Background
Hemorrhoids result from disruption of the anchoring of the anal cushions. They occur most commonly in the right anterior position and are associated with straining and irregular bowel habits. During defecation, straining engorges the cushions, resulting in their displacement. Repetition of this displacement results in stretching and eventual prolapse of the anal cushions, known as hemorrhoids (see the image below).
Hemorrhoids. Image reproduced from original with permission of the American Society of Colon & Rectal Surgeons.
Constipation and all conditions that result in abnormal anal pressure and compliance predispose to the formation of hemorrhoids. Acquired conditions such as portal hypertension cause engorgement of these venous plexuses, which can also contribute to anal cushion displacement. Pregnancy can also cause or aggravate symptoms; direct pressure may play a role, but other factors (eg, hormonal fluctuations) may contribute.
Inflammatory bowel disease (IBD) and consistent diarrhea can cause hemorrhoidal disease. Any patient with a combination of hemorrhoidal disease and IBD should be viewed with caution. [1]
Classification
Hemorrhoids may be broadly classified as either external or internal. External hemorrhoids are located distal to the dentate line and cause pain when they thrombose. This area is covered with sensate squamous epithelium, and thus, the patient typically reports pain, swelling, itching, or a combination of these symptoms.
Internal hemorrhoids are located proximal to the dentate line. This area is composed of insensate columnar-glandular epithelium. Internal hemorrhoids bleed, prolapse, or both. Patients typically present with sudden painless bleeding, usually after a bowel movement. Patients should undergo anoscopic examination or colonoscopy to rule out malignancy or diverticular disease.
Internal hemorrhoids can be graded according to the degree of prolapse, which is clinically useful for characterizing and choosing the correct treatment. Grading is as follows:
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Grade I (primary) – These are engorged but do not prolapse past the dentate line; patients are typically treated with dietary changes, including increased fiber intake; if hemorrhoids persist, sclerotherapy or rubber band ligation may be offered.
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Grade II (secondary) - These prolapse past the dentate line but reduce spontaneously; patients are typically treated with dietary changes including increased water and fiber intake; if hemorrhoids persist, sclerotherapy or rubber band ligation may be offered.
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Grade III (tertiary) - These prolapse past the anal verge and must be reduced manually; depending on the size of the hemorrhoids and the symptoms noted, patients may be treated with sclerotherapy, rubber-band ligation, or surgery
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Grade IV (quaternary) - These prolapse past the anal verge and are not reducible; surgical treatment (eg, hemorrhoidectomy) is indicated [1]
Indications
Depending on the severity of the symptoms, hemorrhoids are managed either medically or surgically.
The 2018 practice parameters published by the American Society of Colon and Rectal Surgeons (ASCRS) provided recommendations for evaluating patients with hemorrhoids, for identifying patients who require endoscopic evaluation of the colon, and for treatment options such as diet modification, office-based procedures, and surgical hemorrhoidectomy. [2]
In general, treatment options vary according to hemorrhoid severity or grade. For example, office-based procedures are reserved for patients with grades I, II, and III hemorrhoids and who have failed medical management. Surgical treatment of hemorrhoidal disease is customarily offered to patients whose disease does not respond to office-based procedures or who are unable to tolerate such procedures, as well as to patients who have large external hemorrhoids or grade III/IV combined internal/external hemorrhoids.
