HAEMORRHOID

dr. M. Hafidh Komar, SpB (K)BD

Departemen Bedah FK UNSRI/RSMH
Dr. Moh. Hoesin Palembang
 Hemorrhoids

Cushions of submucosal tissue containing

venules, arterioles, and smooth muscle fibers
that are located in the anal canal

Functioned as part of the continence mechanism

and aid in complete closure of the anal canal at
rest.

Colon, Rectum and Anus on Schwartz’s Principles of Surgery, 10th ed, 2014
 Hemorrhoids disease
• The symptomatic
enlargement and
distal displacement of
the normal anal
cushions
• Symptoms: itching,
bleeding, mucosal
prolapses, pain.

World J Gastroenterol 2012 May 7; 18(17):

2009-2017
 ANAL CUSHION

• Is vascular cushions
covered by mucosa &
muscularis mucosae

• 3 main cushions: left

lateral, right anterior, right
posterior

Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,
Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002
 THE FUNCTION OF ANAL CUSHION
• Protect anal canal from
injury during defecation
• Play an important role in
accomplishing anal
continence, especially with
respect to liquids.(Provide
15-20% resting pressure of
the anal canal)
• The muscularis submucosa
and its connective tissue The anchoring and supporting
fibers return to the anal canal tissue deteriorates with
lining to its initial position aging,  produces venous
after temporary downward distention, erosion, bleeding
displacement occur during
defecation. and thrombosis

Longo A. Procedure for Prolapse and Hemorrhoids Longo Technique, Corman et al. Hand book of colon and Rectal Surgery 2002,
Sardinha. Hemorrhoids. Surg.Clin N Am. 82. 2002
 Anorectal Anatomy

Colon, Rectum and Anus on Schwartz’s Principles of Surgery, 10th ed, 2014
Anorectal Anatomy

Benign Disorders of The Anorectum on-

Maingots Abdominal Operation, 11th ed
 Vascular structure
Normal vs Hemorrhoid

Normal: a sphincter-like structure, formed by

thickened tunica media containing 5-15 layers of
smooth muscle cells, between the vascular plexus
within the sub epithelial space of the anal
transitional zone
Hemorrhoids: remarkably dilated, thin-walled
vessels within the submucosal arteriovenous
plexus, with absent or nearly-flat sphincter-like
constriction on the vessels
smooth muscle sphincter helps in reducing the
arterial inflow, thus facilitating an effective
venous drainage

World J Gastroenterol 2012 May 7; 18(17): 2009-2017

 PATHOLOGY OF HEMORRHOID
• Microscopic:
abnormal dilatation and distortion of the
vascular channel,
destructive changes in the supporting
connective tissue within the anal cushion
an inflammatory reaction
vascular hyperplasia
decrease the vascular sphincter like
structures
World J Gastroenterol 2012 May 7; 18(17): 2009-2017
 Superior Rectal Artery in Hemorrhoid
• Terminal branches of the superior rectal artery
had a significantly larger diameter, greater blood flow,
higher peak velocity and acceleration velocity in
hemorrhoid patients
• Increase in arterial caliber and flow was well
correlated with the grades of hemorrhoids
• Hyperperfusion of the arteriovenous
plexus will lead to the formation of hemorrhoid

World J Gastroenterol 2012 May 7; 18(17): 2009-2017

 Classification
External hemorrhoids Distal to dentate line
• Covered with anoderm
• Significant pain
• Skin tags are often confused with symptomatic hemorrhoids

Internal Hemorrhoids Proximal to dentate line

• Covered by insensate anorectal mucosa
• Rarely painful unless it develops thrombosis & necrosis
• Divided into 4 grade

Mixed Hemorrhoid Straddle the dentate line

• Both internal and external characteristics

Benign Disorders of The Anorectum on Maingots Abdominal Operation, 11th ed

Colon, Rectum and Anus on Schwartz’s Principles of Surgery, 10th ed, 2014
 GOLIGHER’S CLASSIFICATION
• I : the anal cushions bleed
but do not prolapse
• II : the anal cushions prolapse
through the anus on
straining but reduce
spontaneously
GRADE I GRADE III
• III : the anal cushions
prolapse through the anus
on straining or exertion and
require manual replacement
into the anal canal
• IV :the prolapse stay out at
all times and is irreducible,
acutely thrombosed, and or GRADE II GRADE IV
incarcerated
WGJ 2012, 18 ( 17 ) 2009 - 2017
 Pathophysiology

Hemorrhoids are a normal part of anorectal anatomy

Excessive straining, increased abdominal pressure and hard stools

 increase venous engorgement of the hemorrhoidal plexus

Prolapse of hemorrhoidal tissue

Bleeding
Thrombosis

Colon, Rectum and Anus on Schwartz’s Principles of Surgery, 10th ed, 2014
 Primary Internal Haemorrhoids:
Theory of Developmental
Infection
• Repeated infection of the anal lining
• Secondary to trauma at defecation
• Weakening and erosion ot veins’ wall in submucosa layer

Diet and Stool Consistency

• Hard faecal mass in the rectum could obstruct venous return

• Engorgement of the anal veins
• Disturbance of vascular flow

The Anus and Anal Canal on Bailey and Love’s Short Practice of Surgery, 26th ed, 2012
 Primary Internal Haemorrhoids:
Theory of Developmental
Anal Hypertonia
• Raised anal canal resting pressure
• Surgical haemoroidectomy restores resting pressure to
normal range

Aging

• Higher proportion of collagen than muscle fibres and are

fragamented and disorganzed

The Anus and Anal Canal on Bailey and Love’s Short Practice of Surgery, 26th ed, 2012
 Sliding anal cushions
Rectal reduncancy
Vascular abnormality

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/pdf/WJG-18-2009.pdf
Transperineal color Doppler ultrasound (CDUS) with spectral wave analysis
(SWA) was performed in 38 patients with hemorrhoidal disease and 20
healthy volunteers.

