Haemorrhoids

Anatomy

In the perianal region there are several venous plexuses, which are networks of vessels joined by anastomosis. The haemorrhoidal plexus communicates with the uterovaginal plexus in the female and the vesical venous plexus in the male. Free communication between the portal and systemic venous systems is established thanks to the haemorrhoidal plexus. The plexuses located above the dentate line are covered by the columnar epithelium of the rectum. These structures make up the internal haemorrhoidal plexus and can give rise to so-called internal haemorrhoids. The internal haemorrhoidal plexus is drained by the superior and middle rectal veins. The superior rectal veins are tributaries of the inferior mesenteric vein, which in turn is a branch of the portal vein. The middle rectal veins, on the other hand, are tributaries of the internal iliac vein, which becomes the common iliac vein and eventually forms the inferior vena cava. Below the aforementioned dentate line we find a venous plexus covered by the squamous epithelium which characterises the anal region and which can give rise to external haemorrhoids. The external haemorrhoidal plexus is a tributary of the inferior rectal vein, a branch of the internal pudendal vein, which in itself is a tributary of the internal iliac vein (also known as the hypogastric vein). As we have already seen, the internal iliac vein drains into the inferior vena cava system through the common iliac vein. Internal haemorrhoids occur due to the superior haemorrhoidal plexus, while the inferior haemorrhoidal plexus is the cause of external haemorrhoids. The dentate line represents an important anatomical landmark dividing the two regions.

Pathophysiology and classification

Haemorrhoidsare cushions of highly vascularised tissue located in the anal canal (cavernous section of the rectum) that are part of normal human anatomy, but can become a pathological condition when swollen.
From an anatomical point of view, according to their position in relation to the anal canal, we can identify three main cushions:

  1. left lateral,
  2. right anterior,
  3. right posterior,
  4. ancillary (usually two small ones in varying positions).

Haemorrhoids are structures which cannot be defined as arteries, nor as veins. Instead, they are blood vessels (more specifically sinusoids) located in the submucosal tissue, to which connective stroma and smooth muscular tissue are attached to provide support, along with the veins of the haemorrhoidal plexus and arteriovenous connective tissues associated with them.

Sinusoids differ from veins, since they do not have muscle tissue in their walls.
The traditional theory which claimed that haemorrhoids were varicose veins is now outdated. In 1975, Thomson identified them as vascular cushions due to their relatively constant position (right anterior, right posterior, left lateral) which gives the anal canal a radial form, like a star which can be divided into three parts.

Haemorrhoids play a very important role in faecal continence. Once defecation is complete, they quickly fill with blood and contribute, at rest, to 15-20% of the pressure needed to close the anus. They also help to protect the muscles of the anal sphincter during defecation.

According to a pathogenetic theory, the pressure in the superior haemorrhoidal veins, which have no valves, constantly increases whenever we are in a standing position, and therefore they inevitably begin to dilate over time. This view is supported by the relative rare occurrence of haemorrhoids in quadrupeds.

Internal haemorrhoids are classified based on the degree of prolapse.

  1. The haemorrhoid is dilated but with no prolapse;
  2. The haemorrhoid prolapses during defecation but spontaneously reduces afterwards;
  3. The haemorrhoid prolapses during defecation and must be manually repositioned inside;
  4. The haemorrhoid prolapses and cannot be repositioned inside, even manually. The fourth degree is also known as a haemorrhoidal crisis, and much of the mass of the prolapse is made up of oedema.

In my daily practice, I carry out the aforementioned classification on the basis of a series of morphological contexts that can occur depending on the degree of prolapse. These are characterised by a lower case letter and are linked to different types of treatment:

