The Evaluation and Treatment of Hemorrhoids

A Guide for the Gastroenterologist

Robert A. Ganz

Disclosures

Clin Gastroenterol Hepatol. 2013;11(6):593-603. 

In This Article

Treatment

The common people call them piles, the aristocracy call them hemorrhoids, the French call them figs – what does it matter so long as you can cure them?
Attributed to Ardene, an English surgeon from the Middle Ages

There are a variety of treatments available for the care of patients with symptomatic hemorrhoidal disease.[9,40] The successful resolution of this issue is based on 2 factors: (1) the thorough evaluation of the patient to identify any additional factors that may well be compounding the patients' complaints of hemorrhoids and (2) a care plan that will treat both the hemorrhoids as well as these compounding issues. Internal hemorrhoids typically cause any combination of itching, bleeding, swelling, and prolapse; if pain is a component of the symptom complex, then more often than not, a fissure or thrombosed external hemorrhoid is present. The treatment of fissures, spasm, various skin rashes, thrombosed external hemorrhoids, and other confounding factors is beyond the scope of this article; however, it is strongly suggested that these additional entities be treated concurrently with the hemorrhoids for the best possible clinical results.

The different hemorrhoid therapies typically break down into the groups of conservative management, nonsurgical treatments, and surgical treatments.

Conservative (Medical) Treatment

Dietary and behavioral modifications are typically among the first-line recommendations made to patients with most anorectal disorders, including those with hemorrhoids. Typical recommendations include increasing dietary fiber, the avoidance of straining or minimizing time on the toilet during defecation, and using soothing sitz baths several times per day. There is moderate-quality evidence to support the use of dietary fiber in the medical treatment of symptomatic hemorrhoid disease[38,40,45] as well as an indication that continued use of fiber may decrease the likelihood of recurrence.[46] As noted in a recent guideline by the American Society of Colon and Rectal Surgeons (ASCRS), a Cochrane analysis of increased fiber intake in 378 patients assessed in 7 randomized trials demonstrated benefit in both symptomatic hemorrhoid prolapse (relative risk, = 0.53; 95% confidence interval, 0.38–0.73) and hemorrhoidal bleeding (relative risk, = 0.50; 95% confidence interval, 0.28–0.89).[40]

There is some evidence to support the use of sitz baths in patients with symptomatic anorectal disease as well. Manometric studies have confirmed that application of moist heat to the perianal area reproducibly lowers the internal sphincter and anal canal pressures of treated patients.[47,48] Patients with significant hemorrhoid disease tend to have elevated sphincter tone. Those hemorrhoid patients with pain often have coexistent fissures and thrombosed external hemorrhoids that coincide with elevated anal canal pressures, perhaps explaining why moist heat can prove beneficial.

As for the various products advertised commercially to patients with symptomatic hemorrhoids, Chong and Bartolo noted,[49] "well-designed studies have found no evidence to support the use of any of the myriad of over-the-counter topical preparations that contain low-dose local anesthetics, corticosteroids, keratolytics, protectants, or antiseptics. The use of these agents is widespread for symptomatic relief but the long-term use of these products, particularly steroid preparations, may be detrimental and should be discouraged."

There have been a number of reports describing the potential use of dietary supplements known as flavonoids. These micronized purified flavonoid fractions have been used extensively in Europe and Asia for some time. These compounds may possibly improve venous tone and lymphatic outflow and may help to control local inflammation. Although there have been publications showing potential for these supplements in the treatment of certain hemorrhoid symptoms, there is acknowledgment that additional trials are required and that widespread use of these products cannot yet be justified.[9,49,50]

Nonsurgical, Office-based Treatments

As stated by the ACRCS,[40] there are 3 goals of all nonsurgical hemorrhoid therapies: (1) to decrease hemorrhoid vascularity, (2) to reduce redundant tissue, and (3) to promote hemorrhoid fixation to the rectal wall to improve prolapse.

Rubber Band Ligation. Rubber band ligation (RBL) is widely acknowledged to be highly effective and the most commonly performed nonsurgical procedure in the treatment of hemorrhoids; it is used in up to 80% of treated patients.[3,51,52] As noted by ASCRS guidelines, in a meta-analysis of 18 prospective, randomized trials, RBL was overall superior to injection sclerotherapy or infrared coagulation (IRC) in the treatment of grades I, II, and III hemorrhoids.[40,52] Although some type of ligation probably dates back to the time of Hippocrates,[4] Blaisdell[53] first described the ligation technique in detail in 1958 by using a pre-tied silk suture. Barron[54] then described the ligation of hemorrhoids by using rubber bands in 1963. Barron recommended treating one column of hemorrhoids per session, separating the treatments by several weeks, to minimize pain and postbanding complications. The banding process causes the banded tissue to necrose and slough. The resultant inflammatory reaction causes refixation of the mucosa to the underlying tissue, helping to eliminate hemorrhoidal prolapse. The end result is a return of the hemorrhoidal cushions to a more normal size and configuration, with resolution of hemorrhoidal symptoms.[9,55] These patients do not require bowel preparation, sedation, or narcotics, have no significant recovery period, and typically can return to work immediately.[8]

