Tuesday 27 November 2012

Internal

Internal hemorrhoids are those that originate above the dentate line.[7] They are covered by columnar epithelium which lacks pain receptors.[4] They were classified in 1985 into four grades based on the degree of prolapse.[4][3]
  • Grade I: No prolapse. Just prominent blood vessels.[11]
  • Grade II: Prolapse upon bearing down but spontaneously reduce.
  • Grade III: Prolapse upon bearing down and requires manual reduction.
  • Grade IV: Prolapsed and cannot be manually reduced.

External

A thrombosed external hemorrhoid
External hemorrhoids are those that occur below the dentate or pectinate line.[7] They are covered proximately by anoderm and distally by skin, both of which are sensitive to pain and temperature.[4]

Differential

Many anorectal problems, including fissures, fistulae, abscesses, colorectal cancer, rectal varices and itching have similar symptoms and may be incorrectly referred to as hemorrhoids.[3] Rectal bleeding may also occur due to colorectal cancer, colitis including inflammatory bowel disease, diverticular disease, and angiodysplasia.[11] If anemia is present, other potential causes should be considered.[5]
Other conditions that produce an anal mass include: skin tags, anal warts, rectal prolapse, polyps and enlarged anal papillae.[5] Anorectal varices due to increased portal hypertension (blood pressure in the portal venous system) may present similar to hemorrhoids but are a different condition.[5]

Prevention

A number of preventative measures are recommended including avoiding straining while attempting to defecate, avoiding constipation and diarrhea either by eating a high fiber diet and drinking plenty of fluid or taking fiber supplements, and getting sufficient exercise.[12][5] Spending less time attempting to defecate, avoiding reading while on the toilet,[3] as well as losing weight for overweight persons and avoiding heavy lifting are also recommended.[13]

Management

Conservative

Conservative treatment typically consists of nutrition rich in dietary fiber, uptake of oral fluids to maintain hydration, non-steroidal anti-inflammatory drugs (NSAID)s, sitz baths, and rest.[3] Increased fiber intake has been shown to improve outcomes,[14] and may be achieved by dietary alterations or the consumption of fiber supplements.[3][14] Evidence for benefits from sitz baths during any point in treatment however is lacking.[15] If they are used they should be limited to 15 minutes at a time.[4]
While many topical agents and suppositories are available for the treatment of hemorrhoids, there is little evidence to support their use.[3] Steroid containing agents should not be used for more than 14 days as they may cause thinning of the skin.[3] Most agents include a combination of active ingredients.[4] These may include: a barrier cream such as petroleum jelly or zinc oxide, an analgesic agent such as lidocaine, and a vasoconstrictor such as epinephrine.[4] Flavonoids are of questionable benefit with potential side effects.[16][4] Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery.[17]

Procedures

A number of office based procedures may be performed. While generally safe, rare serious side effects such as perianal sepsis may occur.[11]
  • Rubber band ligation is typically recommended as the first line treatment in those with grade 1 to 3 disease.[11] It is a procedure in which elastic bands are applied onto an internal hemorrhoid at least 1 cm above the dentate line to cut off its blood supply. Within 5–7 days, the withered hemorrhoid falls off. If the band is placed too close to the dentate line, intense pain results immediately afterwards.[3] Cure rate has been found to be about 87%[3] with a complication rate of up to 3%.[11]
  • Sclerotherapy involves the injection of a sclerosing agent, such as phenol, into the hemorrhoid. This causes the vein walls to collapse and the hemorrhoids to shrivel up. The success rate four years after treatment is ~70%[3] which is higher than that with rubber band ligation.[11]
  • A number of cauterization methods have been shown to be effective for hemorrhoids, but are usually only used when other methods fail. This procedure can be done using electrocautery, infrared radiation, laser surgery,[3] or cryosurgery.[18] Infrared cauterization may be an option for grade 1 or 2 disease.[11] In those with grade 3 or 4 disease re-occurrence rates are high.[11]

