At a glance......
- 1 Types of Hemorrhoids
- 2 Causes of Hemorrhoids
- 3 Symptoms of Hemorrhoids
- 4 Diagnosis of Hemorrhoids
- 5 Treatment of Hemorrhoids
- 6 Topical Treatment
- 7 Non-operative Treatment
- 7.1 Sclerotherapy
- 7.2 Rubber Band Ligation
- 7.3 Infrared Coagulation
- 7.4 Radiofrequency ablation
- 7.5 Cryotherapy
- 7.6 Operative Treatment
- 7.7 Hemorrhoidectomy
- 7.8 Plication
- 7.9 Doppler-guided hemorrhoidal artery ligation
- 7.10 Stapled Hemorrhoidopexy
- 7.11 Acutely Thrombosed or Strangulated Internal Hemorrhoids
- 7.12 Acutely Thrombosed External Hemorrhoids
- 7.13 Hemorrhoids in Pregnancy
- 7.14 Hemorrhoids in Immunocompromised Patients
- 7.15 Hemorrhoids in Patients with Cirrhosis or Portal Hypertension
- 7.16 Hemorrhoids in Patients Having Anticoagulant or Antiplatelet drugs
- 7.17 Stapled Hemorrhoidopexy
- 8 Complications
Hemorrhoids are a very common anorectal condition defined as the symptomatic enlargement and distal displacement of the normal anal cushions. They affect millions of people around the world and represent a major medical and socioeconomic problem. Multiple factors have been claimed to be the etiologies of hemorrhoidal development, including constipation and prolonged straining. The abnormal dilatation and distortion of the vascular channel, together with destructive changes in the supporting connective tissue within the anal cushion, is a paramount finding of hemorrhoidal disease[rx]. An inflammatory reaction[rx] and vascular hyperplasia[rx,rx] may be evident in hemorrhoids. This article firstly reviewed the pathophysiology and other clinical backgrounds of hemorrhoidal disease, followed by the current approaches to non-operative and operative management.
Types of Hemorrhoids
Hemorrhoids can be classified according to how severe they are
Grade 1 – Slightly enlarged hemorrhoids that can’t be seen from outside the anus.
Grade 2 – Larger hemorrhoids that sometimes come out of the anus, for example, while passing stool or – less commonly – during other physical activities. They then go back inside again on their own.
Grade 3 – Hemorrhoids that come out of the anus when you go to the toilet or do other physical activities, but don’t go back inside on their own. They can be pushed back inside, though.
Grade 4 – Hemorrhoids that are always outside the anus and can no longer be pushed back inside. Usually, a small bit of the anal lining comes out of the anus too. This is also known as rectal prolapse.
Causes of Hemorrhoids
Increased pressure on the anal canal (the last section of the rectum) can cause hemorrhoids to become enlarged. Various factors might make this more likely. For example
Regularly lifting heavy objects
Pregnancy and giving birth
The risk of enlarged hemorrhoids increases with age – probably because the tissue becomes weaker over time. And hemorrhoid problems are thought to run in families too.
- Age – as you get older, your body’s supporting tissues get weaker, increasing your risk of hemorrhoids
- Pregnant – this can place increased pressure on your pelvic blood vessels, causing them to enlarge; read more about piles in pregnancy
- Chronic diarrhea
- Lifting heavy weights
- Straining when passing a stool
- Chronic (long-term) diarrhea can also make you more vulnerable to getting hemorrhoids.
- Overweight or obese
- Having a family history of hemorrhoids
- Regularly lifting heavy objects
- A persistent cough or repeated vomiting
- Sitting down for long periods of time
Symptoms of Hemorrhoids
In most cases, the symptoms of piles are not serious. They normally resolve on their own after a few days.
An individual with piles may experience the following symptoms:
- A hard, possibly painful lump may be felt around the anus. It may contain coagulated blood. Piles that contain blood are called thrombosed external hemorrhoids.
