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Hemorrhoidectomy
Goals/Objectives
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Anatomy
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Indications
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Techniques
Diseases of the Anorectum
From Feldman M, et al: Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 9th edition (Saunders 2010)
Internal Hemorrhoids
Symptoms and Signs
It is speculated that internal hemorrhoids become symptomatic when their supporting structures become disrupted and prolapse of the vascular cushions occurs. Hemorrhoids occur more commonly in people with constipation who have hard, infrequent stools. They also can occur in patients who have frequent loose stools or if prolonged periods of time are spent sitting on the toilet, leading to vascular congestion. Bleeding is typically painless and the patient describes bright red blood usually seen on the toilet tissue, dripping into the toilet bowl, or streaking the outside of a hard stool. If the bleeding is more substantial, the blood can accumulate in the rectum and be passed later as dark blood or clots. If the patient has chronic hemorrhoidal prolapse, blood or mucus might stain the patient's underwear, and the mucus against the anal skin might lead to itching.
Diagnosis
The diagnosis of internal hemorrhoids is best made with the beveled anoscope or by flexible sigmoidoscopy and retrograde view of the anorectal junction. The vascular cushions can be seen to bulge into the anal lumen, or the tissue might prolapse out through the anal canal. It is important to note that hemorrhoids are dynamic structures and may be symptomatic only intermittently. If the patient is seen outside of a flare, the hemorrhoids can appear entirely normal.
Treatment
Treatment is based on the grade of the hemorrhoids. Grade 1 and some early grade 2 internal hemorrhoids usually respond to manipulation of the diet, along with avoidance of medications that promote bleeding, such as nonsteroidal anti-inflammatory drugs (NSAIDs). A high-fiber diet, with 20 to 30 g of fiber daily introduced gradually into the diet, should be accompanied by six to eight glasses of nonalcoholic, noncaffeinated fluid daily. Patients are encouraged to read the package regarding the amount of fiber per serving; for instance, a bowl of raisin bran cereal can have eight grams of dietary fiber per serving whereas a similar portion of corn flakes has only one gram. Fiber supplementation with psyllium or hydrophilic colloid may be added to achieve the optimal amount of daily fiber, if the patient's daily dietary fiber is insufficient. In my experience, patients who can achieve adequate dietary fiber intake without supplements have better long-term relief of hemorrhoidal disease with dietary change than those who need daily supplementation.
Patients are urged to avoid straining during defecation and reading while on the toilet. Excessive scrubbing of the anus when showering or bathing or excessive wiping after a bowel movement is discouraged. Most over-the-counter agents are not efficacious, even though many patients report some relief of their symptoms with use of these products. Sometimes a stool softener such as docusate sodium or a lubricant such as mineral oil can be prescribed if the stool is hard and does not respond to increased intake of fiber and fluid; laxatives and enemas rarely are needed. Even patients who require more aggressive treatment of their hemorrhoids should be advised to increase their dietary fiber and fluids and to avoid straining during defecation to prevent recurrence after treatment.
When manipulation of the diet does not work, more aggressive treatment may be needed; these measures can apply to grades 1, 2, and 3 internal hemorrhoids. Unless the patient has fourth-degree internal hemorrhoids, aggressive nonsurgical treatment usually is tried; the majority of patients with fourth-degree hemorrhoids require surgical intervention. Most nonoperative treatments are designed to affix the vascular cushion to the underlying sphincter. Options to achieve such fixation include sclerotherapy, rubber band ligation, cryotherapy, and infrared photocoagulation.
Sclerosing Agents.
Injection therapy for hemorrhoids has been practiced for more than 100 years. The goal is to inject an irritant into the submucosa above the internal hemorrhoid at the anorectal ring (the area that does not have somatic innervation) to create fibrosis, tack down the hemorrhoid and prevent hemorrhoidal prolapse. Usually less than one milliliter of sclerosant is needed to create a raised area. Many substances have been used, but sterile arachis oils containing 5% phenol are the most popular. This approach usually is advocated for first- and second-degree hemorrhoids.
Sclerotherapy can produce a dull pain for up to two days after injection. A rare but severe complication is life-threatening perineal sepsis, which can occur three to five days after injection and usually is manifested by any combination of perianal pain or swelling, watery anal discharge, fever, leukocytosis, and other signs of sepsis. Prompt surgical intervention and intravenous antibiotics are mandatory. Approximately 75% of patients with second-degree hemorrhoids improve after injection therapy.
In patients with active acquired immunodeficiency syndrome (AIDS), injection therapy may be favored over surgical treatments because of concerns about the patient's poor overall general condition. There also may be problems with wound healing for these patients, but successful treatment of second-, third-, and fourth-degree hemorrhoids without complications has been reported in patients with AIDS, some of whom did require repeat treatment to manage persistent symptoms.
Rubber Band Ligation.
Rubber band ligation (RBL) has become the most common office procedure for the treatment of second- and third-degree hemorrhoids. Generally, this approach cannot be used with first-degree hemorrhoids, because there is insufficient tissue to pull into the bander; this treatment is not appropriate for fourth-degree hemorrhoids.
Rubber bands are applied to the hemorrhoidal complex and rectal mucosa just proximal to the internal anal cushion. To avoid severe pain, bands are never placed below the dentate line, which is innervated by somatic fibers. The number of bands that can be safely placed in one setting remains controversial. Several studies have shown that triple RBL is safe and effective at one sitting, but many authorities believe that the severity of pain and risk of complications are less if one band is applied per visit. I typically place a single band at the first visit, and if that is well tolerated, I place two bands during the next and subsequent visit. Most grade 2 or 3 hemorrhoids can be managed successfully with two or three RBL procedures.
Patients can experience discomfort after RBL; soaking in a sitz bath and taking acetaminophen usually constitute sufficient treatment. Immediate severe pain usually signals that the band has been placed too close to the dentate line and that it must be removed. After RBL, patients are instructed to increase the fiber in their diet and modify their bowel habits, as discussed previously. When RBL can be performed, success is reported in 75% of patients with first-degree and second-degree hemorrhoids and in 65% of those with third-degree hemorrhoids. Repeated RBL is an option for patients who continue to have prolapsing tissue.
Major complications from RBL include bleeding, sepsis, cellulitis, and death. Bleeding when the band and necrotic hemorrhoidal tissue comes off four to seven days after application may be severe and even life-threatening; severe bleeding occurs in about 1% of patients and usually can be tamponaded by placing a large-caliber Foley catheter in the rectum, filling the balloon with 25 to 30 mL or more of fluid, and pulling the balloon tightly against the top of the anal ring. If this approach fails, epinephrine can be injected at the bleeding site, but sometimes a suture is required to stop the bleeding.
A more serious complication is sepsis. There have been five recorded deaths, two additional patients with life-threatening sepsis, and three cases of severe pelvic cellulitis following RBL of hemorrhoids. The onset of sepsis usually is two to eight days after RBL in otherwise healthy people. New or increasing anal pain, sometimes radiating down the leg, or difficulty voiding may be the first indications of a life-threatening infection. Immediate intravenous antibiotics and surgical débridement are required.
Cryotherapy.
Cryotherapy freezes tissue, thereby destroying the hemorrhoidal plexus. Once a popular treatment, its use has declined because of the profuse, foul-smelling discharge resulting from tissue necrosis. The procedure also can be painful, and healing can be prolonged.
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