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Hemorrhoid Brochure (PDF)

Hemorrhoids

Hemorrhoids are perhaps the most misunderstood anorectal problem. In fact, hemorrhoids are a normal part of human anatomy. They are simply blood vessels. Hemorrhoidal disease refers to blood vessels which have grown and can manifest as prolapse, bleeding, and itching. Internal hemorrhoids originate above the dentate line, the line that separates skin from the lining of the colon. They are classified into four grades: first-degree which do not prolapse, second-degree which prolapse but return spontaneously, third-degree which prolapse but can be reduced manually, and fourth-degree which cannot be reduced. External hemorrhoids are located closer to the anal verge and are covered by skin. Although the exact incidence of hemorrhoidal disease is unknown, 10% to 25% of the adult population is thought to be affected. Symptoms seem to be more common in older individuals, with a peak in prevalence at 45 to 65 years.

Internal Hemorrhoids

It is speculated that internal hemorrhoids become symptomatic when their supporting structures become disrupted and the vascular anal cushions prolapse; however, the exact pathogenesis is not clear. Hemorrhoids occur more frequently in people with constipation who have hard, infrequent stools. Painless bleeding occurs, and red blood usually is seen on the toilet tissue or dripping into the toilet at the end of defecation. Sometimes the bleeding can be more substantial, and the blood can accumulate in the rectum, to be passed later as dark blood or clots. When hemorrhoids prolapse, blood or mucus may stain a patient’s underwear, and the mucus against the anal skin may lead to itching.

The diagnosis of internal hemorrhoids is made with the anoscope or by flexible sigmoidoscopy and retrograde view of the anorectal junction. Hemorrhoids may be symptomatic only intermittently.

Treatment

Treatment is based on the grade of the hemorrhoid. Grade 1 and 2 can respond to dietary modifications. Fiber intake can be important. Straining should be avoided. Stool softeners can help. Use of baby wipes or moistened tissue paper may help prevent irritation.

If dietary modifications fail, more aggressive approaches are available. Unless grade 4 hemorrhoids are present, non-surgical treatments should be tried. Most patients with grade 4 hemorrhoids require surgical intervention. Options for hemorrhoids which are grades 1-3 include injection with a sclerosing agent, rubber band ligation, cryotherapy, infrared photocoagulation, electrocoagulation, and application of a heater probe. Many of these procedures can be performed in the office.

Sclerotherapy

The goal is to inject an irritant into the submucosa above the internal hemorrhoid to create fibrosis and prevent hemorrhoidal prolapse. This approach can be used for grade 1 and 2 hemorrhoids. Sclerotherapy can produce a dull pain for up to 2 days after injection. A rare but severe complication is life-threatening pelvic sepsis, which can occur 3-5 days after injection and usually is manifested by any combination of perianal pain or swelling, watery anal discharge, fever, and other signs of sepsis. Prompt surgical intervention and intravenous antibiotics are mandatory. Approximately 75% of patients with grade 2 hemorrhoids improve after injection therapy.

Rubber Band Ligation

Rubber band ligation has become the most common office procedure for the treatment of grade 2 and 3 hemorrhoids. This approach cannot usually be used with grade 1 hemorrhoids because there is insufficient tissue to pull into the bander. Treatment of grade 4 hemorrhoids is almost never appropriate with this method. Rubber bands are applied to the rectal mucosa just proximal to the internal anal cushion. Patients may experience discomfort after rubber band ligation; soaking in a sitz bath and taking acetaminophen usually constitute sufficient treatment. Immediate severe pain usually signals that the band has been placed too close to the dentate line and that it must be removed. Success is reported in 75% of patients with grade 1 and 2 hemorrhoids and 65% of those with grade 3 hemorrhoids. Repeat ligation is an option.

One potential complication is bleeding; severe bleeding occurs in about 1% of patients and usually can be tamponaded by placing a large-caliber Foley catheter in the rectum, filling the balloon with 25-30 mL or more of fluid, and pulling the balloon tight against the top of the anal ring. If this approach fails, epinephrine can be used. Another option is a suture. A more serious complication is sepsis. The onset of sepsis is usually 2-8 days after ligation in otherwise healthy people. New or increasing anal pain, sometimes radiating down the leg, or difficulty voiding may be the first indications of a life-threatening infection. Immediate intravenous antibiotics and surgical debridement are required.

