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management of haemorrhoids

management of haemorrhoids



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management of haemorrhoids
management of haemorrhoids

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Published by: Prof Dr Dr Ernst Hanisch on Apr 05, 2008
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Austin G Acheson and John H Scholefield
Management of haemorrhoids
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on 5 April 2008bmj.comDownloaded from 
Management of haemorrhoids
Austin G Acheson, John H Scholefield
Haemorrhoids or
are enlarged vascular cush-ions within the anal canal that have been described formany centuries and continue to form a large part of a colorectal surgeon
s workload. The exact incidence of this common condition is difficult to estimate as manypeoplearereluctanttoseekmedicaladviceforvariouspersonal, cultural, and socioeconomic reasons, but epidemiological studies report a prevalence varying from4.4%inadultsintheUnitedStatestoover30%ingeneral practice in London.
The treatment of haemorrhoidsisstillevolving,andthisarticleprovidesan update on the role of established and innovativetreatments (fig 1).
Sources and selection criteria
ArticleswereretrievedfromtheMedlinedatabaseandCochrane library under the MeSH subheadings
. We included ran-domised controlled trials and meta-analyses.
What is the pathogenesis and aetiology?
The anal canal consists of three fibrovascular cushionsthatarefeddirectlybyarteriovenouscommunications.Thesecushionsaresupportedwithintheanalcanalbyconnectivetissueframework,andtheyareimportantinproviding a watertight seal to the anus. The degen-erative effects of ageing may weaken or fragment thesupporting tissues, and this along with the repeatedpassageofhardstoolandstrainingproducesashearing force on the cushions, leading to their descent andprolapse. The prolapsed cushions have impairedvenous return, which results in engorgement that may be further exacerbated by straining, inadequatefibre intake, prolonged time on the lavatory, andconditions such as pregnancy that raise intra-abdom-inal pressure. Bleeding from the engorged prolapsedhaemorrhoid occurs as a result of localised mucosaltrauma or inflammation, which damages the under-lying blood vessels.
How are haemorrhoids classified?
Haemorrhoids can be classified according to theirrelationtothedentate(pectinate)line,whichdemarcatesthe transition from the squamous epithelium below tothecolumnarepitheliumabove.Internalhaemorrhoidsoriginate above the dentate line, whereas externalhaemorrhoids originate below the line. The morewidely used Goligher classification system describesfourgrades, whicharebasedonthe degree ofprolapse,but this system fails to reflect the severity of thesymptoms.
The grade of haemorrhoid is important (box)andcanbeusefulindecidingoptimaltreatmentorin evaluating the effectiveness of the treatment given.
How do haemorrhoids present and how should they beassessed?
The most common symptom is painless fresh rectalbleeding, but patients may also experience pruritus,swelling, prolapse, discharge, or soiling. Severe analpain is usually seen only if the haemorrhoid isthrombosed or strangulated.Initial examination involves inspection of theperineum followed by rectal examination and ano-scopy. This will help differentiate haemorrhoids fromother causes of anal canal bleeding such as fissures,fistulas,tumour,polyps,analwarts,andrectalprolapse.Large external haemorrhoids can be easily seen oninspection, but anoscopy allows the haemorrhoidalcushions to be more easily visualised in the usual left 
Haemorrhoidal symptomsNon-prolapsing pilesProlapsing pilesFibre supplementationRefer to colorectal surgeryFourthdegreeThirddegreeFirst andsecond degreeSurgical
Rubber bandligation/fibre
Rubber bandligation/injection
Stapled haemorrhoidectomy or Doppler guide haemorrhoidal arteryligation, depending on surgeon’sexperience and preference
    G   r   a    d   e   o    f    h   a   e   m   o   r   r    h   o    i    d    A   p   p   r   o   p   r    i   a   t   e   t   r   e   a   t   m   e   n   t
Fig 1 Suggested algorithm for management of haemorrhoids(dotted arrows indicate failure of initial treatment)
Section of GastrointestinalSurgery, University Hospital,Queen
s Medical Centre,Nottingham NG7 2UH
Correspondence to: A G Achesonaustin.acheson@nottingham.ac.uk
BMJ 2008;336:380-3
16 FEBRUARY 2008
For the full versions of these articles see bmj.com
 on 5 April 2008bmj.comDownloaded from 
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?
Conservative treatment
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, relievinconstipation,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.
Outpatient treatments
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 suctionbandshasallowedthisproceduretobeperformedbysingle 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-analysisin1995suggesthat 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.
Injection sclerotherapy
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.
Differentgradesof haemorrhoids
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 groupsMostpatientscanbetreatedinprimarycarewithdietaryadviceandavoidanceofstraininPatients 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
 on 5 April 2008bmj.comDownloaded from 

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