CHAPTER 106 Office Treatment of Hemorrhoids

Hemorrhoidal disease occurs in approximately 50% to 80% of the U.S. population. Although this disease is rarely fatal, it accounts for a great deal of human pain and suffering. Internal hemorrhoids are the most common cause of lower gastrointestinal (GI) bleeding. Nonetheless, it is imperative that the clinician confirm that bleeding is indeed originating from hemorrhoidal disease and not from a more proximal lesion. Occasionally, bleeding can be severe and is associated with anemia.

Most hemorrhoidal symptoms can be managed with medical therapies that include suppositories, topical agents, and fiber supplementation. Patients who fail medical therapies are appropriate candidates for in-office treatments of hemorrhoids. Only a minority of individuals requires definitive treatment for severe symptomatic hemorrhoids with a surgical hemorrhoidectomy or hemorrhoidopexy. A hemorrhoidectomy requires general or regional anesthesia and is associated with significant discomfort and loss of time from work and usual activities after surgery.

Rubber-band ligation is a time-tested and proven method for treating internal hemorrhoids. However, other approaches have been developed, with infrared photocoagulation (IRC) being used most frequently and, rarely, sclerotherapy. Direct-current (Ultroid) and radiofrequency (Bicap) techniques were described in the first edition of this text. Bicap is no longer available, and although Ultroid has recently been reintroduced to the market, the time required and the cost of the probes make it less likely to be used. Cryotherapy was also used in the past but not currently because of the availability of more cost-effective modalities. These therapies can be used selectively or in combination depending on the extent and severity of internal disease. Lasers have also been used for the treatment of internal disease. The treatment for external hemorrhoid disease has been unchanged for decades.

Two meta-analyses have been reported on the treatment of internal hemorrhoids. One concludes that band ligation is best, whereas the other supports IRC. In both instances, hemorrhoid symptoms resolved in 80% to 90% of properly selected cases.

The physician must know the anorectal anatomy (see Chapter 97, Clinical Anorectal Anatomy and Digital Examination) and must be able to perform a thorough anoscopic examination (see Chapter 98, Anoscopy) to appropriately assess and treat hemorrhoids.

After completion of any of these procedures, a medical program to regulate bowel habits should be implemented to prevent recurrence, which is as important as the surgical intervention itself.

Classifications and Symptoms

Hemorrhoids are enlarged arteriovenous vessels within fibrous tissue and are classified according to their origin either above or below the dentate (pectinate) line. Those developing from above the dentate line are internal hemorrhoids; those from below are external hemorrhoids. It should be clear that classification depends on origin, not on the location of the most distal portion of the hemorrhoid (Fig. 106-1).

Figure 106-1 Various types of hemorrhoids. A, Internal hemorrhoid. Note that although an internal hemorrhoid may be visible “externally” (grade IV), it is classified by its origin, which, as shown here, is above the dentate line. B, Internal hemorrhoid as seen through the Ives slotted anoscope. C, External hemorrhoids. D, External hemorrhoid as seen through the Ives anoscope. E, Mixed hemorrhoid disease (both internal and external hemorrhoids with a vascular communication). F, Thrombosed external hemorrhoid. G, Large acute thrombosed hemorrhoid. H, Normal progression of a thrombosed external hemorrhoid 4 to 5 days after occurrence. The skin over the top becomes necrotic and appears to be a thin membrane.

(A, C, E, and F, Redrawn from Pfenninger JL, Surrell J: Nonsurgical treatment options for internal hemorrhoids. Am Fam Physician 52:821–837, 1995. Original art copyrighted by Steve Oh. B, D, G, and H, Courtesy of John L. Pfenninger, MD, The Medical Procedures Center, PC, Midland, Mich.)

Hemorrhoids above the dentate line—internal hemorrhoids—are covered by mucosa and do not have somatic sensory innervation. Thus, internal hemorrhoids are well suited for treatment in the office setting without anesthesia because they lack pain fibers. Those below the dentate line—external hemorrhoids—are covered by skin (anoderm) and are extremely sensitive. Treatment of external hemorrhoids requires some form of anesthesia. Mixed hemorrhoids refers to those vessels that originate right at the dentate line or to the presence of both internal and external hemorrhoidal tissue in continuity.

The anal canal can be divided into eight segments. With the patient lying in the left lateral decubitus position, they are as noted in Figure 106-2A. Internal hemorrhoids usually occur in three major positions based on the vascular architecture of the anal canal: the right anterior, right posterior, and left lateral positions (Fig. 106-2B). However, they can occur anywhere and even be circumferential. They also seem to “shift” with insertion of the anoscope, so absolute position is not that critical.

Figure 106-2 A, Representation of eight segments in the rectum as seen through a slotted (Ives) anoscope, with the patient in the left lateral decubitus position. B, Usual three primary hemorrhoidal groups.

Internal hemorrhoids are also characterized by their size and degree of prolapse from grades I to IV, as noted in Table 106-1 and Figure 106-3. Symptoms of internal hemorrhoids include painless bleeding, prolapse, aching after defecation, and discharge. The key step in diagnosis and classification of internal hemorrhoids is anoscopic examination (see Chapter 98, Anoscopy). External hemorrhoids can form clots that are painful. Patients then present with a “painful lump.”

