Management of Hemorrhoidal Disease in Special Conditions
In this chapter, management of hemorrhoidal disease in special conditions is discussed. These special conditions include acutely thrombosed or strangulated external hemorrhoids and hemorrhoidal disease in pregnancy, in patients with cirrhosis or portal hypertension, in patients having anticoagulant or antiplatelet drugs, and in patients with immune deficiency. Medical and surgical treatments, alternatives of treatment, complications, and outcome are presented.
1 Acutely Thrombosed or Strangulated External Hemorrhoids
Hemorroidal disease is mainly painless when not complicated. It is basically because of lack of sensitive nerve endings above the level of dentate line. When the blood within the vessels of the external piles clotted then the thrombosis process starts. When the thrombosis process is completed, patients mostly present with pain and a hard oval mass around the anus. Acutely tender thrombosed hemorrhoids can be surgically removed within the first 72 h, and patients who are admitted later than this period are treated conservatively in most centers (Zuber 2002).
The evidence for current management of thrombosed hemorrhoids has been reviewed by Chan et al. (Chan and Arthur 2013). Among 800 articles on hemorrhoids, only two prospective studies encompassing 248 patients and two retrospective studies of 571 patients were found. Excision significantly relieves presenting symptoms by postoperative day 4 compared with incision or topical GTN (Level IB evidence). Symptoms last over 3 weeks with conservative treatment (Level III evidence), and this period may be reduced by combining topical nifedipine and lignocaine rather than using lignocaine alone (Level IB evidence).
The data about the treatment modalities and outcome of thrombosed hemorrhoids is not sufficient. One study is composed of 231 patients with thrombosed external hemorrhoids. The cases were managed conservatively in 51.5% and surgically in 48.5%.
Complaints of most patients with thrombosed hemorrhoids resolve eventually; however, at least in this study symptoms resolved within 24 days in conservative group and 3.9 days in the surgical group (p < 0.0001). The overall recurrence rate was also significantly high in the conservative group. Eventually, surgical treatment of thrombosed hemorrhoids offers a faster resolution of symptoms with lower rates of recurrence (Greenspon et al. 2004).
A long discussion has been coming along whether to incise or excise the thrombosed pile. Incising and removing the thrombosis should be avoided for several reasons. Reaccumulation of a bigger clot is one and bleeding from the incised vein is another reason for excising the entire pile (Rivadeneira et al. 2011).
For the conservative treatment, phlebotonics (synthetic calcium dobesilate or natural flavonoids), in general, offers benefit for alleviating hemorrhoidal symptoms like itching, bleeding, post-hemorrhoidectomy pain, and discomfort (Perera et al. 2012).
The most important component of the conservative management is high-fiber diet and sufficient water intake. In a double-blind randomized controlled study, patients with third and fourth degree hemorrhoids are randomized to receive high-fiber diet versus placebo. After 6 weeks, high-fiber group had significant improvement symptoms of bleeding, painful defecation, itching, and wet anus due to prolapsus (Moesgaard et al. 1982). Sitz bath has been historically recommended in almost all treatment algorithms and probably helpful in at least temporarily alleviating the symptoms (Song and Kim 2011).