  • Oedema: This is characteristic of haemorrhoidal crisis or Grade 4 haemorrhoids; in this phase surgical procedures are contraindicated, and only treatment with medication is possible.
  • Thrombosis: Treatment is an immediate thromboembolectomy without anaesthesia. This resolves the symptoms straight away, avoiding lengthy and costly medical treatments;
  • Ulceration below or above dentate line: In these cases, a biopsy of the ulcer must be carried out along with a histological assessment. The treatment can then be carried out, once we are certain of the histological nature of the ulcer.
  • Ulceration of haemorrhoidal swelling: Band ligation of the ulcerated haemorrhoid is recommended;
  • Haemorrhoids with regular epithelium surface: Unlikely to lead to carcinogenesis; if necessary for non-medical reasons, band ligation treatment can be postponed.
  • Haemorrhoids where the epithelium surface has degenerated: (usually characterised by susceptibility to bleeding) indicates that inflammation has been present for a long time - prompt treatment is recommended to prevent carcinogenesis. Paradoxically, patients in this group often put off treatment, because the bleeding decongests the venous plexus so the patient feels better and does not feel the need to resort to surgical treatment. This situation is the one most closely associated with rectal cancer. Furthermore, it is the scenario most often associated with chronic anaemia, so a blood count and a test for iron and ferritin levels should always be done. Finally, in these cases rectoscopic exams should be carried out at least every 6-12 months to avoid nasty surprises.
  • Associated with occult anterior mucosal prolapse: In these cases, firstly band ligation of the haemorrhoids takes place, followed by ligation of the mucosal prolapse in the second session. Note the difference between the wine-red haemorrhoidal tissue (containing blood) and the prolapse made of normal pinkish mucosa.
  • Associated with anal papillae: Hypertrophied anal papillae undergo ligation along with the haemorrhoids in the same sitting.
  • Associated with fissures: In these cases, the haemorrhoids undergo ligation first, then a month later the fissures undergo cryo-sphincterotomy, otherwise a haemorrhoidal crisis could result.
  • Associated with fistulas: Similarly, in this case the haemorrhoids undergo ligation and then the fistulas are treated, for the same reasons.
  • Associated with external haemorrhoids: Both issues can be treated in the same session, but after ligation the external haemorrhoids are cryo-treated to reduce the pain caused by skin binding.
  • Associated with skin tags: Band ligation of the haemorrhoids is done first, and at the end the skin tags are surgically excised and sutured to heal by primary intention.
  • Associated with comedonic abscesses: Caused by perianal sebaceous cysts, often ulcerated as in the case shown. These are excised in a separate session from the ligation of the haemorrhoids.
  • Associated with perianal abscesses: The same procedure as the previous case applies.
  • Associated with benign tumours (polyps)
  • Associated with malign tumours: In these cases, the haemorrhoidal disorder becomes irrelevant, since resecting the cancer also removes the haemorrhoidal tissue.

HAEMORRHOIDS

ANATOMY

 

In the perianal region there are several venous plexuses, which are networks of vessels joined by anastomosis. The haemorrhoidal plexus communicates with the uterovaginal plexus in the female and the vesical venous plexus in the male. Free communication between the portal and systemic venous systems is established thanks to the haemorrhoidal plexus. The plexuses located above the dentate line are covered by the columnar epithelium of the rectum. These structures make up the internal haemorrhoidal plexus and can give rise to so-called internal haemorrhoids. The internal haemorrhoidal plexus is drained by the superior and middle rectal veins. The superior rectal veins are tributaries of the inferior mesenteric vein, which in turn is a branch of the portal vein. The middle rectal veins, on the other hand, are tributaries of the internal iliac vein, which becomes the common iliac vein and eventually forms the inferior vena cava. Below the aforementioned dentate line we find a venous plexus covered by the squamous epithelium which characterises the anal region and which can give rise to external haemorrhoids. The external haemorrhoidal plexus is a tributary of the inferior rectal vein, a branch of the internal pudendal vein, which in itself is a tributary of the internal iliac vein (also known as the hypogastric vein). As we have already seen, the internal iliac vein drains into the inferior vena cava system through the common iliac vein. Internal haemorrhoids occur due to the superior haemorrhoidal plexus, while the inferior haemorrhoidal plexus is the cause of external haemorrhoids. The dentate line represents an important anatomical landmark dividing the two regions.

PATHOPHYSIOLOGY AND CLASSIFICATION

 

Haemorrhoids are cushions of highly vascularised tissue located in the anal canal (cavernous section of the rectum) that are part of normal human anatomy, but can become a pathological condition when swollen.

From an anatomical point of view, according to their position in relation to the anal canal, we can identify three main cushions:

1. left lateral,

2. right anterior,

3. right posterior,

4. Ancillary (usually two small ones in varying positions).

Haemorrhoids are structures which cannot be defined as arteries, nor as veins. Instead, they are blood vessels (more specifically sinusoids) located in the submucosal tissue, to which connective stroma and smooth muscular tissue are attached to provide support, along with the veins of the haemorrhoidal plexus and arteriovenous connective tissues associated with them.

Sinusoids differ from veins, since they do not have muscle tissue in their walls.

The traditional theory which claimed that haemorrhoids were varicose veins is now outdated. In 1975, Thomson identified them as vascular cushions due to their relatively constant position (right anterior, right posterior, left lateral) which gives the anal canal a radial form, like a star which can be divided into three parts.

Haemorrhoids play a very important role in faecal continence. Once defecation is complete, they quickly fill with blood and contribute, at rest, to 15-20% of the pressure needed to close the anus. They also help to protect the muscles of the anal sphincter during defecation.

According to a pathogenetic theory, the pressure in the superior haemorrhoidal veins, which have no valves, constantly increases whenever we are in a standing position, and therefore they inevitably begin to dilate over time. This view is supported by the relative rare occurrence of haemorrhoids in quadrupeds.

