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• W1491380816 abstract "Hemorrhoids are a common condition, but their true prevalence is unknown. Most patients and many physicians tend to attribute any anorectal symptom to hemorrhoids. Furthermore, anal cushions are normal structural components of the anal canal that are present from infancy.1Thomson W.H. The nature of haemorrhoids.Br J Surg. 1975; 62: 542-552Crossref PubMed Google Scholar Despite their confusing epidemiology, it is important for gastroenterologists, surgeons, and primary care physicians alike to be able to accurately diagnose hemorrhoids and offer a rational, effective treatment plan. We performed a literature search for all English-language articles dealing with hemorrhoids published from 1990 to 2002. Databases searched included MEDLINE, PreMEDLINE, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effectiveness, the American College of Physicians Journal Club, and the Cochrane Central Registry of Controlled Trials. Additional references were obtained from the bibliographies of selected articles. We selected pertinent studies emphasizing randomized controlled trials to formulate this technical review. Hemorrhoids are found in the subepithelial space of the anal canal. They consist of connective tissue cushions surrounding the direct arteriovenous communications between the terminal branches of the superior rectal arteries and the superior, inferior, and middle rectal veins.1Thomson W.H. The nature of haemorrhoids.Br J Surg. 1975; 62: 542-552Crossref PubMed Google Scholar Anal subepithelial smooth muscle arises from the conjoined longitudinal muscle layer, passes through the internal anal sphincter, and inserts into the subepithelial vascular space. There, the smooth muscle suspends and contributes to the bulk of the hemorrhoidal cushions.1Thomson W.H. The nature of haemorrhoids.Br J Surg. 1975; 62: 542-552Crossref PubMed Google Scholar, 2Hansen H.H. The importance of the Musculus canalis ani for continence and anorectal diseases (author’s translation).Langenbecks Arch Chir. 1976; 341: 23-37Crossref PubMed Google Scholar The cushions contribute approximately 15%–20% of the resting anal pressure.3Lestar B. Penninckx F. Kerremans R. The composition of anal basal pressure. An in vivo and in vitro study in man.Int J Colorectal Dis. 1989; 4: 118-122Crossref PubMed Google Scholar Perhaps more importantly, they serve as a conformable plug to ensure complete closure of the anal canal. Most people have 3 of these cushions, but cadaver studies have shown that the so-called typical right anterior, right posterior, and left lateral configuration of the cushions occurs only 19% of the time.1Thomson W.H. The nature of haemorrhoids.Br J Surg. 1975; 62: 542-552Crossref PubMed Google Scholar Symptoms attributed to hemorrhoids include bleeding, protrusion, itching, and pain.4Dennison A.R. Whiston R.J. Rooney S. Morris D.L. The management of hemorrhoids.Am J Gastroenterol. 1989; 84: 475-481PubMed Google Scholar, 5Loder P.B. Kamm M.A. Nicholls R.J. Phillips R.K. Haemorrhoids pathology, pathophysiology and aetiology.Br J Surg. 1994; 81: 946-954Crossref PubMed Scopus (101) Google Scholar For the most part, external hemorrhoids are asymptomatic unless they become thrombosed, in which case they present as an acutely painful perianal lump. Persisting skin tags after resolution of the thrombosis can lead to problems with hygiene and secondary irritation. Most hemorrhoidal symptoms arise from enlarged internal hemorrhoids. Abnormal swelling of the anal cushions, stretching of the suspensory muscles, and dilation of the submucosal arteriovenous plexus result in the prolapse of upper anal and lower rectal tissue through the anal canal. This tissue is easily traumatized, leading to bleeding. The blood is typically bright red due to the arterial oxygen tension caused by arteriovenous communications within the anal cushions.5Loder P.B. Kamm M.A. Nicholls R.J. Phillips R.K. Haemorrhoids pathology, pathophysiology and aetiology.Br J Surg. 1994; 81: 946-954Crossref PubMed Scopus (101) Google Scholar, 6Thulesius O. Gjores J.E. Arterio-venous anastomoses in the anal region with reference to the pathogenesis and treatment of haemorrhoids.Acta Chir Scand. 