Please click on the following link to view a video demonstrating this procedure: http://www.youtube.com/watch?v=vT_AsC6qfuw

Cryotherapy

Cryotherapy freezes tissue, thereby destroying the hemorrhoidal plexus. Its use has declined because of the profuse, foul-smelling discharge resulting from necrosis of tissue. The procedure can be painful, and healing can be prolonged.

Infrared Photocoagulation

Infrared photocoagulation utilizes infrared radiation to coagulate the tissue, thereby leading to fibrosis. The device is applied for 1.5 seconds in two or three sites proximal to the hemorrhoidal plexus. Reported results for grade 1 and 2 hemorrhoids are as good as those reported for rubber band ligation or sclerotherapy. One study reported a 10% relapse rate at 3 years in patients who had grade 3 hemorrhoids. Pain and other complications are rare with infrared photocoagulation.

Please click on the following link to view a video demonstrating this procedure: http://www.redfieldcorp.com/video/redfield_hemorrhoids.wmv

Electrocoagulation and Heater Probe

Use of thermal injury to fix the internal hemorrhoidal plexus is the basis for electrocoagulation and heater probe therapy. Both types of therapy compare favorably with rubber band ligation for the treatment of grade 1 and 2 hemorrhoids but have not gained popularity.

Surgery

Methods to reduce internal anal sphincter pressure in patients with internal hemorrhoids have been advocated in the past. Hemorrhoidectomy is the surgical procedure of choice for grade 4 and some grade 3 hemorrhoids and is rarely needed for grade 1 and 2 hemorrhoids. Hemorrhoidectomy can be done with local, regional, or general anesthesia. Whether the edges of the mucosa are closed or left open after excision of the hemorrhoidal tissue is a matter of preference, as results and postoperative pain are similar with either approach. In one of the few long-term studies of hemorrhoidectomy, recurrent hemorrhoids were found in 26% at a median follow-up of 17 years, but only 11% of patients needed an additional procedure.

Methods to reduce internal anal sphincter pressure in patients with internal hemorrhoids have been advocated in the past. Hemorrhoidectomy is the surgical procedure of choice for grade 4 and some grade 3 hemorrhoids and is rarely needed for grade 1 and 2 hemorrhoids. Hemorrhoidectomy can be done with local, regional, or general anesthesia. Whether the edges of the mucosa are closed or left open after excision of the hemorrhoidal tissue is a matter of preference, as results and postoperative pain are similar with either approach. In one of the few long-term studies of hemorrhoidectomy, recurrent hemorrhoids were found in 26% at a median follow-up of 17 years, but only 11% of patients needed an additional procedure.

Treatment Options for Internal Hemorrhoids

External Hemorrhoids

External hemorrhoids are visible at the anal verge and actually represent residual redundant skin from previous episodes of external hemorrhoidal inflammation and edema. These skin tags typically occur in young and middle-aged adults and are easily seen when the buttocks are parted. Some people are uncomfortable during anal wiping due to irritation or the uncomfortable sensation of redundant tissue. Occasionally, external hemorrhoids interfere with perianal hygiene and cause itching and irritation. External hemorrhoids can be associated with acute pain from thrombosis. The level of pain is variable, but patients may notice a rapidly increasing throbbing or burning pain accompanied by a new “lump” in the anal region. Sometimes the lump has a bluish discoloration caused by the clot. With time, a small area of necrosis may form over the lump followed by extrusion of the clot, with relief of the pain.

Treatment of external hemorrhoids usually is reassurance and proper anal hygiene, including delicate washing of the anal area and avoidance of aggressive wiping with harsh toilet tissue. Rarely is resection done; it is painful, and because of the swelling that accompanies any surgical excision, redundant tissue may persist after healing. The treatment of thrombosed hemorrhoids depends on the associated symptoms. With time, the pain associated with the acute thrombosis subsides. If the patient has minimal or moderate pain, sitz baths and analgesics are prescribed. For severe pain, the clot is removed under local anesthesia. This procedure also can be done in the office with scissors and local anesthesia. Another successful therapy has been topical application of 0.3% nifedipine cream.

Therapeutic Approach to Skin Tags and External Hemorrhoids

References:

1. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease
2. Images are from Google Images
3. Videos are from YouTube