Bleeding and protrusion are among the most common symptoms of hemorrhoids. However, Mazier reported on a series of 500 patients with complaints of “hemorrhoids” and found that only one third had any significant hemorrhoids (personal communication). hemorrhoids bleeding typically results in bright red blood that drops into the toilet or is noted on the toilet. It is generally painless. More vigorous bleeding can occur as the hemorrhoids enlarge. Usually, prompt reduction of the protruding mass will cause this bleeding to abate. Acute thromboses of internal or external hemorrhoids are usually associated with severe pain that occurs with a palpable perianal mass. These patients are generally very uncomfortable, and the diagnosis is immediately obvious on clinical examination.
Examination of the patient with hematochezia, although dictated largely 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. Moreover, hemorrhoids bleeding is rarely a cause of iron-deficiency anemia.
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Bipolar diathermy involves the use of electrical current to coagulate the hemorrhoids, including the mucosa and submucosa. The machine generates a 2-second pulse of energy to accomplish the treatment. This approach is applicable for small bleeding hemorrhoids and probably has no greater efficacy than sclerosing.
Other variations on the use of energy to scarify internal hemorrhoids and fix them to underlying tissues includes infrared coagulation and direct current therapy or Ultroid (Microvasive, Boston, MA) therapy. Infrared coagulation uses a tungsten halogen lamp that generates heat energy for 1.5 seconds, resulting in destruction of the mucosa and submucosa at the application site . The depth of penetration of this injury is usually 3 mm. Conversely, the Ultroid uses electrical current that is applied for up to 10 minutes per complex treated. Ultimately, these new modalities are a variation on the theme of local tissue destruction and fixation of the hemorrhoids at the appropriate level.
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A new entry into the arena of excisional hemorrhoidectomy is the circular stapled hemorrhoidectomy .The technique uses a circular, transanally placed pursestring suture 4 cm from the dentate line and within the enlarged internal hemorrhoids. A 31-mm stapler is then placed transanally to perform a circumferential excision of the hemorrhoidal tissue and a repositioning and fixation of the anoderm to its proper location in the anal canal. The results appear promising, with decreased postoperative pain, shorter periods of convalescence, and similar complication rates compared with other forms of excisional hemorrhoidectomy.
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Although sclerotherapy, first advocated by Mitchell in 1871, has been used often in hemorrhoids, it is rarely performed in the United States.The purpose of sclerotherapy is to scar the submucosa, resulting in atrophy of the tissue injected and scarification with fixation of the hemorrhoidal complex within its normal location in the anal canal. A variety of solutions have been advocated, although it appears that sodium morrhuate and sodium tetradechol sulfate predominate. This modality is most effective in situations with minimal enlargement of hemorrhoidal complexes where the primary complaint is bright red rectal bleeding.
The procedure is performed with the patient in the left lateral decubitus position. An anoscope is inserted to clearly identify the symptomatic complex, and a 25-gauge spinal needle is used to instill the sclerosant into the submucosal space . The syrine should be aspirated before injection to avoid a direct intravascular injection. Typically, 1 to 2 ml of sclerosant is adequate. The surgeon can inject as many locations as desired because the procedure is essentially painless. It is important, however, not to circumferentially inject the anal canal, because this may induce stricture formation.
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The majority of patients evaluated for hematochezia that ultimately proves to be hemorrhoidal in origin can be and should be managed with fiber supplementation. Although it is not clearly proved that constipation contributes to hemorrhoidal symptoms, it is certainly reasonable to improve bowel function to reduce hemorrhoidal complaints in the majority of early-stage patients. The remaining nonoperative and operative interventions should be reserved for patients with advanced hemorrhoids and patients who are unresponsive to this simple but effective medical management routine.
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About hemorrhoids ,there are few diseases that are more chronicled in human history than symptomatic hemorrhoidal disease.References occur in ancient texts dating back to Babylonian, Egyptian, Greek, and Hebrew cultures. Included in many of these writings are multiple recommended treatment regimens such as anal dilatation, topical ointments, and the intimidating red-hot poker. Although few persons have died of hemorrhoidal disease, many patients have wished they had, particularly after therapy; this fact led to the beatification of St. Fiacre, the patron saint of gardeners and hemorrhoidal sufferers. This discussion should guide the practitioner in a more humane approach to hemorrhoidal disease with an emphasis on cost effectiveness and minimal complications.
