Perianal complications in puerperium and associated risk factors

Introduction: Puerperium is defined as the period of about 6 weeks after childbirth during which the mother's reproductive organs return to their original nonpregnant condition. Perianal problems, including constipation, hemorrhoids, and fissure, are among the most common digestive complications among women in puerperium, observed in about 30 to 50 percent of women. Considering this great prevalence and the paucity of similar research in this aspect in an Indian population, the present study was done to assess the prevalence of perianal problems seen in puerperium and the risk factors associated with it. Methods: This was a prospective observational cohort study done over the span of 3 years on 902 puerperal women. A self-structured questionnaire covered detailed history and per-rectal and proctoscopy examination. Patients were followed up telephonically for regression of perianal problems post management. Results: The total prevalence of all the perianal problems in puerperium encountered in the present study, out of 902 subjects, was 36.3% (327 subjects). The perianal problems encountered were fissure in 185 patients (20.5%) followed by hemorrhoids in 110 patients (12.2%), perianal episiotomy infections in 25 patients (2.8%), and perineal tears in 7 patients (0.8%). On comparative analysis, positive family history, macrosomia, past history of perianal diseases, and second stage of labour > 50 minutes showed a higher prevalence in the perianal disease group as compared with the healthy group. Out of these, positive family history of perianal diseases (p= 0.015) and past history of perianal diseases (p= 0.016) were statistically significant. The percentage of multipara with hemorrhoids was more when compared to primipara (p= 0.01), patients who had a past history of any perianal disease have a higher chance of hemorrhoids during puerperium (p= 0.00). Patients with constipation in pregnancy have higher chance of hemorrhoids in pregnancy (p= 0.00). Patients who had a past history of any perianal disease had higher chance of fissure during puerperium (p= 0.00). A total of 27.74% of the study subjects with macrosomic babies had fissure in their puerperal period which on comparison with patients with non macrosomic babies was only 19.22%, which was statistically significant (p= 0.02). Conclusion: Constipation, hemorrhoids, and anal fissures are the most common perianal problems in postpartum period causing significant reduction in the quality of life of those afflicted with them. (AU)

Role Of Sulphur In Haemorrhoids

Background:As there is controversy and disagreement with respect to treatment of Haemorrhoids adopted by conventional method due to inefficacy, relapse and complications are seen. It is most prevalent ailments and impacts the quality of life significantly. Haemorrhoids are enlarged, swollen veins around the anus externally or in lower rectum1. This study aim to access Role of Sulphur in Cases of Haemorrhoids as a constitutional2,3, medicine follow well2,3, anti miasmatic5,6. The Study showed near about 100% of cases responded to Sulphur4,5, thus proving effective role of Sulphur in Haemorrhoids. The study aim role of Sulphur in Haemorrhoids.Aminimum of 1 year and 15 to 70 yrs of age and six matched controls were included in the study. As there is controversy and disagreement with respect to treatment of Hamorrhoids adopted by conventional method due to inefficacy relapse and complications are seen. It is most prevalent ailments and impacts the quality of life significantly. Haemorrhoids are enlarged, swollen veins around the anus externally or in lower rectum1. Material And Methods:Here patients were subjected on clinical presentation and examination using standard scales measuring severity andanoscopy. The entire process was done using standard case research record with a follow up of minimum 3 months period. Result:Out of 30 patients screened, it was observed that 66.6% of affected patient were in age group of 25-40, 16.7% in 41-54. Males prevalency was present and in that 26.6% were service class, driver 13.3% and mechanics 13.3%. Showing occupation played a significant role. The study should 100% of cases responded to sulphur as a constitutional medicine in 23.3% cases, as a follows well cases in 60%. Conclusion:Hence we conclude that along with Homoeopthic medication used asconstitutional, follow well, Dietary corrections, correction of sedentary habits by exercise etc. Which are the predisposing factorsis alsomandatory.

Effect of High Suspension and Low Incision Surgery Based on Traditional Ligation of Chinese Medicine in Treatment of Mixed Haemorrhoids: A Multi-centre, Randomized, Single-Blind, Non-inferiority Clinical Trial / 中国结合医学杂志

