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FRONTIERS IN ENDOSCOPY, SERIES #14 FRONTIERS IN ENDOSCOPY, SERIES #14

Douglas G. Adler MD, FACG, AGAF, FASGE, Series Editor

Office Management of Disease

Andy Tau Waqar Qureshi

INTRODUCTION ymptomatic are frequently hemorrhoids are distal to the dentate line and are encountered by gastroenterologists in Western covered by richly innervated squamous of Ssocieties. Internal hemorrhoids are the most the . Any therapy whether it be excision or ligation common cause of recurrent in ambulatory must respect the dentate line if done without anesthesia. adults. Hemorrhoids account for approximately 3.5 Three major cushions reside in the left lateral, right million physician visits and 500 million dollars in anterior, and right posterior positions. These positions costs per annum in the USA.1 The gastroenterologist are relatively fixed and allow banding “blind” in certain maintains a unique position between the conservative office techniques. The blood vessels within these treatment offered by the primary care physician and the cushions are sinusoids that have direct arteriovenous more invasive hemorroidectomy offered by the surgeon. communications between branches of the superior and middle hemorrhoidal , and the superior, Anatomy rectal continence. Hemorrhoidal cushions contribute The dentate line is a key anatomical landmark that to 15–20% of the resting pressure of the anal verge divides the insensitive rectal mucosa from the and provide continence by forming complete closure richly innervated anal skin. The dentate line dictates of the .2 classification, sensation, and therapy of hemorrhoids. Internal hemorrhoids are cushions of fibrovascular Etiology & Pathophysiology tissue located proximal to the dentate line. They may Risk factors for symptomatic hemorrhoids include and bleed, but are usually painless. External low , chronic straining, excessive time on the commode, , , , Andy Tau, MD and Waqar Qureshi, MD, FRCP, Baylor and family history.3 The underlying pathophysiology College of Medicine, , Houston TX likely involves a multifactorial process involving

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FRONTIERS IN ENDOSCOPY, SERIES #14 FRONTIERS IN ENDOSCOPY, SERIES #14

venous dilation, arterio-venous distention, protrusion of congested anal cushions downward and progressive stretching and collapse of the support structure of the cushions overtime.4 This culminates in prolapse beyond the anal verge. Internal hemorrhoids that remain prolapsed develop ischemia, , or gangrene. It is only in this setting that internal hemorrhoids become painful or pruritic. More often encountered is painless bleeding which occurs when the submucosal sinusoids are disrupted. The bleeding is bright red from the pre- sinusoidal .5 Classification Hemorrhoids are classified, first, as internal or external relative to the dentate line. (Figure 1) Hemorrhoids Figure 1. above the dentate line are internal hemorrhoids. Hemorrhoids below the dentate line are external hemorrhoids. External hemorrhoids are covered by the very sensitive anoderm. Internal hemorrhoids are further classified by the degree or prolapse, which has direct therapeutic and prognostic consequences:

Grade I Do not prolapse below the dentate line; visible only on

Grade II Prolapse below the dentate line, but spontaneously reduce

Grade III Prolapse below the dentate line, but require manual reduction Figure 1a. Grade IV Prolapse and stay below the dentate line - not reducible

Nearly all patients with symptomatic Grade I internal hemorrhoids respond well to medical therapy. Grade II and small Grade III internal hemorrhoids respond to non-operative therapy. Large, refractory grade III and grade IV internal hemorrhoids often require surgery. Clinical Manifestation and Evaluation Symptoms attributed to hemorrhoids include bleeding, itching and pain.6 Internal hemorrhoids may prolapse and bleed, but are only painful when they have thrombosed, owing to their position proximal to the dentate line. Bleeding is bright red, owing to arterial bleeding from disruption of the arterial-venous connections of the Figure 1b. sinusoids. Drops of bright red blood at the end of a

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FRONTIERS IN ENDOSCOPY, SERIES #14 FRONTIERS IN ENDOSCOPY, SERIES #14

Principles in Medical Management of Hemorrhoids

• Dietary – fiber and fluid intake

• Behavioral – avoid straining, don’t fight urge to go, limit time on commode

• Topical – sitz baths for comfort; various OTC products may help symptoms but don’t affect underlying problem

