Kiss Your Hemorrhoids Goodbye: Surgical and Non-Surgical Management Options

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Kiss Your Hemorrhoids Goodbye: Surgical and Non-Surgical Management Options
Patricia L. Raymond MD FACG, Rx For Sanity
There seem to be many options to manage our patients' hemorrhoids: hemorrhoidectomy, banding, sclerotherapy, laser photocoagulation, topical medications. Which option is the best for your patient? The physiology and management of the bitter end of the gastrointestinal tract.


Objectives: The participant will…
Distinguish between internal and external hemorrhoids, review the anorectal anatomy and understand the grading system for internal hemorrhoids.
Categorize the differential diagnosis of hemorrhoids, including proctalgia fugax, anal fissure, perianal crohns disease, anal cancer, condyloma, skin tags and rectal prolapse
Examine specific medical, endoscopic, office, and surgical treatment options for hemorrhoids and their stated efficacy

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Kiss Your Hemorrhoids Goodbye: Surgical and Non-Surgical Management Options

  1. 1. Kiss Your Hemorrhoids Goodbye:Surgical &Non-SurgicalManagement OptionsPatricia L. Raymond MD FACGRx For SanityNorfolk, Virginia
  2. 2. Hemorrhoids were always with us
  3. 3. • Medieval physicians used cautery irons to treat hemorrhoids• Others believed that simply pulling them out with their fingernails was the cure (a solution endorsed by the Greek physician, Hippocrates)
  4. 4. Hemorrhoids are caused by:• Straining > Work strain (lifting patients, etc.) > Straining while defecating — Chronic constipation — Passing hard, dry, small stools — Laxative abuse• Increased intra- abdominal pressure > Pregnancy• Being alive
  5. 5. • 10 million people in the United States have hemorrhoids > Prevalence rate 4.4%. > Peaks from age 45-65 years > Decrease after age 65 years > Hemorrhoids before age 20 unusual.• Caucasian > African American• Increased prevalence rates associated with higher socioeconomic statusThe prevalence of hemorrhoids and chronic constipation. An epidemiologicstudy. Johanson JF, Sonnenberg A Gastroenterology. 1990;98(2):380.
  6. 6. • Contrast hemorrhoids with the epidemiology of constipation > Exponential increase after age 65 years > More common in blacks > More common in families with low incomes or low social status —Causality between constipation and hemorrhoids questionedThe prevalence of hemorrhoids and chronic constipation. An epidemiologicstudy. Johanson JF, Sonnenberg A Gastroenterology. 1990;98(2):380.
  7. 7. What arehemorrhoids& how do weget them?
  8. 8. • Arise from a plexus (sometimes called a "cushion") of dilated arteriovenous channels and connective tissue • Veins from the superior, middle, and inferior rectal veinhttp://web.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis%27%20surgical%20anatomy%20-%202004/Chapter%2018_%20Large%20Intestine%20and%20Anorectum_fichiers/loadBinaryCABXCEBK.jpg
  9. 9. The Dentate Line • External or internal based upon whether they are below or above the dentate line > The dentate line) is a line which divides the upper 2/3 and lower 1/3 of the anal canal. Developmentally, this line represents the hindgut- proctodeum junction • Often both types of http://shoppe.listentoyourgut.com/hemorrheal-external- hemorrhoids coexist hemorrhoid-kit-ebook-ingredients/
  10. 10. Internal hemorrhoids• Arise from the superior hemorrhoidal cushion.• Three primary locations > left lateral, right anterior, and right posterior• Fed from the end branches of the middle and superior rectal veins• Overlying mucosa is rectal• Innervation is visceral http://tophemorrhoidtreatments.com/internal-and- external-hemorrhoids
  11. 11. External hemorrhoids• Arise from the inferior hemorrhoidal plexus• Located beneath the dentate line• Covered with squamous epithelium > Numerous somatic pain receptors. http://proctologyspecialists.com/procedures/thr ombosed-external-hemorrhoid
  12. 12. What aren‟themorrhoids?
