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Internal Hemorrhoids.
The rectum is observed in the retroflexed maneuver.
For more endoscopic details download the video clips by
clicking on the endoscopic images, wait to be downloaded
complete then press Alt and Enter; thus you can observe
the video in full screen.
All endoscopic images shown in this Atlas contain
video clips.
Medline.
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Video Endoscopic Sequence 1 of 5.
Colonoscopic view of internal hemorrhoids.
Hemorrhoidal disease is a common entity in the general
population and in clinical practice. The most common cause
of hematochezia in adults, it remains high in the differential
diagnosis of almost any anorectal complaint.
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Video Endoscopic Sequence 2 of 5.
Hemorrhoids colonoscopic view in retroflexed image.
Enlarged (hypertrophied) papillae is observed
Hemorrhoids they are clusters of vascular tissue
(eg, arterioles, venules, arteriolar-venular connections),
Hemorrhoids have 3 main cushions. These cushions are
situated in the left lateral, right posterior, and right anterior
areas of the anal canal. Minor tufts can be found between
the cushions.
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Video Endoscopic Sequence 3 of 5.
Another image and video clip of internal hemorrhoids.
Although hemorrhoids are very common, their true
prevalence is unknown. Their presence may be
underestimated due to the large proportion of relatively
asymptomatic patients. Conversely, many nonspecific
anorectal symptoms can be reflexively, and falsely,
attributed to hemorrhoids without the appropriate workup.
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Video Endoscopic Sequence 4 of 5.
This images observed that the hemorrhoids are congested
with reddish color, that is the equivalent of the red sign of
esophageal varices.
Hemorrhoids are one of the most frequent anorectal
disorders encountered in the primary care settings. They
are the most common cause of bleeding per rectum and are
responsible for considerable patient suffering and disability.
With the newer techniques of diagnosis and office-based
interventions, most of the symptoms can be effectively
controlled.
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Video Endoscopic Sequence 5 of 5.
This colonoscopic view of internal hemorrhoids is
appreciated using a magnifying colonoscope.
Most clinicians use the grading system proposed by Banov et al
in 1985, which classifies internal hemorrhoids by their degree of
prolapse into the anal canal. This system both correlates with
symptoms and guides therapeutic approaches.
- Grade I hemorrhoids project into the anal canal and often bleed but do not prolapse.
- Grade II hemorrhoids may protrude beyond the anal verge with straining or defecating but reduce spontaneously when straining ceases.
- Grade III hemorrhoids protrude spontaneously or with straining and require manual reduction.
- Grade IV hemorrhoids chronically prolapse and cannot be reduced. They usually contain both internal and external components and may present with acute thrombosis or strangulation.
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Video Endoscopic Sequence 1 of 3.
Rubber band ligation is the most effective nonoperative
(without incision or excision) treatment for internal
hemorrhoids.
Rubber Band Ligation - This procedure involves placing a small
rubber band at the base of the internal hemorrhoid. The band cuts
off blood supply to the hemorrhoid, causing it to shrivel up and
fall off in about four to seven days. We place two rubber bands
for each hemorrhoid in a basis of one treatment every one week.
Today, nonsurgical methods are an alternative to surgical
ones.
Band ligation of internal hemorrhoids is a well-established
and accepted office procedure.
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Video Endoscopic Sequence 2 of 3.
Endoscopic View of Rubber Band Ligation for Internal
Hemorrhoids
The band causes the hemorrhoid to wither and drop off
painlessly. The treatment is usually applied to one
hemorrhoid at a time at intervals of 1 weeks or longer.
Used only for Internal hemorrhoids.
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Video Endoscopic Sequence 3 of 3.
Retroflexed Image.
In 1954, Blaisdel invented the first automatic ligator of
hemorrhoids, which was modified by Barron in 1962. From
that time, the ligation of hemorrhoids is widely used as an
alternative method for the treatment of internal
symptomatic hemorrhoids and has replaced
hemorrhoidectomy.
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Status Post Rubber Band for Internal Hemorrhoids.
RBL of hemorrhoids is a widely used method for the
treatment of symptomatic hemorrhoids. Removal of the
hemorrhoidal tissue, development of fibroconnective tissue
at the point of the ligation, fixation of the mucosa and
correction of the prolapse are achieved with this method.
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Video Endoscopic Sequence 1 of 7.
Status Post Rubber Band Ligation for Internal Hemorrhoids.
