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Approach to HemorrhoidsA Primer for Gastroenterologists

A good medical history and physical examination,

including anoscopy or office proctoscopy, should guide

the physician to the correct diagnosis; in cases of bleed-

ing, a colonoscopy or sigmoidoscopy in addition to ano-

scopy is necessary to verify the source of the bleeding.

It is the intent of this review to provide gastroentertolo-

gists with a general introduction to the nonsurgical man-

agement of hemorrhoids.

AnatomyThomson, in his description of hemorrhoidal anatomy,

noted a series of 3 cushions in the anal canal, located in

the left lateral, right anterior, and right posterior posi-

tions. These hemorrhoidal cushions receive their blood

supply primarily from the superior and middle hemor-

rhoidal arteries; the superior, middle, and inferior hem-

orrhoidal veins provide venous drainage. A sinusoidal

pattern of arteriovenous communication is formed within

the cushions, which explains why hemorrhoidal bleeding

is arterial, rather than venous in nature.1

In addition to the vessels noted above, the hemor-

rhoidal cushions are also rich in muscular fibers, arising

from the internal sphincter and the conjoined longitudi-nal muscle. These fibers help to anchor the cushions to

the underlying muscular layer of the anorectum, and it is

the breakdown of these supporting fibers that eventually

leads to the changes that can cause hemorrhoidal symp-

toms.1,2The cushions play an important role in the main-

tenance of rectal continence, as they provide 15% to 20%

of the resting pressure at the anal verge.3

The epithelial layer of the anorectum is characterized

by the relatively insensate columnar epithelium, which

covers the internal hemorrhoidal cushions (mucosa) an

the extremely sensitive squamous epithelium, whic

extends up into the anus (anoderm). The junction o

these 2 epithelial layers is known as the dentate line

and is typically located approximately 3 cm inside th

anal verge. This line marks the transition between th

columnar epithelialcovered internal hemorrhoids an

the squamous epithelialcovered external hemorrhoida

vessels.4-6

Pathophysiology

There are a number of proposed mechanisms t

explain the development of symptomatic hemorrhoid

including abnormal venous dilatation, abnormal disten

sion of the arteriovenous anastomoses, downward dis

placement or prolapse of the hemorrhoidal tissue, or

breakdown of the connective tissue anchoring the hem

orrhoidal cushions. Prolapse of hemorrhoidal tissue

what appears to lead to the development of symptoms

This prolapse allows for mucous deposition on the per

anal skin, which causes itching, and leads to tissue fria

bility and bleeding. Other symptoms include swelling o

associated external disease and fecal soiling when thprolapsing tissue precludes complete closure of the ana

opening.1,7

Internal hemorrhoids are covered by the mucosa

they reside proximal to the dentate line and are gener

ally painless. External hemorrhoids are located distal t

the dentate line and are covered by squamous epithe

lium; patients who experience pain as a result of hemor

rhoids often have a thrombosed external hemorrhoid o

an anal fissure.

Hemorrhoids are normal vascular structures of the

anal canal. Often, they are the source of a variety of

troublesome symptoms, including bleeding, anal pruritus,

prolapse, and pain due to thrombosis of external hemorrhoids.

Patients often mistake other anal or perianal problems for

hemorrhoids, such as anal fissures, skin tags, hypertrophied analpapillae, anal cancer, and anal condylomata, as well as other infections.

HARRYSARLESJR., MD

GastroenterologistDigestive Health Associates of Texas

Dallas, Texas

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The causes of symptomatic hemorrhoids are not com-

pletely clear, but a number of factors, including a lack of

dietary fiber, constipation, straining on defecation, diar-

rhea, pregnancy, obesity, a sedentary lifestyle, spending

excess time on the commode, spinal cord injuries, and

family history all have been suggested.8

Epidemiology

It is difficult to quantify the incidence of hemorrhoidal

disease, in large part because many patients do not seek

medical care for their condition; additionally, some attri-

bute almost any anorectal symptom to hemorrhoids.

