CHAPTER 9

Symptomatic HemorrhoidsSusan L Gearhart, MDAssistant Professor of Surgery, Colorectal Surgery, Johns HopkinsMedicallnstitutions, Lutherville, Maryland

A1though the true incidence of symptomatic hemorrhoids isdifficu1t to estimate, the significance and management of this

disorder has been well documented. The earliest writings on thesubject of symptomatic hemorrhoids occurred in 400 BCby Hip-pocrates.1 In these writings, symptomatic hemorrhoids were de-scribed as the resu1t of infection of the veins within the rectum withstool, causing the temperature within the vein to rise and the vein toswell. Successful treatment could be obtained by cauterizing thehemorrhoids with a red-hot iron. Napo1eon was finally defeated bythe British at the Battle of Waterloo in 1815. Severa1 accounts bythose who were dose to him have indicated that the battle was 10stbecause ofNapoleons aftliction with hemorrhoids.2 Contrary to hisusual batt1e conduct, he spent most of his time resting on a hilltopoverlooking the battlefield rather than on his horse. When he didwa1k, he had a difficu1t time. Furthermore, a 1etter to his brotherwritten severa1 years before the Battle of Waterloo indicated he hadbeen routine1y treating his hemorrhoids with 3 to 4 1eeches. Today,if one browses the Internet on the topic of hemorrhoids, there aremore than 65,000 sites that can be visited.

ANATOMYANDPATHOPHYSIOLOGYFigure 1 demonstrates the anatomic abnormalities associated withthe development of symptomatic hemorrhoids. Hemorrhoidal cush-ions are essential to the function ofthe anal canal. The hypervascu-lar nature of these cushions allows control of fecal continence andthe easy passage of formed stool. In contrast with the submucosa ofthe proximal gastrointestinal tract, the submucosa of the anal canalis not a continuous rim, but a discontinuous series ofvascu1ar cush-ions. 3,4These hemorrhoidal cushions are found in the right anterior,

Advances in Surgery@, vol 38Copyright 20M, Mosby, Inc. Ali rights reserved.

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44

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168 S.L.Gearhart

Inferiorhemorrhoidal

a.andv.

\

SuperiorrectaJ

a.andv.Mlddle

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FIGURE1.Cross-sectional view of nonprolapsing and prolapsing hemorrhoid com-plexes.

right posterior, and left lateral position. These cushions are sup-ported by a connective tissue framework derived from the internalanal sphincter and longitudinal muscle within the anal canal. Theblood supply to the anal canal. which terminates in the anal cush-ions, stems from the superior rectal artery from the inferior mesen-teric artery and the middle and inferior rectal arteries from the inter-nal iliac artery. Above the dentate line within the anal canal, thevenous drainage follows the portal system into the inferior mesen-teric vein. In contrast, below the dentate line. the venous plexusdrains into the systemic system.

In the process of elimination of stool, anal cushions serve 2 pur-poses: 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 mucosallining. The distention of the rectum with waste results in engorge-ment of the vascular cushions of the anal canal. Within the mucosaoverlying the anal cushions are sensory receptors that are essentialto fine adjustments in continence.5.6 These receptors function. forexample, to promote the elimination of gaseous waste in preferenceto liquid or solid waste. The engorgement of the vascular cushionsallows solid waste to be evacuated completely and without injury tothe anal canal.

Although severa! theories exist regarding the pathogenesis ofsymptomatic hemorrhoids, it is generaIly believed that this disorderarises from a history of straining with defecation and as part of theaging process.7-9It is believed that the supportive connective tissuegives way with constant straining resulting in prolapse of the hem-orrhoid cushion. Once the hemorrhoid complex begins to prolapse.venous return is impaired. resulting in engorgement, irritation, andinflammation. Erosion of the inflamed epithelium results in bleed-ing. Congenital internal anal sphincter hypertension has also beenimplicated in the pathogenesis ofhemorrhoidal disease.9.10

CLASSIFICATIONAs in most disease states, classification is considered useful for themanagement of symptomatic hemorrhoids. Hemorrhoids histori-cally have been classified based on their location and the degree ofprolapse.ll The dentate line demarcates the upper anal canal, linedwith columnar epithelium. from the lower ana! canal, which islined with sensate squamous epithelium. Internal hemorrhoids, inthe most common location of hemorrhoids, occur above the dentateline. External hemorrhoids are found below the dentate line (seeFig 1).

