Treatment Of Hemorrhoids: A Coloproctologist’s View

Lohsiriwat V. Treatment of hemorrhoidsGrade 1Grade 2Grade 3Grade 4ComplicatedDietary and lifestyle modification(such as high-fiber diet, laxatives, hydration, avoidance of straining)Medication(topical or systemic)Office-based procedure(such as banding, sclerotherapy)Non-excisional operation(such as DG-HAL, SH/PPH)Excisional operation(such as open and closed hemorrhoidectomy)Figure 1 Current treatment of internal hemorrhoids based on their severity and degree of prolapse. DG-HAL: Doppler-guided hemorrhoidal artery ligation; SH:Stapled hemorrhoidopexy; PPH: Procedure for prolapse and hemorrhoids.with uncomplicated hemorrhoid manifest any anal pain.In fact, severe anal pain in patient with hemorrhoids is[2]more likely due to anal fissure and anorectal abscess .A precise history and thorough physical exam ination, including digital rectal examination andanoscopy, are imperative for the diagnosis of hemo rrhoids. Unless bright red blood is clearly seen fromhemorrhoids, any patients with rectal bleedingshould be scheduled for flexible sigmoidoscopy orcolonoscopy, especially those being at risk of colorectal[1,2]cancer .Hemorrhoids are generally classified by theirlocation; internal (originates above the dentate lineand covered by anal mucosa), external (originatesbelow the dentate line and covered by anoderm) andmixed type. Internal hemorrhoids are further gradedbased on their appearance and degree of prolapse:(1) Grade Ⅰ: non-prolapsing hemorrhoids; (2) GradeⅡ: prolapsing hemorrhoids on straining but reducespontaneously; (3) Grade Ⅲ: prolapsing hemorrhoidsrequiring manual reduction; and (4) Grade Ⅳ: nonreducible prolapsing hemorrhoids which include acutely[16]thrombosed, incarcerated hemorrhoids .it becomes acutely thrombosed or causes patientdiscomfort.Dietary and lifestyle modificationA meta-analysis of 7 clinical trials comprising of378 patients with hemorrhoids showed that fibersupplement had a consistent benefit of relievingsymptom and minimizing risk of bleeding by appro [17]ximately 50% . Although there is relatively littleinformation of the efficacy of dietary and lifestylemodification on the treatment of hemorrhoids, manyphysicians include advice on dietary and lifestylemodification as a part of conservative treatment ofhemorrhoids and as a preventive measure. The adviceusually includes increasing the intake of dietary fiberand oral fluid, having regular exercise, refraining fromstraining and reading on the toilet, and avoiding drugcausing constipation or diarrhea.Medical treatmentThe main goal of medical treatment is to control acutesymptoms of hemorrhoids rather than to cure theunderlying hemorrhoids. There are several moderndrugs and traditional medicine used which are availablein a variety of format including pill, suppository,cream and wipes. However, the published literaturelacks strong evidence supporting the true efficacy oftopical treatment for symptomatic hemorrhoids. Foran oral preparation, flavonoids are the most common[18]phlebotonic agent used for treating hemorrhoids .It is apparent that flavonoids could increase vasculartone, reduce venous capacity, decrease capillarypermeability, facilitate lymphatic drainage and has[2]anti-inflammatory effects . A large meta-analysisof phlebotonics for hemorrhoids in 2012 showedthat phlebotonics had significant beneficial effects onbleeding, pruritus, discharge and overall symptomMANAGEMENT OF HEMORRHOIDSTreatment options mainly depend on the type andseverity of hemorrhoids, patient’s preference andthe expertise of physicians. Low-graded internalhemorrhoids are effectively treated with dietary andlifestyle modification, medical treatment and/or officebased procedures such as rubber band ligation andsclerotherapy (Figure 1). An operation is usuallyindicated in low-graded hemorrhoids refractory tonon-surgical treatment, high-graded hemorrhoids,[2]and strangulated hemorrhoids . Meanwhile, externalhemorrhoid requires no specific treatment unlessWJG www.wjgnet.com9247August 21, 2015 Volume 21 Issue 31

