Haemorrhoidal Disease: Overview, Classification, and Treatment

1. Haemorrhoidal disease Prof Walid El shazly Assisstant professor MD of Surgery

2. Haemorroidal disease How common? • The most frequently observed anal pathology • Overall prevalence 80% population • No difference in prevalence between men and women • Women are slightly more symptomatic than men • 80% of all patients attending colorectal clinic present with symptoms of piles

3. Anal Cushions • Constant position R anterior (11 o’clock) R posterior (7 o’clock) L lateral (3 o’clock) • Rich intercommunicating blood supply from superior, middle and inferior rectal arteries

6. Etiology of haemorrhoids • Thomson “Vascular Cushion Theory” Anatomical support of muscularis submucosae weakens (degeneration, disintegration) • Aging (deterioration after the third decades) Straining effort Hormonal influence Genetic predisposition

8. Haemorroidal disease

15. Classification • Internal haemorrhoids Arise above the dentate line Microscopically covered by transitional or columnar epithelium • External haemorrhoids Appear at perianum Situated below dentate line Microscopically covered by modified skin epithelium (no skin appendages) • Skin tags Residue from previous external haemorrhoids

16. Classification • First degree No prolapse • Second degree Spontaneously reducible • Third degree Prolapse requiring manual replacement • Fourth degree Permanent prolapse

17. First degree piles

19. Second degree piles

21. Third degree piles

23. Fourth degree piles

25. Symptoms • Bleeding • Prolapse • Burning or pressure sensation • Pain (not a prominent symptom except at the time of thrombosis) • Pruritis

26. Bleeding • Bright red (AV shunts) • Mucosal erosion • Episodic • May or May Not associates with motion • Drip or Squirt into toilet bowl • Staining tissue paper • Severe anaemia (uncommon)

27. Prolapse • Usually not associates with pain in the early stage • May be unaware of the protruding anal cushions • Spontaneous reduction • Manual reduction

28. Burning sensation • Engorgement with blood • Swelling • Increase pressure sensation • Temporary • Subsides over few days • Sustained  Thrombosis  Pain

29. Complications Complications

36. strangulation

38. Treatment Treatment

39. Non-surgical treatment • Dietary advise Recommend high fiber diet with sufficient fluid intake • Modify defecatory habit • Straining has never been proved to have a causative role in piles • Excessive straining precipitates symptoms or worsens existing ones • Avoid constipation

40. Non-surgical treatment • Topical treatment (cream / suppository) • antiseptic • local anaesthetic • steroids (atrophy of anoderm, eczema) • Nonsteriodal • Vasoactive • anti-thrombotic • Oral drug – phlebotropic drug Daflon (micronized purified flavonoid fraction)

41. Surgery • Milligan and Morgan: Open technique (UK) • Ferguson and Heaton: Closed technique (USA) • Whitehead (circumferential) haemorrhoidectomy • Parks (submucosal) haemorrhoidectomy

42. Open haemorrhoidectomy • Described by two surgeons in St Marks Hospital in 1935 E.T.C. Milligan C. Naughton Morgan • Fulfilled three criteria 1. Acceptable post-op pain 2. Low risk 3. Low recurrence rate • Initiated modern surgical treatment for haemorrhoids

43. Haemorroidectomy

49. Closed haemorrhoidectomy • Described in 1959 by Ferguson and Heaton • Proponents believed that primary wound closure decreases post-op pain • No difference shown in terms of pain, complication rate, hospital stay and post-op recovery Wolfe et al 1979 Dis Colon Rectum Roe et al 1987 Br J Surg