Update in the Management of Haemorrhoids

Manish CHAND, Natalie DABBAS, Guy F NASH – MD, FRCS (Consultant Colorectal Surgeon)

Abstract

Haemorrhoidal disease is a common presenting anorectal condition. Although its treatment dates several hundreds of years, there has been no consensus on an optimal treatment modality. Advances in the understanding of the pathophysiology of haemorrhoids are aiding clinicians in providing the most appropriate form of treatment. Once more sinister pathologies have been excluded management strategies are tailored to the individual patient depending on the severity of the disease. Clinical classification systems are particularly useful as a measure of severity. In many patients conservative measures may prove to be highly effective, but persistence and progression of symptoms may necessitate more interventional procedures. This article aims to define and classify haemorrhoids, and review the efficacy of current treatment modalities including the latest techniques.

Introduction

The word “piles” is derived from the Latin word pila, meaning ball. It has traditionally been the layman’s term for haemorrhoids, for which treatment dates back almost 4000 years. Although there are many well recognised precipitating factors associated with haemorrhoids (such as low fibre intake, prolonged straining and pregnancy) the precise aetiology remains unclear, which is certainly reflected in the number of treatment options available. This review aims to define haemorrhoidal disease both anatomically and clinically and further explain how this affects subsequent management strategies. The efficacy of the most popular modalities of treatment is reviewed and a novel surgical technique is introduced.

Anatomy and Pathophysiology

The concept of anal cushions being the precursors of haemorrhoids was first introduced in 1975 and described in the classical 3, 7 and 11 o’clock positions (1). These cushions lie predominantly above the dentate line and are separated from the sphincter complex by the submucosal layer – a combination of blood vessels, muscular and connective tissue;  related to which is the inferior haemorrhoidal plexus which can become engorged at the anal verge. This is important in distinguishing prolapsing internal haemorrhoids which are lined by an insensate covering and whose neck arises above the dentate line, from external haemorrhoids which arise below this line. The importance of anal cushions lies in part in the maintenance of faecal continence; vascular filling is thought to be responsible for approximately 20% of resting anal pressure (2), and the cushions are able to provide a conformable plug to maintain complete closure of the anal canal. Theories of the aetiology of haemorrhoids are thought by some to be related to their vascularity and underlying supportive structure. Local changes in pressure are thought to cause venous dilatation in the anal cushions and (along with a valveless venous system) lead to their engorgement, seen in the increased prevalence of haemorrhoids in pregnancy. The alternative connective tissue theory suggests that the underlying support provided by the collagenous fibres of the submucosa degenerates over time and ultimately leads to a caudal displacement of the anal cushions (3), perhaps explaining the phenomenon of haemorrhoidal prolapse.

Figure 1 - Anatomy of the Anal Canal (4)

Classification

Improved understanding of local anatomy has led to helpful clinical classifications for haemorrhoids. The product of underlying pathophysiological and anatomic changes, they allow examination findings to be standardized, and therefore allow the most appropriate form of treatment to be offered. One such classification is the Goligher classification, which describes 4 clinical entities (5). Grade I describes a normal appearance externally with haemorrhoids which bleed but do not prolapse whereas in grade II the haemorrhoids may prolapse but reduce spontaneously. Grade III and IV describe prolapsing haemorrhoids which require manual digital reduction or remain prolapsed permanently, repectively – figure 2. However, with the increased availability of endoscopy, haemorrhoids are being able to be visualized during colonoscopic or sigmoidoscopic examination with a retroflexed scope – figure 3. This has led to the development of endoscopic classification systems which again address and closely correlate to the patient’s symptoms (6).

Although this classification is limited by the assumption of bleeding and prolapse being the only symptoms attributed by haemorrhoids, it still has an important place in the management of the condition when used in conjunction with the wider clinical picture.

Figure 2 – Goligher Classification of Haemorrhoids.