OBJECTIVE@#To observe the clinical effect of high suspension and low incision (HSLI) surgery on mixed haemorrhoids, compared with Milligan-Morgan haemorrhoidectomy.@*METHODS@#A multi-centre, randomized, single-blind, non-inferiority clinical trial was performed. Participants with mixed haemorrhoids from Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing Rectum Hospital, Air Force Medical Center of People's Liberation Army of China, and Puyang Hospital of Traditional Chinese Medicine were enrolled from September 2016 to March 2018. By using a blocked randomization scheme, participants were assigned to two groups. The experimental group was treated with HSLI, while the control group was treated with Milligan-Morgan haemorrhoidectomy. The primary outcome was the clinical effect evaluated at 12 weeks after operation. The secondary outcomes included the number of haemorrhoids treated during the operation, pain scores, use of analgesics, postoperative oedema, wound healing, incidence of anal stenosis, anorectal manometry after operation, as well as surgical duration, length of stay and total hospitalization expenses. A safety evaluation was also conducted.@*RESULTS@#In total, 246 eligible participants were enrolled, with 123 cases in each group. There was no significant difference in the clinical effect between the two groups (100.00% vs. 99.19%, P>0.05). Compared with the control group, the number of external haemorrhoids treated during the operation and the pain scores after operation were significantly reduced in the experimental group (P0.05). The surgical duration and length of stay in the experimental group were significantly longer than those in the control group, and the total hospitalization expense was significantly higher than that in the control group (all P<0.05). No adverse events were reported in either group during the whole trial or follow-up period.@*CONCLUSION@#HSLI had the advantages of preserving the skin of anal canal completely, alleviating postsurgical pain and promoting rapid recovery after operation. (Registration No. ChiCTR1900022883).

Evaluation of outcome in open and stapler haemorrhoidectomy in grade III/IV haemorrhoids

Background: Haemorrhoids are one of most common benign anorectal malformation worldwide. There are various surgical treatment modalities for 3rd and 4th degree haemorrhoids. Open haemorrhoidectomy was the most widely practiced and is considered the current gold standard. In search of a newer surgical technique, stapler has been introduced for haemorrhoidectomy and has revolutionised operative procedures over the last decade world-wide due to its ease and simplicity and lesser post-operative complications. The following study was done to evaluate the outcome of open versus stapled haemorrhoidectomy in terms of post-operative pain, postoperative bleeding, duration of surgery, duration of hospital stays in a medical college hospital at Raipur, Chhattisgarh.Methods: This was a prospective follow-up study, in patients undergoing surgery for grade III/IV haemorrhoids conducted in the Department of Surgery, Dr BRAM Hospital, Raipur, from August 2017 to July 2018. Fourteen patients underwent stapled haemorrhoidopexy and eighteen underwent open haemorrhoidectomy. All patients were reviewed immediately after surgery, at discharge and at 1, 3 and 10 weeks post-operatively. The two groups were compared for post-operative outcomes and complications.Results: The majority of patients in the study were males and had grade 4 haemorrhoids. Stapled haemorrhoidopexy group had shorter duration of surgery, less postoperative pain, shorter duration of hospital stays as compared with open haemorrhoidectomy group. There were no major post-operative complications in the follow up period of 10 weeks in the stapled group.Conclusions: Stapled haemorrhoidopexy is a safer alternative to open haemorrhoidectomy with many short-term benefits.

Uncontrolled per rectal bleeding in chronic myeloid leukaemia: a mere coincidence or a dangerous sign report of an unusual case

Bleeding haemorrhoids present commonly to surgical outpatient departments (OPDs) and sometimes in emergency. Most often conservative management suffices but infrequently the patients can land up in emergency operation theatre for uncontrolled bleeding. Some haematological disorders can also present with rectal bleeding and amongst them Chronic myeloid leukaemia (CML), a haematological malignancy, presenting as bleeding per rectum has been not been reported so far, though instances of CML with gingival bleed, epistaxis have been reported. CML per se is known to be asymptomatic (40% cases) and bleeding is rarely seen. Here we present an interesting case of an emergency hemorrhoidal bleed that was subsequently diagnosed as CML. The patient after failed conservative management for bleeding haemorrhoids was taken up for emergency haemorrhoidectomy and again a relook under general anaesthesia in the post-operative period as he continued to ooze. The total leucocyte counts which were initially high continued to rise further and the bone marrow examination was reported as chronic myeloproliferative neoplasm and the excised mass was consistent with haemorrhoids. Rectal bleeding associated with CML is so far unreported even though bleeding is seen due to platelet dysfunction from gums and nose in chronic phases of the disease. A high index of suspicion is needed particularly with deranged haematological parameters for considering a diagnosis of these rare presentations. and anaesthesia.

