Kiss Your Hemorrhoids Goodbye: Surgical and Non-Surgical Management Options Patricia L. Raymond MD FACG, Rx For Sanity There seem to be many options to manage our patients' hemorrhoids: hemorrhoidectomy, banding, sclerotherapy, laser photocoagulation, topical medications. Which option is the best for your patient? The physiology and management of the bitter end of the gastrointestinal tract. Objectives: The participant will… Distinguish between internal and external hemorrhoids, review the anorectal anatomy and understand the grading system for internal hemorrhoids. Categorize the differential diagnosis of hemorrhoids, including proctalgia fugax, anal fissure, perianal crohns disease, anal cancer, condyloma, skin tags and rectal prolapse Examine specific medical, endoscopic, office, and surgical treatment options for hemorrhoids and their stated efficacy

1. Kiss Your Hemorrhoids Goodbye:
Surgical &
Non-Surgical
Management Options
Patricia L. Raymond MD FACG
Rx For Sanity
Norfolk, Virginia

2. Hemorrhoids were always with us

3. • Medieval physicians used
cautery irons to treat
hemorrhoids
• Others believed that
simply pulling them out
with their fingernails was
the cure (a solution
endorsed by the Greek
physician, Hippocrates)

4. Hemorrhoids are caused by:
• Straining
> Work strain (lifting
patients, etc.)
> Straining while
defecating
— Chronic constipation
— Passing hard, dry,
small stools
— Laxative abuse
• Increased intra-
abdominal pressure
> Pregnancy
• Being alive

5. • 10 million people in the United States have
hemorrhoids
> Prevalence rate 4.4%.
> Peaks from age 45-65 years
> Decrease after age 65 years
> Hemorrhoids before age 20 unusual.
• Caucasian > African American
• Increased prevalence rates associated with
higher socioeconomic status
The prevalence of hemorrhoids and chronic constipation. An epidemiologic
study. Johanson JF, Sonnenberg A Gastroenterology. 1990;98(2):380.

6. • Contrast hemorrhoids with the epidemiology
of constipation
> Exponential increase after age 65 years
> More common in blacks
> More common in families with
low incomes or low social status
—Causality between constipation and
hemorrhoids questioned
The prevalence of hemorrhoids and chronic constipation. An epidemiologic
study. Johanson JF, Sonnenberg A Gastroenterology. 1990;98(2):380.

7. What are
hemorrhoids
& how do we
get them?

8. • Arise from a plexus
(sometimes called a
"cushion") of dilated
arteriovenous
channels and
connective tissue
• Veins from the
superior, middle, and
inferior rectal vein
http://web.uni-
plovdiv.bg/stu1104541018/docs/res/skandalakis%27%20surgical%20anatomy%2
0-
%202004/Chapter%2018_%20Large%20Intestine%20and%20Anorectum_fichier
s/loadBinaryCABXCEBK.jpg

9. The Dentate Line
• External or internal based
upon whether they are
below or above the
dentate line
> The dentate line) is a line
which divides the upper
2/3 and lower 1/3 of the
anal canal.
Developmentally, this line
represents the hindgut-
proctodeum junction
• Often both types of
http://shoppe.listentoyourgut.com/hemorrheal-external-
hemorrhoids coexist
hemorrhoid-kit-ebook-ingredients/

10. Internal hemorrhoids
• Arise from the superior
hemorrhoidal cushion.
• Three primary locations
> left lateral, right anterior, and
right posterior
• Fed from the end
branches of the middle
and superior rectal veins
• Overlying mucosa is rectal
• Innervation is visceral
http://tophemorrhoidtreatments.com/internal-and-
external-hemorrhoids

11. External hemorrhoids
• Arise from the inferior
hemorrhoidal plexus
• Located beneath the
dentate line
• Covered with
squamous epithelium
> Numerous somatic pain
receptors.
http://proctologyspecialists.com/procedures/thr
ombosed-external-hemorrhoid

12. What aren‟t
hemorrhoids?

13. Skin tags
• Sometimes confused
with external
hemorrhoids.
• Associated with
> anal fissures
> perianal Crohn's disease
> residual excess skin
associated with prior
thrombosis of external
hemorrhoids
http://hemorrhoidheal.com/Services/anorectal-care-
http://skin212.com/anal-flap.php hemorrhoid-hemorrhoids/anorectal-care-anal-tag-
removal.html

14. Anal fissures and fistulae
http://www.sciencedirect.com/science/article/pii/S http://www.specialityclinic.com/DiseaseCondition.
1043148912000486 aspx?DID=48

15. Anal fissures
http://www.homeouniverse.com/category/disease
http://www.chennaicolorectalclinic.com/#!anal-fissure s/stomach-diseases/

