Successful MIPH Treatment for Complex Hemorrhoids in a 50 Y.O. Hypertensive Patient

PACE Hospitals

The PACE Hospitals’ Gastroenterologist team successfully performed a Minimally Invasive Procedure for Haemorrhoids (MIPH) on a 50-year-old male patient who had been experiencing both internal and external haemorrhoids, along with a known history of hypertension (HTN).

Chief Complaints

A 50-year-old male patient with a BMI of 25.8 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of constipation, characterised by hard stools and bleeding per rectum, without any associated perianal pain.

Past History

The patient has a known history of hypertension, diagnosed several years ago, and has been under regular medical supervision. His blood pressure is currently well-controlled with the use of Angiotensin II Receptor Blockers (ARBs), which he has been taking as part of his long-term antihypertensive therapy.

Diagnosis

Upon admission to PACE Hospitals, the patient underwent a comprehensive evaluation, including a detailed review of his medical history and a thorough clinical examination by the gastroenterology team. Based on his presenting symptoms, there was a strong clinical suspicion of both internal and external haemorrhoids. This prompted the decision to proceed with further diagnostic workup, which confirmed the need for a Minimally Invasive Procedure for Haemorrhoids (MIPH).

To support the diagnosis and assess the extent of the condition, a series of relevant investigations were conducted:

Anoscopy, using a small, lighted instrument, was performed to directly visualize the internal haemorrhoids and played a crucial role in grading them, confirming the presence of the internal component in his mixed (external and internal) haemorrhoids.
Proctoscopy provided a deeper view into the rectum, offering a more comprehensive assessment, especially useful given the persistence of symptoms such as bleeding per rectum.
As the patient was over 50 years old and presented with rectal bleeding, a flexible sigmoidoscopy was also recommended to rule out other potential causes such as polyps, tumors, or inflammatory bowel disease (IBD).
Additionally, a Faecal Occult Blood Test (FOBT) was conducted to detect any hidden gastrointestinal bleeding that might not be visible externally.
A Complete Blood Count (CBC) was performed to check for anaemia related to chronic blood loss and to assess the patient's overall health before considering surgical intervention.

These diagnostic evaluations collectively confirmed the diagnosis of both internal and external haemorrhoids and guided the medical team in planning an appropriate treatment approach.

Based on the confirmed findings, the patient was advised to undergo Haemorrhoids Treatment in Hyderabad, India, under the expert care of the Gastroenterology Department, ensuring comprehensive management, relief of symptoms, and prevention of future complications.

Medical Decision Making (MDM)

After a thorough consultation with consultant gastroenterologists Dr. Govind R. Verma, Dr. Sudhir, Dr. Padma Priya, and other specialists, including Dr. Suresh Kumar S, a comprehensive evaluation was conducted to determine the most appropriate diagnostic and therapeutic approach for the patient, ensuring personalized and effective treatment.

Based on the expert assessment by the gastroenterology team, it was determined that a Minimally Invasive Procedure for Haemorrhoids (MIPH) would be the most appropriate and effective treatment for the patient’s combined internal and external haemorrhoids, offering the advantages of reduced postoperative pain, minimal tissue trauma, and a faster recovery.

Surgical Procedure

Following the decision, the patient was scheduled for a Minimally Invasive Procedure for Haemorrhoids (MIPH) surgery in Hyderabad at PACE Hospitals, under the expert supervision of the Gastroenterology Department, ensuring optimal care and a smooth recovery process.

Following the decision of the gastroenterology team, the patient agreed to undergo surgery and was admitted to the inpatient (IP) unit for the procedure. Before the surgery, a thorough investigation was conducted, including a colonoscopy, which revealed a caecal diverticulum in addition to external and internal haemorrhoids. A consultation with the surgical gastroenterology (SGE) team was sought, and after completing a pre-anaesthetic evaluation and obtaining informed consent, the patient was scheduled for the Minimally Invasive Procedure for Haemorrhoids (MIPH).