Internal haemorrhoids are classified based on the degree of prolapse.

Grade 1: The haemorrhoid is dilated but with no prolapse;

Grade 2: The haemorrhoid prolapses during defecation but spontaneously reduces afterwards;

Grade 3: The haemorrhoid prolapses during defecation and must be manually repositioned inside;

Grade 4: The haemorrhoid prolapses and cannot be repositioned inside, even manually. The fourth degree is also known as a haemorrhoidal crisis, and much of the mass of the prolapse is made up of oedema.

 

In my daily practice, I carry out the aforementioned classification on the basis of a series of morphological contexts that can occur depending on the degree of prolapse. These are characterised by a lower case letter and are linked to different types of treatment:

 

a) Oedema: This is characteristic of haemorrhoidal crisis or Grade 4 haemorrhoids; in this phase surgical procedures are contraindicated, and only medical treatment is possible. (Fig. 4)

 

 

b) Thrombosis: Treatment is an immediate thromboembolectomy without anaesthesia. This resolves the symptoms straight away, avoiding lengthy and costly medical treatments. (Fig 5/6)

 

c) Ulceration below or above dentate line: In these cases, a biopsy of the ulcer must be carried out along with a histological assessment. The treatment can then be carried out, once we are certain of the histological nature of the ulcer. (Fig. 7)

 

 

d) Ulceration of haemorrhoidal swelling: Band ligation of the ulcerated haemorrhoid is recommended. (Fig. 8)

 

e) Haemorrhoids with regular epithelium surface: Unlikely to lead to carcinogenesis; if necessary for non-medical reasons, band ligation treatment can be postponed.

f) Haemorrhoid where the surface of the epithelium has degenerated: (usually characterised by susceptibility to bleeding) indicates that inflammation has been present for a long time - prompt treatment is recommended to prevent carcinogenesis. Paradoxically, patients in this group often put off treatment, because the bleeding decongests the venous plexus so the patient feels better and does not feel the need to resort to surgical treatment. This situation is the one most closely associated with rectal cancer. Furthermore, it is the scenario most often associated with chronic anaemia, so a blood count and a test for iron and ferritin levels should always be done. Finally, in these cases rectoscopic exams should be carried out at least every 6-12 months to avoid nasty surprises.

 

g) Associated with occult anterior mucosal prolapse:(Fig. 9) In these cases, firstly band ligation of the haemorrhoids takes place, followed by ligation of the mucosal prolapse in the second session. Note the difference between the wine-red haemorrhoidal tissue (containing blood) and the prolapse made of normal pinkish mucosa.

 

 

Associated with anal papillae: Hypertrophied anal papillae undergo ligation along with the haemorrhoids in the same sitting. In Fig. 10 we see a hypertrophied papilla with papillitis.

h) Associated with fissures: In these cases, the haemorrhoids undergo ligation first, then a month later the fissures undergo cryo-sphincterotomy, otherwise a haemorrhoidal crisis could result.

i) Associated with fistulas: Similarly, in this case the haemorrhoids undergo ligation and then the fistulas are treated, for the same reasons.

j) Associated with external haemorrhoids: Both issues can be treated in the same session, but after ligation the external haemorrhoids are cryo-treated to reduce the pain caused by skin binding

 

Associated with anal papillae: Hypertrophied anal papillae undergo ligation along with the haemorrhoids in the same sitting. In Fig. 10 we see a hypertrophied papilla with papillitis.

h) Associated with fissures: In these cases, the haemorrhoids undergo ligation first, then a month later the fissures undergo cryo-sphincterotomy, otherwise a haemorrhoidal crisis could result.

i) Associated with fistulas:Similarly, in this case the haemorrhoids undergo ligation and then the fistulas are treated, for the same reasons.

j) Associated with external haemorrhoids: Both issues can be treated in the same session, but after ligation the external haemorrhoids are cryo-treated to reduce the pain caused by skin binding

 

 

k) Associated with skin tags: (Fig. 11) Band ligation of the haemorrhoids is done first, and at the end the skin tags are surgically excised and sutured to heal by primary intention.

Associated with comedonic abscesses: Caused by perianal sebaceous cysts, often ulcerated as in the case shown. These are excised in a separate session from the ligation of the haemorrhoids.

l) Associated with perianal abscesses: The same procedure as the previous case applies.

m) Associated with benign tumours (polyps): same procedure as described in Point M

n) Associated with malign tumours: In these cases, the haemorrhoidal disorder becomes irrelevant, since resecting the cancer also removes the haemorrhoidal tissue.

