1_PATOGENESIS HEMORROID

8/13/2019 1_PATOGENESIS HEMORROID

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PATOGENESIS OF

HEMORRHOIDI.RIWANTO

Div. Digestive SurgeryDep. Of Surgery

Diponegoro Medical faculty



External hemorrhoidal plexus: in thesubcutaneous space of anal canal, belowpectineal line; supplied by branch ofinternal pudendal artery; venous drainageis inferior hemorroidal vein.

Internal hemorrhoidal plexus: in thesubmucosal space of anal canal; suppliedby superior rectal artery; venous drainageare superior and midle hemorrhoidal veins.

Within hemorrhoidal tissue, arteriovenous

shunts have been shown histologically

Anatomyof the

anorectalregion



Superior hemorrhoidalartery divided in 3 mainbranches: left (3 o’clock),anterior right (11 o’clock)and posterior right (7o’clock), corresponding tothe three normalhemorrhoidal groups

ANATOMY OF THE ANORECTAL REGION



ANAL CUSHION1975, Thomson: plexus isvascular cushionsMucosa does not form acontinuous ring of thickeningtissue in the anal canal, but adiscontinuous series ofcushions.3 main cushions: left lateral,right anterior, right posteriorInternal hemorroids aresecured by fibroelasticnetwork (Parks’ ligament)coming from int. sphincter,muscularis propia ormuscularis mucosa of therectum

Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002



THE FUNCTION OF ANAL CUSHION

Protect anal canal frominjury during defecationPlay an important role inaccomplishing analcontinence, especially withrespect to liquids.Provide 15-20% restingpressure of the anal canalThe muscularis submucosaand its connective tissue

fibers return to the analcanal lining to its initialposition after temporarydownward displacementoccur during defecation.

Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,

Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002

The anchoring and supportingtissue deteriorates withaging,

produces venousdistention, erosion, bleedingand thrombosis



PATHOGENESIS OF HEMORROIDALDISEASE

Plexus hemorrhoidalis: normal condition withoutsymptom. Congested plexus hemorrhoidalisgives symptoms.

The patogenesis of hemorrhoidal disease(symptomatic hemorrhoid) is not completelyunderstood, there are 2 theories:

1. vascular theory2. increase the laxity of the hemorrhoidal support

tisue.Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002



VASCULAR THEORY

Hemorrhoids arevaricose dilatations of the radicles of the

hemorrhoidal veins

Internal hemorrhoid:varicose enlargementof the veins of

superior hemorrhoidalplexus.External hemorrhoid:varicose enlargementof the veins of inferiorplexus.

Netter FH (1987)



HEMORRHOID vs RECTAL VARICESDUE TO PORTAL HYPERTENSION

A number of study failedto demonstrate anincreased incidence ofhemorrhoid in patientswith portalhypertension.

Rectal varicesenlarged portal-systemiccollateral throughmiddle and inferiorhemorrhoidal veins.

Hemorrhoid and rectalvarices are differentdisease entity.Corman et al. Hand book of colon and Rectal Surgery 2002



INCREASE LAXITY OF THEHEMORRHOIDAL SUPPORT TISSUE

The main structural disturbancescharacterizing anal prolapse are the

stretching of the upper and midlehemorroidal vessels and formation ofkinks. Under such condition, closingpressure of the anal sphincter creates anobstacle to the venous flow, creatingpredisposition to thrombosis

Chronic straining myweaken and increase thelaxity of hemorrhoidalsupport tissue piles arenothing more thansliding downward of partof the anal canal lining.

Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002, Abramowitz et al. Gastroenterologie June-July 2001.



EPIDEMIOLOGY OF HEMORRHOID

Prevalence: difficult to estimate Varies 4.4%-86% depend on: populationstudies, definition used, type datacollection.Identical in two sexes

Prevalence increase by ageMore well-off social classes complain moreFamily history is frequently mentioned

Abramowitz et al. Gastroenterologie June-July 2001.



Following factors suggested contribute to thedevelopment of hemorrhoid

Heredity Anatomic featuresNutrition

OccupationClimatePsychological problem

SenilityEndocrine changes

Food and drugsInfectionPregnancy

ExerciseCoughingStraining

VomitingConstrictive clothingConstipation

Corman et al. Hand book of colon and Rectal Surgery 2002



DEGREE OF INTERNAL HEMORROID

1st stage: congestive nonprolapsed hemorrhoids2nd stage: prolapsingduring defecation,reducing spontaneouslyat the end of defecation,3rd stage: prolapsingduring defecation andrequiring manualreduction4 th stage: permanentlyprolapsed which cannotbe reduced manually

Abramowitz et al. Gastroenterologie June-July 2001.



RELATIONSHIP BETWEEN PATHOGENESIS AND MODE OF TREATMENT

GENERAL: Ovoid/ minimizing the risk factors,anti-inflammatory drugs, faeces softener

VASCULAR THEORY:

- Phlebotrophic drugs (micronized diosmin)- Excision of hemorrhoidal tissue

INCREASE LAXITY OF HEMORRHOIDAL SUPPORTTISSUE:- Sclerotheraphy- Rubber band ligation- Longo hemorrhoidectomy



Longo’s technique is based onthe theory of increase laxity ofhemorrhoidal support tissue



SUMMARY

Hemorrhoid is is normal vascular cushion,important for protecting anal canal andcontribute in maintaining anal continence.Symptomatic hemorrhoid because of analcushion congestion prolapsingPathogenesis symptomatic hemorrhoid is notwell understand, there are two theories:vascular and laxity of hemorrhoidal support.

Many factors contribute the development ofsymptomatic hemorrhoidPrinciples of treatment are based on sign &symptom, stage and on the pathogenesis.



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1_PATOGENESIS HEMORROID