HEMORRHOIDS

DISORDERS OF THE ANORECTUM 0889-8553/01 $15.00 + .OO

HEMORRHOIDS M. Hulme-Moir, BSc, FRACS, and D. C. Bartolo, MS, FRCS

Hemorrhoids is a condition that has been known and treated for at least 4000 yearsx but has only recently come to be partially understood. Ardene (1307-1390), a surgeon from Newark, England, was reputed to have said: "The common people call them piles, the aristocracy call them hemorrhoids, the French call them figs-what does it matter so long as you can cure them?"' Definition, anatomy, cause, and successful treatment all are intertwined, and to understand and manage hemorrhoids correctly, an understanding of each must be sought.

The word hemorrhoid is derived from the Greek adjective haimorr- hoides, which means bleeding (kuirna = blood; rhoos = flowing). The word pile is derived from the Latin word pila, meaning u bull. The two words, hemorrhoids and piles, have become misused over time. They have come to be used by laypeople for many of the conditions and symptoms associated with the perianal region. Medical personnel also use the terms imprecisely, which historically has led to confusion in the medical literature.

CLASSIFICATION

For the purposes of this article, hemorrhoids refers to symptomatic abnormalities of the normal vascular hemorrhoidal tissue of the anal canal. Hemorrhoids can be classified into external and internal, with further subclassification of the internal group into first-degree, second- degree, third-degree, and fourth-degree hemorrhoids. First-degree hemorrhoids are enlarged symptomatic masses of hemorrhoidal tissue that

From the Department of Colorectal Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland

~~

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184 HULME-MOIR & BARTOLO

do not prolapse out of the anal canal and can be seen only on proctos- copy. Masses that prolapse and reduce spontaneously are classified as second-degree hemorrhoids. Mass that prolapse easily and require man- ual reduction are third-degree hemorrhoids. Fourth-degree hemorrhoids are prolapsed permanently and are prone to thrombosis and infarction. Whether this classification is of any help in deciding on treatment is doubtful. External hemorrhoids are the continuation of the normal submucosal venous plexus that lies below the dentate line and has a sensate epithelial lining. Thrombosis in these vessels often is called perianal hematoma although Thomson71 sensibly suggested that they be known as subpectineal thromboses.

INCIDENCE

Because of the lack of clarity surrounding hemorrhoids; precise data on the incidence and prevalence are difficult to ascertain. Figures of 58% to 86% incidence can be found in the literature.8, 22 Hospital-based data represent a different subgroup than community-based data. A nation- wide questionnaire in the United States showed a prevalence of 4.4%, of which one third presented for medical advice.% A similar questionnaire in a London general practice showed a prevalence of 36.4Y0.l~ In the United States, physicians report 1177 visits for hemorrhoids per 100,000 population per ~ e a r . 3 ~ Data from England and Wales showed similar figures of 1123 visits per 100,000 population per year.33 There appears to be a peak in middle age with a decline in the incidence after the age of 65. Although men are thought to seek medical help more often than women, there appears to be an equal distribution of hemorrhoidal disease between the sexes.l0, 39 Whatever the true figures are, hemorrhoids are a common problem that account for significant morbidity in commu- nities.

ANATOMY

Although many features of the normal anatomic structure of the anal canal have been known for years, it is only relatively recently that a clearer understanding of the mucosal and submucosal tissues has been achieved. In an excellent study, Thomson70 confirmed many important anatomic facts concerning the anal canal. Within the anal canal, the mucosa and submucosa are arranged into thickened cushions. On pro- ctoscopy, these cushions can be seen to approximate the right anterior, right posterior, and left posterior positions. Variations and secondary cushions are The cushions are not circumferential, and the longitudinal clefts between them form the columns of M ~ r g a g n i . ~ ~ Each of these cushions is made up of venous plexus plus arterial supply that

HEMORRHOIDS 185

is embedded in a stroma, which consists of connective tissue and smooth muscle and is supplied richly by nerves.

The arterial supply to the anal canal is extremely variable and does not follow the classic description by which was long accepted as surgical dogma. Thomson7" showed that there is extreme variation in the way that the terminal vessels of the superior rectal artery branch to supply the anal canal, and none of his 50 dissections matched the classic pattern. In some cases, the supply was partially or completely from the middle rectal vessels. Thomson70 confirmed the presence of multiple small arteriovenous anastomoses between the arterial supply and the venous plexus. It also appears that the blood flow to the area far exceeds the metabolic requirements of the anal canal."