Surgery

A number of surgical techniques may be used if conservative management and simple procedures fail.[11] All surgical treatments are associated with some degree of complications including bleeding, infection, anal strictures and urinary retention, due to the close proximity to the rectum to the nerves that supply the bladder.[3] There may also be a small risk of fecal incontinence, particularly of liquid,[19][4] with rates reported between 0% and 28%.[20] Mucosal ectropion is another condition which may occur after hemorrhoidectomy (often together with anal stenosis).[21] This is where the anal mucosa becomes everted from the anus, similar to a very mild form of rectal prolapse.[21]
  • Excisional hemorrhoidectomy is a surgical excision of the hemorrhoid used primarily only in severe cases.[3] It is associated with significant post-operative pain and usually requires 2–4 weeks for recovery.[3] However, there is greater long term benefit in those with grade 3 hemorrhoids as compared to rubber band ligation.[22] It is the recommended treatment in those with a thrombosed external hemorrhoid if carried out within 24-72 hours.[11][7] Glyceryl trinitrate ointment post procedure, helps both with pain and healing.[23]
  • Doppler-guided, transanal hemorrhoidal dearterialization is a minimally invasive treatment using an ultrasound doppler to accurately locate the arterial blood inflow. These arteries are then "tied off" and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate, but fewer complications compared to a hemorrhoidectomy.[3]
  • Stapled hemorrhoidectomy, also known as stapled hemorrhoidopexy, is a procedure that involves the removal of much of the abnormally enlarged hemorrhoidal tissue, followed by a repositioning of the remaining hemorrhoidal tissue back to its normal anatomic position. It is generally less painful and is associated with faster healing compared to complete removal of hemorrhoids.[3] However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorroidectomy[24] and thus it is typically only recommended for grade 2 or 3 disease.[11]

Epidemiology

It is difficult to determine how common hemorrhoids are as many people with the condition do not see a healthcare provider.[9][6] However, it is believed that symptomatic hemorrhoids affect at least 50% of the US population at some time during their lives and around ~5% of the population is affected at any given time.[3] Both sexes experience approximately the same incidence of the condition[3] with rates peaking between 45 and 65 years.[5] They are more common in Caucasians[25] and those of higher socioeconomic status.[4] Long term outcomes are generally good, although some people may have recurrent symptomatic episodes.[6] Only a small proportion of persons end up needing surgery.[4]

History

11th century English miniature. On the right is an operation to remove hemorrhoids.
The first known mention of this affliction is from a 1700 BC Egyptian papyrus, which advises: “… Thou shouldest give a recipe, an ointment of great protection; Acacia leaves, ground, titurated and cooked together. Smear a strip of fine linen there -with and place in the anus, that he recovers immediately."[26] In 460 BC, the Hippocratic corpus discusses a treatment similar to modern rubber band ligation: “And hemorrhoids in like manner you may treat by transfixing them with a needle and tying them with very thick and woolen thread, for application, and do not forment until they drop off, and always leave one behind; and when the patient recovers, let him be put on a course of Hellebore.”[26] Descriptions of hemorrhoids also occur in the Bible.[27][5]
Celsus (25 BC – AD 14) described ligation and excision procedures, and discussed the possible complications.[28] Galen advocated severing the connection of the arteries to veins, claiming that it offered reduced pain and the spread of gangrene.[28] The Susruta Samhita, (4th – 5th century AD), similar to the words of Hippocrates, but emphasizes wound cleanliness.[26] In the 13th century, European surgeons such as Lanfranc of Milan, Guy de Chauliac, Henri de Mondeville and John of Ardene made great progress and development of the surgical techniques.[28]
The first use of the word "hemorrhoid" in English occurs in 1398, derived from the Old French "emorroides", from Latin "hæmorrhoida -ae",[29] in turn from the Greek "αἱμορροΐς" (haimorrhois), "liable to discharge blood", from "αἷμα" (haima), "blood"[30] + "ῥόος" (rhoos), "stream, flow, current",[31] itself from "ῥέω" (rheo), "to flow, to stream".[32]

