The Evaluation and Treatment of Hemorrhoids

Introduction

The Lord will smite thee with … the emerods [hemorrhoids], and with the scab, and with the itch, whereof thou canst not be healed.
Deuteronomy 28:27, King James Bible
… and he smote the men of the city, both small and great, and they had emerods in their secret parts … and the men that died not were smitten with the emerods: and the cry of the city went up to heaven.
Samuel 5:1, King James Bible

Ancient references to symptomatic hemorrhoidal disease date back thousands of years and can be found in the Bible as well as early Egyptian, Babylonian, and Greek scripts.^[1–3] The first known mention of this condition is from an Egyptian papyrus in 1700 BC, which advises … "Thou shouldest give an ointment of acacia leaves, ground and titurated together … and place in the anus, that he recovers immediately."^[4] Indeed, there are few diseases more recounted in human history than hemorrhoids. The word hemorrhoid is derived from the Greek, with haima meaning blood and rhoos meaning flowing. Another common word for hemorrhoids used in the vernacular is "pile," which comes from the Latin pila, meaning a ball. As aptly noted by Senagore, "although few people have died of hemorrhoidal disease, many patients who have undergone certain hemorrhoid therapies wish they had," and this entity is one of the few diseases with its own patron saint (St Fiachre, the patron saint of gardeners and hemorrhoid sufferers).^[1]

Symptomatic hemorrhoids are common, and those with hemorrhoids along with other anorectal diseases frequently present to the gastroenterologist with lower gastrointestinal (GI) bleeding and perianal complaints for evaluation and treatment. These patients and their referring physicians have an expectation that the gastroenterologist who examines this area should be able to provide comprehensive care of any nonsurgical anorectal ailments that are present. However, in large part because of the fact that formal training in anorectal pathology is not included in the combined Gastroenterology Core Curriculum, the care of these problems is often deferred to surgical specialties.^[5,6]

There now seems to be an increasing recognition of this gap in the training of gastroenterology fellows, because an increasing number of GI programs are beginning to include nonsurgical anorectal care into their curricula. Some have called for the formal inclusion of anorectal entities into GI fellowship training.^[5] It is the intent of this article to serve as a general introduction of the nonsurgical care of hemorrhoids to gastroenterologists, helping them provide a more complete continuum of care to their patients.

Table 1. Grades and Types of Hemorrhoids
Grades of internal hemorrhoids (Banov³⁶)
I	Nonprolapsing internal hemorrhoids
II	Internal hemorrhoids prolapse during defecation, spontaneously reduce
III	Internal hemorrhoids prolapse during defecation, must be manually reduced
IV	Internal hemorrhoids prolapsed and incarcerated
Types of hemorrhoids
Internal	Covered by columnar epithelium, Figure 2
External	Covered by squamous epithelium (anoderm), Figure 2
Mixed hemorrhoids	Involving and bridging both of the above spaces, Figure 4

Table 2. Single vs Multiple RBL at a Single Setting
Complication	Single RBL (%)	Multiple RBL (%)
Pain	4.5	29
Vasovagal reflexes	0	5.2
Urinary symptoms	0	12.3
Bleeding	0	11.6
Swelling/edema	0	2.6
Thrombosed external hemorrhoids	0	1.3

NOTE. Adapted from Lee et al.⁶⁴

Table 3. Treatment Options by Grade of Hemorrhoids
	Grade I	Grade II	Grade III	Grade IV	Comments (see text for citations)
Medical management	X	X	X	X	May provide symptomatic relief as well as lessen likelihood of recurrence.
Sclerotherapy	X	X			Limitations with prolapse and complications discussed.
IRC	X	X			Best suited to smaller hemorrhoids, need for more frequent treatments, higher recurrence rates.
Bipolar/heater probe coagulation	X	X			Heater probe with quicker results, but more pain; bipolar with more overall complications.
Direct current therapy (Ultroid)	X	X	X		Limited by time required for therapy.
RBL	X	X	X		Current first-line therapy in I, II, and III. Pain most frequent complication, can be minimized by proximal placement, touch technique, single banding at a session.
Cryosurgery/anal dilatation (Lord's)	NA	NA	NA	NA	Complications prohibitive
Surgery		(X)	(X)	X	For use in patients unresponsive to lesser treatments. More effective than RBL in grade III, but pain/disability caused by surgery leads to recommendation of attempting RBL or IRC first and saving surgery for resistant cases.