- After passing a stool, a person with piles may experience the feeling that the bowels are still full.
- Bright red blood is visible after a bowel movement.
- The area around the anus is itchy, red, and sore.
- Pain occurs during the passing of a stool.
- Bleeding when you have a bowel movement – you may see blood (usually bright red) on toilet paper or drips in the toilet or on the surface of your poo
- A lump in or around your anus
- A slimy discharge of mucus from your anus
- A feeling of ‘fullness’ and discomfort in your anus, or a feeling that your bowels haven’t completely emptied after going to the toilet
- Itchy or sore skin around your anus
- Pain and discomfort after you go to the toilet
Piles can escalate into a more severe condition. This can include
- Excessive anal bleeding, also possibly leading to anemia
- Fecal incontinence, or an inability to control bowel movements
- Anal fistula, in which a new channel is created between the surface of the skin near the anus and the inside of the anus
- Strangulated hemorrhoid, in which the blood supply to the hemorrhoid is cut off, causing complications including infection or a blood clot
Diagnosis of Hemorrhoids
For practical purposes, internal hemorrhoids are further graded based on their appearance and degree of prolapse, known as Goligher’s classification:
- First-degree hemorrhoids (grade I) – The anal cushions bleed but do not prolapse;
- Second-degree hemorrhoids (grade II) – The anal cushions prolapse through the anus on straining but reduce spontaneously;
- Third-degree hemorrhoids (grade III) – The anal cushions prolapse through the anus on straining or exertion and require manual replacement into the anal canal; and
- Fourth-degree hemorrhoids (grade IV) – The prolapse stays out at all times and is irreducible. Acutely thrombosed, incarcerated internal hemorrhoids and incarcerated, thrombosed hemorrhoids involving circumferential rectal mucosal prolapse are also fourth-degree hemorrhoids.
- Hemorrhoids are typically diagnosed by physical examination.[rx]
- A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids.[rx]
- A rectal exam may be performed to detect possible rectal tumors, polyps, an enlarged prostate, or abscesses.[rx]
- This examination may not be possible without appropriate sedation because of pain, although most internal hemorrhoids are not associated with pain.[rx]Visual confirmation of internal hemorrhoids may require anoscopy, insertion of a hollow tube device with a light attached at one end.[rx]
- The two types of hemorrhoids are external and internal. These are differentiated by their position with respect to the pectinate line.[rx] Some persons may concurrently have symptomatic versions of both.[rx] If the pain is present, the condition is more likely to be an anal fissure or external hemorrhoid rather than internal hemorrhoid.[rx]
- Your GP may examine the outside of your anus to see if you have visible hemorrhoids, and they may also carry out an internal examination called a digital rectal examination (DRE). During a DRE, your GP will wear gloves and use lubricant. Using their finger, they’ll feel for any abnormalities in your back passage. A DRE shouldn’t be painful, but you may feel some slight discomfort.
- In some cases, further internal examination using a proctoscope may be needed. A proctoscope is a thin hollow tube with a light on the end that’s inserted into your anus. This allows your doctor to see your entire anal canal (the last section of the large intestine). GPs are sometimes able to carry out a proctoscopy. However, not all GPs have the correct training or access to the right equipment, so you may need to go to a hospital clinic to have the procedure.
