A 45-year-old female came to the ER with severe pain in her Rt hypochondrium radiating to the Rt shoulder. On examination, she is feverish & has olive-green jaundice.
There's history of fat dyspepsia & similar attacks of pain.

🔴Haemorrhoids (Piles)

▪︎Enlargement & Protrusion Of Normal Anal Cushions Into The Anal Canal (Symptomatic Anal Cushions Arise From Anal Venous Plexuses)

▪︎Due To Shearing Forces Acting On The Anus Leads To Trauma To Anal Mucosa & Downward Displacement Of Anal Cushions With Fragmentation & Loss Elasticity Of Anal Supporting Structures Leads To Anal Cushions Protrusion & No Retraction After Defecation

🔹Risk Factors For Haemorrhoids
1. Chronic Constipation & Straining
2. Pregnancy & Multiple Births
3. Obesity
4. Portal Hypertension
5. Diet Low in Fibers
6. Repeated Anal Infections
7. Anal Sphincter HyperTonia
8. Sitting in Toilet For Long Time

🔰Types Of Haemorrhoids
🔶A. Primary Internal Haemorrhoids
▪︎Symptomatic Anal Cushions Arise From Superior (Deep Or Internal) Haemorrhoidal Plexus Above The Dentate Line (Pectinate Line Or Upper Anal Canal)

▪︎Covered By Columnar Epithelium Of The Upper Anal Canal That Lacks Pain Receptors (Painless)

▪︎Present in 3 & 7 & 11 O'clock Position Inside The Anal Canal (Left Lateral/Right Posterior/Right Anterior in Lithotomy)

▪︎Not Visible From Outside

▪︎Idiopathic Aetiology


🔹Clinical Features Of Internal Haemorrhoids
1. Bright-Red Painless Rectal Bleeding After Defecation & Separated From The Stool (Seen On Paper After Wiping Or in The Pan)

2. Anal Discomfort & Irritation (Itching) Due To Mucous Discharge

3. Lump Prolapse During Defecation

4. Acute Thrombosis Of Prolapsed Haemorrhoids Results in Severe Anal Pain With Anal Sphincter Spasm & Large Swollen Irreducible Haemorrhoid


🔹Degree Of Internal Haemorrhoids
1. Only Bleeding (No Prolapse)
2. Prolapse Reduced Spontaneously
3. Prolapse Reduced Manually
4. Permanent Prolapse (Irreducible)


🔹Mx Of Internal Haemorrhoids
📍1. Exclusion Other Causes Of Rectal Bleeding (ColoRectal Cancer)


📍2. Normalize The Bowel & Defaectory Habits
▪︎Stool Softeners

▪︎Increase Dietary Fibers & Fluids Intake

▪︎Warm Baths & Local Anesthetics To Relive Pain

▪︎Defecation Only When Natural Desire Present

▪︎Minimize Straining


📍3. ScleroTherapy Injection (5ml 5% SubMucosal Phenol Injection) ➡️ For 1st & 2nd Degree Haemorrhoids Not Improved On Conservative Tx


📍4. Haemorrhoidal Banding (Barron's Banding) ➡️ For More Bulky (Large) Haemorrhoids


📍5. Haemorrhoidal Artery Ligation & Tissue Fixation (THD/HALO/HaemorrhoidoPexy) ➡️ For 2nd & 3rd Degree Haemorrhoids


📍6. Surgical Haemorrhoidectomy For
▪︎3rd & 4th Degree Haemorrhoids

▪︎2nd Degree Haemorrhoids Not Cured By Other Methods

▪︎Fibrosed Haemorrhoids (Thrombosed External Haemorrhoids Undergo Fibrosis)

▪︎Mixed (Internal & External Haemorrhoids) When The External One is Well Defined

▪︎Chronic Rectal Bleeding Causing Anemia


📍7. Postoperative Care
▪︎Two Warm Baths Each Day
▪︎Stool Softeners/Metronidazole/Analgesics


🔹Complications Of Internal Haemorrhoids
🔶A. Preoperative
1. Chronic Bleeding & Anemia

2. Severe Acute Bleeding ➡️ Do Local Compression & Adrenaline Injection & Blood Transfusion Then Ligation & Excision Of The Haemorrhoid

3. Strangulation Then Thrombosis & Gangrene ➡️ Give AB & Analgesics With Hot Baths For 3-4 Days (To Induce Shrinkage) Then Do Haemorrhoidectomy

4. Ulceration/Fibrosis

5. Portal Pyaemia


🔶B. Postoperative
📍1. Early ➡️ Pain/Urine Retention/Reactionary Bleeding (More Common)

📍2. Late
▪︎Secondary Bleeding
▪︎Anal Strictures
▪︎Anal Fissures & Abscess
▪︎Incontinence

#Haemorrhoids
#surgery
https://t.me/Surgery_Practice

🔶B. External Haemorrhoids (PeriAnal Hematoma)
▪︎Thrombosis In Veins Of Inferior (Superficial Or External) Haemorrhoidal Plexus Below The Dentate Line (Pectinate Line Or Lower Anal Canal)

▪︎Covered By Squamous Epithelium Of Lower Anal Canal & Skin (Painful)

🔹Clinical Features Of External Haemorrhoids
1. Sudden Onset Of Painful Olive-Shaped Blue Subcutaneous Mass Protrusion At Anal Opening (Anal Verge)

2. Visible From Outside (Mass Can Be Seen Near The Anus)

3. Present After Straining/Coughing/Lifting Heavy Weight


🔹Mx Of External Haemorrhoids
📍1. Incision & Clot Evacuation If Present Within 48h

📍2. Mostly Resolve Spontaneously Or Fibrosed (Called 5 Day Pain Or Self Curing Lesion)

📍3. Haemorrohidectomy (If Symptomatic & Persist)

📍4. Its Fate If Not Treated ➡️
▪︎Form Cutaneous Tag
▪︎Burst & Disappears
▪︎Continue Bleeding
▪︎Suppurate (Become Infected)


🔶C. Secondary Internal Haemorrhoids Due To
1. AnoRectal Carcinoma Or Deformity/HypoTonic Anal Sphincter

2. Abdominal Ascites

3. Uterine Enlargement/Uterine & Ovarian & Bladder Tumour

4. ParaPlegia/Multiple Sclerosis


🔶D. InteroExternal Haemorrhoids (Mixed) ➡️ External Extension Of Internal Haemorrhoids To Involve The Superior & Inferior Haemorrhoidal Plexuses

#Haemorrhoids
#part 2
#surgery
https://t.me/Surgery_Practice

#GIT_disorders
#Surgery
#Liver mcqs