Editing Haemorrhoids (section)

== '''Management''' ==

=== '''Lifestyle     measures:''' (low     risk, worth trying to see if it helps, then move on to intervention if     not) ===

** Stool texture - high-fibre      diet and supplementation; stool softeners - movicol; stay hydrated
** Topical LA or steroid-based      suppositories for pain (proctosedyl 30g tube contains steroid and LA)
** Stool habits - avoid      straining and limit time on toilet, use a footstool to improve      puborectalis sling angle
** Hygiene - sitz bath or      shower after defecation

=== '''Office-based     therapy''' ===

** Indication - grade I, II or      III internal haemorrhoids refractory to 8 weeks of conservative      management
** Options:
*** RBL (proven to be best and       easiest)
**** Strangulates haemorrhoidal        tissue, leading to ischaemia and necrosis of the prolapsing mucosa,        followed by scar fixation to the rectal wall. Resolves symptoms by        decreasing the size of the haemorrhoidal tissue and fixes it to the        wall.
**** Place band 2cm above        dentate line
**** >90% success rate
**** Best to band only one        haemorrhoid at initial session
**** Band sloughs off in a        week, which can cause bleeding, especially for those on        anticoagulation. Fletcher says do not band unless you can withhold        anticoagulation for two weeks.
**** Complications
***** Aside from the usual         pain, bleeding
***** Can cause thrombosis of         adjacent external haemorrhoid
***** Severe pain immediately         after placement = placed too close to dentate line
***** Pelvic sepsis can develop         - fever, severe pain, retention, requiring debridement of necrotic         tissue
*** Sclerotherapy
**** Sclerosant injected to        haemorrhoid (e.g. 5% phenol in 5ml almond or vegetable oil, hypertonic        salt solution, or ethanolamine) which results in fibrosis and fixation        of the haemorrhoid to the bowel wall
**** Inject 1cm above dentate        line into submucosa of each haemorrhoid, at the apex of the haemorrhoid
**** For phenol, inject 1-3mL        into each haemorrhoid (Sabiston says 1mL per haemorrhoid)
**** Don't need to stop        anticoagulation
**** If needle site bleeding -        manual pressure, should stop easily
**** Long-term inferior to RBL,        but useful in anticoagulated patients or those immunocompromised (lower        risk of sepsis)
*** Infra-red coagulation
**** Direct application of        infra-red light, resulting in protein coagulation within the        haemorrhoid
**** Typically need 3-4        applications for each haemorrhoid
**** Infra-red energy results        in thrombosis and tissue destruction, leading to scarring and fibrosis
**** More expensive and less        effective than RBL
**** Best for patients on        anticoagulants
**** Best for grade 1 and 2        haemorrhoids

=== '''Formal     haemorrhoidectomy''' ===

** Indications
*** Grade IV internal
*** Grade I, II or III internal       in the presence of other anorectal disease, including substantial skin       tags
*** Internal with failure of       office-based therapy
*** Symptomatic external       haemorrhoids refractory to medical treatment and office-based treatment       (not required very often)
*** Consider haemorrhoidectomy       for thrombosed haemorrhoids within 72 hours of initial pain
**** Best to formally excise -        5-19% recurrence rate compared with 30% recurrence rate for simple        incision
**** Conservative management        first, as there is some evidence that there is a higher incidence of        sphincter injury when haemorrhoidectomy is done electively
** Technique
*** See separate topic

[[Category:Colorectal]]
[[Category:Intern education]]