Efficacy of foam sclerotherapy in treatment of grade I and grade II bleeding hemorrhoids at Nalanda Medical College and Hospital, Patna

Background: Sclerotherapy is the treatment of choice for first and second grade haemorrhoidal disease. The aim of this study is to assess the efficacy and safety of polidocanol foam for haemorrhoidal disease.Methods: A total of 50 patients were treated with foam sclerotherapy (polidocanol 3%). Patients who presented with complain of bleeding per anum and diagnosed with first and second grade hemorrhoidal disease were included. Patients without bleeding per anum were not included. The primary objective was the stopping of perianal bleeding after one sclerotherapy session. Sclerotherapy was repeated at 2-week intervals until patients were free of bleeding. The final follow-up was 12 weeks after the last sclerotherapy session.Results: After one foam sclerotherapy session, 82% of patients (41 out of 50) were treated successfully. After second sclerotherapy, 98% of the patients (46 out of 50) were treated successfully. 2% of the patients received third sclerotherapy.Conclusions: In the treatment of first and second grade haemorrhoidal disease, polidocanol 3% foam is very effective and safe. The results of this study show that foam sclerotherapy is a new, innovative, effective and safe non-surgical treatment option for haemorrhoidal disease.

A Prospective Interventional Study of Outcome of Internal Sphincterotomy in Closed Haemorrhoidectomy.

Haemorrhoids are nowadays a very common anorectal disease in the community. It may be attributed to increased consumption of more refined and junk food by the present generation of people. We have been seeing symptomatic haemorrhoids as early as late teenagers, and early 20's. Well, there are plenty of treatment options available, among them, in our hospital we have been doing Ferguson's closed haemorrhoidectomy, but pain and urinary retention are frequently seen and sometimes troublesome requiring removal of per-anal pack overnight/Foley’s catheterization. And also, in those patients with tight sphincters, because of straining to pass the stools for the first time, the wound margins used to give away, converting into an open haemorrhoidectomy. Aim of this study was to assess the effect of sphincterotomy in patients undergoing closed haemorrhoidectomy, in terms of immediate post-operative pain and urinary retention.METHODSPatients who came with symptomatic haemorrhoids to our hospital during the period January 2018 to August 2019 were assessed and patients requiring haemorrhoidectomy were included in the study according to inclusion and exclusion criteria. Patients included in the study were randomly divided into 2 groups (without/with sphincterotomy) till target of 50 was achieved. Post-operative outcomes of pain and incidence of urinary retention was compared among the 2 groups.RESULTSOn analysing the data regarding severity of pain and incidence of urinary retention between the 2 groups, there was significant difference (p value <0.001) in perceiving pain on all the days of assessment, and incidence of urinary retention was significantly low in sphincterotomy group (p value 0.001).CONCLUSIONSDoing internal sphincterotomy at the base of haemorrhoidectomy wound significantly reduces the immediate post-operative pain and urinary retention following closed haemorrhoidectomy. So, when sphincter tone is high, it's better and safer to do sphincterotomy to alleviate immediate post-operative pain and urinary retention.

Comparison of single versus double versus triple site band ligation for haemorrhoids in a single visit: a case-controlled double blind randomized study

Background: Rubber band ligation is considered one of the most popular non-surgical procedures available, representing the most reasonable balance between efficacy, pain and potential of complication. The present study was a controlled double blinded randomized study to compare Single versus double versus triple site band ligation for haemorrhoids in single treatment visit with special regards to its safety and efficacy in our patient population.Methods: There were 78 patients equally randomized in three groups by closed enveloped method. The number of patients in each group was 26, In Group A, a single, in Group B, two, and in Group C three major haemorrhoidal groups were rubber band ligated, in a single treatment visit on outpatient basis under topical anaesthesia with lignocaine 2% jelly.Results: Rubber band ligation was effective with significant symptom improvement seen in all patients with 88% patient satisfaction at end of 30 days period. Post ligation pain score and number of analgesic requirement in immediate post band ligation period, at 12 hours, at 1,7,14, 21 and 30 days post band ligation were similar in all three groups with p value >0.05. Multiple site haemorrhoidal bandings was done safely at single session without severe discomfort, pain or bleeding or severe complications requiring hospitalization.Conclusions: The study finding shows that triple site band ligation in a single session is a safe way of treating symptomatic haemorrhoids with similar post-procedure pain and patient satisfaction as conventional single or double site band ligation.

