Haemorrhoids I84.9

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Definition
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Soft, nodular or pillow-shaped vascular dilatations of the anus, anal canal and lower rectum. Significant filling and enlargement when the intra-abdominal pressure is increased.

Classification
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Classification according to severity and symptoms:
  • Grade I: Haemorrhoids are only visible proctoscopically; cherry red nodular protrusion of the mucosa; dilatation of the vascular sponge due to surface tears during defecation; recurrent bleeding (light red on the stool); no pain.
  • Grade II: Hemorrhoids prolapse during pressing, followed by retraction; pain and bleeding during defecation.
  • Grade III: The haemorrhoids are prolapsed but can be reduced manually. Beginning incontinence, slight bleeding during defecation, pruritus and pain.
  • Grade IV: The haemorrhoids are prolapsed and fixed and can no longer be reduced. No or only slight bleeding. Strong painfulness often occurs.

Etiopathogenesis
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Hereditary disposition. Mainly discussed are hyperplasia of the arterially fed anorectal corpus cavernosum or a venous cause such as portal hypertension, congestion in the pelvis and lower portal vein area. Predisposition in chronic constipation, laxative abuse, increased sphincter tone, lack of exercise, low-fibre or high-fat diet, pregnancy, stress, alcohol abuse. This leads to an excessive load situation of the pelvic floor.

Manifestation
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Haemorrhoids are detectable proctoscopically in 70% of > 30 year old adults. Common in industrialized countries. Age peak: 50th-70th LJ.

Localization
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Predilection sites in lithotomy position: at 3, 7 and 11 o'clock.

Clinical features
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Peranal bleeding events. Spontaneous haemorrhoidal bleeding originates from the arteriolar supply vessels and is therefore often perceived as injecting, bright red bleeding. Inflammatory states of the anoderma, disturbances of anal fine continence, itching, intraanal pressure or foreign body sensation possibly with defecation disturbances, prolapse situations can occur. Less frequent are cramp-like pains in the rectum lasting several minutes.

Notice!

Behind every rectal bleeding there can be an intestinal tumour!

Differential diagnosis
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Acute hemorrhoidal vein thrombosis; mariscs; hypertrophic anal papilla; rectal adenoma, prolapsing.

Therapy
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In addition to the therapeutic procedures, stool regulation is essential in haemorrhoidal diseases: regular exercise, regular defecation ("educating the bowel to be punctual"), dietary measures with a high-content diet, avoidance of filling sweets such as chocolate (see Table 1).
  • Grade I and II: Sclerotherapy: use of sclerosing agents containing polidocanol(Aethoxysklerol Kreussler 4%). Blond method: Aethoxysclerol is injected through the lateral window of the proctoscope, strictly submucous, extravasally at the base of the node. Cave! Anaphylactic reactions to polidocanol are possible! In order to avoid a feeling of pressure, it is recommended to extend the number of sessions to about 10. Disadvantage: Elaborate. Advantage: Few recurrences.
    If the injection is too shallow, ulcers of the mucous membrane may occur. If the injection is too deep, abscesses can appear in the muscles or in a neighbouring organ. Recurrences: < 10%. 6-month follow-ups are necessary.
  • An alternative procedure to sclerotherapy is the rubber band ligature according to Barron. In this procedure, the hemorrhoidal knot is grasped with grasping forceps and a rubber ring is pulled over the knot to ligate the base of the knot. After a few days necrotic tissue is rejected. Sessions in 3-week intervals, no more than 2 ligatures per session! Cave! Typically, bleeding may occur several days after the procedure.
  • Grade III and IV haemorrhoids: surgical measures such as 3-tip resection according to Milligan-Morgan or submucous haemorrhoidectomy according to Parks: preparation of the three main nodes (if possible while preserving the anoderma), excision of the haemorrhoidal node, ligation of the three afferent arteries, mucosal suture with absorbable thread, tamponade of the wound area. If necessary, additional sphincterotomy to reduce the anal sphincter tone. 1st postoperative day: removal of the tamponade, then 2 times/day (and after each bowel movement) sitz baths with chamomile. Softening of the stools e.g. with Agiolax or Lactuflor. Complications: Bleeding, postoperative anal stenosis, adhesions in case of extensive anoderm resection.
  • Alternatively: Doppler-guided haemorrhoidal artery ligation (HAL) or stacker haemorrhoidectomy after Longo (circular cuff resection of the rectal mucosa).

Prophylaxis
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Balanced diet rich in fibre (e.g. muesli, wholemeal bread, fruit and vegetables), regular exercise, sports.avoid laxatives, use linseed or lactose if necessary.in case of pelvic floor weakness: gymnastic exercises for the pelvic floor and gluteal muscles.intimate hygiene (e.g. cleaning with a moist but soap-free, soft toilet paper after bowel movement)

Tables
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Therapy of hemorrhoidal disease (modified according to Stein)

Stadium

Therapy

Haemorrhoids I°

1st choice

Sclerotherapy or infrared coagulation

2nd choice

Anal tampons and conservative therapy with local anti-inflammatory and analgesic ointments or suppositories (e.g. DoloPosterine N, LidoPosterine)

Accompanying

Chair regulation

Haemorrhoids II°

1st choice:

Sclerotherapy or infrared coagulation

2nd choice

Rubber ring ligature (Barron)

3rd choice

Operation

Accompanying

Chair regulation

Haemorrhoids III° and IV°

1st choice

Hemorrhoidectomy possibly with plastic

2nd choice

Sclerotherapy (possibly 1-2 times for relief)

3rd choice

Rubber ring ligature and sclerotherapy

In addition, sphincterotomy may be necessary in the case of greatly increased sphincter tone

No laxatives! If laxatives must be used, preferably fillers and swelling agents for a short time (e.g. linseed). In case of pronounced complaints local anaesthetics in various forms (e.g. Xylocaine ointment, LidoPosterine ointment, LidoPosterine Hämotamp)

Literature
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  1. Ashraf S et al (2003) Stapled haemorrhoidectomy: a novel procedure. Hosp Med 64: 526-529
  2. Balasubramaniam S et al (2003) Management options for symptomatic hemorrhoids. Curr Gastroenterol Rep 5: 431-437
  3. Cheetham MJ et al (2003) A randomized, controlled trial of diathermy hemorrhoidectomy vs. stapled hemorrhoidectomy in an intended day-care setting with longer-term follow-up. Dis Colon Rectum 46: 491-497
  4. Goulimaris I et al (2002) Stapled haemorrhoidectomy compared with Milligan-Morgan excision for the treatment of prolapsing haemorrhoids: a prospective study. Eur J Surg 168: 621-625
  5. Johannsson HO et al (2002) Long-term results of haemorrhoidectomy. Eur J Surg 168: 485-489
  6. Muller-Lobeck H (2001) Ambulatory hemorrhoid therapy. Surgeon 72: 667-676

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020