Treatment of Hemorrhoids
- Conservative treatment typically – consists of foods rich in dietary fiber, intake of oral fluids to maintain hydration, nonsteroidal anti-inflammatory drugs, sitz baths, and rest.[rx] Increased fiber intake has been shown to improve outcomes[rx] and may be achieved by dietary alterations or the consumption of fiber supplements.[rx][rx] Evidence for benefits from sitz baths during any point in treatment, however, is lacking.[rx] If they are used, they should be limited to 15 minutes at a time.[rx] Decreasing the time spent on the toilet and not straining is also recommended.[rx]
- While many topical agents and suppositories – are available for the treatment of hemorrhoids, little evidence supports their use.[rx] Steroid-containing agents should not be used for more than 14 days, as they may cause thinning of the skin.[rx] Most agents include a combination of active ingredients.[rx] These may include a barrier cream such as petroleum jelly or zinc oxide, an analgesic agent such as lidocaine, and a vasoconstrictor such as epinephrine.[rx] Some contain Balsam of Peru to which certain people may be allergic.[rx][rx]
- Flavonoids – are of questionable benefit, with potential side effects.[rx][rx] Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery.[rx] Evidence does not support the use of traditional Chinese herbal treatment[rx].[rx]
- Corticosteroid cream – If you have severe inflammation in and around your back passage, your GP may prescribe corticosteroid cream[rx], which contains steroids. You shouldn’t use corticosteroid cream for more than a week at a time as it can make the skin around your anus thinner and the irritation worse.
- Painkillers – Common painkilling medication, such as paracetamol, can help relieve the pain of hemorrhoids. But if you have excessive bleeding, avoid using non-steroid anti-inflammatory drugs (NSAIDs), such as ibuprofen, as they can make rectal bleeding worse. You should also avoid using codeine painkillers as they can cause constipation. Your GP may prescribe products that contain a local anesthetic to treat painful hemorrhoids. Like over-the-counter topical treatments, these should only be used for a few days because they can make the skin around your back passage more sensitive.
- Laxatives – If you’re constipated, your GP may prescribe a laxative. Laxatives are a type of medicine that can help you empty your bowels.
- A treatment called sclerotherapy may be used as an alternative to banding. During sclerotherapy, a chemical solution is injected into the blood vessels in your back passage. This relieves pain by numbing the nerve endings at the site of the injection.
- It also hardens the tissue of hemorrhoid so a scar is formed. After about 4 to 6 weeks, hemorrhoid should decrease in size or shrivel up. You should avoid strenuous exercise for the rest of the day after having the injection. You may experience minor pain for a while and may bleed a little. You should be able to resume normal activities, including work, the day after the procedure.
- Electrotherapy, also known as electrocoagulation, is another alternative to banding for people with smaller hemorrhoids. During the procedure, a device called a proctoscope is inserted into the anus to locate hemorrhoid.
- An electric current is then passed through a small metal probe placed at the base of hemorrhoid, above the dentate line. The specialist can control the electric current using controls attached to the probe. The aim of electrotherapy is to cause the blood supplying hemorrhoid to thicken, which shrinks it. If necessary, more than one hemorrhoid can be treated during each session.
- Electrotherapy can either be carried out on an outpatient basis using a low electric current, or a higher dose can be given while the person is under a general anesthetic or spinal anesthetic. Rectal bleeding is another possible side effect of the procedure, but this is usually short-lived.
- Electrotherapy is recommended by the National Institute for Health and Care Excellence (NICE), and has been shown to be an effective method of treating smaller hemorrhoids.
- These venotonic agents were first described in the treatment of chronic venous insufficiency and edema. They appeared to be capable of increasing vascular tone, reducing venous capacity, decreasing capillary permeability[rx], and facilitating lymphatic drainage[rx] as well as having anti-inflammatory effects[rx].
- Although their precise mechanism of action remains unclear, they are used as an oral medication for hemorrhoidal treatment, particularly in Europe and Asia. Micronized purified flavonoid fraction (MPFF), consisting of 90% diosmin and 10% hesperidin, is the most common flavonoid used in clinical treatment[rx].
- The micronization of the drug to particles of less than 2 μm not only improved its solubility and absorption but also shortened the onset of action. A recent meta-analysis of flavonoids for hemorrhoidal treatment, including 14 randomized trials and 1514 patients, suggested that flavonoids decreased the risk of bleeding by 67%, persistent pain by 65% and itching by 35%, and also reduced the recurrence rate by 47%[rx]. Some investigators reported that MPFF can reduce rectal discomfort, pain and secondary hemorrhage following hemorrhoidectomy[rx].
