Haemorrhoids are swollen, enlarged veins that form inside and outside the anus and rectum.
Depends on the degree of prolapse into:
1.Anal cushions bleed without prolapse.
2.Anal cushions prolapse on straining but reduce spontaneously.
3.Anal cushions prolapse on straining or exertion and require manual reduction.
4.The prolapse is irreducible and remains out all the time.
1.To reduce pain.
2.Improve quality of life.
3.To reduce the morbidity affecting daily living activities.
Grade 1 and Grade 2
1.) Life style modification.
– Avoid prolonged straining.
– Diet and bulk forming agents.
– Increase oral fluids intake.
– Improve anal hygiene.
2.) Oral medications
i) Micronized Purified Flavonoid Fraction is composed of 90% Diosmin and 10% Hesperidin (Dafflon).
– Efficacy in the treatment.
– Most common drug, phlebotonic activity.
– Meta analysis of 14 RCTs, role of flavonoids concluded that limitations in methodological quality, heterogeneity and potential publication bias raise questions about the apparent beneficial effects9,10,11
ii) Calcium Dobesilate.
-It improves the response of symptomatic acute attacks.
3.) Topical treatment.
i) Topical preparations that contain low-dose local anesthetics, corticosteroids, keratolytic, protectants, or antiseptics.
Note: Chong et al12, noted that well-designed studies have found no evidence to support the use of any of the myriad of over-the-counter topicals12.
– To relieve symptoms.
– Long term usage of steroids is detrimental.
ASCRS Guidelines for Management of Haemorrhoids (2010)
– Evidence 1b, Grade 1,2 and 3 haemorrhoids do not respond to conservative management but more to outpatient procedures.
– Decrease blood flow.
– Reduce redundant tissue.
– Fix haemorrhoid to the underlying tissue to reduce prolapse.
1.) Rubber Band Ligation (RBL)
A simple and quick means treating grades 1 and 2 haemorrhoids.
Method: place tight rubber band around prolapsing cushion to ligate the redundant rectal mucosa just above the internal hemorrhoids (at least 1.5 cm above dentate line) as many sites as required in a single session.
More than 1 band can be done and may need multiple sessions.
Band at dentate line & below: intense pain and need to remove the rubber band.
Warn patient that some bleeding can occur at 5-10 days.
Success rate: 80-89% with recurrence rate of 68% in 4-5 years13.
Formerly was the treatment of choice for grades 1 and 2 haemorrhoids.
Agent: 5% phenol in almond or arachis oil.
Uses long injecting needle and proctoscope with 3-5 ml of sclerosant agent into submucosa above dentate line at each haemorrhoid.
Aim: produce fibrosis and reduce degree of prolapse.
Inject too superficial: ulceration.
Inject too deep: ineffective, injury to prostate (painful erection), seminal vesicles (hemospermia) and perirectal sepsis.
Results: 30% had minor complications; 30% required further treatment in the 24 months after the initial procedure, and 8% were symptom-free at four years14.
3.) Infrared Photocogulation
Applying a flat tip probe proximal to the hemorrhoidal tissue.
Giving 3 to 4 pulses of infrared energy to the normal mucosa to cause tissue destruction, protein coagulation, and inflammation, which then leads to scarring and tissue fixation.
May need several visits at monthly intervals as only one section of the haemorrhoids is treated per visit.
Advantages of infrared coagulation include being quick, painless, effective with a low rate of complications, and with a rapid return to work.
2 RCTs reported success rates of 67% and 96% of this procedure15,16.
Uses very low temperature to create water crystals within the cells resulting in destruction of the cell membrane and eventually the tissue.
Lead to less pain by freezing the sensory nerve ending.
Lengthy procedure, other disadvantages included profuse discharge, prolonged recovery, and late return to work5.
5.) Bipolar diathermy and direct-current electrotherapy
Local heat application to induce coagulation .
Success rates of both methods have been reported by several studies to be comparable to those of infrared coagulation with low rate complications16.
6.) Laser therapy/photocoagulation
Nd:YAG laser was first utilized in anorectal surgery in the 1960s.
Outcomes have improved later with the advent of the CO2 laser and the development of the pulsed and the scanned laser.
Plapler et al, in their study of 350 patients treated with CO2 laser open haemorrhoidectomy reported that laser therapy resulted in less postoperative pain and a better cosmetic scar when compared with conventional surgery17.
Grade 3 and 4 Haemorrhoids
Haemorrhoidectomy is considered to be the most effective treatment modality for hemorrhoids with the lowest recurrence rate as compared to other modalities.
Conventional Haemorhoidectomy (CH).
1.) Milligan–Morgan Procedure (Open)
2.) Ferguson Technique (Closed)
LigaSure vessel sealing system® (Valleylab, Tyco Health Care Group) is a method that uses a bipolar electrothermal device for without the need for sutures.
– Avoid painful diathermy burns.
-Allow better tissue adhesions at the wound site.
– Decrease post operative haemmorhage.
Meta-analysis of articles published between January 2000 and September 2009, and RCTs showed superiority of LigaSure haemorrhoidectomy (LH) versus CH regarding operation time, the incidence of postoperative pain and urinary retention, as well as the time required to resume normal physical activity18
Harmonic scalpel haemorrhoidectomy
Harmonic scalpel® (Johnson and Johnson Medical KK, Ethicon Endo-Surgery, Cincinnati, OH) is an ultrasonically-activated instrument, which vibrates at a rate of 55000 MHz per second.
Ability to coagulate small- and medium-sized vessels by converting electrical energy to a mechanical one.
Submucosal haemorrhoidectomy (technique of Parks)
Hemorrhoidal Artery Ligation (HAL)
(HAL) with or without anopexy is a non-excisional procedure aiming at reduction of symptoms of haemorrhoidal disease by reducing the blood flow to the hemorrhoids.
Localization of the hemorrhoidal arteries may facilitated by using the Doppler probe.
Systematic review of 17 studies on 1996 patients with haemorrhoidal disease treated with HAL showed recurrence of bleeding and prolapse in 6.3% and 7.8% of patients respectively20.
In 1998, Longo21 proposed the use of a specially designed circular stapler (Ethicon Endo-Surgery, Inc) for treatment of grade III and grade IV haemorrhoids.
Aims at reducing the haemorrhoidal prolapse by excising a complete ring of mucosa above the dentate line and fixing the hemorrhoids to the distal rectal muscular wall leading to repositioning the hemorrhoids into the anal canal.
Transecting the superior haemorrhoidal arteries, which reduces the venous engorgement by transection of the feeding arteries resulting in reduction of the size of the hemorrhoids.
Haemorrhoid – it the most common Ano-rectal conditions.
Consultant General & Laparoscopic Surgeon
KMI Taman Desa Medical Centre
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