RBL has been shown to be a very effective treatment for the majority of hemorrhoid patients, with short-term success rates of up to 99% and long-term success rates of up to 80%.[25,31] The risk of complications is low, reported in <1%–3% of patients, and includes postbanding pain, bleeding, and vasovagal symptoms.[40,56,57] Because of bleeding potential, the procedure is contraindicated in those with bleeding diatheses or those on anticoagulants or antiplatelet agents.[9] The occurrence of postbanding pain is quite variable, ranging from <1%–50%, and is likely due to differences in technique[25,58] because the location, route, and number of areas banded vary, as does the apparatus used to apply the band.

Location of Band Placement: The internal hemorrhoidal cushions tend to be in the left lateral, right anterior, and right posterior positions, are located proximal to the dentate line, and are covered by columnar epithelium. The hemorrhoidal tissue to be banded must be proximal to the dentate line to minimize the risk of pain, but the optimal location varies in the literature from "a few millimeters"[59] to "at least 2 cm proximal to the dentate line."[7,9,13] Many now use a technique that involves placing the band at least 2 cm above the dentate line, because this practice appears to be associated with the lowest rates of pain.[9,25] Most studies, however, do not specify the exact location of the band placement; therefore, it is difficult to ascertain how many of the differences noted in the rates of pain are due purely to this factor. The pain associated with RBL tends to be minimal and is generally easily managed with sitz baths and over-the-counter pain relievers.[9]

Method of Band Placement: RBL is generally a simple, inexpensive procedure, and there are any number of devices and ways of applying rubber bands for hemorrhoid treatment, each with its proponents.[8,9,25] Ligation can be performed with either a disposable suction device or a forceps ligator.[7,13,25,31] There are also ligation techniques applied via the flexible endoscope that have demonstrated better visibility and comparable results;[41,60] however, the endoscopic approach is associated with increased time and costs, and some studies suggest a higher frequency of pain with this route compared with other banding techniques.[61] There are also a number of devices that are used through an anoscope or proctoscope as well as a "touch" method[8] in which bands are placed without visualization by using a hand-held, disposable suction device[25] (Figures 6 and 7).

Figure 6.

Illustration of RBL by using the touch technique without anoscopy. Courtesy of Iain Cleator, MD, Vancouver, BC, Canada.

Figure 7.

Photograph of an internal hemorrhoid after banding. Courtesy of Neal Osborn, MD, Atlanta, Georgia.

Apart from banding, multiple insertions of a conventional slotted anoscope to expose the hemorrhoid beds may result in an increased incidence of pain in the postbanding period.[62] This may partly account for the relatively low frequency of pain (<1%) after the touch technique,[8] which bands hemorrhoids without the use of an anoscope or flexible endoscope, although studies of this technique are limited.[8,25]

How much tissue to band: There are 2 aspects to the discussion of how much tissue should be banded, both of which are controversial. The first is how much tissue to band for a given hemorrhoid, and the other is regarding how many of the hemorrhoidal columns should be treated at a single setting. As noted, the various methods each use different tools for band placement, and bands are positioned at differing locations relative to the dentate line. It is not clear as to exactly how much tissue is banded during these various procedures. The frequent description of placing the band around the "base of the hemorrhoid"[13] can be very difficult to quantify because this can be quite a large area, particularly when visualized anoscopically in patients with more severe disease.

The aim of RBL is to cause an inflammatory reaction that helps fix "loose" mucosa back to the underlying anorectal muscular layer by causing ischemic necrosis of the banded mucosa/submucosa rather than causing the necrosis of the entire hemorrhoidal cushion.[8,9] It is not known how much tissue is necessary to achieve this goal; moreover, banding the deeper muscle layer can cause significant postbanding pain.[25] Pain arises from ischemia of the muscle, and in the event of immediate postbanding pain, capture of muscle in the band needs to be considered. The band should be freely mobile if no muscle is trapped and will feel "fixed" if there is muscle caught in the band. In this event, digital rectal examination with manipulation of the banded tissue and rolling the band off of any captured muscle should immediately alleviate discomfort, assuming that the band was placed well proximal to the dentate line.[25] Rarely, perineal sepsis can occur when muscle is trapped in the band, resulting in necrosis and subsequent microperforation. This should be suspected and treated emergently if patients develop severe pain, high fever, and urinary retention.[9,25]

