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HEMORRHOIDS

Hemorrhoids, or enlarged veins in the anal area, represent one of the most frequent and familiar anorectal problems seen in the primary care office setting. There are estimates that hemorrhoids occur in up to 80% to 90% of the US population. Because the term hemorrhoids is so often misused by patients to describe a multitude of other anorectal problems contributing to perianal pain and bleeding, the actual prevalence based on epidemiologic studies is more in the range of 40%. The prevalence of hemorrhoids is equal between men and women, but men are more likely to seek treatment. The prevalence of hemorrhoids also increases with age until the seventh decade, at which point there appears to be a slight decline. Pregnancy is a common predisposing risk factor for the development of hemorrhoids.

When appropriately diagnosed, most hemorrhoids can be treated successfully in the outpatient setting by the primary care provider. Careful clinical assessment is required to ensure that more significant bowel disease is not missed in the process.

CLASSIFICATION OF INTERNAL HEMORRHOIDS

Internal hemorrhoids are graded based on the degree of bleeding and prolapse observed by the patient and what can be confirmed by the physician on anoscopy. First-degree hemorrhoids bleed but do not prolapse. On anoscopy, the hemorrhoidal tissue projects into the anal canal, but there is no change with patient straining.

TREATMENT

Internal Hemorrhoids

The treatment of internal hemorrhoids depends on the severity of symptoms and the grade of internal hemorrhoid. In patients with minor or infrequent symptoms corresponding to Grades I and II, treatment begins with dietary modification, bulk laxatives, and topical hydrocortisone creams. A high-fiber diet with plenty of raw fruits and vegetables, commercial fiber supplements, and increased oral fluids is recommended to help promote soft, bulky, regular stools.

Injection Sclerotherapy

Injection sclerotherapy is ideal for the treatment of first-degree internal hemorrhoids and mild second-degree hemorrhoids in which there may be a paucity of tissue for banding. It is inexpensive, easily learned, and has a low complication rate. Using a 25-gauge spinal needle through a slotted anoscope, approximately 1 to 2 cc of a sclerosing agent.

Rubber Band Ligation

For second and third-degree hemorrhoids, rubber band ligation usually can control symptoms in both the short and long term. This method is cheap, safe, effective and remains the standard with which newer nonoperative methods are compared. Figure 4 (Figure Not Available) summarizes the technique of rubber band ligation. It involves placing a tiny rubber band around the base.

At the time of band placement, most people feel minimal or no discomfort. If band placement does cause significant pain immediately, then the physician can inject approximately 1 cc of 0.25% bupivicaine with 1:100,000 epinephrine beneath the band.

Bleeding is the most common complication after ligation and usually is of scant quantity. Patients sometimes experience more significant bleeding between 7 and 10 days postligation when the hemorrhoid actually sloughs. Aspirin and nonsteroidal anti-inflammatory agents, therefore, are relatively contraindicated for 2 weeks postprocedure.

Infrared Coagulation

Using infrared light to induce photocoagulation is another method that can be used to control bleeding of first and second-degree hemorrhoids. It is a simple, quick procedure that attains results comparable to injection sclerotherapy, but is more expensive. Basically, an infrared coagulation probe is applied transanally via anoscope to four sites on each hemorrhoidal complex: one at the midportion, one at the apex, and one on each lateral aspect.

Electrocoagulation

Electrocoagulation, either unipolar (low voltage DC) or bipolar, can be used to destroy hemorrhoidal tissue in grades I through III internal hemorrhoids. The technique is similar to that of infrared coagulation, in that a probe is applied via a nonconductive anoscope to various sites of the hemorrhoidal complex inducing tissue destruction, coagulation.

Laser Therapy

Both carbon dioxide and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers are used for coagulation and tissue destruction of internal hemorrhoids. Equipment expense makes it impractical for use in an office setting.

Cryotherapy

Cryotherapy is the freezing destruction of hemorrhoidal tissue with a liquid nitrogen probe that inserts via anoscope. It is currently not recommended for the treatment of hemorrhoids for a variety of reasons. The size and depth of destruction cannot be accurately predicted, with sphincter damage being a problem in the past.

Surgical Hemorrhoidectomy

Referral for surgical excision of internal hemorrhoids generally is reserved for the small proportion of patients who suffer from third-degree and fourth-degree hemorrhoids, those in whom conservative treatment of lower grade hemorrhoids has failed consistently, those with strangulated internal hemorrhoids.

Thrombosed External Hemorrhoids

Symptoms of a thrombosed external hemorrhoid range from minimal discomfort to severe pain. The severity of a patient's symptoms and the timing of presentation help to determine the course of treatment. If this is the patient's first episode, and the patient has only mild symptoms, then a conservative medical regimen of frequent sitz baths.

External Hemorrhoidal Skin Tags

Perianal skin tags represent the stretching and enlargement of normal perianal skin that occurs secondary to a previously thrombosed external hemorrhoid. Patients most often seek treatment for these not because of pain, but because they interfere with maintaining anal hygiene.