Hemorrhoids:

A common condition and

Effective treatment optionsKevin J. Holzman, MD, FACS, FASCRS

1/15/2015

What are hemorrhoids?

• Alternative Names

• Rectal Lump

• Piles

• Lump in the Rectum

• Definition:

• Dilated or enlarged veins in the lower

portion of the rectum or anus.

Frequency

• 10 million

• Peak ages: 45-65 years

• ½ of adults experience hemorrhoids by

age 50

• Common among pregnant women

Anatomy

• Right anterior, Right posterior and Left lateral

positions

• Only 19% of the time

• Additional smaller accessory bundles between these

• Those originating above the dentate line which are

termed internal

• Those originating below the dentate line which are

termed external.

Pathophysiology

• Represent engorgement or enlargement of the normal

fibrovascular cushions lining the rectum and anal canal.

• Chronic straining secondary to constipation or occasionally

diarrhea

Trauma, inflammation

• Fibrovascular cushions lose their attachment to the underlying

rectal wall

prolapse

Pathophysiology

• Prolapse of internal hemorrhoidal tissue through the

anal canal.

• Overlying mucosa becomes more friable and the

vasculature increases

• With overlying thinning of the mucosa and vascular

engorgement, subsequent rectal bleeding occurs.

Classification

• Classified by history and not by physical examination.

• For INTERNAL hemorrhoids

• Grade I - bleeding without prolapse.

• Grade II - prolapse with spontaneous reduction.

• Grade III - prolapse with manual reduction.

• Grade IV - incarcerated, irreducible prolapse.

Symptoms

• Rectal Bleeding

• Bright red blood in stool

• Pain during bowel movements

• Anal Itching

• Difficult hygeine

• Rectal tissue Prolapse

• Leakage (mucus or stool)

• Thrombosis

Symptoms

• Bright red blood per rectum or a prolapsing anal mass.

• With, or following, bowel movements, is almost universally

bright red, and very commonly drips into the toilet water.

• Blood may also be seen while wiping after defecation.

Described as on “toilet tissue”

Symptoms

• Prolapse usually occurs in association with a bowel movement

• May also prolapse during walking or heavy lifting as a result of

increased intra-abdominal pressure.

Coughing, sneezing

obesity

• Extreme pain, bleeding and occasionally signs of systemic

illness in case of strangulation

rare

Causes

• Chronic trauma/inflammation

• Constipation

• Diarrhea

• Sitting or standing for long periods of time

• Obesity

• Heavy Lifting

• Pregnancy

• Aging

Physical exam

• Patients should be examined in the left lateral decubitus

position

Prone-jackknife

• Rule out any rashes, condylomata, fissures, lesions,

abscesses

• External sphincter function

• Rule out tumors

Physical exam

• What to expect

Visual inspection

Digital rectal exam

Small scope

Evaluation of rectal bleeding

• Rule out rectal cancer!!

• Young individual with bleeding associated with hemorrhoidal

disease and no other systemic symptoms, and no family history,

perhaps anoscopy and rigid sigmoidoscopy

• Older individual, with either a family history of colorectal cancer,

or change in bowel habits, a complete colonoscopy should be

performed to rule out proximal neoplasia.

Treatment options

• Varies from simple reassurance to operative hemorrhoidectomy.

• Treatments are classified into three categories:

• 1) Dietary and lifestyle modification.

• 2) Non operative/office procedures.

• 3) Operative hemorrhoidectomy.

• Many patients will require a combination

Dietary and lifestyle modification

• The main goal of this treatment is to minimize straining at stool.

• Achieved by increasing fluid and fiber in the diet, recommending

exercise, and perhaps adding fiber agents to the diet such as

psyllium or methycellulose

• If necessary, stool softeners may be added.

Miralax

• "you don't defecate in the library so you shouldn't read in the

bathroom".

Dietary

• Mild cases are controlled by: Preventing constipation

Drinking Fluids

High-fiber diet

Use of Fiber supplements

Stool softeners

Topicals

Fiber

• 20-30 grams/day

• Psyllium

Metamucil – 3.4g/teaspoon

Metamucil capules – 0.52g/capsule

Konsyl – 6.0g/teaspoon

• Methycellulose

Citrucel – 2.0g/dose

• Calcium polycarbophil

FiberCon – 0.5g/capsule

Fiber

• Insoluble

Does not dissolve in water

Bulks – helps with constipation

Whole grains, wheat cereals

• Soluble

Dissolves in water

Helps control blood sugar and reduce cholesterol

Barley, oat meal, beans, nuts

Nonsurgical

• Apply OTC cream or suppository containing

hydrocortisone

inflammation

• Keep anal area clean

• Soak in a warm bath

• Apply ice packs or compresses x 10min

Thrombosed hemorrhoid

Nonsurgical

• If prolapses, gently push back into anal canal

• Use a sitz bath with warm water

• Use moist towelettes or wet toilet paper

instead of dry toilet paper.

Many options

• For painful or persistant hemorrhoids:

Tying off a hemorrhoid-rubber band ligation

Sclerotherapy

Infrared Light

Laser Therapy

Freezing

Electrical Current

Surgery

Office Rubber Band Ligation

• Grade I or Grade II hemorrhoids and, in some

circumstances, Grade III hemorrhoids.

• Complications include bleeding, pain, thrombosis

• Successful in two thirds to three quarters of all

individuals with first and second degree hemorrhoids.

Office RBL

• Minor pain

• Resume usual activities immediately

• May have feeling of incomplete emptying

• No blood thinners

Office Infrared Coagulation

• Generates infrared radiation which coagulates tissue protein

and evaporates water from cells.

• Most beneficial in Grade I and small Grade II hemorrhoids.

Beneficial for patients on anticoagulants

• 3-4 applications per hemorrhoid/per session

More pain

More time consuming

Office BICAP (bipolar diathermy)

• It works, in theory, similar to photocoagulation

or to rubber banding.

• the probe must be left in place for ten

minutes.

• poor patient tolerance minimized the effect of

this procedure.

Office Sclerotherapy

• Injection of an irritating material into the submucosa

in order to decrease vascularity and increase fibrosis.

• Injecting agents have traditionally been phenol in oil,

sodium morrhuate, or quinine urea.

• Not when prolapse present

• Potential for stricture or scarring

Surgical hemorrhoidectomy

• Indications

Persistent itching

External disease

Anal bleeding

Pain

Blood clots

Infection

Patient wishes

Surgical hemorrhoidectomy

• Risks

Reactions to medications of anesthesia

Bleeding

Infection

Narrowing of the anus

• *The outcome is usually very good in the majority of

cases.

Options

• Excisional hemorrhoidectomy

• Single or multiple

• Transanal hemorrhoidal dearterialization

• With or without hemorrhoidopexy

Ultrasound guided

No excision of tissue

• Stapled hemorrhoidectomy - PPH

Prevention

• Eat high fiber diet

• Drink Plenty of Liquids

• Fiber Supplements

• Exercise

• Avoid long periods of standing or sitting

• Don’t Strain

• Go as soon as you feel the urge