 Hi all, I'm Dr. Vinay. I'm a consultant general laparoscopic surgeon at Northside Manipal Hospital, Malaysia, Bangalore. Today, I'll be presenting upon the management of hemorrhoids. So, now coming to the introduction of hemorrhoids. Hemorrhoids are piles. It is one of the most common presentations involving one in four individuals. Hemorrhoids is derived from the Greek word means blood flowing. It's nothing but the enlargement and displacement of normal anal cushions. Normal anal cushions are the component in the anal wall which has the connective tissues and helps in the maintenance of the evacuation of bubble and the continents. So, the pathological enlargement of the anal cushions and the displacement resulting in the symptoms of bleeding is what we call hemorrhoids. Now coming to the types of hemorrhoids, it is classified as an internal hemorrhoid when it is above the dentate line, external hemorrhoid when it is below the dentate line and both internal external hemorrhoids when it involves both the above and below the dentate line. Characteristically, they are present in the three locations, three, seven and eleven o'clock positions which are called as a primary hemorrhoids and when it is present in between these positions, it is called as a secondary hemorrhoid. The external hemorrhoids are the false hemorrhoids because it is present below the dentate line. It is covered by the skin while the internal hemorrhoids are the true hemorrhoids which is covered by the mucosa and it is present above the dentate line. Now coming to the grades of internal hemorrhoids, it is classed the primarily the internal hemorrhoids are classified into four grades depending upon the symptoms and displacement of the anal cushion. Grade one is just the bleeding without any prolapse. Grade two when there is a prolapse of the hemorrhoids below the dentate line, but it spontaneously reduces by itself. Grade three is when there is a prolapse of the hemorrhoidal tissue, but it requires some manual reduction into the anal canal and grade four when the internal hemorrhoids are prolapsed outside and it can't be reduced inside. Now coming to the causes of hemorrhoids. The hemorrhoids are usually secondary to the chronic long-sanding pressure in the anal canal and this is caused by the chronic pressure when the person is trying to pass the motion. So straining during the bowel movement is one of the most common cause for the internal hemorrhoids. The obese patient, pregnant ladies, liver patients with portal hypertension can also form the hemorrhoids. Now coming to the clinical features, usually the patients present with a painless bleeding, that is a most common symptom of the patient. Usually patient can also present with the prolapse of the hemorrhoidal tissue when there is a mucus discharge. There is some perianal irritation due to seepage of the fecal soiling. The pain occurs only when there is a prolapse or the thrombosis of the internal hemorrhoids. Now coming to the diagnosis and evaluation, hemorrhoids is basically diagnosed by the clinical examination and a brief detailed history. It is also, it can be examined by the digital examination where the external hemorrhoids can be palpated, the spencer tone can be assessed by the digital examination and any other lower enorectal lesions can be excluded. The enoscope or a proctoscope examination reveals the internal hemorrhoids and the grading can also be done. Another way to diagnose the hemorrhoids is a sigmoidoscopy or the colonoscopy. Now coming to the complication of hemorrhoids, the main complications being the thrombosis or strangulation of the hemorrhoids, there may be ulceration of the hemorrhoidal mucusa, there may be gangrene of the hemorrhoidal tissues and sometimes it may be causing severe hemorrhage. Coming to the most common complication what we see in the clinical practices, the thrombost external hemorrhoids or the internal hemorrhoids, usually they are the painful hemorrhoidal tissues which are prolapsed and not reducible inside. Thrombosis is usually, thrombosis external hemorrhoids is usually managed by conservative method. Usually with the antibiotics analgesics, the pain and the thrombosis do come down. If it is not relieved then surgically excision is indicated. Now coming to the management of hemorrhoids, basically the hemorrhoids can be managed by a conservative way in a lower grades of the hemorrhoids. Usually it involves a dietary modifications where high fiber diet is prescribed at lifestyle modifications where the patient is advised for reduction of the weight if the patient is obese, less consumption of the fat, regular exercises can also cause symptomatic improvement in the hemorrhoidal tissue. Then some of the medical management like oral flavonoids or oral calcium double salate can also decrease the hemorrhoidal tissues. Next coming to the topical applications like NTG or Nephidipine calcium channel blockers can cause constriction of the hemorrhoidal blood vessels leading to the some symptomatic improvement. The other conservative management includes the usage of analgesia if there is some painful condition like thrombosis, external hemorrhoids, Sitzbath where we advise the patient to sit in a warm water basin for at least 10 to 15 minutes thrice daily to give some relief to the patient. If there is any severe bleeding then underlying the bleeding dioceses should be evaluated and application of local adrenaline soap gauze can also