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Home , Anoscopy, Hemorrhoid, Telangiectasia

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TREATMENT UPDATE

Definitive Therapy for Internal —New Opportunities and Options

Gordon V. Ohning, MD, PhD, Gustavo A. Machicado, MD, Dennis M. Jensen, MD The David Geffen School of Medicine at UCLA, Greater Los Angeles VA Healthcare Center, Center for Research and Education (CURE): Digestive Diseases Research Center, Los Angeles, CA

Hemorrhoids are common in Western societies. Appropriate assessment and treatment of symptomatic hemorrhoids can substantially reduce morbidity and improve patient well-being. In this article, the clinical presentation, differential diagnoses, and current treatment options, including the CRH-O’Regan banding device, an emerging technology for the anoscopic treatment of symptomatic internal hemorrhoids, are reviewed. [Rev Gastroenterol Disord. 2009;9(1):16-26]

© 2009 MedReviews®, LLC

Key words: Symptomatic internal hemorrhoids • Anorectal symptoms • • Thermocoagulation • Electrocoagulation • Infrared coagulation •

emorrhoids are common in Western societies. Appropriate assessment and treatment of symptomatic hemorrhoids can substantially reduce morbidity Hand improve patient well-being. We review the clinical presentation, differential diagnoses, and current treatment options, including the CRH-O’Regan banding device, an emerging technology for the anoscopic treatment of sympto- matic internal hemorrhoids.

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New Opportunities and Options in Therapy

Epidemiology and Prevalence of (Figure 1). External hemorrhoids are ment and enlargement usually result Symptomatic Hemorrhoids located distal to the dentate line and in hemorrhoidal symptoms. The most The incidence and prevalence of are covered with sensitive anoderm. common symptoms of internal hem- symptomatic internal hemorrhoids Proximal to the dentate line, pain orrhoids are painless rectal bleeding, are difficult to measure accurately sensation diminishes as the innerva- or protrusion, pain, itching, because self-treatment with over-the- tion changes. As external hemor- or soiling. Mixed hemorrhoids occur counter products is common. The rhoids enlarge, they commonly across the dentate line between the National Center for Health Statistics present with pain, swelling, and, if external and internal hemorrhoids reported that up to 23 million people occurs, intense pain and and may cause pain, bleeding, and other symptoms.

Inadequately controlled symptoms or complications from internal hemor- Grading of Internal Hemorrhoids rhoids can result in disability, hospitalization, and, rarely, death. Grade I internal hemorrhoids remain above the dentate line and do not pro- (12.8% of US adults) have symptoms spontaneous rupture and bleeding. lapse below it (Figure 1, Table 1). They from internal hemorrhoids,1 and other Internal hemorrhoids originate proxi- are best visualized with a slotted epidemiologic studies report up to mal to the dentate line from dilated anoscope (Figure 2), but can also be a 40% prevalence of symptomatic venous plexuses that are covered with seen (but not graded well) on retroflex- internal hemorrhoids in the United colonic mucosa. As internal hemor- ion in the with an endoscope States.2 Substantially fewer patients rhoids enlarge, the congested and (Figure 3). Most patients with symp- seek medical attention, but studies redundant tissue protrudes below the tomatic grade I internal hemor- report that 1.9 million people received dentate line. Chronic venous engorge- rhoids respond to medical therapy outpatient medical care for sympto-

matic internal hemorrhoids in ambu- Figure 1. Anorectal anatomy, including latory care units.3 Inadequately internal and external hemorrhoids and dentate line. (Image courtesy of Iain controlled symptoms or complica- Cleator, MD.) tions from internal hemorrhoids can result in disability,4 hospitalization,5 6 and, rarely, death. 6 is associated with the Spine development of internal hemor- rhoids.7 A definitive association Internal between chronic or por- hemorrhoidal tal has not been plexus shown.8,9 Age and gender are also Dentate line associated with symptomatic internal hemorrhoids with an increasing inci- External hemorrhoidal dence in people over the age of plexus 45 years and in women (24.9% vs 15.2% for men). Although people with a family history of hemorrhoids appear predisposed to developing symptomatic disease, neither definite Table 1 genetic markers nor racial differences Internal Hemorrhoid Grades have been identified for symptomatic 1 internal hemorrhoids. Grade I Do not prolapse below the dentate line; visible only on Grade II Prolapse below the dentate line, but spontaneously reduce Anatomy of the Anorectum Grade III Prolapse below the dentate line, but require manual reduction The dentate line is a landmark sepa- rating anal (squamous) and colonic Grade IV Prolapse and stay below the dentate line—not reducible (columnar) mucosa in the anal canal

