Please forward this error screen to orion1. Please forward this error screen to orion1. Please forward this error screen to orion1. Please confirm that you would like to log out of Medscape. If you log out, you will be required to enter your username and password the next time you visit. The old adage that it is hard to make an asymptomatic patient better applies here. No matter how bad the hemorrhoids look to the practitioner, they should not be treated unless they bother the patient.
Treatment of hemorrhoids is divided by the cause of symptoms, into internal and external treatments. Accurately classifying a patient’s symptoms and the relation of the symptoms to internal and external hemorrhoids is important. The ACG guidelines, for example, recommend that patients with symptomatic hemorrhoids initially be treated with increased fiber and adequate fluid intake. The guidelines also recommend that if dietary modifications do not eliminate symptoms in patients with first- to third-degree hemorrhoids, various office procedures, including banding, sclerotherapy, and infrared coagulation, should be considered, with ligation probably being the most effective treatment. Internal hemorrhoids Internal hemorrhoids do not have cutaneous innervation and can therefore be destroyed without anesthetic, and the treatment may be surgical or nonsurgical. Internal hemorrhoid symptoms often respond to increased fiber and liquid intake and to avoidance of straining and prolonged toilet sitting. Nonoperative therapy works well for symptoms that persist despite the use of conservative therapy. Short- and medium-term results are excellent. Patients with minimal external tags and large internal hemorrhoids are easily treated with procedure for prolapsing hemorrhoids and skin tag excision.
Operative resection is sometimes required to control the symptoms of internal hemorrhoids. Remember that therapy is directed solely at the symptoms, not at aesthetics. However, these recurrences can usually be addressed with further nonoperative treatments. Long-term results from procedure for prolapsing hemorrhoids are unavailable at this time. Controversies The major controversies regarding the treatment of hemorrhoids center on the indications for treatment and the choice of operative versus nonoperative therapy. Most experienced surgeons are using office-based nonoperative therapies and are relying less on operative hemorrhoidectomy than they previously were. Infiltration of a local anesthetic containing epinephrine is followed by elliptical incision and excision of the thrombosed hemorrhoid, its accompanying vein, and overlying skin. Note: Simple incision and clot evacuation is inadequate therapy and should not be performed.
The incision should not extend beyond the anal verge or deeper than the cutaneous layer. A pressure dressing is applied for several hours, after which time the wound is left to heal by secondary intention. In patients presenting after 72 hours from the start of symptoms, conservative medical therapy is preferable. Retraining the patient’s toilet habit is also a consideration. Many patients see improvement or complete resolution of their symptoms with conservative measures. Aggressive therapy is reserved for patients who have persistent symptoms after 1 month of conservative therapy.
Treatment is directed solely at symptoms and not at the appearance of the hemorrhoids. Warm baths Bathing in tubs with warm water universally eases painful perianal conditions. Relaxation of the sphincter mechanism and spasm is probably the etiology. Ice can relieve the pain of acute thrombosis. Some authors do not suggest mechanisms such as the sitz bath for symptom relief. The rigid structure of these portable bathing apparatuses can act in a similar fashion as a toilet seat, causing venous congestion in the perianal area and potentially exacerbating the problem. However, sitz baths do have a role in the treatment of older or immobile patients who cannot routinely get in and out of a bathtub. High-fiber diet Psyllium seed significantly decreases bleeding and pain compared with placebo.
25 g of fiber per day. Many hemorrhoidal symptoms resolve only when they are treated with dietary alterations, including increased fiber and the addition of fiber supplements. Antidiarrheal agents, toilet habit retraining, and stool softeners Antidiarrheal agents are sometimes required in patients with hemorrhoidal symptoms and loose stools. Toilet retraining involves reminding patients that the lavatory is not the library. Patients should sit on the toilet only long enough to evacuate the lower intestines. Persistent straining or prolonged sitting can lead to engorged hemorrhoids. Stool softeners play a limited role in the treatment of routine hemorrhoidal symptoms. Oral fiber intake and fiber supplements almost always cure constipation and straining. Suppositories, except for providing lubrication, also have a small role in the treatment of hemorrhoidal symptoms.
Topical agents Few high-quality data exist regarding the use of topical treatment in patients with hemorrhoids. Topical hydrocortisone can sometimes ease internal hemorrhoidal bleeding. It is important to consider the principles of steroid use and the associated side effects, such as mucosal atrophy. As such, the prolonged use of topical steroids should be avoided. Submucosal veins do not get smaller with anti-inflammatory medications. Topical nitroglycerine and nifedipine have also been used to relieve symptoms associated with anal sphincter spasm. These agents should also be used with caution because of associated side effects, such as hypotension. Good evidence suggests that high-fiber diets in particular help reduce severity and duration of symptoms. Nonsurgical techniques function by rubber band ligation, ablation, sclerosis, or necrosis of mucosal tissues.
Lord dilatation, in which the anal canal is manually stretched under anesthesia, is seldom used in the United States, and many colorectal surgeons condemn its use, because it is essentially an uncontrolled disruption of the sphincter mechanism. Rubber band ligation Rubber band ligation is the most-used remedy for grade II and grade III hemorrhoids and is the standard by which other methods are compared. This procedure is most common in the United States, because it is the most commonly taught method in training programs. With experience, many third-degree and some fourth-degree internal hemorrhoids can be treated nonoperatively. Blaisdell and Barron described and refined ligation therapy. A band ligature is passed through an anoscope and placed on the rectal mucosa proximal to the dentate line.
The tissue necroses and sloughs off in 1-2 weeks, leaving an ulcer that later fibroses. Necrotizing pelvic sepsis is a rare, but serious, complication of rubber band ligation. The diagnosis is suggested by the triad of severe pain, fever, and urinary retention. It occurs 1-2 weeks after ligation, frequently in immune-compromised patients, and requires prompt surgical debridement. Coagulation, electrocautery, and electrotherapy Infrared coagulation serves best for grades I and II and some grade III hemorrhoids. This method may be as effective as banding with fewer and less severe complications. Low-voltage direct current works best for higher-grade hemorrhoids. Low-voltage direct current requires grounding time and provides excellent control of pain.
Preliminary findings appear to indicate that the novel technique of retroflexed endoscopic monopolar coagulation of grade II-III internal hemorrhoids is safe and effective, and it may be seamlessly incorporated into the end of a colonoscopy for the evaluation of hematochezia. Sclerotherapy and cryotherapy Sclerotherapy can provide adequate treatment of early internal hemorrhoids. However, sclerotherapy and cryotherapy are infrequently used and generally reserved for grade I or II hemorrhoids. Although minimally invasive, these treatment methods have a higher rate of postprocedure pain. Impotence, urinary retention, and abscess formation have also been reported. Laser therapy and radiowave ablation Laser therapy is more costly and provides no advantage over other methods. Operators must control the laser to avoid bleeding. Radiowave ablation followed by suture ligation could prove to be a safe, cost-effective, and convenient way to treat prolapsing hemorrhoids.
When questioned, the patients are asymptomatic. Treat hemorrhoids only if they cause problems for the patient. Similarly, patients often ask when they should have surgery. Patients with ulcerative colitis can tolerate aggressive surgery if it is needed. Treat underlying acute disease before any elective anorectal surgery. Avoid aggressive treatment in patients with Crohn disease, especially if the rectal mucosa is acutely inflamed. Drain abscesses as soon as possible, despite active disease elsewhere. If necessary, operative hemorrhoidectomy is safe in pregnant women.
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