This 60 year-old lady who two days previously undergone a
rubber band treatment for internal hemorrhoids, a
colonoscopy was performed finding this image, immediately
after the colonoscopy a second treatment was carry out.
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Video Endoscopic Sequence 2 of 7.
Retroflexed image and video clip.
Rubber band ligation is followed by a lower complication rate when performed in a single ligation.
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Video Endoscopic Sequence 3 of 7.
Rubber band ligation is a procedure in which the
hemorrhoid is tied off at its base with rubber bands, cutting
off the blood flow to the hemorrhoid.
Candidates for this method are patients with 2nd and 3rd
degree hemorrhoids, although some authors consider RBL
also suitable in appropriately selected cases of advanced
hemorrhoidal disease, cases with 4th degree hemorrhoids
and permanent prolapse were also treated.
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Video Endoscopic Sequence 4 of 7.
Endoscopic Image of Rubber Band Ligation for Internal
Hemorrhoids
The Second treatment with band that strangulated the hemorrhoids
Five minutes after the second band has been applied , it is
observed that the hemorrhoid started with necrosis signs,
which is the result of the therapeutic success of this
procedure.
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Video Endoscopic Sequence 5 of 7.
Retroflexed image.
It is observed that the first hemorrhoid that was tied has a yellowih image(fibrin) and the second hemorrhoids is with little signs of necrosis.
Highlighting the efficacy and cost containment of
hemorrhoidal ligation.
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Video Endoscopic Sequence 6 of 7.
Rubber band ligation is a useful, safe and successful
method for treating symptomatic 2nd and 3rd degree
hemorrhoids, which can be applied successfully in selected
cases with 4th degree hemorrhoids, but with an increased
rate of recurrence and additional treatment requirements.
Also,Rubber band ligation seems to be safe in patients with
liver cirrhosis and portal hypertension.
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Video Endoscopic Sequence 7 of 7.
Today, nonsurgical methods are an alternative to surgical
ones. They aim at tissue fixation with or without tissue
destruction (sclerotherapy, cryotherapy, photocoagulation,
BiCAP, laser), or to fixation with tissue excision (rubber
band ligation, RBL).
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Status Post Rubber Band for Internal Hemorrhoids.
Rubber band ligation is the most-used remedy for grade II
and grade III hemorrhoids and is the standard to which
other methods are compared. A band ligature is passed
through an anoscope and placed on the rectal mucosa
proximal to the dentate line. The tissue necroses and
sloughs off in 1-2 weeks, leaving an ulcer that later
fibroses. No anesthesia is required; complications are
uncommon and usually benign.
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Video Endoscopic Sequence 1 of 3.
Status post rubber band treatment for internal hemorrhoids
This 36 year-old female, who 3 years previously undergone
4 rubber bands treatment for internal hemorrhoids, several
scar are seen at colonoscopy close to the dentate line.
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Video Endoscopic Sequence 2 of 3.
One scar is observed close to the dentate line.
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Video Endoscopic Sequence 3 of 3.
Retroflexed image, there are 4 scar.
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Third-degree hemorrhoids seen in the colonoscopy.
Third degree hemorrhoids prolapse but require "manual
reduction.
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Rubber Band Ligation.
Rubber band ligation as showed in the image, the
hemorrhoid has been strangulated.
Necrotizing pelvic sepsis is a rare, but serious, complication
of rubber band ligation. The diagnosis is suggested by the
triad of severe pain, fever, and urinary retention. It occurs
1-2 weeks after ligation, frequently in
immune compromised patients, and requires prompt
surgical debridement.
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Status Post Rubber Band Ligation.
The hemorrhoid has been strangulated as it can be
observed in white color “necrosis”.
Generally the hemorrhoids, after been legated it takes
from two to seven days to become white in color, meaning
that it had “necrosis”.
Medline.
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Status Post Rubber Band Ligation.
Rubber band ligation, as the video clip shows, two
hemorrhoids have been strangulated.
This method is similar to variceal ligation of the esophagus
see varices.
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Status Post Rubber Band Ligation.
Status post rubber band treatment, the rectum in
retroflexed view. Two yellow ulcers are observed, which is
the normal process after the hemorrhoids have been fallen
out after necrosis.
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Video Endoscopic Sequence 1 of 2.
Anal Fissure.
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Video Endoscopic Sequence 2 of 2.
Anal Fissure.
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Anal Fissure.
