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