755 Mount Vernon Hwy NE, Ste 350 Atlanta, GA 30328 404-943-9579 2500 Hospital Blvd.

, Ste 410 Roswell, GA 30076 www.crhcenter.com agoldman@crhcenter.com

The Evaluation of Rectal Pain and Bleeding and The Non-Operative Treatment of Hemorrhoids and Anal Fissures

Hemorrhoids
2007, Alan L. Goldman, M.D., F.A.C.S., all rights reserved

Objectives

1. Office evaluation of rectal pain and bleeding. Not all rectal complaints are due to hemorrhoids. 2. Signs and symptoms of hemorrhoids and anal fissure. 3. Etiology and epidemiology of hemorrhoids. 4. Treatment options. 5. Colorectal Cancer Screening.

Presenting Ano-rectal complaints

1. Pain-50% 2. Bleeding-40% 3. Swelling-25% 4. Pruritus-24% 5. Associated with pregnancy, constipation, diarrhea, stress, certain foods, alcohol. Hemorrhoids, anal abscess and fissures, pruritus ani, colorectal cancer, or proctitis.

Hemorrhoids by the numbers

1.Over half the population will have some hemorrhoidal symptoms by age 50 and the incidence peaks between 45-65. Men and women effected equally but men are more likely to seek treatment. 2. 10-20 million Americans have active hemorrhoids and as many as 5 million seek medical help each year. 3. We spend over 250 million dollars each year on hemorrhoid products. 1.5 million prescriptions. 4. More than 120,000 surgical hemorrhoidectomies are done each year. Most are unnecessary. 5. 1.5 million colonoscopies are done each year.

Normal Anatomy

Anal Canal

What are hemorrhoids?

Internal hemorrhoids are dilated blood vessels and the surrounding tissue above the dentate line. Covered by mucosa. Direct arteriovenous communications of the terminal branches of the superior rectal and superior hemorrhoidal arteries and to a lesser extent the inferior and middle hemorrhoidal arteries. They usually form three anal cushions (right anterior, right posterior, left lateral) that help maintain continence. Symptoms come from dilation of the blood vessels and increased friability, weakening of the surrounding tissue and attachment to rectal wall, injury from passing stool, and prolapse. External hemorrhoids are below the dentate line and are covered with modified squamous epithelium and richly innervated with somatic nerves. Hemorrhoids tend to enlarge over time and prolapse.

Anatomy of hemorrhoids

Grades

The severity is graded by the degree of prolapse  Grade 1 -no prolapse and cause painless bleeding.  Grade 2 - prolapse on defecation, go back spontaneously. Seen on straining.  Grade 3 - prolapse and have to be pushed back leading to bleeding and aching pain.  Grade 4 - Cant be pushed back leading to mucoid discharge, bleeding, pain, necrosis.

Internal Hemorrhoids

Prolapsed Hemorrhoids

Prolapsed Internal Hemorrhoids

What causes hemorrhoids?

Lack of soluble fiber and enough water in the diet, straining, and sitting longer than 2 minutes on the toilet which promotes prolapse of the anal cushions. Hemorrhoids may be inherited, but it may only be the behaviors and diet habits that are passed along. Failure to eat breakfast. Increase in abdominal pressure e.g. pregnancy, obesity, pelvic tumors, lifting, sitting, coughing, constipation, diarrhea, anal intercourse, aging. Correlation with decreased connective tissue strength as seen in hernias and genitourinary prolapse. Hemorrhoids can be exacerbated by excessive cleaning, rubbing, steroids, and hemorrhoid creams. Enlargement comes from the dragging of the hemorrhoids downward, weakened supporting tissue. Elevated sphincter tone increases straining.

Risk Factors
1. Past history of hemorrhoid symptoms or anal fissure 2. Age 30-65 3. Heavy lifting, prolonged sitting 4. Constipation/Diarrhea 5. Pregnancy 6. Failure to eat breakfeast. 7. Diet-Spicy food, fats, alcohol, smoking, low water intake. 8. Obesity 9. Spinal cord injuries 10. Increased sphincter tone

Hemorrhoid Prevention

1. 2. 3. 4. 5. 6. 7.

Add fiber to prevent constipation and diarrhea Drink lots of water Do not ignore the urge to go Do not strain Limit time on commode to two minutes Remove the library from the bathroom Avoid obesity

Typical Hemorrhoid Symptoms

Internal Hemorrhoids
1. chronic intermittent bright red bleeding with bowel movements. On tissue, in commode, or streaked on stool surface. 2. Feeling of fullness, swelling, extra tissue, incomplete BM. 3. Irritation or itching from seepage of mucus, fecal soiling or dermatitis from hemorrhoid creams causes rash. 4. Pain may occur with prolapse, associated external hemorrhoids or anal fissure. Visceral nerves above dentate line sense pressure not pain.

External Hemorrhoids
1. Rectal pain from stimulation of somatic nerves of anal skin. 2. Bulge of tissue on anal skin 3. Blood on toilet tissue. 4. Thrombosis leading to a hard painful lump. 5. Skin tags left over after dilated external hemorrhoids, hemorrhoidectomy, or resolved thrombosis. Can trap stool and cause dermatitis and pruritus.

Diagnosis of Hemorrhoids
1. History and physical exam including perianal inspection and digital rectal exam. Done in left lateral position. Ask patient to strain. Side viewing anoscopy. Significant pain suggests thrombosis, fissure, spasm, proctitis, abscess. 2. Sigmoidoscopy-rigid vs. flexible to rule out tumors of lower colon and IBD (dull mucosa, absent vascular pattern, friable bleeding mucosa, ulcers, and pseudopolyps. 3. Manometry/endorectal ultrasound-incontinence 4. Colonoscopy for persistent bleeding, polyps, IBD 5. Anal complaints are not always hemorrhoids.