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patients with acute hemorrhoidal symptoms and grade II internal hem- orrhoids respond to medical therapy, but those with recurrent or chronic internal hemorrhoidal symptoms often require anoscopic therapies to control recurrent bleeding or other symptoms (Figure 4). Grade III inter- nal hemorrhoids prolapse with defe- cation and other physiologic events, but must be reduced (pushed back inside) manually to decrease hemor- rhoidal swelling or anal pressure. They can be seen on physical exami- Figure 2. Slotted anoscope with trochar (A) in place and (B) removed. (Images courtesy of Iain Cleator, MD.) nation by inspection of the or during anoscopy or retroflexed exam- ination (Figure 5). Symptomatic chronic grade III internal hemorrhoids respond well to banding or surgical therapies, but usually not to medical therapies alone. Grade IV internal hemorrhoids remain prolapsed below the dentate line and cannot be reduced. Most patients with chronic symptoms from grade IV internal hemorrhoids respond best to surgery, although bleeding can be controlled in some patients by banding or other Figure 3. Grade I internal hemorrhoids on retroflexion on (left) and slotted anoscopy (right). anoscopic therapies.

Differential Diagnosis of Patients With Rectal Bleeding or Other Anorectal Symptoms In a recent Center for Ulcer Research and Education (CURE) study of ambu- latory adult patients referred by physicians (eg, primary care or spe- cialists) for recurrent rectal bleeding suspected to be from internal hemor- rhoids, at least 50% were bleeding from other anorectal or distal colonic lesions.10 The differential diagnoses of anorectal conditions causing acute or chronic symptoms or bleeding are Figure 4. Grade II internal hemorrhoids on slotted anoscopy before (left) and after (right) bipolar electrocoagula- listed in Table 2; etiologies are divid- tion, just above dentate line. ed into those with or without anorec- tal pain. Uncomplicated or untreated (see Table 3) and do not require Valsalva maneuver, swatting, or lift- internal hemorrhoids are not usually anoscopic or surgical therapies. Grade ing, but spontaneously return inside. associated with much pain. Therefore, II internal hemorrhoids prolapse below These can be accurately graded with a significant anal pain suggests the the dentate line with , slotted anoscope (Figure 4). Some presence of a nonhemorrhoidal

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polypectomy ulcers); pelvic cancer and AB radiation treatment (radiation telang- iectasia); and (rectal varices); chronic human immunodeficiency virus infec- tion (Kaposi sarcoma or opportunistic infections); infection, swelling, or fever (rectal or rectal ); recent antibiotics (Clostridium difficile ); inflammatory bowel disease or other colitis or ; and chronic constipation (anal fissures or solitary CD rectal ulcer syndrome). In addition to a careful medical history, a physical examination of the Figure 4. Grade II internal hemorrhoids on slotted anoscopy before (left) and after bipolar electrocoagulation (right), just above dentate line. perirectal area and anus will facilitate diagnosis of thrombosed external hem- orrhoids, , perirectal fistula, anal abscess, anal warts, rectal pro- lapse, rectal cancers, or anal polyps.

