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SSAT Patient Care Guidelines

Surgical Management of Hemorrhoids

Introduction
Every individual is born with hemorrhoidal vascular plexuses, 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 physical activity.

Hemorrhoids are generally categorized as internal (covered with mucosa) and external (covered with squamous epithelium). Internal hemorrhoids bleed and prolapse to give a mass effect, and patients will notice that hemorrhoids may protrude with bowel movements. Internal hemorrhoids are staged according to the degree of prolapse.

Stage I: Bleeding only, no prolapse
Stage II: Prolapse that reduces spontaneously, with or without bleeding
Stage III: Prolapse that requires manual reduction, with or without bleeding
Stage IV: Irreducible prolapsed hemorrhoidal tissue

Symptoms and Diagnosis
Hemorrhoids may present with symptoms typical of many pathologic anal conditions, including bleeding, pain, discharge, or a mass. 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.

External hemorrhoids generally do not bleed, but can thrombose and cause acute pain. Although external hemorrhoids can become necrotic and drain, most thrombosed hemorrhoids resolve spontaneously. Redundant "skin tags" may remain and may cause pruritis if the area cannot be properly cleansed.

Acute complications can occur with either prolapse of internal hemorrhoids or thrombosis of the external hemorrhoids. Acute pain is usually constant and related to a visible mass. Pain occurring after a bowel movement is rarely due to a hemorrhoid complication, but is more likely due to an anal fissure or ulcerating anal mass. Chronic anal pain and pruritus are more commonly the results of non hemorrhoidal processes including anal fissure, mucosal prolapse, anal mass, or anal fistula.

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 bleeding, pain or incarcerated protrusions should be seen promptly.

Treatment
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 is necessary.

In patients with Stage I, II, or III internal hemorrhoids, local treatment can be 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. Surgical intervention with operative excision is required in Stage lV disease. This is associated with long-term resolution of symptoms in 95% of patients. Surgical excision may also be indicated in earlier stage disease that is primarily composed of external hemorrhoids. Circular stapled hemorrhoidopexy is associated with less postoperative pain but a higher long-term risk of recurrence. 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 with a local anesthetic if symptoms warrant.

Risks
The risks of hemorrhoidal disease are protracted 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 transient pain is likely from the dilation and pressure effects of the treatments. Notable pain after banding or injection of internal hemorrhoids requires medical attention. The pain could be 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 generally requires narcotics for relief. The fear of a bowel movement causing pain may lead to fecal impaction in some patients. Co-morbid conditions such as diabetes, AIDS 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. Anal sphincter injury leading to incontinence is a recognized risk, but is extremely rare in experienced hands.

Expected Outcomes
Following local treatment, symptoms of local protrusion and bleeding should be eradicated. The risk of recurrent symptoms following such treatment varies with the extent of the 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 early stage hemorrhoidal disease can be treated in the office. Simple surgical hemorrhoidectomies can generally be carried out under local anesthesia with intravenous sedation. More complex excisions for advanced disease typically require a general anesthetic. A brief stay in the hospital may be necessary for pain control, depending on the patient's pain threshold. Activity levels after any of the described interventions should be advanced according to the patient’s comfort. Strenuous physical activity should be limited considerably due to the resultant increase in anorectal venous pressure.

Qualification for Performing Surgery for Hemorrhoids
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.

Suggested Readings

  1. Kaidar-Person O, Person B, Wexner SD. Hemorrhoidal disease: A comprehensive review. J Am Coll Surg. 2007 Jan;204(1):102-17.
  2. Cheetham MJ, Phillips RK. Evidence-based practice in haemorrhoidectomy. Colorectal Dis. 2001 Mar;3(2):126-34.
  3. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005393.
  4. Sardinha TC, Corman ML. Hemorrhoids. Surg Clin North Am. 2002 Dec;82(6):1153-67, vi.
  5. Senagore AJ. Surgical management of hemorrhoids. J Gastrointest Surg. 2002 May-Jun;6(3):295-8.

Keywords - patient, guideline, hemorrhoids, hemorrhoidectomy, banding, infrared coagulation, anoscopy, colonoscopy, pain, skin tags.

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
Revised & Board Approved 10/13/08

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Disclaimer
SSAT Patient Care Committee Guidelines

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.

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