Internal hemorrhoids are further classified by the degree of pro-lapse.

· First-degree hemorrhoids do not prolapse with straining. but canbe 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 withstraining and require manual reduction.· Fourth degree hemorrhoids remain prolapsed independent ofstraining and are irreducible.

46

170 S. L. Gearhart

PRESENTATlONAND DIAGNOSIS

Bleeding is the symptom most commonly associated with hemor-rhoids. The bleeding is bright red, noted on wiping or filling the toi-let bowl, and occurring predictably with defecation. Prompt reduc-tion of the prolapsed hemorrhoid will significantly reduce thebleeding. Patients with third- or fourth-degree hemorrhoids com-plain of protruding, irritated tissue in the perianal region. Third-and fourth-degree hemorrhoids may aIso cause a feeling of incom-plete evacuation. The prolapsed tissue gives a sense of fullness anda continuing sense of the need to evacuate. Soiling in the form ofmucus discharge is not uncommon, because of an impairment of thefine control of continence. Constant exposure of the perianal skin tomucus may result in irritation and itching. Discomfort may be asso-ciated with prolapsed hemorrhoids; however, intolerable pain israre. A painful hemorrhoid is usually an acutely thrombosed, pro-lapsed internal or external hemorrhoid. Pain is associated with aperianal mass, which is immediately evident on physical examina-tion.

The diagnosis ofhemorrhoidal disease is usually made with pal-pation and direct visualization of the perianal region and anal canalthrough anoscopy. Prolapsing or thrombosed hemorrhoids are evi-dent on inspection of the perianal tissue. These findings can be ex-aggerated with straining. Thrombosed hemorrhoids have a blue hueas a result of the clotted blood inside. On anoscopy, inflamed hem-orrhoids may be visualized in their previously mentioned anatomi-cal position.

Individuals seeking medical attention for perianal discomfortoften report that they have hemorrhoids. Unfortunately, this is dueto the lack ofpatient and physician education. Most perianal condi-tions are incorrectly labeled as "hemorrhoids." Anal fissures arise inthe sensate portion of the anal canal and are associated with excru-ciating pain more so than bleeding. It is true that because the pathois similar to that of hemorrhoids, it is not uncommon for the two toexist together. Mucosal prolapse, a circumferential prolapse of theanal canal mucosa, is a common condition of older women. Thesymptoms resulting from mucosal prolapse as well as the medicalmanagement are similar to hemorrhoidal disease. Most importantly,a more serious condition often mistaken for hemorrhoids is anal orrectal cancer. Any examination of patients with hematocheziashould include suf:ficient investigations to rule out a proximalsource of bleeding if the bleeding does not cease afier appropriate

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Symptomatic Hemorrhoids 171

therapy. Furthermore, hemorrhoidal bleeding rarely causes iron-deficiency anemia.12 Other disorders, such as intlammatory boweldisease or cancer, should be ruled out.

TREATMENT

DIETARYAND UFESTYLEALTERATlONS

It has been shown that fiber supplementation reduces the bleedingand discomfort associated with hemorrhoids.13 However, fiber sup-plementation will not reduce the prolapse. It may be weeks beforethe use of fiber for the treatment of symptomatic hemorrhoids is ef-fective. It is recommended that patients take 30 gm of fiber a day andincrease liquid intake. This goal is difficult to reach without the as-sistance of fiber supplementation. Fiber therapy should be insti-tuted gradually over the course of a week. This will reduce the inci-dence of unwanted side effects of bloating. Supplemental semi-synthetic tlavonoids are commonly prescribed in Europe and Asiafor the treatment of hemorrhoids. This remedy willlikely improvevenous tone and inhibit the release ofprostaglandins, thus resultingin symptomatic relief.14

Patients should be counseled on specific activity related to def-ecation. Avoiding straining is essential. The bathroom is to be usedfor the sole purposes of evacuation of waste and not for reading. Pa-tients should be instructed to remain on the toilet seat for no longerthan 1 minute. Furthermore, attempts at defecation should be madeonly afier the patient receives a clear call to eliminate waste.

