EXCERPTS FROM:
The American Society of Colon and Rectal Surgeons
Clinical Practice Guidelines for the Management of
haemorrhoids
EXCERPTS FROM:
The American Society of Colon and Rectal Surgeons
Clinical Practice Guidelines for the Management of
haemorrhoids
Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. Dis Colon Rectum. 2018;61(3):284-292.
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Background
The American Society of Colon and Rectal Surgeons (ASCRS) created a committee chosen from members who have demonstrated expertise in the speciality of colon and rectal surgery to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. The purpose of these guidelines is to provide information on which decisions can be made rather than to dictate a specific form of treatment, meaning the guidelines are inclusive and not prescriptive.
The Problem
Symptoms related to haemorrhoids are very common in industrialised societies. Published prevalence estimates are varied, yet it represents one of the most common medical and surgical disease processes encountered in the United States, resulting in >2.2 million outpatient evaluations per year.
Many diverse symptoms may, correctly or incorrectly, be attributed to haemorrhoids by both patients and physicians. Hence, the importance to identify symptomatic haemorrhoids as the underlying source of an anorectal symptom and to have a clear understanding of the evaluation and management of this disease process.
The Solution
The current guidelines address both diagnostic and therapeutic modalities in the management of haemorrhoidal disease.
Evaluation of Haemorrhoids
1. A disease-specific history and physical examination should be performed, emphasising degree and duration of symptoms and risk factors. Grade of Recommendation: Strong recommendation based on low-quality evidence.
The diagnosis of haemorrhoids should start with a medical history. Great care must be taken to identify symptoms suggestive of haemorrhoidal disease and risk factors such as constipation. This should be followed by a focused physical examination.
The primary signs of internal haemorrhoids are painless bleeding with bowel movements with intermittent protrusion. Focus should be on the:
- extent
- severity
- duration of symptoms
e.g. bleeding and prolapse, issues of perineal hygiene, and presence or absence of pain.
Constipation predisposes patients to haemorrhoidal disease, hence a careful review of fibre intake and bowel habits, including frequency, consistency, and ease of evacuation, should be performed. Faecal incontinence symptoms must also be noted, as this may affect management decisions, to include the possibility of surgical treatment.
Physical examination should include visual inspection of the anus*, as well as digital rectal examination to evaluate for other anal pathology and sphincter integrity.
Internal haemorrhoids, located above the dentate line, can be assigned a grade based on the definitions below, this may help to guide therapy.
| Classification of internal haemorrhoids | |
|---|---|
|
Grade |
Physical findings |
|
I |
Prominent haemorrhoidal vessels, no prolapse |
|
II |
Prolapse with Valsalva and spontaneous reduction |
|
III |
Prolapse with Valsalva requires manual reduction |
|
IV |
Chronically prolapsed manual reduction ineffective |
Laboratory evaluation is not typically required for diagnostic purposes.
*in the prone, knee-chest, or lateral decubitus position
Evaluation of Rectal Bleeding
1. Complete endoscopic evaluation of the colon is indicated in select patients with symptomatic haemorrhoids and rectal bleeding. Grade of Recommendation: Strong recommendation based on moderate-quality evidence.
Haemorrhoidal disease is the most common reason for haematochezia. However, other disease processes such as colorectal cancer, inflammatory bowel disease (IBD), other colitides, diverticular disease, and angiodysplasia, can also precipitate bleeding.
Although the majority of patients with haematochezia will not have colorectal cancer, rectal bleeding attributed to haemorrhoids still represents the most common missed opportunity to establish a cancer diagnosis. A thorough personal and family history and a physical examination, will identify high-risk patients requiring more extensive evaluation.
It is advised that previous endoscopy records should be reviewed (if available). A full colonic evaluation with colonoscopy or other colorectal cancer screening modality is suggested for those who fulfil select criteria set in the table below:
| Indications for complete colon evaluation | |
|---|---|
|
1 |
Age ≥50 years if no complete examination within 10 years |
|
2 |
Age ≥40 years or 10 years younger than the age at diagnosis with history positive for a single, first-degree relative with colorectal cancer or advanced adenoma diagnosed at age <60 years |
|
3 |
Age ≥40 years or 10 years younger than the age at diagnosis with history positive for two first-degree relatives with advanced adenomas or colorectal cancer |
|
4 |
Positive faecal immunochemical testing (FIT) |
|
5 |
Positive FIT-faecal DNA test |
Medical Treatment of Haemorrhoids
1. Dietary modification consisting of adequate fluid and fibre intake and counselling regarding defecation habits typically form the primary first-line therapy for patients with symptomatic haemorrhoid disease. Grade of Recommendation: Strong recommendation based on moderate-quality evidence.
Increased fibre and fluid intake have been shown to improve symptoms of mild-to-moderate prolapse and bleeding, and should be recommended to all patients.
Patients should also be counselled to maintain proper bowel habits, such as avoidance of straining and limiting time on the commode, as these practices have been associated with higher rates of symptomatic haemorrhoids.
2. Medical therapy for haemorrhoids represents a heterogeneous group of treatment options that can be offered with expectations of minimal harm and a decent potential for relief. Grade of Recommendation: Weak recommendation based on moderate-quality evidence.