An anal fissure is a laceration in the lining of the anal
canal distal to the dentate line, which most commonly
occurs in the posterior midline and is often caused by
local trauma such as the passage of hard stool. Anal
fissures can occasionally be seen in patients with leukemia,
tuberculosis, and Crohn's disease.
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Enlarged (hypertrophied) papillae of the rectum.
In addition to the hypertrofied papillae, some internal
hemorrhoids are observed, through the image in retroflexed
view.
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Video Endoscopic Sequence 1 of 2.
Anal fissure Retroflexed Image.
An anal fissure is a small split or tear in the anal mucosa
that may cause painful bowel movements and bleeding.
There may be blood on the outside of the stool or on the
toilet tissue following a bowel movement.
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Video Endoscopic Sequence 2 of 2.
Anal Fissure.
The image and the video clip is appreciated using an
anoscope.
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Anal Fissure.
An anal fissure is a small tear or cut in the skin lining the
anus which can cause pain and or bleeding.
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Peri Anal Tuberculosis.
Cutaneous manifestations of tuberculosis are exceptional.
In patients with protracted peri-anal ulceration, a biopsy
should be performed that will show a typical tuberculoid
granuloma. The most frequently encountered anorectal
tuberculous lesions are suppurations and fistulae. The main
differential diagnosis is Crohn's disease with anorectal
manifestations.
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Condyloma Acuminatum.
Cauliflower-like projections.
Extensive perianal condyloma acuminata. This condition is
generally caused by infection with human papillomavirus.
Condylomata can reach substantial size, and multiple
lesions are common. If one lesion is present, a complete
genital and anorectal examination is indicated to detect
additional growths.
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Perianal fistula.
A perianal fistula, almost always the result of a previous
abscess, is a small passage connecting the anal gland from
which the abscess arose to the skin where the abscess was
drained.
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Mucocutaneous folds
Mucocutaneous folds are seen above and fistulous tract
below.
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Video Endoscopic Sequence 1 of 2.
Internal Hemorrhoids.
In the video clip you can observe the colonoscope in
retroflexed maneuvering, passing across to the anus
observing the colonoscopist.
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Video Endoscopic Sequence 2 of 2.
The colonoscopist (myself) is observing the colonoscope
that has been removed by this route from the rectun and
anus in retroflexed maneuver.
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Status after rubber band ligation of internal hemorrhoid.
The rubbers bands have strangulated the hemorrhoid, and
ulcerated the mucosa, as a result of the treatment, which is
normal. The complete cure of this status can be expected
within average of 3 weeks for each hemorrhoid. You can get
treatment by this method as an outpatient, one a weekly
basis; that means one treatment each week
This treatment is exclusive for internal hemorrhoids.
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Video Endoscopic Sequence 1 of 2.
Colonoscopic view of internal hemorrhoids, a status of
after rubber band ligation of internal hemorrhoid is seen.
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Video Endoscopic Sequence 2 of 2.
Same case as above. Retroflexed image.
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Hypertrophied Papillae.
Large Anal hypertrophied papillae that introduced into
the rectum.
The presence of Hypertrophied anal papillae and fibrous
anal polyps are often ignored in the proctology practice.
But the experience is that they tend to produce minor but
disturbing symptoms.
Removal of hypertrophied anal papillae and fibrous polyps
should be carried out as a routine during surgical treatment
of anal fissure. This would add to effectiveness and
completeness of the procedure.
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Video Endoscopic Sequence 1 of 4.
Endoscopic Image of Anal Fissure
Anal fissure Retroflexed Image.
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Video Endoscopic Sequence 2 of 4.
Anal fissure Retroflexed Image.
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Video Endoscopic Sequence 3 of 4.
Anal fissure Retroflexed Image.
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Video Endoscopic Sequence 4 of 4.
Anal fissure Retroflexed Image.
Magnifying Image
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Video Endoscopic Sequence 1 of 4.
Prolapsed Hemorrhoid
Stage III - Internal hemorrhoids that bleed and prolapse
with straining and require manual effort for replacement
into the anal canal.
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Video Endoscopic Sequence 2 of 4.
Stage III - Internal hemorrhoid that Prolapsed internal
hemorrhoids extend into the anal canal or through the anus,
outside the anal sphincter; with these, pain usually ensues.
(If the internal hemorrhoid pushes out of the anal opening, this
hemorrhoid is called a prolapsed hemorrhoid).
Third degree hemorrhoids prolapse but require "manual
reduction.
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Video Endoscopic Sequence 3 of 4.
