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I Think I Have Hemorrhoids Farrell Adkins, MD FACS FASCRS Colon and Rectal Surgery Assistant Professor of Surgery, VTC School of Medicine 71st Annual Spring Symposium Carilion Clinic APRIL 22, 2021 Disclosures • No financial disclosures Objectives • Recognize common anorectal symptoms attributable to hemorrhoids • Describe initial non-surgical management options for treatment of hemorrhoids • Recognize surgical options for treatment • Increase awareness of alternative pathologies commonly misattributed to hemorrhoids Hemorrhoidal disease • Common in industrialized nations • Greater than 2.2 million outpatient evaluations per year in US1 • Greater than 2 million prescriptions for hemorrhoid therapies per year2 • Important to identify hemorrhoids as source of symptoms 1Peery AF, Crockett SD, Barritt AS, et al. Burden of gastrointestinal, liver, and pancreatic diseases in the United States. Gastroenterology. 2015;149:1731–1741.e3. 2Everhar, JE, ed. ”The burden of digestive diseases in the United States” US Dept of Health and Human Services, 2008. St. Fiacre (d.670 AD) Origins • The term “hemorrhoids” first coined by Hippocrates, approximately 400 BCE • “The disease of the hemorrhoids is formed in this way: if bile or phlegm be determined to the veins in the rectum, it heats the blood in the veins; and these veins becoming heated attract blood from the nearest veins, and being gorged the inside of the gut swells outwardly, and the heads of the veins are raised up, and being at the same time bruised by the faeces passing out, and injured by the blood collected in them, they squirt out blood, most frequently along with the faeces, but sometimes without faeces.” Medieval painting circa 1200 ACE German wood cutting 15th century Hemorrhoids • Ubiquitous but frequently misunderstood • Hemorrhoids are normal but hemorrhoidal disease is not • Patients have very little understanding of anorectal complaints • Many providers may have minimal training in anorectal diseases Internal hemorrhoids Anatomy and physiology • Proximal/confluent with dentate line • Vascular cushions • Elastic and connective tissue • Treitz’s suspensory muscle • “Corpus cavernosum recti” • AV shunts and sinusoids • Superior rectal aa. terminal branches • Predominantly arterial • Columnar epithelium • Poorly innervated • 15-20% of resting anal pressure • Augment pressure (cough, Valsalva) External hemorrhoids Anatomy and physiology • Distal to the dentate line • Confluent with the anal verge • Somatic sensory branches of the pudendal nerve • Fewer, but larger sinuoids • Predominantly venous blood flow • Squamous epithelium (anoderm) 3Aigner et. al. “The Vascular Nature of Hemorrhoids” J GI Surg 2006; 10:1044-1050. 4Schumann et. al. “Anatomical branches of the superior rectal artery in the superior rectum” Colorectal Dis 2009; 11:967-971. Hemorrhoidal disease pathophysiology Bowel habits Deterioration of Straining Treitz’s muscle Diet Vascularity Inflammation Hypertonicity Chronic dilation Enzymatic Downward tissue of hemorrhoidal displacement imbalance plexus AV anastomosis distention Adapted from 5Corman MI. ”Hemorrhoids” in Colon and Rectal Surgery, 1998. 6Thomson, WH “The Nature of Hemorrhoids” Br J Surg 1975; 62:542-52; 7Ganz, RA “The Evaluation and Treatment of Hemorrhoids” Clin Gastroenterol Hepatol 2013; 11(6) 593-603. Internal hemorrhoids Presentation and evaluation • Bleeding (60%) • Itching (55%) • Protrusion/prolapse • Seepage (10%) • Pain • Worrisome mass • Vague, difficult to describe • Pins & needles/burning/dull • Timing Internal hemorrhoids Presentation and evaluation • Must evaluate bowel habits • Frequency • Character of stools • Straining • IBS? • Continence issues • Gynecologic history • Surgical history Internal hemorrhoids Presentation and evaluation Internal hemorrhoids Presentation and evaluation Internal hemorrhoids Severity Internal hemorrhoids Severity Internal hemorrhoids Severity Internal hemorrhoids Severity Does all hematochezia require a colonoscopy? Outlet Bleeding •Bright red blood during/after BM, on toilet paper or in toilet bowel •No change in bowel habits •No family or personal history of neoplasia Suspicious Bleeding •Dark red blood •Mixed with stool •Any personal or family history of neoplasia Hemorrhage •Large volume bleeding requiring hospital admission/transfusion Occult Bleeding •Anemia •Positive FOBT 8Marderstein and Church. “Classic outlet rectal bleeding does not require full colonoscopy to exclude significant pathology” DCR 2008;51:202-206. Does all hematochezia require a colonoscopy? 