• Treat sphincteric spasm with Nitroglycerin ointment if necessary, to minimize straining, allow for more rapid/complete evacuation Figure 2. • Minimize use of topical . Prolonged use counterproductive. Maximum 10 days – 2 weeks

bowel movement or on tissue paper, or blood that coats solid brown stool are suggestive features, but are not reliably predictive.7 External hemorrhoids can become very painful when acutely thrombosed. Three Myths Three common misconceptions should be dispelled about hemorrhoids. One is the association with portal . produces rectal varicies rather than hemorrhoids. In fact, patients with Figure 2a. portal hypertension are no more at risk for hemorrhoids.8 The second misconception is that hemorrhoids alone anorectal pathology. Careful external inspection of can cause a positive result on stool guaiac tests. This the anus and perirectal area may reveal thrombosed is not true.9 should not be attributed external hemorrhoids, but also anal fissures, fistula, to hemorrhoids until the full colon is adequately condylomata, rectal , locally advanced rectal evaluated. Lastly, the misconception that bleeding from cancer, or . Meanwhile painless hemorrhoids causes .10 It cannot be overstated bleeding will often require an exam complemented that patients who present with anemia require further by flexible , or anoscopy. investigation of the gastrointestinal tract.11 All patients Digital is usually unable to detect older than 50 years or at high risk for internal hemorrhoids unless prolapsing or thrombosed. presenting with rectal bleeding or anorectal symptoms Besides internal hemorrhoids, painless rectal bleeding should undergo a full colonoscopy before focusing on can also be caused by colorectal carcinoma, polyps, internal hemorrhoids as the culprit. , rectal varices, Kaposi sarcoma, and . A painful digital rectal examination Diagnosis should raise the suspicion of concomitant While many patients with anorectal complaints will which is not uncommon. ascribe their symptoms to “hemorrhoids”, a careful history and examination will often reveal other (continued on page 27)

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(continued from page 24)

Medical Treatment Conservative treatment begins with the universal recommendation to add fiber to the diet, increased fluid intake, and avoid prolonged straining or sitting on the commode. Prospective studies have shown improvement in pain and bleeding from hemorrhoids with dietary fiber supplementation, though the evidence has not been overwhelming.12,13,14,15 Over the counter sitz baths, suppositories, and topical analgesics and corticosteroids provide symptomatic relief, but no evidence supports their use in reducing actual hemorrhoid swelling, bleeding or prolapse. Long term use of corticosteroid creams is harmful and should Figure 3a. be discouraged. Grade I and II hemorrhoids have a decent chance of resolution with medical therapy alone. Taking all comers, the majority of patients presenting with symptomatic hemorrhoids improve with a bowel management program alone.16 Non-Surgical Procedures When these conservative measures fail, non-surgical procedures are recommended, which is particularly the case with Grade II and small grade III hemorrhoids. It is here where the gastroenterologist can offer an alternative before invasive surgical excision. All of these procedures affix the hemorrhoidal tissue back onto the muscle wall and do not require anesthesia. While they are not excisional, they ablate the mucosa of the hemorrhoid by controlled via various Figure 3b. mechanisms. These include:

•

• Bipolar Diathermy

• Direct Current Electrotherapy

• Infrared Coagulation

•

Sclerotherapy is the oldest method and involves injecting a sclerosant (mixture of phenol in oil, quinine, urea and hypertonic saline) into the submucosa at the base of the hemorrhoid through an anoscope using a spinal needle. The technique is suitable for smaller Figure 3c. hemorrhoids. Cure rates are reported to be 90%.17

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Figure 4a. Figure 4b.

Recurrence rates are 30% at 4 years.18 Significant pain and notably rare incidences of pain and bleeding have is a limiting factor in this method and has reported in made this the most commonly used method amongst 12-70% of cases.19,20 the three coagulant therapies.