Oral Calcium Dobesilate
- This is another venotonic drug commonly used in diabetic retinopathy and chronic venous insufficiency as well as in the treatment of acute symptoms of hemorrhoids[rx]. It was demonstrated that calcium dobesilate decreased capillary permeability, inhibited platelet aggregation and improved blood viscosity; thus resulting in a reduction of tissue edema[rx].
- A clinical trial of hemorrhoid treatment showed that calcium dobesilate, in conjunction with a fiber supplement, provided an effective symptomatic relief from acute bleeding, and it was associated with a significant improvement in the inflammation of hemorrhoids[rx].
- The primary objective of most topical treatment aims to control the symptoms rather than to cure the disease. Thus, other therapeutic treatments could be subsequently required. A number of topical preparations are available including creams and suppositories, and most of them can be bought without a prescription.
- Strong evidence supporting the true efficacy of these drugs is lacking. These topical medications can contain various ingredients such as local anesthesia, corticosteroids, antibiotics and anti-inflammatory drugs[rx].
- Topical treatment may be effective in selected groups of hemorrhoidal patients. For instance, Tjandra et al[rx] showed a good result with topical glyceryl trinitrate 0.2% ointment for relieving hemorrhoidal symptoms in patients with low-grade hemorrhoids and high resting anal canal pressures. However, 43% of the patients experienced a headache during the treatment.
- Which contains 0.25% phenylephrine, petrolatum, light mineral oil, and shark liver oil. Phenylephrine is a vasoconstrictor having a preferential vasopressor effect on the arterial site of circulation, whereas the other ingredients are considered protectants. Preparation-H is available in many forms, including ointment, cream, gel, suppositories, and medicated and portable wipes[rx]. It provides temporary relief of acute symptoms of hemorrhoids, such as bleeding and pain on defecation.
- A vast industry has evolved around preparatory creams and suppositories for treating hemorrhoids. These combinations of steroids, anesthetics, antiseptics and barrier creams may be effective in temporarily relieving the acute symptoms of the haemorrhoidal disease. Patients often return to these agents if symptoms recur, not realizing that symptoms fluctuate with time and may have resolved with simple hygiene alone.
- Unlike for these over-the-counter remedies, there is some evidence for the effectiveness of venotonic therapies. Oral flavonoid medication can control acute bleeding.[rx][rx]
Rubber Band Ligation
- Various outpatient treatments for symptomatic hemorrhoids exist. In the UK and many other countries, rubber band ligation (RBL) is the most commonly performed of these therapies.[rx] RBL uses a device that allows a rubber band to be applied to each hemorrhoid via a proctoscope.
- This band constricts the blood supply causing hemorrhoid to become ischaemic before being sloughed approximately 1–2 weeks later. The resultant fibrosis reduces any element of haemorrhoidal prolapse that may have been present. Although easy to perform, and with a short learning curve, care has to be taken to place the bands correctly to reduce the potential for severe pain.
- Various sclerosant solutions have been used for injecting piles. The comparative efficacy of these solutions is unclear. Less potent solutions such as 5% phenol in almond oil are more commonly used and probably have a lower risk of mucosal necrosis. Injection treatment is simple, safe and rapid, but probably not as effective as RBL.[rx]
- This treatment modality should probably be reserved for patients where bleeding is the main symptom and conservative therapy has not improved the symptoms (and other causes having been excluded). Other indications possibly include patients with a high risk of secondary hemorrhage (patients on anticoagulants and patients with advanced cirrhosis) and those who are immunocompromised.[rx],[rx]
- Infrared coagulation consists of a direct application of infrared waves to the haemorrhoidal pedicle resulting in necrosis and sloughing of the pile. Several applications are required per hemorrhoid but each takes a few seconds. Complications and efficacy are similar to RBL with some suggesting less pain presumably related to the lower volume of tissue necrosis.[rx]–[rx] Although a potential alternative to RBL, the equipment is expensive and there is a longer learning curve.