For grade I and II hemorrhoids, medical treatment is indicated as first-line management. Medical treatment consists of dietary changes and bulk-forming agents. Dietary management is the first line of therapy. Patients are advised to ingest adequate fiber and water and avoid straining. This conservative management is effective for hemorrhoids with lesser degrees of prolapse. [3, 4]
For grade I and II hemorrhoids—as well as some prolapsed grade II hemorrhoids and some grade III hemorrhoids—and for cases in which medical management is not adequate, an office procedure may be indicated. Such procedures include the following:
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Rubber-band ligation
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Infrared photocoagulation
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Electrocoagulation
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Sclerotherapy
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Cryotherapy
Surgery is reserved for cases in which conservative management is not adequate—for instance, hemorrhoids refractory to office procedures, large external hemorrhoids, hemorrhoids with significant bleeding, and prolapsed internal hemorrhoids. The following surgical procedures may be indicated, with excisional hemorrhoidectomy being the gold standard:
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Open vs closed excisional hemorrhoidectomy
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Transanal hemorrhoidal artery ligation (HAL)
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Stapled hemorrhoidopexy
Contraindications
Contraindications for office treatments include the following:
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Anal stenosis
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Bleeding hemorrhoids
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Grade III or IV hemorrhoids
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Use of nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners
Technical Considerations
Anatomy
Hemorrhoidal cushions are anal cushions of tissue composed of blood vessels, smooth muscle, and connective tissue. These cushions are located in the upper anal canal at three different sites: left lateral, right anterolateral, and right posterolateral. They are separate structures rather than a continuous ring of vascular tissue and therefore allow the anal canal to dilate during defecation without tearing.
Anal cushions are thought to aid in anal continence, though their function is not entirely understood. During the act of defecation, the anal cushions become engorged and tense with blood, cushioning the anal canal lining.
The anal canal above the dentate line is supplied by the terminal branches of the superior rectal (hemorrhoidal) artery, which is the terminal branch of the inferior mesenteric artery. The middle rectal artery (a branch of the internal iliac artery) and the inferior rectal artery (a branch of the internal pudendal artery) supply the lower anal canal. For more information about the relevant anatomy, see Anal Canal Anatomy.
Outcomes
There have been numerous studies comparing techniques used both in the office setting and in the operating room. Ultimately, the choice of procedure requires consideration of the patient’s comorbidities, risk factors, and prior treatments; the treatment approach should be an individualized one determined by the surgeon in conjunction with the patient.
Perhaps the most common office-based procedures for the treatment of grade II/III hemorrhoids are rubber-band ligation and closed or open hemorrhoidectomy. In a 2021 meta-analysis (N = 1308; eight clinical trials), Dekker et al compared the outcomes of the two techniques. [5] They found that hemorrhoidectomy was better at controlling symptoms but was also associated with a higher risk of complications; they also found that rubber-band ligation was associated with less pain and earlier return to work. Because of the heterogeneity of the studies, the authors were unable to establish either method as superior to the other and recommended that the choice be based on individualized patient discussion.
The two most commonly approaches to surgical hemorrhoidectomy have been the closed (Ferguson) and open (Milligan-Morgan) techniques. A meta-analysis (N = 1326; 11 randomized controlled trials) by Bhatti et al evaluated closed hemorrhoidectomy against open hemorrhoidectomy. [6] Closed hemorrhoidectomy was associated with reduced postoperative pain, faster wound healing, and a lower risk of postoperative bleeding.
This is not to say that the other surgical techniques are without merit. In a systematic review of 38 articles between 1998 and 2019, Ruan et al compared stapled hemorrhoidopexy with open hemorrhoidectomy. [7] They found stapled hemorrhoidopexy to be associated with shorter operating times, reduced intraoperative bleeding, less early postoperative pain, and a shorter hospital stay; however, they also found that at 2 years, open hemorrhoidectomy was associated with greater patient satisfaction.
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Hemorrhoids. Image reproduced from original with permission of the American Society of Colon & Rectal Surgeons.
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Rubber band ligation. Image reproduced from original with permission of the American Society of Colon & Rectal Surgeons.
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Electrocoagulation for hemorrhoids. Image reproduced from original with permission of the American Society of Colon & Rectal Surgeons.
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Closed hemorrhoidectomy. Image reproduced from original with permission of the American Society of Colon & Rectal Surgeons.
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Open hemorrhoidectomy. Image reproduced from original with permission of the American Society of Colon & Rectal Surgeons.
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Stapled hemorrhoidopexy. Image reproduced from original with permission of the American Society of Colon & Rectal Surgeons.
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Transanal hemorrhoidal artery ligation (HAL). Marking of rectal mucosa at location of best Doppler signal to identify site for ligation of hemorrhoidal artery and subsequent mucopexy. Courtesy of SpringerNature, Springer International Publishing AG.
