From Medscape Medical News

Hemorrhoid Management Reviewed Dr. A. Ghomeishi MD Dr. Charles Mccoy MD

February 25, 2008 The best options for evaluating and treating hemorrhoids are reviewed in the February 16 issue of the BMJ. "Haemorrhoids or 'piles' are enlarged vascular cushions within the anal canal that have been described for many centuries and continue to form a large part of a colorectal surgeon's workload," write Austin G. Acheson and John H. Scholefield from University Hospital, Queen's Medical Centre in Nottingham, United Kingdom. "The exact incidence of this common condition is difficult to estimate as many people are reluctant to seek medical advice for various personal, cultural, and socioeconomic reasons, but epidemiological studies report a prevalence varying from 4.4% in adults in the United States to over 30% in general practice in London. The treatment of haemorrhoids is still evolving, and this article provides an update on the role of established and innovative treatments." The reviewers identified randomized controlled trials and meta-analyses from the MEDLINE database and Cochrane library. Based on this evidence, they describe the pathogenesis and causes of hemorrhoids, their classification based on their relationship to the dentate (pectinate) line, their presenting symptoms and evaluation, and their treatment. Painless, fresh rectal bleeding is the most common symptom, but pruritus, swelling, prolapse, discharge, or soiling may occur, with severe anal pain only if the hemorrhoid is thrombosed or strangulated. Inspection of the perineum, rectal examination, and anoscopy help differentiate hemorrhoids from other causes of anal canal bleeding, such as fissures, fistulas, tumor, polyps, anal warts, and rectal prolapse. Inspection is usually sufficient to visualize large external hemorrhoids. In patients older than 40 years with suspected hemorrhoidal bleeding, specialist opinion is indicated to rule out colorectal cancer, and flexible sigmoidoscopy, colonoscopy, virtual colonoscopy, or a barium enema may be needed. When soiling or incontinence is present, anorectal physiologic studies and endoanal ultrasound examination may help the surgeon choose the best treatment option. Conservative treatment of hemorrhoids includes early use of fiber supplements, which has been associated with moderate relief of bleeding and overall symptoms. Useful lifestyle modifications may include better anal hygiene, sitz baths, greater fluid intake, relieving constipation, and avoiding straining, although these measures are not supported by good evidence. Over-the-counter topical preparations containing local anesthetics, corticosteroids, astringents, and antiseptics may relieve pruritus and discomfort, but long-term use is not recommended. Steroid creams in particular may cause permanent damage or ulceration of perianal skin. Flavonoids used as dietary

supplements may improve venous tone, decrease hyperpermeability, and have anti-inflammatory effects, but solid evidence is lacking. Outpatient interventions may cause tissue loss and ulceration, or by causing fibrosis, they may help to fix the mucosa of the prolapsed tissue back onto the underlying muscle. These include rubber band ligation (up to 3 bands at each visit), applied above the dentate line to minimize pain. Nearly 80% of patients are satisfied with the short-term outcome of rubber band ligation, although common complications include pain and hemorrhage. Delayed hemorrhage may occur 5 to 10 days after banding, and urinary retention, liver abscesses, and perineal sepsis are rare. An alternative to banding is injection sclerotherapy with use of a submucosal injection of 5% oily phenol into first- or second-degree hemorrhoids. This technique is not helpful for large, prolapsing hemorrhoids or for those with a large external component, and it has a high failure rate, with results no better than those achieved with fiber supplementation. Complications, such as local infections, prostatitis, portal pyemia, and erectile dysfunction, seldom occur. Other outpatient techniques include infrared coagulation, which is less effective than banding and is not widely used. Limited evidence exists to support the use of cryosurgery, bipolar diathermy, and directcurrent electrotherapy. Open and closed hemorrhoidectomy surgery is used only for large, symptomatic hemorrhoids refractory to outpatient treatment. In the open technique, the hemorrhoid is dissected out from the underlying anal sphincter complex with electrocauterization, laser surgery, the LigaSure vessel-sealing system (Valleylab, Boulder, Colorado) the harmonic scalpel, or scissors. The vascular pedicle is controlled, and the mucosal defects are left open and are allowed to granulate by secondary intention. In the closed technique, which is more popular in the United States, the mucosal edges and skin are closed with a continuous suture. Although both open and closed hemorrhoidectomies are safe and effective, the closed procedure promotes faster wound healing. Because surgical hemorrhoidectomy is a painful procedure often performed on a day-case basis, a careful perioperative pain package should be prescribed, including local anesthetics, analgesics, and laxatives. Complications may include hemorrhage 7 to 10 days after surgery, urinary retention, infection, fecal incontinence from sphincter damage, and anal stenosis. Other surgical techniques include Doppler-guided hemorrhoidal artery ligation, which is relatively painless, has minimal morbidity, and has a patient satisfaction rate of up to 60%; and stapled hemorrhoidopexy. "Acutely thrombosed prolapsed haemorrhoids are very painful but most can be treated at home and usually settle within 10-14 days using ice packs, stool softeners, and analgesia," the review authors conclude. "Topical calcium antagonists may help to relieve the pain. Emergency surgery may be needed in severe cases to remove the engorged hemorrhoid or debride necrotic tissue. This can resolve symptoms more rapidly but is often associated with severe morbidity." The review authors have disclosed no relevant financial relationships. BMJ. 2008;336:380-383.

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