Lohsiriwat V. Treatment of hemorrhoidsimprovement. Phlebotonics also alleviated post[19]hemorrhoidectomy symptoms .addition, perioperative care for hemorrhoids has been[1,27]significantly improved.Surgical excision of hemorrhoids can be done by avariety of instrument such as a scalpel, scissors (FigureTM2A), a cautery device, and more recently Ligasure a vessel sealing device (Figure 2B). A recent CochraneReview demonstrates that Ligasure hemorrhoidectomyresulted in shorter operative time, less postoperativepain, and shorter convalescence period when compared[28]to conventional hemorrhoidectomy . Meanwhile,there was no significant difference in postoperativecomplications and long-term outcomes betweenthe two techniques. Excisional hemorrhoidectomycan be performed safely in a day-case basis under[29]the perianal infiltration of local anesthetics , orregional anesthesia, or general anesthesia. It isevident that some medications could decrease posthemorrhoidectomy pain such as perioperative analgesia[30]with oral non-steroidal anti-inflammatory drugsand[31][32]gabapentin , topical administration of sucralfateor[33]metronidazole , and postoperative administration of[19]phlebotonic drugs .Non-excisional operation for hemorrhoids includesdoppler-guided hemorrhoidal artery ligation (DG-HAL)or known as transanal hemorrhoidal dearterialization(THD), and plication of hemorrhoids (or known asligation anopexy or mucopexy). DG-HAL has beenintroduced into a surgical practice to cut off theblood supply to hemorrhoids without the need ofhemorrhoid removal. It involves the surgical ligationof terminal branches of superior hemorrhoidal arterycausing shrinkage of hemorrhoid bundles. Plicationof hemorrhoids is often performed with DG-HALto control the prolapse more effectively. However,the recurrence rate following DG-HAL was up to60% for grade Ⅳ hemorrhoids. DG-HAL is thereforeconsidered as one of the effective operations only forgrade Ⅱ-Ⅲ hemorrhoids with a one-year recurrence[34]rate of 10% for prolapse and 10% for bleeding .Notably, DG-HAL is not a totally painless operationas approximately 20% of patients experienced[34]postoperative pain especially during the defecation .Meanwhile, a ligation anopexy or mucopexy was alsodemonstrated to be a good alternative to excisionalhemorrhoidectomy for grade Ⅱ -Ⅲ hemorrhoids,with shorter operative time and lower postoperative[35]pain . Given the fact that there is the possibilityof revascularization and recurrent prolapse, furtherstudies on the long-term outcomes of non-excisionaloperations for hemorrhoids are needed.Stapled hemorrhoidopexy, also known as a proce dure for prolapse and hemorrhoids (PPH), is analternative operation for treating advanced internalhemorrhoids. A circular staple device is used toexcise a ring of redundant rectal mucosa just abovehemorrhoid bundles - not hemorrhoids per se. Bydoing this, prolapsing hemorrhoids will be repositioning(hemorrhoidopexy) and shrinking (due to a partialOffice-based proceduresMany office-based procedures (such as rubberband ligation, injection sclerotherapy, infraredcoagulation, cryotherapy, radiofrequency ablationand laser therapy) are effectively performed forgrade Ⅰ- Ⅱ hemorrhoids and some cases of grade Ⅲhemorrhoids with or without local anesthesia. Amongseveral office-based procedures, rubber band ligation(RBL) appeared to have the lowest incidence of[20]recurrent symptom and the need for retreatment .RBL is also the most popular non-surgical intervention[21]for hemorrhoids performed by surgeons . It is arelatively safe and painless procedure with minimalcomplication. However, RBL is contraindicated inpatient with anticoagulants or bleeding disorder,and those with concurrent anorectal sepsis. With atechnical note, the proper position of rubber bandshould be at the base of hemorrhoid bundle or overthe bleeding site, but not too close to the dentate line.Vacuum suction ligator may offer clearer visualisationof hemorrhoids and more precise placement ofbanding when compared to a traditional forcep[22]ligator . Multiple sites and serial sessions of bandingmay be required for large internal hemorrhoids.Operative treatmentSurgical intervention is usually required in low-gradedhemorrhoids refractory to non-surgical treatment,high-graded symptomatic hemorrhoids, and hemorr hoids