Sunday, 20 November 2011
Hemorrhoids are swellings around the anal area. These swellings arise as a result of interference with the normal return of venous blood into the main branches. There is pooling of excess venous blood causing the skin or mucosa to swell, corresponding with the venous dilatation. The cause is chronic (happening over a long period of time; months to years) constipation & straining during defecation. With modern diet (processed food), there is less fibers that contributes stool bulkiness resulting in excessive straining during defecation.
There is external & internal types:
External: composing of skin & the base may be easily visualized, therefore surgical excision may be easy
Internal: composing of mucosa (pinkish part of rectum or gut wall). The base may not be visible & it may be difficult to excise
There are 4 grades of hemorrhoids, that indicates severity, using the criteria of prolapse:
Grade 1 - No prolapse
Grade 2 - Prolapse upon defecation but spontaneously reduce
Grade 3 - Prolapse upon defecation and must be manually reduced
Grade 4 - Prolapse and cannot be manually reduced
Surgical excision has many complications associated:
2. Sores which may not heal
Surgical excision is also very expensive despite the many complications stated above. Recently Dr. Mol introduced sclerotherapy (injection of medicine to shrink the veins) for hemorrhoids at Goroka General Hospital. With sclerotherapy there is not much complication & the patient can go home on the same day (no need for admission to the wards), thereby cutting down the costs of treatment, making it easier & convenient for both the patient & the healthcare workers.
The steps taken for this new treatment strategy are as follows:
1. Insertion of medicine that numbs the skin & prevents swelling afterwards & a 1 hour waiting period is given
2. After 1 hour, the sclerosants (medicine that causes veins to shrink) are injected into the swelling without much pain
3. Regular insertion of medicine that prevents swelling & pain for 3 days
as well as ingesting of medicine that softens stool, to prevent straining during defecation
4. Review after 1 week to asses state of swelling & to assess & advice on diet changes to prevent constipation (straining during defecation)
5. Review after 1 month to check on the state of the swelling as well as the diet & to decide wether further injections of sclerosants are required or not
With a good diet adjustment, there shouldn't be any recurrences. With the injection of sclerosants, the only complication is excessive swelling, which will maximize after 3 days & then slowly regress. If the right sclerosants are injected & into the right sites, then the swelling should completely disappear within 3 months time. Otherwise, it may be needed to repeat the injections 2-3 times or repeated once a month until complete resolution occurs.
Below is a photo of a patient who initially had excision of external hemorrhoids Grade 4, however he suffered persistent bleeding & worsening of internal hemorrhoids. There was improvement (cessation of bleeding & regression of the swelling) after just 1 session of sclerotherpy, throughout a 1 month period.
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