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Siouxland GI Surgery 

​Colorectal Surgery

HEMORRHOIDS

PROLAPSED STRANGULATED INTERNAL HEMORRHOIDS
When an internal hemorrhoid gets very enlarged, it protrudes out through the anal canal. Most of the times it goes back inside, but sometimes it gets stuck outside the anal canal. With the anal sphincter muscles getting contracted the hemorrhoids lose their blood supply and gets thrombosed. This can be very painful.

In such situations the patient is taken to the operating room for an urgent hemorrhoidectomy.

INTERNAL HEMORRHOIDS
Based on the size and nature of the hemorrhoids it is graded into 4 classes.


Conservative management for Small Hemorrhoids-
1. Changing bowel habits:
- Avoid straining during defecation
- Drink 64 oz of water daily
- Fiber supplements (e.g. Metamucil, Citrucel, Benefiber)
- Stool softeners/laxatives (Colace, Milk of magnesium)
- Avoid spending long time on the toilet
 
2. Shrink the Hemorrhoids:
- Zinc/Cortisone cream/suppository
 
3. Relieve the Pain:
- Sitz bath (Sitting in plain warm water for 15 minutes)

It takes weeks to heal properly. During this time you may have days when it seems healed, only to have a 'bad' bowel movement and a recurrence of symptoms. Stay on the Program!

Intervention for large hemorrhoids
1. Office based procedures
- Rubber band ligation
- Injection sclerotherapy

2. Operating room procedures
- Hemorrhoidopexy and dearterialization

- Hemorrhoidectomy

INJECTION SCLEROTHERAPY

Depending on the size of the hemorrhoid injection sclerotherapy can be considered. It is generally done with a sclerosant such as 5% phenol in a vegetable oil medium. Approximately 3-5 ml is injected in one sitting in and around the hemorrhoids with an aim to shrink the hemorrhoids.

This injection is generally done in the non sensitive part of the anal canal so this should not be painful. Patients may experience some discomfort due to this procedure lasting for 2-3 days. Taking over the counter Tylenol should help with this discomfort. Patients may notice some bleeding which might last for 2-3 days.

Hemorrhoidal symptoms of bleeding and protrusion can persist and will likely persist until all hemorrhoids have been treated. Based on the size and number of hemorrhoids, generally it takes some 3-4 treatments at intervals of 4 weeks to eradicate all the enlarged internal hemorrhoids that are present.

Hemorrhoids are a normal part of the anatomy. We are born with them. We have two sets; internal and external. Symptomatic Hemorrhoids are swollen (enlarged, dilated) veins inside and outside the anus. Hemorrhoids are usually caused by increased pressure; such as straining when constipated or pressure during pregnancy. Hemorrhoids may cause pain, bleeding, blood clots, and itching.

HEMORRHOIDECTOMY
Operative excision of both inside and outside hemorrhoids is considered when non operative measures have failed to achieve symptom control for the smaller hemorrhoids, and when the internal and external hemorrhoids are large.

Hemorrhoidectomy is done as an outpatient procedure. The advantages of surgery include long term relief from pain, bleeding, itching, and soilage. Time off of work will depend on your pain threshold, how well you can soften the bowel movement, and what type of work you do.

COMPLICATIONS -
The complications of hemorrhoid surgery include, but are not limited to:
- Pain as you heal: The most common problem is intense pain as you heal. You will need anywhere from 1-6 weeks off work, depending on the number of hemorrhoids removed, your pain threshold, and the type of work you do.
- Trouble Urinating: Some patients experience trouble urinating immediately after the operation, requiring a catheter to be placed in the bladder for several days.
- Infection: On a rare occasion, infection can develop requiring hospitalization, antibiotics, and further surgery.
- Bleeding: Everyone sees a teaspoon or tablespoon of blood now and then, but if a larger blood vessel is torn open, the bleeding can be heavy. Apply pressure and call the office number.
- Anus heals too tight: Occasionally the anus heals 'too tight', or the wounds are slow to heal requiring further surgery.


Complete recovery from hemorrhoid surgery typically takes about 4 weeks.

THROMBOSED EXTERNAL HEMORRHOIDS
Engorgement of an external hemorrhoidal vessel with acute swelling may allow blood to pool and, subsequently, clot; this leads to the acutely thrombosed external hemorrhoid, a bluish-purplish discoloration often accompanied by severe incapacitating pain

Although conservative nonsurgical treatment (stool softeners, increased dietary fiber, increased fluid intake, warm baths, and analgesia) ultimately results in improvement of symptoms for most patients, surgical excision of the thrombosed external hemorrhoid often precipitates resolution

Acute pain and thrombosis of an external hemorrhoid within 48-72 hours of onset is an indication for excision. This is performed in the office under local anesthesia. Most patients tolerate this procedure well and notice instant relief from the excruciating pain.

HEMORRHOID BANDING/LIGATION
The rubber band ligation treatment works wells on internal hemorrhoids that protrude with bowel movements. A small rubber band is placed over the hemorrhoid, cutting off its blood supply. The hemorrhoid and band falls off in 3-7 days and the wound heals in 1-2 weeks.
Procedure sometimes produces mild discomfort and bleeding.

Hemorrhoidal symptoms of bleeding and protrusion can persist and will likely persist until all hemorrhoids have been treated. Generally it takes some 3-6 treatments at intervals of 4 weeks to eradicate all the enlarged internal hemorrhoids that are present.

HEMORRHOIDOPEXY/ DEARTERIALIZATION
This procedure is more painful than rubberband ligation, but less painful than hemorrhoidectomy.

During this procedure sutures are placed through the enlarged hemorrhoids with an aim of cutting its blood supply and at the same time fixing it to the anal canal. To achieve better results and decrease the chances of recurrences and bleeding we use Doppler guidance to locate the feeding vessel and to ensure that the feeding vessel has been occluded.

This procedure is done as a same day surgery. This procedure is done in the operating room under local anesthesia and sedation.

Hemorrhoids enlargement can be seen in internal or external group or both the groups.