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Dr Stephanie UlmerGeneral Surgeon
Middlemore Hospital
Auckland
16:30 - 17:25 WS #168: Modern Treatment of Haemorrhoids
17:35 - 18:30 WS #180: Modern Treatment of Haemorrhoids (Repeated)
BOTTOMSScience and Art
Questions…
• What is the commonest symptom attributed to haemorrhoids?• A bleeding
• B painful lump
• C itch
• D all of the above
• What are other conditions that can be confused with haemorrhoids?• A anal cancer
• B rectal prolapse
• C anal fissure
• D all of the above
• Which symptom is generally not associated with external haemorrhoids?• A rectal bleeding
• B lump
• C itch
• D pain
The Who Dunnit…
Commonest Symptoms
• Lumps
• Pain
• Bleeding
• Itching
• Discharge
Commonest Conditions
• Haemorrhoids• Internal vs External
• Anal Fissure
• Anal Fistula
• Rectal Prolapse
• Rectal Cancer
• Proctitis
Key to Accurate diagnosis?
• History
• History
• History
• Examination
Haemorrhoids
Haemorrhoids• Internal Haemorrhoids
painless fresh rectal bleeding• Volume varies
intermittent or every BM
rarely between BMs
nothing to see or feel
• On Examination
mostly nil
• External Haemorrhoids
Swollen painful lump on anal verge
• Pain can be directed to the lump
Pain lasts 3-5 days
Indolent skin tags remain• Difficulty with hygiene
Episodic symptoms
Itchiness
Bleeding – nil or spot on toilet paper only
• On Examination
Skin tags only unless acute
Haemorrhoids
• Essential history• Bowel habit – detail
• Frequency
• Sits for long periods
• Prone to constipation
• Use of laxatives
• Blood
• Mucous
• Fibre intake/ Water intake
• Obstetric history:
• number, NVD vs C section, instrumentation, perineal suturing
• Symptoms associated with rectal prolapse:
• stress incontinence, urge incontinence, incomplete emptying, tenesmus, assisted evacuation
• Family history bowel conditions or cancer
• Previous colonoscopy
• Change in weight
• Anticoagulant use
Questions
• What are types of laxatives?• A softening
• B stimulant
• C probiotics
• D bulking
• What is not indicated for bleeding haemohhoids?• A Haemorrhoidectomy
• B Rubber band ligation
• C Phenol injections
Haemorrhoids
• Examination• Abdomen - ?mass
• Rectal – on inspection
- palpation - ?perianal tenderness
- DRE – NOT if pain ++ (fissure)
Haemorrhoids• Management:
• Optimise bowel habit – must be once a day
Lactulose (softener)
Kiwicrush (bulking)
Alpine Tea (stimulant)
• Titrate to needs
• Other options: Laxsol tablets, Movicol sachets, coloxyl and senna, Aloe juice, prunes or prune juice, LSA
• Ultraproct/ Proctosedyl Suppositories w KY Jelly
• bd for 2 weeks then stop for 2 weeks
• Much better than ointment
• Lignocaine Gel
• Salt baths/Ice
Thrombosed Haemorrhoid
• Symptoms; • more severe pain than normal
• Throbbing
• Management:• Same as for acute haemorrhoids
• Surgical excision if not responding
• Refer to ED
Ouch!!
Internal HaemorrhoidsStage 1:
• Little enlargement of hemorrhoidal mucosa but no prolapse. In this stage hemorrhoids often bleed.
Stage 2:
• Mucosa prolapsewhich reduces spontaneously.
Internal Haemorrhoids
Stage 3:
• Mucosa prolapsewhich has to be reduced manually.
