35) Haemorrhoids / Piles скачать в хорошем качестве

35) Haemorrhoids / Piles

Haemorrhoids (Piles)- Dilated vains with in the anal canal in the subepithelial region formed by radicles of the superior, middle & inferior rectal veins . Haemorrhoids are clearly divided into 2 categories– I) Internal & II) External Internal Haemorrhoids – It is within the anal canal & internal to the anal orifice. It is covered with mucous membrane and it is bright red or purple in colours. Usually commences at the ano rectal ring & ends. External Haemorrhoids – is situated outside the anal orifice & is covered by skin. 2 peculiar conditions which are associated with external haemorrhoids. . i) Dilatation of the veins at the anal verge is sometimes seen in persons of sedentary life particularly during straining. ii) Perianal haematoma – or thrombosed external haemorrhoids – this condition due to back pressure on the anal venule consequent upon staining at stool, coughing or lifting heavy weight. -Painful, tense and tender swelling –if untreated -resolve by itself or may suppurate or may fibrose or may burst – rise to bleeding. Treatment- To incise the haemorrhoids under local anaesthesia. Aetiology of internal haemorrhoids- i)Hereditory, ii)Anatomical –consequences of adoption of erect posture by mankind . a)absence of valves in the superior haemorrhoidal veins . b)occlusion of the veins & congestion during defaecation. c)radicles of superior rectal vein lie unsupported in base submucous connective tissue of the rectum. iii)Exacting causes –straining to expel constipated stool caused dilatation of the venous plexus. iv)Physiological cause- -a corpus cavernosum with direct arteriovenous communication termed corpus covernosum rectum. Hyperplasia of the corpus cavernosum rectum may result from failure of mechanism controlling the anterio-venous shunts producing superior haemorrhoidal veins varicosity and haemirroids. v)Diet- how roughage ‘western’ diet may exite haemorrhoids formation. Secondary haemorrhoids – -Haemorrhoids may be secondary to a few condition. a)Carcinoma of the rectum b)Pregnancy c)Chronic constipation d)Difficulty in micturation e) Portal hypertension has hardly ever caused haemorrhroids. Clinical features –1)Bleeding , 2)Prolapsed Ist degree- haemorrhoid does not come out of the anus . IInd degree- come out only during defaecation & is reduced spontaneously after defaecation. IIIrd degree- come out only during defaecation & do not return by themselves, but need to be replaced manually & then they stay reduced. IVthdegree- permanently prolapsed. 3)Pain - is not characteristic of haemorrhoid unless there is thrombosis . 4)Mucous discharge 5)Anaemia Digital examination – can not feel an uncomplicated internal pile unless it is thrombosed. Proctoscopy- the proctoscope is introduced as for as it does. -The obturator is then removed & with an illuminator the inside of the anal canal is visualized. -The protoscope is now withdrawn slowly and the internal haemorrhoid will be seen bulging into the protoscope. Complications – 2 main complication –i)Bleeding, ii)Thrombosis . i)Bleeding ii)Thrombosis iii)Strangulation iv)Gangrene v)Fibrosis. vi)Suppuration vii)Pylephebities- (Portal pyaemia) TREATMENT – treatment of haemorrhoid should start with bowel regulation which has a prophylactic effect. Bowel Regulation- can be done by advising high residue diet & mild laxatives. Definitive treatment- Injection therapy- Sclerosant injection is the method of Rx of small vascular haemorrhoids. -Sclerosant agent 5% phenol in almond or Arachis oil with 140 mg menthol to make 30 ml solution (Albright solution). -Injected into the submucosa around the pedicle of the haemorrhoid with two objects in view. First to produce a chemical thrombosis in int. haemorrhoid plexus & Secondly- to produce a fibrous reaction in the submucous layer which will fix the loose redundant mucous membrane to avoid prolapse. Dis-advantages – i)contraindicated in prolapsed pilse, in arterial piles and in presence of infection, ii)faulty technique may lead to sloughing, which is dangerous. Rubber band ligation – Cryo-Surgery – Maximal anal dilatation (Lord’s procedure)- Haemorrhoidectomy – For large third degree haemorrhoids particularly with associated tags and an external haemorrhoidal plexus haemorrhoidectomy is the Rx of choice & is the only method to give lasting relief. Ligature and excision method Closed haemorrhoidectomy Submucous haemorrhoidectomy (Park’s) Circular stapled Haemorrhoidctomy Endo stapling technique Choice of treatment Ist degree haemorrhoids – Sclerosing inj. & elastic band ligation. Cryosurgery. IInd degree – Ligature & excision Closed haemorrhoidectomy . IIIrd degree –Haemorrhoidectomy (Park’s) (submucous) -Haemorrhoids with prolapse –circular stapled haemorrhoidectomy.