1973; 139: 476-478PubMed Google Scholar Prolapse of the rectal mucosa leads to deposition of mucus on the perianal skin, causing itchiness and discomfort. The pathogenesis of the enlarged, prolapsing cushions is unknown. Many clinicians believe that inadequate fiber intake, prolonged sitting on the toilet, and chronic straining at stool contribute to the development of symptomatic hemorrhoids, yet rigorous proof of such beliefs is lacking. Other factors have also been proposed, including constipation, diarrhea, pregnancy, and family history.5Loder P.B. Kamm M.A. Nicholls R.J. Phillips R.K. Haemorrhoids pathology, pathophysiology and aetiology.Br J Surg. 1994; 81: 946-954Crossref PubMed Scopus (101) Google Scholar None of these have been rigorously proven, although 0.2% of pregnant women require urgent hemorrhoidectomy for incarcerated prolapsed hemorrhoids.7Saleeby Jr, R.G. Rosen L. Stasik J.J. Riether R.D. Sheets J. Khubchandani I.T. Hemorrhoidectomy during pregnancy risk or relief?.Dis Colon Rectum. 1991; 34: 260-261Crossref PubMed Scopus (27) Google Scholar Multiple studies have shown elevated anal resting pressure in patients with hemorrhoids when compared with controls5Loder P.B. Kamm M.A. Nicholls R.J. Phillips R.K. Haemorrhoids pathology, pathophysiology and aetiology.Br J Surg. 1994; 81: 946-954Crossref PubMed Scopus (101) Google Scholar; voluntary contraction pressure is unchanged. Whether the elevated resting pressure is caused by or due to enlarged hemorrhoids is unknown, but resting tone becomes normal after hemorrhoidectomy.8Read M.G. Read N.W. Haynes W.G. Donnelly T.C. Johnson A.G. A prospective study of the effect of haemorrhoidectomy on sphincter function and faecal continence.Br J Surg. 1982; 69: 396-398Crossref PubMed Scopus (68) Google Scholar Ultraslow pressure waves are more common in patients with hemorrhoids, but the significance of the waves is uncertain.9Sun W.M. Read N.W. Shorthouse A.J. Hypertensive anal cushions as a cause of the high anal canal pressures in patients with haemorrhoids.Br J Surg. 1990; 77: 458-462Crossref PubMed Google Scholar The epidemiology of hemorrhoids has been studied using a number of approaches, each of which has shortcomings. Accordingly, the data must be interpreted with caution. Population-based surveys rely on self-reporting of a condition with symptoms that are nonspecific; moreover, a physician observer does not validate these supposed diagnoses. Hospital discharge data are more reliable in this regard but still remain imperfect; it is likely that most patients with a diagnosis of hemorrhoids at discharge have not in fact undergone a directed anorectal examination. Similar criticism may be leveled at physician visit data; a complete evaluation, including anoscopy, cannot be assumed to have taken place, particularly if the data are from primary care providers. Hospital-based proctoscopy studies show prevalence rates of up to 86%,10Haas P.A. Haas G.P. Schmaltz S. Fox Jr, T.A. The prevalence of hemorrhoids.Dis Colon Rectum. 1983; 26: 435-439Crossref PubMed Google Scholar even though many of their patients are asymptomatic. Despite these caveats, the community-wide prevalence of hemorrhoids in the United States is reported to be 4.4%, with a peak prevalence occurring between 45 and 65 years of age.11Johanson J.F. Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study.Gastroenterology. 1990; 98: 380-386Abstract PubMed Google Scholar Increased prevalence rates are associated with higher socioeconomic status, but this association may reflect differences in health-seeking behavior rather than true prevalence.11Johanson J.F. Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study.Gastroenterology. 1990; 98: 380-386Abstract PubMed Google Scholar Population-based surveys suggest that the prevalence of hemorrhoids decreased in both the United States and United Kingdom during the second half of the 20th century.12Johanson J.F. Sonnenberg A. Temporal changes in the occurrence of hemorrhoids in the United States and England.Dis Colon Rectum. 1991; 34 (discussion 591–593.): 585-591Crossref PubMed Google Scholar Hemorrhoids are frequently seen in patients with spinal cord injury.13Stone J.M. Nino-Murcia M. Wolfe V.A. Perkash I. Chronic gastrointestinal problems in spinal cord injury patients a prospective analysis.Am J Gastroenterol. 1990; 85: 1114-1119PubMed Google Scholar, 14Delco F. Sonnenberg A. Associations between hemorrhoids and other diagnoses.Dis Colon Rectum. 