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C
HAPTER 9
Symptomatic Hemorrhoids
Susan L Gearhart, MD
Assistant Professor of Surgery, Colorectal Surgery, Johns Hopkins
Medicallnstitutions,
Lutherville, Maryland
A
1though the true incidence of symptomatic hemorrhoids is
difficu1t to estimate, the significance and management of this
disorder has been well documented. The earliest writings on the
subject of symptomatic hemorrhoids occurred in 400 BCby Hippocrates.1 In these writings, symptomatic hemorrhoids were described as the resu1t of infection of the veins within the rectum with
stool, causing the temperature within the vein to rise and the vein to
swell. Successful treatment could be obtained by cauterizing the
hemorrhoids with a red-hot iron. Napo1eon was finally defeated by
the British at the Battle of Waterloo in 1815. Severa1 accounts by
those who were dose to him have indicated that the battle was 10st
because ofNapoleons aftliction with hemorrhoids.2 Contrary to his
usual batt1e conduct, he spent most of his time resting on a hilltop
overlooking the battlefield rather than on his horse. When he did
wa1k, he had a difficu1t time. Furthermore, a 1etter to his brother
written severa1 years before the Battle of Waterloo indicated he had
been routine1y treating his hemorrhoids with 3 to 4 1eeches. Today,
if one browses the Internet on the topic of hemorrhoids, there are
more than 65,000 sites that can be visited.
ANATOMYANDPATHOPHYSIOLOGY
Figure 1 demonstrates the anatomic abnormalities associated with
the development of symptomatic hemorrhoids. Hemorrhoidal cushions are essential to the function ofthe anal canal. The hypervascular nature of these cushions allows control of fecal continence and
the easy passage of formed stool. In contrast with the submucosa of
the proximal gastrointestinal tract, the submucosa of the anal canal
is not a continuous rim, but a discontinuous series ofvascu1ar cushions. 3,4These hemorrhoidal cushions are found in the right anterior,
Advances in Surgery@, vol 38
Copyright 20M, Mosby, Inc. Ali rights reserved.
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S.L.Gearhart
Superior
rectaJ
Mlddle
a.andv.
hemorrholdaJ
a.andv.
Inferior
hemorrhoidal
a.andv.
\
FIGURE
1.
Cross-sectional view of nonprolapsing and prolapsing hemorrhoid complexes.
right posterior, and left lateral position. These cushions are supported by a connective tissue framework derived from the internal
anal sphincter and longitudinal muscle within the anal canal. The
blood supply to the anal canal. which terminates in the anal cushions, stems from the superior rectal artery from the inferior mesenteric artery and the middle and inferior rectal arteries from the internal iliac artery. Above the dentate line within the anal canal, the
venous drainage follows the portal system into the inferior mesenteric vein. In contrast, below the dentate line. the venous plexus
drains into the systemic system.
In the process of elimination of stool, anal cushions serve 2 purposes: 1) the control of fine continence and 2) the evacuation of
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Symptomatic Hemorrhoids
169
formed stool through a muscular tube without injury to the mucosal
lining. The distention of the rectum with waste results in engorgement of the vascular cushions of the anal canal. Within the mucosa
overlying the anal cushions are sensory receptors that are essential
to fine adjustments in continence.5.6 These receptors function. for
example, to promote the elimination of gaseous waste in preference
to liquid or solid waste. The engorgement of the vascular cushions
allows solid waste to be evacuated completely and without injury to
the anal canal.
Although severa! theories exist regarding the pathogenesis of
symptomatic hemorrhoids, it is generaIly believed that this disorder
arises from a history of straining with defecation and as part of the
aging process.7-9It is believed that the supportive connective tis sue
gives way with constant straining resulting in prolapse of the hemorrhoid cushion. Once the hemorrhoid complex begins to prolapse.
venous return is impaired. resulting in engorgement, irritation, and
inflammation. Erosion of the inflamed epithelium results in bleeding. Congenital internal anal sphincter hypertension has also been
implicated in the pathogenesis ofhemorrhoidal disease.9.10
CLASSIFICATION
As in most disease states, classification is considered useful for the
management of symptomatic hemorrhoids. Hemorrhoids historically have been classified based on their location and the degree of
prolapse.ll The dentate line demarcates the upper anal canal, lined
with columnar epithelium. from the lower ana! canal, which is
lined with sensate squamous epithelium. Internal hemorrhoids, in
the most common location of hemorrhoids, occur above the dentate
line. External hemorrhoids are found below the dentate line (see
Fig 1).
