The Evaluation and Treatment of Hemorrhoids
The Evaluation and Treatment of Hemorrhoids
Patients presenting with most anorectal symptoms will often assume that they are due to hemorrhoids. Keeping this in mind, it is always important to determine whether the patient's symptoms are due to hemorrhoids, some other anorectal disorder, or a combination thereof. The symptoms, in large part, depend on the location of the hemorrhoidal changes in relation to the dentate line. Internal hemorrhoids are located proximal to (above) the dentate line and tend to be associated with painless bleeding, prolapse, mucus discharge, soiling, and symptoms of pruritus ani. Perceived incontinence or soiling can be caused by prolapsed hemorrhoids that create a "wicking effect" by which anal content may seep out. Internal hemorrhoids rarely cause significant pain unless they become prolapsed, incarcerated, and begin developing gangrenous changes. On the other hand, external hemorrhoids are typically asymptomatic unless they become thrombosed. Mixed hemorrhoids involve areas both above and below the dentate line and can present with bleeding, pain, or other symptoms (Figure 4).
A detailed history is mandatory in patients presenting with symptoms consistent with hemorrhoidal disease. Significant anal pain could come from other entities, and in this regard the timing of the pain is important. Acute onset of pain associated with perianal swelling suggests a thrombosed external hemorrhoid, but pain on defecation typically indicates the presence of a coexistent anal fissure, which can be found in up to 20% of hemorrhoid patients. This may be related to findings that patients with hemorrhoids tend to have higher resting anal sphincter pressures than those without. It is not clear whether these elevated pressures are the cause or the result of the associated hemorrhoids, but the relationship does seem consistent. Other pain-associated entities to consider include inflammatory bowel disease with proctitis or perirectal fistula or abscess, anal warts, rectal cancers, anal polyps, or solitary rectal ulcer syndrome.
Additional information that may be of importance includes the relationship between symptoms and defecation and a description of factors that might either relieve or exacerbate a patient's symptoms. There may be value in finding out how often a patient defecates, whether constipation or diarrhea is an issue, how much time they spend on the commode, and whether they must manually reduce their hemorrhoids after defecation. It is also important to ask about soiling or incontinence because many patients may be hesitant to discuss this.
Rectal bleeding should never be assumed to be from hemorrhoids without at least some type of visual examination. Depending on the patient's age, history, presence of alarm symptoms, risk of colon cancer, and digital rectal examination, anoscopy, flexible sigmoidoscopy, or colonoscopy should be performed. Published guidelines support this recommendation. Studies have demonstrated the unreliability of physician diagnosis without visualization; in some reports, up to 50% of rectal bleeding initially attributed to hemorrhoids turned out to have a different diagnosis after endoscopic evaluation.
A visual inspection of the perianal area will allow for the description of any external abnormalities. The examination is classically performed in the prone or left lateral decubitus position, but generally the left lateral position is preferred because it is more comfortable for patients and typically less intimidating than the prone or prone jack-knife positions. Entities that may be encountered include skin rashes, external hemorrhoids or tags, fissures, fistulae, abscesses, neoplasms, condylomata, prolapse, hypertrophic papillae, or any combination thereof.
A digital rectal examination is also required. The digital rectal examination seems to be a bit of a "lost art" for many clinicians, but it is a tremendously important aspect of the evaluation of patients presenting with anorectal complaints. It should be stressed that the proper evaluation of the anal verge and its structures can provide important information that is useful in formulating a treatment plan for these patients. Care should be taken to evaluate the introitus, looking for signs of inflammation, skin lesions, and the anal sphincters, all of which can be evaluated in the anal canal. Too often, the digital rectal examination begins up in the rectum after the examining finger has passed through the internal sphincter, assuring that the examiner will not be able to appreciate evidence of scars, small fissures, origins of fistulae, and more. In addition to looking and palpating for any masses, lesions, areas of inflammatory change, fluctuance, tenderness, etc, characterizing the anal sphincters is an important feature of any digital examination. A careful examination will help depict the tone of the sphincters and whether the internal sphincter has separated from the external sphincter, amplifying the intersphincteric groove. This double sphincter sign can indicate the presence of coexistent sphincter spasm. In addition, a partially healed anal fissure can be deduced by the presence of thickening or scar in the posterior midline or roughening of the otherwise smooth anoderm. Palpation is important, because these areas may be difficult to see.
