5. RIGD0343_03-25.qxd 3 /25/09 1:48 PM Page 16 TREATMENT UPDATE Definitive Therapy for Internal Hemorrhoids—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 Ulcer 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 • Sclerotherapy • Thermocoagulation • Electrocoagulation • Infrared coagulation • Rubber band ligation 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. 16 VOL. 9 NO. 1 2009 REVIEWS IN GASTROENTEROLOGICAL DISORDERS 5. RIGD0343_03-25.qxd 3/25/09 08:17 PM Page 17 New Opportunities and Options in Hemorrhoid 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- prolapse 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 thrombosis 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 rectum 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 Anal canal controlled symptoms or complica- Cleator, MD.) tions from internal hemorrhoids can result in disability,4 hospitalization,5 6 and, rarely, death. 6 Pregnancy is associated with the Spine development of internal hemor- rhoids.7 A definitive association Internal between chronic constipation or por- hemorrhoidal tal hypertension 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 anoscopy 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 VOL. 9 NO. 1 2009 REVIEWS IN GASTROENTEROLOGICAL DISORDERS 17 5. RIGD0343_03-25.qxd 3/25/09 09:02 PM Page 18 New Opportunities and Options in Hemorrhoid Therapy continued 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 anus 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 endoscopy (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 defecation, slotted anoscope (Figure 4). Some presence of a nonhemorrhoidal 18 VOL. 9 NO. 1 2009 REVIEWS IN GASTROENTEROLOGICAL DISORDERS 5. RIGD0343_03-25.qxd 3 /25/09 1:48 PM Page 19 New Opportunities and Options in Hemorrhoid Therapy polypectomy ulcers); pelvic cancer and AB radiation treatment (radiation telang- iectasia); liver cirrhosis and portal hypertension (rectal varices); chronic human immunodeficiency virus infec- tion (Kaposi sarcoma or opportunistic infections); infection, swelling, or fever (rectal abscess or rectal fistula); recent antibiotics (Clostridium difficile colitis); inflammatory bowel disease or other colitis or proctitis; 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, anal fissure, 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 sigmoidoscopy or Table 2 colonoscopy 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