Haemorrhoids - Standard Treatment Guidelines

Three haemorrhoidal cushions are found in the left lateral, right anterior and right posterior positions of the anal canal. Bleeding results when these cushions are engorged and subjected to raised intra abdominal pressure while straining during defecation.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Haemorrhoids. Following are the major recommendations :

Definition :

Haemorrhoids are cushions of submucosal tissue containing venules, arterioles and smooth muscle fibers located in the anal canal.

Treatment is indicated only if they become symptomatic due to venous engorgement of the haemorrhoidal plexus.

Incidence :

Haemorrhoids is a common condition but the exact incidence in our country is not documented.

Differential Diagnosis

• Prolapsed rectum


• Anal fissure


• Anal polyp


• Carcinoma anal canal


• Rectal varices due to portal hypertension


• Perianal abscess


• Proctitis

Prevention & Counselling

Excessive straining, increased intra abdominal pressure and hard stools increase venous engorgement of haemorrhoidal plexus. Avoidance of these would prevent the development of haemorrhoids.

Optimal Diagnostic Criteria :

Situation 1: Diagnosis is largely

Clinical Diagnosis

Symptoms:

• Bleeding per rectum, bright red, painless


• Anemia due to frequent bleeding


• Mass prolapsing per rectum


• Pain on prolapsed


• Mucous discharge


• Pruritus


• Skin tag

Examination

Direct Visulisation : thrombosed/prolapsed haemorrhoids, external haemorrhoids & skin tags be visualized.

Digital Rectal Examination :

Thrombosed haemorrhoids, as well as other associated conditions such as anal cancer, BPH may be felt per rectum.

Proctoscopy :

Internal haemorrhoids occur in 3, 7 & 11 “o” clock positions. These are visualized during prctoscopy. Haemorrhoids are classified into 4 graes by descent

Grade Presentation

1. Bleeding


2. Protrusion below the anal verge while straining with spontaneous reduction


3. Protrusion regressing with manual reduction


4. Irreducible protrusions

Based on their location, haemorrhoids can be classified into

External – located distal to dentate line, covered by anoderm, painful, arise from inferior haemorrhoidal plexus

Internal – located prominal to dentate line, covered by insensuate anorectal mucosa, painless, may prolapsed or bleed

Interno – external – features of both

Investigations:

Hb

Peripheral smear

TLC, DLC, ESR

Blood grouping and Rh typing

USG abdomen

Treatment:

Medical :

• Laxatives


• Haematinics if anemia is present


• Sitz bath


• Ointment


• Antibiotics when infection or complications are present


• Emergency transfusion when presentation is of profuse haemorrage or severe anaemia due to chronic blood loss

Surgical :

I. Minor Outpatient procedures:

1. Sclerotherapy – for grade 1 & II haemorrhoids and bleeding haemorrhoids

2 to 5 ml of 5% phenol in almond oil injected around pedicle in the submucosa aseptically

2. Banding – gr II & III haemorrhoids by modified Barron’s band applicator above the dentate line

In patient

GR III & IV haemorrhoids

1. Haemorrhoidectomy

• Open: MILLIGAN – MORGAN operation


• Closed: HILL – FERGUSON operation

2. Excision of thrombosed pile mass:

ANESTHESIA: GA/Spinal/Caudal block

Referral criteria:

Patients who opt for stapled haemorrhoidopexy

Patients with portal hypertension

Patients with bleeding disorders

Patients with co-morbidities that may require ICU care

SOP

Outpatient / day care procedures: Minor procedures for Grade I & II

In Patient: Operative procedures for Grade III & IV

Situation 2:

Clinical Diagnosis

Symptoms:

• Bleeding per rectum, bright red, painless


• Anemia due to frequent bleeding


• Mass prolapsing per rectum


• Pain on prolapsed


• Mucous discharge


• Pruritus


• Skin tag

Examination

Direct Visulisation : thrombosed/prolapsed haemorrhoids, external haemorrhoids & skin tags be visualized.

Digital Rectal Examination :

Thrombosed haemorrhoids, as well as other associated conditions such as anal cancer, BPH may be felt per rectum.

Proctoscopy :

Internal haemorrhoids occur in 3, 7 & 11 “o” clock positions. These are visualized during proctoscopy. Haemorrhoids are classified into 4 grades by descent.

Grade Presentation

1. Bleeding


2. Protrusion below the anal verge while straining with spontaneous reduction


3. Protrusion regressing with manual reduction


4. Irreducible protrusions

Based on their location, haemorrhoids can be classified into

External – located distal to dentate line, covered by anoderm, painful, arise from inferior haemorrhoidal plexus

Internal – located prominal to dentate line, covered by insensuate anorectal mucosa, painless, may prolapsed or bleed

Interno – external – features of both

Investigations:

Hb

Peripheral smear

TLC, DLC, ESR

Blood grouping and Rh typing

USG abdomen

Colonoscopy – to r/o other conditions (malignancy) and co-existing when required

Coagulation profile

Treatment:

Medical :

• Laxatives


• Haematinics if anemia is present


• Sitz bath


• Ointment


• Antibiotics when infection or complications are present


• Emergency transfusion when presentation is of profuse haemorrage or severe anaemia due to chronic blood loss

Surgical :

I. Minor Outpatient procedures:

1. Sclerotherapy – for grade 1 & II haemorrhoids and bleeding haemorrhoids

2 to 5 ml of 5% phenol in almond oil injected around pedicle in the submucosa aseptically

2. Banding – gr II & III haemorrhoids by modified Barron’s band applicator above the dentate line

In patient

GR III & IV haemorrhoids

1. Haemorrhoidectomy

• Open: MILLIGAN – MORGAN operation


• Closed: HILL – FERGUSON operation

2. Excision of thrombosed pile mass:

ANESTHESIA: GA/Spinal/Caudal block

Outpatient procedures:

1. Photocoagulation – 1&II degree haemorrhoids

Infrared coagulation probe applied to the apex of each haemorrhoid to coagulate the underlying venous plexus

In-patient procedures:

1. Stapled haemorrhoidectomy: for grade III haemorrhoids. May be done as a day care procedure or as an in-patient

SOP:

In-patient

Day care procedure – depending on the education and awareness of the patient

WHO DOES WHAT?

Doctor

• Clinical examination


• Diagnosis


• Planning surgery


• Surgery


• Post op care


• Anesthesia

Nurse

• Pre & post operative care


• Assisting during surgery

Technician

• Pre operatively equipment and drugs to be checked and kept ready


• Assist anesthetist in the OT


• Assist the surgeon, positioning of the patient

Resources Required For One Patient / Procedure (Patient weight 60 Kgs)

Guidelines by The Ministry of Health and Family Welfare :

Dr Ajit Sinha Department of Surgery Safdarjung Hospital New Delhi