Estimates of the prevalence of hemorrhoidal disease

in the United States range from 4.4% to 40%.9Some

research suggests that 75% of the population will expe-

rience symptomatic hemorrhoid disease at some point

in their lives.10Although these estimates vary widely, it

seems clear that symptomatic hemorrhoids have a sig-

nificant effect on health and well-being.

Grading of Hemorrhoidal Disease

Banov et al11developed a grading system for inter-

nal hemorrhoids based on the degree of prolapse. The

grade of hemorrhoidal disease has some bearing on the

treatment options available to a patient with internal

hemorrhoids: grade I: non-prolapsing internal hemorrhoids

grade II: prolapse of internal hemorrhoids during defeca-

tion with spontaneous reduction

grade III: prolapse of internal hemorrhoids during defeca-

tion that requires manual reduction

grade IV: prolapse and incarceration of internal hemor-

rhoids; hemorrhoids cannot be reduced

Diagnosis

PATIENTHISTORY

As previously stated, patients often attribute any ano-

rectal symptom to hemorrhoidal disease, and althoughthis may partly explain symptoms, it is important for the

physician to determine whether there are other issues

involved as well.5,12

Internal hemorrhoids are associated with pain-

less bleeding, prolapse, mucus discharge, soiling, and

symptoms of pruritus ani; these symptoms rarely cause

significant pain. External hemorrhoids usually are

asymptomatic, unless they become thrombosed. Pain

with defecation is commonly due to the presence of an

anal fissure, which is found in up to 20% of patients with

hemorrhoids.13

The relationship between symptoms, defecation habits,

bleeding, and a description of factors that might relieveor exacerbate a patients symptoms are important to

consider in the medical history.

PHYSICALEXAMINATION

A visual inspection of the perianal area will allow for

the discovery and description of rashes, tags, fissures,

fistulae, abscesses, neoplasms, condylomata, some cases

of prolapse, and so forth. The left lateral decubitus posi-

tion is preferred for the examination, as this position

seems to be better tolerated than the prone, jack-knife

position.14

A digital rectal examination will identify such things

scars, small fissures, and the origins of fistulae. These

clinical findings will be important in formulating a com-

prehensive treatment plan for the symptomatic patient.15

ENDOSCOPICEXAMINATION

Anoscopy is an accurate, efficient, inexpensive way

to evaluate the anal canal quickly, with minimal discom-

fort to the patient. Flexible endoscopy frequently is

performed to evaluate patients with symptoms of hem-

orrhoids, however, it is not as accurate as anoscopy. A

prospective study showed that anoscopy revealed 99% of

anorectal lesions, whereas endoscopy revealed 78% when

performed with straight withdrawal of the endoscope,

and 54% with retroflexion.16 The limitations of flexible

endoscopy, along with increased cost and inconvenience

to the patient, stress the need to consider anoscopy in

the evaluation of hemorrhoidal disease.

Treatment

CONSERVATIVEMEDICALTREATMENT

There are a number of over-the-counter prepara-

tions intended to treat patients with symptomatic hem-

orrhoids. These compounds contain ingredients such as

antiseptics, astringents, topical anesthetics, and cortico-

steroids. There is not a lot of evidence to support the use

of many of these products, and the potential negative

effects of the long-term use of topical steroids should

be considered.17

Common dietary and behavioral recommendations

for patients with hemorrhoids include increasing the

intake of dietary fiber, minimizing the amount of time

spent on the commode, avoiding straining during defe-

cation, and taking sitz baths several times a day. There

is evidence to support these recommendations both forthe treatment of symptomatic disease and in limiting the

risk for recurrence.18These measures are a reasonable

first-line approach for patients with mild symptoms.