1998; 41 (discussion 1541–1542.): 1534-1541Crossref PubMed Google Scholar For many patients, the presence of any anorectal symptom is indicative of hemorrhoids. Physicians should not make the same assumption. Hemorrhoids are, in fact, frequently the cause of common symptoms such as bleeding, a lump, itching, or pain. However, when hemorrhoids are simply assumed to be the cause, other pathology is too often overlooked. Prolapsing hemorrhoids may cause anal itching, but itching is just as likely to be due to inadequate hygiene, minor incontinence, or perianal dermatitis. Pain associated with a palpable lump is the hallmark of a thrombosed external hemorrhoid, but anal fissure and perianal abscess are equally common causes of anal pain and, in particular, painful defecation. A precise patient history and a careful physical examination are essential for accurate diagnosis; neither should be omitted when a patient has anorectal symptoms. Bleeding is the most common presenting symptom of hemorrhoids. The blood is typically bright red and may frequently drip or squirt into the toilet bowl. Darker blood and blood mixed in the stool suggest a more proximal source of bleeding. However, because physicians’ predictions are not reliable in the evaluation of hematochezia,15Segal W.N. Greenberg P.D. Rockey D.C. Cello J.P. McQuaid K.R. The outpatient evaluation of hematochezia.Am J Gastroenterol. 1998; 93: 179-182Crossref PubMed Scopus (43) Google Scholar exclusive reliance on patients’ descriptions of bleeding is unwise; further investigation is warranted. Current practice guidelines from both the American Society for Gastrointestinal Endoscopy and the Society for Surgery of the Alimentary Tract advocate a minimum of anoscopy and flexible sigmoidoscopy for bright-red rectal bleeding.16American Society for Gastrointestinal EndoscopyThe role of endoscopy in the patient with lower gastrointestinal bleeding. Guidelines for clinical application.Gastrointest Endosc. 1988; 34: 23S-25SAbstract Full Text PDF PubMed Google Scholar, 17The Society for Surgery of the Alimentary Tract.Surgical management of hemorrhoids. 2003Google Scholar Complete colonic evaluation by colonoscopy or air-contrast barium enema is indicated when the bleeding is atypical for hemorrhoids, when no source is evident on anorectal examination, or when the patient has significant risk factors for colonic neoplasia. The decision to pursue further evaluation also depends on the patient’s age and general medical condition.16American Society for Gastrointestinal EndoscopyThe role of endoscopy in the patient with lower gastrointestinal bleeding. Guidelines for clinical application.Gastrointest Endosc. 1988; 34: 23S-25SAbstract Full Text PDF PubMed Google Scholar Hemorrhoids alone do not cause a positive result with a stool guaiac test,18Nakama H. Kamijo N. Fujimori K. Horiuchi A. Abdul Fattah S. Zhang B. Immunochemical fecal occult blood test is not suitable for diagnosis of hemorrhoids.Am J Med. 1997; 102: 551-554Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 19Korkis A.M. McDougall C.J. Rectal bleeding in patients less than 50 years of age.Dig Dis Sci. 1995; 40: 1520-1523Crossref PubMed Scopus (29) Google Scholar so fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated. Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population) and responds to hemorrhoidectomy.20Kluiber R.M. Wolff B.G. Evaluation of anemia caused by hemorrhoidal bleeding.Dis Colon Rectum. 1994; 37: 1006-1007Crossref PubMed Scopus (14) Google Scholar Because symptoms caused by other conditions are frequently attributed to hemorrhoids, a careful anorectal evaluation is warranted for any patient who reports hemorrhoids. External examination will enable the discovery of pathology such as perianal abscess or anal fistula. The cardinal symptom of anal fissure is postdefecatory pain, but anal fissure also frequently causes minor rectal bleeding. Anal fissure is best seen with eversion of the anal canal by opposing traction with the thumbs. Any skin tags, thrombosed external hemorrhoids, mixed hemorrhoids, and incarcerated rectal mucosal prolapse will be evident on external examination. Internal hemorrhoids and associated rectal mucosal prolapse are best evaluated through an anoscope with an adequate light source. Portal hypertension can cause varices of the anal canal. These varices are distinct from hemorrhoids and should not be considered a cause of hemorrhoids.21Misra S.P. Dwivedi M. Misra V. Prevalence and factors influencing hemorrhoids, anorectal varices, and colopathy in patients with portal hypertension.Endoscopy. 