Atlas of Primary Care Procedures, 1st Edition

Gastroenterology

52

Treatment of Internal Hemorrhoids

It is estimated that nearly 75% of all adults in the United States suffer at some time from hemorrhoids. Hemorrhoids are distended vascular cushions that line the anal canal. These cushions normally reduce the effect of stool passing through the canal. With chronic passage of hard stool or straining, the cushions can lose their fibrocollagenous internal support. Without this support, the cushions dilate and prolapse into the anal canal as hemorrhoids.

The sensory innervation of the anal tissues generally travels inward to the dentate line. Internal hemorrhoids develop above the dentate line and usually manifest with painless bleeding. Patients often notice bleeding into the toilet or on the toilet tissue, but they also may complain of a protruding mass or itching. The four degrees of internal hemorrhoids are described in Table 52-1.

Internal hemorrhoids and the anal cushions occur in three consistent locations within the anal canal. These areas are described as the right posterior position, right anterior position, and left lateral position. The lubricated, slotted anoscope is inserted three times to adequately view each of these locations. Most often, patients are examined in the left lateral position (i.e., patient's left side down on the table). In this position, the hemorrhoid positions correspond to the 10-, 2-, and 6-o'clock locations within the canal (see Figure 3).

Hemorrhoids can be managed conservatively with medications, physical measures, or lifestyle changes (Table 52-2). Surgical therapy is effective but usually must be performed in expensive settings (i.e., operating rooms) and can produce significant postoperative discomfort. Primary care physicians often encounter second- and third-degree internal hemorrhoids that can be eliminated with simple

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office procedures. The two most commonly used techniques, rubber band ligation and infrared coagulation, are discussed in this chapter.

Rubber band ligation is performed by placing two latex rings at the base of the internal hemorrhoid using a special applicator. The banding produces necrosis and sloughing of the tissues in the week after the procedure. The procedure is popular because it requires inexpensive equipment, is easy to perform, and has a proven track record over many decades. Rubber band ligation can produce postoperative bleeding and discomfort and rarely causes a life-threatening condition known as pelvis sepsis.

Infrared coagulation is an office procedure that is a safe and highly efficacious. A 0.7-cm light tip applies the infrared energy to the superior aspect of the hemorrhoid in a 1.25- to 1.5-second timed pulse. The energy produces a burn with a maximum penetration of 3 mm and tethers the hemorrhoid to the underlying tissues. The resulting scar prevents the hemorrhoid from distending with blood and from bleeding or prolapsing. Several applications are applied to each hemorrhoid, and the treatment generally is well tolerated without the need for anesthesia. Patients may report some mild burning during the procedure, but this technique has the advantage of no postoperative sloughing, less postoperative discomfort, and no reported cases of pelvic sepsis. Many studies have demonstrated equal efficacy of infrared treatment with other common treatments for internal hemorrhoids.

Narcotics should be avoided after hemorrhoid treatment, because they can produce further constipation, straining, and bleeding. Nonprescription ibuprofen (three 200-mg tablets three times daily with food) and acetaminophen (two tablets every 6 hours) can be used if needed for discomfort. Mild bleeding should be expected after treatment of internal hemorrhoids, but excessive bleeding that requires medical attention is rare. The recommendations in Table 52-2 are given to individuals following treatment.

INDICATIONS

• Persistent bleeding from internal hemorrhoids
• Symptomatic second-, third-, or fourth-degree internal hemorrhoids
• Failure of symptomatic internal hemorrhoids to respond to conservative or medical management

RELATIVE CONTRAINDICATIONS

• Uncooperative patient
• Presence of serious anorectal disorders such as infectious proctitis, untreated syphilis, draining fistulas, or anorectal abscesses
• Cellulitis or bacteremia

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PROCEDURE

The anatomy of the anal canal is shown, demonstrating the location of internal and external hemorrhoids.