The veins in the submucosal plexus contain numerous dilations predominantly above the dentate line but also below it to a lesser degree." These dilations are present in infants, confirming work first published in 1874 by Sappep and suggesting strongly that these are normal anatomic structures. There is free communication between the portal and systemic venous channels.70

Within the submucous space are many smooth muscle fibers and elastic tissue arising from the internal sphincter and the conjoined longitudinal muscle.70 T r e i t ~ ~ ~ first described this muscle in 1853, which probably corresponds in part to suspensory ligament at the level of the dentate line. These fibers appear to act as a supportive network to the venous plexus and the rest of the anal submucosal and mucosal tissue (Fig. l).70 It appears that with age there is a gradual replacement of this smooth muscle with fibrous tissue as well as a loss of some of the connective tissue organization seen in younger specimens.2o

CAUSE

The cause of hemorrhoids is not clear, although over the centuries numerous theories abounded.71 By the middle of the twentieth century, three main theories existed: (1) the varicose vein theory, (2) the vascular hyperplasia theory, and (3) the concept of a sliding anal lining. The last theory suggests that hemorrhoidal tissue is the normal lining of the anal canal and that slippage of this lining leads to symptomatic hemor-

Varicose veins were thought to be the cause of hemorrhoids as early as the time of Galen and Hippocrates.54 M ~ r g a g n i ~ ~ further popularized this theory by suggesting that the upright position led to the development of anal varicosities. Work by T h o m s ~ n ~ ~ and earlier authors6* showed the venous dilations to be present in infants, suggesting that they are part of normal anal anatomy. The associated suggestion that low fiber intake, constipation, and straining are important causative factors5 is not supported by subsequent work:, 9, 16, 33 Hemorrhoids are no more common in patients with portal hypertension than the normal

rhoids.14.39. 70

186 WME-MOIR & BARTOLO

Figure 1. Longitudinal cross-sectional anatomy of the anal canal. (From Thomson WHF: The nature of haemorrhoids. Br J Surg 62:542-552, 1975; with permission.)

populati~n.~~, 31 suggested that local increases in pressure because of a fecal bolus caused the varicose swellings; however, the confirmation of the presence of portosystemic anastomoses contradicts this theory.70

During the nineteenth century, several authors suggested that hemorrhoids were a sort of vascular hyperplastic process.39, 70 This suggestion was based on the histologic similarities between hemorrhoidal specimens and other erectile tissues. In 1963, StelzneF proposed the concept of the corpus cuvernosum recti. T h o m ~ o n ~ ~ and Loder et a13g pointed out that there are no significant differences in the vascular anatomy between normal and pathologic hemorrhoidal tissue. Hemorrhoidal bleeding seems to arise from capillaries in the lamina propria rather than the venous di1ati0ns.l~. 70

If one accepts that hemorrhoidal tissue is the normal lining of the anal canal, symptoms caused by pathologic slippage of this lining account for the disease known as hemorrhoids. Gass and Adams14 first proposed in 1950 that hemorrhoids are caused by slippage of the normal anal canal lining, a theory later supported by 0 t h e r s . 3 ~ ~ ~ ~ Changes in the connective tissue seen in hemorrhoid specimens include loss of organization, muscular hypertrophy, and fragmentation of the muscle and the elastin component^,'^, 70 When the sliding process has started,

HEMORRHOIDS 187

shearing forces during defecation tend to exacerbate the problem. Some data suggest an association between hemorrhoids and hernia and prolapse of the genitourinary ~ystem.3~ Although no hereditary link has been proved, there often is a strong family history.39

Abnormalities of anorectal physiology can be shown in patients with hemorrhoids. Resting anal pressures are found consistently to be raised.", 16, 38, 66, 67 Sun et aP7 reported that the increases in anal resting pressure were not found in patients with prolapsed hemorrhoids. Other studies did not report this finding.12,38 Some authors postulated that the pressure increase occurs in the vascular beds.66, 67 After hemorrhoidectomy, pressures return to normal within 3 months, suggesting the abnor- mal findings are a result rather than a cause of the pathology.12,26 Rubber band ligation causes only an insignificant decrease in anal pressure with no return to normal as with surgical treatment.'l

Ultraslow waves are more common in hemorrhoid sufferers than in normal controls.76 It is possible that the ultraslow waves are associated with the high resting pressures and probably originate in the internal sphincter muscle, although their significance is not clear.39 Other changes have been recorded but are less reproducible, including increased external sphincter activity (spike decreased anal sensati0n,3~ and an increased number of sampling response^.^^ At present, the temporal relationship between these physiologic findings and the development of hemorrhoids is not clear.