History and Physical

Name:_______________________ Weight:______________________ LOS:_________________________ CC:__________________________ Date:_____________________________ BP:_______________________________ Past RX:___________________________ Family Hx:_________________________

ROS:________________________________________________________________________ Bleeding:________________________ Irritation/Itching:__________________ Constipation:_____________________ Time on Commode:_________________ OTC RX:__________________________ Abdomen:______________________ Fissure:_________________________ Ext Hem:__________________________________ Int Hem: LL___ RA___ RP___ Pain:_______________________________ Swelling:____________________________ Diarrhea:____________________________ Straining:____________________________ RX:_________________________________ Heart:____________________________ Sentinel Pile:_________________________ Skin :___________________________ Spasm:_____________________________

Proctosigmoidoscopy;_________________________________________________________ Anoscopy:__________________________________________________________________

Hemorrhoids or Not?
Rectal Conditions Causing Similar Symptoms
1. Anal Fissure, Skin tags, pruritus ani, candidiasis. 2. Fistula in Ano/Perirectal Abscess, Pilonidal Disease, IBD. 3. Rectal Prolapse, Incontinence 4. Carcinoma-Adenocarcinoma, Squamous Cell, Lymphoma, Melanoma. 5. Levator Syndrome, Proctalgia Fugax, Foreign Bodies. 6. STD-Condyloma (HPV), Syphilis, Gonorrhea, Herpes, Chlamydia-LGV, Molluscum Contagiosum, Pediculosis Pubis, Trichomoniasis, Chancroid, CMV, and Scabies. Traumatic proctitis. 7. Rectal varices

Anal Fissure

Thrombosed External Hemorrhoid

Anal Skin Tag

Pruritus Ani

Perianal Yeast Infection

Perirectal Abscess

1. Perianal, Ischiorectal, Intersphincteric, Supralevator location. 2. Caused by infection of mucus-secreting anal glands. 3. Tender mass at anal verge or on rectal exam. 4. Fistula in ano may be present. Re-examine in 2-3 weeks. 5. Incision and drainage may be done under local anesthesia. Limit packing to keep skin edges open. 6. Antibiotics are of unproven value but should be used in immunocompromised patients, sepsis, or who have valvular heart disease or prosthesis.

Perirectal Abscess

Perianal Abscess

Ischiorectal Absces

Fistula in Ano

Pilonidal Abscess

Complete Rectal ProlapseProcidentia

Anal Cancer

Condyloma Accuminata

Human papilloma virus (HPV) most common STD, 6.2 million new cases/yr. Types 6,11, and 42 cause raised lesions. Types 16,18, & 31 associated with anal squamous cancer. Transmitted via skin contact, risk reduced but not prevented by condoms. Vaccine for 6,11,16, 18 females age 11-12.

Anal Herpes

Groups of small painful sores or blisters caused by herpes simples virus-1 or 2. Transmitted via direct contact leads to chronic infection. Treat with Acyclovir, Famvir, or Valtrex.

Rectal Syphilis

STD caused by Treponema pallidum. Can cause proctitis and painful ulcers above the dentate line in primary. Wart like Condyloma lata in second stage. Ulcerated mass may be confused with anal cancer. Bx shows spirochetes. Rx 2.4 million units of benzathine penicillin G.

Rectal Gonorrhea

1. Rectal discharge-mucopurulent to bloody. Proctitis with itching or tenesmus. Diarrhea. 2. Thayer-Martin culture positive. 3. Rx-250 mg Cetriaxone IM + doxycycline 100 mg po bid for 7 days. 4. Previously the most common STD affecting the anorectum. Asymptomatic 50% of males and 95% of females.

Chlamydia Proctitis
1. Rectal pain, bleeding, and discharge due to proctitis. Asymptomatic in 43% of males and 79% of women. Malaise, fever, chills, joint and muscular pain, vomiting. 2. Friable rectal mucosa without ulceration and matted inguinal lymph nodes. Lymphogranuloma venereum. 3. Chlamydia trachomatis Dx antibody test. 4. Rx with Doxycycline 500 mg bid for one-three weeks or one dose of Azithromycin. 5. May cause late strictures of rectum. 6. Most Common bacterial STD with 2.8 million cases per year in US.

Molluscum Contagiosum

1. Painless multiple umbilicated pearl-like papular skin lesions caused by a poxvirus. Effects genitals, lower abdomen, inner thighs, and buttocks. 2. Common infection in children. 3. STD which has increased in prevalence 2nd to AIDS. 4. Self-limited disease. 5. Rx includes cryotherapy, pulsed dye laser, remove the core, podofilox, tretinion cream, antivirals and immunomodulatores.

Molluscum Contagiosum

AIDS

1. Ulcerative disease of the anorectum often proximal to the dentate line. May bleed and burrow into muscles causing incontinence and collections of pus. Broad-based cavities with over-hanging edges and occult pockets. 2. Fissures in HIV secondary to rectal intercourse, diarrhea from infections or side effect of antiretroviral medications.

Cytomegalovirus Proctitis

CMV is a member of the herpes virus group. Proctitis typically occurs in immunosuppressed patients, including AIDS. May occur with IBD.

Levator Syndrome

1. Episodic intense pain in the high rectum, sacrum, and coccyx due to spasms of the pelvic floor muscles. 2. Coccydynia, proctalgia fugax (night), proctodynia. 3. Tender levator muscle on digital exam. 4. Normal work up other than abnormal EMG. Pain relieved by blocking the area between the rectum and coccyx with marcaine and steroids. 5. Muscle relaxants, warm baths, biofeedback, NTG, calcium channel blockers, Botox, salbutamol. 6. Variant is neuralgia of the pudendal nerve.

Diagnosis of Hemorrhoids
1. History and physical exam including perianal inspection and digital rectal exam. Done in left lateral position. Ask patient to strain. Side viewing anoscopy. Significant pain suggests thrombosis, fissure, spasm, proctitis, abscess. 2. Sigmoidoscopy-rigid vs. flexible to rule out tumors of lower colon and IBD (dull mucosa, absent vascular pattern, friable bleeding mucosa, ulcers, and pseudopolyps. 3. Manometry/endorectal ultrasound-incontinence 4. Colonoscopy for persistent bleeding, polyps, IBD 5. Anal complaints are not always hemorrhoids.

