Out-Patient Treatment of Haemorrhoids

David Jones

Powerpoint File

Natural history
Symptoms from haemorrhoids are very common in the population. The majority of patients can be managed on an out-patient basis. They should be treated according to their symptoms and not on the appearance or mere presence of their haemorrhoids.

Conservative management.
Many patients are content to live with their symptoms, with the reassurance that they do not have any serious pathology. Symptoms are often intermittent and patients can be helped by making changes to their bowel habit and diet. There are numerous popular remedies for haemorrhoids, which are widely available over the internet and will be covered in the presentation.

Bowel habit
Poor bowel habit, such as straining to pass every last bit of faeces, is purported to contribute to problems from haemorrhoids. It is common to advocate correcting such abnormal bowel habits. It is unclear whether a coloproctologist can easily modify a patient’s bowel habit.

Dietary manipulation
Correcting constipation by adopting a high fibre diet with or without the aid of bulking agent is logical and seems to work in clinical practice, although there have been few scientific studies.

Topical applications
These are commonly prescribed in the community or purchased over the counter. There is little objective evidence about their efficacy, although patients seem to obtain some relief from their use.

Vasotopic agents
These are frequently used outside the United Kingdom. They work by reducing oedema and inflammation in haemorrhoids. There is some evidence to support their use.

Interventional Therapy
The various techniques work by preventing prolapse of the mucosa, with varying degrees of tissue destruction. The resulting scarring, fixes the remaining mucosa, preventing further prolapse. A meta-analysis of haemorrhoid treatments shows injection sclerotherapy and infra-red coagulation to be of similar efficacy and cause least disruption to lifestyle. Rubber band ligation is more effective, but is associated with more pain and complications than injections or coagulation (MacRae et al, Dis Col Rectum 38 (7); 687, 1995 ). Technical aspects of these techniques will be covered in the presentation.

Injection therapy
Phenol is injected into the base of a haemorrhoid. 3-5ml can be injected at each site. This should be a painless procedure, but the patient may be left with a dull sensation in the anal canal. Patients with a tendency to constipation may be helped by laxatives. This is usually a very safe procedure, but serious complications have been reported, including severe pain, urinary tract infection, impotence and excessive scarring. These may be related to badly sited injections.

Photocoagulation
Tissue at the base of a haemorrhoid is coagulated using a contact infra-red probe. This is usually painless, unless applied close to the dentate line. Minor secondary haemorrhage is occasionally observed. There have been recent difficulties in the supply of the equipment in the UK.

Rubber band ligation
This can be performed using disposable equipment. Bands should be applied at the base of a haemorrhoid about 1.5.-2cm from the dentate line. This is usually a safe procedure. About 20% of patients experience some discomfort, and a small proportion suffer pain. This is considered to arise if the bands are applied too low, or too close to the dentate line. Secondary haemorrhage between one and two weeks after the procedure is common as the necrotic tissue sloughs away. A small minority of patients suffer severe haemorrhage necessitating hospital admission. Severe pelvic cellulitis with fatal consequences has been reported.

Conclusion
The majority of patients with haemorrhoidal disease can be managed on an out-patient basis. The ability to manage haemorrhoidal problems with high patient satisfaction is probably an indicator of a good Coloproctologist.

Reference: Practice Parameters for the management of hemorrhoids. Cataldo et al, Dis Colon Rectum 2005; 48: 189