ALA AKHIL

BANDARU VARUN RAM

BLOCK 1-2
 B.I
 39years old Male
 Married
 Catholic
 Date of birth: 9/14/1979
 Dapitan city
 Admitted: 10/10/2018
ANAL MASS
8yrs ptc
(+)anal mass
5months ptc
(-)difficulty in defecating
(+)increase in size of anal
2weeks ptc
(-)bloody stools mass
(-)pain (+)difficulty in defecating (+)still with above mentioned
symptoms
(+)blood on passing hard
stools (+)pain PS of 4/10
(-)medications were taken Suggested for surgical
intervention hence eventually
admitted
 Awake, conscious, not in cardiorespiratory distress, oriented to three
spheres
 VITAL SIGNS: BP-120/80 mm-hg CR-73 bpm RR-20 cpm
Temp 37.0 C
 MENTAL STATUS: GCS 15
 SKIN: No Jaundice, No Cyanosis, No Pallor, Good skin turgor, Warm
to touch
 HEENT: Anicteric Sclera, Pupils reactive to light, Pink palpebral
conjunctiva, (-) TPC, No cervical lymphadenopathies.
 CHEST: Symmetric chest expansion, Clear breath sounds, No
retractions
 HEART: Adynamic precordium, Normal rate and regular rhythm, No
murmurs
 ABDOMEN: Soft, Non- distended, Non-tender abdomen, Normoactive
bowel sounds.
 GENITALS: (+)protruding mass proximally 2x2cms, good sphincteric
tone, empty rectal vault, (-)blood on examination
 EXTREMITIES: Full equal pulses, no edema.
 PAST MEDICAL HISTORY: unremarkable
 FAMILY HOSTORY: (+)HPN-father
 PREVIOUS SURGERIES: none
 PERSONAL AND SOCIAL HISTORY: non-smoker and occasional alcoholic beverage
drinker
 ALLERGIES: none
 39years old Male
 (+)anal mass
 (+)difficulty in defecating
 (+)blood on passing hard stools
 (+)pain on sitting PS 4/10
MIXED HEMORRHOIDS
Examination Results Normal values
RED BLOOD CELL 5.41 4.50-6.0 x 10^12/L
HEMATOCRIT 0.42 0.40 – 0.54 L
HEMOGLOBIN 144 120-160 g/l
WHITE BLOOD CELL 5.70 4.50 -10.00 x10^9/L(H)

SEGMENTERS 0.60 0.50 – 0.70 (H)

EOSINOPHILS 0.08 0.00 – 0.05
LYMPHOCYTES 0.27 0.20 – 0.40 (L)
MONOCYTES 0.05 0.00 – 0.07
PLATELET COUNT 222 150 – 400X10^9/L
MCV 78.00 80 -100 FL
MCH 26.65 26 -34 pg.
MCHC 342 320 – 360 g/L
 PARTIAL THROMBOPLASTIN TIME
TEST: 32.90seconds
CONTROL: 31.90seconds

 PROTHROMBIN TIME
CONTROL: 13.20seconds
TEST: 13.00seconds
INR: 1.15
ACTIVITY: 78%
DIAGNOSIS RULE IN RULE OUT

RECTAL PROLAPSE (+)mass (-)incontinence of stools

(+)tenderness (-)feeling of fullness in bowel
(-)circumferential folds
PROCTITIS (+)tenderness (-)tenesmus
(+)pain (-)pain on the left side of
(+)bleeding abdomen
(-)feeling of fullness
(-)diarrhea
HEMORRHOIDS (+)mass
(+)bleeding
(+)pain upon defecating
(+)difficulty in defecating
(+)protruding mass
proximally 2x2cms
MIXED HEMORRHOIDS GRADE 4
PROCTOSIGMOIDOSCOPY, HEMORRHOIDECTOMY
 Pre op diagnosis: mixed hemorrhoids
 Post op diagnosis: mixed hemorrhoids grade 4 non thrombosed
 Procedure: proctosigmoidoscopy, hemorrhoidectomy
 OR findings: 1.5x1cm anterior pile (12’o clock position)
1.5x1cm posterior pile (6’o clock position)
 Hemorrhoids are swollen blood vessels in the lower rectum.
 Hemorrhoidal cushions are the normal part of the anal canal.
 The vascular structures contained within this tissue aid in continence by preventing
damage to the sphincter muscle.
 Engorgement of the venous plexus of rectum or anus with protrusion of the mucosa
and anal margin.
 Three main hemorrhoidal complexes transverse the anal canal:
1) Left lateral ( 3 o’ clock)
2) Right posterior ( 7 o’clock)
3) Right anterior ( 11 o’clock)
 Sliding anal cushion theory: repeated stretching causes
fragmentation of the submucosal muscle of Treitz which anchors and
suspends the anal lining.
 Proposed factors for the development of hemorrhoids:
Deterioration of connective tissue anchors.
Increased tone of the internal anal sphincter.
Abnormal distention of the veins of the internal hemorrhoids.
 INTERNAL HEMORRHOIDS:
 Located above the dentate line.
 Covered with mucosa.
 Usually presents as painless bright red bleeding during defecation.
 EXTERNAL HEMORRHOIDS:
 Located below or distal to the dentate line.
 Covered by anoderm.
 Enlarges sec. to dilation or thrombus.
 Usually with itching and pain around the anus.
 MIXED HEMORRHOIDS:
 Combination of both internal and external.
 Straining
 Constipation
 Low fiber diet
 Age
 Secondary: pregnancy, anorectal deformities, ascites, uterine or ovarian
neoplasms.
 Signs of bleeding ( blood on tissue paper, blood in stools)
 Pruritus
 Prolapsed mass
 Anal pain (usually for external hemorrhoids)
 Physical examination
 Proctoscopy
 Flexible Sigmoidoscopy
 NON-SURGICAL:
 Main goal of this treatment is to minimize straining at stools.
 Warm sitz bath is the most effective topical treatment.
 Increasing in oral fluid intake and fiber in diet.

SURGICAL:
 Excision hemorrhoidectomy.
STAGE DESCRIPTION OF
CLASSIFICATION
1 ENLARGEMENT WITH
BLEEDING
2 PROTRUSION WITH
SPONTANEOUS REDUCTION
3 PROTRUSION REQUIRING
MANUAL REDUCTION
4 IRREDUCIBLE PROTRUSION
TREATMENT
Fiber supplementation
Cortisone suppository
Sclerotherapy
Fiber supplementation
Cortisone suppository
Fiber supplementation
Cortisone suppository
Banding
Operative hemorrhoidectomy
Fiber supplementation
Cortisone suppository
Operative hemorrhoidectomy