1996; 28: 340-345Crossref PubMed Google Scholar, 22Goenka M.K. Kochhar R. Nagi B. Mehta S.K. Rectosigmoid varices and other mucosal changes in patients with portal hypertension.Am J Gastroenterol. 1991; 86: 1185-1189PubMed Google Scholar In fact, patients with portal hypertension and varices do not have an increased incidence of hemorrhoids.22Goenka M.K. Kochhar R. Nagi B. Mehta S.K. Rectosigmoid varices and other mucosal changes in patients with portal hypertension.Am J Gastroenterol. 1991; 86: 1185-1189PubMed Google Scholar Variceal bleeding should not be considered the same as hemorrhoidal bleeding, so standard hemorrhoidal treatments should not be used. Rectal variceal bleeding is best treated by correction of the underlying portal hypertension; transjugular intrahepatic portosystemic shunts have been successfully used in the treatment of refractory bleeding.23Shibata D. Brophy D.P. Gordon F.D. Anastopoulos H.T. Sentovich S.M. Bleday R. Transjugular intrahepatic portosystemic shunt for treatment of bleeding ectopic varices with portal hypertension.Dis Colon Rectum. 1999; 42: 1581-1585Crossref PubMed Google Scholar If local therapy is necessary, oversewing of the varices rather than attempted excision is the procedure of choice. There are a few case reports of injection sclerotherapy for bleeding rectal varices,24Herman B.E. Baum S. Denobile J. Volpe R.J. Massive bleeding from rectal varices.Am J Gastroenterol. 1993; 88: 939-942PubMed Google Scholar, 25Ikeda K. Konishi Y. Nakamura T. Nabeshima M. Yamamoto S. Migihashi R. Chiba T. Rectal varices successfully treated by endoscopic injection sclerotherapy after careful hemodynamic evaluation a case report.Gastrointest Endosc. 2001; 54: 788-791Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar but the overall success rate of this approach is unknown. The evaluation of patients with hemorrhoids should include an assessment of their symptoms. As mentioned previously, the presence, quantity, and frequency of bleeding are important. The presence, timing, and reducibility of prolapsed tissue help to classify the extent of the hemorrhoids and dictate therapeutic options. The effect of the hemorrhoids on hygiene is a factor when deciding on operative treatment. Anal pain is generally not associated with hemorrhoids unless thrombosis has occurred. Thus, anal pain suggests other pathology and mandates closer investigation. As many as 20% of patients with hemorrhoids have concomitant anal fissures.26Bleday R. Pena J.P. Rothenberger D.A. Goldberg S.M. Buls J.G. Symptomatic hemorrhoids current incidence and complications of operative therapy.Dis Colon Rectum. 1992; 35: 477-481Crossref PubMed Scopus (140) Google Scholar New-onset anal pain in the absence of a visible source suggests the possibility of a small intersphincteric abscess. Hemorrhoids are defined as internal or external according to their position relative to the dentate line. External hemorrhoids become symptomatic only when thrombosed or when skin tags are so large that hygiene is impossible. Thrombosed external hemorrhoids are common. Such patients present with acute-onset anal pain and a palpable perianal lump. Thrombosed external hemorrhoids occasionally bleed when local pressure causes erosion through the overlying skin. Thrombosed internal hemorrhoids are far less common; typical symptoms include pain, pressure, bleeding, mucus production, and an inability to reduce spontaneously prolapsing tissue. Symptoms of internal hemorrhoids include bleeding and protrusion. Prolapsed hemorrhoids are a cause of soiling and mucus discharge, and both lead to secondary pruritus ani. Advanced prolapsed hemorrhoids may become incarcerated and strangulated. Most colorectal surgeons use the grading system published in 1985 by Banov et al.27Banov Jr, L. Knoepp Jr, L.F. Erdman L.H. Alia R.T. Management of hemorrhoidal disease.J S C Med Assoc. 