Hemorrhoids Xử trí

Several pharmacological preparations are available for the relief of hemorrhoidal symptoms; however, further studies are needed to establish their definitive role in the treatment of hemorrhoids. Hemorrhoids during pregnancy are preferably managed medically with surgical intervention reserved for severe cases such as strangulated internal hemorrhoids. The recurrence following conservative medical management ranges from 10-50% within 5 years.

Analgesics

Topical analgesics may be used to relieve local pain and pruritus. These include Lidocaine, and Cinchocaine. Oral analgesics (eg Paracetamol) may be used to relieve pain caused by thrombus.

Corticosteroids

Topical corticosteroids can reduce perianal inflammation due to poor hygiene, mucus discharge or fecal seepage. Avoid prolonged use of potent corticosteroids.

Herbal Medicines

Herbal medicines decrease hemorrhoidal symptoms, including bleeding, inflammation, pain and venous congestion, and have a favorable safety and tolerability profile. Examples of herbal medicines are witch hazel (Hamamelis virginiana), butcher’s broom (Ruscus aculeatus), horse chestnut (Aesculus hippocastanum), calendula (Calendula officinalis), aloe vera (Aloe barbadensis), chamomile (Matricaria chamomilla), gotu kola (Centella asiatica), marshmallow root (Althaea officinalis), comfrey (Symphytum officinale), St John’s wort (Hypericum perforatum), and frankincense (Boswellia serrata).

Phlebotonics

Phlebotonics are a heterogenous class of drugs consisting of plant extracts (eg flavonoids) and synthetic compounds (eg Calcium dobesilate) which can be used to treat both acute and chronic hemorrhoidal disease. These are associated with strengthening blood vessel walls, increasing venous tone, increasing lymphatic drainage and normalizing capillary permeability. A meta-analysis comparing herbal venotonics with conventional synthetic agents reported that natural compounds offered comparable, and in some instances greater, symptomatic relief in patients with grade I-II hemorrhoids. Bioflavonoids (eg Diosmin, Hesperidin, Rutin) control rectal bleeding and improve symptoms. Oral, micronized, purified, flavonoid fraction derived from citrus fruits have been studied.

Other Agents

Bulk-forming agents¹ in combination with fluids and stool softeners¹ can be helpful. Suppositories may help in lubrication during defecation, thus avoiding straining.

¹Various laxatives and purgatives for hemorrhoids are available. Please see the latest MIMS for specific formulations and prescribing information.

Dietary Modification and Supportive Measures

Dietary Modification

Conservative treatment for all symptomatic hemorrhoids mainly entails increasing dietary fiber and fluid intake. Fiber and fluid intake increase stool caliber and decrease straining and constipation, which in turn causes hemorrhoids to shrink. Increased fiber and fluid intake have been reported to improve mild-to-moderate prolapse and rectal bleeding. Fiber may also be used to control diarrhea which can exacerbate hemorrhoids. Intake should be increased gradually up to 25-30 g/day. Examples of supplements include Psyllium and Methylcellulose.

Evidence indicates that triphala, an Ayurvedic preparation composed of three fruits (amalaki, bibhitaki and haritaki), can improve bowel function and reduce discomfort in patients with hemorrhoids. Incorporating rutin-rich foods (eg citrus fruits, berries and buckwheat) into the diet or using rutin supplementation may help strengthen blood vessel integrity and reduce bleeding, pain and perianal pressure in patients with hemorrhoids.

Toilet Habit Retraining

Toilet habit retraining consists mainly of reminding patients to avoid prolonged sitting or straining when using the toilet. Limit the time on the toilet to 3-5 minutes. Reading when using the toilet should be avoided. Maintenance of a regular bowel habit should be encouraged.

Warm Baths and Ice

Warm water (Sitz) baths relieve perianal pain by relaxing the anal sphincter mechanism and spasm. Use warm water (approximately 40°C) with a soak time limited to 15 minutes. Ice may lessen the pain of acute thrombosis.

Hygiene

Patients may be advised to wipe the anal area gently after defecation with moist tissue. Discourage excessive scrubbing during shower or bath.

Other Supportive Measures

Regular exercise and maintenance of a healthy body weight can help reduce hemorrhoidal symptoms. Avoidance of medications that promote bleeding (eg nonsteroidal anti-inflammatory drugs [NSAIDs]).

Ablative Office Procedures

Rubber Band Ligation 

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Rubber band ligation is most commonly used for grade I, II or III hemorrhoids. This is considered the most effective treatment option and it is the most frequently performed procedure due to its safety and cost-effectiveness. Redundant mucosa, connective tissue and hemorrhoidal complex blood vessels are tightly encircled well proximal to the dentate line; a scar that forms fix the connective tissue to the rectal wall and resolves the prolapse. Single or multiple banding may be done per session and up to three hemorrhoids can be banded in one session. Recurrent symptoms may be relieved by repeat ligations. The limitation of the procedure is that this does not address the external hemorrhoidal component. The most common complication is minor pain. Delayed hemorrhage may occur while sepsis usually develops in immunocompromised patients. Avoid in patients with bleeding diathesis or those receiving antiplatelet or anticoagulant agents. The risk of bleeding should be weighed against the risk of thrombotic events.