Notable cases

Hall-of-Fame baseball player George Brett was removed from a game in the 1980 World Series due to hemorrhoid pain. After undergoing minor surgery, Brett returned to play in the next game, quipping "...my problems are all behind me."[33] Brett underwent further hemorrhoid surgery the following spring.[34] Conservative political commentator Glenn Beck underwent surgery for hemorrhoids, subsequently describing his unpleasant experience in a widely viewed 2008 YouTube video.[35]

References

  1. ^ Chen, Herbert (2010). Illustrative Handbook of General Surgery. Berlin: Springer. p. 217. ISBN 1-84882-088-7.
  2. ^ a b c d e f g h i j k l m n o Schubert, MC; Sridhar, S; Schade, RR; Wexner, SD (July 2009). "What every gastroenterologist needs to know about common anorectal disorders". World J Gastroenterol 15 (26): 3201–9. doi:10.3748/wjg.15.3201. ISSN 1007-9327. PMC 2710774. PMID 19598294.
  3. ^ a b c d e f g h i j k l m n o p q r s t u v w x y Lorenzo-Rivero, S (August 2009). "Hemorrhoids: diagnosis and current management". Am Surg 75 (8): 635–42. PMID 19725283.
  4. ^ a b c d e f g h i j k l m n o Beck, David (2011). The ASCRS textbook of colon and rectal surgery (2nd ed. ed.). New York: Springer. pp. 174-177. ISBN 9781441915818.
  5. ^ a b c d e f g h i j k l m n o p q r s Kaidar-Person, O; Person, B; Wexner, SD (2007 Jan). "Hemorrhoidal disease: A comprehensive review". Journal of the American College of Surgeons 204 (1): 102-17. PMID 17189119.
  6. ^ a b c d e Davies, RJ (2006 Jun). "Haemorrhoids.". Clinical evidence (15): 711-24. PMID 16973032.
  7. ^ a b c d e Dayton, senior editor, Peter F. Lawrence; editors, Richard Bell, Merril T. (2006). Essentials of general surgery (4th ed. ed.). Philadelphia ;Baltimore: Williams & Wilkins. p. 329. ISBN 9780781750035.
  8. ^ Azimuddin, edited by Indru Khubchandani, Nina Paonessa, Khawaja (2009). Surgical treatment of hemorrhoids (2nd ed. ed.). New York: Springer. p. 21. ISBN 978-1-84800-313-2.
  9. ^ a b Reese, GE; von Roon, AC; Tekkis, PP (2009 Jan 29). "Haemorrhoids.". Clinical evidence 2009. PMID 19445775.
  10. ^ National Digestive Diseases Information Clearinghouse (November 2004). "Hemorrhoids". National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), NIH. Retrieved 18 March 2010.
  11. ^ a b c d e f g h i j k l Rivadeneira, DE; Steele, SR; Ternent, C; Chalasani, S; Buie, WD; Rafferty, JL; Standards Practice Task Force of The American Society of Colon and Rectal, Surgeons (2011 Sep). "Practice parameters for the management of hemorrhoids (revised 2010)". Diseases of the colon and rectum 54 (9): 1059-64. PMID 21825884.
  12. ^ Frank J Domino (2012). The 5-Minute Clinical Consult 2013 (Griffith's 5 Minute Clinical Consult). Hagerstown, MD: Lippincott Williams & Wilkins. p. 572. ISBN 1-4511-3735-4.
  13. ^ Glass, [edited by] Jill C. Cash, Cheryl A.. Family practice guidelines (2nd ed. ed.). New York: Springer. p. 665. ISBN 9780826118127.
  14. ^ a b Alonso-Coello, P.; Guyatt, G. H.; Heels-Ansdell, D.; Johanson, J. F.; Lopez-Yarto, M.; Mills, E.; Zhuo, Q.; Alonso-Coello, Pablo (2005). Alonso-Coello, Pablo. ed. "Laxatives for the treatment of hemorrhoids". Cochrane Database Syst Rev (4): CD004649. doi:10.1002/14651858.CD004649.pub2. PMID 16235372.
