SSAT - Physician Guidelines - Surgical Management Of Hemorrhoids

SSAT Patient Care Guidelines

Surgical Management of Hemorrhoids

Every individual is born with hemorrhoids, but they are clinically known as "hemorrhoids" only when they become enlarged and symptomatic. Hemorrhoids are symptomatic in approximately 4% of the general population and in 50% of Americans over the age of 50 years. Predisposing or associated conditions include heredity factors, constipation, and increased intra-abdominal pressure due to pregnancy, ascites, coughing, vomiting, or strenuous work.

Symptoms of hemorrhoids include local protrusion and swelling, discomfort related to protruding or swollen masses, and bleeding that may be significant enough to result in anemia. These symptoms are nonspecific, and the presence of hemorrhoids should not be presumed since more severe conditions such as inflammatory bowel disease and cancer can mimic hemorrhoidal symptoms. Patients with severe pain or incarcerated protrusions should be seen promptly.

Diagnosis is established with direct visualization by anoscopy or proctoscopy. All patients with rectal bleeding should have their colon examined to rule out proximal sources of bleeding, even in the presence of enlarged hemorrhoids. Since most sources of bright red bleeding are within the reach of a flexible sigmoidoscope, patients should undergo flexible sigmoidoscopy as well as anoscopy to rule out other causes of bleeding. Intermittent protrusion or occasional bleeding does not require urgent consultation. However, patients with acute symptoms of bleeding, pain or incarcerated protrusions should be seen promptly.

Initial therapy for chronic symptoms of hemorrhoidal disease should be conservative, including stool bulking and topical therapy with ointments or suppositories. Outpatient surgical treatment is appropriate if conservative treatment fails and the patient desires relief of symptoms. Operative treatment is reserved for symptomatic patients with Stage III or IV hemorrhoids. If the patient has evidence of anemia, full colonic examination is indicated and more aggressive treatment necessary.

In patients with Stage I, II, or III disease, local treatment is appropriate in the form of infrared coagulation, local injection, or rubber banding. Stage I and II diseases are effectively treated by any of these modalities, with resolution of symptoms in at least 90% of patients. Cryotherapy should be avoided because of excessive post-treatment symptoms. Stage III disease is probably best treated by hemorrhoidal banding to remove redundant tissue, but long-term resolution of symptoms is likely in only 70% of these patients. Stage IV disease requires surgical intervention, which is associated with long-term resolution of symptoms in 95% of patients. The term "laser hemorrhoidectomy" refers to excision of hemorrhoidal tissues using a laser rather than standard surgical instruments, but is a surgical procedure nonetheless.

Symptoms may also arise from residual hemorrhoidal tissue after an episode of acute thrombosis of external hemorrhoids. These external anal tags may prevent proper cleansing and can be excised during an office procedure if symptoms warrant.

The risks of hemorrhoidal disease are continued symptoms, anemia-producing bleeding, and thrombosed hemorrhoids that undergo necrosis. Risks of treatment include bleeding and infection. The risk of bleeding after local therapy is about 1%. The risk of infection after local treatment is unknown, but is certainly less than 1%. Local pain is a common side effect of local treatment. Pain after banding and injection typically lasts 24-36 hours, and continued pain requires medical attention. Excessive pain after treatment is due to sphincter spasm, and may render urination difficult. Urinary retention is an occasional symptom of occult sepsis.

Bleeding and infection are greater risks after open hemorrhoidectomy, but occur less than 5% of the time. Pain after open hemorrhoidectomy is significant and generally requires narcotics for relief. The fear of a bowel movement because of pain may lead to fecal impaction in a few patients. Co-morbid conditions such as diabetes, HIV and heart disease increase the risks of local treatment, but do not alter the type of complications. There may be subtle changes in continence of gas or liquid stool following local treatment or surgery, but they are rarely socially significant. Injury to the anal sphincter muscle is a recognized risk, but is extremely rare in experienced hands. Anal incontinence is a rare complication of surgery for hemorrhoidal disease.

Following local treatment, symptoms of local protrusion and bleeding should be eradicated. The risk of recurrent symptoms following local treatment varies with the extent of local disease, with a 10% recurrence rate for Stage I and II disease, and 30% for Stage III disease. Hemorrhoidectomy carries a 5% risk of recurrent symptoms.

Most hemorrhoidal disease can be treated in the office. Surgical hemorrhoidectomies can generally be carried out under local anesthesia with sedation. A brief stay in the hospital may be necessary for pain control, depending on the patient's pain threshold.

Symptoms following local treatment are minimal after 24-48 hours, with patient activity limited only by discomfort. After surgical hemorrhoidectomy, pain may persist for two weeks, with activity again permitted by the level of comfort.

The qualifications of a surgeon to perform any operative procedure should be based on education, training, experience and outcomes. At a minimum, the surgical treatment of hemorrhoids should be carried out by surgeons who are certified or eligible for certification by the American Board of Surgery, the American Board of Colon and Rectal Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent.

1. Cheetham MJ, Phillips RK. Evidence-based practice in haemorrhoidectomy. Colorectal Dis. 2001 Mar;3(2):126-34.

2. Smyth EF, Baker RP, Wilken BJ, Hartley JE, White TJ, Monson JR. Stapled versus excision haemorrhoidectomy: long-term follow up of a randomised controlled trial. Lancet. 2003 Apr 26;361(9367):1437-8.

3. Sardinha TC, Corman ML. Hemorrhoids. Surg Clin North Am. 2002 Dec;82(6):1153-67, vi.

4. Wilson MS, Pope V, Doran HE, Fearn SJ, Brough WA. Objective comparison of stapled anopexy and open hemorrhoidectomy: a randomized, controlled trial. Dis Colon Rectum. 2002 Nov;45(11):1437-44.

5. Senagore AJ. Surgical management of hemorrhoids. J Gastrointest Surg. 2002 May-Jun;6(3):295-8.

Board Approved October 8, 1996
5/11/96
8/15/98
Revised 9-27-96
Revised 5-9-97
Revised 9/29/99
Revised 11/1/99
Revised 1/8/2000
Revised 2/9/04
Approved 2/21/04

These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.