lateral, right anterior, and right posterior positions (3o
clock, 7 o
clock, and 11 o
clock positions; fig 2).Patients older than 40 who have suspected haemor-rhoidal bleeding generally require additional flexiblesigmoidoscopy, colonoscopy, virtual colonoscopy, ora barium enema to exclude colorectal carcinomas andshould always be referred for a specialist opinion.Haemorrhoidal disease associated with the symp-toms of soiling or incontinence may require anorectalphysiology studies and endoanal ultrasound, particu-larly if the patient is being considered for surgery.These patients have a higher risk of developing incontinence after surgery, and these investigationsmayhelpthesurgeonchoosethebesttreatmentoption.
How are haemorrhoids treated?
Arecentmeta-analysisconfirmedthatfibresupplementsmoderately improve overall symptoms and bleeding and should be recommended at an early stage.
Otherlifestyle modifications such as improving anal hygiene,taking sitz baths, increasing fluid intake, relieving constipation,andavoidingstrainingareusedinprimarycare and may help in the treatment and prevention of haemorrhoids, although theevidence forthis is lacking.Over the counter topical preparations that contain a combination of local anaesthetics, corticosteroids,astringents, and antiseptics are available, and thesecan alleviate symptoms of pruritus and discomfort inhaemorrhoidal disease. Long term use of these agentsshould be discouraged, particularly steroid creams,which can permanently damage or cause ulceration of the perianal skin. No randomised controlled trials areavailable to support their widespread use.Venotonics such as flavonoids have been used asdietarysupplementsinthetreatmentofhaemorrhoids.The mechanism of action of these drugs remainsunclear, but they may improve venous tone, reducehyperpermeability, and have anti-inflammatoryeffects.ThistreatmentispopularincontinentalEuropeand the Far East, but a recent meta-analysis concludedthatlimitationsinmethodologicalqualityandpotentialpublicationbiasraisedoubtsaboutthebenefitsoftheseagents in treating haemorrhoids.
Several outpatient interventions that have been avail-ableformanyyearsremainpopularinthetreatmentof first degree, second degree, and third degree haemor-rhoids.These officebasedprocedurescause tissuelossand ulceration or help, by causing fibrosis, to fix themucosa of the prolapsed tissue back on to the under-lying muscle.
Rubber band ligation
The technique of applying rubber bands to haemor-rhoidswasfirstdescribedin1963.
Modificationoftheoriginal method through the introduction of suctionbandshasallowedthisproceduretobeperformedbya single operator (figs 3 and 4). The original papersuggested that one haemorrhoid should be bandedduringeachsession,withrepeatbandingsatthreeweekintervals. Subsequent prospective studies showed noincrease in post ligation pain or complications withmultiple banding, however, so many surgeons applyup to three bands at each visit.
The bands should beapplied above the dentate line to minimise pain, andinjecting local anaesthetic into the banded haemor-rhoids does not seem to reduce anal discomfort.
Mostlargetrialsandameta-analysisin1995suggest that rubber band ligation is the most effective out-patienttreatmentforhaemorrhoids,withsomeauthorssuggesting that up to 80% of patients are satisfied withthe short term outcome.
Common complications of the procedure includepain and haemorrhage. All patients should be warnedabout the possibility of delayed haemorrhage (five to10 days after the procedure), and the technique iscontraindicatedinthosewhoareanticoagulated.Otherrarely reported complications include urinary reten-tion, liver abscesses, and perineal sepsis.
A submucosal injection of 5% oily phenol into first orsecond degree haemorrhoids is an alternative tobanding. It has no benefit in large prolapsing haemor-rhoids or those with a large external component. It ischeapandeasytoperform,butitislesswidelyusedthanbanding because of the high failure rate. Conservativetreatment with fibre supplementation may be aseffective as injection sclerotherapy.
First degreehaemorrhoids: thesebleed but do notprolapse
Second degreehaemorrhoids: theseprolapse but reducespontaneously
Third degreehaemorrhoids: theseprolapse but can bereduced manually
Fourth degreehaemorrhoids: theseare permanentlyprolapsed and cannotbe reduced
Left lateral(3 o
clock)Right anterior (11 o
clock)Right posterior (7 o
Fig 2 Usualposition ofhaemorrhoidswhenpatientisin supineposition with legs in stirrups
Haemorrhoids are common in all age groupsMostpatientscanbetreatedinprimarycarewithdietaryadviceandavoidanceofstraining Patients with rectal bleeding alone who are over 40 should be referred to a specialist for imaging of the colonAll patients with haemorrhoids who have symptoms in the lower gastrointestinal tract
such as change in bowel habit, abdominal pain, or tenesmus
must be referred to aspecialistAnal cancer can have a similar appearance to a prolapsed haemorrhoid
16 FEBRUARY 2008
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