TREATMENT

"To Tie; to Stab; to Stretch; Perchance to Freeze"-so questions the title of an editorial in the Lancet." Treatment regimes for hemorrhoids date back thousands of years.% Many of these treatments would have had doubtful efficacy, for example, poultices, cold water enemas, and the intervention of St. Fiacre, the patron saint of hemorrhoid sufferers.8,54 Less pleasant for the patient in preanesthetic days were ligation, cautery, and surgical excision.18 Modern treatments are merely sophisticated modifications of these historical methods.

The first step of any successful treatment is correct diagnosis and an understanding of the underlying pathology. As mentioned earlier, there is a common pool of symptoms that many anorectal conditions share. A careful history and examination, including rigid sigmoidoscopy, is essential. The authors have a low threshold for imaging the colon for bleeding, especially in patients older than age 40. Anorectal physiology is not used routinely, although in some situations, such as coexistent incontinence, it is a useful adjunct.

The choice of treatments is huge (Table 1). With a good understanding of the anatomy and pathology of hemorrhoids, it is clear that symptom management or cure is the aim of treatment (Fig. 2). Treatment of bulky but asymptomatic hemorrhoids is unnecessary and possibly harmful.42, 53 All of the treatment modalities except fiber modification


Table 1. TREATMENT MODALITIES FOR HEMORRHOIDS ~ ~~~

Treatment Modality Suggested Patient Group

Dietary modification/fiber Unlikely to curve symptomatic hemorrhoids, may be supplementation

Injection sclerotherapy

Photocoagulation Cryotherap y

Unipolar diathermy

useful in the subgroup of patients with constipation and/or symptoms of straining

Grade 1 and 2 hemorrhoids. Safe in pregnancy. Repeat treatment often required

Grade 1 f grade 2. Repeat treatment often needed Grade 1 and 2 hemorrhoids. Repeat treatment may be

Grade 1 and 2 hemorrhoids. Repeat treatment may be required, and discharge may be a problem

required. Ten minutes per hemorrhoid is required for optimal results

required Bipolar diathermy

Banding Laser

Surgical hemorrhoidectomy,

Grade 1 and 2 hemorrhoids. Repeat treatment may be

Grades 1 through 3. Repeat treatment may be necessary Grade 1 and 2 hemorrhoids, expensive set up costs, few

Definitive treatment for failure of nonoperative data available

modalities and as primary therapy for grade 3,4, and acute hemorrhoids

Awaiting definitive prospective trials, potentially the treatment of choice for circumferential hemorrhoids and recurrent hemorrhoids post surgical resection

open* or closed

Stapled hemorrhoidectomy

‘Authors’ preference.

work by causing fixation of the sliding tissue back onto the muscle wall. This fixation is either by directly initiating tissue fibrosis as with sclerotherapy or by tissue destruction with subsequent scarring and fibrosis. These various techniques can be divided into sclerotherapy; banding; and tissue destruction by light, heat, or cold. Large series comparing all the various modalities are not available. Meta-analyses suggest that banding is more efficacious than injection or photocoagulation and that surgical excision is the definitive treatment.43

Diet and Bulking Agents

Bulking agents are used widely for the treatment of hemorrhoids and are thought to be useful for softening motions and reducing shear forces during defecation. Hard data on their efficacy are limited: and constipation has not been shown to be a cause of hemorrhoids.s,9,33 Data that are available are not conclusive.4, Moesgaard et a147 showed that a high-fiber diet gave better symptom reduction than placebo.

Injection Sclerotherapy

Morgan of Dublin is credited with introducing injection sclerotherapy in 1869 using an iron protosulfate solution.18 Phenol in oil is now a

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commonly used solution. It is a quick, safe one-person outpatient technique. Repeated treatments may be necessary to attain lasting effects. Santos et a P reported only 42% of patients were improved or cured by a single treatment. It is most useful for grade 1 and 2 hemorrhoids,4* as recommended by The Standards Task Force, American Society of Colon and Rectal Surge0ns.6~ Injection sclerotherapy is not entirely without risk, as testified by two case reports of necrotizing fasciitis and retroperitoneal sepsis.3, 35

Rubber Banding

Rubber banding was developed by Barron2 in the 1960s. In contrast to injection sclerotherapy, it leads to removal of excess tissue, plication of remaining tissue, and healing by secondary intention with resulting fibrosis and fixation. The technique requires two people to perform. In a meta-analysis by MacRae and McLeodIa rubber banding was found to be superior to injection sclerotherapy and photocoagulation. In the same study, pain was found to be more of a problem with rubber banding compared with sclerotherapy or photocoagulation.a The use of local anesthetic at the time of banding does not appear to provide sustained relief from this 37 There is a slightly higher risk of severe sepsis with this technique, although it is extremely rare, and rubber banding probably should not be used in patients who are immunocom- pr0mised.4~. 59