Some have suggested that descriptions of the physical position of any finding not be described by using the face of a clock but rather by using right/left and anterior/posterior in the description. Thus, for example, the left lateral hemorrhoid is at 3:00 when viewed in the classic supine position, 6:00 in the left lateral decubitus position, and 9:00 when in the prone position.
Anoscopy is a technique that seemingly is rarely taught in GI fellowship programs. It is the most accurate method for examining the anal canal and the distal-most rectum. With the availability of inexpensive disposable anoscopes, the procedure may be performed in the office on unprepped patients quickly, safely, and with minimum patient discomfort. There are a number of types of anoscopes available, but they can best be broken down into the categories of being slotted or non-slotted. Slotted anoscopes feature a cutout from the wall that allows the tissue in question to bulge into the slot, improving visibility, whereas in non-slotted anoscopes, no such cutout exists. Each has its advantages and disadvantages, but both offer an opportunity to visualize the anus and distal rectum in a manner that is not possible to do with a flexible endoscope. Non-slotted anoscopes do not require rotation to see pathology but tend to compress hemorrhoids; slotted anoscopes cannot be rotated because of patient discomfort and need to be completely withdrawn and rotated by using an obturator if the pathology is not identified on the initial pass.
Flexible endoscopy is much more frequently performed to evaluate a patient with anorectal issues but appears to be not as accurate as anoscopy. In a prospective study, Kelley et al found that anoscopy identified 99% of anal lesions in subjects, whereas colonoscopy revealed only 78% when straight withdrawal of the scope was performed and only 54% during retroflexion. The limitation of flexible endoscopy pertaining to the anorectum emphasizes the importance of the anorectal physical examination as well as the advantages of incorporating the techniques of anoscopy in the GI setting.
There are some maneuvers that can be performed during flexible endoscopy to increase the accuracy and diagnostic yield in regard to the diagnosis of hemorrhoids and other anorectal issues. When performing a colonoscopy (or flexible sigmoidoscopy) and when in retroflexion, the act of insufflation causes the rectal vault to distend and stretch, and this can cause flattening of internal hemorrhoids. If the rectum is not partially deflated during this portion of the examination, the only hemorrhoids that can be seen are at or near the dentate line, ie, external hemorrhoids by definition. To more adequately evaluate this area, partial deflation will allow the hemorrhoidal tissue to become more obvious and easier to characterize; failure to do so will very likely underestimate the presence of hemorrhoidal disease (Figure 5). Excess air insufflation during flexible endoscopy can account for negative findings in patients presenting with a compatible hemorrhoid history, whereas anoscopic examination of these patients can reveal significant hemorrhoidal findings.
(Enlarge Image)
Figure 5.
Hemorrhoids identified via endoscopy. Courtesy of Neal Osborn, MD, Atlanta, Georgia.
Another limitation of flexible endoscopy is the difficulty in describing the spatial orientation of the hemorrhoidal disease. A technique that can help with this dilemma is to irrigate the rectal cavity while examining for hemorrhoids. For example, when patients are in the left lateral decubitus position, fluid will tend to puddle in the dependent portion of the rectum on the patient's left side. Therefore, the hemorrhoidal column that sits in or immediately adjacent to that puddle is the left lateral column. Once that point of reference has been established, the other hemorrhoids can be identified and described as well (personal communication, Mitch Guttenplan, MD, Atlanta, GA).
It should be stressed that even when using the tips mentioned above, there still is a role for anoscopy in the evaluation of these patients, particularly because it can be done in the office setting in an unprepped patient. The procedure is quick, relatively painless, and inexpensive, yet it can yield a significant amount of information.