1985; 81: 398-401PubMed Google Scholar Internal hemorrhoids that bleed but do not prolapse are designated as first-degree hemorrhoids. Those that prolapse and reduce spontaneously (with or without bleeding) are second-degree hemorrhoids. Prolapsed hemorrhoids that require reduction are third-degree hemorrhoids. Prolapsed internal hemorrhoids that cannot be reduced are fourth-degree hemorrhoids; they usually include both internal and external components and are confluent from skin tag to inner anal canal. Acutely thrombosed, incarcerated internal hemorrhoids and incarcerated, thrombosed hemorrhoids involving circumferential rectal mucosal prolapse are also fourth-degree hemorrhoids. Accurate classification is important for both assessing the reported efficacy of various hemorrhoidal treatments and selecting the optimal treatment for an individual patient. The American Society of Colon and Rectal Surgeons uses the Banov classification in its practice parameters for the treatment of hemorrhoids. However, a descriptive system is sometimes more useful than one based on symptoms because of the range in severity within each grade. Large third-degree hemorrhoids may only be treatable with excision, for example, if they extend to the dentate line, if chronic prolapse has caused epithelial changes, or if the volume of tissue is simply too large to be managed nonoperatively. Smaller third-degree hemorrhoids, in contrast, may be readily treatable by nonoperative methods. Few recent studies concern either the prevention or the medical management of hemorrhoids. The almost-universal recommendations are to add dietary fiber and to avoid straining at stool. One double-blind, placebo-controlled trial showed that the use of psyllium reduced hemorrhoidal bleeding and painful defecation,28Moesgaard F. Nielsen M.L. Hansen J.B. Knudsen J.T. High-fiber diet reduces bleeding and pain in patients with hemorrhoids a double-blind trial of Vi-Siblin.Dis Colon Rectum. 1982; 25: 454-456Crossref PubMed Scopus (57) Google Scholar but other studies of fiber have shown less impressive or insignificant results.29Perez-Miranda M. Gomez-Cedenilla A. Leon-Colombo T. Pajares J. Mate-Jimenez J. Effect of fiber supplements on internal bleeding hemorrhoids.Hepatogastroenterology. 1996; 43: 1504-1507PubMed Google Scholar, 30Broader J.H. Gunn I.F. Alexander-Williams J. Evaluation of a bulk-forming evacuant in the management of haemorrhoids.Br J Surg. 1974; 61: 142-144Crossref PubMed Google Scholar, 31Webster D.J. Gough D.C. Craven J.L. The use of bulk evacuant in patients with haemorrhoids.Br J Surg. 1978; 65: 291-292Crossref PubMed Google Scholar Because diarrhea exacerbates hemorrhoidal symptoms, controlling it with fiber, antimotility agents, and specific treatment of any underlying cause will likely be of benefit. Over-the-counter topical agents and suppositories have become equally ubiquitous in the empirical treatment of hemorrhoidal symptoms, but data supporting their use are lacking. Topical analgesics may bring symptomatic relief of local pain and itching. Corticosteroid creams may ameliorate local perianal inflammation, but no data suggest that they actually reduce hemorrhoidal swelling, bleeding, or protrusion. Long-term use of high-potency corticosteroid creams is deleterious and should be avoided. In one prospective series, nitroglycerin ointment relieved pain due to thrombosed external hemorrhoids, presumably by decreasing anal tone.32Gorfine S.R. Treatment of benign anal disease with topical nitroglycerin.Dis Colon Rectum. 1995; 38 (discussion 456–457.): 453-456Crossref PubMed Scopus (123) Google Scholar Several studies have assessed the use of oral micronized, purified flavonoid fraction (MPFF) (Daflon; Servier Laboratories, Neuilly-Sur-Seine, France). Flavonoids increase venous tone, lymphatic drainage, and capillary resistance and normalize capillary permeability. Two placebo-controlled trials showed symptomatic improvement with use of MPFF,33Cospite M. Double-blind, placebo-controlled evaluation of clinical activity and safety of Daflon 500 mg in the treatment of acute hemorrhoids.Angiology. 1994; 45: 566-573PubMed Google Scholar, 34Godeberge P. Daflon 500 mg in the treatment of hemorrhoidal disease a demonstrated efficacy in comparison with placebo.Angiology. 