Photocoagulation

Photocoagulation relies on tissue coagulation by infrared radiation with tissue destruction limited to a depth of 3 mm. It is smoke-free and odor-free, in contrast to diathermy, and can be performed by one person.8 The main use of photocoagulation is for grade 1 and 2 hemorrhoids, and repetitive treatment often is required.43, 65, 69

Electrocoagulation

Bipolar electrocoagulation (Bicap) works by the local application of heat through a specialized probe? Similar to photocoagulation, it can be performed by a single operator without the need for assi~tance.~ It is as effective as photocoagulation and unipolar diatherm~?~

Unipolar electrocoagulation or Galvanic Generator (Ultroid, Micro- vasive) uses a low-voltage current of maximally tolerable amplitude passing through a probe to an earthed patient. The major disadvantage is that it requires 10 minutes per hemorrhoid for effective treatment, which limits its use in a busy outpatient setting. Randall et a157 reported

HEMORRHOIDS 191

similar efficacy and complication rates between the bipolar and unipolar electrocoagulation techniques.

Cryotherapy

Cryotherapy is performed with a liquid nitrogen (-196" C) or nitrous oxide probe ( - 60" to - 80" C). Tissue swelling is followed by delayed thrombosis and infarction during a 24-hour p e r i ~ d . ~ Cryother- apy is time-consuming and requires specialized equipment; its main problem is prolonged and heavy discharge after the 52 In a nonrandomized trial, M a c L e ~ d ~ ~ reported it to be more effective than banding and sclerotherapy, although he treated only one hemorrhoid per patient at a time, requiring multiple treatments per patient.

Laser

Carbon dioxide and neodymiumyttrium aluminum garnet lasers have been used for the treatment of hemorrhoids in a many different ways. Endoscopic spot welding, excisional surgery, and vaporization have been de~cr ibed .~~ Lasers have not yet been shown to be superior to other techniques in large randomized trials and are considerably more expen~ive.6~

Lord's Procedure and Lateral Internal Sphincterotomy

Forcible anal dilation was introduced by Lordm to reduce hospital stay and because of the measured increases in resting anal pressures. Although this procedure has been shown to be effective, it is associated with high levels of incontinen~e,2~. 41 and it is no longer recommended as a treatment for her nor rho id^.^^

Internal sphincterotomy addresses the high pressures usually associated with hemorrhoids. If the raised pressures are as a result of, rather than a cause of, hemorrhoids, however, cutting healthy sphincter muscle is a cause for concern. Good results have been obtained with this technique?, 63 There is concern, however, that 25% of patients may have some degree of in~ontinence.~~ The authors do not use this procedure for the treatment of hemorrhoids.

Surgical Excision

When required, surgical excision, whether open or closed, is the definitive treatment for troublesome hemorrhoids.", 69 Increased complications, especially pain, and hospital bed usage accompany excision, however.@ Only 5% to 10% of patients with symptomatic hemorrhoids


require surgery.lO, From the current anatomic knowledge of hemorrhoidal pathology, many points can be made about surgery for hemorrhoids:

Symptom control rather than cosmesis is the aim of treatment, and alternative nonoperative treatments usually should be tried first. The grade of hemorrhoidal disease at presentation is not an indica- tion for primary surgical intervention.

Bulky, asymptomatic hemorrhoidal tissue should be left alone.“, 53

Given that hemorrhoidal tissue is a vital part of the continence mecha- nism, radical surgical tissue removal seldom is indicated. There is evidence that removal of just the offending hemorrhoidal beds is as good as a traditional three-position hemorrhoidectomy with respect to long-term ~ o n t r o l . ~ ~ ~ 6o

Anatomically, it is difficult to justify the existence of a vascular pedicle for each hemorrhoidal cushion. The question is whether the pedicle should be ligated.

Focus should be on the need for day surgery, better pain control, and minimizing the complications of surgery.

The question of whether open or closed surgical excision should be performed is a difficult one. There does not appear to be any difference in postoperative pain levels between open and closed techniques, although a reduction in anal sensation can be ~ h ~ w n . ~ , ~ ~ , ~ ~ Evidence exists that overall the open technique may heal faster than the closed technique.27 The authors practice open hemorrhoidectomy with early discharge as soon as the patient is comfortable, usually the same day. Patients are given lactulose, metronidazole, isorbide paste, and simple oral analgesia, including diclofenac. They are given the option of calling the ward if they have a concern. Follow-up is usually at 6 weeks in the outpatient clinic and as often thereafter as required.