BAND LIGATION

Band ligation is a proctological procedure that can be used to treat various anorectal disorders, particularly:

  1. Internal haemorrhoids from Grade 1 to Grade 3
  2. External haemorrhoids (+cryotherapy)
  3. occult anterior mucosal prolapse;
  4. Rectal mucosal prolapse (+infiltration of fibrosis)
  5. Rectal prolapse with inversion of the sphincter (+fibrosis)
  6. Rectocele (+infiltration of fibrosis)
  7. Hypertrophied anal papillae
  8. Inflamed polyps

BAND LIGATION: DEVELOPMENTS AND ADVANTAGES


As shown by the preceding list, band ligation of haemorrhoids has today developed into a procedure that can be used for many anorectal disorders, allowing sufferers to receive relatively painless outpatient treatment, removing the need for hospital admissions, risky surgery and major (i.e. general and spinal cord) anaesthesia which in itself is not risk-free.
Being admitted to hospital to treat proctological disorders exposes patients to the risk of infection, which is a serious problem that often requires lengthy and difficult treatment, since hospitals are invaded by germs resistant to most antibiotics, while the germs that circulate in an outpatient centre separate from a hospital are easy to control with most antibiotics found on the market.
Invasive anorectal surgeries that require suturing (such as the Longo or Milligan Morris techniques) run a high risk of the wound becoming infected and bursting open, since they are done in an environment that may not be sterile for the anatomical area in question; when the needle or clip penetrate the mucosa they bring with them germs which are potentially very dangerous if introduced in environments other than those in which they normally live. At this point it is clear that being able to use a technique that does not penetrate the mucosal barrier, such as band ligation, avoids these serious complications which can entail further operations and even lead to death in the most serious cases.
As noted, general anaesthesia damages the brain - only minimally with new technologies, but in time this can build up and produce significant illnesses, especially when used on diabetic patients or those with cerebrovascular diseases, which can be aggravated.
Spinal or epidural anaesthesia exposes the patient to the risk of lesions in the spinal plexus, which can result in painful chronic neuropathy.
At this point it is clear that whenever possible, using a technique free from such complications, which produces excellent results without running risks, and which does not require admission to hospital and the use of major anaesthetics, should guide the patient towards choosing these techniques, such as band ligation.

Band ligation is carried out with a special, ingenious and yet simple instrument, which is the Barron ligator but modified to add suction. The instrument (shown in the image below) is connected to a vacuum and rubber rings are applied to the conical tip. Once the suction cup is positioned above the tissue to be bound, part of the suction channel is blocked using a finger, creating a vacuum which sucks the tissue to be bound into the cup. The rings are then pushed out using a ring pusher and positioned at the base of the tissue, whose circulation is therefore cut off, so that it undergoes necrosis.

Band ligation is a technique free from complications, and is very precise in the sense that the doctor cannot bind arteries or nerves by mistake, since they are positioned between the muscle structures and therefore cannot be sucked into the instrument. The only structures that can be sucked into the instrument are mucosa and venous cushions which are dilated (and thus diseased).

Band ligation procedure

CASE REPORT
BAND LIGATION VS LONGO TECHNIQUE

49-year-old woman operated on using the Longo technique six months prior: condition of the anus before band ligation.

Notice the prolapse of the rectal mucosa (pink) and the skin of the anal canal.

There was also a occult anterior mucosal prolapse with an initial rectocele.

Firstly the occult anterior mucosal prolapse was bound, located above the haemorrhoidal swellings. The proof that the structure being bound consists of mucosa and not haemorrhoidal tissue lies in the pinkish colour of the tissue, which indicates a normal relationship between arteries and veins, while the subsequent haemorrhoids become blackish due to being filled with venous blood after ligation

Binding the first haemorrhoid

Binding the second haemorrhoid

Binding the third haemorrhoid

Anus after ligation - the mucosa has completely disappeared

Supporters of the Longo technique claim that band ligation is only to be used for Grade 1 and Grade 2 haemorrhoids, but this case report clearly belies that affirmation. The surgery was performed in an outpatient clinic under local anaesthesia. The patient did not experience any pain, and once the treatment was over she drove home without any problems. At home she was able to carry out household tasks without any problems and without needing to stay in bed. The recovery period was pain-free and no particular ailments were encountered, the patient took only 25 drops of painkillers when the local anaesthetic begin to wear off. She could also eat and go to the bathroom regularly, and eliminated the rubber rings after 7 days. The only potential problem could have been on the third day, when the tied-off tissue started to undergo necrosis, and the necrotic liquid started to drain out from the anus. The problem was prevented by inserting a tampon of toilet paper between the buttocks, to be replaced often, and frequently washing the area with water, to prevent the necrotic liquid stagnating outside the anus and irritating the skin of the buttocks.

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