While the pain is the most prominent symptom, internal sphincter hypertonicity is likely to play a major role in the etiology of the pain. In one study, the efficacy and safety of an intrasphincteric injection of botulinum toxin are used to lower the anal resting pressure for pain relief in patients with thrombosed external hemorrhoids. Thirty patients with thrombosed external hemorrhoids who refused surgical operation were randomized into two groups. Patients received an intrasphincteric injection of either 0.6 ml saline or 0.6 ml of a solution containing 30 units botulinum toxin. Anorectal manometry was performed before treatment and 5 days afterwards. Anal resting pressure fell in both groups but was significantly lower in the botulinum toxin group (P = 0.004). Pain intensity was significantly reduced within 24 h of botulinum toxin treatment (P < 0.001), but only after 1 week in the placebo group (P = 0.019). Eventually, a single injection of botulinum toxin into the anal sphincter seems to be effective in rapidly controlling the pain associated with thrombosed external hemorrhoids and could represent an effective conservative treatment for this condition (Patti et al. 2008). Similarly, nitric oxide has recently been identified as the “novel biologic messenger” that mediates the anorectal inhibitory reflex in humans. Lowering the anal resting tone by means of nitric oxide gives similar results compared to botulinum toxin. In one study, patients with thrombosed external hemorrhoids were treated with topically administered 0.5% nitroglycerin ointment. All patients reported dramatic relief of anal pain following application of nitroglycerin. Pain relief lasted from 2 to 6 h. Side effects were limited to transient headache in one fourth of patients. Topically applied nitroglycerin ointment appears to have a therapeutic role in the treatment not only in anal fissures but also in thrombosed external hemorrhoids (Gorfine 1995). In another study, topical nifedipine, was used to treat and control the symptoms of acute thrombosed hemorrhoids. Topical 0.3% nifedipine and 1.5% lidocaine ointment was used twice daily for 2 weeks. The control group received topical 1.5% lidocaine ointment only. The headache, side effect of nitroglycerin, was not observed with nifedipine. Complete relief of pain in 43 patients (86%) of the nifedipine-treated group while only 24 patients (50%) of the control group after 7 days of therapy (P < 0.01); oral analgesics were used by 4 patients (8%) in the nifedipine-treated group but in 26 patients (54.1%) of the control group after 7 days of therapy (P < 0.01). At the end of 14 days of treatment, 46 patients (92%) in nifedipine groups and 22 patients (45.8%) showed complete resolution of thrombosed external hemorrhoids. Nonetheless, topical nifedipine 0.3% is also a reliable option in the conservative treatment of thrombosed external hemorrhoids with less side effects to control the pain and offers a faster resolution of the disease (Perrotti et al. 2001).
Stapled hemorrhoidectomy, a modified technique of stapler hemorrhoidopexy, was compared to conventional hemorrhoidectomy for 41 patients with acute thrombosed hemorrhoids in a prospective randomized study. Thrombosed anal cushions were incised to remove the clots and the hemorrhoidal tissue is largely excised during operation by placing the purse string at 3 cm level above the dentate line in this particular technique. Patients were followed up by independent assessors to evaluate pain, recurrence, continence function, and satisfaction at regular intervals. The follow-up period was more than a year for both groups. There was no significant difference in terms of the hospital stay, complication rate, and continence function; however, the mean pain intensity in the first postoperative week was significantly less in the PPH group (4.1 vs. 5.7, P = 0.02). Patients in the PPH group recovered significantly faster in terms of the time to become analgesic-free (4 vs. 8.5 days, P = 0.01), resumption of work (7 vs. 12.5 days, P = 0.01), and time for complete wound healing (2 vs. 4 weeks, P < 0.01) (Patti et al. 2008). Our experience with this particular way of hemorrhoidectomy is limited, but in selected cases where the disease is circumferential and feasible for no remaining thrombosed residual tissue is left after surgery, the advantages of stapler technique including less pain and faster recovery are obtained (Wong et al. 2008).