Internal hemorrhoids are further classified by the degree of prolapse.
·
·
·
·
46
First-degree hemorrhoids do not prolapse with straining. but can
be associated with bleeding.
Second degree hemorrhoids protrude below the dentate line dur-
ing straining but wiIl spontaneously retract.
Third degree hemorrhoids protrude outside the anal canal with
straining and require manual reduction.
Fourth degree hemorrhoids remain prolapsed independent of
straining and are irreducible.
170
S. L. Gearhart
PRESENTATlON
AND DIAGNOSIS
Bleeding is the symptom most commonly associated with hemorrhoids. The bleeding is bright red, noted on wiping or filling the toilet bowl, and occurring predictably with defecation. Prompt reduction of the prolapsed hemorrhoid will significantly reduce the
bleeding. Patients with third- or fourth-degree hemorrhoids complain of protruding, irritated tissue in the perianal region. Thirdand fourth-degree hemorrhoids may aIso cause a feeling of incomplete evacuation. The prolapsed tissue gives a sense of fullness and
a continuing sense of the need to evacuate. Soiling in the form of
mucus discharge is not uncommon, because of an impairment of the
fine control of continence. Constant exposure of the perianal skin to
mucus may result in irritation and itching. Discomfort may be associated with prolapsed hemorrhoids; however, intolerable pain is
rare. A painful hemorrhoid is usually an acutely thrombosed, prolapsed internal or external hemorrhoid. Pain is associated with a
perianal mass, which is immediately evident on physical examination.
The diagnosis ofhemorrhoidal disease is usually made with palpation and direct visualization of the perianal region and anal canal
through anoscopy. Prolapsing or thrombosed hemorrhoids are evident on inspection of the perianal tissue. These findings can be exaggerated with straining. Thrombosed hemorrhoids have a blue hue
as a result of the clotted blood inside. On anoscopy, inflamed hemorrhoids may be visualized in their previously mentioned anatomical position.
Individuals seeking medical attention for perianal discomfort
often report that they have hemorrhoids. Unfortunately, this is due
to the lack ofpatient and physician education. Most perianal conditions are incorrectly labeled as "hemorrhoids." Anal fissures arise in
the sensate portion of the anal canal and are associated with excruciating pain more so than bleeding. It is true that because the patho
is similar to that of hemorrhoids, it is not uncommon for the two to
exist together. Mucosal prolapse, a circumferential prolapse of the
anal canal mucosa, is a common condition of older women. The
symptoms resulting from mucosal prolapse as well as the medical
management are similar to hemorrhoidal disease. Most importantly,
a more serious condition often mistaken for hemorrhoids is anal or
rectal cancer. Any examination of patients with hematochezia
should include suf:ficient investigations to rule out a proximal
source of bleeding if the bleeding does not cease afier appropriate
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Symptomatic Hemorrhoids
171
therapy. Furthermore, hemorrhoidal bleeding rarely causes irondeficiency anemia.12 Other disorders, such as intlammatory bowel
disease or cancer, should be ruled out.
TREATMENT
DIETARYAND UFESTYLE
ALTERATlONS
It has been shown that fiber supplementation reduces the bleeding
and discomfort associated with hemorrhoids.13 However, fiber supplementation will not reduce the prolapse. It may be weeks before
the use of fiber for the treatment of symptomatic hemorrhoids is effective. It is recommended that patients take 30 gm of fiber a day and
increase liquid intake. This goal is difficult to reach without the assistance of fiber supplementation. Fiber therapy should be instituted gradually over the course of a week. This will reduce the incidence of unwanted side effects of bloating. Supplemental semisynthetic tlavonoids are commonly prescribed in Europe and Asia
for the treatment of hemorrhoids. This remedy willlikely improve
venous tone and inhibit the release ofprostaglandins, thus resulting
in symptomatic relief.14
Patients should be counseled on specific activity related to defecation. Avoiding straining is essential. The bathroom is to be used
for the sole purposes of evacuation of waste and not for reading. Patients should be instructed to remain on the toilet seat for no longer
than 1 minute. Furthermore, attempts at defecation should be made
only afier the patient receives a clear call to eliminate waste.