Diagnosis
Patient History
Patients presenting with most anorectal symptoms will often assume that they are due to hemorrhoids. Keeping this in mind, it is always important to determine whether the patient's symptoms are due to hemorrhoids, some other anorectal disorder, or a combination thereof. The symptoms, in large part, depend on the location of the hemorrhoidal changes in relation to the dentate line. Internal hemorrhoids are located proximal to (above) the dentate line and tend to be associated with painless bleeding, prolapse, mucus discharge, soiling, and symptoms of pruritus ani. Perceived incontinence or soiling can be caused by prolapsed hemorrhoids that create a "wicking effect" by which anal content may seep out. Internal hemorrhoids rarely cause significant pain unless they become prolapsed, incarcerated, and begin developing gangrenous changes. On the other hand, external hemorrhoids are typically asymptomatic unless they become thrombosed. Mixed hemorrhoids involve areas both above and below the dentate line and can present with bleeding, pain, or other symptoms (Figure 4).
A detailed history is mandatory in patients presenting with symptoms consistent with hemorrhoidal disease. Significant anal pain could come from other entities, and in this regard the timing of the pain is important. Acute onset of pain associated with perianal swelling suggests a thrombosed external hemorrhoid, but pain on defecation typically indicates the presence of a coexistent anal fissure, which can be found in up to 20% of hemorrhoid patients. This may be related to findings that patients with hemorrhoids tend to have higher resting anal sphincter pressures than those without. It is not clear whether these elevated pressures are the cause or the result of the associated hemorrhoids, but the relationship does seem consistent. Other pain-associated entities to consider include inflammatory bowel disease with proctitis or perirectal fistula or abscess, anal warts, rectal cancers, anal polyps, or solitary rectal ulcer syndrome.
Additional information that may be of importance includes the relationship between symptoms and defecation and a description of factors that might either relieve or exacerbate a patient's symptoms. There may be value in finding out how often a patient defecates, whether constipation or diarrhea is an issue, how much time they spend on the commode, and whether they must manually reduce their hemorrhoids after defecation. It is also important to ask about soiling or incontinence because many patients may be hesitant to discuss this.
Rectal bleeding should never be assumed to be from hemorrhoids without at least some type of visual examination. Depending on the patient's age, history, presence of alarm symptoms, risk of colon cancer, and digital rectal examination, anoscopy, flexible sigmoidoscopy, or colonoscopy should be performed. Published guidelines support this recommendation. Studies have demonstrated the unreliability of physician diagnosis without visualization; in some reports, up to 50% of rectal bleeding initially attributed to hemorrhoids turned out to have a different diagnosis after endoscopic evaluation.
Physical Examination
A visual inspection of the perianal area will allow for the description of any external abnormalities. The examination is classically performed in the prone or left lateral decubitus position, but generally the left lateral position is preferred because it is more comfortable for patients and typically less intimidating than the prone or prone jack-knife positions. Entities that may be encountered include skin rashes, external hemorrhoids or tags, fissures, fistulae, abscesses, neoplasms, condylomata, prolapse, hypertrophic papillae, or any combination thereof.
A digital rectal examination is also required. The digital rectal examination seems to be a bit of a "lost art" for many clinicians, but it is a tremendously important aspect of the evaluation of patients presenting with anorectal complaints. It should be stressed that the proper evaluation of the anal verge and its structures can provide important information that is useful in formulating a treatment plan for these patients. Care should be taken to evaluate the introitus, looking for signs of inflammation, skin lesions, and the anal sphincters, all of which can be evaluated in the anal canal. Too often, the digital rectal examination begins up in the rectum after the examining finger has passed through the internal sphincter, assuring that the examiner will not be able to appreciate evidence of scars, small fissures, origins of fistulae, and more. In addition to looking and palpating for any masses, lesions, areas of inflammatory change, fluctuance, tenderness, etc, characterizing the anal sphincters is an important feature of any digital examination. A careful examination will help depict the tone of the sphincters and whether the internal sphincter has separated from the external sphincter, amplifying the intersphincteric groove. This double sphincter sign can indicate the presence of coexistent sphincter spasm. In addition, a partially healed anal fissure can be deduced by the presence of thickening or scar in the posterior midline or roughening of the otherwise smooth anoderm. Palpation is important, because these areas may be difficult to see.