TABLE 106-1 Classification of Internal Hemorrhoids

Grade	Description
I	Small, do not prolapse
II	Medium, prolapse and return spontaneously
III	Large, prolapse but reduce manually
IV	Largest, prolapse, not reducible

Figure 106-3 Grading of internal hemorrhoids. A, Grade I hemorrhoids are present and identifiable. B, Grade II hemorrhoids prolapse with a bowel movement but return spontaneously. C, Grade III hemorrhoids prolapse and can be replaced manually. D, Grade IV hemorrhoids remain prolapsed in spite of all efforts at reduction and are often associated with varying amounts of mucosal prolapse. E, Grade IV prolapsed internal hemorrhoid.

(A–D, From Pfenninger JL, Surrell J: Nonsurgical treatment options for internal hemorrhoids. Am Fam Physician 52:821–837, 1995. Original art copyrighted by Steve Oh.)

Hemorrhoidal skin tags are residual fibrotic masses of stretched skin. Their size can vary significantly. They are generally asymptomatic except for occasional pruritus. Most commonly, when larger, they can cause problems with hygiene.

Approximately 25% of internal hemorrhoid symptoms do not respond adequately to medical treatment and require further therapy. Most thrombosed external hemorrhoids require evacuation or excision to provide symptomatic relief.

Internal Hemorrhoids

Indications

Bleeding or other symptomatology, such as prolapse, from internal hemorrhoids that has failed medical management (i.e., bulk agents, suppositories, topical preparations, and sitz baths) is an indication for treatment.

NOTE: The mere presence of hemorrhoids alone, without symptoms, is not necessarily an indication for treatment.

Contraindications

• Bleeding diathesis (relative). If on warfarin, the international normalized ratio (INR) should be in the therapeutic range. There is always an increased risk of bleeding if the patient is on aspirin or clopidogrel, but generally this is not a contraindication to treatment.

• Pregnancy or immediately postpartum (<8 weeks).

• Inflammatory bowel disease.

• Anorectal fissures.

• Active anorectal infections.

• Acquired immunodeficiency syndrome or other immunodeficiency states.

• Portal hypertension (relative).

• Rectal wall mucosal prolapse.

• Anorectal tumors.

Recommendations for antibiotic subacute bacterial endocarditis prophylaxis have been updated (see Chapter 221, Antibiotic Prophylaxis). Basically, antibiotics are not indicated for hemorrhoidal procedures. For those in the very–high-risk categories, they would be optional.

Preprocedure Patient Preparation

1 Give the patient one or two enemas before the procedure. Although not absolutely necessary, it is aesthetically helpful and improves visualization of the anatomy.

2 Ask the patient to avoid aspirin or clopidogrel for 1 week before treatment in low-risk situations.

3 Provide a patient education handout to ensure informed consent (see the sample patient education handouts online at www.expertconsult.com).

4 A complete history of the complaints as well as the pertinent past medical history and physical examination are essential. Record these on the sample encounter forms (go to www.expertconsult.com) that summarize the information.

5 The patient may be examined and treated in the left lateral decubitus position, which is usually more comfortable, the prone jackknife position, or even in the customary stirrups. The latter two positions can be used when exposure is difficult. No sedation is necessary for a patient having only anoscopy and internal hemorrhoid treatment. The patient may take four ibuprofen 200-mg tablets 1 to 2 hours before the office visit. Before performing anoscopy, perform an external visual and a digital anorectal examination. Ask the patient to perform a Valsalva maneuver (bearing down) to rule out full-thickness rectal prolapse. (Occasionally, examination with the patient sitting on the commode is necessary to assess for this.)

NOTE: Only internal hemorrhoids are treated by IRC, banding, or sclerotherapy. Treatment of external hemorrhoids requires excision and is associated with pain, so at least local anesthetics are needed.

Treatment

Rubber-band ligation (Barron or McGivney ligation), IRC, and sclerotherapy for internal hemorrhoids are discussed in the following sections. A summary of techniques and their indications is found in Table 106-2. The treatment of external hemorrhoids is covered later in this chapter and the treatment of perianal skin tags is dealt with separately in Chapter 108, Removal of Perianal Skin Tags (External Hemorrhoidal Skin Tags). Because of the associated discharge and poor patient acceptance, cryotherapy is not covered in this discussion.

TABLE 106-2 Comparison of Therapeutic Modalities for Treatment of Internal Hemorrhoids

Rubber-Band Ligation

Rubber-band ligation involves placing a rubber band around the base of an internal hemorrhoid. The ensnared tissue undergoes necrosis and sloughs. Rubber-band ligation is used for treatment of second- or third-degree bleeding or prolapsing internal hemorrhoids.

Equipment

• Slotted Ives anoscope (see Chapter 98, Anoscopy, Fig. 98-1)

• McGivney ligator with bands (or an acceptable alternative device; Fig. 106-4) is the traditional applicator. Alternatively, a disposable hemorrhoid ligator is available, the O’Regan Hemorrhoid Banding System (Fig. 106-5).

• Alligator forceps (similar to long-handled Allis clamp)

• External light source

• Large obstetric/gynecologic cotton swabs