Management of Internal and Mixed Hemorrhoids Nonsurgical Treatment

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Most patients visiting a physician have already tried some form of conservative therapy and come for medical attention because of persistent symptoms. A variety of office-based therapies are available, and common to these nonoperative procedures is the aim of abolishing the underlying patho-

physiologic mechanism of advanced hemorrhoidal disease. By promoting tissue fibrosis in various ways, the vascular cushions become fixed to the underlying muscular tissue.

Injection Sclerotherapy

Injection sclerotherapy has been used for hemorrhoidal disease treatment for over 100 years. Indicated to treat bleeding first, second, or early third degree internal hemorrhoids, a small amount of a sclerosing agent is injected above the dentate line. Five percent phenol in vegetable oil has been traditionally used, but other agents such as quinine, urea hydrochloride, and sodium morrhuate, are available. It is a straightforward, quick, painless, and inexpensive method, with success reported in up to 75% of patients. Although complications of pelvic sepsis and perianal necrosis have been reported, sloughing of the overlying mucosa, local infections, and allergic reactions to the injected material are more commonly described side effects.

Rubber Band Ligation

Rubber band ligation is probably the most commonly used nonoperative modality to treat internal hemorrhoids. It is generally a safe, simple and cost effective procedure indicated for second or third degree hemorrhoidal disease. An elastic rubber band is applied anoscopically or endoscop-ically by means of a special introducer to the tissue just above or at the base of a symptomatic pile. Care must be taken to apply the band above the dentate line, otherwise severe pain will ensue, and the band will need to be removed. Rubber band ligation induces necrosis and slough of the strangulated mucosa. Fibrosis occurs, and the remaining cushion becomes fixed to the underlying tissue. Patients should be informed to expect delayed rectal bleeding in about 7 to 10 days after the procedure.

Treatment of more than one hemorrhoidal group per session is the subject of continued debate. Proponents of multiple banding at a single session cite a low completion rate and quicker total treatment time with less office visits and more rapid resolution of symptoms (Armstrong, 2003). Alternatively, those who believe in banding only one group per visit avoid multiple bands because of the potential for increased discomfort, potential for obstruction, and an increased risk of septic complications. Up to 80% of patients will benefit from rubber band ligation. The recurrence rate is between 15 to 20%, with < 2% incidence of minor complications such as anal pain and bleeding. Rare cases of pelvic sepsis have been reported.

Thermal Injury

Alternative methods of treatment use different energy sources to induce hemorrhoidal fixation by way of thermal injury. These techniques include electrocoagulation, heater probes, laser photocoagulation, and infrared photocoagula-

tion (IRC). IRC uses an infrared source to generate high temperature to induce submucosal tissue destruction. This technique is uncomplicated, easy to perform, and mild with good results and low morbidity. However, the expense of this equipment for office-based therapy has diminished its use. Cyrotherapy produces tissue destruction by a rapid cellular freezing and thawing. Postprocedural pain, slow healing and risk for internal sphincter damage have led most surgeons to abandon this method.

There are no good prospective randomized control studies that compare the various fixation modalities, and existing trials do not demonstrate superiority of any particular method. In a meta-analysis comparing injection sclerother-apy, IRC, and rubber band ligation, injection sclerotherapy was found to be somewhat less efficient than the other forms of therapy.5 In the absence of randomized trials, and because treatment methods appear equally effective, the technique chosen for each patient should be customized to the problem and to the experience of the treating surgeon or physician. Regardless of the solution offered, patients should be advised to continue following general recommendations, such as avoiding straining and maintaining fiber use. Patient follow-up should continue for treatment effectiveness and to complete the colon evaluation as described above.

Strangulated Prolapsed Internal Hemorrhoids

Strangulated prolapsed internal hemorrhoids are often edematous and thrombosed due to a compromised venous return. Initial management is usually nonoperative. If the piles are not gangrenous, a perineal field block may be performed to aid in manual reduction. Application of table sugar (sucrose) to prolapsed hemorrhoids acts as a desic-cant to absorb fluid and reduce hemorrhoidal edema. If successful in reducing incarcerated piles, less morbid treatment may then be performed more electively. Severe pain accompanied by a foul smelling discharge usually implies the presence of gangrene. Under these conditions, urgent hemorrhoidectomy is indicated.

Special situations deserve mention. Pregnant women frequently endure hemorrhoidal disease. Conservative treatment is recommended, because symptoms usually subside after delivery. Nonsurgical treatment is also advised for immunocompromised patients and/or in patients suffering from IBD. Perianal procedures may result in infection and delayed wound healing in these patients.

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