1994; 45: 574-578PubMed Google Scholar but results were inconsistent when MPFF and fiber were combined. Ho et al. reported that a combination of MPFF and fiber led to faster relief of hemorrhoidal bleeding than either fiber and rubber band ligation or fiber alone.35Ho Y.H. Tan M. Seow-Choen F. Micronized purified flavonidic fraction compared favorably with rubber band ligation and fiber alone in the management of bleeding hemorrhoids randomized controlled trial.Dis Colon Rectum. 2000; 43: 66-69Crossref PubMed Google Scholar In contrast, Thanapongsathorn et al. compared fiber with and without MPFF in a double-blind trial and found similar improvement at 14 days.36Thanapongsathorn W. Vajrabukka T. Clinical trial of oral diosmin (Daflon) in the treatment of hemorrhoids.Dis Colon Rectum. 1992; 35: 1085-1088Crossref PubMed Scopus (20) Google Scholar MPFF has not been approved for use in the United States by the Food and Drug Administration. Several methods that do not involve surgical excision are available to treat patients with hemorrhoids. These procedures are usually performed in the office setting and do not require anesthesia. Although nonexcisional, they all function as ablative by thrombosis, sclerosis, or necrosis of the mucosal portion of the hemorrhoidal complex. Sclerotherapy is one of the oldest forms of nonoperative treatment; it was first described in 1869 by Morgan in Dublin. It is reserved for first- or second-degree hemorrhoids. A submucosal injection of 5 mL of 5% phenol in oil, 5% quinine and urea, or hypertonic (23.4%) salt solution at the base of the hemorrhoidal complex causes thrombosis of vessels, sclerosis of connective tissue, and shrinkage and fixation of overlying mucosa. Sclerotherapy requires no anesthesia and takes only minutes to perform through an anoscope.37Walker A.J. Leicester R.J. Nicholls R.J. Mann C.V. A prospective study of infrared coagulation, injection and rubber band ligation in the treatment of haemorrhoids.Int J Colorectal Dis. 1990; 5: 113-116Crossref PubMed Scopus (65) Google Scholar Khoury et al. performed a prospective trial of patients with first- or second-degree hemorrhoids who had initially been treated with medical therapy.38Khoury G.A. Lake S.P. Lewis M.C. Lewis A.A. A randomized trial to compare single with multiple phenol injection treatment for haemorrhoids.Br J Surg. 1985; 72: 741-742Crossref PubMed Google Scholar In that trial, sclerotherapy improved or cured 89.9% of the patients, with no difference between single or multiple injections. In contrast, Senapati and Nicholls performed a randomized controlled trial and found no difference in bleeding rates at 6 months following sclerotherapy with bulk laxatives or bulk laxatives alone.39Senapati A. Nicholls R.J. A randomised trial to compare the results of injection sclerotherapy with a bulk laxative alone in the treatment of bleeding haemorrhoids.Int J Colorectal Dis. 1988; 3: 124-126Crossref PubMed Google Scholar Even though sclerotherapy is minimally invasive, it can cause complications. Pain is variably reported in 12%–70% of patients.37Walker A.J. Leicester R.J. Nicholls R.J. Mann C.V. A prospective study of infrared coagulation, injection and rubber band ligation in the treatment of haemorrhoids.Int J Colorectal Dis. 1990; 5: 113-116Crossref PubMed Scopus (65) Google Scholar, 40Sim A.J. Murie J.A. Mackenzie I. Three year follow-up study on the treatment of first and second degree hemorrhoids by sclerosant injection or rubber band ligation.Surg Gynecol Obstet. 1983; 157: 534-536PubMed Google Scholar, 41Sim A.J. Murie J.A. Mackenzie I. Comparison of rubber band ligation and sclerosant injection for first and second degree haemorrhoids—a prospective clinical trial.Acta Chir Scand. 1981; 147: 717-720PubMed Google Scholar Impotence,42Bullock N. Impotence after sclerotherapy of haemorrhoids case reports.Br Med J. 1997; 314: 419Crossref PubMed Google Scholar urinary retention, and abscess26Bleday R. Pena J.P. Rothenberger D.A. Goldberg S.M. Buls J.G. Symptomatic hemorrhoids current incidence and complications of operative therapy.Dis Colon Rectum. 