Clinical Management of Patients With Anorectal Symptoms Figure 5. Grade III internal hemorrhoids before (on slotted anoscopy [A] and on retroflexion [B]) and after stan- Complementing the history and dard rubber band ligation (retroflexion [C] and end-on views [D]). physical examination are anoscopy and either flexible or Table 2 in patients referred to a Differential Diagnosis of Anorectal Conditions Causing gastroenterologist for evaluation of Acute or Chronic Symptoms or Bleeding rectal bleeding or other anorectal symptoms (Figure 7). All patients older than 50 years or at high risk for col- Painless Painful orectal cancer (CRCa; a family history Internal hemorrhoids Thrombosed external hemorrhoids of CRCa or predisposing condition Mixed hemorrhoids such as chronic or a Polyps (anal or rectal) Anal fissure familial polyposis syndrome) should Early cancer (1° or 2°)* Anal trauma undergo a full colonoscopy before focusing on internal hemorrhoids. Radiation Advanced cancer Other laboratory testing (such as stool Kaposi sarcoma Rectal abscess cultures, C. difficile toxin tests, or Solitary rectal ulcer syndrome Anal warts serologies) is also recommended to Rectal varices exclude infectious etiologies in Postsurgical anastomotic ulcer Proctitis ani selected cases. Postpolypectomy ulcer Proctitis or colitis Once nonhemorrhoidal etiologies have been excluded as the cause of the *1° refers to cancers originating in anorectum (squamous, cloacal, or adenocarcinoma); 2° cancers are metastatic (, uterine, ovarian, or other etiologies) to the anorectum. patient’s anorectal complaints, medical treatment is recommended (Table 3). If medical therapies have already failed anorectal condition, such as an anal medical history that can be elicited and the patient’s bleeding or internal fissure (Figure 6). from the patient, such as prior hemorrhoidal complaints persist, Most patients with nonhemor- anorectal surgery or nonsurgical anoscopic treatment is recommended rhoidal anorectal conditions have a treatments (anastomatic or post- (Figure 7, Table 4).

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Figure 6. Anorectal pathology including an anal fissure, hypertrophied rectal papillae, and sentinel . (Image courtesy of Iain Cleator, MD.)

Hypertrophied papilla

Site of dentate line

Fissure Sentinel skin tag

Rectal Bleeding or Anorectal Symptoms

Age 50 y and Age 50 y or High Average Risk Risk for CRCa

Flexible Sigmoidoscopy Colonoscopy Screening and Anoscopy and Anoscopy

Polyps or Other Lesions Only Internal Hemorrhoids

Treat Treat Medically

Success Failure

Continue Anoscopic Medical Rx Treatment

Success Failure

Med Rx and Alternative Anoscopic Anoscopy F/U Rx and Med Rx Success Failure

Continue Medical Surgery and Anoscopy F/U

Figure 7. Clinical management algorithm for anorectal symptoms and possible internal hemorrhoids. CRCa, ; F/U, follow-up; Rx, prescription.

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Table 3 Medical Therapy for Bleeding or Symptomatic Internal Hemorrhoids

Patients should be advised to: Avoid straining with bowel movements, prolonged standing, and heavy lifting Use fiber supplementation and drink extra, nonalcoholic, caffeine-free fluids Take daily stool softeners during severe episodes Use hydrocortisone suppositories or creams Take frequent sitz baths (warm water without soap or irritants) Stop aspirin and nonsteroidal anti-inflammatory drugs Reduce prolapsing hemorrhoids after bowel movements or exercise Avoid dietary irritants such as pepper, spices, coffee, and cola Exercise daily, such as walking or swimming

Table 4 Treatment Options for Internal Hemorrhoids*

Minor Major Complications Complications Treatment Treatment Sessions Success Rate (%) (%) (%) Lost Time† Medical Continuous 50 0 0 0 BICAP probe 3-5 75 10-15 2 1 day Infrared coagulator 3-5 75 10-15 2 1 day Heater probe 2-4 90 10-20 5 1 day Sclerotherapy 3-5 75 10-20 5 1 day RBL standard 2-4 95 10-20 5 1-2 days CRH-O’Regan RBL 3-5 95 5-10 2 1 day Surgery 1 98 20-30 15 30 days BICAP, biopolar coagulation probe; RBL, rubber band ligation. *Treatments are effective for grades I-III internal hemorrhoids, except for surgery, which also includes grade IV. †Time away from work or usual activity.

Medical Therapies acute hemorrhoidal symptoms have of medical therapy to prevent exacer- Initial treatments for symptomatic either or vasoconstrictors bation of hemorrhoidal symptoms. hemorrhoids typically use noninva- with lubricants. Suppositories are Patients should be counseled about sive therapies that combine medica- usually more effective than topical pathophysiologic mechanisms that tions, dietary changes, and preparations for internal hemorrhoids contribute to hemorrhoid develop- modification of personal habits.11 by providing more uniform dosing ment and progression, such as ad- Many patients will have tried nonpre- and are more easily administered. vising against straining during scription medications prior to presen- Long-term medical treatment includes defecation, heavy lifting, or other tation and these should be reviewed fiber supplementation and stool soft- activities that require substantial for both duration and proper use in eners.11,12 Also, treatment of underly- increase in abdominal muscle use (eg, assessing failures of such treatments. ing conditions such as functional Valsalva maneuver) (Table 3). Dietary Effective medications for treatment of is an important component restrictions include avoidance of

