Surgical Management of Hemorrhoids
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
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.
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.
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.
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
Keywords - patient, guideline, hemorrhoids, hemorrhoidectomy, banding, infrared coagulation, anoscopy, colonoscopy, pain, skin tags.
Board Approved October 8, 1996