A Retrospective Study of Fistula in Ano & Primary Sphincter Repair (Sphincteroplasty) in Complex Fistulas

Fistula in ano is a common perianal disease of the mankind. It is secondary to mainly cryptoglandular infections & abscess. Persistence of chronic infection will lead to fistula formation.1 Management of high-level fistulas is complicated due to incontinence, which is troublesome; hence, many procedures have been tried by many surgeons, but without any supremacy over others. Immediate reconstruction of divided sphincter muscle will give good result.2 We have done fistulectomy & repair of the external anal sphincter & followed for the last two decades with no incontinence & minimal recurrences.METHODS192 cases of fistula in ano for the last 20 years operated by a single surgeon (1st author) were studied & were followed up to now. The differences, in the selection of cases, surgical skill & post-operative management are excluded in the study by including cases done by a single surgeon (first author) only. 136 males & 56 females were operated. Intersphincteric 45.8%, trans-sphincteric 49%, high level fistulas 5.2%, trans-sphincteric & high fistulas with considerable external sphincter loss (54 cases) were repaired with 1–0 Vicryl. Fistula in ano is associated with haemorrhoids in 24/192 & ano rectal abscess (20/192). Fistulotomy done in 16/192, simple & subcutaneous tracts - fistulectomy done in 65%. Curetting of the high tracts done in 16/192.RESULTSMales are predominantly affected 70.8%. This is more common in 3rd, 4th & 5th decades (80.1%). Single external opening was seen in (90%). Posterior & lateral fistula tracts are more commonly seen in (89.6%). Non-specific pyogenic infective pathology is seen 99%. Recurrences- 6/192. Time taken to heal is 3–6 weeks. Incontinence is not seen in any case. No recurrence or incontinence seen in primary sphincter repair of 54 cases.CONCLUSIONSPrimary sphincter repair is simple & best procedure with minimal or no recurrence & decreases the healing time. It is more suitable & advised in fistulas with considerable external sphincter loss.

Comparison of Doppler Guided Haemorrhoidal Artery Ligation (DG-HAL-RAR) with Open Haemorrhoidectomy.

Hemorrhoidal disease is a common reason for consultation in proctology and a public health problem responsible for discomfort and urgent request relief. Patients mostly complain of pain, discomfort, bleeding, and itching. Currently, combining an anoscope and a Doppler transducer makes it possible to detect and bind the arteries responsible for congestion selectively thereby reducing the blood flow and thus collapsing haemorrhoids.(1) Doppler-guided ligation of haemorrhoidal vessels is being proposed as a treatment of grade 2 and 3 haemorrhoids.(2)METHODSAll patients attending the outpatient department of general surgery at Sri Siddhartha Medical College and Research Institute with characteristics of grade 2 and grade 3 haemorrhoids were included in the study. In this prospective study, we compared the results of open haemorrhoidectomy and DGHAL techniques by means of duration of surgery, postoperative pain, post-operative need for analgesics, post hospital stay, and complications. Ninety-six patients were enrolled in this study and were subsequently divided into two groups of 48 members in each. Group A patients received an open haemorrhoidectomy and Group B received a DGHAL.RESULTSDuration of surgery was for DG-HAL group is significantly lesser than open haemorrhoidectomy. Post-operative pain score using VAS was significantly lesser in DG-HAL than open haemorrhoidectomy. Post-operative need for analgesics was significantly lesser in DG-HAL than open haemorrhoidectomy. Post-operative hospital stay, and complications were significantly lesser in DG-HAL group than Open haemorrhoidectomy.CONCLUSIONSDG HAL repair seems to be a safe method of treatment of 2nd and 3rd grade haemorrhoidal disease with no major complications and a high rate of good short-term results. DGHAL is more useful when compared to Milligan–Morgan technique in terms of duration of surgery, post-operative pain, post-operative need for analgesics, post-operative hospital stay, as DGHAL reduces the complications in surgery.

Primary anorectal malignant melanoma: A clinical, radiology and pathology correlation

@#Introduction: Primary gastrointestinal melanomas are mucosal malignancies that arise from melanocytes in the oropharynx, rectum, and anus. Anorectal malignant melanoma (ARMM) are exceedingly rare, accounting for less than 1% of all melanomas, 0.1% of all rectal malignancies and 4% of anal malignancies. Diagnosis is frequently delayed as these lesions are often mistaken for haemorrhoids. Histological evaluation with special immunohistochemical stains is often necessary for definitive diagnosis. Due to the aggressive nature, 61% of patients with ARMM would already have lymph node involvement or distant metastases, by the time of diagnosis. Prognosis is usually poor with 5-year survival rate of <20%. We report a case of metastatic ARMM in an elderly lady who presented with symptoms and signs mimicking a haemorrhoid. Case Report: A 69-year-old lady presented with one year history of intermittent rectal bleed and an anorectal mass that was initially treated as haemorrhoid. Colonoscopy showed a hyperpigmented mass in the anorectal region which was confirmed as malignant melanoma on histopathological examination. Imaging with CT and MRI demonstrated locally advanced tumour with distant metastases to the liver and lung. Patient was referred for palliative management. Conclusion: ARMM is a rare malignancy and often presented with non-specific clinical signs. Diagnosis is frequently delayed without high index of suspicion. MRI pelvis is the imaging of choice to assess local extent of disease. Histologic evaluation with special immunohistochemical stains is often necessary for definitive diagnosis. Prognosis is poor despite surgical and chemotherapeutic interventions.