with complication such as strangulation andthrombosis. An operation for hemorrhoids may beperformed if patient has other concomitant anorectalconditions requiring surgery, or due to patient’spreference.An ideal operation for hemorrhoids should removeinternal and external component of hemorrhoidscompletely, have minimal postoperative pain andcomplication, demonstrate less recurrence, and areeasy to learn and perform. The procedure could becheap and cost-effective too. Unfortunately, none ofthe currently available operation achieves all the idealconditions. So far, excisional hemorrhoidectomy isthe mainstay operation for grade Ⅲ-Ⅳ hemorrhoidsand complicated hemorrhoids. Of note, closed(Ferguson) hemorrhoidectomy and open (MilliganMorgan) hemorrhoidectomy were equally effective and[23,24]safe, but the Ferguson method was superior to theMilligan-Morgan method in term of long time patient[25]satisfaction and continence . Nevertheless, both[26]techniques may lead to severe postoperative pain .In order to minimize or avoid post-hemorrhoidectomypain, more recent approaches including Ligasurehemorrhoidectomy, doppler-guided hemorrhoidalartery ligation and stapled hemorrhoidopexy have beenadopted into the surgical treatment of hemorrhoids. InWJG www.wjgnet.com9248August 21, 2015 Volume 21 Issue 31

Lohsiriwat V. Treatment of hemorrhoidsABFigure 2 Hemorrhoidectomy by (A) scissors and (B) Ligasure TM - a vessel sealing device.hemorrhoids may become necrotic and drain. Thissituation is quite difficult to treat particularly in a caseof extensive strangulation or thrombosis (Figure 3A),or the presence of underlying circumferential prolapseof high-graded hemorrhoids. Manual reduction ofthe hemorrhoid masses, with or without intravenousanalgesia or sedation, might help reducing pain andtissue congestion. Urgent hemorrhoidectomy is usuallyrequired in these circumstances. Unless the tissues arenecrotic, mucosa and anoderm should be preservedas much as possible to prevent postoperative analstricture. In expert hands, surgical outcomes of urgenthemorrhoidectomy were comparable to those of[40]elective hemorrhoidectomy .interruption of blood supply to hemorrhoid plexus). Arecent systematic review of 27 randomized controlledtrials demonstrated that, compared with conventionalhemorrhoidectomy, stapled hemorrhoidopexy hadless pain, shorter operative time, and quicker patient’s recovery of patient, but a significantly higher[36]rate of prolapse and reintervention for prolapse .Interestingly, the latest meta-analysis comparingsurgical outcomes between stapled hemorrhoidopexyand Ligasure hemorrhoidectomy in 2013 revealed thatboth surgical techniques were practically comparable- with a slightly favorable immediate postoperativeresults and technical advantages for Ligasure hemor [37]rhoidectomy .Given the fact that stapled hemorrhoidopexy didnot offer any significant advantages over Ligasure[37]hemorrhoidectomyand it is a relatively expensiveoperation which may cause serious postoperativecomplications such as rectal stricture and rectal[38][39]perforationas well as severe chronic anal pain ,stapled hemorrhoidopexy should be reserved forpatients with circumferential prolapsing hemorrhoids[2]and it must be performed by a well-trained surgeon .Acutely thrombosed external hemorrhoidsAcutely thrombosed external hemorrhoids oftendevelop in patients with acute constipation, or thosewith a recent history of prolonged straining. A painfulbluish-colored lump at the anal verge is a paramountfinding (Figure 3B). The severity of pain is mostintense within the first 24-48 h of onset. After that, thethrombosis will be gradually absorbed and patients willexperience less pain. As a result, surgical removal ofacute thrombus or excisional hemorrhoidectomy maybe offered if patients experience severe pain especiallywithin the first 48 h of onset. Otherwise, conservativemeasure will be exercised including pain control, warmsitz baths, and avoidance of constipation or straining. Aresolving thrombosed external hemorrhoid could leavebehind as a residual perianal skin tag -which may orSPECIFIC CONSIDERATIONAcutely thrombosed or strangulated internalhemorrhoidsPatients with acutely thrombosed or strangulatedinternal hemorrhoids usually present with severelypainful and irreducible hemorrhoids. The incarceratedWJG www.wjgnet.com9249August 21, 2015 Volume 21 Issue 31