  15. ^ Lang, DS; Tho, PC; Ang, EN (2011 Dec). "Effectiveness of the Sitz bath in managing adult patients with anorectal disorders". Japan journal of nursing science : JJNS 8 (2): 115-28. PMID 22117576.
  16. ^ Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, et al. (August 2006). "Meta-analysis of flavonoids for the treatment of haemorrhoids". Br J Surg 93 (8): 909–20. doi:10.1002/bjs.5378. PMID 16736537.
  17. ^ Quijano, CE; Abalos, E (2005 Jul 20). "Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium". Cochrane database of systematic reviews (Online) (3): CD004077. PMID 16034920.
  18. ^ Misra, MC; Imlitemsu, (2005). "Drug treatment of haemorrhoids". Drugs 65 (11): 1481-91. PMID 16134260.
  19. ^ Pescatori, M; Gagliardi, G (2008 Mar). "Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures". Techniques in coloproctology 12 (1): 7-19. PMID 18512007.
  20. ^ Ommer, A; Wenger, FA; Rolfs, T; Walz, MK (2008 Nov). "Continence disorders after anal surgery--a relevant problem?". International journal of colorectal disease 23 (11): 1023-31. PMID 18629515.
  21. ^ a b Lagares-Garcia, JA; Nogueras, JJ (2002 Dec). "Anal stenosis and mucosal ectropion.". The Surgical clinics of North America 82 (6): 1225-31, vii. PMID 12516850.
  22. ^ Shanmugam, V; Thaha, MA; Rabindranath, KS; Campbell, KL; Steele, RJ; Loudon, MA (2005 Jul 20). "Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids". Cochrane database of systematic reviews (Online) (3): CD005034. PMID 16034963.
  23. ^ Ratnasingham, K; Uzzaman, M; Andreani, SM; Light, D; Patel, B (2010). "Meta-analysis of the use of glyceryl trinitrate ointment after haemorrhoidectomy as an analgesic and in promoting wound healing". International journal of surgery (London, England) 8 (8): 606-11. PMID 20691294.
  24. ^ Jayaraman, S; Colquhoun, PH; Malthaner, RA (2006 Oct 18). "Stapled versus conventional surgery for hemorrhoids". Cochrane database of systematic reviews (Online) (4): CD005393. PMID 17054255.
  25. ^ Christian Lynge, Dana; Weiss, Barry D.. 20 Common Problems: Surgical Problems And Procedures In Primary Care. McGraw-Hill Professional. p. 114. ISBN 978-0-07-136002-9.
  26. ^ a b c Ellesmore, Windsor (2002). "Surgical History of Haemorrhoids". In Charles MV. Surgical Treatment of Haemorrhoids. London: Springer.
  27. ^ King James Bible. 1 Samuel 6 4.
  28. ^ a b c Agbo, SP (1 January 2011). "Surgical management of hemorrhoids". Journal of Surgical Technique and Case Report 3 (2): 68. doi:10.4103/2006-8808.92797.
  29. ^ hæmorrhoida, Charlton T. Lewis, Charles Short, A Latin Dictionary, on Perseus Digital Library
  30. ^ αἷμα, Henry George Liddell, Robert Scott, A Greek-English Lexicon, on Perseus Digital Library
  31. ^ ῥόος, Henry George Liddell, Robert Scott, A Greek-English Lexicon, on Perseus Digital Library
  32. ^ ῥέω, Henry George Liddell, Robert Scott, A Greek-English Lexicon, on Perseus Digital Library
  33. ^ Dick Kaegel (March 5, 2009). "Memories fill Kauffman Stadium". Major League Baseball.
  34. ^ "Brett in Hospital for Surgery". The New York Times. Associated Press. March 1, 1981.
  35. ^ "Glenn Beck: Put the 'Care' Back in Health Care". ABC Good Morning America. Jan. 8, 2008. Retrieved 17 September 2012.
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