MEDICALMANAGEMENT
Historically, symptomatic relief from acutely intlamed hemorrhoids
was bed rest and ice packs. Acute surgical therapy was deemed unsafe because of the risk of internal sphincter injury. However, with
improvement in surgi cal techniques, patients need not suffer endlessly with acute disease. Studies have shown that offering surgical
therapy is safe and effective.15 There is a plethora of ointments available that contain steroids, local anesthetics, or mild astringents and
can provi de short-term relief from acute or chronic hemorrhoidal
discomfort or bleeding. Some common commercial preparations include: Thcks, Anusol, Preparation H, and Balneol. Other remedies
include warm-water sitz baths to ease the discomfort often associated with a thrombosed hemorrhoid. Persistent use of local remedies should be avoided because sensitization of the anoderm may
result in a permanent dermatologic condition.16
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S.L. Gearhart
SURGICAL
MANAGEMENT
Surgical management is dictated by the folIowing: 1) the degree of
prolapse (Tables 1 and 2) associated medical conditions; 3) and the
lifestyle of the patient. The folIowing section describes the various
methods of surgical treatment of symptomatic hemorrhoids. In general, treatment is performed either in the clinic or in the outpatient
operating room. Patients are rarely admitted to the hospital. Before
treatment, patients should be counseled on dietary and lifestyle
modifications. Regardless of age, evaluation for alternative sources
of bleeding should always be incorporated into the treatment plano
AlI patients should be prescribed 2 enemas to be administered the
morning before undergoing treatment.
Procedures that ean be performed in an OUlpatientclinic:
·
Simple excision: For the painful thrombosed external hemorrhoid, relief is provided by excision of the thrombosis. This is accomplished by complete excision and not by simple incision (Fig
2). Simple incision wilI result in recurrence of the thrombosis and
probable infection. However, if the thrombosis has been present
for more than 2 to 3 days, and the discomfort has begun to subside,
conservative management should be recommended. This consists
of warm sitz baths and stool softeners, as well as local analgesics.
The inflamed mass will resolve in 8 to 10 days. Whether or not the
thrombosis is excised, further treatment of the prolapsed hemorrhoid can be offered in the form of either banding or excisional
hemorrhoidectomy.
-
TABLE1.
Recommended
Grade
1
2
3
4
Mild
Severe
Treatment of Hemorrhoids
Based on Degree of Prolapse
Treabnent
Fiber supplementation or
Sclerotherapy
Fiber supplementation or
Sclerotherapy
Fiber supplementation and
Rubber-band ligation
Stapled hemorrhoidectomy
Conventional hemorrhoidectomy
Fiber supplementation and
Stapled hemorrhoidectomy
Conventional hemorrhoidectomy
49
Symptomatic
TABLE
2.
Randomized.
Patients. n
Clínical
FoUow-up
Return to
Work (dy)
55
6mo
NA
31
60
55
22
119
8mo
12 mo
15 mo
6wk
19wk
10 vs 14
8 vs 14
3 vs 4
8 vs 17*
17 vs 23*
2 vs 1
5 vs 0*
7 vs 0*
NA
74
36
89
84
40
80
30
100
200
80
40
6mo
37 mo
6wk
7mo
12 mo
20 mo
6wk
16 mo
12 mo
3 mo
4mo
28 vs 34
NA
14 vs 18*
6 vs 15
NA
8 vs 15*
NA
5 vs 13*
8 V5 54*
NA
17 vs 34*
NA
O vs O
NA
1 vs O
1 vs 1
O vs O
O vs O
3 vs 2
1 vs 2
O vs O
O vs O
Stapled vs Banding
Peng 2003
Stapled vs Diathermy
Cheetham 2003
Kairaluoma 2003
Ortiz 2002
RowseU 2000
Ho 2000
Stapled vs
Conventional
Palimental 2003
Smyth 2003
Wilson 2002
Correa-Rovelo 2002
Hetzer 2002
Boccasanta 2002
Brown 2001
Ganio 2001
Shalaby 2001
Pavlidis 2001
Mehigan 2000
Statistica11y
173
Controlled Trials for the Treatment of Prolapsing Symptomatic Hemorrhoids
Procedures
.