Lohsiriwat V. Treatment of hemorrhoidsAform bleeding anorectal varices because the latter canbe managed by suture ligation along the course ofvarices, transjugular intrahepatic portosystemic shunt,[1]or pharmacological treatment of portal hypertension .Since a majority of bleeding hemorrhoids in such patientsis not life threatening, conservative measure with thecorrection of any coagulopathy is a preferential initialapproach. Of note, rubber band ligation is generallycontraindicated in patients with advanced cirrhosis dueto the risk of profound secondary bleeding followingthe procedure. Injection sclerotherapy is an effectiveand safe procedure for treating bleeding hemorrhoidsin this situation. In a refractory case, suture ligation atthe bleeder is advised. Hemorrhoidectomy is indicatedwhen bleeding hemorrhoids are refractory to otherapproaches.BFigure 3 Complicated hemorrhoids. A: Strangulated internal hemorrhoid; B:Acutely thrombosed external hemorrhoid.may not require a subsequent excision.Hemorrhoids in patients having anticoagulant orantiplatelet drugsHemorrhoids in pregnancyHemorrhoids are very common during pregnancy[41]especially in the third trimester . Acute crisis suchas profound bleeding and irreducible prolapsingmay be found in pregnant women with pre-existinghemorrhoids. Since hemorrhoids and its symptomswill gradually resolve after giving birth, the primarygoal of treatment is to relief acute symptoms relatedto hemorrhoids - mostly by means of dietary andlifestyle modification. Kegel exercises, lying on leftside, and avoidance of constipation could reducethe episode and severity of bleeding and prolapse.Fiber supplement, stool softener and mild laxativesare generally safe for pregnant women. Topicalmedication or oral phlebotonics may be used withspecial caution because the strong evidence of theirsafety and efficacy in pregnancy is lacking. In case ofmassive bleeding, anal packing could be a simple anduseful maneuver. Hemorrhoidectomy is reserved instrangulated or extensively thrombosed hemorrhoids,and hemorrhoids with intractable bleeding.Anticoagulant or antiplatelet drugs may promoteanorectal bleeding in patients with hemorrhoids and[45]increase risk of bleeding after banding or surgery .Unless the bleeding is persistent or profound,the discontinuity of antithrombotic drugs may beunnecessary because most of the bleeding episodesare self-limited and stop spontaneously. Conservativemeasure is therefore the mainstay treatment in thesepatients. Injection sclerotherapy is a preferentialtreatment for bleeding low-graded hemorrhoidsrefractory to medical treatment. Rubber band ligationis not recommended in patients with the current useof anticoagulant or antiplatelet drugs due to the riskof secondary bleeding. If banding or any form ofsurgery for hemorrhoids is scheduled, the cessation ofanticoagulant or antiplatelet drugs about 5-7 d before[46]and after the procedure is suggested .Hemorrhoids in immunocompromised patientsTo date, it is obvious that, apart from oral flavonoidsbased phlebotonic drugs, currently available medi cation for hemorrhoids has no or limited beneficial[19]effects on bleeding and prolapsing . Since emergingevidence has suggested that perivascular inflammation,dysregulation of the vascular tone and vascular hyper plasia could play an important role in the development[2]of hemorrhoids , the microcirculatory system ofhemorrhoid tissue could be a potential and robusttarget for medical treatment. The combinations ofvasoconstrictive and venoconstrictive agents, withor without anti-inflammatory drugs, might be a newpharmacological approach for hemorrhoids.If an intervention, either office-based procedureor surgery - is indicated, evidence-based approachesmust be exercised. Day-case operation or ambulatorysurgery should be fully developed together with an[30]effective program for peri-operative care . DespiteFUTURE PERSPECTIVES IN THETREATMENT OF HEMORRHOIDSIn general any intervention or operation should beavoided, or performed