help in the control of bleeding. Now coming to the non-operative methods of management of hemorrhoids, first most commonly what we use is banding. Banding is usually indicated in grade 2 and grade 3 hemorrhoids where a rubber band ligation is used as a treatment modality. It can be done as an outpatient procedure, a barrens rubber band ligation device is introduced, the hemorrhoidal tissue is suctioned out and the rubber band ligation is done to the pedicle of the hemorrhoidal tissue. This usually causes the avascular necrosis of the hemorrhoidal tissue and usually it slips off within about a week. The main side effect being the pain especially if the rubber band ligation is used for the external hemorrhoid. So preferably this is done for an internal hemorrhoid grade 1 and grade 2. This is usually done as an office procedure and the success rate is quite good. About 80% of the people do symptomatically get better. The recurrence chance is also there when the rubber band ligation is done in a not a correct way. Sclerotherapy, sclerotherapy is another type of a non-operative management of hemorrhoids whereas sclerosant usually 5% phenol in a oil solution or a hypotonic saline is injected in the submucosal plane of the hemorrhoidal tissue. This usually causes the vascular occlusion resulting in the devascularization of the hemorrhoidal tissue and some symptomatic improvement. The main complication being pelvic subsist, improper injection of the sclerosant into the hemorrhoidal tissue can cause severe pain in the area. The sclerosant therapy is again reassessed 8 weeks later and if any repeat injections are required the sclerosant is reinjected. The other modalities include the cryotherapy infrared photocoagulation of the hemorrhoidal tissue or the radiofrequency ablation. In cryotherapy they use a freezing probe which is used to touch the hemorrhoidal tissue. It causes the tissue destruction. The main complication being pain and mucus discharge from the anal canal. So it is an obsolete method now. Infrared photocoagulation uses a probe which causes infrared radiations causing the coagulation of the blood vessels and the tissues resulting in sloughing of the hemorrhoidal tissue. The other modality being a radiofrequency ablator. It also uses a probe which has connected to the radiofrequency machine causing the destruction of the tissues and symptomatic improvement of the hemorrhoidal tissue. Now coming to the surgical management of hemorrhoidal disease. Usually operative management of the hemorrhoids or the piles is the most preferred way as it reduces the symptoms and reduces the chance of recurrence also. Usually indication is grade 3 and grade 4 hemorrhoidal tissue. The grade 2 hemorrhoids where the non-operative treatment has failed. Fibros, hemorrhoids, prolapse hemorrhoids. These are the few indications where the surgical management is preferred way of treatment. Usually excision of hemorrhoidal tissue is done by either scissors, diatomy using of electrocogulation, harmonic scalpel technique or a ligar shore excision. Techniques of open hemorrhoidectomy includes Milligan-Morgan's technique where the excision site is left open or a closed or a Ferguson technique in where the excision of an internal excision hemorrhoid is done and the site is closed using the suture materials. Complications of hemorrhoidectomy usually involves pain in the early postoperative phase. It may cause reactionary hemorrhage. Late complications include stenosis or incontinence which is very rare. The other modality is the stapler hemorrhidopexy. Here using a circular stapling device the lower rectum and the upper anal canal mucosa and submucosa is excised. It is usually indicated in grade 4 prolapsing circumferential hemorrhoidal treatment. Usually it preserves the anal cushion and hence the continence is also preserved. Usually the advantage is being it is a quick less painful and the patient can recover in a better way. The disadvantages of stapler hemorrhidopexy being the cause of the device and sometimes it may cause pelvic sepsis. The other modality of the treatment includes trans-anal hemorrhoidal dearteralization or a Doppler guided hemorrhoidal artery ligation. Here a Doppler guided probe is inserted into the anal canal. The pedicle or the vascular supply of the hemorrhoidal tissue is identified and hemorrhoidal artery ligation is done. So this is a newer way in where usually patient comes as an outpatient procedure. It is done and the recovery is quite fast and it is usually a painless procedure since the procedure is involved ligation of the artery above the dentate line. So the take home message or the summary of the presentation will be a hemorrhoidal or the piles is a common condition affecting one in four individuals. The most common symptom being the bleeding which is painless. A painful hemorrhoidal indicates either a thrombosis or strangulation. The treatment of the management includes variation from the conservative where it involves a dietary modification, lifestyle modification to a radical surgery. Hemorrhoidal the surgery being the most preferred way since the recurrence and the management is most effective method. Thank you all. If you have any doubts or clarification please do leave a comment. We will try to reply back to the clarifications or doubts. If you like this video please share this video to the others who require such information. 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