Rubber band ligation of hemorrhoids: a hospital based study

Background: Hemorrhoids are symptomatic anal cushions containing arteriovenous anastomosis. Patient with haemorrhoids can present as bleeding per rectum, something (mass) coming out per rectum, perianal itching, Anaemia due to occult blood loss. Various modalities of treatment have been developed to treat symptomatic haemorrhoids. This study was undertaken to determine the efficacy of rubber band ligation in the management of haemorrhoids.Methods: This study was a prospective study conducted in the Department of Surgery, Government Medical College, Srinagar from June 2015 to June 2018. Patients at any age with first, second- or third-degree internal haemorrhoids were included in the study. Patients with fourth degree, complicated haemorrhoids, previous anorectal surgery or anorectal pathology, and chronic liver disease were excluded. A total of 212 patients were included in the study. Rubber band ligation was done as an OPD procedure. The patients were followed at 2 weeks, 4 weeks, 3-month, 6 month and 1 year after the procedure.Results: In this study, out of 212 patients, 154(72.6%) were males and 58(27.4%) females. The mean age of this study was 38.7 yr. (Range 17-73 yr.). Patients presented with the complaints of bleeding (184, 86.8%), prolapse (114, 53.7%), constipation (116, 54.7%), priuritis ani (36, 17.0%), pain (12, 5.6%). Band ligation was successful in 188(88.8%) patients, 169(79.7%) patients were cured and in 19(8.9%) improvement was obtained. Various complications occurred after band ligation including vasovagal syncope (2, 0.9%), bleeding per anum (6, 2.8%), pain (12, 5.6%), fissure in ano (1, 0.5%). Recurrence after one year was seen in 9(4.2%) patients.Conclusions: Author concluded in this study that RBL is an effective outpatient treatment for grade II and III internal haemorrhoids without much complications.

MIPH versus Open Haemorrhoidectomy in a Tertiary Care Hospital –A Comparative Study

Background: Haemorrhoids are one of the most common benign anorectal problems worldwide. The treatment of thirdand fourth-degree haemorrhoids is surgical. Surgical haemorrhoidectomy and Stapled haemorrhoidopexy are the currently available surgical interventions in the management of haemorrhoids. The aim of the study is to evaluate the effectiveness of open haemorrhoidectomy with minimal invasive procedure for haemorrhoids (MIPH). Methods: 80 cases were selected for this study which were divided into two groups of 40 each. Open surgery (Milligan-morgan haemorrhoidectomy ) was done in one group and MIPH in the other group .The follow up period was one year. The duration of post. operative pain, complications, level of satisfaction was documented. The relative merits and demerits of the procedures were assessed and the results documented.Results: MIPH is a safe and effective procedure in patients presenting with haemorrhoids .Duration of hospital stay is less and hence return to work is earlier. Conclusion: MIPH can be considered as a procedure of choice in patients presenting with grade II,grade III and grade-IV haemorrhoids.

Clinical Efficacy of Concurrent Therapy with Oral FDC Tablet of Euphorbia Prostrata plus Calcium Dobesilate and Topical FDC Cream of Euphorbia Prostrata plus Lidocaine in the Management of Haemorrhoids: A Prospective, Open-Labeled Multicentric Study

Objective: Haemorrhoids are associated with bleeding, pain, itching, exudation and swelling. So there is an unmet need foreffective treatment by both oral and topical drugs. Hence this study was designed to evaluate the efficacy of oral EuphorbiaProstrata fortified with Calcium Dobesilate and topical cream of Euphorbia Prostrata with Lidocaine. Methods: The study was aprospective, open label, single arm, multicentric study, in 30 patients with hemorrhoids treated with oral FDC EuphorbiaProstrata extract 100 mg plus Calcium Dobesilate 500 mg and topical FDC cream of Euphorbia Prostrata extract 1% w/w plusLidocaine 3% w/w for 14 days.Symptoms like bleeding, pain, itching, exudation and swelling were assessed and scored duringand at the end of the study. Results: There was decline from the baseline value scores right from day 4 i.e. bleeding (0.97±0.15),pain (0.60±0.13), itching (0.47±0.13), exudation (0.13±0.06) and swelling (0.43±0.09); after 7 days bleeding (0.15±0.07), pain(0.12±0.06), itching (0.15±0.07), exudation (0.15±0.07) and swelling (0.19±0.08) and after day 14 the symptoms of bleeding(0.09±0.06), pain (0.08±0.06) and swelling (0.08±0.06) were almost cured while symptoms like itching (0.00±0.00), exudation(0.00±0.00) disappeared completely. There was reduction in the number of patient’s population with symptoms towards the end ofthe study. Conclusion: Oral Euphorbia Prostrata extract 100 mg fortified with Calcium Dobesilate 500 mg and topical cream ofEuphorbia Prostrataextract 1% w/w with Lidocaine 3% w/w showed maximum improvement during first 4 days of therapy andachieved total improvement till the end of therapy thus providing multimodal targeted approach to treat a multimodalhaemorrhoidal disease.

