HAEMORRHOIDS
ANAL CANAL
• Anatomy of Anal Canal
• Blood Supply of Anal Canal
Basic Anatomy
Anal canal is the terminal part of large intestine.
Anal canal is located in anal triangle of perineum between right and left
ischiorectal fossa.
The anal canal is 3.8cm long.
Begins at anorectal junction and ends at the anal verge.
Interior of Anal
Canal
Is divided into 3 parts:
a) Upper part — 15mm long
b) Middle part — 15mm long
c) Lower part — 8 mm long
Dentate / Pectinate
line
Divides anal canal into upper and lower anal canal.
Upper and lower anal canal differ in their source of development, epithelial
lining ,blood supply, nerve supply and lymphatic drainage.

Blood Supply of Anal Canal
Arterial supply
A. Above pectinate line— Superior Rectal Artery (continuation of IMA)
B. Below pectinate line — Inferior Rectal Artery (branch of internal pudendal artery)
Venous drainage
A. Internal rectal venous plexus (haemorrhoidal plexus )
lies in submucosa, drains into Superior rectal vein and also communicates with
external plexus.
B. External rectal venous plexus
lies outside muscular coat of rectum and anal canal, communicates with internal
plexus.
Hemorrhoids
Hemorrhoids are cushions of submucosal tissue containing venules,
arterioles, and smooth muscle fibers that are located in the anal
canal.
Three hemorrhoidal cushions are found in the
1. left lateral
2. right anterior
3. right posterior positions.
These are involved in continence mechanism(completely close
the anal canal so that there is no leakage of any liquid and gas)
Hemorrhoids are a normal part of anorectal anatomy, treatment is
only indicated if they become symptomatic.
Types
A) Internal hemorrhoids— located proximal to the dentate line and covered by
insensate anorectal mucosa.
B) External hemorrhoids—located distal to the dentate line and are covered with anoderm.
C) Combined internal and external hemorrhoids
Causes of Internal Hemorrhoids
Prolonged straining, constipation , Prolonged lavatory sitting, trauma, aging, lack
of fiber rich diet etc contribute for development of symptomatic hemorrhoids.
According to current view,
shearing forces acting on anus
caudal displacement of anal cushions and mucosal trauma
with time there occurs fragmentation of supporting structures which leads to loss
of elasticity of cushions such that they do not retract following defecation
Grading of Internal hemorrhoids
GRADE I —painless bleeding, no prolapse.
GRADE II —prolapse on defecation that reduces spontaneously.
GRADE III —prolapse that has to be reduced manually.
GRADE IV —permanent prolapse.
CLINICAL FEATURES
1. Bleeding- principal and earliest symptom.
bright red painless bleeding
2. Mucus discharge
3. Prolapse
4. Pain only on prolapse
COMPLICATIONS
1. Strangulation(blockage of artery) and thrombosis
2. Ulceration
3. Gangrene
4. Portal pyaemia(collection of pus in Portal Venous System)
5. Fibrosis
Treatment
1. Nonoperative measures.
• Sitz bath— patient has to sit in warm water with the anal region dipped in water
for about 30 minutes, 2-3 times a day. This reduces edema, pain and promotes
healing.
• local applicants to reduce pain, itching and edema can be used.
• Intake of high fiber diet (35 grams/day) and plenty of water.
• Laxatives such as lactulose— softens bowel motions and relieve constipation.
calcium dobesilate in conjuction with fiber supplement provide effective symptomatic relief from acute bleeding and
it was a/w significant improvement in the inflammation of hemorrhoids.
2. Sclerotherapy
For patients with 1st and 2nd degree piles whose symptom are not improved by
conservative measures.
submucosal injection of 5% phenol in arches oil or almond oil is given using
proctoscope and Gabriel syringe. This procedure is repeated for each pile and patient is
reassessed after 8 weeks, if necessary injections are repeated.
This causes FIBROSIS in the submucosal region — leading to mucosal fixation on to
deeper planes— fixation of anal cushions(so no prolapse) and strengthening of the
vessel wall and obliteration of vessel lumen.
3. Banding
Rubber band ligation is done for 1st, 2nd and selected 3rd degree hemorrhoids.
Barron’s bander— used to slip elastic bands onto the base of the pedicle of each
hemorrhoids— causes ischemic necrosis of piles— slough offs within 10 days with
bleeding
4. Surgical management
Indications for hemorrhoidectomy :
• 3rd and 4th degree hemorrhoids
• 2nd degree hemorrhoids that have not been cured by non operative measures
• Fibrosed hemorrhoids
• Interno-external hemorrhoids when the external hemorrhoids is well defined
• hemorrhoidal bleeding sufficient to cause anemia
•
Techniques of hemorrhoidectomy
1. Open technique(Milligan-Morgan Operation)
2. Closed technique
Both involve ligation and excision of the hemorrhoids but in open technique the
mucosa and skin are left open to heal by secondary intension and in closed
technique the wound is sutured.
3. Stapled hemorrhoidopexy
Post operative care
• Patient is discharged from hospital after 1-2 days of operation
• instructed to take 2 warm bath daily and given a bulk laxative to take twice a day together
with appropriate analgesia
• 5 day course of metronidazole reduces pain
• Dry dressings are applied
• patient is again seen after 3-4 weeks of discharge, rectal examination is done —if there is
evidence of stenosis, patient is encouraged to use a dilator
Post operative complications
• Early — pain, acute retention of urine, Reactionary hemorrhage
• Late — Secondary hemorrhage, Anal stricture , Anal fissures , Incontinence(damage to
Internal sphincter)
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