MEDICALMANAGEMENT

Historically, symptomatic relief from acutely intlamed hemorrhoidswas bed rest and ice packs. Acute surgical therapy was deemed un-safe because of the risk of internal sphincter injury. However, withimprovement in surgi cal techniques, patients need not suffer end-lessly with acute disease. Studies have shown that offering surgicaltherapy is safe and effective.15 There is a plethora of ointments avail-able that contain steroids, local anesthetics, or mild astringents andcan provi de short-term relief from acute or chronic hemorrhoidaldiscomfort or bleeding. Some common commercial preparations in-clude: Thcks, Anusol, Preparation H, and Balneol. Other remediesinclude warm-water sitz baths to ease the discomfort often associ-ated with a thrombosed hemorrhoid. Persistent use of local rem-

edies should be avoided because sensitization of the anoderm mayresult in a permanent dermatologic condition.16

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172 S.L. Gearhart

SURGICALMANAGEMENT

Surgical management is dictated by the folIowing: 1) the degree ofprolapse (Tables 1 and 2) associated medical conditions; 3) and thelifestyle of the patient. The folIowing section describes the variousmethods of surgical treatment of symptomatic hemorrhoids. In gen-eral, treatment is performed either in the clinic or in the outpatientoperating room. Patients are rarely admitted to the hospital. Beforetreatment, patients should be counseled on dietary and lifestylemodifications. Regardless of age, evaluation for alternative sourcesof bleeding should always be incorporated into the treatment planoAlI patients should be prescribed 2 enemas to be administered themorning before undergoing treatment.

Procedures that ean be performed in an OUlpatientclinic:

· Simple excision: For the painful thrombosed external hemor-rhoid, relief is provided by excision of the thrombosis. This is ac-complished by complete excision and not by simple incision (Fig2). Simple incision wilI result in recurrence of the thrombosis andprobable infection. However, if the thrombosis has been presentfor more than 2 to 3 days, and the discomfort has begun to subside,conservative management should be recommended. This consistsof warm sitz baths and stool softeners, as well as local analgesics.The inflamed mass will resolve in 8 to 10 days. Whether or not thethrombosis is excised, further treatment of the prolapsed hemor-rhoid can be offered in the form of either banding or excisionalhemorrhoidectomy.

-TABLE1.Recommended Treatment of Hemorrhoids Based on Degree of Prolapse

Grade Treabnent

1 Fiber supplementation orSclerotherapy

Fiber supplementation orSclerotherapy

Fiber supplementation andRubber-band ligationStapled hemorrhoidectomyConventional hemorrhoidectomy

Fiber supplementation andStapled hemorrhoidectomyConventional hemorrhoidectomy

2

3

4MildSevere

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Symptomatic Hemorrhoids 173

.Statistica11y significant resulto(Data from BMJ 327:649. 2003.J

. Injection sclerotherapy: For first- and second-degree hemor-rhoids, when the primary complaint is bleeding and not protrud-ing tissue, sclerotherapy can be employed. The agents commonlyused are sodium morrhuate and sodium tetradecyl sulfate. Theprocedure is performed in an officevisit while the patient is in theprone jack-knife or left lateral position. A 25-gaugespinal needleis used to insti1l1 to 2 ml of the sclerosing agent into the submu-cosal space afier careful aspiration to avoid intravascular injec-tion. Injection of sclerosant for first- and second-degree hemor-rhoids should be painless. given that. by definition, thesehemorrhoids are located above the dentate line.