8Marderstein and Church. “Classic outlet rectal bleeding does not require full colonoscopy to exclude significant pathology” DCR 2008;51:202-206. Does all hematochezia require a colonoscopy? Yes No • Screening guidelines • Young age • Personal/Family history • Outlet bleeding • Alarm symptoms • Confirmed anorectal source • Refractory bleeding • Recent colonoscopy • Bleeding ceases with treatment Internal hemorrhoids Treatment • Dietary and Behavioral • Surgical procedures • Bowel management program • Hemorrhoidectomy • Sitz baths • Open or Closed • Medical Therapy • Stapled hemorrhoidopexy • Over the counter • Topical/suppository • Arterial ligation • Office based procedures • Doppler guided • Rubber banding • Anatomic • Infrared coagulation • Sclerotherapy • Bipolar ligation Dietary and bowel management program • USDA and HHS recommends 25g/day for women and 38g/d for men • Average American fiber intake 15g/d • 90% of women and 97% of men fail to meet recommendations • Alonso-Cuello (2006) meta-analysis (7 studies) • Fiber improved bleeding (50%) • Fiber improved prolapse (20%, *NS) • Fiber improved pain (70%, *NS) • Pooled analysis risk of recurrent symptoms decreased by 47% with fiber therapy 9US Department of Agriculture and Health and Human Services “Dietary Guidelines for Americans 2020-2025” 10Alonso-Cuello et. al. “Fiber for the treatment of hemorrhoid complications: A systematic review and meta-analysis” Am J Gastroenterol 2006; 101:181-188. Sitz baths 11Shafik et. al. “Role of Warm Water Bath in Anorectal Conditions” J Clin Gastroenterol 1993; 16(4)304-8. Internal hemorrhoids Medical management • Huge market • Easy to recommend over the counter or prescribe • Paucity of data to suggest effectiveness of topical therapies • Witch hazel (Tucks) • Phenyephrine (Preparation H) • Hydrocortisone +/- pramoxine (Anusol, Pramasone, Proctofoam) Internal hemorrhoids Medical management • Flavinoids (Diosmin, troxerutin, hesperidin) • Venotonics, mechanism unclear • Lower extremity venous insufficiency • No FDA-approved formulations in the US • May be used by patients previously treated outside the US • Some availability as an over the counter herbal supplement • Improved pain and bleeding but not prolapse12 12Giannini et. al. “Flavinoids mixture in the treatment of acute hemorrhoidal disease: A prospective, randomized, triple-blind controlled trial.” Tech Coloproctol 2015; 19:339-45. Internal hemorrhoids Rubber band ligation Illustration from Jacobs,“Hemorrhoids” NEJM 2014; 371:944-51. Internal hemorrhoids Rubber band ligation • 25-year retrospective review • 805 patients, 2,114 bandings • Mean follow-up: 3.5 years • Post-procedural pain: 9% • Complications: 4.7% • Thrombosis (2%) • Sepsis (1 patient, 0.09%) • Bleeding (3%) 13Iyer et. al. “Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids.” DCR 2004; 47:1364-70. Internal hemorrhoids Rubber band ligation 13Iyer et. al. “Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids.” DCR 2004; 47:1364-70. Internal hemorrhoids Rubber band ligation 13Iyer et. al. “Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids.” DCR 2004; 47:1364-70. Internal hemorrhoids Injection Sclerotherapy • Sclerosing agents • Phenol • Quinine • Sodium morrhuate • Safe, minimal pain • Inferior to RBL • Limited durability • Ineffective for prolapse • May be useful for grade I patients unable to stop anticoagulants or anti- platelet therapies Internal hemorrhoids Infrared Coagulation • Infrared light thrombose and coagulate vessels • Selective IRC of inflow arterial vessels • Easy, fast, and relatively painless • Inferior to RBL across all hemorrhoid grades14 • Frequently requires more repeat treatments14 14MacRae and McLeod “Comparison of Hemorrhoid Treatment Modalities: A Meta-Analysis: DCR 1995: 38:687-694. Internal hemorrhoids Doppler-guided arterial ligation Excisional hemorrhoidectomy • Closed technique “Ferguson” Excisional hemorrhoidectomy • Complications • Pain • Urinary retention (2-36%) • Sitz baths • UTI (3.3%) • Bowel management • Bleeding (0.03-6%) • Fecal impaction (2.4%) • Topicals • Anal stenosis (0-6%) • Local anesthetics • Fecal incontinence (0-12%) • Topical metronidazole • Anal fistula (1%) • Nifedipine • Sucralfate Stapled Hemorrhoidopexy Procedure for Prolapsing Hemorrhoids (PPH) Stapled Hemorrhoidopexy Procedure for Prolapsing Hemorrhoids (PPH) • Not a true hemorrhoidectomy • Does not treat external hemorrhoids • Less painful than traditional hemorrhoidectomy • Return to work: 6 vs. 15 days15 • Rare, but horrific complications • Rectovaginal fistula • Pelvic sepsis • Chronic pain and tenesmus 15Girodano et. al. “Long-term Outcomes of Stapled Hemorrhoidopexy vs. Conventional Hemorrhoidectomy: A Meta-analysis of Randomized Controlled Trials. Arch Surg 2009; 144(3)266-272. Stapled Hemorrhoidopexy Procedure for Prolapsing Hemorrhoids (PPH) 15Girodano et. al.
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