Treatment of Internal Hemorrhoids

Larry S. Sasaki, MD, FACS
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Subject: Treatment of Internal Hemorrhoids

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Introduction

Hemorrhoidal disease affects more than a million Americans each year. Most sufferers will avoid medical attention and self-medicate with over-the-counter treatments. This accounts for the lucrative business of nonprescriptive hemorrhoidal treatments. 
Hemorrhoids are vascular cushions of the anus. These vascular cushions are a normal anatomic part of the anus; thus, hemorrhoids are not pathologic. However, the term hemorrhoids is most commonly meant to describe symptoms due to enlargement of these vascular cushions. They are also considered varicose veins of the anus and rectum. Symptoms range from painless swelling to painful thrombosis. 
The probable pathogenesis of symptomatic hemorrhoids is the abnormal dilatation of the internal hemorrhoidal venous plexus and destruction of the suspensory ligaments of the internal hemorrhoids (corrugator cutis ani). The suspensory ligaments and connective tissue deteriorate with age, usually after the third decade of life. Subsequently, hemorrhoidal dilatation and prolapse may occur, resulting in swelling, erosion, bleeding, thrombosis, and pain. 
Medical treatment of internal hemorrhoids are primarily used to alleviate the symptoms. A wide variety of anal creams and suppositories are composed of a combination of topical steroids and anesthetics. Any of the prescription-strength combinations should suffice. Warm tub or sitz baths should be taken at least four times daily and after bowel movements. Fiber supplementation should be taken to prevent constipation and straining. 
Persistent internal hemorrhoidal symptoms such as bleeding, swelling, and prolapse that are unresponsive to medical treatment warrant additional treatment options. Common office treatments include infrared coagulation and rubber band ligation, which will be outlined later. Other less utilized office treatments include cryosurgery, sclerotherapy, and bipolar diathermy. 
Hemorrhoids that are unresponsive or refractory to medical and office treatments are candidates for surgery. A new less invasive procedure with dramatically less pain and morbidity is the procedure for prolapsed hemorrhoids (PPH). PPH is preferable over the conventional hemorrhoidectomy for these reasons. It is performed on an outpatient basis. The PPH removes a circumferential band of anorectal mucosa and submucosa above the dentate line with a circular stapler. This effectively treats hemorrhoids that are bleeding and prolapsing by reducing the blood flow to the internal hemorrhoids and repositions the anal canal tissue resulting in “lifting up” the hemorrhoidal tissue. Ultimately, patients experience less pain and recover faster than patients who are treated with conventional hemorrhoidectomy procedures. 

Equipment

  • Surgical water-soluble lubricant

  • Anoscopes: disposable fiber optic or metallic

  • Illumination instrument

  • Preferred treatment devices:

    • Redfield infrared coagulator (Model #IRC 2100)

    • McGivney hemorrhoid rubber band ligator

Indications

  • Rectal symptoms: bleeding, itching, swelling, pain

  • Prolapse

Contraindications

  • Bleeding diathesis

  • Anal stenosis (relative due to discomfort of anoscope)

The Procedure

Step 1

Internal hemorrhoids are defined by their anatomic position in the anus, which is above the dentate line. External hemorrhoids develop below the dentate line. 

Step 2

The most common presenting complaint of hemorrhoids is bleeding. Other common symptoms include itching, pain, swelling, and mucous discharge. Anoscopy is the optimal diagnostic examination for the anal canal. Thus, the initial physical examination should include anoscopy. Later, either rigid or flexible proctosigmoidoscopy should be performed. Those patients with occult blood in stool, or those 50 years of age or older, should undergo a colonoscopy. 
  • PITFALL: A diagnosis of “hemorrhoids” may conceal a colorectal cancer.

  • Pearl: All rectal bleeding must have a thorough colorectal examination. All occult blood in stool must have a colonoscopy.

Step 3

Several other anorectal conditions can mimic the signs and symptoms of hemorrhoids, such as fissures, abscesses, fistulas, condylomas, pruritus ani, and rectal prolapse. These must be differentiated at the time of presentation, which can often be achieved by external examination and anoscopy. An anal fissure can often be diagnosed by external examination without anoscopy. By digitally spreading the perianal skin, the anal fissure can be visualized, usually at the anterior and/or posterior midline. 
  • PITFALL: Anoscopy performed for an anal fissure may cause excessive discomfort and is unnecessary.

  • Pearl: Anal fissures are most commonly located at the anterior and/or posterior midline. Look for the frequently associated anal skin tag.

Step 4

Perirectal abscesses and anal fistulas can be diagnosed by external examination. Anoscopy is helpful in identifying the internal opening of an anal fistula. The internal opening is identified with the fistula probe. 