. Rubber-band ligation: Rubber-band ligation has been a recognizedtechnique for symptomatic second- and third-degree hemorrhoidssince Barron's first description in 1963.11 The technique is easy todo in an outpatient setting and is associated with very little dis-comfort. The steps using the McGivney ligator with forceps are

50

TABLE2.Randomized. Controlled Trials for the Treatment of Prolapsing Symptomatic Hemorrhoids

Clínical Return to Recurrence or ProlapseProcedures Patients. n FoUow-up Work (dy) (patients. n)

Stapled vs BandingPeng 2003 55 6mo NA

Stapled vs DiathermyCheetham 2003 31 8mo 10 vs 14 2 vs 1

Kairaluoma 2003 60 12 mo 8 vs 14 5 vs 0*

Ortiz 2002 55 15 mo 3 vs 4 7 vs 0*

RowseU 2000 22 6wk 8 vs 17* NA

Ho 2000 119 19wk 17 vs 23*

Stapled vsConventional

Palimental 2003 74 6mo 28 vs 34 NA

Smyth 2003 36 37 mo NA Ovs O

Wilson 2002 89 6wk 14 vs 18* NA

Correa-Rovelo 2002 84 7mo 6 vs 15 1 vs O

Hetzer 2002 40 12 mo NA 1 vs 1

Boccasanta 2002 80 20 mo 8 vs 15* O vs O

Brown 2001 30 6wk NA O vs O

Ganio 2001 100 16 mo 5 vs 13* 3 vs 2

Shalaby 2001 200 12 mo 8 V5 54* 1 vs 2

Pavlidis 2001 80 3 mo NA O vs O

Mehigan 2000 40 4mo 17 vs 34* O vs O

174 S.L. Gearhart

A ; ..1'" B C

FIGURE2.Complete excision of a thrombosed hemorrhoid. A, An elliptical excision that fullyencompasses the thrombosed hemorrhoid should be made. B, The excision shouldcompletely remove the hemorrhoid complexo C, The excision site is left open toheal. (Reprinted with permission from Cameron JL:Atlas of SurgeIj, 2nd ed. Hamil-ton, Ontario, Inc. [In press].)

outlined in Figure 3. Alternatively, a suction ligator, which elim-inates the need for a grasping forceps and for an assistant, can beused. Patients are placed in the left lateral position or theprone/jackknife position. It is recommended that the banding in-strument be loaded with 2 bands, because this will prevent break-age and recurrence.11 It is important to identify the dentate lineand place the band above this line. It is recommended that nomore than 2 bands be placed per visit. Although, triple bandinghas been shown to be effective, it has also been associated with37% incidence ofprolonged post-ligation pain.17 Following band-ing, the patient might experience a feeling of pressure or rectalfullness for a period of 24 to 48 hours. Furthermore, approxi-mately 10 to 14 days following the banding, a small amount oftissue associated with bleeding might be passed. Associated com-plications are rare «2%) and include vasovagal response to theprocedure itself, pelvic sepsis, and secondary thrombosis of exter-nal hemorrhoids. Severe, life-threatening sepsis has been re-

FIGURE3.The technique of rubber band ligation. A, Twobands are placed on the McGivneyhemorrhoid ligator. B, Hemorrhoidal tissue is localized and grasped with the for-ceps. 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

Symptomatic Hemorrhoids 175

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176 S. L. Gearhart

ported in immunocompromised patients undergoing rubber-bandligation.

Proceduresrequiringan outpatientoperativesuile:

More invasive procedures, such as coagulation, excision, ar sta-pling, are recommended for third- and fourth-degree hemorrhoidswith an extensive external component or failure of more conserva-tive procedures. In general, less than 10% of patients referred fortreatment by a specialist wiIl require a more invasive procedure.These techniques are best performed accompanied with effectiveanesthesia. Any movement of the patient during these procedurescan present a challenge.

· Ligature: The ligature diathermy is used to treat third- and fourth-degree hemorrhoids. The underlying principIe is sjmilar to theconventional hemorrhoidectomy, but the ligature is used insteadof using conventional monopolar cautery or Metzenbaum scis-sors. If necessary, the mucosa can be reapproximated using a 3-0Vicryl stitch.