2 Hemorrhoids in Pregnancy
Thrombosed external hemorrhoids are one of the frequent problems during pregnancy. Constipation is probably the most important factor in the etiology. In many cases, anal fissure diseases accompany the hemorrhoids. The incidence of thrombosed external hemorrhoids during pregnancy is reported as 12.2–34% (Abramowitz and Batallan 2003). The largest series reporting surgical treatment of thrombosed external hemorrhoids goes back to 1970. In this series, 100 patients were operated immediately or within 4 days after delivery with no serious complications. It was reported that postoperative pain was significantly less and healing time was 20–30% faster in postpartum women compared to other women. As in other cases, simple thrombectomy was not recommended as remaining tissue may cause further problems (Ruiz-Moreno 1970). Another group reported 4–10% of symptomatic hemorrhoidal disease during pregnancy and 85% of them in the second and third trimester. In the third trimester, 7.8% of pregnant females will experience a TEH. Options of treatment historically have included rubber band ligation, sclerotherapy, cryotherapy, anal dilation, sphincterotomy, infrared photocoagulation, etc. Operative hemorrhoidectomy is considered when hemorrhoids have become severely prolapsed, incarcerated, ulcerated, and thrombosed or are persistently bleeding. In their series, 1700 female patients with a clinical diagnosis of thrombosed external hemorrhoids were identified. Of these patients, 333 (19.6%) underwent excision of a thrombosed external hemorrhoid and 1367 (80.4%) received medical management only. Forty (12.2%) of the 333 patients were pregnant. These 40 patients with an average gestational age of 31.7 weeks were diagnosed with a thrombosed external hemorrhoid and underwent subsequent office-based excisional treatment. The recurrence rate for a thrombosed external hemorrhoid was 32.5% (13 patients) with an average time for recurrence at 76.8 weeks. The most common post-op complication was redevelopment of a thrombosed external hemorrhoid (32.5%), 10% of which occurred during the pregnancy. The second most common complication was a fissure or nonhealed wound (25%) followed by development of a hemorrhoidal tag (17.5%). No spontaneous abortions or admissions for preterm labor occurred. As a consequence, the approach and outcome in thrombosed external hemorrhoids are more or less same in the pregnant and nonpregnant population. The reluctance to perform office thrombosed hemorrhoid excision on the pregnant patient is unfounded. The surgery can be performed easily in the office under local anesthesia without any special monitoring. This data suggests that there is no increased risk of inducing preterm labor or miscarriage. The common complications after surgery, recurrence, anal fissure, and development of hemorrhoidal tags, are amenable to further definitive treatment after the delivery (Mirhaidari et al. 2016). For the conservative treatment, fiber supplement, stool softener, and mild laxatives are generally safe for pregnant women. Topical medications or oral phlebotonics may be used with special caution because the strong evidence of their safety and efficacy in pregnancy is lacking (Lohsiriwat 2015).
3 Hemorrhoids in Patients with Cirrhosis or Portal Hypertension
A clinician must differentiate bleeding hemorrhoids from bleeding anorectal varices because the latter can be managed by suture ligation along the course of varices, transjugular intrahepatic portosystemic shunt, or pharmacological treatment of portal hypertension (Lohsiriwat 2013). In a prospective study of 100 consecutive patients with cirrhosis, 44% had anorectal varices. The prevalence of anorectal varices rose with progression of portal hypertension; it was 19% in cirrhotic patients without portal hypertension compared with 59% in those who had bled from oesophageal varices. There was no evidence that endoscopic sclerotherapy directly increased the prevalence of anorectal varices. Hemorrhoids occurred independently of anorectal varices and their presence was unrelated to the degree of portal hypertension. These data provide further evidence that hemorrhoids and anorectal varices are separate and distinct entities. However, both can bleed and careful examination is essential to prevent misdiagnosis and inappropriate treatment (Hosking et al. 1989).
Since a majority of bleeding hemorrhoids in such patients is not life threatening, conservative measure with the correction of any coagulopathy is a preferential initial approach. Of note, rubber band ligation is generally contraindicated in patients with advanced cirrhosis due to the risk of profound secondary bleeding following the procedure. Injection sclerotherapy is an effective and safe procedure for treating bleeding hemorrhoids in this situation. In a refractory case, suture ligation at the bleeder is advised. Hemorrhoidectomy is indicated when bleeding hemorrhoids are refractory to other approaches (Lohsiriwat 2013, 2015).