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irritating foods, such as peppers, comparing sclerotherapy, rubber band it was associated with significantly spices, coffee, and colas. Use of aspirin ligation, and infrared coagulation less postoperative pain and fewer or nonsteroidal anti-inflammatory reported that rubber band ligation had complications.18,19 drugs should be avoided, particularly longer-term efficacy than the other Bipolar and heater probe coagula- during bleeding episodes. Warm water treatments.15 However, it was associ- tion were compared in a RCS by our sitz baths without soap or other irritat- ated with more posttreatment pain group.20 The efficacy was equivalent ing agents are recommended. Patients and complications. Infrared coagula- for both probes with a 6.2% recur- should be advised to manually reduce tion had similar efficacy and less post- rence of bleeding at 12 months that prolapsed hemorrhoids during periods treatment pain or complications, but responded to retreatment. Heater of symptom exacerbation. required more treatment sessions.15 probe treatment achieved hemor- Sclerotherapy is not indicated for rhoid reduction and control of bleed- Anoscopic and Endoscopic the treatment of external hemorrhoids ing in a shorter period than bipolar Treatment of Internal and grade III or IV internal hemor- coagulation (76.5 vs 120.5 days). Hemorrhoids rhoids, nor is it indicated for rectal or However, postoperative pain was When patients do not respond to anal pathology such as proctitis, fistu- more severe with heater probe treat- medical therapy, several different las, fissures, tumors, or perianal infec- ment. Overall, more complications anoscopic and endoscopic therapies tion (eg, acute perianal ). occurred with bipolar coagulation can be offered. These include injection Care must be taken during injection than with heater probe (11.9% vs sclerotherapy, rubber band ligation, of the sclerosant because different 5.1%) and 1 patient in the bipolar thermocoagulation, electrocoagula- complications have been reported group required surgical hemor- tion, and infrared coagulation12,13; with this technique. Inadvertent rhoidectomy due to sphincter spasms refer to Table 4 for a summary. injection into the paraprostatic with bipolar treatments. Sclerotherapy parasympathetic nerves may lead to In another RCS by our group,10 the Injection sclerotherapy is the oldest impotence. Systemic bacteremia or rubber band ligation group required nonsurgical therapy for symptomatic and hepatic toxicity may significantly fewer treatment sessions internal hemorrhoids and is indicated occur,16,17 and perirectal abscess or (2.3 vs 3.8) than the bipolar group for the treatment of grade I and II pelvic cellulitis occurs rarely. for symptomatic relief, and there symptomatic internal hemorrhoids. were fewer failures and crossovers Several injectable sclerosants are Infrared, Bipolar, and Heater (8% vs 35%). available, but this procedure is most Probe Coagulation commonly performed with a 5% phe- Coagulation of internal hemorrhoids Rubber Band Ligation nol solution. The procedure is per- can be achieved by a variety of ther- Application of a small rubber band formed by passing a slotted anoscope mal modalities. Infrared coagulation around the base of an internal hemor- into the anal canal and then with- utilizes infrared light to cause tissue rhoid causes ischemic and drawing it until the hemorrhoid coagulation. A bipolar probe has posi- sloughing of hemorrhoidal tissue, with bulges into the lumen (Figures 2 and tive and negative electrodes located at ulceration resulting in fibrosis and 4). The injection is then made into the the tip of the probe that generate heat obliteration of the submucosal tissue. submucosa at the base of the hemor- when current is applied and thereby This procedure was originally per- rhoid. The subsequent inflammatory coagulates the tissue. A heater probe formed via rigid and reaction produced by the phenol has a thermocouple located inside the required 2 people for proper placement causes hemorrhoid thrombosis and probe tip that heats up quickly when of the bands: one to hold the procto- finally submucosal fibrosis with oblit- current is applied and causes tissue scope and the other to place the rubber eration of the hemorrhoid tissue. coagulation. All 3 of these modalities band. Despite the difficulties involved A meta-analysis of randomized are easy and quick to apply. with this system, hemorrhoidal band- controlled studies (RCS) comparing In RCS, infrared coagulation has ing was found to be quite effective, anoscopic, endoscopic, and surgical been compared with banding, scle- caused much less pain than surgical therapies for internal hemorrhoids rotherapy, and surgical hemor- hemorrhoidectomy, and was associated reported that sclerotherapy was less rhoidectomy.14,15 Although infrared with fewer complications. Hemorrhoid effective than rubber band ligation or coagulation is well tolerated, it was banding was reported to cure 79% of surgery. However, surgery was associ- less effective than banding or surgical patients, have a recurrence rate of ated with more pain and complica- hemorrhoidectomy and usually 20%, and a failure rate of 2%.14,15 tions.14 Another meta-analysis of RCS required more treatments. However, Newer techniques for hemorrhoidal