Some have suggested that descriptions of the physical position of any finding not be described by using the face of a clock but rather by using right/left and anterior/posterior in the description. Thus, for example, the left lateral hemorrhoid is at 3:00 when viewed in the classic supine position, 6:00 in the left lateral decubitus position, and 9:00 when in the prone position.
Anoscopy
Anoscopy is a technique that seemingly is rarely taught in GI fellowship programs. It is the most accurate method for examining the anal canal and the distal-most rectum. With the availability of inexpensive disposable anoscopes, the procedure may be performed in the office on unprepped patients quickly, safely, and with minimum patient discomfort. There are a number of types of anoscopes available, but they can best be broken down into the categories of being slotted or non-slotted. Slotted anoscopes feature a cutout from the wall that allows the tissue in question to bulge into the slot, improving visibility, whereas in non-slotted anoscopes, no such cutout exists. Each has its advantages and disadvantages, but both offer an opportunity to visualize the anus and distal rectum in a manner that is not possible to do with a flexible endoscope. Non-slotted anoscopes do not require rotation to see pathology but tend to compress hemorrhoids; slotted anoscopes cannot be rotated because of patient discomfort and need to be completely withdrawn and rotated by using an obturator if the pathology is not identified on the initial pass.
Flexible Sigmoidoscopy and Colonoscopy
Flexible endoscopy is much more frequently performed to evaluate a patient with anorectal issues but appears to be not as accurate as anoscopy. In a prospective study, Kelley et al found that anoscopy identified 99% of anal lesions in subjects, whereas colonoscopy revealed only 78% when straight withdrawal of the scope was performed and only 54% during retroflexion. The limitation of flexible endoscopy pertaining to the anorectum emphasizes the importance of the anorectal physical examination as well as the advantages of incorporating the techniques of anoscopy in the GI setting.
There are some maneuvers that can be performed during flexible endoscopy to increase the accuracy and diagnostic yield in regard to the diagnosis of hemorrhoids and other anorectal issues. When performing a colonoscopy (or flexible sigmoidoscopy) and when in retroflexion, the act of insufflation causes the rectal vault to distend and stretch, and this can cause flattening of internal hemorrhoids. If the rectum is not partially deflated during this portion of the examination, the only hemorrhoids that can be seen are at or near the dentate line, ie, external hemorrhoids by definition. To more adequately evaluate this area, partial deflation will allow the hemorrhoidal tissue to become more obvious and easier to characterize; failure to do so will very likely underestimate the presence of hemorrhoidal disease (Figure 5). Excess air insufflation during flexible endoscopy can account for negative findings in patients presenting with a compatible hemorrhoid history, whereas anoscopic examination of these patients can reveal significant hemorrhoidal findings.
(Enlarge Image)
Figure 5.
Hemorrhoids identified via endoscopy. Courtesy of Neal Osborn, MD, Atlanta, Georgia.
Another limitation of flexible endoscopy is the difficulty in describing the spatial orientation of the hemorrhoidal disease. A technique that can help with this dilemma is to irrigate the rectal cavity while examining for hemorrhoids. For example, when patients are in the left lateral decubitus position, fluid will tend to puddle in the dependent portion of the rectum on the patient's left side. Therefore, the hemorrhoidal column that sits in or immediately adjacent to that puddle is the left lateral column. Once that point of reference has been established, the other hemorrhoids can be identified and described as well (personal communication, Mitch Guttenplan, MD, Atlanta, GA).
It should be stressed that even when using the tips mentioned above, there still is a role for anoscopy in the evaluation of these patients, particularly because it can be done in the office setting in an unprepped patient. The procedure is quick, relatively painless, and inexpensive, yet it can yield a significant amount of information.
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