16. Rectal varices
• Hemorrhoids have direct
communication with the portal
system, and can also exist in
close proximity to rectal varices
in patients who have portal
hypertension
• Hemorrhoids are not more
common in patients with portal
hypertension
• Rectal varices are treated with
banding or TIPPS
http://integrisok.com/nazih-zuhdi-transplant-institute-
oklahoma-city-ok/pre-liver-transplant-work-up
http://www.gastrointestinalatlas.com/English/Colon_and_
Rectum/Miscellaneous/miscellaneous.html

17. Perianal Crohn‟s disease
http://learncolorectalsurgery.blogspot.com/2009/04/colon-was-
http://www.karelsavry.com/guide_7/clinical_signs_and_symptoms_1.html fully-mobilized-and-extensive.html

18. Condyloma Acuminata (Anal
warts)
• Human papilloma
virus
http://missinglink.ucsf.edu/lm/DermatologyGlossa http://ibmi3.mf.uni-lj.si/mmd/derma/eng/sz-
ry/condylomata_lata.html 00/sldr00047.html

19. Rectal Prolapse (Rectal Procidentia)
• Pelvic floor disorder
http://www.primehealthchannel.com/r
ectal-prolapse.html
http://dakkoss.seesaa.net/category/71
00169-1.html

20. Can you identify it?

21. EXTERNAL HEMORRHOIDS
http://vanithango.org/cream/do-internal-hemorrhoids-cause-stomach-pain

22. ANAL/RECTAL FISTULAS
http://intranet.tdmu.edu.ua/data/kafedra/internal/surgery2/classes_stud/%D0%A5i%D1%80%D1%83%D1%80%D0%B3i%D1%8F/6%20
%D0%BA%D1%83%D1%80%D1%81/English/Topic%2012.%20Non-
neoplastic%20diseases%20of%20the%20rectum%20%28Hemorrhoids.%20Acute%20and%20chronic%20paraproctitis%29.htm

23. RECTAL PROLAPSE
http://www.orlandocolon.com/photo-library/full-thickness-rectal-prola.html

24. PROLAPSING INTERNAL
(STAGE 4)
& EXTERNAL HEMORRHOIDS
tp://www.consultant360.com/article/anorectal-complaints-office-diagnosis-and-treatment-part-1

25. PROLAPSED & STRANGULATED
INTERNAL HEMORRHOIDS
(GRADE 4)
http://www.gastrohep.com/images/image.asp?id=241

26. RECTAL CANCER
http://medicalpicturesinfo.com/rectal-cancer/

27. NORMAL ANUS
http://www.gastrolab.net/g4g03.htm

28. RECTAL PROLAPSE
http://www.emedicinehealth.com/rectal_prolapse/page16_em.htm

29. INTERNAL HEMORRHOIDS
ttp://www.sciencedirect.com/science/article/pii/S0016510703028189

30. CONDYLOMA
http://dermatology.cdlib.org/1412/case_presentations/intraanal_condyloma/dianzani.html

31. ANAL FISSURE
http://www.topgradtv.com/hemorrhoids-symptoms-and-causes /

32. RECTAL CANCER
http://medicalpicturesinfo.com/rectal-cancer/

33. RECTAL FISTULA
http://www.murrasaca.com/proctology.htm

34. CONDYLOMA
ttp://www.hemorrhoidshemroids.com/anal-warts-hpv-hemroids-hemorrhoids.html

35. RECTAL CANCER
http://medicalpicturesinfo.com/rectal-cancer/

37. How are
hemorrhoids
graded or
described?

38. Classification of internal hemorrhoids
• Degree of prolapse
from the anal canal:
> Grade I visualized on
anoscopy, and may
bulge into the
lumen, but do not
extend below the
dentate line
> Grade II prolapse out of
the anal canal with
defecation or with
straining, but reduce http://www.endoatlas.org/index.php?page=results_jquery&mstc
spontaneously at=5&subcat=8

39. Prolapsed Internal Hemorrhoids
> Grade III prolapse out
of the anal canal with
defecation or straining,
and require the patient
to reduce them into
their normal position
> Grade IV hemorrhoids
are irreducible and may
strangulate
http://www.uptodate.com/contents/image?imageKey=SURG%2
F64871&topicKey=SURG%2F15025&rank=1~34&source=see_
link&search=rectal+prolapse&utdPopup=true

40. No widely used classification system
of external hemorrhoids exists!

41. iPhone Mania!