Bipolar, direct current and radiofrequency ablation therapy
- Application of low wattage bipolar diathermy results in tissue coagulation. The process takes up to 30 s and multiple applications to the same site are often required.[rx] Complications, including pain, bleeding, and fissuring, occur in around 10% of patients.
- Direct current therapy has gained recent favor in the form of Ultroid therapy, although the reasons for its popularity, other than aggressive marketing, are unclear. The procedure involves the application of a probe onto the haemorrhoidal cushion and application of a low direct current for around 10 min per hemorrhoid. Results are at best equivalent to injection sclerotherapy[rx] and RBL, but with the procedure taking significantly longer.
- Radiofrequency ablation cuts and coagulates haemorrhoidal tissue using less power (and hence less temperature) than other electrical equipment. A comparison with RBL suggested similar efficacy to RBL with less pain.[rx] Again equipment is expensive and the procedure has not gained universal acceptance.
- Numerous combinations of therapies have been described and include RBL with injection sclerotherapy[rx]or infrared coagulation.[rx] Again, the studies are of poor quality. Indeed, the description of some therapies involves almost daily outpatient visits over a few weeks. Such an intense therapy negates the advantage of an outpatient procedure, particularly as efficacy is not clear.
- With this caveat, the combination of RBL with injection sclerotherapy does make practical sense. Not only is the double therapy a ‘belt and braces’ approach but also the bolus of sclerosant below the band ligation may act to secure the band, reducing failure due to premature slippage.
- This is currently recommended as a treatment option for first- and second-degree hemorrhoids. The rationale of injecting chemical agents is to create a fixation of mucosa to the underlying muscle by fibrosis. The solutions used are 5% phenol in oil, vegetable oil, quinine, and urea hydrochloride or hypertonic salt solution[rx].
- It is important that the injection is made into submucosa at the base of the hemorrhoidal tissue and not into the hemorrhoids themselves; otherwise, it can cause immediate transient precordial and upper abdominal pain[rx].
- Misplacement of the injection may also result in mucosal ulceration or necrosis, and rare septic complications such as prostatic abscess and retroperitoneal sepsis[rx].
- Antibiotic prophylaxis is indicated for patients with predisposing valvular heart disease or immunodeficiency because of the possibility of bacteremia after sclerotherapy[rx].
Rubber Band Ligation
- Rubber band ligation (RBL) is a simple, quick, and effective means of treating first- and second-degree hemorrhoids and selected patients with third-degree hemorrhoids. Ligation of the hemorrhoidal tissue with a rubber band causes ischemic necrosis and scarring, leading to fixation of the connective tissue to the rectal wall.
- Placement of rubber band too close to the dentate line may cause severe pain due to the presence of somatic nerve afferents and requires immediate removal. RBL is safely performed in one or more than one place in a single session[rx] with one of several commercially available instruments, including hemorrhoid ligator rectoscope[rx] and endoscopic ligator[rx] which use suction to draw the redundant tissue into the applicator to make the procedure a one-person effort.
- The infrared coagulator produces infrared radiation which coagulates tissue and evaporates water in the cell, causing shrinkage of the hemorrhoid mass. A probe is applied to the base of hemorrhoid through the anoscope and the recommended contact time is between 1.0-1.5 s, depending on the intensity and wavelength of the coagulator[rx].
- The necrotic tissue is seen as a white spot after the procedure and eventually heals with fibrosis. Compared with sclerotherapy, infrared coagulation (IRC) is less technique-dependent and avoids the potential complications of misplaced sclerosing injection[rx]. Although IRC is a safe and rapid procedure, it may not be suitable for large, prolapsing hemorrhoids.
- Radiofrequency ablation (RFA) is a relatively new modality of hemorrhoidal treatment. A ball electrode connected to a radiofrequency generator is placed on the hemorrhoidal tissue and causes the contacting tissue to be coagulated and evaporized[rx].
