Systemic Surgery Eindra

PILES / HEMORRHOIDS
DEFINITION

 It is a varicose vein of submucosal venous plexus at the anal canal

TYPES
1. Internal hemorrhoids
 Arise in upper 2/3 of anal canal
 Between anorectal ring & dentate line
 Covered totally by pinkish mucosa of anal canal
2. External hemorrhoids
 Arise in lower third of anal canal
 Below the dentate line
 Covered by skin
3. Interoexternal hemorrhoids
 Covered partly by skin & partly by mucosa

DEGREES OF PILES
1. 1st degree piles
 BPR (+) but do not prolapse from anus
nd
2. 2 degree piles
 Prolapse on defecation
a. Early 2nd degree  spontaneous reduction (+)
b. Late 2nd degree  need manual reduction
3. 3rd degree piles
 Permanently prolapse & cannot be reduced

AETIOLOGY
I. Primary ( No underlying disease )
1. Human anatomical
 Upright posture of human
 Absence of valves in portal system
2. Hereditary

II. Secondary
1. CA Ano-rectum
 By compressing or causing thrombosis of the superior rectal vein
2. Straining due to
 Chronic constipation
 Difficulty in micturition ( eg: Urethral stricture , BPH )
3. Increased intra-abdominal pressure
 Ascites
 Intra-abdominal & pelvic tumors (eg: Ovarian tumor )
 Pregnancy

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 Compression of veins by gravid uterus

 Progesterone  relaxation of smooth m/s in the walls of veins
 Increased pelvic circulating volume
4. Portal hypertension

Positions of Piles
 Primary haemorrhoids  3, 7 & 11 o’clock position
 Secondary haemorrhoids  between these 3 primary positions

CLINICAL FEATURES
A. Symptoms
1. BPR
 Bright red in color
 Occurs during defecation ( spurt with defecation )
 Chronic  IDA
2. Something protruding from the anus
 Initially spontaneously reducible  then, need manual reduction  finally,
totally irreducible
3. Mucus discharge
4. Pruritus ani
5. Pain
 Only when the complications ( eg: strangulation, thrombosis) occur
6. Features d/t underlying pathology
 Portal hypertension, CA ano-recatum, BPH etc ……..

B. Signs
General
 Pallor
 Jaundice in portal hypertension
 Features of underlying pathology
 Palpable abdominal mass, ascites, gravid uterus etc ……

PR examination
1. Inspection
 Mucous d/c +
 In 4th degree pile  Protruding mass (+)
 In 2nd& 3rd degree  Appears on straining

2. DRE ( Digital Rectal Examination )

 Pile mass can be palpable only when Complications (+)
 Ano-rectal carcinoma may be palpable

3. Proctoscope
 Can visualize site, size, position of piles

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 Can detect any proximal tumor

COMPLICATIONS

1. Chronic occult bld loss  IDA  Anaemia Ht failure

2. Strangulation
3. Gangrene
4. Thrombosis
5. Ulceration  secondary infection  suppuration
6. Fibrosis
7. Pyelophlebitis  portal pyemia  Liver abscess & septicemia

TREATMENT OF UNCOMPLICATED PILES

I. Conservative Tx
 Diet  High residue diet, fruits, vegetables & fluids intake
 Bowel habit  Normalize , avoid straining , avoid prolonged sitting in squatting
position in the toilet
 Use of fecal softners & suppositories

II. Injection sclerotherapy

 Indications  all 1st degree & early 2nd degree, late 2nd degree ( small size )
 Method
 inj: of sclerosants (5%phenol) 3-5cc into each pile mass
 Site of inj: - pedicle of pile mass, into submucosa
 MOA  chemical inflammation  fibrosis  obliteration of vascular channels
 Only one pile mass / each session  another session on 6wk interval

III. Barron’s Rubber Band Ligation

 Indications  all 1st degree & early 2nd degree, late 2nd degree ( very large for inj: )
 Method  rubber band ligation at the pedicle of pile mass
 MOA  ligation  ischaemic necrosis  sloughing off pile mass
 3 pile mass / session  another session on 3 wk interval

IV. Hemorrhoidectomy
 Indications
 2nd degree piles which not cured by non-operative Tx
 All 3rd degree piles
 Fibrosed piles
 Intero-external piles

 Methods
1. Pre-op preparations
 Liquid diet x 2days
 Low bowel wash out hs & cm

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2. Operation  Ligation & Excision

 Ligation at the pedicle of pile mass
 Excision of the pile mass distal to ligature

a. Open method ( Milligan-Morgan )  anal mucosa & skin left open to

heal
b. Close method  wound is resutured
3. Post-operative care
 Use of laxatives
 Analgesics & antibiotics
 Hot sitz bath
 Daily dressing

COMPLICATED PILES
( STRANGULATED, INFLAMMED, PROLAPSED )

CLINICAL FEATURES
A. Symptoms
 h/o pile (+)
 Before strangulation  pile mass is reducible ( spontaneously or manually )
 On strangulation  pile mass becomes irreducible, painful, progressively increase in
size, blackish discoloration

B. Signs
General
 Pallor & fever
 Features of septicemia may be present

PR examination
 On inspection  prolapsed inflamed pile mass with marked odema , blackish
coloration
 DRE & proctoscopic examination cannot be done d/t pain

TREATMENT
1. Hospitalization of the patient
2. Bed rest with foot end raised
3. Drugs
 Analgesics & sedatives for pain relief
 Anti-inflammaotory agents to reduce inflammation
 Antibiotics to prevent infection & portal pyemia
 Phlebotrophic agent ( Daflon 500mg )
4. Topical application of MgSO4compressive dressing over the pile mass

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5. Diet  soft semisolid diet

6. Monitoring of
 Vital signs ( eg: Temp, BP, PR, SpO2, UO )
 Size of inflamed prolapsed pile & (+)ce of Cx
7. If the patient RESPOND 
 Size of pile mass decreased , becomes reducible
 No local or systemic Cx

 Continue conservative Tx x 2-4 wk f/by elective hemorrhoidectomy

8. If the patient DO NOT RESPOND 

 Size increases & irreducible

 Manual dilatation of Anus under analgesia & reduction of pile mass

OR
 Sphincterotomy & manual reduction
OR
 Emergency hemorrhoidectomy

THROMBOSED EXTERNAL PILE / PERIANAL HEMATOMA

DEFINITION
 It is a small hematoma occurring in perianal subcutaneous fat as a result of intense
straining
 Comes from external hemorrhoidal plexus

CLINICAL FEATURES
A. Symptoms
 Recent h/o straining ( defecation, coughing or weight lifting )
 On straining  sudden onset of perianal pain
 Appearance of a small mass at the anus

B. Signs
 PR examination  subcutaneous swelling at the anus ( blue, tender, cystic )

OUTCOMES
1. Resolution ( 5th day – painful self-curing perianal condition )
2. Fibrosis
3. Secondary infection  perianal abscess
4. Ulceration  dislodgement of clot  bleeding

TREATMENT
 If the patient come early within 48hrs of onset

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 Under spinal anesthesia

 Urgent incision & evacuation of the clot ( Bi-half incision )

 If the patient comes late after 48hrs of onset  conservative Tx

 Liquid diet
 Fecal softeners
 Antibiotics & analgesics
 Hot sitz bath