Hemorrhoids are vascular cushions that lie close to the anus and are subject to the stresses and strains of defecation. They are normal structures that become symptomatic when thrombosis or prolapse develops as a result of either a congenital weakness in the area or because of excessive or repeated straining. The challenges of managing patients with symptomatic hemorrhoids include making a correct diagnosis, persuading patients to improve their defecatory habits, and using the appropriate procedure to manage the problem at hand. In this chapter, external and internal hemorrhoids will be considered separately.
The external hemorrhoidal plexus is a network of veins that run around the anus at the anal verge. The veins become symptomatic when they thrombose. Resolution of external hemorrhoid thrombosis may predispose to anal tags that are usually asymptomatic but are typically excised along with prolapsing internal hemorrhoids. Acute thrombosis of the external hemorrhoidal plexus is a painful condition that tends to follow straining, either during lifting, childbirth, or defecation. Affected patients are in considerable pain and have an edematous lump at the anal verge caused by the clot. Often the blue color of the clot confirms the diagnosis. Surgical excision of acutely thrombosed external hemorrhoids is warranted when the thrombosis is large, painful, and identified within 72 hours of onset. Sometimes the clot ulcerates through the skin and patients experience anal bleeding independent of bowel habits, with partial easing of the pain. This presentation is another indication for surgery. Small external hemorrhoidal thromboses are easily managed in the office setting with a local anesthetic and complete excision of the clot and vein, with or without skin closure. More extensive thromboses should be excised with use of a general anesthetic to allow careful planning of the excision and preservation of the anoderm.
Anatomy and Etiology of Internal Hemorrhoids
Internal hemorrhoids are vascular cushions lying above the dentate line under the mucosa of the low rectum. The classic orientation of the hemorrhoidal cushions is right anterior, right posterior, and left lateral, although intervening secondary hemorrhoidal complexes may blur this classic anatomy. The arterial blood supply, which contributes to the frequent symptom of bright red rectal bleeding, is derived from the superior rectal artery, a branch of the inferior mesenteric artery, the middle rectal arteries arising from the internal iliac arteries, and the inferior rectal arteries arising from the pudendal arteries. Above the dentate line the venous drainage enters the portal venous system, whereas below the dentate line it passes to the systemic venous system. This vascular anatomy creates the cushions that contribute to anal continence and can be damaged by excessive straining, leading to the prolapse and bleeding typical of symptomatic hemorrhoids.
An understanding of the stages of hemorrhoidal pathophysiology is the basis for developing a strategy for management of symptomatic hemorrhoids. The staging system is shown in Box 2-1 . At the earliest stage of disease, transudation of blood through thin-walled, damaged veins and/or arterioles presents primarily as painless bleeding and can be managed with astringents or local ablation of the vessels. Later, as the damage progresses to significant disruption of the mucosal suspensory ligament, a technique capable of relocating the prolapsing tissue to its normal location and fixing the tissue at that location will be required.
Grade I = bleeding
Grade II = protrusion with spontaneous reduction
Grade III = protrusion requiring manual reduction
Grade IV = irreducible protrusion of hemorrhoidal tissue
The typical constellation of hemorrhoidal symptoms includes bleeding, protrusion, and pain. However, only about one third of all patients with anorectal symptoms will actually have hemorrhoids as the cause of their symptoms. Hemorrhoidal bleeding, which typically occurs after bowel movements, is painless and visible as bright red blood either on the toilet paper or in the commode. The bleeding can become more severe as the hemorrhoids enlarge and are either partially or completely trapped in a prolapsed position. Patients with tight internal sphincters are prone to magnified hemorrhoidal symptoms because of the increased pressure in the anus. The history then addresses bowel habits, the frequency of straining upon defecation, recent changes in medications, diet, or lifestyle, and the presence of a family history of colorectal cancer. The patient should be asked about prior procedures performed to treat hemorrhoids, although the answer must be taken with a grain of salt unless it is supported by medical records.
Examination of the patient with hematochezia, although tailored by the age of the patient, should include sufficient investigations to rule out a proximal source of bleeding such as inflammatory bowel disease or neoplasia. Hemorrhoids should not be accepted as the cause of iron deficiency anemia because this cause is rare.
First, a careful digital examination of the anal canal and distal rectum should be performed, including palpation of the prostate in men. Inspection of the anus may reveal skin tags, bulging external hemorrhoidal cushions (clues to the presence of internal hemorrhoidal prolapse), or fourth-degree internal hemorrhoids. Other conditions may be present that mimic or co-exist with hemorrhoids, such as anal excoriation, anal neoplasms, condylomata, or fissure. If the patient does not have a fissure, an anoscopy is performed to determine the size and degree of prolapse of the hemorrhoids. Poking the cushions with a cotton-tipped swab gives an impression of the degree of redundancy and the suitability of the hemorrhoid for elastic band ligation. White plaques on the hemorrhoids (pseudoepitheliomatous hyperplasia) are an indication of chronic prolapse. Hemorrhoids should be classified as previously described to define the degree of mucosal irritation, prolapse, columns involved, and associated anal skin tags. If the patient has presented with bleeding, has an increased risk for colorectal cancer, or is at average risk but is overdue for screening, a colonoscopy is requested. No physical treatment should be performed without clearing the colon, because drop metastases from a cancer proximal to an anal canal wound can occur.