Hypertrophic Anal Papillae

Colorectal Polyp

Rectal Villous Adenoma

Colorectal Cancer

Rectal Cancer

Inflammatory Bowel Disease

A. Dull mucosa and lack of normal vascular pattern. B. After Rx

Crohns Disease

Ulcerative Colitis

Rectal Varices

Rectal Hemangioma

Radiation Proctitis

Hemorrhoids or Not?
Raise your level of suspicion
1. Recent changes in bowel habits, constipation, diarrhea, small caliber. 2. Abdominal Pain 3. Weight Loss 4. Anemia 5. Family history of Colo-rectal cancer 6. HIV infection, genital warts-HPV, rectal sex, cigarette smoking and increased risk of anal cancer 7. First-degree-only hemorrhoids. 8. Proctitis

Bloody Stools-Lower GI Hemorrhage in Adults

Melena-Black Tarry stools due to digested blood from upper digestive tract, esophagus, stomach, and jejunum. Esophagitis, varices, gastritis, gastric ulcer, peptic ulcer, angiodysplasia, jejunal diverticulum. Rarely from a slow bleeding right colon lesion. Black licorice, lead, iron, bismuth medicines-Pepto Bismol can also cause black stools. Hematochezia-Red or maroon-colored stools frequently foul smelling. Diverticulosis, angiodysplasia, inflammatory bowel disease, anorectal disease such as hemorrhoids, anal fissure, fistula in ano, colorectal polyps or cancer, ischemic colitis, infectious colitis, radiation enteritis, coagulopathy, aortoenteric fistula, postpolypectomy, post-hemorrhoidectomy, hemobilia, or massive UGI bleeding. Massive lower GI bleeding causes shock and may require transfusion. Diverticulosis is the most common cause of major lower GI bleeding. Blood mixed with stool, shorter duration of sx, and more episodes per month are more common with cancer, polyps, IBD when compared to hemorrhoids. Rectal Bleeding from Hemorrhoids or Anal Fissure-Blood on tissue, on outside of formed stool, or drips into commode after bowel movement. Blood is bright red in color. Typically mild and intermittent but occasionally massive. Hemorrhoids are the most common cause of chronic intermittent minor or non-massive lower GI bleeding associated with bowel movements.

Medical Management of Hemorrhoids

1. Add 15 grams of fiber and drink 6-8 glasses of water each day. Avoid constipation and diarrhea. Rx IBS. 2. Avoid straining and prolonged sitting on commode. Remove reading materials from bathroom. Weight loss. Moderate exercise but avoid heavy lifting and strenuous exercise. 3. Tub baths with warm water 4. Keep area clean with warm water and avoid scented or colored tissue 5. Lubricating ointment-Vaseline 6. Generic 2.5% HC + 1% Pramoxine HCL-$10 limit to two weeks. 7. Long airline flights aggravate hemorrhoids. 8. Micronized, purified flavonoid fraction. Not approved by FDA 9. Hemorrhoid products can reduce symptoms of itching or minor discomfort but will not help significant bleeding, prolapse, or cure the problem.

Fiber

1. Trials of fiber show a consistent beneficial effect for symptoms and bleeding in the treatment of symptomatic hemorrhoids. Fiber for the treatment of hemorrhoids complication: a systematic review and meta-analysis. Am J Gastroenterol. 2006 Jan;101(1):181-8. About a 50% decrease in symptoms.

Fiber in food
A healthy diet should include 30 grams of fiber. The typical western diet contains 15 grams. Low fiber diets can cause smaller harder stools leading to hemorrhoids and diverticulosis. Fiber is an indigestible polysaccharides found in plant cells. Soluble fibers (Gums, Pectin, Hemicelluloses) dissolve in water and form a thick jelly like substance, where insoluble fibers (Cellulose and Lignin) do not. Soluble fiber improves stool bulk and water content and is the important component for proper function of the colon. Also stays in stomach longer and reduces glycemic load and cholesterol levels. Bulkier stools preventing each end of lengths of the colon closing off with the normal segmentation movement of the colon preventing rise in colonic pressure and results in less cramps and lower rectal pressure on vessels. Try a variety of fibers, increase slowly, and wait up to six weeks to see benefit.

Low Fiber Diet

 Fiber has been removed during the refining of food particularly bread and starches. The typical diet has 15 grams of fiber.  Low fiber contributes to obesity and disturbance of the enteroinsular axis and in many the onset of NIDDM.  Adding fiber slows digestion, lowers cholesterol and blood sugar, decreases risk of cardiovascular disease, and may help reduce the risk of CRC.

Fiber Products-Bulk Forming Laxatives

1. Fibersure-vegetable fiber inulin from chicory roots5gms/tsp, $20/ 20.6 oz 2. Benefiber-Guar gum-3gms/2 teaspoons- $18/ 17 oz. 3. Psyllium-Plantago ovata, Fiberall, Metamucil $14/ 29 oz., Hydrocil, Alramucil, Konsyl, Reguloid, Serutan 4. Fiberone Cereal-14 grams per 4 oz. 5. Fiber Choice Tablet-4 grams $12/90 6. Citrucel-Methylcellulose $15/ 30 0z. Less gas production 7. Fibercon- Polycarbophil- $18/ 140 caplets

Laxatives

1. Stool softeners-Docusate (Colace, Surfak), Poloxamer 188 2. Hyperosmotic-Lactulose, Polyethylene glycol, Magnesium Citrate, Sodium Phosphate (Fleets), MOM 3. Lubricants-Mineral Oil 4. Stimulants-Bisacodyl (Ducolax, Correctol), Cascara, Castor Oil, Senna (X prep), Sennosides (Senokot, ExLax), Casanthranol 5. Combinations- Perdiem (Psyllium and Senna), Pericolace (Casanthranol and Docusate)