Another point of discussion is the number of hemorrhoids to be banded at a single session. In his original description of the technique, Barron[54] found that banding only one hemorrhoid at a session resulted in less pain and fewer problems in the postbanding period. Others have concurred with these recommendations, and banding one hemorrhoid at a time has become an accepted practice.[3,25,27] There are authors who have challenged this practice in an effort to see whether multiple bandings could be safely and more conveniently performed at a single setting.[62–64] Multiple-banded patients, however, may experience a significant increase in the incidence of pain, the need for analgesics, urinary symptoms (including urinary retention), vasovagal symptoms, swelling, and edema (Table 2).[64]

Although there is a need for additional studies comparing single with multiple band ligation, at the present time it would seem reasonable to band a single hemorrhoidal column per treatment, place the band at least 2 cm proximal to the dentate line, and minimize instrumentation of the anorectum during treatment. Conforming to these tenets should allow RBL to be performed effectively, safely, and with minimal postbanding discomfort.[25]

Sclerotherapy. Sclerotherapy dates back more than a century[65] and typically is reserved for grades 1 or 2 internal hemorrhoids. It involves the injection of one of a number of sclerosants into the submucosal space of the hemorrhoid to be treated or into the apex of the hemorrhoid itself. The soft tissue reaction that follows causes thrombosis of the involved vessels, sclerosis of the connective tissue, and a refixation of the prolapsing mucosa to the underlying rectal muscular tissue.[9]

In a prospective study Khoury et al[66] demonstrated that 89.9% of patients with grades 1 and 2 hemorrhoids were helped, whereas a recent randomized, controlled trial demonstrated no advantage of sclerotherapy over bulk laxatives.[67]

The potential complications from sclerotherapy include pain (12%–70%), urinary retention, abscess, and impotence, although serious complications are uncommon.[9,40] Cadaveric dissections have shown the close proximity of parasympathetic ganglia to the typical site of injection. If the sclerosant is injected too deeply, affecting the parasympathetics in the area, impotence can result.[65,68] Fortunately, these reports are rare, as are those of hematuria, hematospermia, epididymitis, urethral stricture, and urinary perineal fistula.[65,69] These complications stress the importance of precise placement of the sclerosing injection. In large part because of the proximity of the genitourinary structures to the right anterior hemorrhoid cushion, a suggestion has been made to avoid the use of sclerotherapy and defer to another technique such as RBL rather than to inject the right anterior hemorrhoid.[70]

Infrared Coagulation. This technique was described by Neiger[71] in 1979. The technique calls for delivery of a controlled amount of infrared energy (converted to heat) via a tungsten-halogen lamp to the hemorrhoidal tissue by way of a polymer tip delivered through an anoscope[9] (Figure 8). Three to 4 pulses of infrared energy are applied to the normal mucosa proximal to the hemorrhoidal tissue, not the hemorrhoid itself. One or 2 hemorrhoids are treated per session, with sessions repeated as necessary every 2–4 weeks.[3] The bulk of the reaction takes place in the submucosa, producing tissue destruction, protein coagulation, and inflammation, which then lead to scarring and tissue fixation.[9,72]

Figure 8.

Illustration of transanoscopic approach to hemorrhoid treatment by using IRC probe.

The procedure seems best suited for cases of small (grade 1 or 2) bleeding hemorrhoids, with reported success rates of 67%–96% for these grades in 2 randomized, controlled trials.[9] Advantages attributed to IRC include a relative lack of serious complications and the fact that the maximal discomfort occurs during the procedure, as opposed to occurring at a later time. Disadvantages include the cost of the equipment, the limitations of the technique when treating larger, bulkier hemorrhoids and those with prolapse, the need for more retreatments than RBL, and a higher recurrence rate,[3,13,52,73] although recent randomized studies suggest outcomes similar to RBL.[40]

Bipolar Diathermy, Direct Current Electrotherapy, Heater Probe Coagulation. These hemorrhoid technologies are also delivered via anoscopy and have been used in grades 1, 2, and 3. The heater probe and bipolar diathermy devices generate heat (1-second pulses, 20 W), which causes coagulation of the treated tissue, leading to a fibrotic reaction at the site of treatment with fixation of the treated tissue.[9] Multiple applications to the same hemorrhoid are typically necessary, particularly for larger lesions. Bipolar cautery success rates in randomized trials range from 88%–100%, but the complication rate is relatively high.[74–78] When comparing bipolar and heater probes, both technologies afforded similar efficacy when treating bleeding, with a 6.2% recurrence of bleeding at 1 year, but the heater probe controlled the bleeding more quickly (76.5 vs 120.5 days), while causing more pain. The overall complication rate was higher with the bipolar technology (11.9% vs 5.1%).[74] Complications include pain, bleeding, fissure formation, or spasm of the internal sphincter, and bipolar coagulation required more treatment sessions and had more treatment failures than did RBL.[41] The depth of the wound created by bipolar cautery is similar to that of IRC.[79] Another study demonstrated symptomatic mucosal ulceration in 24%, significant bleeding in 8%, and prolonged pain in 4%, and neither technology was able to reliably eliminate prolapsing tissue.[9,76]