- By this method, vascular components of hemorrhoids are reduced and hemorrhoidal mass will be fixed to the underlying tissue by subsequent fibrosis. RFA can be performed on an outpatient basis and via an anoscope similar to sclerotherapy. Its complications include acute urinary retention, wound infection, and perianal thrombosis. Although RFA is a virtually painless procedure, it is associated with a higher rate of recurrent bleeding and prolapse[rx].
- Cryotherapy ablates the hemorrhoidal tissue with a freezing cryoprobe. It has been claimed to cause less pain because sensory nerve endings are destroyed at very low temperature. However, several clinical trials revealed that it was associated with prolonged pain, foul-smelling discharge and a high rate of persistent hemorrhoidal mass[rx]. It is therefore rarely used.
- The operation is indicated when non-operative approaches have failed or complications have occurred. Different philosophies regarding the pathogenesis of hemorrhoidal disease create different surgical approaches.
|Theory||Short description||Surgical approach|
|Sliding anal cushions||Hemorrhoids develop when the supporting tissues of the anal cushions disintegrate or deteriorate||Hemorrhoidectomy, plication|
|Rectal redundancy||Hemorrhoidal prolapse is associated with an internal rectal prolapse||Stapled hemorrhoidopexy|
|Vascular abnormality||Hyperperfusion of arteriovenous plexus within anal cushion results in the formation of hemorrhoids||Doppler-guided hemorrhoidal artery ligation|
- Excisional hemorrhoidectomy is the most effective treatment for hemorrhoids with the lowest rate of recurrence compared to other modalities[rx]. It can be performed using scissors, diathermy[rx,rx], or vascular-sealing device such as Ligasure (Covidien, United States)[rx,rx] and Harmonic scalpel (Ethicon Endosurgery, United States)[rx,rx]. Excisional hemorrhoidectomy can be performed safely under perianal anesthetic infiltration as an ambulatory surgery[rx,rx].
- Indications for hemorrhoidectomy include failure of non-operative management, acute complicated hemorrhoids such as strangulation or thrombosis, patient preference, and concomitant anorectal conditions such as anal fissure or fistula-in-ano which require surgery[rx]. In clinical practice, the third-degree or fourth-degree internal hemorrhoids are the main indication for hemorrhoidectomy.
- A major drawback of hemorrhoidectomy is postoperative pain[rx]. There has been evidence that Ligasure hemorrhoidectomy results in less postoperative pain, shorter hospitalization, faster wound healing and convalescence compared to scissors or diathermy hemorrhoidectomy[rx–rx]. Other postoperative complications include acute urinary retention (2%-36%), postoperative bleeding (0.03%-6%), bacteremia and septic complications (0.5%-5.5%), wound breakdown, unhealed wound, loss of anal sensation, mucosa prolapse, anal stricture (0%-6%), and even fecal incontinence (2%-12%)[rx–rx]. Recent evidence has suggested that hemorrhoidal specimens can be exempt from pathological examination if no malignancy is suspected[rx].
- Plication is capable of restoring anal cushions to their normal position without excision. This procedure involves oversewing of hemorrhoidal mass and tying a knot at the uppermost vascular pedicle. However, there are still a number of potential complications following this procedure such as bleeding and pelvic pain[rx].
Doppler-guided hemorrhoidal artery ligation
- A new technique based on doppler-guided ligation of the terminal branches of the superior hemorrhoidal artery was introduced in 1995 as an alternative to hemorrhoidectomy[rx]. Doppler-guided hemorrhoidal artery ligation (DGHAL) has become increasingly popular in Europe. The rationale of this treatment was later supported by the findings from vascular studies[rx,rx], which demonstrated that patients with hemorrhoids had increased caliber and arterial blood flow of the terminal branch of the superior rectal arteries.