Hemorrhoids
significant
Recurrence or Prolapse
(patients. n)
resulto
(Data from BMJ 327:649. 2003.J
. Injection sclerotherapy: For first- and second-degree hemorrhoids, when the primary complaint is bleeding and not protruding tissue, sclerotherapy can be employed. The agents commonly
used are sodium morrhuate and sodium tetradecyl sulfate. The
procedure is performed in an officevisit while the patient is in the
prone jack-knife or left lateral position. A 25-gauge spinal needle
is used to insti1l1 to 2 ml of the sclerosing agent into the submucosal space afier careful aspiration to avoid intravascular injection. Injection of sclerosant for first- and second-degree hemorrhoids should be painless. given that. by definition, these
hemorrhoids are located above the dentate line.
. Rubber-band ligation: Rubber-band ligation has been a recognized
technique for symptomatic second- and third-degree hemorrhoids
since Barron's first description in 1963.11 The technique is easy to
do in an outpatient setting and is associated with very little discomfort. The steps using the McGivney ligator with forceps are
50
174
S.L. Gearhart
A
;
..1'"
B
C
FIGURE2.
Complete excision of a thrombosed hemorrhoid. A, An elliptical excision that fully
encompasses the thrombosed hemorrhoid should be made. B, The excision should
completely remove the hemorrhoid complexo C, The excision site is left open to
heal. (Reprinted with permission from Cameron JL: Atlas of SurgeIj, 2nd ed. Hamilton, Ontario, Inc. [In press].)
outlined in Figure 3. Alternatively, a suction ligator, which eliminates the need for a grasping forceps and for an assistant, can be
used. Patients are placed in the left lateral position or the
prone/jackknife position. It is recommended that the banding instrument be loaded with 2 bands, because this will prevent breakage and recurrence.11 It is important to identify the dentate line
and place the band above this line. It is recommended that no
more than 2 bands be placed per visit. Although, triple banding
has been shown to be effective, it has also been associated with
37% incidence ofprolonged post-ligation pain.17 Following banding, the patient might experience a feeling of pressure or rectal
fullness for a period of 24 to 48 hours. Furthermore, approximately 10 to 14 days following the banding, a small amount of
tissue associated with bleeding might be passed. Associated complications are rare «2%) and include vasovagal response to the
procedure itself, pelvic sepsis, and secondary thrombosis of external hemorrhoids. Severe, life-threatening sepsis has been re-
FIGURE3.
The technique of rubber band ligation. A, Twobands are placed on the McGivney
hemorrhoid ligator. B, Hemorrhoidal tissue is localized and grasped with the forceps. C, The ligating instrument is advanced above the dentate line and fired. D,
The hemorrhoid ligator is removed. (Reprinted with permission from Cameron JL:
Atlas of Surgery, 2nd ed., Hamilton, Ontario. BCDecker. [In press].)
51
L
Symptomatic Hemorrhoids
.-
~
A
B
c
.,
-'
o
52
175
176
S. L. Gearhart
ported in immunocompromised patients undergoing rubber-band
ligation.
Proceduresrequiringan outpatientoperativesuile:
More invasive procedures, such as coagulation, excision, ar stapling, are recommended for third- and fourth-degree hemorrhoids
with an extensive external component or failure of more conservative procedures. In general, less than 10% of patients referred for
treatment by a specialist wiIl require a more invasive procedure.
These techniques are best performed accompanied with effective
anesthesia. Any movement of the patient during these procedures
can present a challenge.
·
·
Ligature: The ligature diathermy is used to treat third- and fourth-
degree hemorrhoids. The underlying principIe is sjmilar to the
conventional hemorrhoidectomy, but the ligature is used instead
of using conventional monopolar cautery or Metzenbaum scissors. If necessary, the mucosa can be reapproximated using a 3-0
Vicryl stitch.
Conventianal hemorrhoidectomy: Excision hemorrhoidectomy is
reserved for fourth-degree and occasionally third-degree hemorrhoids. This can be performed with an open technique, as originally described by Milligan and Morgan in 1937,18and in a closed
manner, as described by Ferguson in 1959.19The patient is placed
in either the lithotomy or prone jackknife position. A mixture of
bupivacaine and adrenaline is useful in establishing hemostasis
and in the dissection and removal of the symptomatic portion of
the hemorrhoidal complexo Both methods emphasize the importance of careful dissection of the internal sphincter. Care must be
taken to avoid overzealous dissection ofthe mucosa, which could
lead to anal canal stenosis. Despite low complication rates and
high efficacy of conventional hemorrhoidectomy, severe pain can
result because of excision of sensate anoderm below the dentate
line. This leads to a delay in the retum to wark and patients' unwillingness to undergo the procedure.