Hemorrhoid Products
Anorectal preparations may temporarily help relieve anal itching or irritation. Will not cure the problem of rectal bleeding and prolapse. Patients prefer creams over suppositories.
1. 2. 3. 4. 5. 6. 7. 8. 9. Local anesthetics Vasoconstrictors Protectants or emollients Astringents Antiseptics Keratolytics Antipruritics Corticosteroids Natural wound healers

Local Anesthetics
Relieves mild discomfort, burning, and itching by blocking nerve conduction, but can cause allergic reaction (burning and itching) and aggravate symptoms.
1. 2. 3. 4. 5. 6. Benzocaine-5 to 20% Americaine, Lanacane. External use only. Benzyl alcohol-5 to 20% Dibucaine-.25% to 1.0% Nupercainal Dyclonine-.5 to 1% Lidocaine-2 to 5% Pramoxine-1%-Anusol, Fleet Pain Relief, Procto Foam non-steroidal, Tronolane, Preparation H Cream with Maximum Strength Pain Relief. 7. Tetracaine-.5% to 5%

Vasoconstrictors

Constricts blood vessels by stimulating alpha and beta receptors. May reduce swelling but will not stop bleeding. May reduce itching and mild discomfort. Topical use has a low risk of aggravating angina, arrhythmias, hypertension, hyperthyroidism, diabetes, or BPH. May cause nervousness, tremor, or insomnia. Contact dermatitis. 1. Ephedrine sulfate - .1 to 1.25% 2. Epinephrine-.005% to .01% 3. Phenylephrine HCL- .25% in Medicone Suppository, Preparation H, Rectacaine

Protectants or Emollients
Coats the skin with a physical barrier and lubricates it to decrease irritation, burning, and drying of skin. Present as a base in many products. Applied after bowel movements. 1. Aluminum hydroxide-Absorbent 2. Cocoa butter-emolient 3. Glycerin-emolient 4. Kaolin-emolient 5. Lanolin-emolient 6. Mineral oil-Balneol, Preparation H ointment 7. White petrolatum-Vaseline-emolient 8. Starch-emolient 9. Zinc oxide or calamine when combined with above-emolient 10.Cod liver oil or shark liver oil with vitamin A when combined with above

Astringents

Coagulates skin proteins, decreases cell volume and secretions. Decreases irritation, burning, and itching but not pain. 1. Calamine- 5 to 25% 2. Zinc oxide- Calmol 4, Nupercainal, Tronolane 3. Witch hazel- Fleet Medicated, Tucks, Witch Hazel Hemorrhoidal Pads-external use only. May cause contact dermatitis.

Antiseptics
No proven advantage over soap and water to prevent infection. Present in many products as preservatives. 1. 2. 3. 4. Boric acid Hydrastis Phenol Benzalkonium chloride-Tucks/Fleet Medicated Wipes 5. Cetylpyridinium chloride 6. Benzethonium chloride 7. Resorcinol-used for psoriasis, acne and eczema

Keratolytics

Removes skin exposing tissue to therapeutic agents. May help itching. Do not use near open wounds around the anus. For external hemorrhoids only. Found in naturopathic ointments.
1. Aluminum chlorhydroxy allantoinate-alcloxa-.2 to 2% 2. Resorcinol- 1 to 3%. Methemoglobinemia 3. Do not use near open wounds.

Antipruritics
Causes a feeling of comfort, cooling, tingling that distracts from the feeling of irritation and itching. 1. Menthol-not safe. Allergic reactions, laryngospasm, dyspnea & cyanosis. 2. Camphor-not safe 3. Turpentine oil-not safe 4. Juniper tar

Herbs and Natural Wound Healers

FDA ruled in 1990 which ingredients are allowed in OTC products.
1. Local anesthetics, analgesics, vasoconstrictors, lubricants, astringents, and Keratolytics allowed. Benzyl alcohol, cocoa butter, witch hazel may be used. 2. Live yeast cell derivative, goldenseal, mullein, tannins, menthol, camphor-not approved by FDA for OTC products 3. Balsam Peru, pilewort (Ranunculus ficaria) and skin respiratory factor or SRF, no proven effectiveness. 4. Plantain (Plantago), Butchers broom (Ruscus acu-leatus), alumroot, slippery elm bark. 5. Topical calendual, camomile, yarrow, plantain, St. Johns-wort, almond oil, witch hazel, aloe 6. Avoid Horse Chestnut & Corn Cockle-toxic. Comfrey-veno-occlusive disease of the liver.

Corticosteroids

Anti-inflammatory, lysosomal membrane stabilization, antimitotic, and vasoconstrictive to reduce itching and swelling. OTC products containing hydrocortisone are not FDA approved for internal anorectal use. Prolonged use can weaken tissue, promote infection, cause allergic reaction.

Rectal Steroid Concerns

Prolonged use of higher concentrations can lead to systemic effects and weaken skin.
1. Do not use with associated fistula or abscess 2. Allergic reactions to steroid or emollients 3. Not proven to be safe in pregnancy or breast feeding 4. May increase blood sugar in diabetics. 5. May exacerbate Glaucoma, Myasthenia gravis, Osteoporosis 6. Serum levels may increase in hypothyroidism or cirrhosis 7. May lead to increased gastric acid levels 8. May cause slower wound healing and increased infections. 9. May worsen acute psychosis. 10. Weight gain, swelling, acne, sweating, increased hair.

