The Role of Endoscopy in the Management of Hemorrhoids

Shaffer R.S. Mok, MD, MBS

David L. Diehl, MD, FACP, FASGE

INCIDENCE

Approximately 2.2 million outpatient evaluations occur annually for hemorrhoidal adverse events.¹,²,³ Additionally, almost half of patients undergoing colonoscopy are found to have hemorrhoids. In the United States, 50% of adults age 50 years or older have reported gastrointestinal symptoms attributed to hemorrhoids.⁴ As a result, it is vital for the endoscopist to be aware of the workup, staging, and indication for specific therapies aimed at hemorrhoids.

ANATOMY AND PATHOPHYSIOLOGY

Hemorrhoids are a normal part of the anatomy of the anal canal. They are described as clusters or “cushions” of vascular spaces, smooth muscle, and connective tissues within the anal canal. As hemorrhoidal vasculature has no muscular wall, hemorrhoids are strictly defined as sinusoids and thus are not anatomically categorized as veins or arteries.⁵ Embryologically, the dentate line is a sharp division of the endoderm and ectoderm in the anal canal. This allows classifications of hemorrhoids into internal and external depending on whether they are above or below the dentate line. Somatic sensory neurons supply sensation to the perianal skin, therefore external hemorrhoids, when inflamed, can produce pain.

External hemorrhoids obtain vascular drainage via the inferior rectal vein, which drains via the pudendal vein into the internal iliac vein. In contrast, internal hemorrhoids receive their vascular drainage via the superior and middle rectal veins, which empty into the internal iliac vein directly.

Hemorrhoids are located in the anal canal in three major locations: left lateral, right anterior, and right posterior and can be internal, external, or both. For the purposes of this book, we will be discussing only internal hemorrhoids, as these are the target of endoscopic therapy.

GRADE

Hemorrhoids are usually graded based upon the Banov classification.⁶ Grade I hemorrhoids are defined as nonprolapsing, grade II prolapse with defecation and spontaneously reduce, grade III prolapse with or without defecation and require manual reduction, and grade IV hemorrhoids are prolapsed permanently or are incarcerated. Grade I and II hemorrhoids can be treated conservatively (i.e., fiber, laxatives) or with endoscopic therapies. Grade III and IV hemorrhoids are typically managed surgically although there are some approved indications for endoscopic options.

CONTRAINDICATIONS

Absolute

1. Cardiopulmonary instability
2. Peritonitis or pelvic sepsis
3. Perforation
4. Fulminant colitis

Relative/Considerations

1. Immunosuppression
2. Portal hypertension
3. Active inflammation
4. Active inflammatory bowel disease

5. Torrential colonic bleeding

TABLE 21.1 Grade of Hemorrhoids Using the Banov Classification

	Hemorrhoidal Grade
Therapy	Grade I	Grade II	Grade III	Grade IV
Conservative Therapy (i.e., Laxatives, fiber)	X	X	X	X
Rubber Band Ligation	X	X	X^a
Sclerosant	X	X
Infrared Coagulation	X	X	X^a
Bipolar Electrocautery	X	X
Surgery		X	X	X
^aCan be performed.⁶

6. Poor bowel preparation
7. Uncooperative patient
8. Active use of antiplatelet agents or anticoagulants

ADVERSE EVENTS

1. See Colonoscopy for general endoscopic adverse events
2. See below for unique potential adverse events

PREPARATION

The initial evaluation of the patient includes obtaining vital signs, history, and physical examination. An assessment by the physician of patient capacity to consent for an endoscopic procedure is a vital second step. The patient should undergo informed consent in an understandable language, and preprocedure discussion should include indications for the procedure, alternative therapy, possible adverse events, and the possibility of overlooking lesions.

Certain endoscopic hemorrhoidal therapies may require a bowel preparation. Please see below for which variations may require this. Procedures not requiring endoscopy can be performed safely in the office without the need of a bowel preparation or sedation. Endoscopic hemorrhoidal treatments may necessitate the use of IV sedation, again outlined in prior chapters.

THERAPIES

Rubber Band Ligation

Placement of the band over the hemorrhoid induces a pressure necrosis via ischemia, leading to subsequent ulceration and then fibrogenesis. This induces fixation of the hemorrhoid against the rectal wall.⁷,⁸ Rubber band ligation (RBL) is the most commonly utilized endoscopic hemorrhoidal therapy. This treatment leads to an overall cure rate of as high as 93%.¹,⁹,¹⁰ Though some trials have demonstrated lower success rates, most patients in these trials were able to be retreated with repeat RBL. RBL also has demonstrated higher postprocedural pain and bleeding rates.¹¹,¹²,¹³,¹⁴ Globally, trial data have shown improved clinical response, lower adverse event rates, and need for fewer sessions using RBL.

At present the only device marketed for RBL is the Stiegmann-Goff Bandito Endoscopic Hemorrhoidal Ligator (ConMed Corp, Utica, NY). Similar banding devices have been developed for variceal banding which involves a wire or string that runs from the transparent cap through the working channel to a handle—SmartBand (Olympus, Tokyo, Japan), Speedband Superview Super 7 (Boston Scientific Corp, Malborough, MA), and SixShooter Universal Saeed, Multi-Band Ligator (Cook Medical
Winston-Salem, NC). Several iterations of hemorrhoidal ligation using an anoscope alone have been created. The first is the McGivney Hemorrhoidal Ligator (Miltex, York, PA) (Fig. 21.1). This device is a stainless-steel 7-10-inch, gun-shaped ligation, holding four rubber ligation bands. This device is reusable, and the bands are latex-free. Another device that works via an anoscope is the ShortShot Saeed Hemorrhoidal Multi-Band Ligator (Cook Medical, Winston-Salem, NC) (Fig. 21.2).

FIG. 21.1 The McGivney Hemorrhoidal Ligator (Miltex, York, PA) with bands and forceps. (Image used with permission from Integra York PA, Inc.)

Finally, two single-use devices, CRH O’Regan Disposable Hemorrhoid Banding System, CRH Medical Corp (Vancouver, BC, Canada) and SpaceBander (ConMed, Utica, NY), utilize direct suction to capture the hemorrhoid into the target area using a
plunger at the end of the device (Fig. 21.3). The mechanism of hemorrhoidal therapy is the same for endoscopic and anoscopic RBL devices. Though studies performed have only evaluated older bipolar electrocautery technologies, RBL has also revealed higher success rates and symptom control as compared with this method.⁸,¹⁵,¹⁶

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