42. How do we
treat
hemorrhoids?

43. Hemorrhoid Advice by Anonymous
Even though it may take Though its been said, it
weeks bears repeating;
To heal the wound Nothing but canned soup
between your cheeks, for eating.
I provide this rule of Fruit will get your bowels
thumb a-grooving
To nurse your Before you know it, you’ll
recuperating bum. be up and moving

44. Exercise is out of the Heed my advice and
question! don’t be foolish,
Beware of any such The results may be so
suggestion. very ghoulish.
No unicycles, horseback To avoid a thrombosis so
riding. abrupt,
Leapfrog, bowling, or Keep your cool and
ninja fighting. Bottoms Up!

46. Conservative Management of Hemorrhoids
• Bleeding
> Fiber
• Pruritis
> Topical Creams
> Hydrocortizone
> Sitz Baths
> (?Fiber)
• General
> Cleansing wipes
> NTG/Ca channel
blockers

47. Fiber and Hemorrhoids
• Meta-analysis of
seven controlled trials
> fiber supplementation
reduced bleeding (RR
0.50, 95% CI 0.28-0.68)
• Hemorrhoidal
prolapse was not
affected by fiber
supplementation
Laxatives for the treatment of hemorrhoids.
Alonso-Coello P, Guyatt G, Heels-Ansdell D,
Johanson JF, Lopez-Yarto M, Mills E, Zhou Q
Cochrane Database Syst Rev. 2005

49. Irritation and pruritus
• Sitz baths • Analgesic creams,
> Warm water two to hydrocortisone
three times per day suppositories, & warm
— Effectiveness may in part sitz baths
be related to relaxation of
the internal anal sphincter • Do not use creams or
• Fiber supplementation hydrocortisone > one
may relieve pruritus week
related to fecal soilage > Side effects may occur
> bulking effect of fiber — Contact dermatitis with
analgesic creams
may reduce leakage of
— Mucosal atrophy with
liquid stool steroid creams

50. Avoid Spicy Foods? Capsaicin for hemorrhoids
• No evidence that spicy
foods worsen irritation
and pruritus
Red hot chili pepper and
hemorrhoids: the explosion of a
myth: results of a prospective,
randomized, placebo-controlled,
crossover trial.
Altomare DF, Rinaldi M, La Torre F,
Scardigno D, Roveran A, Canuti S,
Morea G, Spazzafumo L Dis Colon
Rectum. 2006;49(7):1018.
Gut. 2003 September; 52(9): 1323–
1326. Topical capsaicin—a novel
and effective treatment for
idiopathic intractable pruritus ani: a
randomised, placebo controlled,
crossover study J Lysy, M Sistiery-
Ittah, Y Israelit, et al.

51. Witch hazel (Hamamelis)
• Astringent
• Various forms
> Ointments, pads
> Little scientific
evidence, said to
temporarily shrink
hemorrhoids
„Napoleon's Haemorrhoids', by Phil Mason,
says that the French emperor was suffering from
an acute attack of piles that stopped him riding
his horse, and supervising the troops during the
battle of Waterloo.
Two days before the battle, Napoleon's doctors
lost the leeches that they used to relieve his
agony, and accidentally overdosed him with the
painkiller laudanum. Napoleon was still suffering
from the effects of the painkiller when the battle
broke out.

53. Other Conservative Management Ideas
• Moistened hypoallergenic
wipes
• Nitoglycerine ointment
> Rectiv 0.4%
• Diltiazem/Nifedipine ointment or
combined
Dis Colon Rectum. 2001 Mar;44(3):405-9.
Conservative treatment of acute
thrombosed external hemorrhoids with
topical nifedipine. Perrotti P, Antropoli C,
Molino D, De Stefano G, Antropoli M.
J Coll Physicians Surg Pak. 2009
Oct;19(10):614-7
Topical diltiazem hydrochloride and
glyceryl trinitrate in the treatment of
chronic anal fissure Jawaid M, Masood Z,
Salim M

55. Ambulatory Procedures for Internal Hemorrhoids
• Remove or to cause • Rubber band ligation
sloughing of excess • Infrared coagulation
hemorrhoidal tissue • Bipolar diathermy (Bicap)
• Healing and scarring • Laser photocoagulation
fixes the residual • Sclerotherapy
tissue to the • Cryosurgery
underlying anorectal
muscular ring

56. Which ambulatory technique for internal hemorrhoids?
Meta analysis of 18 trials
• Surgical hemorrhoidectomy • Rubber band ligation
better than dilation or band obliterated varices better than
ligation for preventing recurrent sclerotherapy.
symptoms. • Patients treated with
• Rubber band ligation was sclerotherapy or infrared
associated with fewer coagulation were more likely to
complications and pain than require further treatment than
surgery. those with rubber-band ligation.
Based upon these findings, it was suggested
that the optimal treatment for symptomatic
grade I to III hemorrhoids unresponsive to
conservative measures was rubber band
ligation. of hemorrhoidal treatments: a meta-analysis.
Comparison
MacRae HM, McLeod RS Can J Surg. 1997;40(1):14.