NONSURGICALTREATMENT

Sclerotherapy

Sclerotherapy uses the injection of a sclerosant into

the submucosa, beneath the hemorrhoid, to create an

inflammatory reaction in the soft tissue that affixes the

loose hemorrhoidal mucosa back to the underlying mus-

culature. The procedure dates back to the 1800s. Some

research shows sclerotherapy to be beneficial in patients

with grade I and II hemorrhoids,19whereas other researchshows it to be no more beneficial than bulk laxatives.20

Potential complications of sclerotherapy include pain,

urinary retention, abscess, and impotence. Avoidance of

these complications depends on precise placement of

the injection.21

Rubber Band Ligation

Rubber band ligation (RBL) is the most commonly

performed nonsurgical procedure used in the treatment

of hemorrhoids; it is performed in up to 80% of patients

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with hemorrhoids.22,23Blaisdell first described a ligation

technique using a silk suture in 1958,24with Barron begin-

ning to use rubber bands in 1963.25Barron treated one

column of hemorrhoids per session to minimize pain and

post-banding complications. The process causes the

banded tissue to necrose and slough, with the resultant

inflammatory reaction causing refixation of the mucosa

to the underlying tissue, eliminating hemorrhoidal pro-

lapse. This mechanism of action is common among the

nonsurgical treatments for hemorrhoids, stressing the

importance of hemorrhoidal prolapse in the etiology of

symptoms.

RBL is a simple, inexpensive procedure, effective for

grade I to III hemorrhoids.2Patients undergoing RBL typ-

ically do not require bowel preparation, sedation, nar-

cotics, or a significant recovery period; they are able to

return to work immediately.5One of the disadvantages

of earlier RBL procedures was the need for 2 operators

to perform the procedure, but this has since been over-

come with the development of single-use, disposable

devices that do not require an assistant.6,7

RBL leads to reconfiguration and reduction in the size

of hemorrhoidal cushions, resulting in symptom resolu-

tion. Short-term success rates of up to 99% and long-

term success rates of up to 80% have been described;

however, there is a large range in the reported incidence

of complications. The predominant issue in patients

undergoing RBL is significant pain, with the incidence

rates ranging from less than 1% to 50%, in some series.6,26

Other reported complications include bleeding, urinary

retention, vasovagal reactions, and the very rare compli-

cation of sepsis. Based on the literature, the incidence of

complications appears to be related to the techniques

that are used to perform the banding.

Endoscopic RBL has been shown to have excellent

results, however, the method is more expensive than the

others and requires patient preparation as well as anes-thesia.27Endoscopic RBL also has been reported to be

more painful than other banding techniques.28 Other

common techniques use an anoscope to gain access to

the hemorrhoids. There also is a procedure that allows

for a blind placement of the band, obviating the need

for an anoscope.