1992; 35: 477-481Crossref PubMed Scopus (140) Google Scholar have also been reported. In one study, hemorrhoidal symptoms recurred in about 30% of patients 4 years after initially successful sclerotherapy.37Walker A.J. Leicester R.J. Nicholls R.J. Mann C.V. A prospective study of infrared coagulation, injection and rubber band ligation in the treatment of haemorrhoids.Int J Colorectal Dis. 1990; 5: 113-116Crossref PubMed Scopus (65) Google Scholar Cryotherapy has been advocated as a technique for destroying enlarged internal hemorrhoids. Initial reports were enthusiastic43O’Callaghan J.D. Matheson T.S. Hall R. Inpatient treatment of prolapsing piles cryosurgery versus Milligan-Morgan haemorrhoidectomy.Br J Surg. 1982; 69: 157-159Crossref PubMed Google Scholar; however, the technique is relatively time consuming, and subsequent reports have shown disappointing results.44Goligher J.C. Cryosurgery for hemorrhoids.Dis Colon Rectum. 1976; 19: 213-218Crossref PubMed Google Scholar Smith et al. performed a trial comparing cryotherapy with closed hemorrhoidectomy on different hemorrhoids in the same patient.45Smith L.E. Goodreau J.J. Fouty W.J. Operative hemorrhoidectomy versus cryodestruction.Dis Colon Rectum. 1979; 22: 10-16Crossref PubMed Scopus (14) Google Scholar The cryotherapy site was associated with prolonged pain, foul-smelling discharge, and a greater need for additional therapy. Cryotherapy is now only rarely used for the treatment of patients with hemorrhoids. Rubber band ligation relies on the tight encirclement of redundant mucosa, connective tissue, and blood vessels in the hemorrhoidal complex. The encirclement must be well proximal (at least 2 cm) to the dentate line. Placement of the band too far distally leads to immediate, usually severe pain due to the presence of somatic sensory nerve afferents that are absent above the anal transition zone. Internal hemorrhoid ligation can be performed in the office setting with one of several commercially available instruments, including devices that use suction to draw the redundant tissue into the applicator to make the procedure a one-person effort.46Budding J. Solo operated haemorrhoid ligator rectoscope. A report on 200 consecutive bandings.Int J Colorectal Dis. 1997; 12: 42-44Crossref PubMed Scopus (5) Google Scholar No anesthesia is required. The resulting scar fixes the connective tissue to the rectal wall and resolves the prolapse. Endoscopic variceal ligators have also been shown to be effective tools for hemorrhoid ligation.47Trowers E.A. Ganga U. Rizk R. Ojo E. Hodges D. Endoscopic hemorrhoidal ligation preliminary clinical experience.Gastrointest Endosc. 1998; 48: 49-52Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Rubber band ligation is most commonly used for first-, second-, or third-degree hemorrhoids. Some authorities recommend it for fourth-degree hemorrhoids after operative reduction of the incarcerated prolapse.48Rasmussen O.O. Larsen K.G. Naver L. Christiansen J. Emergency haemorrhoidectomy compared with incision and banding for the treatment of acute strangulated haemorrhoids. A prospective randomised study.Eur J Surg. 1991; 157: 613-614PubMed Google Scholar Up to 3 hemorrhoids can be banded in a single session,49Lee H.H. Spencer R.J. Beart Jr, R.W. Multiple hemorrhoidal bandings in a single session.Dis Colon Rectum. 1994; 37: 37-41Crossref PubMed Google Scholar, 50Lau W.Y. Chow H.P. Poon G.P. Wong S.H. Rubber band ligation of three primary hemorrhoids in a single session. A safe and effective procedure.Dis Colon Rectum. 1982; 25: 336-339Crossref PubMed Google Scholar, 51Khubchandani I.T. A randomized comparison of single and multiple rubber band ligations.Dis Colon Rectum. 1983; 26: 705-708Crossref PubMed Google Scholar although many authorities prefer to limit treatment to 1 or 2 columns at a time. Like the other nonoperative treatments, rubber band ligation does not address the external hemorrhoid component. Success rates vary, depending on the degree of hemorrhoids treated, length of follow-up, and criteria for success.37Walker A.J. Leicester R.J. Nicholls R.J. Mann C.V. A prosp" @default.
• W1491380816 created "2016-06-24" @default.
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• W1491380816 date "2004-05-01" @default.
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• W1491380816 title "American gastroenterological association technical review on the diagnosis and treatment of hemorrhoids1 1This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice Committee. The paper was approved by the Committee on January 8, 2004, and by the AGA Governing Board on February 13, 2004." @default.
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