Prescription Hemorrhoid Products

Generic 2.5% HC + 1% Pramoxine HCL-$10
1. Proctocort/Dermol HC- 1% hydrocortisone cream-$73-28 gm 2. Proctofoam-1 % hydrocortisone and pramoxine HCL-$65-10 gm can 3. Analpram HC- 1% hydrocortisone and 1 % pramoxine HCL-$48-30 gm 4. ProctoCream HC-2.5% hydrocortisone cream-$44-30 gm 5. Anusol HC Cream-2.5% hydrocortisone cream - $42-30 gm 6. Proctosol HC-2.5% hydrocortisone cream-$22-35 gm 7. Analpram 2.5% hydrocortisone, 1% Pramoxine HCL-$54-30 gm 8. Suppositories-Anucort-HC, Anumed HC, Anusol-HC, Proctocort OTC Hydrocortisone Acetate 1% cream, Cortizone 10 plus Aloe - $9.00-57 gm Suppositories or foams have no advantage over creams and have worse patient compliance.

Micronized Flavonoids
1. Phlebotropic drug derived from Rutaceae aurantieae, a small orange from Spain, North Africa, and China. 2. Daflon 500 mg -Micronized Purified Flavonoid Fraction (MPPF). Reduced particles to allow digestion. 90% micronized diosmin and 10% hesperidin. 3. Used in chronic venous disease to improve venous tone, reduce capillary hyperpermeability, edema, and inflammatory mediators. 4. 2 tablets per day for chronic hemorrhoids, up to 6 per day for acute attacks. About $1 per pill. 5. May help reduce pain and bleeding. 6. Not approved by the FDA and trials have given mixed results. 7. May be safe in pregnancy.

Complications of Hemorrhoids

 Bleeding - can be severe but rarely life threatening unless the patient is taking meds like Warfarin.  Severe Pain-anal fissure with spasm of the sphincter is often associated with hemorrhoids and the hemorrhoids can thrombose (clot), prolapse, or incarcerate (become trapped) and then are very painful and can become infected or gangrenous.

Hemorrhoid Procedures
1. Hemorrhoidectomy: Milligan-Morgan(open), Ferguson(closed). 1-2 days in hospital. Anesthesia required. Effective but more expense, pain, complications, and disability compared to office treatments. Its reputation causes many to avoid effective Rx and to buy ineffective hemorrhoid creams. PPH-Procedure for Prolapse and Hemorrhoids. Introduced in 1998. Lower pain than above but may have higher recurrence rate and similar complication rate. Learning curve. Perforations, stenosis, bleeding, or chronic pain may occur. Rubber Band Ligation causes ischemic necrosis and scarring, which results in shrinkage of tissue and fixation to rectal wall. Office procedure with minimal pain and complications. Low recurrence rate which can be Rx with rebanding. IRC-infrared coagulation requires 5-7 Rx, is more expensive than banding, higher recurrence rate, and may make external disease worse. Coagulates and scleroses tissue with heat. Less painful than old banders but more painful than CRH bander. Sclerotherapy-Phenol or vegetable oil, urea hydrochloride or hypertonic salt injected into base. Out of favor 2nd to complications and high recurrence rate. Bipolar diathermy-Coagulates and fibroses with heat. Direct-current electrotherapy-Coagulates and fibroses with heat. Doppler ligation-more expensive and no proven advantage over banding. Cryosurgery and anal stretch no longer recommended because of complications

2.

3.

4.

5. 6. 7. 8. 9.

Procedure for Prolapsing Hemorrhoids - PPH

Stapled hemorrhoidectomy offers less pain than traditional hemorrhoidectomy but leaves persistent tags, higher recurrence rate, and rarely severe complications not usually seen.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Learning curve may contribute to complications. 4% bleeding. Staple line bleeding to uncontrollable bleeding. Reoperation 1.5-11% Pain with BM or Urge to defecate for several weeks. 5-14% Pain, anal fissure, missed polyps Recurrence Perforations, Stenosis, Retained staples Pelvic Sepsis, Urinary retention Rectovaginal fistula, incontinence Inflammatory polyps causing late bleeding-11 %

PPH33-03 is a new stapler reported to have fewer complications.

Rubber Band Ligation vs Hemorrhoidectomy

Rubber Band
Minor Bleeding Major Bleeding Significant pain Thrombosis Urinary Retention Pelvic Sepsis Perianal Infection Rectal Stenosis Incontinence/Soiling Reoperation Total Complications Effectiveness Recurrence Death 0.4-3.7% 0-1% 0.2-7% 0.3-2% 0-1% 0-.1% 0-.2% 0% 0% 0% 1-6% 44-95% 5-20% 0-.1%

Hemorrhoidectomy
2-25% 1-2% 3-80% 1% 1-16% .5% 1% 1.6-3% 7%/21% .4-8% 20-40% 85-97% 10-20% 0-.2%

CRH-ORegan Ligation System

1. 1963 Barron report on 150 patients banded in office. 2. 1999 Dr. Patrick ORegan develops a disposable ligation system featuring gentle suction instead of metal grasper. 3. 2003-Dr. Iain Cleator, Professor Emeritus of Surgery, University of British Columbia, opens Cleator Clinic. 4. 2005-Dr. Cleator reports on 5,424 bandings on 1,852 patients. Complication rate of .3%, 99.1% effective, 2 year recurrence rate of 5%. No pain medication and immediate return to normal activities. 5. 2006-CRH opens offices in Chicago, Atlanta, Las Vegas, San Francisco, Los Angeles. 6. 2007-Ligator has now been proven safe and reliable in over 15,000 applications. 7. Banding normalized the size of hemorrhoidal cushions. 8. Inflammation reattaches tissue to surrounding muscles. 8. External disease improves but skin tags may be left behind.

Who can be banded

1. All grades of hemorrhoids can be banded. Grade I may respond to conservative measures but should be considered for CRC screen using FIT. 2. Grade IV cases can be reduced with NTG and topical Lidocaine or a pudendal block. Banding done later after swelling reduced. Rx associated fissures and encourage sitz baths and supine position. Consider Flagyl Rx. 3. External disease can not be banded but will frequently shrink and be retracted by banding. 4. Associated symptomatic skin tags can be removed as a separate office procedure under local anesthesia. Less than 10% of cases.

Hemorrhoidectomy Indications

1. 2. 3. 4.

Failed Banding Not capable of tolerating office procedure Large external hemorrhoidal disease? Grade III to IV hemorrhoidal disease?

