Hemorrhoid internal

Hemorrhoid or pile

Incidence

increases with age, age 50 > 50 % have some degree of hemorrhoid

male > female 2 เท่า

Classification

Internal hemorrhoid : in the upper two-thirds of the anal canal

External hemorrhoid : in the lower one-thirds of the anal canal

Number and position of internal pile

Three main pile:

right anterior, right posterior and left lateral

Two accessory pile

Degrees of hemorrhoidal formation

1. First : ก้อนอยู่ภายใน anal canal

2. Second : ก้อนออกมาที่ anal orifice กลับเองได้

3. Third : ก้อนออกนอก anal orifece , ใช้นิ้วดันกลับ

4. Fourth : complete irreducible pile

Symptoms

Two cardinal symptoms: bleeding and prolapse

other: pain, discharge, anal irritation and secondery anemia

Bleeding: bright red

a slight streak of blood on motion or toilet paper, drip of blood for afew minute after the motion has been passed, loose blood

Examination

rectal examination, abdomen and CBC (suspected anemia)

Proctoscopy: assess the size and degree of the hemorrhoid

Sigmoidoscopy: in all case if the patients are over 40 years of age

Complications and sequelae

Thrombosis: prolapsed thrombosed hemorrhoids

Course:

-spontaneous resolution in the few day in most case

-sloughing and ulceration

-less extensive form: ulcerating area whicch gradually becomes retracted into anal canal

-spread of the thrombosis, sloughing may eextend to the rectal wall - serious sepsis in the pelvis

-abscess formation: submucosal, perianal oor ischiorectal region

-excessively rare septic complication: porrtal pyremia

Treatment

Palliative: bulk-forming agent: Fybogel®, Mucillin®

Proctosedryl suppository®, Daflon®

Injection in 1st-2nd degree, somtime 3rd degree: given into submucous areolar tissue in the hemorrhoidal veins lie

(10-20% phenol in glycerine and water, 5% phenol in almond oil)

Operative treatment

A. Formal hemorrhoidectomy

1. Ligation and excision

2. Submucosal hemorrhoidectomy

3. Excision with suture :

- excision of the individual pile with suture over a clamp

- excision of the individual pile snd immediate suture without a clamp

4.Excision of the entire pile-bearing area with suture

5. Excision with clamp and cautery

6. Closed hemorrhoidectomy

B. Alternative forms

Rubber band ligation

Manual dilatation of the anus and lower rectum

Cryosurgery

Management of prolapsed thrombosed internal hemorrhoids

Very earliest stage: reduction

Choice of treatment : 2 choice

External hemorrhoid