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banding can be used by a single oper- associated with significant rectal pro- using any technique. First, place the ator with better visualization and lapse, or for complications (perianal band at least 1 cm above the dentate improved efficacy. abscess, fistula, or fissure).11-13 line. When suctioning the internal The most common complication of Techniques include carbon dioxide or hemorrhoidal tissue, ask the patient if hemorrhoid banding is postoperative neodymium-doped yttrium aluminum there is pain. If so, do not deploy the anal pain that can last 1 to 2 days or as garnet laser and cold scalpel and scis- band at that location and move proxi- many as 7 days. It usually responds to sor without a definitive mally with repeat suctioning and warm sitz baths and analgesics. Severe advantage for any particular method.13 inquiry about pain. Second, place no pain immediately following the proce- Excisional hemorrhoidectomy provides more than 3 bands per session because dure is usually due to banding on or definitive treatment and involves pain and other complications correlate too close to the dentate line and is usu- either an open or closed technique with the number of bands per session. ally relieved by prompt removal of the with similar outcomes and complica- Third, place the bands in different offending band.10,13 Other less common tion rates.23 Successful surgery locations around the rectal canal, such complications include delayed hemor- removes substantial amounts of the as in the 2, 6, and 9 o’clock positions rhage, , and, rarely, hemorrhoidal plexus and can be effec- with the patient in left lateral decubi- pelvic or perineal cellulitis.13,14,16 tive for long periods (up to and beyond tus position and avoid placing bands 10 years). However, surgical procedures adjacent to each other. Fourth, wait Flexible Endoscopic are associated with substantial postsur- 4 to 6 weeks between sessions and Hemorrhoid Banding gical morbidity, particularly postopera- continue medical treatment. This delay Flexible video endoscopy is an alter- tive pain, and patients typically cannot will allow the full effects of banding, native to the rigid proctoscopic return to work or usual activities for healing (of 2° ulcers), and retraction of method. Internal hemorrhoid visual- 2 to 4 weeks after surgery. Other report- internal hemorrhoidal tissue to be ization is either direct or in retroflex- ed complications include hemorrhage achieved. Finally, be cautious with ion (Figures 3-5). Endoscopic banding (0.03%-6%), anal (0%-6%), patients who have irritable bowel syn- allows for placement of 2 or more perianal or pelvic infection (0.5%- drome (IBS) because banding of inter- bands, 1 to 2 cm above the dentate 5.5%), urinary retention (2%-36%), and nal hemorrhoids often aggravates IBS line, on internal hemorrhoids.10,13 The (2%-12%).23 symptoms. Discuss this with the dentate line can be clearly visualized patient prior to initiating therapy, prior to placement of the bands so Rubber Band Ligation Techniques reduce the number of bands per ses- bands can be placed 1 to 2 cm above General sion, and be prepared to intensify it. Comparative studies have shown Although 3 dominant internal hemor- medical treatments for both IBS and endoscopic banding to be highly rhoidal plexus have been described internal hemorrhoids. effective with almost 90% cure rates and emphasized by proctologists, and only 3% to 9% relapses during patients with chronic internal hemor- Standard Rubber Band Ligation long-term observation.10,16-19,21 rhoids develop cushions circumferen- Ligation can be performed using a Complication rates of endoscopic tially distributed in all sectors around standard rigid anoscopic rubber band and anoscopic (conventional) banding the rectal canal.13 We advocate grad- ligator (RBL) through an anoscope or are similar.22 Postligation bleeding ing of internal hemorrhoids in 8 sec- with an endoscope. For the endo- scope, we use a diagnostic size instru- ment with either single shot or Surgery is usually considered when medical and endoscopic therapies fail. multiple band ligators. End-on inter- nal hemorrhoidal ligators or banding rates requiring endoscopic treatment tors around the rectal canal with a above the dentate line in retroflexion occurred in 3.2% of cases (none slotted anoscope (Figures 2-5). Useful is feasible. Figure 5 shows an exam- required transfusions). accessories are a head lamp (for ple of standard RBL of chronic hands-free illumination), a suction grade III internal hemorrhoids. Surgical Therapies machine (if anoscopy is done), and an Surgery is usually considered when examining table that elevates to facil- CRH-O’Regan Hemorrhoid medical and endoscopic therapies fail, itate anal examination and treatment. Ligator and Kit although this is the primary treatment We recommend several guidelines to The CRH-O’Regan Disposable of acute or recurrent thrombosis, avoid or reduce pain or complications Hemorrhoid Banding System (CRH grade IV hemorrhoids, hemorrhoids for banding of internal hemorrhoids, Medical Corporation, Vancouver, BC,