Step 5

Rectal prolapse can easily be differentiated from prolapsing internal hemorrhoids by external examination. Prolapsing internal hemorrhoids (A) are characterized by radial crevices or “sulci” that radiate peripherally from the center. Whereas, rectal prolapse (B) has concentric crevices or rings. 
  • PITFALL: Symptomatic hemorrhoids, even prolapsing, can regress and have an unremarkable external examination.

  • Pearl: Have the patient take an enema in the office to allow for symptomatic hemorrhoids and rectal prolapse to enlarge and prolapse.

Infrared Coagulation

Step 1
An infrared coagulation is applied directly with a probe through an anoscope. An assistant holds the anoscope in place. 
Step 2
Three to five pulses are applied to the normal mucosa above the hemorrhoidal column. Try to avoid applying the pulse directly on the hemorrhoid. Pulses are 1 to 1.5 seconds in duration. Treatments may be repeated every 2 weeks. 
  • Pearl: Any patient with bleeding is a candidate. Prolapse is not as effectively treated with this method.

Rubber Band Ligation

Step 1
The McGivney hemorrhoid rubber band ligator is used to ligate internal hemorrhoids. Placement of the rubber band above the dentate line should be painless. The mucosa at the proximal apex of the hemorrhoidal column is grasped with the forceps while the patient is asked whether “pain” or “pressure” are felt. If pain is ilicited, then the forceps should be repositioned more proximally (i.e., away from the dentate line). Once an area of “pressure” is reported, then the rubber band is deployed. If despite grasping a more proximal area the patient still reports “pain,” then the procedure should be abandoned, and surgical treatment may be indicated. Usually, there are three major hemorrhoidal columns that will require ligation: (1) left lateral, (2) right anterior, and (3) right posterior. The first session of rubber banding should be performed only once. If the patient tolerates this well, then the other areas can be treated 3 to 4 weeks later. 
  • Pearl: Any patient with bleeding, prolapse, or both is a candidate.

Step 2
Prepare rubber band ligator by placing two bands on the end of the device. 
Step 3
Insert an anoscope, and examine the canal circumferentially to identify the largest hemorrhoidal columns. 
Step 4
Identify the internal hemorrhoid, and confirm that the location is above the dentate line. Note the forceps grabbing the appropriate area above the dentate line. 
Step 5
Prepare the instrument with the ligator at the joint of the forceps. This allows for maximal separation of forceps to grasp the hemorrhoidal tissue. 
Step 6
Grasp the internal hemorrhoidal tissue to be ligated above the dentate line. The patient should report “pressure” but not “pain.” Gently advance the ligator against the rectal wall while applying traction on the forceps to optimize correct deployment of rubber bands at the base of the redundant internal hemorrhoidal tissue. 
Step 7
Examine the rubber band. The patient should not report “pain.” If painful, then the rubber band should be removed by using suture scissors. 

Complications

  • Bleeding

  • Pain

  • Infection, such as pelvic sepsis

  • Urinary retention (mandates examination to identify possible infection)

Pediatric Considerations

Hemorrhoids are rare in the pediatric population. 

Postprocedure Instructions

Instruct patients to bathe in a warm tub as needed for spasm or pain. Have them report excessive rectal bleeding, especially blood clots, or any signs of infection. Narcotics should be avoided after hemorrhoid treatment, as they can produce further constipation, straining, and bleeding. 

Coding Information and Supply Sources

Common ICD-9 Codes

Equipment Sources

  • The infrared coagulator and the metal, slotted Ives anoscope are available from Redfield Corporation, 336 West Passaic Street, Rochelle Park, NJ (phone: 800-678-4472; http://www.redfieldcorp.com).

  • The McGivney hemorrhoidal ligator (including loading cone), latex O-rings (i.e., rubber bands), and McGivney hemorrhoid grasping forceps are available from Miltex Inc., 589 Davies Dr., York, PA 17402 (phone: 800-645-8000; http://www.ssrsurgical.com).

Bibliography

Ambrose NS, Morris D, Alexander-Williams J, et al. A randomized trial of photocoagulation or injection sclerotherapy for the treatment of first- and second-degree hemorrhoids. Dis Colon Rectum .  1985;28:238–240. [View Abstract]
Corman ML. Colon and Rectal Surgery (5th ed.). Baltimore: Lippincott;  2004:165–180.
Johanson JF, Rimm A. Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. Am J Gastroenterol .  1992;87:1601–1606.
Ganio E, Altomare F, Gabrielli F, et al. Prospective randomized multicenter trial comparing stapled with open hemorrhoidectomy. British J Surg .  2001;88:669–674. [View Abstract]
Walker AJ, Leicester RJ, Nicholls RJ, et al. A prospective study of infrared coagulation, injection and rubber band ligation in the treatment of haemorrhoids. Int J Colorectal Dis .  1990;5:113–116. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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