HEMORRHOIDS: CONSERVATIVE MANAGEMENT AND CLASSIFICATION

Hemorrhoids are a common condition with varying symptoms and treatment options depending on their severity and type. Here’s an overview of their classification and conservative management:

Clinical Features of Hemorrhoids

• Asymptomatic Cases: Many small-sized haemorrhoids may not show symptoms.
• Painless Bleeding: Bright red bleeding, which can range from mild to severe.
• Mucous Discharge and Prolapse: Prolapse of piles and mucous discharge may occur, with occasional pain due to proctitis.
• Chronic Cases: Continuous blood loss can lead to anaemia.

Types of Hemorrhoids

• Internal Hemorrhoids: Located proximal to the dentate line, painless, and can be treated with banding.
• External Hemorrhoids: Located distal to the dentate line, painful, and often require excision. Repeated thrombosis can give them a semi-ripe black currant appearance.

Medical Therapy

1. Tab. Micronized Purified Flavonoid Fraction (MPFF): Daflon 500mg tablets, 3 Tabs x BD for 3 days, 2 tabs x BD for 3 days, 1 Tab x BD for 21 Days.
2. Topical Lidocaine 2% Jelly: Applied twice daily for pain relief.
3. Topical Ointments: Posterison Forte Ointment or Hadensa Forte Ointment, applied twice daily.
4. Stool Softeners: For constipation, use Syp Lactulose 10ml x TDS (Duphalac, Lilac), Or Syp Cremaffin 10ml x TDS and increase dietary fibre.
5. Cap. Omeprazole 40mg (Risek, Ruling): Taken once daily.
6. Systemic Painkillers: For severe rectal pain, Tab. Diclofenac sodium 50mg, 100mg (Voren, Voltral) or Tab. Tramadol + Paracetamol (Distalgasic, Pentra Plus) can be used.
7. Anaemia Management: Chronic cases may require oral ferrous sulphate or blood transfusion.

Surgical Indications

• Surgery is recommended for cases unresponsive to conservative treatment or for late third and fourth-degree haemorrhoids.
• Pre-surgical preparation includes NPO status, IV hydration, pain management, and IV antibiotics.
• Lab tests such as CBC, PT INR, urea, creatinine, and electrolytes should be conducted before surgery.

Classification of Internal Hemorrhoids

1. First Degree: Painless bleeding only, no prolapse.
2. Second Degree: Bleeding with prolapse during straining, which reduces spontaneously.
3. Third Degree: Prolapse during defaecation, requiring manual reduction.
4. Fourth Degree: Large, permanently prolapsed haemorrhoids that cannot be manually reduced.

Treatment Options

• Rubber Band Ligation: Suitable for 1st, 2nd, and selected 3rd-degree haemorrhoids.
• Infrared Photocoagulation: Used for 1st and 2nd-degree haemorrhoids.
• Sclerotherapy: Effective for 1st, 2nd, and selected 3rd-degree haemorrhoids, commonly using 5% phenol in spinal cord or arachis oil.
• Operative Haemorrhoidectomy: Recommended for 3rd and 4th-degree haemorrhoids.
  • Milligan-Morgan Open Haemorrhoidectomy: For 2nd-degree haemorrhoids not cured by non-operative methods.
  • Ferguson Closed Haemorrhoidectomy: For mixed internal/external haemorrhoids.
  • Whitefield Submucosal Haemorrhoidectomy: For fibrosed haemorrhoids.
  • Longo’s Stapler Haemorrhoidectomy: Another surgical option.