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Figure 8. CRH-O’Regan Disposable Comparisons of Standard Rubber Hemorrhoid Banding System (CRH Medical Corporation, Vancouver, BC, Canada) Band Ligation and CRH-O’Regan (anoscope, ligator, bands). (Image courtesy Ligation of Iain Cleator, MD.) To our knowledge, randomized studies comparing internal hemorrhoid liga- tion results for standard RBL versus the CRH-O’Regan ligation system have not been reported. The most extensive experience was reported by Cleator and Cleator24 as a large case series of 1852 patients with symptomatic grade I to IV internal hemorrhoids. Their suc- cess rate was 95.5% and the recurrence 24 Figure 9. CRH-O’Regan band application rate was 4.5%. Minor complications using an anoscope. (Image courtesy of Iain reported were bleeding (0.4%), throm- Cleator, MD.) bosis (0.3%), and minor pain (0.2%) for a total complication rate of 0.9%. Pelvic sepsis, urinary retention, and anal stenosis were not reported. Cleator and Cleator24 relate this to placement of a single band per session and avoidance of banding the underly- ing muscle. Another prospective study in 60 patients also reported very high efficacy with very few complications.25 Minor early rebleeding occurred in 10% and late rebleeding in 6.7% of patients. Manageable pain was observed in 6.7% of patients.25 In experienced hands, both stan- dard and CRH-O’Regan band liga- Figure 10. CRH-O’Regan blind technique tion are reported to be safe and for internal hemorrhoid banding. (Image effective. Refer to Table 5, which courtesy of Iain Cleator, MD.) highlights the similarities and differ- ences of the techniques. The range of complications in the literature correlates with the experience of the physician, the number of bands placed per session, and the stan- dardization of banding techniques (such as placement 1 cm above Canada) for internal hemorrhoid lig- Internal hemorrhoid ligation can be the dentate line). ation consists of a slotted anoscope, a performed with the anoscope for visu- For the physician, the advantages ligator that resembles a syringe, and alization of the placement site, as of the CRH-O’Regan ligator are that rubber bands for ligation (Figure 8). shown in Figure 9. Another option is it is a single-use disposable complete The advantages of the CRH-O’Regan placement of the bands with a blind kit, bands can be deployed easily kit are the inclusion of key elements technique, as shown in Figure 10. This (by either blind technique or via for slotted anoscopic diagnosis, the latter technique is particularly useful anoscopy), and complications may be ligator for treatment, and the single- for patients returning for follow-up somewhat fewer than with standard use disposable design that does not in an office setting who did well after RBL (if guidelines are followed). require equipment reprocessing initial or prior treatments of internal One of the recommendations advo- (Table 5).24,25 hemorrhoids with this ligator. cated with use of the CRH-O’Regan

