1. SURGICAL CAUSES OF
ANEMIA
- HAEMORRHOIDS
Dr Vijay Kumar
Associate Professor

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3. Causes of anemia
Acute blood loss:
● Surgery, childbirth, trauma
Chronic blood loss :
● Endometriosis
● Malignancy
● Gastritis
● Hemorrhoids
● NSAID
● Menorrhagia
Decreased ability to absorb iron:
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4. Haemorrhoids
● Symptomatic anal cushions
Internal
● Primary : 3, 7 and 11 o’clock positions
● Secondary : positioned between the main pile masses
External :
● Venous channels of the inferior haemorrhoidal plexus
Interoexternal piles
● Involve both haemorrhoidal plexuses
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7. CAUSES
● Upright posture
● Lack of valves in the portal venous system
● Raised abdominal pressure
● Repeated infection
● Ageing- supporting structures in anal cushions-disorganised
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8. CAUSES
Diet and stool consistency
● Low fibre diet → Prolonged gut transit time→Harder stools → Straining to
expel →Obstruct venous return→ Engorgement of the anal veins→
haemorrhoids
● Sitting for prolonged periods on the lavatory
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10. CAUSES - current view
● Shearing forces → caudal displacement of the anal cushions
● Later - fragmentation of the supporting structures→ loss of elasticity of the
cushions → they no longer retract → remain out
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11. Haemorrhoids: Clinical features
● Bulge at 3, 7 and 11 o’clock
● Bright-red, painless bleeding separate from the motion
● Mucus discharge
● Prolapse
● Itching
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12. Four degrees of haemorrhoids
● First degree – bleed only, no prolapse
● Second degree – prolapse but reduce spontaneously
● Third degree – prolapse and have to be manually reduced
● Fourth degree – permanently prolapsed
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14. Complications
● Profuse haemorrhage
● Strangulation and thrombosis
● Ulceration
● Gangrene
● Portal pyaemia
● Fibrosis
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15. TREATMENT OF COMPLICATIONS
Strangulation, thrombosis and gangrene :
1. Immediate surgery
2. Conservative approach
Pain relief
Bed rest
Sitz baths
Cold saline compresses
Anal dilatation
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16. TREATMENT OF COMPLICATIONS Contd…
Severe haemorrhage :
1. Local compress with adr.
2. Blood transfusion
3. Ligation and excision
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17. Management of haemorrhoids
Normalising defecatory habits:
1. Only evacuating when the natural desire
2. Adopting a defecatory position to minimise straining,
3. Addition of stool softeners and bulking agents to ease the defecatory act
4. Topical ointments at night and before defecation
5. Suppositories
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18. Management of haemorrhoids Contd…
Injection sclerotherapy
● Aim - create fibrosis - obliteration of vascular channels and hitch up mucosa
● 1st - 2nd degree piles not responding to by conservative measures
● Submucosal injection of 5% phenol in almond oil
RISK
● Pain
● Superficial ulcer
● Sepsis, prostatitis, impotence and fistula
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21. Management of haemorrhoids Contd…
Piles banding
● Slip tight elastic bands onto the
base of each haemorrhoid
Cryotherapy
Infrared photocoagulation
Laser
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22. BANDING
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23. Surgical treatment
Indications
● Haemorrhoidal bleeding sufficient to cause anaemia
● III / IV degree haemorrhoids
● II degree haemorrhoids not responding to conservative
● Fibrosed haemorrhoids
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24. Haemorrhoidectomy
Open technique
● Ligation and excision of the haemorrhoid
● Anal mucosa and skin are left open to heal by secondary intention
● UK
● Milligan–Morgan operation
Closed technique
● Ligation and excision of the haemorrhoid
● Wound is sutured
● USA
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27. Haemorrhoidectomy
Stapled haemorrhoidopexy(Longo)
● Symptom relief +preservation of the anal cushions
● Utilises a purpose-designed stapling gun
● Excises a strip of mucosa and submucosa circumferentially,above dentate
line
● Less painful and less traumatic
● Equally efficacious
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29. Haemorrhoidectomy
TRANSANAL HAEMORRHOIDAL DEARTERIALISATION (THD) OR
HAEMORRHOID ARTERY LIGATION OPERATION (HALO)
● Transanal Doppler-guided ligation of those vessels feeding the haemorrhoidal
masses
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31. Choice ?
● Symptomatic – advice defaecatory habits, stool softeners and bulking agents
● Injection of sclerosant
● Banding
● THD /HALO/ haemorrhoidopexy
● Haemorrhoidectomy
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32. Complications of haemorrhoidectomy
● Pain
● Acute retention of urine
● Reactionary haemorrhage
● Secondary haemorrhage
● Anal stricture
● Anal fissure
● Incontinence
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