Protrusion can occur with both internal and external
varicosities; while some may regress spontaneously, others
may require manual replacement. Other symptoms may
include steady aching in the affected area, non-severe pain,
soreness, discomfort, burning, swelling, mild inflam-mation,
mucous discharge, and seepage.
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Video Endoscopic Sequence 4 of 4.
Retroflexed image.
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Fistula-in-ano
A fistula-in-ano is a hollow tract lined with granulation
tissue connecting a primary opening inside the anal canal to
a secondary opening in the perianal skin. Secondary tracts
may be multiple and from the same primary opening.
Fistula-in-ano is nearly always caused by a previous
anorectal abscess. Anal canal glands situated at the
dentate line afford a path for infecting organisms to reach
the intramuscular spaces
Other fistulae develop secondary to trauma, Crohn disease,
anal fissures, carcinoma, radiation therapy.
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Fistula-in-ano
Pathophysiology
The cryptoglandular hypothesis states that an infection
begins in the anal gland and progresses into the muscular
wall of the anal sphincters to cause an anorectal abscess.
Following surgical or spontaneous drainage in the perianal
skin, occasionally a granulation tissue–lined tract is left
behind, causing recurrent symptoms. Multiple series have
shown that the formation of a fistula tract following
anorectal abscess occurs in 7-40% of cases.
Physical examination findings remain the mainstay of
diagnosis. The examiner should observe the entire
perineum, looking for an external opening that appears as
an open sinus or elevation of granulation tissue.
Spontaneous discharge via the external opening may be
apparent or expressible upon digital rectal examination.
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Fistula-in-ano
Digital rectal examination may reveal a fibrous tract or
cord beneath the skin. It also helps delineate any further
acute inflammation that is not yet drained. Lateral or
posterior induration suggests deep postanal or ischiorectal
extension.
The examiner should determine the relationship between
the anorectal ring and the position of the tract before the
patient is relaxed by anesthesia. The sphincter tone and
voluntary squeeze pressures should be assessed before
any surgical intervention to delineate whether preoperative
manometry is indicated. Anoscopy is usually required to
identify the internal opening.
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Sequence 1 of 2.
Acute Trombosed hemorrhoids
This is the case of a 62 year-old male that during 12 years have been suffering from internal hemorrhoids grade III hemorrhoids protrude spontaneously and require manual reduction but never seek medical help, suddenly had an acute trombosed internal and external hemorrhoids .
There are two hemorrhoids that are trombosed one is
external and one is internal both are trombosed contain
both internal and external components with acute
thrombosis and strangulation
Are hemorrhoids that have clotted on the inside of the anus
(a ‘thrombus’). These clots form in the veins of the rectum just
under the skin. External hemorrhoids can be seen and/or felt.
Sometimes they are soft. Other times they are hard.
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Sequence 2 of 2.
Internal hemorrhoids drain through the superior rectal vein
into the portal system. External hemorrhoids drain through
the inferior rectal vein into the inferior vena cava. Rich
anastomoses exist between these 2 and the middle rectal
vein, connecting the portal and systemic circulations.
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Sequence 1 of 7.
Fistula in Ano
Fistula-In-Ano: External opening of fistulus tract is apparent in
photo above. Proximal opening would be at level of crypts,
within the anal canal. Fistulas are frequently associated with
perirectal abscesses, though none are present in this case.
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Sequence 2 of 7.
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Sequence 3 of 7.
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Sequence 4 of 7.
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Sequence 5 of 7.
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Sequence 6 of 7.
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Sequence 7 of 7.
An anal fistula usually lasts until it is surgically removed.
The fistula tract must be opened along with the source of
the infection. Usually, tissue around the external opening
and the internal opening is excised along with a small
margin of tissue lining the tract, called a fistulotomy.
Excision of the complete tract is called a fistulectomy.
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Video Endoscopic Sequence 1 of 4.
Ulcerated Internal Hemorrhoid
This is the case of a 79 year-old male, who had several
episodes of hematemesis, the hemoglobin drop until
5.9 Gr./dl, the colonoscopy was negative.
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Video Endoscopic Sequence 2 of 4.
Endoscopic Image of Ulcerated Internal Hemorroid
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Video Endoscopic Sequence 3 of 4.
Video Endoscopic Image of Ulcerated Internal Hemorroid
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Video Endoscopic Sequence 4 of 4.
Video clip of Ulcerated Internal Hemorroid
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