  13. 13. Skin tags • Sometimes confused with external hemorrhoids. • Associated with > anal fissures > perianal Crohns disease > residual excess skin associated with prior thrombosis of external hemorrhoids http://hemorrhoidheal.com/Services/anorectal-care-http://skin212.com/anal-flap.php hemorrhoid-hemorrhoids/anorectal-care-anal-tag- removal.html
  14. 14. Anal fissures and fistulaehttp://www.sciencedirect.com/science/article/pii/S http://www.specialityclinic.com/DiseaseCondition. 1043148912000486 aspx?DID=48
  15. 15. Anal fissures http://www.homeouniverse.com/category/diseasehttp://www.chennaicolorectalclinic.com/#!anal-fissure s/stomach-diseases/
  16. 16. Rectal varices • Hemorrhoids have direct communication with the portal system, and can also exist in close proximity to rectal varices in patients who have portal hypertension • Hemorrhoids are not more common in patients with portal hypertension • Rectal varices are treated with banding or TIPPS http://integrisok.com/nazih-zuhdi-transplant-institute- oklahoma-city-ok/pre-liver-transplant-work-uphttp://www.gastrointestinalatlas.com/English/Colon_and_ Rectum/Miscellaneous/miscellaneous.html
  17. 17. Perianal Crohn‟s disease http://learncolorectalsurgery.blogspot.com/2009/04/colon-was-http://www.karelsavry.com/guide_7/clinical_signs_and_symptoms_1.html fully-mobilized-and-extensive.html
  18. 18. Condyloma Acuminata (Analwarts) • Human papilloma virushttp://missinglink.ucsf.edu/lm/DermatologyGlossa http://ibmi3.mf.uni-lj.si/mmd/derma/eng/sz- ry/condylomata_lata.html 00/sldr00047.html
  19. 19. Rectal Prolapse (Rectal Procidentia) • Pelvic floor disorderhttp://www.primehealthchannel.com/r ectal-prolapse.htmlhttp://dakkoss.seesaa.net/category/71 00169-1.html
  20. 20. Can you identify it?
  21. 21. EXTERNAL HEMORRHOIDShttp://vanithango.org/cream/do-internal-hemorrhoids-cause-stomach-pain
  22. 22. ANAL/RECTAL FISTULAShttp://intranet.tdmu.edu.ua/data/kafedra/internal/surgery2/classes_stud/%D0%A5i%D1%80%D1%83%D1%80%D0%B3i%D1%8F/6%20%D0%BA%D1%83%D1%80%D1%81/English/Topic%2012.%20Non-neoplastic%20diseases%20of%20the%20rectum%20%28Hemorrhoids.%20Acute%20and%20chronic%20paraproctitis%29.htm
  23. 23. RECTAL PROLAPSEhttp://www.orlandocolon.com/photo-library/full-thickness-rectal-prola.html
  24. 24. PROLAPSING INTERNAL (STAGE 4) & EXTERNAL HEMORRHOIDStp://www.consultant360.com/article/anorectal-complaints-office-diagnosis-and-treatment-part-1
  25. 25. PROLAPSED & STRANGULATED INTERNAL HEMORRHOIDS (GRADE 4)http://www.gastrohep.com/images/image.asp?id=241
  26. 26. RECTAL CANCERhttp://medicalpicturesinfo.com/rectal-cancer/
  27. 27. NORMAL ANUShttp://www.gastrolab.net/g4g03.htm
  28. 28. RECTAL PROLAPSEhttp://www.emedicinehealth.com/rectal_prolapse/page16_em.htm
  29. 29. INTERNAL HEMORRHOIDSttp://www.sciencedirect.com/science/article/pii/S0016510703028189
  30. 30. CONDYLOMAhttp://dermatology.cdlib.org/1412/case_presentations/intraanal_condyloma/dianzani.html
  31. 31. ANAL FISSUREhttp://www.topgradtv.com/hemorrhoids-symptoms-and-causes /
  32. 32. RECTAL CANCERhttp://medicalpicturesinfo.com/rectal-cancer/
  33. 33. RECTAL FISTULAhttp://www.murrasaca.com/proctology.htm
  34. 34. CONDYLOMAttp://www.hemorrhoidshemroids.com/anal-warts-hpv-hemroids-hemorrhoids.html
  35. 35. RECTAL CANCERhttp://medicalpicturesinfo.com/rectal-cancer/
  36. 36. How arehemorrhoidsgraded ordescribed?
  37. 37. Classification of internal hemorrhoids• Degree of prolapse from the anal canal: > Grade I visualized on anoscopy, and may bulge into the lumen, but do not extend below the dentate line > Grade II prolapse out of the anal canal with defecation or with straining, but reduce http://www.endoatlas.org/index.php?page=results_jquery&mstc spontaneously at=5&subcat=8
  38. 38. Prolapsed Internal Hemorrhoids > Grade III prolapse out of the anal canal with defecation or straining, and require the patient to reduce them into their normal position > Grade IV hemorrhoids are irreducible and may strangulate http://www.uptodate.com/contents/image?imageKey=SURG%2 F64871&topicKey=SURG%2F15025&rank=1~34&source=see_ link&search=rectal+prolapse&utdPopup=true
  39. 39. No widely used classification systemof external hemorrhoids exists!
  40. 40. iPhone Mania!
  41. 41. How do wetreathemorrhoids?