The Minimally Invasive Procedure for Haemorrhoids (MIPH) is an advanced surgical technique designed to treat internal and external haemorrhoids with significantly reduced discomfort and quicker postoperative recovery compared to conventional approaches. Utilizing a specialized stapling device, the procedure effectively repositions and secures the prolapsed hemorrhoidal tissue without requiring traditional incisions. MIPH is particularly well-suited for patients with Grade II to Grade IV haemorrhoids, offering durable symptom relief, minimal postoperative complications, and a prompt return to daily activities.

Findings

The patient underwent the Minimally Invasive Procedure for Haemorrhoids (MIPH) to treat prolapsed haemorrhoids. A circumferential suture was initially placed around the hemorrhoidal tissue, followed by the insertion of a stapler to reposition and secure the tissue in place. The stapler was tightened and fixed, and a "donut" check was performed to ensure proper positioning. Additional plicating sutures were placed at the 11 o'clock to 2 o'clock positions for further stabilization of the area. Haemostasis was successfully achieved, and an anal pack was applied to promote healing and minimize the risk of post-operative complications.

Postoperative Care

The patient’s postoperative recovery was smooth and uneventful. He was monitored closely in the inpatient unit, with regular assessments of vital signs and wound healing. Pain management was provided as needed, and supportive care was initiated to ensure comfort during the recovery process. The patient was encouraged to follow a high-fibre diet and increase fluid intake to support bowel function and prevent strain during defecation.

Multidisciplinary support was provided by the gastroenterology team, ensuring proper management of his digestive health and advising on preventive measures for long-term recovery.

Discharge Notes

The patient was clinically stable and showed no signs of complications post-surgery. He was discharged with detailed medical advice, including instructions for managing pain, maintaining a high-fibre diet, staying well-hydrated, and avoiding activities that may strain the affected area. Additionally, the patient was instructed on proper hygiene and lifestyle modifications to support healing and prevent future hemorrhoidal issues.

Discharge Medications

Upon discharge, the patient was prescribed a course of antibiotics, laxatives, a proton pump inhibitor (PPI), and a non-steroidal anti-inflammatory drug (NSAID) for pain management and to support healing. Additionally, the patient was advised to continue taking his prescribed antihypertensive medications as previously instructed.

Emergency Care

The patient was informed to contact the Emergency ward at PACE Hospitals in case of any emergency or development of symptoms like fever, abdominal pain, swelling, bleeding or vomiting.

Review and Follow-up Notes

The patient was advised to return for a follow-up visit with the Gastroenterologist in Hyderabad at PACE Hospitals, seven days after discharge. This visit would allow for a thorough evaluation of the patient’s recovery, address any concerns or complications, and ensure that the post-operative progress was proceeding as expected.

Conclusion

This case demonstrates the effectiveness of the Minimally Invasive Procedure for Haemorrhoids (MIPH) in treating hemorrhoidal conditions, providing significant symptom relief, quicker recovery, and a lower risk of complications compared to traditional surgery.

The Importance of Colonoscopy in Diagnosing and Managing External and Internal Haemorrhoids

Colonoscopy is an essential diagnostic tool in the management of both external and internal haemorrhoids, particularly when symptoms are severe or persistent. While haemorrhoids are typically diagnosed through physical examination and patient history, colonoscopy helps rule out other serious conditions, such as colorectal cancer or inflammatory bowel disease, which can present with similar symptoms. It provides a detailed view of the colon and rectum, allowing healthcare providers to assess the severity of the haemorrhoids and identify any underlying gastrointestinal issues. Colonoscopy is also crucial for distinguishing between internal haemorrhoids and other rectal or anal conditions that may require different treatments. In complex or high-risk cases, it ensures accurate diagnosis and helps guide the appropriate treatment plan, whether non-invasive or surgical. A gastroenterologist/gastroenterology doctor can use the findings from a colonoscopy to tailor a personalized treatment approach, ensuring optimal outcomes for the patient.