm is excised. D. A submucosal dissection of the hemorrhoidal plexus from the underlying anal sphincter is performed. E. Redundant mucosa is anchored to the proximal anal canal, and the wound is closed with a running absorbable suture. F. Additional quadrants are excised to complete the procedure.

OPEN HEMORRHOIDECTOMY

(Milligan and Morgan hemorrhoidectomy)

Follows the same principles of excision described in submucosal hemorrhoidectomy, but the wounds are left open and allowed to heal by secondary intention.

WHITEHEAD’S HEMORRHOIDECTOMY

(Total hemorrhoidectomy)

Involves circumferential excision of the hemorrhoidal cushions just proximal to the dentate line. After excision, the rectal mucosa is then advanced and sutured to the dentate line

Risk of ectropion (Whitehead’s deformity)

PROCEDURE for PROLAPSE and HEMORRHOIDS/STAPLED

HEMORRHOIDECTOMY

Not involve excision of hemorrhoidal tissue, but instead fixes the redundant mucosa above the dentate line

Removes a short circumferential segment of rectal mucosa proximal to the dentate line using a circular stapler. This effectively ligates the venules feeding the hemorrhoidal plexus and fixes redundant mucosa higher in the anal canal.

COMPLICATIONS of HEMORRHOIDECTOMY

Postoperative pain Urinary retention Fecal impaction Bleeding Infection –necrotizing soft tissue infection

Long-term sequelae – incontinence, anal stenosis, ectropion (Whitehead’s deformity)

THANK YOU!