  42. 42. Hemorrhoid Advice by AnonymousEven though it may take Though its been said, itweeks bears repeating;To heal the wound Nothing but canned soupbetween your cheeks, for eating.I provide this rule of Fruit will get your bowelsthumb a-groovingTo nurse your Before you know it, you’llrecuperating bum. be up and moving
  43. 43. Exercise is out of the Heed my advice andquestion! don’t be foolish,Beware of any such The results may be sosuggestion. very ghoulish.No unicycles, horseback To avoid a thrombosis soriding. abrupt,Leapfrog, bowling, or Keep your cool andninja fighting. Bottoms Up!
  44. 44. Conservative Management of Hemorrhoids • Bleeding > Fiber • Pruritis > Topical Creams > Hydrocortizone > Sitz Baths > (?Fiber) • General > Cleansing wipes > NTG/Ca channel blockers
  45. 45. Fiber and Hemorrhoids• Meta-analysis of seven controlled trials > fiber supplementation reduced bleeding (RR 0.50, 95% CI 0.28-0.68) • Hemorrhoidal prolapse was not affected by fiber supplementation Laxatives for the treatment of hemorrhoids. Alonso-Coello P, Guyatt G, Heels-Ansdell D, Johanson JF, Lopez-Yarto M, Mills E, Zhou Q Cochrane Database Syst Rev. 2005
  46. 46. Irritation and pruritus• Sitz baths • Analgesic creams, > Warm water two to hydrocortisone three times per day suppositories, & warm — Effectiveness may in part sitz baths be related to relaxation of the internal anal sphincter • Do not use creams or• Fiber supplementation hydrocortisone > one may relieve pruritus week related to fecal soilage > Side effects may occur > bulking effect of fiber — Contact dermatitis with analgesic creams may reduce leakage of — Mucosal atrophy with liquid stool steroid creams
  47. 47. Avoid Spicy Foods? Capsaicin for hemorrhoids • No evidence that spicy foods worsen irritation and pruritus Red hot chili pepper and hemorrhoids: the explosion of a myth: results of a prospective, randomized, placebo-controlled, crossover trial. Altomare DF, Rinaldi M, La Torre F, Scardigno D, Roveran A, Canuti S, Morea G, Spazzafumo L Dis Colon Rectum. 2006;49(7):1018. Gut. 2003 September; 52(9): 1323– 1326. Topical capsaicin—a novel and effective treatment for idiopathic intractable pruritus ani: a randomised, placebo controlled, crossover study J Lysy, M Sistiery- Ittah, Y Israelit, et al.
  48. 48. Witch hazel (Hamamelis)• Astringent• Various forms > Ointments, pads > Little scientific evidence, said to temporarily shrink hemorrhoids„Napoleons Haemorrhoids, by Phil Mason,says that the French emperor was suffering froman acute attack of piles that stopped him ridinghis horse, and supervising the troops during thebattle of Waterloo.Two days before the battle, Napoleons doctorslost the leeches that they used to relieve hisagony, and accidentally overdosed him with thepainkiller laudanum. Napoleon was still sufferingfrom the effects of the painkiller when the battlebroke out.
  49. 49. Other Conservative Management Ideas• Moistened hypoallergenic wipes• Nitoglycerine ointment > Rectiv 0.4%• Diltiazem/Nifedipine ointment or combinedDis Colon Rectum. 2001 Mar;44(3):405-9.Conservative treatment of acutethrombosed external hemorrhoids withtopical nifedipine. Perrotti P, Antropoli C,Molino D, De Stefano G, Antropoli M.J Coll Physicians Surg Pak. 2009Oct;19(10):614-7Topical diltiazem hydrochloride andglyceryl trinitrate in the treatment ofchronic anal fissure Jawaid M, Masood Z,Salim M
  50. 50. Ambulatory Procedures for Internal Hemorrhoids• Remove or to cause • Rubber band ligation sloughing of excess • Infrared coagulation hemorrhoidal tissue • Bipolar diathermy (Bicap)• Healing and scarring • Laser photocoagulation fixes the residual • Sclerotherapy tissue to the • Cryosurgery underlying anorectal muscular ring
  51. 51. Which ambulatory technique for internal hemorrhoids?Meta analysis of 18 trials• Surgical hemorrhoidectomy • Rubber band ligation better than dilation or band obliterated varices better than ligation for preventing recurrent sclerotherapy. symptoms. • Patients treated with• Rubber band ligation was sclerotherapy or infrared associated with fewer coagulation were more likely to complications and pain than require further treatment than surgery. those with rubber-band ligation. Based upon these findings, it was suggested that the optimal treatment for symptomatic grade I to III hemorrhoids unresponsive to conservative measures was rubber band ligation. of hemorrhoidal treatments: a meta-analysis. Comparison MacRae HM, McLeod RS Can J Surg. 1997;40(1):14.