- Therefore, ligating the arterial supply to hemorrhoidal tissue by suture ligation may improve hemorrhoidal symptoms. DGHAL is most effective for second- or third-degree hemorrhoids. Notably, DGHAL may not improve prolapsing symptoms in advanced hemorrhoids. Short-term outcomes and 1-year recurrence rates of DGHAL did not differ from those of conventional hemorrhoidectomy[rx]. Given the fact that there is the possibility of revascularization and recurrence of symptomatic hemorrhoids, further studies on the long-term outcomes of DGHAL are still required[rx].
- Stapled hemorrhoidopexy (SH) has been introduced since 1998[rx]. A circular stapling device is used to excise a ring of redundant rectal mucosa proximal to hemorrhoids and resuspend the hemorrhoids back within the anal canal. Apart from lifting the prolapsing hemorrhoids, blood supply to hemorrhoidal tissue is also interrupted.
- A recent meta-analysis comparing surgical outcomes between SH and hemorrhoidectomy, which included 27 randomized, controlled trials with 2279 procedures, showed that SH was associated with less pain, earlier return of bowel function, shorter hospital stay, earlier return to normal activities, and better wound healing, as well as a higher degree of patient satisfaction[rx].
- However, in the longer term, SH was associated with a higher rate of prolapse[rx,rx,rx]. Considering the recurrence rate, cost of stapling device and potential serious complications including rectovaginal fistula[rx] and rectal stricture[rx,rx], SH is generally reserved for patients with circumferential prolapsing hemorrhoids and having ≥ 3 lesions of advanced internal hemorrhoids.
Acutely Thrombosed or Strangulated Internal Hemorrhoids
- Patients with acutely thrombosed or strangulated internal hemorrhoids usually present with severely painful and irreducible hemorrhoids. The incarcerated hemorrhoids may become necrotic and drain. This situation is quite difficult to treat particularly in a case of extensive strangulation or thrombosis [rx]), or the presence of underlying circumferential prolapse of high-graded hemorrhoids.
- Manual reduction of the hemorrhoid masses, with or without intravenous analgesia or sedation, might help reducing pain and tissue congestion. Urgent hemorrhoidectomy is usually required in these circumstances. Unless the tissues are necrotic, mucosa and anoderm should be preserved as much as possible to prevent postoperative anal stricture. In expert hands, surgical outcomes of urgent hemorrhoidectomy were comparable to those of elective hemorrhoidectomy[rx]. Complicated hemorrhoids. A: Strangulated internal hemorrhoid; B: Acutely thrombosed external hemorrhoid.
Acutely Thrombosed External Hemorrhoids
- Acutely thrombosed external hemorrhoids often develop in patients with acute constipation, or those with a recent history of prolonged straining. A painful bluish-colored lump at the anal verge is a paramount finding (Figure [rx]. The severity of pain is most intense within the first 24-48 h of onset. After that, the thrombosis will be gradually absorbed and patients will experience less pain.
- As a result, surgical removal of acute thrombus or excisional hemorrhoidectomy may be offered if patients experience severe pain especially within the first 48 h of onset. Otherwise, the conservative measure will be exercised including pain control, warm sitz baths, and avoidance of constipation or straining. A resolving thrombosed external hemorrhoid could leave behind as a residual perianal skin tag -which may or may not require a subsequent excision.
Hemorrhoids in Pregnancy
- Hemorrhoids are very common during pregnancy especially in the third trimester[rx]. An acute crisis such as profound bleeding and irreducible prolapsing may be found in pregnant women with pre-existing hemorrhoids. Since hemorrhoids and its symptoms will gradually resolve after giving birth, the primary goal of treatment is to relieve acute symptoms related to hemorrhoids – mostly by means of dietary and lifestyle modification.