with a careful considerationin immunocompromised patients because of anincreases risk of anorectal sepsis and poor tissue[42]healing in such cases . A conservative measure isthe mainstay for the treatment of hemorrhoids in thisgroup of patients. If required, injection sclerotherapyappeared to be a better and safer alternative tobanding and hemorrhoidectomy for treating bleeding[43,44]hemorrhoids. Antibiotic prophylaxis is alwaysgiven before performing any intervention, even aminor office-based procedure, due to the possibility ofbacteremia.Hemorrhoids in patients with cirrhosis or portalhypertensionA clinician must differentiate bleeding hemorrhoidsWJG www.wjgnet.com9250August 21, 2015 Volume 21 Issue 31

Lohsiriwat V. Treatment of hemorrhoids14advances in office-based procedures and bettersurgical approaches, post-procedural pain and diseaserecurrence remain the most challenging problems inthe treatment of hemorrhoids. Consequently, futureresearches and novel management of hemorrhoidsmay focus on how to minimize pain following aprocedure and how to prevent recurrent hemorrhoids.Meanwhile, long-term results of newly or recentlydeveloped interventions are definitely required.In conclusion, the better understanding of thepathophysiology of hemorrhoids would prompt thedevelopment of effective treatments for hemorrhoids.Preventive measures, by means of dietary andlifestyle modification, may be the best treatment ofhemorrhoids. Once hemorrhoids develop, its treatmentoptions mainly depend on the type and severity ofhemorrhoids, patient’s preference and the expertiseof physicians. Post-procedural pain and diseaserecurrence remain the most challenging problems inthe treatment of 321Lohsiriwat V. Approach to hemorrhoids. Curr Gastroenterol Rep2013; 15: 332 [PMID: 23715885]Lohsiriwat V. Hemorrhoids: from basic pathophysiology toclinical management. World J Gastroenterol 2012; 18: 2009-2017[PMID: 22563187]Thomson WH. The nature and cause of haemorrhoids. Proc R SocMed 1975; 68: 574-575 [PMID: 1197343]Lee JH, Kim HE, Kang JH, Shin JY, Song YM. Factors associatedwith hemorrhoids in korean adults: korean national health andnutrition examination survey. Korean J Fam Med 2014; 35:227-236 [PMID: 25309703]Riss S, Weiser FA, Schwameis K, Riss T, Mittlböck M, Steiner G,Stift A. The prevalence of hemorrhoids in adults. Int J ColorectalDis 2012; 27: 215-220 [PMID: 21932016]Tucker H, George E, Barnett D, Longson C. NICE TechnologyAppraisal on Stapled Haemorrhoidopexy for the Treatment ofHaemorrhoids. Ann R Coll Surg Engl 2008; 90: 82-84 [DOI: 10.1308/003588408X242178b]Baker H. Hemorrhoids. In: Longe JL, editor Gale Encyclopedia ofMedicine. 3rd ed. Detriot: Thomson Gale, 2006: 1766-1769Rohde H, Christ H. [Haemorrhoids are too often assumed andtreated. Survey of 548 patients with anal discomfort]. Dtsch MedWochenschr 2004; 129: 1965-1969 [PMID: 15375737]Yeung TM, D’Souza ND. Quality analysis of patient informationon surgical treatment of haemorrhoids on the internet. Ann R CollSurg Engl 2013; 95: 341-344 [PMID: 23838496]Aigner F, Gruber H, Conrad F, Eder J, Wedel T, Zelger B,Engelhardt V, Lametschwandtner A, Wienert V, Böhler U,Margreiter R, Fritsch H. Revised morphology and hemodynamicsof the anorectal vascular plexus: impact on the course ofhemorrhoidal disease. Int J Colorectal Dis 2009; 24: 105-113[PMID: 18766355 DOI: 10.1007/s00384-008-0572-3]Morgado PJ, Suárez JA, Gómez LG, Morgado PJ. Histoclinicalbasis for a new classification of hemorrhoidal disease. Dis ColonRectum 1988; 31: 474-480 [PMID: 3378471]Chung YC, Hou YC, Pan AC. Endoglin (CD105) expression in thedevelopment of haemorrhoids. Eur J Clin Invest 2004; 34: 107-112[PMID: 14764073 DOI: 10.1111/j.1365-2362.2004.01305.x]Corman ML, Gravié JF, Hager T, Loudon MA, Mascagni D,Nyström PO, Seow-Choen F, Abcarian H, Marcello P, Weiss E,Longo A. Stapled haemorrhoidopexy: a consensus position paperby an internat

Fax: perspectives in the treatment of hemorrhoids are also 66-2412-1370 Received: January 26, 2015 Peer-review started: January 27, 2015 First decision: April 14, 2015 Revised: April 21, 2015 Accepted: July 3, 2015 Article in press: July 3, 2015 Published online: August 21, 2015 Abstract Hem