Dr Stephanie Ulmer General Surgeon Middlemore Hospital Auckland 16:30-17:25 WS #168: Modern Treatment of Haemorrhoids 17:35-18:30 WS #180: Modern Treatment of Haemorrhoids (Repeated)
BOTTOMS Science and Art
Questions What is the commonest symptom attributed to haemorrhoids? A bleeding B painful lump C itch D all of the above Which symptom is generally not associated with external haemorrhoids? A rectal bleeding B lump C itch D pain What are other conditions that can be confused with haemorrhoids? A anal cancer B rectal prolapse C anal fissure D all of the above
The Who Dunnit Commonest Symptoms Lumps Pain Bleeding Itching Discharge Commonest Conditions Haemorrhoids Internal vs External Anal Fissure Anal Fistula Rectal Prolapse Rectal Cancer Proctitis
Key to Accurate diagnosis? History History History Examination
Haemorrhoids
Haemorrhoids Internal Haemorrhoids painless fresh rectal bleeding Volume varies intermittent or every BM rarely between BMs nothing to see or feel On Examination mostly nil External Haemorrhoids Swollen painful lump on anal verge Pain can be directed to the lump Pain lasts 3-5 days Indolent skin tags remain Difficulty with hygiene Episodic symptoms Itchiness Bleeding nil or spot on toilet paper only On Examination Skin tags only unless acute
Haemorrhoids Essential history Bowel habit detail Frequency Sits for long periods Prone to constipation Use of laxatives Blood Mucous Fibre intake/ Water intake Obstetric history: number, NVD vs C section, instrumentation, perineal suturing Symptoms associated with rectal prolapse: stress incontinence, urge incontinence, incomplete emptying, tenesmus, assisted evacuation Family history bowel conditions or cancer Previous colonoscopy Change in weight Anticoagulant use
Questions What are types of laxatives? A softening B stimulant C probiotics D bulking What is not indicated for bleeding haemohhoids? A Haemorrhoidectomy B Rubber band ligation C Phenol injections
Haemorrhoids Examination Abdomen -?mass Rectal on inspection - palpation -?perianal tenderness - DRE NOT if pain ++ (fissure)
Haemorrhoids Management: Optimise bowel habit must be once a day Lactulose (softener) Kiwicrush (bulking) Alpine Tea (stimulant) Titrate to needs Other options: Laxsol tablets, Movicol sachets, coloxyl and senna, Aloe juice, prunes or prune juice, LSA Ultraproct/ Proctosedyl Suppositories w KY Jelly bd for 2 weeks then stop for 2 weeks Much better than ointment Lignocaine Gel Salt baths/ice
Thrombosed Haemorrhoid Symptoms; more severe pain than normal Throbbing Management: Same as for acute haemorrhoids Surgical excision if not responding Refer to ED
Ouch!!
Internal Haemorrhoids Stage 1: Little enlargement of hemorrhoidal mucosa but no prolapse. In this stage hemorrhoids often bleed.
Internal Haemorrhoids Stage 2: Mucosa prolapse which reduces spontaneously.
Internal Haemorrhoids Stage 3: Mucosa prolapse which has to be reduced manually.
Internal Haemorrhoids Stage 4: Non-reducible mucosal prolapse
Internal Haemorrhoids Treatment (Grade 1 or 2) ie If painless bleeding predominant symptom Management: Haemorrhoidal Rubber Band Ligation In rooms no anaesthetic Suction applicator puts rubber band onto apex of haemorrhoid, blocks it off, involutes, scars down and stops bleeding 95% success rate for bleeding Ongoing bleeding -?other cause for bleeding (cancer/fissure) Colonoscopy If not, repeat banding
Internal Haemorrhoids Other Treatments for Grade 1 or 2 Sclerotherapy Infrared Light Therapy Lower resolution rates compared with rubber band ligation
External Haemorrhoids Treatment ie predominant symptoms is painful lumps, itchiness, I don t like the lumps HAL-RAR
HAL-RAR Treatment Principles * HAL part (Haemorrhoid Artery Ligation) Doppler Sensor detects the hemorrhoidal arteries 5-7 arteries are being ligated
Step 1: HAL Pressure equalisation! Balances arterial inflow and venous outflow by ligating some (5-7) feeding arteries using HAL.
HAL- Hemorrhoidal Artery Ligation Reduced blood supply to the hemorrhoidal plexus Better balance between inflow and outflow of blood Hemorrhoidal cushions shrink back to normal within 6 to 8 weeks
RAR Step 2: Mucopexy Fixes the haemorroidal prolapse back to its original position by means of mucopexy (plastic surgery)
HAL-RAR Treatment Principles
HAL-RAR vs Traditional Haemorrhoidectomy HAL-RAR Advantages: Minimally-invasive ie no cutting Minimal necrosis No thermal tissue treatment Precise Every step under direct vision ie stay above the dentate line Short recovery period High patient acceptance Can combine with skin tagectomy Traditional Haemorrhoidectomy Doesn t address Internal haemorrhoids Cutting++ Pain++ Potential for serious complications ie incontinence, stenosis Likely lower risk of recurrence
Questions Which is the predominant symptom for Anal Fissure disease? A bleeding B Pain C lump Which are red flags for Colorectal Cancer type bleeding? A associated bowel changes B bright red blood C blood mixed with bowel motion What are symptoms associated with rectal prolapse? A bleeding B frequency C tenesmus D incomplete emptying
Anal Fissure Classical History Hurts to have a poo Is the pain like passing glass? Severity How long does the pain last? Few secs to most of the day Bad enough to send people to bed Acute vs Chronic fissure
Anal Fissure Treatment Aim: Facilitate patients body to heal the cut Management - acute; Optimise bowel habit must be once a day Benefibre and Lactulose Rectogesic Oint bd Top for 2 weeks Instructions use gloved finger or cotton bud Insert tip of finger Should sting If headache; once a day just before going to bed 66% success rate
Anal Fissure Management; Chronic fissure Rectogesic and Botox injection into Internal Anal Sphincter Relaxes smooth muscle sphincter Increased blood flow to the cut 75% success rate Ongoing/recurrent symptoms repeat Botox Injection 6 weeks later 90% success rate after 2 nd injection Lateral Sphincterotomy Almost obsolete NB not for young women
Rectal Prolapse History Perineal pressure-type pain Deep to perineum ie can t touch it Tenesmus, incomplete emptying, assisted defecation, circumferential lump Frequency or urgency Obstetric history Investigation Defecating Proctogram Anterior rectocoele, intussusception, perineal descent/movement Treatment Physio Surgery
Anal Fistula History; Discharge through sinus adjacent to back passage May be bloody It is a result of chronic infection in the para-rectal space Idiopathic, prev history trauma, inflammatory bowel disease, rectal cancer Investigation MRI pelvis Treatment Aim: optimise body to heal the hole ie Seton for drainage then laying open Advancement flap Glue
Take home messages History, history, history Rectal bleeding always need investigation and treatment, or treatment and investigation Which patients need referral? Any rectal bleeding If the patient thinks there is a significant problem to them - refer Often discrepancy between history and examination