· Conventianal hemorrhoidectomy: Excision hemorrhoidectomy isreserved for fourth-degree and occasionally third-degree hemor-rhoids. This can be performed with an open technique, as origi-nally described by Milligan and Morganin 1937,18and in a closedmanner, as described by Ferguson in 1959.19The patient is placedin either the lithotomy or prone jackknife position. A mixture ofbupivacaine and adrenaline is useful in establishing hemostasisand in the dissection and removal of the symptomatic portion ofthe hemorrhoidal complexo Both methods emphasize the impor-tance of careful dissection of the internal sphincter. Care must betaken to avoid overzealous dissection ofthe mucosa, which couldlead to anal canal stenosis. Despite low complication rates andhigh efficacy of conventional hemorrhoidectomy, severe pain canresult because of excision of sensate anoderm below the dentateline. This leads to a delay in the retum to wark and patients' un-willingness to undergo the procedure.

Stapled hemorrhoidectomy (procedure for prolapse and hem-orrhoids): This procedure was largely developed to treat third- andsmall fourth-degree symptomatic hemorrhoids as an alternative tothe conventional hemorrhoidectomy. The procedure itself repre-sents a paradigm shift in the management of prolapsing hemor-rhoids in that the hemorrhoidal tissue is not actually removed,rather a circumferential mucosectomy is performed, which resultsin an anopexy. The procedure can be performed under sedation ar

53

Symptomatic Hemorrhoids 177

general anesthesia in the prone or lithotomy position. A purse-string suture with 2-0 polypropylene is placed approximately 2 to4 cm above the dentate line. The 31-mm PPH stapler (Ethicon,Endo-Surgery, Ohio, USA) is used to pexy the hemorrhoidal tissueabove the dentate line (Fig 4). Early reports on the use of stapledhemorrhoidectomy called attention to severe complications in-cluding pelvic sepsis, rectovaginal fistula, persistent pain, andfecal urgency.20-22However, there is, without question, a learningcurve associated with the stapled hemorrhoidectomy, and, withincreased surgical experience, these complications are rare. It isrecommended that a careful vaginal examination be performedprior to firing the stapler to ensure the vagina was not caught up inthe purse-string and, thus. the stapling device.

CUNICALTRIALSOUTCOMESOutcome trials reviewing outpatient clinic techniques have demon-strated that sclerotherapy may provide a short-term benefit, butlong-term improvements have been seen in only 28% of patients.Therefore, rubber-band lígation remains the most effective methodfor the management of symptomatic grade 2 and 3 hemorrhoids inthe outpatient clínico This procedure is associated with nearly an80% short-term cure rate for patients with up to third-degree hem-orrhoids.23 Of the remaining 20% of patients, 18% wiIl be curedwith a repeat procedure with only 2% failing to respondoUltimately,rubber-band ligation is associated with approximately 90% long-term success rate.

For the management of grade 3 and 4 prolapsing hemorrhoids,there are several randomized, controIled trials comparing stapledhemorrhoidectomy to conventional hemorrhoidectomy (see Table2). Ho et al24demonstrated that the stapled hemorrhoidectomy issafe and effective, associated with less pain; however, it is more ex-pensive than con~entional hemorrhoidectomy. Those in favor of thestapling procedure contend that there is an earlier return to workwith the stapling technique andothus, a decreased cost to society.25However, it is important to note that patients who are candidates forthe stapling procedure are usually candidates for banding. It is alsoknown that patients with severe grade 4 prolapse are best managedby conventional hemorrhoidectomy, because an anopexy proceduremay not completely eliminate an extensive external component.Peng et al,26realizing this paradox, demonstrated that rubber-bandligation and the stapled hemorrhoidectomy were equally effectivein controlling prolapse from third- and small fourth-degree hemor-rhoids. Although the number of participants was small, with only a

54

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Symptomatic HemoIThoids 179

6-month follow-up, there was more perioperative morbidity assoei-ated with the stapled hemorrhoidectomy, and recurrent bleedingwas more common in the banded patients. The benefits of ligatureover conventional hemorrhoidectomy include reduced bleeding,anesthetic time, and healing time.27Those who oppose the use ofthe ligature are concerned that the lack of dissection may result ininadvertent injury to the internal sphincter. Further long-term stud-ies need to be performed.

