David A. Johnson, MD


August 13, 2014

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Hemorrhoids: A Common Clinical Problem

Hello. I'm Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School. Welcome to another GI Common Concerns -- Computer Consult.

Today, I will talk briefly about a very common clinical problem that I see routinely in day-to-day practice, and that is the diagnosis and management of hemorrhoids and anal fissures. These problems are very significant to patients and dismissed too often by the treating care providers. I want to give you some insight as to what you might think about the next time you tackle one of these patient complaints in the clinic.

Hemorrhoids are a very common problem. The dating of hemorrhoids by report goes back to the Bible and to ancient Babylonian times. There were hemorrhoidal inferences on papyrus scriptures. This has been around for a long time. It's not a new problem.

Hemorrhoids are vascular problems. Internal hemorrhoids are fibrovascular cushions that are normal when we start out in life. As we age, and there are changes in the supporting structures, these fibrovascular cushions can be much more of a problem.

All hemorrhoids are internal or begin that way, and the predominance of the blood flow for hemorrhoids is internal. When patients come in and say, "I just have external hemorrhoids," that is very unlikely. More likely, they have internal hemorrhoids that have prolapsed. When we talk about treatment, we are going to direct it toward the internal plexus, because that is where the lion's share of the hemorrhoidal disease comes from, even though the patient may have disease that prolapses and is therefore external.

Internal hemorrhoids typically aren't painful because the endoderm in the rectum is very pain-insensitive, as opposed to the ectoderm in the anus. In the area where this is coated by the anal ectoderm, those external hemorrhoids may become quite painful, particularly if they become thrombosed.

Examination and Detection

What is the best examination for hemorrhoids?

The best exam you can conduct is a digital rectal exam with a good perianal exam. A digital rectal exam begins by looking at the anus before you put your finger in.

Look for fissures, because about 20% of patients with hemorrhoids will have a fissure.[1] The classic history for fissures is that the patient will tell you, "It feels like I have a razor blade or a piece of glass coming out when I have to pass stool." You will see a little split. It's important to recognize that these splits are in the midline -- 90% in the posterior midline, and 10% in the anterior midline -- for the standard anal fissure.[2]

If you find a fissure off the midline, you need to be thinking about other things, such as Crohn disease or such granulomatous diseases as tuberculosis or actinomycosis. A variety of things can cause fissures that aren't standard anal fissures.

Hemorrhoidal Symptoms

Hemorrhoids typically cause symptoms of burning and itching, as well as signs of bleeding. The internal hemorrhoids can secrete a little bit of mucus, and if this mucus gets down to the anal ectoderm, it can be very irritating. Pruritus, or perianal itching, is a very common complaint.

You need to pay particular attention to, or ask about, fecal leakage. This is something that many patients have but few like to bring up. So be sure to ask them about soiling -- not frank incontinence, but fecal leakage on the underwear. This can happen very frequently with hemorrhoids because as the internal hemorrhoids prolapse down through the anal canal, they have a wick effect and are somewhat disruptive to the anal sphincter, so fecal leakage and soiling can occur. As we start to talk about the treatment of hemorrhoids, resolution of fecal leakage may be something that patients are particularly interested in.

Management of Hemorrhoids

Management in terms of medical therapy of hemorrhoids is to avoid constipation.

Typically, we recommend fiber, and tell the patient to try and get about a 30-g fiber diet and drink lots of water.

We typically tell these patients to avoid sitting on the commode for more than 2 minutes. A prolonged commode stretch can actually aggravate this. If the patient can't have a bowel movement when he or she sits down, the patient should get up, do something else, and come back when it's more facile. That is something that is very simple to educate the patients on.

I recommend a breakfast cereal routinely for my patients with hemorrhoids and who have any tendency toward constipation. Get a high-fiber cereal; I personally use All-Bran®. (This is not a commercial for All-Bran.) I recommend a mixture of cereal and yogurt instead of milk. It's a marvelous, easy breakfast starter, and it gives them a probiotic and a fiber supplement, and it seems to work very well in a lot of these patients. When you are trying to get them through their hemorrhoids, it's not a short-term issue. You take care of those hemorrhoids for the long term.