Internal Haemorrhoids
Stage 4:
• Non-reducible mucosal prolapse
Internal Haemorrhoids
Internal Haemorrhoids
Treatment (Grade 1 or 2)
• ie If painless bleeding predominant symptom• Management:
Haemorrhoidal Rubber Band Ligation• In rooms – no anaesthetic
• Suction applicator puts rubber band onto apex of haemorrhoid, blocks it off, involutes, scars down and stops bleeding
• 95% success rate for bleeding
• Ongoing bleeding - ?other cause for bleeding (cancer/fissure)
• Colonoscopy
• If not, repeat banding
Internal Haemorrhoids
Other Treatments for Grade 1 or 2
• Sclerotherapy
• Infrared Light Therapy
• Lower resolution rates compared with rubber band ligation
External Haemorrhoids
Treatment
• ie predominant symptoms is painful lumps, itchiness, “I don’t like the lumps”• HAL-RAR
HAL-RAR Treatment Principles*’HAL’ part (Haemorrhoid Artery Ligation)
Doppler Sensor detects the hemorrhoidal arteries 5 - 7 arteries are being ligated
Step 1: HAL
• Pressure equalisation!
• Balances arterial inflow and venous outflow by ligating some (5 - 7) feeding arteries using HAL.
HAL- Hemorrhoidal Artery Ligation
• Reduced blood supply to the hemorrhoidal plexus
• Better balance between inflow and outflow of blood
• Hemorrhoidal cushions shrink back to normal within 6 to 8 weeks
RAR Step 2: Mucopexy
• Fixes the haemorroidal prolapse back to its original position by means of mucopexy (plastic surgery)
HAL-RAR Treatment Principles
HAL-RAR vs Traditional Haemorrhoidectomy
HAL-RAR
Advantages:
• Minimally-invasive ie no cutting
• Minimal necrosis
• No thermal tissue treatment
• Precise
• Every step under direct vision ie stay above the dentate line
• Short recovery period
• High patient acceptance
• Can combine with skin tagectomy
Traditional Haemorrhoidectomy
• Doesn’t address Internal haemorrhoids
• Cutting++
• Pain++
• Potential for serious complications ieincontinence, stenosis
• Likely lower risk of recurrence
Questions
• Which is the predominant symptom for Anal Fissure disease?• A bleeding
• B Pain
• C lump
• Which are red flags for Colorectal Cancer type bleeding?• A associated bowel changes
• B bright red blood
• C blood mixed with bowel motion
• What are symptoms associated with rectal prolapse?• A bleeding
• B frequency
• C tenesmus
• D incomplete emptying
Anal Fissure
• Classical History• “Hurts to have a poo” – “Is the pain like passing glass?”
• Severity – “How long does the pain last?”
• ‘Few secs’ to ‘most of the day’
• Bad enough to send people to bed
• Acute vs Chronic fissure
Anal Fissure
• Treatment
• Aim: Facilitate patients body to heal the cut
• Management - acute;
• Optimise bowel habit – must be once a day
Benefibre and Lactulose
• Rectogesic Oint – bd Top for 2 weeks
• Instructions – use gloved finger or cotton bud
• Insert tip of finger
• Should sting
• If headache; once a day just before going to bed
• 66% success rate
Anal Fissure
• Management;• Chronic fissure
• Rectogesic and Botox injection into Internal Anal Sphincter
• Relaxes smooth muscle sphincter
• Increased blood flow to the cut
• 75% success rate
• Ongoing/recurrent symptoms – repeat Botox Injection 6 weeks later
• 90% success rate after 2nd injection
• Lateral Sphincterotomy
• Almost obsolete
• NB not for young women
Rectal Prolapse
• History• Perineal pressure-type pain
• Deep to perineum ie can’t touch it
• Tenesmus, incomplete emptying, assisted defecation, circumferential lump
• Frequency or urgency
• Obstetric history
• Investigation• Defecating Proctogram
• Anterior rectocoele, intussusception, perineal descent/movement
• Treatment• Physio
• Surgery
Anal Fistula
• History;• Discharge through sinus adjacent to back passage
• May be bloody
• It is a result of chronic infection in the para-rectal space• Idiopathic, prev history trauma, inflammatory bowel disease, rectal cancer
• Investigation• MRI pelvis
• Treatment• Aim: optimise body to heal the hole ie Seton for drainage then laying open
• Advancement flap
• Glue
Take home messages…
• History, history, history
• Rectal bleeding always need investigation and treatment, or treatment and investigation…
• Which patients need referral?• Any rectal bleeding
• If the patient thinks there is a significant problem to them - refer
• Often discrepancy between history and examination
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