Hemorrhoids Update Review

Posts Tagged ‘Hemorrhoids’

Thrombosis is a fairly common complication of hemorrhoids disease. Most patients give no history of straining or physical exertion and do not have histories of hemorrhoids disease. The complication develops with an abrupt onset of anal mass,hemorrhoids and pain that peaks within 48 hours. Usually, the pain becomes minimal after the fourth day. Occasionally, the skin overlying the hematoma becomes necrotic, causing bleeding and discharge or infection, which causes further necrosis and more pain. Treatment should be aimed at relief of severe pain, prevention of recurrent clot, and prevention of residual skin tags. If the patient is experiencing severe pain of hemorrhoids at the time of examination, excision should be performed. Conversely, if the pain is already subsiding and the clot is starting to shrink, thrombosis may be managed conservatively with warm sitz baths for comfort, proper anal hygiene, and bulk-producing agents such as bran or psyllium seed. The procedure can often be performed with the use of local anesthesia, and the wound can be left open without packing. Relief of pain is usually immediate. Postoperative care is simple and is aimed at keeping the wound clean with warm sitz baths and washing. An analgesic drug may be required during the first 24 hours. Patients must be warned of a relatively high recurrence rate about 6% after excision and 25% with noninvasive treatment.

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.

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.

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.

Barron was the first to describe hemorrhoidal banding with rubber bands in 1963.Since this original description, there have been a number of reports that have documented the efficacy banding offers for the management of the majority of patients with bleeding stage II and III internal hemorrhoids.The procedure is generally well tolerated without the need for prescription analgesia if the band is placed above the level of the dentate line. The technique is demonstrated in the picture below . It is important to ask the patient if he or she experiences any pain during placement of the bander, before deployment of the band. Discomfort immediately after band placement may be reduced by the injection of a local anesthetic agent, but this does not appear to be a long-lasting benefit. Banding is associated with the rare but frequently fatal complication of postbanding sepsis, which is heralded by the symptoms of increasing rectal pain, fever, and inability to void.It is essential to treat these symptoms early and aggressively with early antibiotic treatment coupled with surgical drainage

The decision to excise the hemorrhoidal plexi requires acceptance by the physician and patient that medical and non-excisional options have either failed or are not appropriate. The usual clinical symptoms that lead to excision are frequent prolapsing of the internal hemorrhoids that results in discomfort and anal seepage. Alternatively, the thickened and prolapsing internal/external hemorrhoidal complexes may make anal hygiene difficult for the patient and may make excision preferable. The final indication for excisional hemorrhoidectomy, although debatable, is the development of acutely thrombosed and gangrenous internal hemorrhoids. It is apparent, however, that hemorrhoidectomy can be performed using standard closed hemorrhoidectomy techniques without undue complications. Specifically, the risk of stenosis appears unwarranted if careful technique is used and the maximum amount of anoderm is preserved with skin bridges between excision sites. In the case of limited external hemorrhoidal thromboses, surgical excision is warranted for more rapid pain relief and avoidance of a residual skin tag.External thromboses are usually easily managed in an office setting with local anesthesia

A, Thrombosed external hemorrhoid in the right lateral quadrant. B, Allis clamp applied to apex of thrombosis and elliptical incision made. C, Thrombosis dissected free of sphincter. D, Appearance of wound after thrombectomy.