Many topical therapies are available. I'm not a strong advocate of topical therapies. They may work for some patients, but they are not durable as a final treatment.

I try to stay away from products that contain lidocaine for more than a week or so. You can become sensitized to that. If you are mixing up compounds for this purpose, it may be something to limit if you use them even in the short term. For example, if you were treating somebody with an anal fissure, you might want to use a topical agent for the first week or two.

It is the same for steroids. You don't want to put steroids in the anal area for very long. It's not something that I routinely recommend. Limit the use of these products to a week or two if you are going to use them at all; for example, if there is some type of perianal rash that you think is nonfungal.

Other therapies are more sustainable, durable, and definitive. These include surgery, which I don't routinely recommend because it is associated with significant morbidity, including incontinence, which patients don't like in the long term. Furthermore, surgery puts them out of work for quite some time.

Among coagulative therapies that patients have been treated with are infrared coagulation and monopolar coagulation. These are in commercial use, but I don't use them in my practice.

Rubber Band Ligation

The most common treatment of hemorrhoids, particularly by gastroenterologists, is rubber band ligation.

We perform it in the office. It's simple and quick, and it requires no prep or recovery time. The patients walk in and walk out, and they come back for a series of 3-4 treatments.

The success rate reported for this procedure is > 94% as far as durable relief.[3] Patients sometimes will actually start to feel immediate relief within the first banding session. It's very simple, safe, and effective. The literature supports that this is easy and deliverable.

We use what is called the O'Regan bander, which is commercially available. You should look at this if you haven't seen it or your patients ask about this.

Management of Fissures

I want to spend a minute talking about the treatment of perianal fissures, because this condition can be problematic.

When these patients come in with anal fissures, the best therapy is nitroglycerin. Nitroglycerin is a problem because the standard nitroglycerin used for cardiac conditions is too concentrated to be used in the perianal area. The headache risk is significant. The commercially available product now for anal fissures is a 0.4%. Before this became commercially available, we used a compounded formulation. I like a lower concentration of about 0.13%.

I suggest that you try to have nitroglycerin compounded at a lower percentage. If you can't, and you use the standard prescription of 0.4%, have the patient dilute it with a little bit of a petrolatum or liquid soap.

You tell the patient to put about a pea-sized dollop on the tip of their gloved finger. Tell them to insert the ointment into the anus up to about their first knuckle. I tell patients that they are not just painting it on the external sphincter. It has to really coat the sphincter. Nitroglycerine is a vasodilator, so it lowers the tone. Many people have anal spasms or a hypertonic sphincter, and the blood flow is diminished. It promotes wound healing and resolution of this anal spasm.

If you are treating a fissure, I would start them at 3 times a day for the first week. If they do not improve, go down to twice daily and continue for 2 weeks. I have them continue this for at least a month, and sometimes longer if it's slow to resolve. Fissures do take some time, but they have to get the ointment in the right place.

Do a Better Job

Treatment of these conditions is something that we should all be doing a better job of. Patients often don't bring these up if you don't ask the right question. When I do a colonoscopy now, I routinely ask the patient whether their hemorrhoids bother them. If they say no, then we don't have any further discussion. But if you ask, many people will say, "Well, they actually are bothersome." Ask about incontinence, and you capture the attention of patients.

These are some of the most grateful patients I've had in treatment of their hemorrhoids. I get more thank-you notes for treatment of hemorrhoids than I do for life-saving interventions we have made in different patients -- but nonetheless, it's not a small problem; it's not inconsequential to patients.

Take a good look at some of these tips today, and hopefully this will give you some guidance the next time you are in the clinic and a patient says, "You know, I have this little bit of a problem down here."

I hope this is helpful, and we'll see you next time on GI Common Concerns -- Computer Consult . I'm Dr. David Johnson. Thanks again for listening.

Suggested Reading

Cleator IG, Cleator MM. The Long Term Results of Hemorrhoid Banding. Using the O'Regan Disposable Suction Ligator


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