SPECIAL PROBLEMS

Crohn’s Disease

Symptomatic hemorrhoids occur in patients with Crohn’s disease, although probably not as a result of the inflammatory process. Tradition- ally, any form of intervention causing tissue damage has been warned against because of the prohibitively high complication rate incurred.32 It seems from more recent work that the risks of intervention are not as high as initially thought as long as all proximal disease is quiescent and perianal sepsis is contr~l led.~~ Any form of tissue destruction should not be undertaken lightly and only when the disease process is well controlled. In light of the effectiveness of metronidazole and ciprofloxacin in controlling perianal Crohn’s disease,” it seems prudent to cover any procedure with antibiotics, although no data exist to support this recommendation.

HEMORRHOIDS 193

Pregnancy

Hemorrhoidal symptoms are common in pregnancy, although it is difficult to establish a true incidence, and not all pregnant women suffer from them.39, 44 Many factors probably account for hemorrhoidal symptoms in pregnancy, including hormonal changes, connective tissue laxity, constipation, pelvic pressure and congestion, and increased circu- lating blood volume.39, Treatment usually consists of dietary control, laxatives, and rest. SimmonsM showed injection sclerotherapy to be safe. In theory, the other conservative modalities should be safe as well; however, no data exist to support this. Surgery is not often indicated. During a 7-year period in a population of 12,455 pregnant women, only 25 required surgical intervention.60 They all underwent surgical excision of the symptomatic tissue under local anesthesia with no maternal or fetal problems as a result and only one significant problem with bleeding.'j0 There is evidence that surgery leads to an increased rate of preterm labor, but no evidence suggests an increase in fetal abn~rmalities.'~ Surgical intervention should be delayed when possible until the fetus is viable, but intervention should not be withheld on the grounds of pregnancy alone.

Acute Hemorrhoids

The authors' policy, in line with other units, is to excise acutely prolapsed, thrombosed hemorrhoids as an acute or next list type of pr~cedure.'~, 50 It seems unnecessary to keep patients in the hospital for prolonged periods on bed rest waiting for the problem to resolve spontaneously. Historical concerns of portal pyemia do not appear to be real, and stricturing can be prevented by careful conservative s~rgery. '~ In a large series of 204 acute patients and 500 elective patients, Eu et all3 showed no difference with respect to bleeding, anal strictures, sepsis, recurrence, or incontinence. It is probably not necessary to perform a standard three-position hemorrhoidectomy but rather just to remove the symptomatic tissue.24* ' j0

FUTURE DEVELOPMENTS

Circular Stapled Hemorrhoidectomy

Circumferential hemorrhoidectomy is not a new concept; however, it is technically challenging and was thought to have a higher rate of stricturing. A technique using a circular stapler has been developed that allows a circumferential mucosectomy 2 cm proximal to the dentate

This technique in effect hitches up the prolapsed anal lining and interrupts the proximal blood flow. Reported complication rates are low, and patients are said to be more comfortable and return to work more


quickly than after a traditional 45 Large prospective randomized trials are needed; however, this technique may be useful for large prolapsed hemorrhoids that can be difficult to treat.

Day Surgery

One of the problems with hemorrhoidectomy in the past has been the prolonged periods of hospitalization required by surgeons.55 With the mounting costs of medical care, hospital beds are at a premium, and clinicians have been forced to reconsider the necessity of inpatient surgery for hemorrhoids. The key to this approach being successful seems to be a combination of good preemptive pain and nausea control as well as open access to help should it be required. That outpatient surgery can be done and that it is safe have been shown in many trials.6* ~ 5 , 30

Preoperative and postoperative lactulose, perioperative metronidazole, glyceryl trinitrate ointment, and nonsteroidal analgesia all are used currently to reduce postoperative pain6,

SUMMARY

Understanding of hemorrhoidal pathology and treatment has come a long way. The theory of a sliding anal canal lining and the knowledge that hemorrhoidal cushions are a normal part of the anal anatomy should encourage symptom control rather than radical removal of tissue. Techniques that fix the cushions back in position can be performed in outpatients with reasonable success rates. When required, surgery should be aimed at symptomatic hemorrhoids. It is hoped that new developments such as circular stapling and better pain management will promote increased day surgery, better pain control, and less time off work for patients.

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North Shore Hospital Private Bag 93-503

Takapuna Auckland

New Zealand

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HEMORRHOIDS