One Year Comparative Prospective Study on MIPH Versus Milligan –Morgan open Haemorrhoidectomy in a Tertiary Care Hospital

Haemorrhoids are dilated veins which descend down to the anus present as pain during defaecation, bleeding and a protruding mass outside the anus. The aim of the study is to evaluate the effectiveness of open haemorrhoidectomy with minimal invasive procedure for haemorrhoids (MIPH). Methods: 60 cases were selected for this study .30 patients each were divided into two groups.Open surgery ( Milligan-morgan haemorrhoidectomy ) was done in one group and MIPH for the other group .The follow up period was one year .The duration of post. operative pain, complications, level of satisfaction was documented . The relative merits and demerits of the procedures were assessed and the results documented. Results: MIPH is a safe and effective procedure in patients presenting with haemorrhoids .Duration of hospital stay is less and hence return to work is earlier. Conclusion: MIPH can be considered as a procedure of choice in patients presenting with grade II, grade III and grade-IV haemorrhoids.

Hemorrhoidectomy versus rubber band ligation in treatment of second and third degree hemorrhoids: a comparative study

Background: Optimum surgical intervention for low-grade haemorrhoids is unknown. Haemorrhoidal artery ligation (HAL) has been proposed as an efficacious, safe therapy while rubber band ligation (RBL) is a commonly used Out patient treatment.Methods: We compared recurrence after HAL versus RBL in patients with grade II-III haemorrhoids. The diagnosis of hemorrhoids is primarily based on the proctoscopic  examination. The study evaluates comparative results of rubber band ligation (RBL) and hemorrhoidectomy. This study was conducted over a period of 1 year from January 2017 to December 2017. It includes 50 patients having second- or third-degree primary hemorrhoids who attended surgical OPD of Tertiary Care Hospital in Gujarat. These 50 patients were selected randomly and divided into two groups of 25 patients each (hemorrhoidectomy group and RBL group). Patients of fissure, fistulae, and malignancy were excluded. All parameters were recorded and finally analysed.Results: Hemorrhoidectomy and RBL are equally effective especially in second-degree hemorrhoids. However, RBL should be considered the first-line treatment in second-degree hemorrhoids because being an outpatient procedure, it is cost effective for the patients, saves many hospital beds for more sick patients, and takes the pressure off the surgical waiting list. Although RBL is not as effective as hemorrhoidectomy in third-degree hemorrhoid, it does improve bleeding and prolapse and is highly recommended for patients who are unfit for surgery.Conclusions: RBL should be considered as the first-line treatment for second-degree hemorrhoid. However, in the third-degree hemorrhoids, hemorrhoidectomy achieves better results, and RBL is recommend as the first-line treatment for those patients in whom there is contraindication for surgery or anesthesia.

Role of colonoscopy in haemorrhoids with other colorectal disorders

Background: Haemorrhoids are the enlargement or engorgement of the normal fibrovascular anal cushions. These fibrovascular cushions lose their attachment to the underlying rectal wall and lead to prolapse with repeated straining over time, thinning of rectal mucosa and subsequent bleeding. The objective of the present endeavour was to study the prevalence of associated colorectal lesions like colonic carcinoma, diverticular disease, inflammatory bowel disease which present the rectal bleeding and role of colonoscopy in these lesionsMethods: This study was conducted in hundred fifty patients presenting with bleeding and haemorrhoids were analyzed. All patients were examined locally and endoscopically. All significant endoscopic findings (diverticuli, polyps, cancer, angiodysplasia and varices or colitis) were recorded.Results: Majority of patients were males (102), accounting for (68 percent). The main symptom at the time of presentation was rectal bleeding (90 percent). The digital rectal examination was normal in 114 patients. The commonest finding on proctoscopy examination was haemorrhoids. Colonoscopy showed haemorrhoids in maximum patients (147 percent). The associate lesions with altered bowel habits were growth in 12, worm in 6, solitary rectal ulcer in 3, pancolitis in 3.Conclusions: It can be concluded that in the present study colonoscopy revealed a high proportion of colorectal pathologies with haemorrhoids presenting with bleeding per rectum.  Colonoscopy thus proved to be very useful procedure in patients with haemorrhoids especially in elderly.