- Kegel exercises, lying on the left side, and avoidance of constipation could reduce the episode and severity of bleeding and prolapse. A fiber supplement, stool softener, and mild laxatives are generally safe for pregnant women. Topical medication or oral phlebotonics may be used with special caution because the strong evidence of their safety and efficacy in pregnancy is lacking. In the case of massive bleeding, anal packing could be a simple and useful maneuver. Hemorrhoidectomy is reserved in strangulated or extensively thrombosed hemorrhoids, and hemorrhoids with intractable bleeding.
Hemorrhoids in Immunocompromised Patients
- In general, any intervention or operation should be avoided, or performed with careful consideration in immunocompromised patients because of an increased risk of anorectal sepsis and poor tissue healing in such cases[rx]. A conservative measure is a mainstay for the treatment of hemorrhoids in this group of patients.
- If required, injection sclerotherapy appeared to be a better and safer alternative to banding and hemorrhoidectomy for treating bleeding hemorrhoids[rx,rx]. Antibiotic prophylaxis is always given before performing any intervention, even a minor office-based procedure, due to the possibility of bacteremia.
Hemorrhoids in Patients with Cirrhosis or Portal Hypertension
- A clinician must differentiate bleeding hemorrhoids from bleeding anorectal varices because the latter can be managed by suture ligation along with the course of varices, transjugular intrahepatic portosystemic shunt, or pharmacological treatment of portal hypertension[rx].
- Since a majority of bleeding hemorrhoids in such patients is not life threatening, conservative measure with the correction of any coagulopathy is a preferential initial approach. Of note, rubber band ligation is generally contraindicated in patients with advanced cirrhosis due to the risk of profound secondary bleeding following the procedure.
- Injection sclerotherapy is an effective and safe procedure for treating bleeding hemorrhoids in this situation. In a refractory case, suture ligation at the bleeder is advised. Hemorrhoidectomy is indicated when bleeding hemorrhoids are refractory to other approaches.
Hemorrhoids in Patients Having Anticoagulant or Antiplatelet drugs
- Anticoagulant or antiplatelet drugs may promote anorectal bleeding in patients with hemorrhoids and increase the risk of bleeding after banding or surgery[rx].
- Unless the bleeding is persistent or profound, the discontinuity of antithrombotic drugs may be unnecessary because most of the bleeding episodes are self-limited and stop spontaneously. Conservative measure is, therefore, the mainstay treatment in these patients. Injection sclerotherapy is preferential treatment for bleeding low-graded hemorrhoids refractory to medical treatment.
- Rubber band ligation is not recommended in patients with the current use of anticoagulant or antiplatelet drugs due to the risk of secondary bleeding. If banding or any form of surgery for hemorrhoids is scheduled, the cessation of anticoagulant or antiplatelet drugs about 5-7 d before and after the procedure is suggested[rx].
- Stapled hemorrhoidopexy, also known as a procedure for prolapse and hemorrhoids (PPH), is an alternative operation for treating advanced internal hemorrhoids. A circular staple device is used to excise a ring of redundant rectal mucosa just above hemorrhoid bundles – not hemorrhoids per se.
- By doing this, prolapsing hemorrhoids will be repositioning (hemorrhoidopexy) and shrinking (due to a partial interruption of blood supply to hemorrhoid plexus). A recent systematic review of 27 randomized controlled trials demonstrated that, compared with conventional hemorrhoidectomy, stapled hemorrhoidopexy had less pain, shorter operative time, and quicker patient’s recovery of a patient, but a significantly higher rate of prolapse and reintervention for prolapse[rx].
Piles rarely cause any serious problems but sometimes they can lead to the following.
- External piles (swellings that develop further down your anal canal, closer to your anus) can become inflamed and swollen; ulcers can also form on them.
- Skin tags can form when the inside of a pile shrinks back but the skin remains. For more information, see our FAQ: Skin tags, below.
- If mucus leaks from your anus, it can make the surrounding skin very sore.
- Internal piles that prolapse (hang down) can sometimes get strangulated and lose their blood supply. If blood clot forms (thrombosis), piles can be very painful. External piles can also become thrombosed.