Bipolar Diathermy, direct current electrotherapy, Rubber band ligation involves completely and infrared coagulation all involve coagulating, encircling the redundant mucosa, vascular bundle, occluding and obliterating the hemorrhoidal vascular and with a ligating rubber band. The pedicle proximal to the dentate line. The area of tissue process must be at least 1-2 cm proximal to the dentate then sloughs and leaves an ulcer that fibrosis at the line lest severe immediate pain due to the innervation of treatment site. Bipolar diathermy success rates range the anoderm. The pain can only be relieved by cutting from 88-100% in randomized trials with first, second the rubber band, which is a technically challenging feat. and third degree hemorrhoids.21,22,23,24,25 Multiple Although internal hemorrhoids can be banded using an applications are required at the same site, and 20% upper endoscope with a variceal ligation kit, there is of cases require excisional hemorrhoidectomy.26,27 a move towards office banding. During colonoscopy Direct electrotherapy has fallen out of favor because or sigmoidoscopy, the internal hemorrhoids are seen of lengthy treatment times (10 minutes) required to during retroflexion but may be missed if air is not obtain coagulation despite similar success rates (88%) suctioned from the (see Figure 4). Figure 2 in first, second and third degree hemorrhoids.28,29 A new shows where the band should be placed in relation to method using a disposable probe that plugs into any the dentate line regardless of the method used. Two electrosurgical generator is now available. (Figure 1) commonly used in-offices devices are available. One involves an instrument that physically grasps the Infrared photocoagulation (IRC) produces mucosa and pulls the tissue into the applicator, and infrared radiation from a tungsten-halogen lamp which other involves an accessory suction device that sucks is directed via a polymer probe tip. Office based IRC the mucosa into the applicator itself. (Figure 5) There (Figure 2) and through the scope probes (Figure 3) are are no reported differences in efficacy. Success rates are available. These are required to make contact with the high and durable, ranging from 80-90% of patients with base of the hemorrhoid under direct vision to deliver 0.5 resolved or improved symptoms on 5 year follow-up.31,32 to 2 second pulses.27 These polses are delivered to all Complications of rubber band ligation include minor 3 hemorrhjoids in positions at base of the hemorrhoid bleeding in less than 5% of cases and severe bleeding column (Figure 3a) Success rates range from 67-96% in 1-2%. Rare incidences of pelvic occurring in first and second degree hemorrhoids. Multiple after rubber band ligation have been reported, carrying hemorrhoids can be treated at once.30 The swiftness a high mortality rate (~30%).33,34 Patients should be

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FRONTIERS IN ENDOSCOPY, SERIES #14 instructed to seek medical care urgently if symptoms of fever, increased perianal pain, or new onset of following the procedure. Multiple randomized controlled trials have compared each of the above method with one another, but no single has compared all 5 at once. Two meta- analyses concluded that rubber band ligation and infrared coagulation are the most effective. One meta- analysis reported that ligation was more effective because it had more durable benefits, requiring fewer additional treatments for symptomatic recurrence than did coagulation and sclerotherapy.35 However, in a randomized crossover trial comparing rubber band ligation versus infrared coagulation, rubber band ligation resulted in more pain and minor bleeding Figure 5. than infrared coagulation. The use of both ligation and infrared coagulation in combination was 97% successful. Most notably, despite ligation having more for 2-4 weeks.38,39,40,41,42 The stapled hemorrhoidectomy, pain and bleeding, there was no preference amongst developed in 1998, is equally safe as conventional patients for one over the other.36 hemorrhoidectomy (open or closed), but with shorter operating time, convalescence and post-operative Surgical Hemorrhoidectomy disability. Effectiveness long term as of yet cannot Overall, 5-10% of patients with hemorrhoids will determined absolutely but hemorrhoid symptoms can require surgery – the vast majority are grade III-IV. recur years later.43 Surgical hemorrhoidectomy is indicated in the following scenarios: CONCLUSION Hemorrhoids are normal fibrovascular structures • Failure of Medical and Nonoperative underlying the rectal mucosa and anal skin. Therapy Physiologically they maintain the continence of the anus. Symptomatic hemorrhoids bleed, itch or hurt, and • Symptomatic third-degree, fourth-degree, require therapy. The dentate line heralds the presence of or significant mixed internal and external pain fibers distally, and any intervention must be well hemorrhoids proximal to it if done without anesthesia. The degree of prolapse has significant therapeutic implications. • Symptomatic hemorrhoids in the presence For the majority of patients with symptomatic grade I of a concomitant anorectal condition that hemorrhoids, lifestyle and dietary changes are effective. requires surgery Hemorrhoids that fail conservative measures (grade II, III) may be amenable to non-operative procedures • Patient preference after discussion of that can be done by the gastroenterologist safely in the the treatment options with the referring office setting without anesthesia, including rubber band physician and surgeon.37 ligation and infrared photocoagulation. While rubber band ligation seems more durable than photocoagulation, Surgical hemorrhoidectomy is the most effective it appears to come at the expense of more pain and minor and durable treatment overall for third and fourth bleeding. However, patients do not seem to favor one degree hemorrhoids. Recurrence following a over the other. Surgical hemorrhoidectomy, including hemorrhoidectomy is quite rare. However, morbidity a newer stapled technique, is the last line of therapy, is higher, especially with respect to incontinence, post- and provide the most durable and effective response operative pain, urinary retention, bleeding, infection, for refractory hemorrhoids, but expectedly with higher and anal . Most patients do not return to work complication rates and prolonged convalescence. n

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