4 Hemorrhoids in Patients Having Anticoagulant or Antiplatelet Drugs
In general, bleeding might be predominant over other symptoms in patients who are on drugs to impair the clotting function. The choice of treatment must also be decided according to the condition of the patient. In patients who can stop anticoagulant medication for a few days, rubber band ligation might be an option. Because of the risk of postoperative hemorrhage, rubber band ligation should not be performed in patients receiving warfarin (Coumadin). Aspirin and other antiplatelet agents should be discontinued 5–7 days before the procedure and restarted 5–7 days after (Mounsey et al. 2011). When the anticoagulant or antiplatelet drugs cannot be stopped for various reasons, any kind of surgery has the risk of bleeding and should be avoided as much as possible. Sclerotherapy is probably the next and optimum option in such cases (Song and Kim 2011). Conventionally, 5% phenol in almond oil has been used as a sclerosing agent for hemorrhoids. Polydocanol, a polyhydroxy alcohol, is also widely used (Ono et al. 2005). Aluminum potassium sulfate and tannic acid (ALTA) was recently developed in Japan as an injecting sclerosing agent for treating hemorrhoids and has been actively applied to grade 2 and 3 internal hemorrhoids. This method is based on the Xiaozhiling injection introduced by Shi et al. (1981). The mechanism is as follows: The agent injected into the hemorrhoid leads to an inflammatory response, and as the blood flow into the hemorrhoid is interrupted, secondary fibrosis is facilitated, shrinking the hemorrhoid. This method is effective for hemorrhoids with bleeding as a major symptom on a short-term basis, but not for protruding hemorrhoids (Ono et al. 2005; Shi et al. 1981).
5 Hemorrhoids in Patients with Immune Deficiency
Besides, 2.3 million people are contracting HIV infection every year; a total of 35 million people were estimated to be affected in the world (Juusola and Brandeau 2016). Perianal diseases including hemorrhoids usually require surgery in HIV infected patients, who comprise 5.9–34% of this special group (Oh et al. 2014). Heterosexual males had fewer hemorrhoids than homosexual or bisexual males (Wolkomir et al. 1990). HIV-positive patients have as many classic anal diseases (hemorrhoids, fistulas, and fissures) and venereal diseases (condylomas, gonorrhea, syphilis, and chlamydia) as systemic diseases typical for HIV-positive diagnoses (cytomegalovirus (CMV), herpes simplex, candida, and idiopathic ulcers). Some neoplastic lesions are also referred to as being more prevalent than in the HIV-negative population, mainly Kaposi’s sarcoma, non-Hodgkin’s lymphomas and epidermoid anal cancer, which is associated with human papillomavirus (HPV) infection. More than one third of patients with hemorrhoidal disease simultaneously have other conditions like condylomas and fistulas (Nadal et al. 1999). One should be aware of all these conditions and be very careful about the differential diagnosis in HIV-positive patients. If the problem is solely hemorrhoids, HIV status should basically not alter indications for hemorrhoidectomy. The treatment should be given in accord with the degree and prominent symptom of the disease (Morandi et al. 1999). However, if hemorrhoidectomy is performed, the rate and severity of postoperative complications differ significantly between the HIV-positive, AIDS, and control group with none of these conditions. In one study, the complication rate was 87.5% in the AIDS, 22% in the HIV-positive, and 5% in the control group. AIDS patients were the most vulnerable for local sepsis compared to HIV-positive and control cases (P < 0.01). When healing time was compared, HIV-positive status, AIDS, and wound infection significantly delayed healing time. After 32 weeks, all of the HIV-positive patients had healed, but only 50% of those with AIDS (P < 0.01) (Hewitt et al. 1996).
In conclusion, hemorrhoidectomy or other interventions for hemorrhoidal disease can be performed in an otherwise healthy HIV-positive patient with comparable morbidity and mortality as seen in the HIV-negative patient. Presence of AIDS, may increase the rate of complications and healing time after surgery; however, HIV status should eventually not alter the treatment indications of hemorrhoidal disease.
- Perera N, Liolitsa D, Iype S, Croxford A, Yassin M, Lang P, Ukaegbu O, van Issum C (2012) Phlebotonics for haemorrhoids. Cochrane Database Syst Rev 15(8):CD004322. doi: 10.1002/14651858.CD004322.pub3Google Scholar
- Shi Z, Zhou J, He X (1981) On treatment of third degree internal hemorrhoids with “Xiaozhiling” injection. J Tradit Chin Med 1:115–120Google Scholar