Stapled hemorrhoidectomy (procedure for prolapse and hemorrhoids): This procedure was largely developed to treat third- and
small fourth-degree symptomatic hemorrhoids as an alternative to
the conventional hemorrhoidectomy. The procedure itself represents a paradigm shift in the management of prolapsing hemorrhoids in that the hemorrhoidal tissue is not actually removed,
rather a circumferential mucosectomy is performed, which results
in an anopexy. The procedure can be performed under sedation ar
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Symptomatic Hemorrhoids
177
general anesthesia in the prone or lithotomy position. A pursestring suture with 2-0 polypropylene is placed approximately 2 to
4 cm above the dentate line. The 31-mm PPH stapler (Ethicon,
Endo-Surgery, Ohio, USA) is used to pexy the hemorrhoidal tissue
above the dentate line (Fig 4). Early reports on the use of stapled
hemorrhoidectomy called attention to severe complications including pelvic sepsis, rectovaginal fistula, persistent pain, and
fecal urgency.20-22However, there is, without question, a learning
curve associated with the stapled hemorrhoidectomy, and, with
increased surgical experience, these complications are rare. It is
recommended that a careful vaginal examination be performed
prior to firing the stapler to ensure the vagina was not caught up in
the purse-string and, thus. the stapling device.
CUNICALTRIALSOUTCOMES
Outcome trials reviewing outpatient clinic techniques have demonstrated that sclerotherapy may provide a short-term benefit, but
long-term improvements have been seen in only 28% of patients.
Therefore, rubber-band lígation remains the most effective method
for the management of symptomatic grade 2 and 3 hemorrhoids in
the outpatient clínico This procedure is associated with nearly an
80% short-term cure rate for patients with up to third-degree hemorrhoids.23 Of the remaining 20% of patients, 18% wiIl be cured
with a repeat procedure with only 2% failing to respondoUltimately,
rubber-band ligation is associated with approximately 90% longterm success rate.
For the management of grade 3 and 4 prolapsing hemorrhoids,
there are several randomized, controIled trials comparing stapled
hemorrhoidectomy to conventional hemorrhoidectomy (see Table
2). Ho et al24 demonstrated that the stapled hemorrhoidectomy is
safe and effective, associated with less pain; however, it is more expensive than con~entional hemorrhoidectomy. Those in favor of the
stapling procedure contend that there is an earlier return to work
with the stapling technique andothus, a decreased cost to society.25
However, it is important to note that patients who are candidates for
the stapling procedure are usually candidates for banding. It is also
known that patients with severe grade 4 prolapse are best managed
by conventional hemorrhoidectomy, because an anopexy procedure
may not completely eliminate an extensive external component.
Peng et al,26realizing this paradox, demonstrated that rubber-band
ligation and the stapled hemorrhoidectomy were equally effective
in controlling prolapse from third- and small fourth-degree hemorrhoids. Although the number of participants was small, with only a
54
UI
UI
FIGURE
4.
Teehnique for stapled hemorrhoidectomy. A, A purse-string suture is plaeed approximately 2 to 4 em from the dentate line. B,
The purse-string suture is seeured around the stapling deviee. At this point, in female patients, the vagina should be examined
for the presenee of a stitch or pulling before firing the stapling deviee. C, The hemorrhoid complexes have been resuspended
and an intaet staple Une is present. (Reprinted with permission from Cameron JL:Atlas ofSurgery, 2nd ed., Hamilton, Ontario,
BCDeeker. [In pressl.)
c
~
r
~
Q
3Q
::l
"""
'i
=
"
Symptomatic HemoIThoids
179
6-month follow-up, there was more perioperative morbidity assoeiated with the stapled hemorrhoidectomy, and recurrent bleeding
was more common in the banded patients. The benefits of ligature
over conventional hemorrhoidectomy include reduced bleeding,
anesthetic time, and healing time.27 Those who oppose the use of
the ligature are concerned that the lack of dissection may result in
inadvertent injury to the internal sphincter. Further long-term studies need to be performed.
