Hemorrhoids are enlarged veins of the hemorrhoidal plexus located in the lower part of the rectum or the anus. Internal hemorrhoids are located over the dentate (pectinate) line and originate from the upper part of the hemorrhoidal plexus. External hemorrhoids are located under the dentate (pectinate) line and originate from the lower part of the hemorrhoidal plexus.
Depending on their degree of prolapse they are classified into:
- 1st degree: Simple enlargement of the hemorrhoidal plexus
- 2nd degree: Varicose veins that heal on their own
- 3rd degree: Prolapsed through the anus, they can be retracted by the patient or the examining physician.
- 4th degree: Prolapsed through the anus, they cannot be retracted.
The clinical image of hemorrhoidopathy varies depending on its degree of prolapse: Hemorrhage is the most frequent symptom (vivid red blood in the stool or on toilet paper), while iron deficiency anemia, anal pruritus, dermatitis and inflammation of the perianal skin may also be present. It is stressed that in any case of rectal bleeding, the presence of other conditions such as malignancies (e.g. rectal cancer) should be excluded.
Hemorrhoid complications are strangulation of the outer sphincter, thrombosis, suppuration, fistula or abscess-in-ano, and rarely serious complications such as pyleophlebitis.
Hemorrhoid treatment depends on their degree and is distinguished into conservative and surgical. Conservative treatment is usually applied to 1st or 2nd degree hemorrhoids and includes diet rich in fibers and intestine residue, mild laxatives, topical use of ointments or suppositories, vasoconstrictors or anti-inflammatory drugs, while various methods of endoscopic management, such as sclerotherapy, cryopexy, electropexy, placement of an elastic annulus etc. 3rd – 4th degree hemorrhoidopathy presents indication for surgical treatment to relieve the patient and to prevent complications. Conservative treatment is recommended during the acute phase while rectal dilation or emergency hemorrhoidectomy are rarely necessary. Emergency dehiscence and clot removal are only recommended in cases of thrombosis – hematoma to relieve the patient. Currently the prevailing methods are THD hemorrhoidopexy, closed and open hemorrhoidectomy.
THD hemorrhoidopexy: THD (Transanal Hemorrhoidal Dearterialization) is the most indicated method to treat internal hemorrhoids. The method is based on the identification of vessels via a special Doppler ultrasound device (HAL-RAR). The arterial flow is identified using a special tool – a proctoscope equipped with a specifically adapted ultrasound head. Hemorrhoidal artery dearteriation is then performed by the surgeon with the use of sutures under direct visualization. It is followed by suturing with a special technique (hemorrhoidopexy) to treat hemorrhoid prolapsed through the annulus. Aesthetic results becomes impressive without performing hemorrhoid resection. If vascularisation is interrupted, this will result in the shrinking. It is a non-invasive, short relatively painless and totally safe method. It can be performed under general anesthesia or sedation while patients may leave the hospital on the same day and immediately return to work and daily activities.
Hemorrhoidectomy: There are two classical hemorrhoidectomy procedures, open surgery (Milligan-Morgan) and closed surgery. The Milligan-Morgan procedure is the typical treatment method during which hemorrhoidal nodules are removed and hemorrhoidal vessels are openly ligated at their typical positions (3rd, 7th, 11th hour). In closed surgery, which is a variation of the open procedure, the part of the mucosa lining being removed is closed with absorbable sutures. Hemorrhoidectomy usually entails more pain and delayed healing of the wound.
Other techniques are used in order to treat hemorrhoids e.g. the Longo method (Procedure for Prolapse and Hemorrhoids-PPH) that is recommended for removing a part of the rectal mucosa over the dentate line using a circular stapler to make hemorrhoids shrink. The complications that have been described in relation to this procedure are rare but serious. Other techniques used include annulus dilation, inner lateral sphintirectomy, etc.
There is no standard procedure for all hemorrhoid cases. Treatment is personalized. THD method is recommended for most cases owing to the significant advantages it presents and which are described above. Alternatively, hemorrhoidectomy is a widely accepted procedure.
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