The direct current probe (Ultroid; Ultroid Technologies, Inc, Tampa, FL) is said to not be a thermal device, but rather it causes the production of sodium hydroxide at the negative electrode of the device, creating the desired tissue effects.[31] Treating hemorrhoids by using direct current technology is limited by the large amount of time necessary to treat the involved tissue, up to 14 minutes per site, and this depends on the grade of the hemorrhoid and the milliamperage tolerated by the patient (110 V up to 16 mA).[9,80] This technique has had limited application because of postprocedure pain that occurs in up to 20% of patients, poor control of prolapse, and the prolonged treatment time.[77] Postprocedural ulcers with bleeding have also been reported. In randomized trials that used this technique, hemorrhoidal bleeding was controlled in 88% of patients.[9]

Meta-analyses. As noted in recent reviews, each of the above methodologies has its advocates, and there is no perfect technique.[9,40] Randomized, controlled trials have compared each method with some of the others, but there is no overarching study that has compared all the techniques together. A highly cited meta-analysis by Helen MacRae queried 18 studies that assessed 2 or more treatment modalities involving grades 1, 2, and 3 hemorrhoids.[79,81] This analysis concluded that RBL was the preferred initial strategy on the basis of a combination of initial outcomes, less need for additional therapy, and low complication rates. Hemorrhoidectomy yielded the best treatment response but had higher complications than RBL. RBL was more effective than sclerotherapy and was similar in efficacy to IRC, with lower recurrence rates than either sclerotherapy or IRC. RBL was associated with more postprocedural pain.[79,81] Another meta-analysis assessing 5 studies involving almost 1000 patients reached similar conclusions but preferred IRC as the initial strategy because of less postprocedural pain.[82]

Cryosurgery and Lord's Procedure. These techniques are mentioned only in passing, because both have lost favor in the United States. Cryosurgery is followed by significant amounts of pain along with a foul-smelling discharge and a prolonged recovery in several series.[7,9,31] Lord[83] recommended manual stretching of the anus to decrease sphincteric pressure. Although the technique initially showed some promise for both hemorrhoids and anal fissures, there were significant numbers of patients with postprocedural incontinence.[83,84] In addition, response rates are lower than other techniques, are more likely to require additional therapy, and because of the high rates of postdilation incontinence, the ASCRS Surgeons recommends that this procedure be abandoned (Table 3).[85]

Surgical Treatment Options

A detailed description of surgical options available for the treatment of hemorrhoids is beyond the scope of this article; patients requiring these more advanced procedures typically fall into one of the following patient groups:[49]

  • Grade III hemorrhoids unresponsive to nonsurgical approaches

  • Grade IV hemorrhoids

  • Large external hemorrhoids or combined internal and external components

  • Concomitant anorectal pathology.

Nonsurgical approaches are successful in 80%–99% of patients with hemorrhoidal issues,[25,27] but in nonresponders, surgery can be contemplated. Surgical hemorrhoidectomy is more effective than RBL in the treatment of grade III hemorrhoids[86] but incurs additional complications, pain, and disability.[79,81]

Surgical treatments fall into several categories. The first is the classic excisional hemorrhoidectomy, which has several technical variations. These techniques are highly effective and have low recurrence rates, but they are offset by significant pain and a prolonged recovery period. Complications have included urinary retention (2%–36%), bleeding (0.03%–6%), infection (0.5%–5.5%), anal stenosis (0%–6%), and incontinence (2%–12%).[79,81]

The procedure for prolapse and hemorrhoids, proposed by Longo in 1998, uses a circular stapling device to divide, resect, and repair the mucosa and submucosa. This causes an interruption of arterial inflow to the hemorrhoids, which "fixes" the previously prolapsing mucosa to the underlying rectal wall. Advantages of the procedure include less postoperative pain and disability than traditional hemorrhoidectomy, but it is not devoid of complications, because there are reports of anovaginal fistula, fistula in ano, hemorrhage, sepsis, and perforation.[52]

Transanal hemorrhoidal dearterialization is a newer surgical technique that uses Doppler identification of the distal rectal arterial branches and suture ligation of the vessels to decrease flow to the hemorrhoidal cushions.[87] This diminution of flow, along with any postinflammatory mucosal fixation that occurs as a result of the surgery, is thought to be responsible for the therapeutic effects noted ( Table 3 ).

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