RESULTS:
• The anorectal vascular plexus was characterized by a network of
submucosal vessels exhibiting multiple thickened venous vessels
separated by distinct sphincter-like constrictions. CDUS and SWA showed
significant flow differences in peak velocities (6.8 +/- 1.3 cm/s vs. 10.7 +/-
1.5 cm/s; P = 0.026) and acceleration velocities (51 +/- 4 ms vs. 94 +/- 11
ms; P = 0.001) of afferent vessels between the control group and patients
with hemorrhoidal disease.

CONCLUSIONS:
• Morphological and functional failure of this vascular system may
contribute to the development of hemorrhoidal disease.
https://www.ncbi.nlm.nih.gov/pubmed/18766355
• There were statistically significant differences in the expression of MVD, VEGF,
MMP9 between internal hemorrhoid tissue and normal anal cushions(P< 0.05).
• iNOS was significantly increased in hemorrhoid tissue, but no significant difference
between normal anal cushions and hemorrhoid tissue.
• Morphological abnormalities such as breaking, distortion, mortality, hyaline
degeneration were found in elastic fibers of internal hemorrhoid tissue, but not in
normal anal cushions.

CONCLUSION:
• Angiogenesis is evident in hemorrhoid tissue, suggesting the possible mechanism in
the pathogenesis of hemorrhoids. The direct degeneration effect of MMP9 on
supporting structure elastic fibers in anal cushion is another important mechanism.
• The high expression of iNOS suggests the inflammatory factors involve in the
pathogenesis of hemorrhoids, and NO may be involve in pathological effect on
hemorrhoids

https://www.ncbi.nlm.nih.gov/pubmed/16149003
• Microvascular density was higher in haemorrhoid tissue than in normal anal
and lower rectal tissues.

• Endoglin, was present in only 25 of 46 (54%) haemorrhoidal vessels, and its

immunoactivity was prominent in venules larger than 100 micro m.

• Thrombosis formation and stromal vascular endothelial growth factor was

significantly associated with the presence of endoglin immunoactivity.

CONCLUSION:
• Neovascularization is one important phenomenon of haemorrhoid disease,
along with conventional venous dilatation and arteriovenous
communication.

• In addition, thrombosis and stromal vascular endothelial growth factor

might be important factors in promoting vascular proliferation.
https://www.ncbi.nlm.nih.gov/pubmed/14764073
Haemorrhoid

Vascular
abnormality ?
MANAGEMENT OF HEMORRHOIDAL
DISEASE
 Dietary and lifestyle modification
 Medical treatment : oral flavonoid , topical treatment
 Non operative management : sclerotherapy, infra red
coagulation, rubber-band ligation, radiofrequency ablation
 Operative treatment :
- Plication
- Doppler guided hemorrhoidal arteial ligation (DGHAL )
- Hemorrhoidectomy ( Milligan – Morgan, Ferquson,
Whitehead procedures )
- Stapled hemorrhoidopexy

WGJ 2012; 18 ( 17 ) 2009- 2017

 ANAL HYGIENE
FECAL MATERIAL MY BE
TRAPPED IN ANAL
CRYPT OR BETWEEN
SKIN TAG
ADEQUATE ANAL
ANAL HYGIENE INCLUDING
CRYPT ANAL CRYP IS
ESSENTIAL
 Fiber supplementation

A meta-analysis of control trials

fiber suplementation was associated
with significant reductions in risk of
persistent symptoms and the risk of
rectal bleeding
 ORAL MEDICATION FOR EARLY
STAGE (GRADE 1,2) AND SMALL
GRADE III
• Purified flavonoid fraction is a botanical extract from
citrus.
• Oral micronized purified flavonoid fraction
(hesperidin  diosmin  hidrosmin)
• It increasing vascular tone, lymphatic drainage, and
capillary resistance; also assumed to have anti
inflammatory effects and promote wound healing.
META-ANALYSIS OF FLAVANOID
FOR HEMORRHOID

14 randomized trial flavanoid

decreased risk of bleeding by 67%,
persisten pain by 65%, iching 35%,
reduced recurrence rate by 47%
Miliigan – Morgan Procedure Plication Approach
Suture Ligation and Mucopexy

Ferguson Technique
 DOPPLER GUIDED
Stapled
HEMORRHOIDAL ARTERY
LIGATION (DGHAL )
Hemorrhoidopexy
HISTORY of Stapled Hemorroidhopexy

Longo (1998) reported

the first series of the
Stapled
hemorrhoidopexy
 PPH 01
 SUMMARY

Hemorrhoid is is normal vascular cushion, important

for protecting anal canal and contribute in
maintaining anal continence.

Symptomatic hemorrhoid enlargement and distal

displacement of the normal anal cushions

The therapeutic treatment of hemorrhoids range

from dietary and life style modification to radical
surgery, depending on degree and severity of
symptoms
Thank you