We have treated all grades of hemorrhoids and have not referred anyone to surgery to date.

Rectal Examination
1. Inspect for rash, skin tags, externals, fissure. 2. Use adequate lubrication and gentle palpation. If pain and spasm present consider NTG and lidocaine ointment. 3. Rigid Sigmoidoscopy to asses lower 15 cm. 4. Side viewing anoscope, rotate handle to banding area, remove obturator. 5. Insert ligator and apply suction 1-2 cm above dentate line. Rotate ligator, lock, and fire if no pain. 6. Check position with finger and roll up band if painful or too tight and muscle is caught in band. 7. Order of LL, RA, RP may be adjusted to avoid an external thrombosis, fissure, or to band a bleeding hemorrhoid.

CRH Banding via Slotted Anoscope

CRH Banding - by position

Rubber Band Ligation

Pre-banding Preparation

1. No laxatives, bowel preparation, enemas are needed. 2. Prophylactic antibiotics should be given in patients with valvular heart disease, stents, prosthesis, or those with decreased immunity. Amoxicillin or Biaxin plus Flagyl if neutropenic. 3. Stop aspirin and anticoagulants if possible for 5 days before and after banding. 4. Three hemorrhoids will require three bands in most patients. Appointments are two weeks apart.

After care
1. Patients may resume normal activities after the banding but should avoid strenuous activities till next day. 2. There may be a feeling of heaviness or fullness for 1-2 days. 3. Avoid constipation. Continue with fiber and fluids. 4. Bleeding may occur which may be from associated fissure or other hemorrhoids. Lie down on side, drink fluids, apply ice to anal area, and if persists call physician. Apply AgNO4, stop NTG for 2 days. 5. Call physician for urinary retention, fever, myalgia, flu like symptoms. Flagyl and Levaquin should be promptly started and hospitalization considered for suspected sepsis. 6. The band will fall off and pass in 1-7 days. 7. Fourth visit 3 weeks after last band for FIT.

Contraindications to Banding
Anticoagulants such as Coumadin, Plavix, or aspirin are a relative contraindication to hemorrhoid treatment and if possible it is best to stop them for 5 days before and after banding. Dr. Cleator has banded patients on coumadin (30 times in 10 patients) and had only one moderate bleed which resolved with lying down. In portal hypertension the rectal varices are treated by treating the portal hypertension. Rx fissures with NTG. In pregnancy try to avoid rectal procedures to avoid the rare complication of pelvic sepsis or the liability of abortion. Anal fissures may be treated with NTG.

FIT-Immunochemical Fecal Blood Test

At the end of the treatment a screening test for human blood in the stool is performed the FIT, fecal immunochemical testing. Two-three stool samples are brushed. Tests for intact human hemoglobin from lower GI tract. Twice the yield of cancer and polyps compared to Hemocult II Sensa. Detects 80-94% of cancers and larger adenomas. No preparation required. InSure, HemeSelect. More expensive. Avoid test for hematuria, menstrual period, cuts on hands. About 2% of patients with typical symptoms of hemorrhoids turn out to have cancer or large polyps. Treating the hemorrhoids first decreases the rate of positive FIT and the need for colonoscopy to less than 10%.

FOBT
Fecal occult blood test is noninvasive test for fecal blood to be done at home. Preferred-Sensitive guaiac Hemoccult II Sensa. Guaic based test-wood resin of Guajacum tree Hemoccult II, Hemoccult II Sensa - guaic smear test done on three samples and developed with hydrogen peroxidase. EZ Detect, ColoCARE-flushable reagent pads for home test uses chromogenic dye and not affected by meat or vitamin C. Patients prefer ease of use but not as sensitive (21 vs. 72%) Stop aspirin, NSAIDs, Vitamin C. No red meat, horseradish, cantaloupe/melon, grapefruit, figs, raw turnips, broccoli, cauliflower, red radishes, and parsnips for 3-5 days. Annual screening reduces death from colon cancer by 33%. 45% false positives. Hemorrhoids, diverticulosis, PUD, fissure.

FIT vs. FOBT

HemeSelect, InSure, Flexsure use monoclonal or polyclonal antibodies to detect globin protein. Globin does not survive passage from upper GI tract. FIT true-positive. CRC 87.5% vs. 54.2%. Significant adenomas (high grade dysplasia, villous change, >10mm) 42-47% vs. 23 %. Reduces false positives and the need for colonoscopy No need to modify diet or avoid aspirin. Cost $5 for Hemoccult II Sensa vs $75 for FIT

ACS Advisory Group Recommendations FIT

Immunochemical tests have advantages over guaiac tests.these tests offer enhanced specificity in colorectal cancer screening compared with guaiacbased testing. in comparison with guaiac-based tests for the detection of occult blood, immunochemical tests are more patient-friendly, and are likely to be equal or better in sensitivity and specificity.

Rectal Bleeding and Colonoscopy

Bright red rectal bleeding with bowel movements is a common complaint. Benign lesions are the most common cause. 1. Incidence of Colon Cancer in patients with chronic intermittent rectal bleeding that is typical of hemorrhoids with no abdominal pain, change in bowel habits and rectal cancer not present on anoscopy is .8 - 3 %. In those under the age of 50 it is 0-3%. Other causes include polyps, fissures, diverticulosis, IBD. 2. The average approved reimbursement for colonoscopy is approximately $2200 compared to $1200 for banding. 3. Complications occur in 1-5% including perforation at a rate of .05-.3% and bleeding at a rate of .1-2%. 4. Colonoscopy misses 2-6% of colon cancers

Do All Patients with Rectal Bleeding Typical of Hemorrhoids Need Colonoscopy

Yes. Symptoms are unreliable and significant pathology is found in 20-40%; CRC, polyps, IBD, fissure, diverticulosis, angiodysplasia, rectal ulcers or proctitis, infectious or ischemic colitis. No. Having an effective office hemorrhoid treatment changes the approach. Banding the hemorrhoids first and restricting colonoscopy to those with positive FIT post banding is safe, cost effective, provides effective treatment, and avoids colonoscopy in over 90% of patients.