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available (http://www.crhcenter.com/ Table 5 physician.html). Comparison of Standard Banding and CRH-O’Regan Hemorrhoid Ligation This review does not include economic or practice considerations Standard Banding CRH-O’Regan Ligation and the reader is referred to a recent 26 Equipment use Reusable/sterilizable Single use/disposable article by Sarles addressing this issue. Packaging Separate parts Complete kit Deployment Via anoscope Yes Yes Conclusions and Blinded No Yes Recommendations Complications* Internal hemorrhoids are a common Minor 10%-20% 5%-10% anatomic finding and often cause anorectal symptoms and signs, such as Major 5% 2% prolapse or bleeding. The differential *Depends upon the number of bands placed per session. diagnosis is long and the anorectal anatomy and diseases are often unfa- miliar to the gastroenterologist or pri- Figure 11. Diagram of rolling the band in mary care physician because they have case of pain or banding of the underlying not been trained to diagnose or treat muscle layer. (Image courtesy of Iain Cleator, MD.) these disorders. Because gastroenterol- ogists are performing an increasing number of for colorectal cancer screening, there is an opportu- nity to diagnose and treat anorectal conditions, including symptomatic internal hemorrhoids. Familiarity with the anatomy, disorders, and treatments of anorectal conditions through retraining is highly recommended. Resources and hands-on workshops are available to learn about and apply nonsurgical treatments, including system is to roll the band off the interested in providing diagnosis and banding. In addition, providing such underlying muscle layer in case the treatment of internal hemorrhoids. training during fel- patient experiences pain after band First, practitioners will require cogni- lowships is highly recommended. A ligation (Figure 11). This and place- tive training about the anatomy of prospective, randomized study of stan- ment of only 1 band per session could the anorectum, disorders and diseases dard rubber band ligation versus the explain the lower complication rates of this organ, differential diagnosis, CRH-O’Regan ligator technique reported in the large series by Cleator and treatments available. Second, an with standard outcomes and an and Cleator24 as compared with stan- adequate knowledge of the technical economic assessment is also highly dard banding reports. This “rolling” guidelines and application of recommended. technique is recommended for anoscopy and anoscopic or endoscopic patients who have banding by any treatments should be obtained. technique and experience Finally, additional instruction or train- The CURE studies and investigators were after band placement above the ing is recommended for anyone con- funded in part by National Institutes of dentate line. templating use of the CRH-O’Regan Health (NIH) grants NIH DK41301 (CURE disposable bander or any other band- Human Studies Core) and NIH K24 Training, Resources, and Economic ing technique. DK02650 (Dr. Jensen). We thank Michelle Meadows for preparing the manuscript Considerations References and review articles are and Iain Cleator, MD, for kindly providing Training is required for gastroenterol- widely available and learning resource Figures 1, 2, 6, and 8 to 11. ogists and other physicians who are materials, an atlas, and videos are

