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06-04-2008, 09:06 AM
Definition:
Varicosities of sup. rectal vein (sup. haemorrhoidal vein) tribuitaries.
Aetiology:
1- 1ry piles:Unknown but some factors may play a role:
a) anatomical factors: valveless veins.
b) Precipitating factors: - Prolonged constipation.
- Prolonged standing .
c) Pathological factor�Heriditary weak veins.
2- 2ry piles: Due to underlying organic cause e.g.
- Portal hypertension - Cancer rectum - Pelvic masses
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Pathology:
1- Degree:
1st degree: the pile does not protrude from the anal canal on straining. It gives only bleeding/rectum.
2nd degree: anal swelling protrudes on straining but reduced spontaneously.
3rd degree: anal swelling protrudes on straining but reduced manually.
4th degree: prolapsed pile with or without straining.
2-Structure:
Each pile consists of central arteriol and punch of veins surrounding it connected with loose areolar tissue and covered with mucosa.
1) Early presentation: Bleeding / rectum (1st degree)
2) Anal swelling with different degrees II, III, IV
3) Pain = complicated piles, as the pain is not a manifestation of non complicted cases. It occurs in, anal fissure, inflammed piles, thrombosed piles & strangulated piles.
4) Mucoid discharge & perianal irritation.
Complications:
1- Anaemia 2- Rectal prolapse
3- Anal fissure: piles may cause sphincteric spasm which cause constipation.
4- Strangulated piles: spasm of the sphincter while piles are protruded leads to its strangulation and sloughing and gangrene if neglected.
5- Infected piles � portal pyaemia
Investigations:
1) P.R: The piles can't be felt but you must exclude CA. rectum in every case.
2) Proctoscope: to diagnose 1st degree pile & also to exclude CA. rectum.
Treatment :
(A) Conservative treatment:
Indications:
a) 2ry piles as haemorrhoidectomy may lead to rapid spread of CA rectum.
b) 1st degree piles
Lines of conservation:
- Ointment which is decongestant, anaesthetic, & disinfectant.
- Avoid constipation (by laxative).
- Avoid prolonged standing. - Prohibit spices.
(B) Injection sclerotherapy:
Indications:
1-1st & 2nd degree piles.
2- Complicated 2ry piles (bleeding).
3- Inoperable patients.
4- Recurrence after surgery.
Drug: 5% phenol in almond oil.
Dose: 2-3 cc per pile. Not more than 3 piles/sitting. With interval of
2 weeks. Successful injection is known by straition sign where there is
a swelling of mucosa with blood vessels crossing over it.
Site of injection: Submucosa (Extravascular).
Action: Induce fibrosis which cause oblitration of veins and fixation of mucosa to muscle layer.
(C) Banding treatment:
Indication: 2nd degree pile.
Technique: By slipping tight elastic bands on to the base of the pedicle of each haemorrhoid with special instrument. The piles will slough off within few days. Not more than 2 piles should be banded / session and 3 weeks in between. It is simple painless procedure done even in outpatient Department.
(D) Cryosurgery:
Technique: Application of liquid nitrogen or Co2 snow{-196 oC} causes coagulation necrosis which subsequently separate and drop off.
Advantage: Painless and can be done in Outpatient Department.
Disadvantage: Causes troublesome mucus discharge which limits its use.
(E) Photocoagulation:
Recent method using infrared coagulation specially designed instrument.
This is an effective and painless method of treatment.
(F) Surgical treatment: (Haemorrhoidectomy)
Ligation excision of the pile mass
Indications:
- 3rd & 4th degree piles.
- Recurrence after injection.
- Strangulated piles.
- Fissure or interoexternal haemorrhoids with well defined external one.
Technique
- The 3 main piles are only excised.
- Leave skin and mucosa inbetween excisions to avoid scar (anal stricture).
- We must start at 1st by excision of No. 7 to avoid masking of the field.
- Sphincterotomy should be done to avoid chronic anal fissure.
Complications of surgery
(1) Haemorrhage
* 1ry hge: during operation. * Reactionary hge: 24 hs later.
* 2ry hge.: 2ry infection (7-10 days)
(2) Post operative retention of urine: Due to pain which cause reflex spasm of the internal urinary sphincter.
Treatment:
Morphia p.o. Hot fomentation (suprapubic)
Prostigmine (parasympathomimitic)
Catheterisation (delayed for fear of ascending infection)
(3) Anal stricture: treated by repeated dilatation or Y V anoplasty is done.
(4) Fissure: sphincterotomy not done.
(5) Recurrencee after surgery