الفهرس 
Anatomy of the anorectumOnly 14 pages are availabe for public view
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Abstract
Hemorrhoids are normal components of human anatomy. External hemorrhoids arise from the inferior hemorrhoidal plexus and are covered by modified squamous epithelium distal to the dentate line.
Internal hemorrhoids originate from the superior hemorrhoidal plexus and are covered by mucosa proximal to the dentate line.
Internal hemorrhoids are classified as first-degree, second-degree, third-degree, and fourth-degree.
Decision to Treat Symptomatic External and Internal Hemorrhoids; Depends on the patient’s symptoms, therefore careful evaluation of the patient must be conducted to determine underlying causes of the patient’s complaints. After the assessment of patient’s general condition. Also rectosigmoid evaluation and anoscopy should be performed.
Medical treatments.
Symptomatic external and internal hemorrhoids can be treated medically if symptoms are secondary to suspected alterations in diet, stool consistency (diarrhea or constipation) or poor hygiene. Medical treatment is reserved for minor symptoms which do not interfere with daily activities.
Surgical treatments.
Surgery may cause complications in patients with hemorrhage, acute thrombosed external or internal hemorrhoids or hemorrhoidal disease superimposed on a chronic or undiagnosed problem, therefore, surgery should not begin treatements.
External hemorrhoids; surgical removal of external hemorrhoids is indicated if symptoms require emergency intervention or if medical treatments has failed and chronic symptoms persists. External hemorrhoidectomy can be performed as an outpatient procedure.
Internal hemorrhoids; surgery is indicated in chronic hemorrhoidal disease in the following cases:
1- Patients who fail more conservative measures of treatment. These include rubber band ligation, dilatation, infra red coagulation, laser surgery and bipolar diathermy coagulation.
2- Patients who have symptomatic hemorrhoidal disease associated with other benign anorectal conditions which require surgery as fistula, fissure, or stenosis.
3- Patients who request initial operative hemorrhoidectomy instead of alternative therapy after consultation with the surgeon.
4- Patients who have had third and fourth degree hemorrhoids, with or without external components and who have severe symptoms and signs from their hemorrhoidal disease.
Following surgical treatments of internal hemorrhoids, ambulatory or inpatient stay is judged by the operating surgeon based on the findings at surgery and the clinical condition of the patient.
Hemorrhoidectomy is currently the ultimate treatment for advanced or severe hemorrhoids. The two most popular techniques of hemorrhoidectomy are the Milligan Morgan open procedure and the Ferguson closed procedure.
Both procedures had achieved up to 90 percent cure for third and fourth degree hemorrhoids with few complications.
In 1997, Longo introduced the treatment of prolapsed hemorrhoids by means of a stapled mucosectomy. It is indeed the only method that does not require the hemorrhoids to be excised and the term ”stapled hemorrhoidopexy” was hence used. It is otherwise known as the procedure for prolapsed hemorrhoids (PPH) and involves excision of rectal mucosa just proximal to dentate line and fixing the two cut ends together using a circular staple device. This results in disruption of hemorrhoidal circulation and produce atrophy of hemorrhoids.
Stapled hemorrhoidopexy may be largely due to the much reduced pain resulted from the procedure.
The major short and long –term complications of stapled hemorrhoidopexy were also rare comparable to the conventional hemorrhoidectomies.
Office therapies
Injection sclerotherapy; traditionally indicated for first and second degree hemorrhoids but not used for external hemorrhoids.
Rubber bands; Rubber banding or elastic band ligation indicated for the treatments of symptoms with first and second degree hemorrhoids that are complicated with symptoms of bleeding and \ or prolapsed.
Cryotherapy; Cryotherapy is most effective with the least side effects when directed at first and second degree hemorrhoids. It is not recommended for use with external hemorrhoids.
Infrared; it is useful for first and second degree hemorrhoids, but not recommended.
Dilatation; Not preferred, due to significant risk of incontinence in published reports.
Laser; Laser advocates a critical advantage in less scarring, more rapid healing and possibly less pain.
Bipolar Diathermy Coagulation; Alternative procedure for fixation.
Most of the office treatments are safe and effective for low grade hemorrhoids.
In summary, patients’ comfort and avoidance of complications are the prime issues in treating symptomatic hemorrhoids