58. Complications of rubber band ligation
• Pain 8% • Thrombosis
> Misapplication of the > distal hemorrhoids
band below the dentate thrombose, leading to
line or spasm pain or a palpable
• Delayed hemorrhage mass.
> When the rubber band • Infection/abscess
dislodges, typically 2-4 > Persistent pain, fever,
days post procedure or or foul smelling rectal
ulceration/ mucosal drainage Sepsis is rare
sloughing at 5-7 days

59. Rubber band ligation of internal hemorrhoids:
Less pain, shorter time off work

61. External hemorrhoids:
Thrombosis management—soon or not at all
• External • After 48 hours,
hemorrhoids do not organization of the
usually require thrombus and
minimally invasive improvement of
or surgical therapy symptoms no need
• Patients seen within for surgical
72 hours of evacuation
thrombosis may
benefit from surgical
evacuation for pain
relief

63. But if you need to say “YES”…
• Initial treatment of choice in patients with
> symptomatic or strangulated grade IV hemorrhoids
> symptomatic grade III hemorrhoids
> thrombosed external hemorrhoids.
• American Gastroenterological Association, 2004
> Failure of medical and nonoperative therapy
> Symptomatic third-degree, fourth-degree, or mixed internal and external
hemorrhoids
> Symptomatic hemorrhoids in the presence of a concomitant anorectal
condition that requires surgery
> Patient preference after discussion of the treatment options with the
referring physician and surgeon.

64. Techniques for the operative treatment of hemorrhoids
• Closed
hemorrhoidectomy
• Open
hemorrhoidectomy
with excision and
ligation
• Stapled
hemorrhoidectomy
• Lateral internal
sphincterotomy

65. Closed hemorrhoidectomy
• The most common • Make the ellipse relatively
surgery for internal narrow, and to remove
hemorrhoids only the redundant
• Elliptical incision is made anoderm and
starting on the external hemorrhoidal tissue, close
hemorrhoidal tissue and defect with continuous
extending proximally absorbable suture
across the dentate line to • Three columns treated
the superior extent of the • 95% successful, low
hemorrhoidal column infection rate

66. http://colorectal.surgery.ucsf.edu/conditions--procedures/hemorrhoidectomy.aspx

67. http://colorectalsurgeonssydney.com.au/?page_id=379

68. You deserve a medal…

69. Proctalgia fugax
• Intermittent, recurrent, • 4 to 18% of population,
severe, self-limited although only 17 to 20
functional rectal pain percent of patients report
> Pain for few seconds to two symptoms to MD
hours, asymptomatic • 58 to 84 female
between episodes, < 5 x per
year in 50% • Mean age at dx 46 - 58
years
• NOT more common in
patients with IBS
• Diagnosis requires
exclusion of other causes
of rectal or anal pain

70. Proctalgia fugax
• Pathophysiology • Treatment (?)
> Spasm of the smooth > Warm water 40 o C /104 o F
muscle of the internal as hot baths and warm water
enemas
anal sphincter (we
> Topical nitroglycerin
think!)
> Oral nifedipine or diltiazem
> Pudendal nerve > Inhaled albuterol
compression or > Also: Botulinum toxin
neuralgia injection, pudendal nerve
blocks, and superior
hypogastric plexus blocks

71. St. Fiacre
the patron saint of
hemorrhoid suffers
Also:
• gardeners
• taxi cab drivers
• venereal disease sufferers
• barrenness
• box makers
• fistula sufferers
• florists
• hosiers
• pewterers
• tile makers
• ploughboys

72. St. Fiacre
the patron saint of hemorrhoid suffers
• Seventh century Irish monk
• Developed hemorrhoids from
digging in his garden
• Sat on a stone which gave
him a miraculous cure.
• The stone survives to this
day with the imprint of his
hemorrhoids and is visited
by many hoping for a
similar cure.
• Inflamed hemorrhoids
often ―St. Fiacre‟s
curse‖ in the Middle
Ages.

73. Why didn’t they call them
Asteroids?

75. Kiss Your Hemorrhoids Goodbye:
Surgical & Non-Surgical Management Options

76. “Hemorrhoids” parody by Butt Meddler
(loosely to “Yesterday”)
Before today,
My anal sphincter was a happy Why they had to come on my
place bum, I couldn’t say
It existed in a state of grace Preparation H and Sitz baths
I didn’t know there’d be hell to are just cliché!
pay.
Suddenly, there’s a thingie Hemorrhoids leave my rectum
hanging out of me feeling so annoyed
And the itch and pain won’t let Now some rubber bands have
me be been deployed
Oh hemorrhoids prolapse Now hemorrhoids are
suddenly. yesterday.