Indications for Colonoscopy in Evaluation of Hemorrhoids

1. History or physical findings suggestive of cancer or IBD. Abdominal pain, weight loss, change in bowel habits, no obvious source of bleeding. 2. Iron deficiency anemia 3. Positive FIT/after RX 4. Age over 40 with 1st degree relative with CRC or adenoma<60 and no BE or colonoscopy within 10 years. 5. Age over 40 with two 1st degree relatives and no evaluation within 3-5 years.

American Cancer Society Colorectal Cancer Screening Guidelines Beginning at age 50 (45 for African Americans), men and women who are at average risk for developing colorectal cancer should have 1 of the 5 screening options below: a fecal occult blood test (FOBT)* or fecal immunochemical test (iFOBT or FIT)* every year**, OR flexible sigmoidoscopy every 5 years, OR an FOBT* or FIT* every year plus flexible sigmoidoscopy every 5 years**, OR (Of these first 3 options, the combination of FOBT or FIT every year plus flexible sigmoidoscopy every 5 years is preferable.) double-contrast barium enema every 5 years**, OR colonoscopy every 10 years *For FOBT or FIT, the take-home multiple sample method should be used. **Colonoscopy should be done if the FOBT or FIT shows blood in the stool, if sigmoidoscopy results show a polyp, or if double-contrast barium enema studies show anything abnormal. If possible, polyps should be removed during the colonoscopy.

2007 ACS Current Guidelines

iFOBT was added in 2003. Postpolypectomy and Postcolorectal cancer resection surveillance revised. Follow-up intervals were often shorter than recommended, raising cost and complications. Single FOBT in the office is not recommended because of low sensitivity.

ACS Guidelines on Screening and Surveillance for the Early Detection of Colorectal Adenomas and Cancer
Risk Category Age to Begin Recommendation Comments

Increased Risk Single <1cm adenoma Multiple adenomas, >1cm, villous, High grade dysplasia S/P Curative Resection 5-10 years later Within 3 years Colonoscopy Colonoscopy If normal resume average risk If normal repeat in 5 years, if normal resume average risk

3-6 months then Colonoscopy 1 year Colonoscopy

Colorectal cancer or Age 40 or 10 yrs Adenomatous polyps, in before youngest 1st degree relative <60, case or 2 or more 1st degree relatives at any age (not a hereditary syndrome)

If normal repeat in 3 years, if normal then repeat every 5 years or more often for HNPCC Every 5-10 years

ACS Guidelines on Screening and Surveillance for the Early Detection of Colorectal Adenomas and Cancer
Risk Category Age to Begin Recommendation Comments

High Risk Family hx FAP Puberty Endoscopy and Genetic testing Colonoscopy counseling for Genetic testing + genetic test, colectomy

Family hx of HNPCC

Age 21

+ genetic test or if not done every 1-2 yrs till age 40 then annually. Every 1-2 years

Ulcerative Colitis Or Crohns disease

8 yrs after Colonoscopy onset of pancolitis or 12-15 years after left sided colitis

Screening for CRC

Ideal screening should be safe, easy, reliable, inexpensive. Current compliance for CRC screening is 35% 4-7% of people develop CRC during lifetime. Screening colonoscopy will result in no benefit to over 90% of us but subject us to the expense and morbidity of the exam. Sufficient colonoscopic and economic resources not available in most areas. Colonoscopy misses 5% of cancers and 20% of polyps. FIT is a reasonable recommendation in the average risk group.

CT Colonography

1. Helical CT scan creates two and three-dimensional images. Prepare with phospha-soda and bisacodyl. Air insufflation. 2. Accurate in detection of polyps greater than 10 mm and colon cancer. 3. False positives 15% unnecessary colonoscopy from retained stool, diverticular disease, thick or complex haustral folds, metal or motion artifacts. 4. May miss flat adenomas which are more aggressive. 5. Non therapeutic. 6. More expensive and not covered by insurance.

DNA Stool Testing

Screening Stool for DNA Mutations Still under investigation. Only one sample required. Non-invasive, no preparation. Requires entire bowel movement be sent to lab. May be more specific for cancer and polyps Expensive at over $400 per test. K-ras, APC, p53, Bat-26, and long DNA tested.

Research Opportunity
4-7% of people develop CRC during their lifetime.

A prospective study on the diagnosis and treatment of rectal bleeding typical of hemorrhoids. The role of hemorrhoidal banding, FIT, and colonoscopy. A cooperative project of primary care providers, GI specialists, and the Center for Colorectal Health. Patients with rectal bleeding typical of hemorrhoids will be evaluated, banded, undergo FIT, and then colonoscopy. When is colonoscopy indicated? Age, sex, length or type of symptoms.

Thrombosed External Hemorrhoid

Thrombosed External Hemorrhoids

1. Typical presentation is acute rectal pain and mass. 2. Associated with heavy lifting, straining, sitting, diarrhea. 3. Rx warm baths, stool softeners, Lidocaine ointment, analgesics, supine position, Nifedipine, NTG, or diltiazem ointment. 4. Surgical excision best done within first 72 hrs. for severe pain, ulceration, rupture. Open vs. closed excision. 5. When associated with 3-4th degree hemorrhoids will require pudendal block and reduction of prolapse. Avoid surgery if possible. 6. Up to 50% will experience further hemorrhoid problems. After acute episode resolves proceed with anoscopy and banding. 7. Look for associated fissure.

Fissure

Anal Fissure

Acute posterior anal fissure producing pain on digital exam. Sphincter tone increased. Exam limited by pain that may respond to NTG and Lidocaine.