Phlebotonics are used to treat both acute and chronic haemorrhoidal disease and are associated with the strengthening of blood vessel walls, increasing venous tone and lymphatic drainage, and normalising capillary permeability. Although beneficial, phlebotonics have not shown a statistically significant effect when compared with a control intervention for pain. Flavoids have been noted to have a beneficial effect on bleeding, pruritus, and recurrence.
Topical applications containing anaesthetics, steroids, emollients, and/or antiseptics are commonly used. Prolonged use can, however, cause allergic reactions or sensitisation.
Office Treatment of Haemorrhoids
1. Most patients with grade I and II and select patients with grade III internal haemorrhoidal disease who fail medical treatment can be effectively treated with office-based procedures, such as banding, sclerotherapy, and infrared coagulation (IRC). Haemorrhoid banding is typically the most effective option. Grade of Recommendation: Strong recommendation based on high-quality evidence.
The goals of office-based procedures are to:
- alleviate patient symptoms by decreasing the size or vascularity of the haemorrhoidal tissue
- increase the fixation of the haemorrhoidal tissue to the rectal wall to minimise prolapse
These procedures are all relatively well tolerated and cause minimal pain and discomfort. However, patients should understand that there may be recurrence and that repeat applications may be necessary.
Rubber band ligation (RBL)
This is the most popular and effective treatment, proven to be superior to sclerotherapy and IRC. It is quick and well tolerated by patients.
Although there is limited evidence regarding the safety of RBL patients on anticoagulation, it is generally considered a contraindication.
Sclerotherapy
The most commonly used sclerosant agents are 5 % phenol in almond or vegetable oil or sodium tetradecyl sulfate.
There are limited data on the efficacy of sclerotherapy, with one recent trial showing only 20 % success at 1 year in the treatment of grade III haemorrhoids. Outcomes seem to be much improved for treatment of grade I haemorrhoids, with a recent trial showing 88 % success with polidocanol at 3 months follow up.
It is recommended that antibiotic prophylaxis be considered for individuals at increased risk.
Newer agents demonstrating greater efficacy in the treatment of more advanced degrees of haemorrhoids are currently being used and evaluated in Asia and Europe.
Infrared coagulation
This is most commonly used for grade I and II haemorrhoids. Previously high rates of recurrence were shown for grades III and IV, however, more recent randomised controlled trials (RCTs) have demonstrated outcomes similar
to RBL.
Complications of Office-Based Procedures
The incidence of major complications is rare; yet, it must be considered that perianal sepsis is a life-threatening complication that can develop after office-based procedures or after anal surgery, in general.
An urgent patient evaluation for perianal sepsis should be performed should one of the following present post procedure:
- urinary dysfunction
- worsening pain
- fever
Medical Treatment of Haemorrhoids
1. Select patients with thrombosed external haemorrhoids may benefit from early surgical excision. Grade of Recommendation: Weak recommendation based on low-quality evidence.
Medical Treatment of Haemorrhoids
1. Haemorrhoidectomy should typically be offered to patients whose symptoms result from external haemorrhoids or combined internal and external haemorrhoids with prolapse (grades III–IV). Grade of Recommendation: Strong recommendation based on high-quality evidence.
Surgical Excision
Surgical excision of haemorrhoids remains a very effective approach for patients who:
- fail or cannot tolerate office-based procedures
- those who have grade III or IV haemorrhoids
- patients with substantial concomitant skin tags
Haemorrhoidopexy
Although effective for internal prolapsing disease, it does not address external haemorrhoids.
Trials and reviews comparing stapled haemorrhoidopexy with excisional haemorrhoidectomy included the following results:
- similar surgical complication rates
- significantly better quality-of-life scores for excisional haemorrhoidectomy vs. haemorrhoidopexy
- 32 % of patients reported recurrence of symptoms with haemorrhoidopexy vs. 14 % in the excisional haemorrhoidectomy group (p<0.0001)
- patients undergoing haemorrhoidopexy were more likely to require an additional operative procedure vs. those who underwent excisional haemorrhoidectomy (p=0.008)
Doppler-Guided Haemorrhoidectomy
Potential benefits of Doppler-guided/assisted haemorrhoid artery ligation (HAL), are the lack of tissue excision and possibly less pain.
HAL has been found to be more expensive than RBL, and was not found to be cost-effective compared with RBL in terms of incremental cost per quality-adjusted life-year.
Complications of Surgical Haemorrhoidectom
Complications after surgical haemorrhoidectomy are low, with the most common being post-procedure haemorrhage and larger series reporting an incidence between 1 % and 2 %.
Acute urinary retention, occurring between 1-15 %, is the most common reason for failure of surgical patients to be discharged from the ambulatory setting. This incidence is higher after spinal anaesthesia and after HAL procedures.
2. Patients undergoing surgical haemorrhoidectomy should use a multimodality pain regimen to reduce narcotic usage and promote a faster recovery. Grade of Recommendation: Strong recommendation based on moderate-quality evidence.
*in the prone, knee-chest, or lateral decubitus position
References
Reference: 1. Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2018;61(3):284-292.
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