The literature is confusing when it comes to where

the band should be placed, as descriptions vary from

a few millimeters above the dentate line29to at least

2 cm proximal to the dentate line.30,31 I prefer a tech-

nique that involves placing the band at least 2 cm above

the dentate line, as this technique has been associated

with less pain.6

Controversy exists regarding the number of hemor-

rhoids to treat during a single session. In the time since

Barrons original work was published,25most research-

ers have recommended treating only one column of

hemorrhoids per session in order to minimize the rate

of complications. Other authors have suggested band-

ing 2 or more columns per session in order to minimize

the number of patient visits required; however, compli-

cation rates are higher when more bands are placed.32

I recommend banding a single hemorrhoid per session

Endoscopic band placement is effective but is mor

costly and is associated with higher rates of post-proce

dural pain compared with in-office band placement.24,3

Personally, I prefer the blind touch techniqu

described by Cleator and Cleator.6This technique allow

placement of the band without an anoscope at 2 cm abov

the dentate line. Using this technique, the researcher

demonstrated a 1% complication rate (primarily pain

and successful treatment of up to 99% of patients, wit

a recurrence rate of 5% at 2 years.5

Infrared Coagulation

Neiger first described infrared coagulation (IRC) i

1979.34 The infrared coagulator is placed through a

anoscope while infrared light is converted to heat in th

hemorrhoidal tissue. The heat produces tissue destruc

tion, protein coagulation, and inflammation, leading t

scarring and tissue fixation. During the procedure, 3 to

pulses of energy are applied to the mucosa at the ape

of the hemorrhoid, and 1 to 2 columns of hemorrhoid

are treated at a time. Treatment is repeated every 2 t

4 weeks.24

Advantages of IRC include a relative lack of signif

icant complications. Disadvantages include equipmen

costs, the need for repeated treatments, higher recu

rence rates, and its ineffectiveness in patients with mor

advanced disease.24,34

Direct Current Electrotherapy

Direct current electrotherapy also uses a device that

inserted through an anoscope (Ultroid, Ultroid Technolo

gies, Inc).35This procedure uses direct current and doe

not create heat but rather produces sodium hydroxide

creating the submucosal reaction that leads to scarring

which helps to eliminate the hemorrhoidal prolapse.7

Limitations of direct current electrotherapy includ

the cost of the technology and the amount of tim

required to treat the involved tissue. The length of thprocedure depends on the grade of hemorrhoidal dis

ease and the amount of current that the patient can to

erate, which ranges from 4:45 to 19:45.35The procedur

has been reported to cause significant pain in up to 20%

of patients, resulting in termination of therapy; 16% o

patients have prolonged post-procedural pain.36

Bipolar Diathermy and Heater Probe Coagulatio

These technologies may be used by way of anoscop

in order to control chronic hemorrhoidal symptoms. Bot

procedures generate heat, which causes coagulation o

the target tissue leading to a fibrotic reaction with fixa

tion of the treated tissue.32

The procedures have similar efficacy for the treatment of bleeding. In one study, the heater probe con

trolled the bleeding more quickly (76.5 vs 120.5 days

at the expense of more pain.37The bipolar technolog

was associated with a higher overall rate of complica

tions (11.9% vs 5.1%), including pain, bleeding, fissure fo

mation, and spasm of the internal sphincter. Anothe

study demonstrated symptomatic mucosal ulceration i

24% of patients treated with bipolar electrocoagulation

significant bleeding in 8%, and prolonged pain in 4%.3

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Neither technology was able to reliably eliminate pro-

lapsing tissue.29,36,37

Cryosurgery and Lords Stretch Procedure

These techniques are mentioned for historical refer-

ence only, as neither is recommended. Cryosurgery is

associated with significant post-procedure pain, along

with foul-smelling discharge and prolonged recovery in

several series.36The Lords Stretch, a forceful dilatation

of the anus in order to reduce elevated sphincter pres-

sures was found to result in incontinence in a significant

number of patients.38Some have recommended that the

procedure be abandoned.39

SURGICALTREATMENTOPTIONS

This review is intended to discuss nonsurgical options

available for the treatment of symptomatic hemorrhoidal

disease, and these approaches have been shown to be

effective in 80% to 99% of patients. A number of surgical

options are available as well, but because of increased

cost, pain, disability, recuperation time, risk for complica-

tions, and so on, surgical options should be reserved only

for nonresponders and for patients with grade IV hemor-

rhoids or hemorrhoids with both internal and external

components.40

Conclusions

Symptomatic hemorrhoids are common and patients

frequently visit a gastroenterologist for diagnosis and

treatment. A number of effective nonsurgical approaches

are available for these patients. RBL is the most com-

monly used office-based hemorrhoidal therapy. Informa-

tion is presented here to aid the gastroenterologist in the

evaluation and definitive treatment of patients with hem-

orrhoidal disease.

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AUTHOR DISCLOSUREDr. Sarles is a member of the advisory board

of CRH Medical.

DISCLAIMERThis review is designed to be a summary of information

and represents the opinions of the author. Although detailed, the review

is not exhaustive. Readers are strongly urged to consult any relevant

primary literature, the complete prescribing information available in the

package insert of each drug, and the appropriate clinical protocols. No

liability will be assumed for the use of this review, and the absence of

typographical errors is not guaranteed. Copyright 2013, McMahon

Publishing, 545 West 45th Street, 8th Floor, New York, NY 10036.

Printed in the USA. All rights reserved, including right of reproduction,

in whole or in part, in any form.

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