Anal Fissures
1. A linear tear in the skin of the anal canal caused by passage of a hard stool, diarrhea, straining, sitting too long. May be seen in IBD or after rectal surgery. Increased sphincter tone. 2. Deep fissures expose underlying internal sphincter, white color. 3. Spasm, irritation, itching, pain after BM, and bleeding. 4. Acute fissures may heal with sitz baths, fiber, brief Rx steroid cream, leading to thin skin and sentinel pile. Pile may shrink after Rx. If persists may be excised after Rx of fissure completed. 5. Associated hemorrhoids are common. 6. NTG, Lidocaine ointment, fiber, fluids, no straining, banding. 7. Infected fissures Rx Flagyl.

Anal Fissure Rx
6 weeks of twice a day intra-rectal NTG ointment, .12%, then 6 weeks of once a day NTG. Watch for headaches, tachycardia, or light headiness. Do not use NTG in patients on Viagra or Cialis. Recurrences require repeat NTG Rx and increasing fiber. 5% Lidocaine ointment as needed. 2 % Diltiazem, calcium channel blocker. ointment is an alternative in those with headaches and is used three time per day and may take longer. Botox effectively paralyzes internal sphincter but costs $600 per vial and may cause incontinence. May be used in combination with NTG. Surgery is effective but has a 10% incontinence rate. Pudendal block may be rarely required for pain relief.

NTG

Nitroglycerin relaxes smooth muscle, decreases resting pressure, and improves blood supply. Side effects: hypotension, bradycardia, tachycardia, headache, rash, dizziness, dyspepsia, flushing, blurred vision, dry mouth, fainting. Avoid with congestive heart failure, calcium channel blockers, beta blockers, Viagra, Cialis. Has been used in pregnancy without difficulty so far but has not been adequately tested.

Diltiazem
Calcium-channel blocker relaxes smooth muscle and increases blood supply. Side effects: dizziness, lightheadedness, flushing, headache, tiredness, bradycardia, dyspepsia, nausea, vomiting, diarrhea, constipation, abdominal pain, dry mouth, edema, nervousness, insomnia. Allergic reactions may occur. 2% ointment of Cardizem, Dilacor, Tiazac. Avoid in heart block, beta-blockers, heart failure. May increase Digoxin or Tegretol levels. Tagamet increases blood levels.

CRH Rx of Fissures

The combined therapy at CRH of using fiber, bathroom behavior modification, NTG, and banding of internal hemorrhoids heals a high percentage of anal fissures while avoiding the expense, pain, disability, and risk of internal sphincterotomy and hemorrhoidectomy.

Skin tags

 Skin tags are extra folds of skin around the anal verge. Caused by stretching of skin from dilated external hemorrhoids. May interfere with cleaning and add to pruritus ani. Cosmetic issue to some.  Skin tag and can be removed or left alone depending on preference.  Removal requires local anesthesia and office excision. Takes 15 minutes and leads to 2-3 days of discomfort.

Associated skin tags

Pruritus Ani
1. Chronic itching and rash around the anus. 2. Caused by leakage of stool and mucous leading to inflammation of skin, dermatitis. 3. Hemorrhoids, fissures, and poor hygiene may lead to itch. 4. Fungal infections may occur, more common in DM. 5. Contact dermatitis may occur from soap, perfumes, dye in toilet paper, or hemorrhoid creams or wipes. 6. Citrus fruits, grapes, tomatoes, spices, beer, milk, tea, or coffee may exacerbate condition. 7. Laxatives, colpermin, and antibiotics may cause itch. 8. Keep area clean and dry at all times. Loose pants and cotton underwear. Balneol and Lotrimin or Lotrisone Rx. Band hemorrhoids and treat fissure.

Pruritus Ani

Balneol
INDICATIONS: Perianal cleanser for Pruritus Ani Balneol is specially formulated to cleanse and soothe the perianal and external vaginal areas. INGREDIENTS: Water, Mineral Oil, Propylene Glycol, Glyceryl Stearate, PEG-100 Stearate, PEG-40 Stearate, Laureth 4, PEG-4 Dilaurate, Lanolin Oil, Sodium Acetate, Carbomer 934, Triethanolamine, Methylparaben, Dioctyl Sodium Sulfosuccinate, Fragrance, Acetic Acid. DIRECTIONS: To reduce discomfort while cleansing after each bowel movement, spread a small amount of BALNEOL on cotton or tissue and wipe skin around perianal area. Also use between bowel movements and at bedtime for additional comfort. WARNINGS: In all cases of rectal bleeding, consult physician promptly. If irritation persists or increases, discontinue use and consult physician. Keep this and all medications out of the reach of children. For External Use Only.

Irritable Bowel Syndrome

Lower abdominal cramping, abdominal pain, bloating, associated with diarrhea and or constipation and relieved by bowel movement. Straining, urgency, hemorrhoids, fissures. 15 percent of adults have IBS. More common in women and starts before the age of 35 in 50 %. Altered motility, visceral hypersensitivity, abnormal brain-gut interaction, autonomic dysfunction, and immune activation. Disturbed gut flora Rx with probiotics or enteric coated peppermint oil (Colpermin 1 po 3-4 per day). Elevated Serotonin levels. Alosetron improves diarrhea(1mg bid). High fiber low fat diet, small meals, stress management, antispasmodics (Colofac), IgGfood elimination diet can help. R/O Celiac disease and inability to digest gluten.

IBS RX with Probiotics

Fecal flora shows decreased Bifidobacterium, and Lactobacillus and increased Enterobacteriaceae. Probiotics help normalize the gut flora and immune system. Bifidobacterium infantis 35624, Lactobacillus. Further randomized studies needed.

Final Questions

1. What is the role of hemorrhoidal creams or suppositories for rectal pain, bleeding or prolapse? 2. What is the role of colonoscopy in the evaluation of rectal bleeding after bowel movements? 3. Who should be referred for the office based nonsurgical treatment of hemorrhoids or anal fissures? 4. What is the role of surgery in hemorrhoidal disease and anal fissure?

Being regular is a good thing. Thank you And Do not Forget 15 grams of Fiber a Day Keeps the Proctologist Away