  52. 52. Complications of rubber band ligation• Pain 8% • Thrombosis > Misapplication of the > distal hemorrhoids band below the dentate thrombose, leading to line or spasm pain or a palpable• Delayed hemorrhage mass. > When the rubber band • Infection/abscess dislodges, typically 2-4 > Persistent pain, fever, days post procedure or or foul smelling rectal ulceration/ mucosal drainage Sepsis is rare sloughing at 5-7 days
  53. 53. Rubber band ligation of internal hemorrhoids:Less pain, shorter time off work
  54. 54. External hemorrhoids:Thrombosis management—soon or not at all• External • After 48 hours, hemorrhoids do not organization of the usually require thrombus and minimally invasive improvement of or surgical therapy symptoms no need• Patients seen within for surgical 72 hours of evacuation thrombosis may benefit from surgical evacuation for pain relief
  55. 55. But if you need to say “YES”…• Initial treatment of choice in patients with > symptomatic or strangulated grade IV hemorrhoids > symptomatic grade III hemorrhoids > thrombosed external hemorrhoids.• American Gastroenterological Association, 2004 > Failure of medical and nonoperative therapy > Symptomatic third-degree, fourth-degree, or mixed internal and external hemorrhoids > Symptomatic hemorrhoids in the presence of a concomitant anorectal condition that requires surgery > Patient preference after discussion of the treatment options with the referring physician and surgeon.
  56. 56. Techniques for the operative treatment of hemorrhoids • Closed hemorrhoidectomy • Open hemorrhoidectomy with excision and ligation • Stapled hemorrhoidectomy • Lateral internal sphincterotomy
  57. 57. Closed hemorrhoidectomy• The most common • Make the ellipse relatively surgery for internal narrow, and to remove hemorrhoids only the redundant• Elliptical incision is made anoderm and starting on the external hemorrhoidal tissue, close hemorrhoidal tissue and defect with continuous extending proximally absorbable suture across the dentate line to • Three columns treated the superior extent of the • 95% successful, low hemorrhoidal column infection rate
  58. 58. http://colorectal.surgery.ucsf.edu/conditions--procedures/hemorrhoidectomy.aspx
  59. 59. http://colorectalsurgeonssydney.com.au/?page_id=379
  60. 60. You deserve a medal…
  61. 61. Proctalgia fugax• Intermittent, recurrent, • 4 to 18% of population, severe, self-limited although only 17 to 20 functional rectal pain percent of patients report > Pain for few seconds to two symptoms to MD hours, asymptomatic • 58 to 84 female between episodes, < 5 x per year in 50% • Mean age at dx 46 - 58 years • NOT more common in patients with IBS • Diagnosis requires exclusion of other causes of rectal or anal pain
  62. 62. Proctalgia fugax• Pathophysiology • Treatment (?) > Spasm of the smooth > Warm water 40 o C /104 o F muscle of the internal as hot baths and warm water enemas anal sphincter (we > Topical nitroglycerin think!) > Oral nifedipine or diltiazem > Pudendal nerve > Inhaled albuterol compression or > Also: Botulinum toxin neuralgia injection, pudendal nerve blocks, and superior hypogastric plexus blocks
  63. 63. St. Fiacrethe patron saint ofhemorrhoid suffersAlso:• gardeners• taxi cab drivers• venereal disease sufferers• barrenness• box makers• fistula sufferers• florists• hosiers• pewterers• tile makers• ploughboys
  64. 64. St. Fiacrethe patron saint of hemorrhoid suffers• Seventh century Irish monk• Developed hemorrhoids from digging in his garden• Sat on a stone which gave him a miraculous cure. • The stone survives to this day with the imprint of his hemorrhoids and is visited by many hoping for a similar cure.• Inflamed hemorrhoids often ―St. Fiacre‟s curse‖ in the Middle Ages.
  65. 65. Why didn’t they call them Asteroids?
  66. 66. Kiss Your Hemorrhoids Goodbye:Surgical & Non-Surgical Management Options
  67. 67. “Hemorrhoids” parody by Butt Meddler(loosely to “Yesterday”)Before today,My anal sphincter was a happy Why they had to come on myplace bum, I couldn’t sayIt existed in a state of grace Preparation H and Sitz bathsI didn’t know there’d be hell to are just cliché!pay.Suddenly, there’s a thingie Hemorrhoids leave my rectumhanging out of me feeling so annoyedAnd the itch and pain won’t let Now some rubber bands haveme be been deployedOh hemorrhoids prolapse Now hemorrhoids aresuddenly. yesterday.

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