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References epidemiologic study. Gastroenterology. 1990;98: 19. Gupta PJ. Infrared coagulation versus rubber 1. LeClere FB, Moss A, Everhart JE, Roth HP. 380-386. band ligation in early stage hemorrhoids. Braz Prevalence of major digestive disorders and bowel 10. Jutabha R, Jensen DM, Chavalitdhamrong D. J Med Biol Res. 2003;36:1433-1439. symptoms, 1989. Adv Data. 1992;(212):1-15. Randomized prospective study of endoscopic 20. Jensen DM, Jutabha R, Machicado GA, et al. 2. Janicke DM, Pundt MR. Anorectal disorders. rubber band ligation compared to bipolar coag- Prospective randomized comparative study of Emerg Med Clin North Am. 1996;14:757-788. ulation for chronically bleeding internal hemor- bipolar electrocoagulation versus heater probe for 3. Burt CW, Schappert SM. Ambulatory care visits rhoids. Am J Gastroenterol. In press. treatment of chronically bleeding internal hemor- to physician offices, hospital outpatient depart- 11. Pfenninger JL. Modern treatments for internal rhoids. Gastrointest Endosc. 1997;46:435-443. ments, and emergency departments: United haemorrhoids. BMJ. 1997;314:1211-1212. 21. Su M-Y, Chiu C-T, Wu C-S, et al. Endoscopic States 1999-2000. Vital Health Stat 13. 2004; 12. Kaidar-Person O, Person B, Wexner SD. hemorrhoidal ligation of symptomatic internal (157):1-70. Hemorrhoidal disease: a comprehensive review. hemorrhoids. Gastrointest Endosc. 2003;58: 4. Collins JG. Prevalence of selected chronic condi- J Am Coll Surg. 2007;204:102-117. 871-874. tions: United States, 1990-1992. Vital Health 13. Jutabha R, Miura-Jutabha C, Jensen D. Current 22. Wehrmann T, Riphaus A, Feinstein J, Stergiou N. Stat 10. 1997;(194):1-89. medical, anoscopic, endoscopic, and surgical Hemorrhoidal elastic band ligation with flexible 5. Kozak LJ, Owings MF, Hall MJ. National hospital treatments for bleeding internal hemorrhoids. videoendoscopes: a prospective, randomized discharge survey: 2002. Annual summary with Tech Gastrointest Endosc. 2001;3:199-205. comparison with the conventional technique detailed diagnosis and procedure data. Vital 14. MacRae HM, McLeod RS. Comparison of hemor- that uses rigid proctoscopes. Gastrointest Health Stat 13. 2005;(158):1-199. rhoidal treatments: a meta-analysis. Can J Surg. Endosc. 2004;60:191-195. 6. National Center for Health Statistics. Technical 1997;40:14-17. 23. Chong PS, Bartolo DC. Hemorrhoids and fissure appendix. In: Vital Statistics of the United 15. Bayer I, Myslovaty B, Picovsky BM. Rubber band in ano. Gastroenterol Clin North Am. 2008;37: States: Mortality 2002. Hyattsville, MD: ligation of hemorrhoids. Convenient and economic 627-644. National Center for Health Statistics; 2004. treatment. J Clin Gastroenterol. 1996;23:50-52. 24. Cleator IGM, Cleator MM. Banding hemorrhoids 7. Medich DS, Fazio VW. Hemorrhoids, anal fissure, 16. Scarpa FJ, Hillis W, Sabetta JR. Pelvic cellulitis: using the O’Regan disposable bander. Business and carcinoma of the colon, rectum and anus a life threatening complication of hemorrhoidal Briefings. US Gastroenterol Rev. 2005:69-73. during pregnancy. Surg Clin North Am. 1995; banding. Surgery. 1988;103:383-385. 25. Paikos D, Gatopoulou A, Moschos J, et al. 75:77-78. 17. Nivatvongs S, Goldberg S. An improved tech- Banding hemorrhoids using the O’Regan 8. Jacobs DM. The relationship of hemorrhoids nique of rubber band ligation of hemorrhoids. Disposable Bander. Single center experience. to portal hypertension. Dis Colon Rectum. 1980; Am J Surg. 1982;144:379-380. Gastrointestin Liver Dis. 2007;16:163-165. 23:567-569. 18. MacRae HM, McLeod RS. Comparison of hemor- 26. Sarles HE. Increase your EASC and practice bot- 9. Johanson JF, Sonnenberg A. The prevalence of rhoidal treatment modalities. A meta-analysis. tom line by providing hemorrhoidal treatment. hemorrhoids and chronic constipation. An Dis Colon Rectum. 1995;38:687-694. EndoEconomics. 2008;16:11-13.

Main Points • Uncomplicated or untreated internal hemorrhoids are not usually associated with much pain. Significant anal pain suggests the presence of a nonhemorrhoidal anorectal condition, such as an anal fissure. All patients older than 50 years or at high risk for colorectal cancer should undergo a full colonoscopy before focusing on internal hemorrhoids. • Initial therapies for symptomatic hemorrhoids typically use noninvasive therapies that combine medications, dietary changes, and modification of personal habits. • Injection sclerotherapy is the oldest nonsurgical therapy for symptomatic internal hemorrhoids and is indicated for the treatment of grade I and II symptomatic internal hemorrhoids. • Although infrared coagulation is well tolerated, it was less effective than banding or surgical hemorrhoidectomy and usually required more treatments. • Comparative studies have shown endoscopic banding to be highly effective with almost 90% cure rates and only 3% to 9% relapses during long-term observation. • Successful surgery removes substantial amounts of the hemorrhoidal plexus and can be effective for long periods (up to and beyond 10 years). However, surgical procedures are associated with substantial postsurgical morbidity, particularly postoperative pain, and patients typically cannot return to work or usual activities for 2 to 4 weeks after surgery. • In experienced hands, both standard and CRH-O’Regan band ligation are reported to be safe and effective. The range of compli- cations in the literature correlates with the experience of the physician, the number of bands placed per session, and the standardization of banding techniques. • A prospective, randomized study of standard rubber band ligation versus the CRH-O’Regan ligator technique with standard outcomes and an economic assessment is highly recommended.

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