I.

Introduction of disease (Hemorrhoids)

A. Definition

Hemorrhoids are enlarged or dilated veins located in and around the rectum and anus. There are two types:
external and internal. External hemorrhoids occur below the anal sphincter and protrude at the anus.
Thrombosed hemorrhoids contain clotted blood and can cause pain. Thrombosis usually occurs in external
hemorrhoids but does occur in both types. Thrombosed external hemorrhoids can be incised and the clot
evacuated.

Beginning in Medieval times, hemorrhoids were known as St. Fiacre's curse, and today hemorrhoid
sufferers from around the world visit St. Fiacre's stone in order to obtain a miracle cure. St. Fiacre, also
known as the patron saint of gardeners, was told he could farm all the land he could cultivate in a single
day.

B. Classifications:

1st degree- confined in the anal canal

2nd degree- prolapse during straining but reduce spontaeneously
3rd degree- prolapsed & requires manual reduction after each bowel movement
4th degree- irreducible

C. Pathophysiology

Hemorrhoids are thought to represent engorgement or enlargement of the normal fibrovascular cushions
lining the anal canal. It has been postulated that chronic straining secondary to constipation or
occasionally diarrhea results in pathologic hemorrhoids. As an individual strains repeatedly over time,
these fibrovascular cushions lose their attachment to the underlying rectal wall. This eventually leads to
prolapse of internal hemorrhoidal tissue through the anal canal. In addition, as these hemorrhoids engorge,
the overlying mucosa becomes more friable and the vasculature increases. Arterio-venous connections are
known to normally exist within these cushions. With overlying thinning of the mucosa and vascular
engorgement, subsequent rectal bleeding, in the form of bright red blood per rectum, occurs. Several
authors have identified stretching and disruption of submucosal muscle in association with hemorrhoidal
prolapse. These microscopic abnormalities support the theory of straining and disruption of connections
with the rectal wall as the etiology of hemorrhoids. Chronic straining either secondary to constipation,
diarrhea and tenesmus, or prolonged attempts at defecation have been implicated in the etiology of
hemorrhoids. Increased resting anal pressure has been found in association with hemorrhoids in various
studies

D. Signs and symptoms

As previously mentioned, individuals with varying rectal complaints seek medical attention complaining
of "hemorrhoids". True hemorrhoidal symptoms, however, are relatively specific. Patients either present
with bright red blood per rectum or a prolapsing anal mass. Bleeding associated with hemorrhoids
generally occurs with, or following, bowel movements, is almost universally bright red, and very
commonly drips into the toilet water. Blood may also be seen while wiping after defecation. Occasionally
blood may stain the underclothes if hemorrhoidal prolapse is present. Bleeding associated with
hemorrhoids is rarely mixed with the stool, dark, or melanotic in nature. Rarely individuals with large
chronic hemorrhoids may present with anemia secondary to chronic blood loss.

E. Assessing for Hemorrhoids

F. Treatments
Treatment for symptomatic internal hemorrhoids varies from simple reassurance to
operative hemorrhoidectomy. Treatments are classified into three categories:

1) Dietary and lifestyle modification.

2) Non operative/office procedures.
3) Operative hemorrhoidectomy. In general, less symptomatic hemorrhoids, such as those
that cause only minor bleeding, can be treated with simple measures such as dietary modification,
change in defecatory habits, or office procedures.

More symptomatic hemorrhoids such as Grade III or Grade IV are more likely to require operative
intervention.

II. Pre – Operative Preperations

Preoperative tests may include blood and urine tests, a chest x-ray, and an EKG, depending on the
patient's health.

Medications that "thin" the blood, including aspirin, are usually discontinued before a scheduled
surgery.

If general anesthesia is going to be used, nothing may be eaten from midnight on the evening before
surgery until the procedure is completed.

Check-in is usually the same day as the surgery and at this time an informed consent form must be
signed.

III. Surgical Procedures

Hemorrhoidectomy may be performed under general anesthesia, under spinal anesthesia, or under local
anesthesia. The choice of anesthesia depends on the extent of surgery, the patient's health and personal
preference, and surgical standards of the facility.

The patient lies on the operating table face down with the buttocks slightly elevated or on their back
with their legs up in stirrups, so the anus and rectal area are exposed.

After the anesthesia has taken effect, the area is cleaned with an antiseptic solution. The hemorrhoids are
clamped, tied off, and cut away. The wound is then sutured.

After the operation, the surgeon packs the anus with gauze or applies antibiotic ointment. A
hemorrhoidectomy takes about 1 to 1 1/2 hours to perform.

IV. Post Operative Care & Complications

After surgery, the patient is taken to the postanesthesia care unit (PACU). Patients are closely monitored
by the nursing staff and remain there until they are stable.
 Outpatients are transferred to another room to finish their recovery, and inpatients are taken to their
hospital room.

During the first hour following surgery, patients lie flat on their back to decrease the risk for an
anesthesia-induced headache, which can be painful and prolonged.

Before being discharged, the patient must regain full sensation in the lower part of the body.Patients
must be able to urinate on their own before being discharged.

Patients experience pain and discomfort during the immediate postoperative period (i.e., about 10 days).
Pain medication is prescribed and should be taken as directed.

An ice pack can help reduce swelling. Soaking in a sitz bath several times a day helps ease the
discomfort. Using a donut ring (cushion with a hole in the middle) can make sitting upright more
comfortable.

It is important to avoid constipation at this time so, the physician will prescribe stool softeners and a
laxative. Eating a high-fiber diet and drinking plenty of liquids also helps.

Complete recovery takes 6 weeks to 2 months. Most patients return to work within 10 days. Heavy
lifting should be avoided for 2 to 3 weeks.

Most patients are satisfied with the results of the surgery and recover without any problems.
Complications associated with hemorrhoidectomy are rare and include:

• Anal fistula or fissure • Severe pain, especially when having a bowel

• Constipation movement
• Excessive bleeding • Severe redness and/or swelling in the rectal
• Excessive discharge of fluid from the rectum area
• Fever • Side effects of anesthesia (e.g., spinal
• Inability to urinate or have a bowel headache)
movement

Nursing interventions:
• Encourage high fiber diet • Soaking in a sitz bath (a shallow bath of warm
• Monitor for bleeding water) several times a day helps ease the
• Wound care discomfort.
• Encourage ambulation • Use a donut ring (cushion with a hole in the
• Express feelings of increased comfort middle) can make sitting upright more
• Take pain medication as prescribed comfortable.
• Take antibiotics as prescribed • Avoid constipation
• Avoid heavy lifting for 2 to 3 weeks.