Many patients with symptomatic hemorrhoids strain during defecation for several reasons. If the straining is due to small-volume stools, they need more roughage in their diet. If the straining is due to hard stools, they need more roughage and perhaps a properistaltic agent such as prune juice. If the straining occurs because defecation is deferred, they need to respond to the urge to defecate when it is first perceived and not shut it down. An analysis of defecation and dietary habits and correction of problematic habits with the aim of avoiding straining may eliminate symptoms and allow patients to avoid a procedure. Correction of problematic habits is important in all patients, however, because straining after banding and after a hemorrhoidectomy may lead to recurrent symptoms. In at least 50% of patients, symptomatic internal hemorrhoids can be successfully managed by improving bowel habits.
Sclerotherapy of symptomatic internal hemorrhoidal disease has been performed since the nineteenth century and remains a highly effective, low-risk means of managing stage I hemorrhoids. Treatment produces local tissue destruction, which simultaneously ablates small vessels in the submucosa and creates tissue fixation and atrophy of the hemorrhoidal complex. The sclerosing agents most commonly used are sodium morrhuate and sodium tetradecyl sulfate. Briefly, the procedure involves anoscopic identification of the hemorrhoidal complex followed by instillation of the sclerosant into the submucosa above the level of the dentate line using a 25-gauge spinal needle. Typically, 1 to 2 mL of sclerosant per location is adequate, and multiple locations can be treated during a single session.
Bipolar diathermy converts electrical current into heat energy to coagulate the hemorrhoidal tissue, including the mucosa and submucosa. The machine generates a 2-second pulse of energy to accomplish the treatment. The technique produces the same basic effect as sclerotherapy, and therefore the indications for treatment are very similar. Other energy-based options include infrared coagulation and therapy with direct current (Ultroid; Ultroid Technologies, Inc., Tampa, Fla.). Infrared coagulation employs a tungsten halogen lamp that generates heat energy, generally for a 1.5-second period at a depth of penetration of 3 mm. Direct-current therapy uses electrical current applied for up to 10 minutes per complex treated. There is probably no advantage of one technique over the other, although the cost to acquire the machines and cleaning requirements between procedures should be considered.
Hemorrhoidal Ligation with Rubber Bands
In 1963, Barron became the first person to describe treatment of hemorrhoids with rubber bands. This technique has withstood the test of time, with multiple large-scale studies documenting both safety and efficacy, and it is a good option for grade II and III internal hemorrhoids. When the bands are applied correctly, pain is minimal both during and after the procedure.
Banding is best performed with the patient in a prone jackknife position. Anoscopy is performed to assess the degree of hemorrhoidal prolapse and to establish the sites of the worst and the least prolapse. A set of two bands is applied above the dentate line at the top of the hemorrhoidal column by pulling the prolapsing tissue into the applicator. An assistant is needed to hold the anoscope and may help by slightly easing it out when the hemorrhoid is pulled or sucked into the applier. The worst affected hemorrhoid is treated first, followed by the next worst affected hemorrhoid. It is wise to place a maximum of three sets of bands at once because discomfort due to the tightness can become severe. Patients are warned to expect to feel an urge to defecate after banding that may be quite uncomfortable and will last the remainder of the day. Some patients may experience vasovagal symptoms after banding and thus patients should be asked to lie down for 10 minutes after the procedure.
Discomfort immediately after band placement may be reduced with the injection of a local anesthetic agent; however, this injection does not appear to provide a long-lasting benefit. Banding is associated with hemorrhage from the ulcers that occur at the band sites. This outcome is uncommon but can occur within the first 2 weeks of the procedure; it seems to be more likely if a large amount of tissue is pulled into the band. The presence of acute pain after banding means that the bands have been applied too low and sensory epithelium has been included in the band, in which case the bands should be removed. Finally, a rare but potentially fatal complication of perineal sepsis can occur, which is heralded by the symptoms of increasing rectal pain, fever, and the inability to void urine. It is essential to evaluate patients with these symptoms early and to treat them aggressively with broad-spectrum antibiotics and aggressive surgical drainage. The full effect of the bands is not noted for a month, by which time the ulcers at the sites of the band application have healed and scarring has occurred.
Bayer and colleagues reported a series of 2934 patients who underwent elastic band treatment of internal hemorrhoids, with 79% experiencing complete relief of symptoms after a single session with treatment of only one or two locations. Multiple sessions were needed as follows: 2 sessions, 32%; 3 sessions, 17%; 4 sessions, 25%; and 5 sessions, 20%. Although the need for multiple sessions is a negative aspect of this technique, only 2.1% of patients required an excisional hemorrhoidectomy. Banding offers sustained, inexpensive relief of symptoms, with 69% of patients maintaining long-term relief and only 7.5% ultimately requiring an excisional hemorrhoidectomy.