Bipolar Diathermy or Cautery

Bipolar diathermy or cautery may be used for grade I, II or III hemorrhoids. One-second pulses of 20 W are applied until underlying tissue coagulates resulting in fibrosis and fixation of tissue. This usually requires multiple applications to the same site. About a fifth of patients still require excisional hemorrhoidectomy. Complications include pain, bleeding, fissure or spasm of the internal sphincter.

Direct Current Electrotherapy

Direct current electrotherapy may be used for grade I, II or III hemorrhoids. This involves prolonged application of 110 V direct current to the base of the hemorrhoidal complex. This requires multiple applications to the same site in about a third of patients. The disadvantages are the extended treatment time and limited control of prolapse in more severe disease.

Infrared Coagulation 

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Infrared coagulation may be used for grade I or II hemorrhoids. Infrared waves are applied directly to the base of hemorrhoidal tissue, resulting in necrosis and subsequent fixation for the treatment of bleeding and tissue prolapse. Recurrence is common in hemorrhoids with marked prolapse.

Injection Sclerotherapy 

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Injection sclerotherapy is used for grade I or II hemorrhoids. A sclerosing agent (eg 5% Phenol in an oil base, hypertonic saline, 5% Quinine, Urea, sodium tetradecyl sulfate, polidocanol foam, and aluminum potassium sulfate and tannic acid) is injected into the apex of the hemorrhoid, which induces inflammation and fibrosis of the hemorrhoidal tissue, leading to vessel thrombosis, sclerosis of connective tissue and subsequent scarring that fixes the overlying mucosa to the submucosa. This is minimally invasive and safe for use in patients receiving anticoagulation therapy. The complications include pain, bleeding with injection, impotence, urinary retention and abscess.

Cryotherapy

Cryotherapy employs cold coagulation to cause local tissue destruction. This is rarely used because of the significant adverse effects. 

SURGICAL HEMORRHOIDECTOMY

Indications for Surgical Hemorrhoidectomy

Surgical hemorrhoidectomy may be considered in the following: Patients who do not respond to, cannot tolerate or are not candidates for ablative office-based procedures for internal hemorrhoids; patients with large grade III or IV hemorrhoids, symptomatic external hemorrhoids including those who have symptoms from skin tags; acutely incarcerated and thrombosed hemorrhoids; and combined external and internal hemorrhoids (grade III-IV) with significant prolapse.

Options for Surgical Therapy

Open or Closed Hemorrhoidectomy

Open hemorrhoidectomy (Milligan-Morgan) leaves the excision site open for natural healing and drainage, while in closed hemorrhoidectomy (Ferguson), incision closure follows after excision. This may be performed using a surgical scalpel, laser, ultrasonic scalpel or diathermy. This involves any of the following: Excising internal and external components; suturing or banding of the internal hemorrhoids and excising the external component; and performing a circular excision of the internal hemorrhoids and prolapsing rectal mucosa proximal to the dentate line.

Thrombosis of external hemorrhoids which has been present for <48-72 hours is best treated by local excision of the external component. This may be done as an office procedure but may sometimes require an operating room setting because of large hemorrhoid size, extension within the canal or patient anxiety. Complications of hemorrhoidectomy are usually minor but may occur frequently. These include bleeding, fecal incontinence, urinary retention, infection, and anal stenosis.

Stapled Hemorrhoidectomy

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The goals of stapled hemorrhoidectomy are the re-suspension of prolapsing tissue back within the anal canal and interruption of arterial blood flow that goes through the excised segment of redundant rectal mucosa. This uses a modified, circular, anastomotic trans-anal stapler to excise the submucosa proximal to the dentate line, producing a mucosa-to-mucosa anastomosis that results in a cephalad fixation of the anal cushions and interruption of the feeding arteries. This is effective for prolapsing internal hemorrhoids but ineffective against large external hemorrhoids and skin tags or thrombosed hemorrhoids. The rates of complication are similar with excisional hemorrhoidectomy but it causes less pain.

Trans-anal Hemorrhoidal Dearterialization

Trans-anal hemorrhoidal dearterialization involves Doppler-guided ligation of four to six branches of the superior hemorrhoidal arteries to reduce hemorrhoidal blood flow and size. This may be used for patients with internal hemorrhoids. This may result in decreased pain but increased recurrence rates compared with excisional hemorrhoidectomy.