Concept Of Haemorrhoids (Bawaseer). Management In Unani System Of Medicine (a Review)

These are dilated veins with in the anal canal in the sub epithelial region formed by radicles of the superior, middle and inferior rectal veins. The word “haemorrhoids ”is derived from the greek “heama”= blood and “rhoos”= flowing, and was originally used Hippocrates to describe the flow of blood from the veins of anus. Commonly in society it is known as piles. In Unani literature , haemorrhoids are known as” bawaseer”.According to Hippocrates (Buqrat) bawaseer is the varicosities of the internal mucous memane of rectum in which the veins get swollen similarly to the veins of the lower limb. It has been stated that the 50% of the population will experience symptomatic haemorrhoid disease in at some point in their lives , the peak incidence of symptomatic disease seems to be between the age of 45—65 years. According to the Unani system of medicine it is advised to treat the disease with mushily–e–Sauda, Mohalll awram, Musakkin, Habis–e–Dam, Mudamil–e–zakhim,and Mulaiyyan Adviya.There are many mufrad and murakkab drugs described in Unani literature to manage bawaseer. In this paper there is an isight of causes ,smptoms and management of bawaseer along with single and compound drugs being used in treatment of haemorrhoids.

Experiences of patients with haemorrhoidal disease - a qualitative study / Experiências de pacientes com doença hemorroidária - estudo qualitativo

ABSTRACT Purpose: To obtain a better understanding of the patients' experiences with haemorrhoidal disease' impact on their daily life and results of treatment by performing a qualitative study. Method: Individually interviews were conducted among patients with haemorrhoidal disease between 2016 and 2017. Each interview was recorded using an audio recorder and transcribed verbatim. A semi-structured interview guide was used with pre-specified topics, based on a previous conducted literature review. Transcripts were coded and the analysis consisted highlighting passages in the text and assigning each passage a code representing the predefined themes from the interview guide. This resulted in a three-level theme hierarchy: overarching theme, mid-level sub-theme and issues. Results: Fifteen participants underwent individual interviews of whom thirteen were conducted by telephone. The mean age was 60.7 years (35-78); five of them were female (33.3%). Pain and blood loss were the most frequently reported symptoms. Participants indicated that these symptoms were directly associated with emotional burden, daily adjustments and social impact. Before diagnosis with haemorrhoidal disease blood loss resulted in feelings of fear and next in embarrassment during social activities. In daily life participants needed to get up early, used sanitary pads for blood loss and anal ice sticks to reduce pain. Participants were often not completely satisfied with the process and outcome of treatment. Conclusion: This first qualitative study provides detailed insight into the patients' experiences with haemorrhoidal disease, impact on daily life and results of treatment. This information may be used in daily practice to create awareness among clinicians.

RESUMO Objetivo: Este estudo qualitativo teve como objetivo propiciar uma melhor compreensão das experiências dos pacientes com doença hemorroidária, o impacto em sua vida diária e os resultados do tratamento. Métodos: Entre 2016 e 2017, pacientes com doença hemorroidária foram entrevistados individualmente. Cada entrevista foi gravada usando um gravador de áudio e transcrita na íntegra. Utilizou-se guia de entrevista semiestruturado, com tópicos pré-especificados baseados em uma revisão de literatura realizada anteriormente. As transcrições foram codificadas; a análise consistiu em destacar passagens no texto e atribuir a cada passagem um código representando os temas predefinidos no guia de entrevista. Isso resultou em uma hierarquia de temas de três níveis: tema abrangente, subtema de nível médio e problemas. Resultados: Quinze participantes foram submetidos a entrevistas individuais, das quais treze foram conduzidas por telefone. A média de idade foi de 60,7 anos (35-78); cinco deles eram do sexo feminino (33,3%). Dor e hemorragia foram os sintomas mais frequentemente relatados. Os participantes indicaram que esses sintomas estavam diretamente relacionados a sobrecarga emocional, ajustes nas atividades diárias e impacto social. Antes do diagnóstico de doença hemorroidária, a hemorragia levou a sentimentos de medo e de constrangimento durante as atividades sociais. No dia-a-dia, os participantes precisavam acordar cedo, usar absorventes higiênicos para perda de sangue e gelo na região anal para reduzir a dor. Geralmente, os participantes não estavam completamente satisfeitos com o processo e o resultado do tratamento. Conclusão: Este primeiro estudo qualitativo apresenta uma visão detalhada das experiências dos pacientes com doença hemorroidária, o impacto na vida diária e resultados do tratamento. Essas informações podem ser usadas na prática diária para conscientizar os médicos.

