gastrointestinal disorders
Hemorrhoids
Treatment of Hemorrhoids
Symptomatic: Stool softeners, sitz baths, analgesics Occasionally excision for thrombosed external hemorrhoids Injection sclerotherapy, rubber band ligation, or infrared photocoagulation for internal hemorrhoids (See also the American Society of Colon and Rectal Surgeons’ [ASCRS]2018 clinical practice guidelinesfor the management of hemorrhoids.) Symptomatic treatment of hemorrhoids is usually all that is needed. It is accomplished with stool softeners (eg,docusate,psyllium), warm sitz baths (ie, sitting in a tub of tolerably hot water for 10 minutes) after each bowel movement and as needed, anesthetic ointments containinglidocaine, orwitch hazel(hamamelis) compresses (which soothe by an unknown mechanism). Pain caused by a thrombosed external hemorrhoid can be treated with nonsteroidal anti-inflammatory drugs. Infrequently, simple excision of the external thrombosed hemorrhoid is done, which may relieve pain rapidly; after infiltration with 1%lidocaine, the thrombosed portion of the hemorrhoid is excised, and the defect is closed with an absorbable suture. Patients with grades I and II internal hemorrhoids and some patients with grade III internal hemorrhoids (see table Classification of Internal Hemorrhoids ) who do not respond to symptomatic treatment can often be treated effectively with the following office-based procedures (see also the ASCRS Injection sclerotherapywith 5%phenolin vegetable oil or other sclerosing agents can be used to treat bleeding internal hemorrhoids. Bleeding should cease at least temporarily. Rubber band ligationis used for larger, prolapsing internal hemorrhoids, bleeding internal hemorrhoids, or those that do not respond to conservative management. With mixed internal and external hemorrhoids, only the internal component should be rubber band–ligated. The internal hemorrhoid is grasped and withdrawn through a stretched ½-cm diameter band, which is released to ligate the hemorrhoid, resulting in its necrosis and sloughing. Typically, one hemorrhoid is ligated every 2 weeks; 3 to 6 treatments may be required. Sometimes, multiple hemorrhoids can be ligated at a single visit, but this may cause more pain. External hemorrhoids should not be banded. Infrared photocoagulationis useful for ablating nonprolapsing, bleeding internal hemorrhoids, or hemorrhoids that are not cured with rubber band ligation. Surgical hemorrhoidectomy is required for patients who do not respond to other forms of therapy and for those who have grade IV internal hemorrhoids. Significant postoperative pain is common, as are urinary retention and constipation. Stapled hemorrhoidopexy is an alternative procedure for circumferential hemorrhoids and causes less postoperative pain but has higher recurrence and complication rates than conventional surgical hemorrhoidectomy. Doppler-guided hemorrhoid artery ligation, in which a rectal ultrasound probe is used to identify vessels for suture ligation, is promising but requires further study to determine its overall utility. Laser destruction, cryotherapy, and various types of electrodestruction are of unproven efficacy. 