This presentation about hemorrhoids includes discussion about causes and preventive measures as well as effective nonsurgical and surgical treatment options.

1. Hemorrhoids:
A common condition and
Effective treatment options
Kevin J. Holzman, MD, FACS, FASCRS
1/15/2015

2. What are hemorrhoids?
• Alternative Names
• Rectal Lump
• Piles
• Lump in the Rectum
• Definition:
• Dilated or enlarged veins in the lower
portion of the rectum or anus.

3. Frequency
• 10 million
• Peak ages: 45-65 years
• ½ of adults experience hemorrhoids by
age 50
• Common among pregnant women

6. Anatomy
• Right anterior, Right posterior and Left lateral
positions
• Only 19% of the time
• Additional smaller accessory bundles between these
• Those originating above the dentate line which are
termed internal
• Those originating below the dentate line which are
termed external.

8. Pathophysiology
• Represent engorgement or enlargement of the normal
fibrovascular cushions lining the rectum and anal canal.
• Chronic straining secondary to constipation or occasionally
diarrhea
 Trauma, inflammation
• Fibrovascular cushions lose their attachment to the underlying
rectal wall
 prolapse

9. Pathophysiology
• Prolapse of internal hemorrhoidal tissue through the
anal canal.
• Overlying mucosa becomes more friable and the
vasculature increases
• With overlying thinning of the mucosa and vascular
engorgement, subsequent rectal bleeding occurs.

10. Classification
• Classified by history and not by physical examination.
• For INTERNAL hemorrhoids
• Grade I - bleeding without prolapse.
• Grade II - prolapse with spontaneous reduction.
• Grade III - prolapse with manual reduction.
• Grade IV - incarcerated, irreducible prolapse.

11. Symptoms
• Rectal Bleeding
• Bright red blood in stool
• Pain during bowel movements
• Anal Itching
• Difficult hygeine
• Rectal tissue Prolapse
• Leakage (mucus or stool)
• Thrombosis

12. Symptoms
• Bright red blood per rectum or a prolapsing anal mass.
• With, or following, bowel movements, is almost universally
bright red, and very commonly drips into the toilet water.
• Blood may also be seen while wiping after defecation.
 Described as on “toilet tissue”

13. Symptoms
• Prolapse usually occurs in association with a bowel movement
• May also prolapse during walking or heavy lifting as a result of
increased intra-abdominal pressure.
 Coughing, sneezing
 obesity
• Extreme pain, bleeding and occasionally signs of systemic
illness in case of strangulation
 rare

14. Causes
• Chronic trauma/inflammation
• Constipation
• Diarrhea
• Sitting or standing for long periods of time
• Obesity
• Heavy Lifting
• Pregnancy
• Aging

15. Physical exam
• Patients should be examined in the left lateral decubitus
position
 Prone-jackknife
• Rule out any rashes, condylomata, fissures, lesions,
abscesses
• External sphincter function
• Rule out tumors

16. Physical exam
• What to expect
 Visual inspection
 Digital rectal exam
 Small scope

17. Evaluation of rectal bleeding
• Rule out rectal cancer!!
• Young individual with bleeding associated with hemorrhoidal
disease and no other systemic symptoms, and no family history,
perhaps anoscopy and rigid sigmoidoscopy
• Older individual, with either a family history of colorectal cancer,
or change in bowel habits, a complete colonoscopy should be
performed to rule out proximal neoplasia.

18. Treatment options
• Varies from simple reassurance to operative hemorrhoidectomy.
• Treatments are classified into three categories:
• 1) Dietary and lifestyle modification.
• 2) Non operative/office procedures.
• 3) Operative hemorrhoidectomy.
• Many patients will require a combination

19. Dietary and lifestyle modification
• The main goal of this treatment is to minimize straining at stool.
• Achieved by increasing fluid and fiber in the diet, recommending
exercise, and perhaps adding fiber agents to the diet such as
psyllium or methycellulose
• If necessary, stool softeners may be added.
 Miralax
• "you don't defecate in the library so you shouldn't read in the
bathroom".

20. Dietary
• Mild cases are controlled by:
 Preventing constipation
 Drinking Fluids
 High-fiber diet
 Use of Fiber supplements
 Stool softeners
 Topicals

21. Fiber
• 20-30 grams/day
• Psyllium
 Metamucil – 3.4g/teaspoon
 Metamucil capules – 0.52g/capsule
 Konsyl – 6.0g/teaspoon
• Methycellulose
 Citrucel – 2.0g/dose
• Calcium polycarbophil
 FiberCon – 0.5g/capsule

22. Fiber
• Insoluble
 Does not dissolve in water
 Bulks – helps with constipation
 Whole grains, wheat cereals
• Soluble
 Dissolves in water
 Helps control blood sugar and reduce cholesterol
 Barley, oat meal, beans, nuts

23. Nonsurgical
• Apply OTC cream or suppository containing
hydrocortisone
 inflammation
• Keep anal area clean
• Soak in a warm bath
• Apply ice packs or compresses x 10min
 Thrombosed hemorrhoid

24. Nonsurgical
• If prolapses, gently push back into anal canal
• Use a sitz bath with warm water
• Use moist towelettes or wet toilet paper
instead of dry toilet paper.

25. Many options
• For painful or persistant hemorrhoids:
 Tying off a hemorrhoid-rubber band ligation
 Sclerotherapy
 Infrared Light
 Laser Therapy
 Freezing
 Electrical Current
 Surgery

26. Office Rubber Band Ligation
• Grade I or Grade II hemorrhoids and, in some
circumstances, Grade III hemorrhoids.
• Complications include bleeding, pain, thrombosis
• Successful in two thirds to three quarters of all
individuals with first and second degree hemorrhoids.

27. Office RBL
• Minor pain
• Resume usual activities immediately
• May have feeling of incomplete emptying
• No blood thinners

28. Office Infrared Coagulation
• Generates infrared radiation which coagulates tissue protein
and evaporates water from cells.
• Most beneficial in Grade I and small Grade II hemorrhoids.
 Beneficial for patients on anticoagulants
• 3-4 applications per hemorrhoid/per session
 More pain
 More time consuming

29. Office BICAP (bipolar diathermy)
• It works, in theory, similar to photocoagulation
or to rubber banding.
• the probe must be left in place for ten
minutes.
• poor patient tolerance minimized the effect of
this procedure.

30. Office Sclerotherapy
• Injection of an irritating material into the submucosa
in order to decrease vascularity and increase fibrosis.
• Injecting agents have traditionally been phenol in oil,
sodium morrhuate, or quinine urea.
• Not when prolapse present
• Potential for stricture or scarring

31. Surgical hemorrhoidectomy
• Indications
 Persistent itching
 External disease
 Anal bleeding
 Pain
 Blood clots
 Infection
 Patient wishes

32. Surgical hemorrhoidectomy
• Risks
 Reactions to medications of anesthesia
 Bleeding
 Infection
 Narrowing of the anus
• *The outcome is usually very good in the majority of
cases.

33. Options
• Excisional hemorrhoidectomy
• Single or multiple
• Transanal hemorrhoidal dearterialization
• With or without hemorrhoidopexy
 Ultrasound guided
 No excision of tissue
• Stapled hemorrhoidectomy - PPH

34. Prevention
• Eat high fiber diet
• Drink Plenty of Liquids
• Fiber Supplements
• Exercise
• Avoid long periods of standing or sitting
• Don’t Strain
• Go as soon as you feel the urge