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hemorrhoids
HEMORRHOIDS
Treatment Guideline Chart
Hemorrhoids are swollen and inflamed vascular structures or veins around the anus or in the lower rectum.
External hemorrhoids are located closer to the anal verge and are covered with squamous epithelium. It produces symptoms only when thrombosed or when they give rise to large skin tags which make hygiene difficult. Common symptoms are anal pain of acute onset and a palpable lump in the perianal area.
Internal hemorrhoids originate above the dentate line and are covered with rectal or transitional mucosa. It does not cause cutaneous pain. Prolapse of internal hemorrhoids may cause bleeding, mucus discharge, fecal soiling and anal pruritus.

Surgical Intervention

Principles of Surgical Therapy

  • The need for treatment of hemorrhoids is based on the patient’s symptoms and not on the appearance of the hemorrhoids
  • Surgical hemorrhoidectomy is considered the most effective treatment for hemorrhoids in general and particularly for grades III-IV hemorrhoids
  • Outpatient ablative (non-surgical) procedures are preferred when possible because surgery is associated with more complications, pain and postoperative disability

Indications for Surgical Hemorrhoidectomy

  • Patients that do not respond to or cannot tolerate ablative office-based procedures
  • Patients with large grade III or IV hemorrhoids, symptomatic external hemorrhoids including those who have symptoms from skin tags
  • Acutely incarcerated and thrombosed hemorrhoids
  • Combined external and internal hemorrhoids (grade III-IV) with significant prolapse

Options for Surgical Therapy

Open or Closed Hemorrhoidectomy

  • May be performed using a surgical scalpel, laser, ultrasonic scalpel or diathermy
  • Involves any of the following:
    • Excising internal and external components
    • Suturing or banding internal hemorrhoids and excising external component
    • Performing a circular excision of internal hemorrhoids and prolapsing rectal mucosa proximal to the dentate line
  • Thrombosis of external hemorrhoids which has been present for <48-72 hours is best treated by local excision of the external component
    • May be done as an office procedure but may sometimes require an operating room setting because of large hemorrhoid size, extension within the canal or patient anxiety
  • Complications of surgery are usually minor but may occur frequently
    • These include bleeding, incontinence, urinary retention, infection, and anal stenosis

Stapled Hemorrhoidectomy

  • Newer alternative for patients with significant prolapse
  • Goals are the re-suspension of prolapsing tissue back within the anal canal and interruption of arterial blood flow that goes through the excised segment of redundant rectal mucosa
  • Uses a modified, circular, anastomotic stapler
  • Ineffective against large external hemorrhoids and skin tags or thrombosed hemorrhoids
  • Rates of complication are similar with excisional hemorrhoidectomy
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