COMPUCATIONS
OF SURGICAL
THERAPY
The most common complications associated with a hemorrhoidectomy are bleeding, pain, and urinary retention. Bleeding complication can occurwithin 24 hours (1%) or in 5 to 10 days (4%).28Early
bleeding is usually secondary to a missed vessel, whereas delayed
bleeding is a result of early separation of the ligated pedide. A returo trip to the operating room may be required. Insertion of a rectal
Foley to tamponade the bleeding may suffice. To avoid bleeding
complication from a stapled hemorrhoidectomy, an additional 3-0
Vicryl suture is used to oversew the staple line. Simple hemostatic
material such as Gelfoam with thrombin can be placed in the anal
canal following the procedure; however, excessive pacldng should
be avoided. Investigators have shown that the use of intravenous
metronidazole and the limitation of intraoperative tluid to less than
250 ml will prevent increased swelling and inflammation, which
can result in pain and urinary retention.29,30Furthermore, the use of
ketorolac to accompany oral narcotics may provide improved analgesia.31
Hemorrhoidectomy is the most common cause of anal stenosis
and ectropion, with an incidence ranging between 2% and 4%. Anal
stenosis results from an overzealous removal of the anoderm with
loss of mucdsal bridges and scarring of the anal canal. Surgical correction of this condition requires either repeated dilatations or surgical anoplasty. Anal ectropion is the abnormal placement of the
anal mucosa distal to the dentate line. Once this occurs, the continence mechanism is unable to prevent the leakage of mucus and
small amounts of stoo1.This will result in maceration ofthe perianal
region and chronic pruritus. Treatment requires restoration of the
ectopic mucosa to a position proximal to the dentate line. Diamondshaped. house-shaped, or V-Y advancement tlaps have been used
with excellent anatomic results.
56
180
S. L. Gearhart
HEMORRHOIDS
ASSOCIATED
WlTH OTHERDISEASES
·
Coagulation Disorders: Patients with known coagulation
disor-
ders and those requiring anticoagulation are a challenge to manage. Most physicians advocate either sclerosing or banding of
hemorrhoids in patients with this condition. If surgery is undertaken for failure of less invasive techniques, assistance from a hematologist in optimizing the patient for surgery may be a benefit.
·
Crohn's disease: Confusing enlarged sldn tags for symptomatic
hemorrhoids can be severely problematic for patients with
Crohn's disease. Poor perianal wound healing in Crohn's disease
may lead to a persistent fissure or fistula if hemorrhoidectomy is
performed. Perianal symptoms are usually exaggerated by bowel
frequency and correction of this will often lead to resolution. For
this reason, hemorrhoidectomy is not recommended in Crohn's
disease.
·
.
HIV infection: Medical therapy is preferable because of the risk of
septic complication and poor wound healing afier surgery. Other
causes of perianal symptoms, induding condyloma, should be excluded. With the addition ofhighly affective anti-removal therapy
and an improved immune status, symptomatic hemorrhoids can
be treated with rubber-band ligation safely.
Pregnancy: This condition clearly predisposes patients to symp-
tomatic hemorrhoids. Although the etiology is unknown, it is
thought to be the result of increased hormone levels and pelvic
venous congestionoPatients revert to their pre-pregnancy condition following delivery. Conventional hemorrhoidectomy provides symptomatic relief from severe disease. This can be performed under local anesthetic safely during the third trimester
when the fetus is viable without maternal or fetal complication.32
However, approximately 25% ofthese patients require additional
hemorrhoidal treatment. For this reason, surgical intervention is
reserved only for intractable symptoms.
SUMMARY
Themost important aspect in the diagnosis of hemorrhoidal disease
is the exclusion of other, more life-threatening conditions. Hemorrhoidal banding remains the most successful method to manage
hemorrhoids in the outpatient clinic. Chronic application of local
medications to the perineum may result in dermatologic conditions.
It is safe to manage acutely inflamed hemorrhoids surgically. Table 1
is a summary of the various methods for the surgical management of
symptomatic prolapsing hemorrhoids. Dietary manipulation, in-
57
Symptomatic Hemorrhoids
181
cluding fiber supplementation, should always accompany surgical
therapy.
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