7. CAUSES
● Upright posture
● Lack of valves in the portal venous system
● Raised abdominal pressure
● Repeated infection
● Ageing- supporting structures in anal cushions-disorganised
7
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
8
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
10
11. Haemorrhoids: Clinical features
● Bulge at 3, 7 and 11 o’clock
● Bright-red, painless bleeding separate from the motion
● Mucus discharge
● Prolapse
● Itching
11
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
12
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
15
16. TREATMENT OF COMPLICATIONS Contd…
Severe haemorrhage :
1. Local compress with adr.
2. Blood transfusion
3. Ligation and excision
16
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
17
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
18
21. Management of haemorrhoids Contd…
Piles banding
● Slip tight elastic bands onto the
base of each haemorrhoid
Cryotherapy
Infrared photocoagulation
Laser
21
23. Surgical treatment
Indications
● Haemorrhoidal bleeding sufficient to cause anaemia
● III / IV degree haemorrhoids
● II degree haemorrhoids not responding to conservative
● Fibrosed haemorrhoids
23
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
24
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
27