Hemorrhoids Update Review

Posts Tagged ‘Treatment’

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.

In the upper anal canal, the hemorrhoids cushions are composed of three submucosal pillars of sinusoids within connective tissue, generally in the left lateral, right anterior, and right posterior. During the act of defecation, the hemorrhoids cushions become engorged with blood, cushioning the anal canal and supporting the anal canal lining. The pathologic term hemorrhoids is used to describe the downward displacement of the cushion along with dilation of the contained sinusoids and sometimes bleeding from the arteriole, venule, or sinusoidal portion.Hence, hemorrhoids develop when the supporting tissues of the anal cushion deteriorate or with extensive downward pressure, as in prolonged straining at stool or pregnancy.

The most common complaints of burning, itching, swelling, and pain usually are not from hemorrhoids but result from pruritus ani, anal abrasion, anal fissure, thrombosed external hemorrhoids, or prolapsed anal papilla. Symptoms are aggravated by constipation and diarrhea. The most common manifestation of hemorrhoids is painless, bright red rectal bleeding associated with bowel movement. With severe hemorrhoids,the patient commonly describes the bleeding episode as blood dripping into the toilet bowl. A feeling of incomplete evacuation is also common. In chronic prolapse, exposed rectal mucosa often causes perianal irritation and mucus staining on the underwear. Congestion of external hemorrhoids or skin tags can cause discomfort. Except in the presence of thrombosis, pain is rarely an early symptom of hemorrhoidal disease and other diagnoses should be excluded.

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

Options for hemorrhoidectomy include the techniques of Milligan-Morgan hemorrhoidectomy, closed Ferguson hemorrhoidectomy, Whitehead hemorrhoidectomy, and the stapled hemorrhoidectomy. The procedures are usually performed in the operating room after minimal preoperative preparation of the bowel. Lasers have no role to play in excisional hemorrhoidectomy, and in fact they cause delayed healing, increased pain, and increased cost.Anesthetic management is usually left to the anesthesiologist and patient; however, local anesthesia supplemented by the administration of intravenous narcotics and propofol is very effective. The use of spinal anesthesia, although effective, may increase the risk of postoperative urinary retention.

The Milligan-Morgan hemorrhoidectomy, which is widely practiced in Europe, was originally described in 1937, and its efficacy has been subsequently documented in many series.This technique includes resection of the entire enlarged internal hemorrhoid complex, ligation of the arterial pedicle, and preservation of the intervening anoderm.[33] The distal anoderm and external skin is left open to minimize the risk of infection in the wounds. This technique is safe and effective. However, the fact that the external wounds are left open can be a cause of considerable discomfort and prolonged morbidity.