Patients are most commonly examined in the left lateral position. The patient lies with the left side down on the table, with the head toward the left when the examiner faces the patient. The patient's hips and knees are slightly flexed. Alternately, patients can be placed in a knee-chest position, but this is more uncomfortable to maintain.

Location of internal hemorrhoids within the canal.

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A slotted, metal anoscope with the obturator in place is inserted into the anal canal (Figure 4A), and the obturator is withdrawn for viewing (Figure 4B). The anoscope and obturator can be autoclaved. The anoscope is used to view all three anal cushions or hemorrhoids, and the findings are documented.

PITFALL: Slotted, metal anoscopes are preferred over the disposable, plastic anoscopes because of the improved visualization above and below the dentate line. The metal, slotted anoscopes provide a larger and longer opening due to the strength of the instrument.

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The McGivney hemorrhoid ligator has a 7-inch working length (Figure 5A). The loading cone (Figure 5B) is used to place the rubber bands on the end of the instrument. The hemorrhoid is pulled inside into the hollow applicator with grasping forceps (Figure 5C).

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Two rubber bands are rolled onto the ligator drum using the loading cone (Figure 6A). The loading cone is removed, leaving two rubber bands on the drum (Figure 6B). The forceps is placed inside the ligator, and both are placed inside the anoscope. The hemorrhoid is grasped with the forceps and pulled into the ligator drum (Figure 6C). The handle of the ligator is squeezed, with the two rubber bands released to the base of the hemorrhoid. Note the appearance of the hemorrhoid after removal of the instruments (Figure 6D). The hemorrhoid sloughs in the next week.

PITFALL: Treatments for internal hemorrhoids cannot be applied to external hemorrhoids or lesions originating below the dentate line. Inadvertent banding of an external hemorrhoid usually produces excruciating discomfort in the week after the procedure.

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The infrared coagulator (Figure 7A) and the handpiece and tip (Figure 7B) are shown.

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The infrared tip is firmly applied to the hemorrhoid (Figure 8A). The instrument handle is squeezed, producing a bright light as infrared energy is delivered to the instrument tip. Several applications can be applied in an arc over the superior aspect of the hemorrhoid (Figure 8B) or in a diamond pattern (Figure 8C). The hemorrhoid shrinks following this treatment.

PITFALL: Do not indent the tissue with excessive force when applying the infrared tip to the tissue. Excessive pressure can push the tip into the tissue and create a burn that is deeper than needed or desired.

PITFALL: The diamond pattern tethers the distal portion of the hemorrhoid but can cause greater patient discomfort because it produces burns closer to the dentate line, which may be highly innervated.

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CODING INFORMATION

INSTRUMENT AND MATERIALS ORDERING

The infrared coagulator ($3,700) and the metal, slotted Ives anoscope ($160) are available from Redfield Corporation, 336 West Passaic Street, Rochelle Park, NJ (phone: 800-678-4472; http://www.redfieldcorp.com). The McGivney hemorrhoidal ligator (including loading cone), latex O-rings (i.e., rubber bands), and McGivney hemorrhoid grasping forceps are available from Miltex Inc., 589 Davies Dr., York, PA 17402 (phone: 800-645-8000; http://www.ssrsurgical.com).

BIBLIOGRAPHY

Ambrose NS, Morris D, Alexander-Williams J, et al. A randomized trial of photocoagulation or injection sclerotherapy for the treatment of first- and second-degree hemorrhoids. Dis Colon Rectum 1985;28:238–240.

Bat L, Melzer E, Koler M, et al. Complications of rubber band ligation of symptomatic internal hemorrhoids. Dis Colon Rectum1993;36:287–290.

Dennison A, Whiston RJ, Rooney S, et al. A randomized comparison of infrared photocoagulation with bipolar diathermy for the outpatient treatment of hemorrhoids. Dis Colon Rectum 1990;33:32–34.

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Walker AJ, Leicester RJ, Nicholls RJ, et al. A prospective study of infrared coagulation, injection and rubber band ligation in the treatment of haemorrhoids. Int J Colorectal Dis 1990;5:113–116.

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