Macroligadura como tratamiento para hemorroides / Macro-ligation as a hemorrhoid treatment

Introducción: Las hemorroides constituyen una dilatación varicosa de los plexos hemorroidales que involucran la mucosa del recto y ano. Estas constituyen la enfermedad anorrectal más frecuente en el mundo occidental, con una alta prevalencia que suele representar el 50 % de las consultas con el proctólogo. Se pueden describir dos grandes grupos de hemorroides, los internos que son aquellos situados por encima de la línea pectínea y los externos que son los que se encuentran por debajo de esta línea, se tendrán en cuenta los internos. A estos últimos se los clasifica por Goligher en relación con el grado de prolapso de la mucosa rectal y la posibilidad de reducción del prolapso. Para las hemorroides grado II y III se han diseñados diferentes métodos quirúrgicos de tratamiento desde la electrocoagulación, la crioterapia, la terapia fotodinámica y RBL El presente trabajo plantea como objetivo describir nuestros resultados iniciales en el tratamiento de patología hemorroidal por medio de la técnica de macroligadura alta por aspiración RBL. Materiales y Métodos: Se incluyeron 40 pacientes a los que se le realizo RBL, comprendidos desde el mes de octubre de 2016 a marzo de 2018, que presenten patología hemorroidal grado II III y IV, técnica de macroligadura alta por succión. Resultados: Del 63% de femenino y un 37% de masculino, la distribución por grados fue de la siguiente manera, grado 2: 75%, grado 3: 17.5% y grado 4: 7.5%, el dolor posterior al procedimiento en forma inmediata fue de 3.78±2.63, a las 48 hs 2.10±2.31 y a los 7 postquirúrgicos 1.10±1.86. Tuvimos un total de 7 (18%) pacientes con recidivas dentro de los 18 meses de seguimiento, tenesmo se presentó 27.59% en los grados 2, un 57,14% en los grados 3 y un 66,67% en los grados 4. Solo reportamos un 23% de sangrado posquirúrgico. Conclusión: Podemos afirmar que la técnica de macro ligadura alta como variante de la RBL, es una técnica segura, aplicable en forma ambulatoria, con un beneficio importante por sobre el resto de las técnicas resectivas que solo requiere una sedación para el procedimiento, con bajos umbrales de dolor postquirúrgicos, pronta recuperación y reinserción laboral; presenta bajos índices de complicaciones. Además, representa una excelente opción para el tratamiento de las hemorroides grado 2 y 3. (AU)

Introduction: Hemorrhoids are a varicose dilatation of the hemorrhoidal plexuses that involve the mucosa of the rectum and anus. These constitute the most frequent anorectal disease in the western world, with a high prevalence that usually represents 50% of consultations with the proctologist. Two large groups of hemorrhoids can be described; the internal ones that are those located above the pectineal line and the external ones that are those below this line, the internal ones will be taken into account. The latter are classified by Goligher in relation to the degree of prolapse of the rectal mucosa and the possibility of prolapse reduction. For the grade II and III hemorrhoids, different surgical methods of treatment have been designed from electrocoagulation, cryotherapy, photodynamic therapy and RBL. The present work aims to describe our initial results in the treatment of hemorrhoidal pathology by means of the macro-adherence technique. High by RBL aspiration. Materials and Methods: Forty patients were included, who underwent RBL, from October 2016 to March 2018, who presented grade II III and IV hemorrhoidal pathology, high suction macroligation technique. Results: Of 63% of female and 37% of male, the distribution by grades was as follows, grade 2: 75%, grade 3: 17.5% and grade 4: 7.5%, pain after the procedure immediately it was 3.78 ± 2.63, at 48 hours 2.10 ± 2.31 and at 7 postsurgical 1.10 ± 1.86. We had 7 (18%) patients with recurrences within 18 months of follow-up; tenesmo presented 27.59% in grades 2, 57.14% in grades 3 and 66.67% in grades 4. We only reported 23% of postoperative bleeding. Conclusion: We can affirm that the high macro ligature technique as a variant of the RBL is a safe technique, applicable in ambulatory form, with an important benefit over the rest of the resection techniques that only requires a sedation for the procedure, with low postoperative pain thresholds, early recovery and re-employment; It presents low rates of complications. In addition, it represents an excellent option for the treatment of grade 2 and 3 hemorrhoids. (AU)