COMPUCATIONSOF SURGICALTHERAPYThe most common complications associated with a hemorrhoidec-tomy are bleeding, pain, and urinary retention. Bleeding complica-tion can occurwithin 24 hours (1%) or in 5 to 10 days (4%).28Earlybleeding is usually secondary to a missed vessel, whereas delayedbleeding is a result of early separation of the ligated pedide. A re-turo trip to the operating room may be required. Insertion of a rectalFoley to tamponade the bleeding may suffice. To avoid bleedingcomplication from a stapled hemorrhoidectomy, an additional 3-0Vicryl suture is used to oversew the staple line. Simple hemostaticmaterial such as Gelfoam with thrombin can be placed in the analcanal following the procedure; however, excessive pacldng shouldbe avoided. Investigators have shown that the use of intravenousmetronidazole and the limitation of intraoperative tluid to less than250 ml will prevent increased swelling and inflammation, whichcan result in pain and urinary retention.29,30Furthermore, the use ofketorolac to accompany oral narcotics may provide improved anal-gesia.31

Hemorrhoidectomy is the most common cause of anal stenosisand ectropion, with an incidence ranging between 2% and 4%. Analstenosis results from an overzealous removal of the anoderm withloss of mucdsal bridges and scarring of the anal canal. Surgical cor-rection of this condition requires either repeated dilatations or sur-gical anoplasty. Anal ectropion is the abnormal placement of theanal mucosa distal to the dentate line. Once this occurs, the conti-nence mechanism is unable to prevent the leakage of mucus andsmall amounts of stoo1.This will result in maceration ofthe perianalregion and chronic pruritus. Treatment requires restoration of theectopic mucosa to a position proximal to the dentate line. Diamond-shaped. house-shaped, or V-Y advancement tlaps have been usedwith excellent anatomic results.

56

180 S. L. Gearhart

HEMORRHOIDSASSOCIATEDWlTHOTHERDISEASES

· Coagulation Disorders: Patients with known coagulation disor-ders and those requiring anticoagulation are a challenge to man-age. Most physicians advocate either sclerosing or banding ofhemorrhoids in patients with this condition. If surgery is under-taken for failure of less invasive techniques, assistance from a he-matologist in optimizing the patient for surgery may be a benefit.

· Crohn's disease: Confusing enlarged sldn tags for symptomatichemorrhoids can be severely problematic for patients withCrohn's disease. Poor perianal wound healing in Crohn's diseasemay lead to a persistent fissure or fistula if hemorrhoidectomy isperformed. Perianal symptoms are usually exaggerated by bowelfrequency and correction of this will often lead to resolution. Forthis reason, hemorrhoidectomy is not recommended in Crohn'sdisease.

· HIV infection: Medical therapy is preferable because of the risk ofseptic complication and poor wound healing afier surgery. Othercauses of perianal symptoms, induding condyloma, should be ex-cluded. With the addition ofhighly affective anti-removal therapyand an improved immune status, symptomatic hemorrhoids canbe treated with rubber-band ligation safely.

. Pregnancy: This condition clearly predisposes patients to symp-tomatic hemorrhoids. Although the etiology is unknown, it isthought to be the result of increased hormone levels and pelvicvenous congestionoPatients revert to their pre-pregnancy condi-tion following delivery. Conventional hemorrhoidectomy pro-vides symptomatic relief from severe disease. This can be per-formed under local anesthetic safely during the third trimesterwhen the fetus is viable without maternal or fetal complication.32However, approximately 25% ofthese patients require additionalhemorrhoidal treatment. For this reason, surgical intervention isreserved only for intractable symptoms.

SUMMARYThemost important aspect in the diagnosis of hemorrhoidal diseaseis the exclusion of other, more life-threatening conditions. Hemor-rhoidal banding remains the most successful method to managehemorrhoids in the outpatient clinic. Chronic application of localmedications to the perineum may result in dermatologic conditions.It is safe to manage acutely inflamed hemorrhoids surgically. Table1is a summary of the various methods for the surgical management ofsymptomatic prolapsing hemorrhoids. Dietary manipulation, in-

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Symptomatic Hemorrhoids 181

cluding fiber supplementation, should always accompany surgicaltherapy.

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25. Nisar PJ, Scholetield JH: Managing hemorrhoids. Br Med /327:847-851,2003.

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Copyright2004.MosbyInc.Reproducedby permission.Further reproduction prohibited without consent ofauthors and publisher.

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