Figure 3 – Retroflexed colonoscope showing internal view of haemorrhoids

The Clinical Picture

Haemorrhoids affect between 4% and 36% of the general population (7), however this figure is indicative only of symptomatic haemorrhoids and may well be an under-estimate. Hospital-based proctoscopy studies have shown prevalence rates of up to 86% with the majority of patients being asymptomatic. (8) Symptoms are widely variable, but haemorrhoids are responsible for the majority of cases of rectal bleeding. The most common symptoms after bleeding include pain, mucous discharge and pruritus with or without associated haemorrhoidal prolapse (9). The colour of the bleeding is attributed to the arterial oxygen tension caused by arteriovenous communications within the anal cushions (10), while pruritis and associated discomfort is thought to be due to prolapse of the rectal mucosa leading to deposition of mucus on the perianal skin. The combination of type and severity of symptoms in addition to examination findings, allows the most appropriate treatment modality to be offered.

It is paramount not to attribute all cases of bright red rectal bleeding to haemorrhoids; Conditions from anal fissure to colorectal malignancy may all produce similar symptoms and concurrent pathology must be excluded with investigation of the proximal colon, which in most cases is performed by sigmoidoscopic or colonoscopic investigation. Also, haemorrhoids are rarely responsible for anaemia (11).

The Treatment Ladder

Classification systems, such as the one described above, allow standardisation of the condition and can also monitor progression.  Once a patient has been satisfactorily investigated, the surgeon is in a position to offer the most appropriate treatment. As haemorrhoids are essentially a benign condition, treatment is directed at alleviating symptoms rather than to necessarily halt progression. Most surgeons have traditionally adopted a step-wise approach in treatment depending on the severity of symptoms and clinical grading of the haemorrhoids, with escalation if necessary. – Fig 3. With the advent of newer more definitive techniques however, the options for treatment have increased and a more individually-tailored management strategy can be employed.

Figure 4 - Step-wise management strategy

 

Conservative Management

Conservative management is usually reserved for the minimum of symptoms and grade I or grade II haemorrhoids. By addressing some of the precipitating factors, they may well prevent the need for further intervention. It essentially involves lifestyle modification and dietary advice as well as medical treatment. Some have suggested that constipation may be a precipitating factor in the development and progression of haemorrhoids and the lower incidence of the condition in populations with high dietary fibre intake may add weight to this theory (12), although this is never been proven definitively, and others have equally proposed that haemorrhoids may actually lead to constipation (13). Adequate fluid and fibre intake may reduce straining effort during defaecation, along with laxatives, but may well also prevent recurrence of haemorrhoids. A recent meta-analysis of fibre supplementation showed that the risk of bleeding was lower with an increased fibre intake, along with the rate of recurrence (14). Furthermore, simple education on toilet habits such as avoiding straining and reading while on the toilet is useful (15). In many circumstances, these measures have been initiated prior to consultation with a surgeon. Medical treatment options are essentially used for alleviating discomfort associated with haemorrhoids. They are for symptomatic relief and have little or no affect on the natural history of the haemorrhoids.

Outpatient Procedures

As new surgical techniques are developed, office procedures are showing a slight decline in popularity. They are considered to be the primary option for grades I and II in particular as they are quick, simple, inexpensive and do not require anaesthesia. The most common of these are rubber band ligation (RBL) and injection sclerotherapy, although cyrotherapy and photocoagulation are potential options.

Figure 5 – Non-conservative Treatments

RBL has been modified over the years from Blaisdell’s original description (16) which advocated the application of a single band alone. Currently, surgeons may apply up to 3 bands at a time and can repeat this every 6 weeks or so. The technique involves the direct visualisation of the haemorrhoidal pedicle through a proctoscope, with application of a band around it using either forceps or a suction device. This results in ischaemic necrosis of the haemorrhoidal tissue which subsequently auto-amputates. It is important to warn patients that they may experience some bleeding after 10-14 days when the banded tissue sloughs off. Success rates of between 69% and 94% have been shown (17) with low complication rates, although there have been potentially life-threatening complications reported. With higher success rates than other office procedures, it is still deemed to be less efficient than haemorrhoidectomy in the long term, albeit with less pain and fewer complications.(18)  Recent evidence suggests that in fact most patients complain of moderate or worse discomfort after banding (19).

Injection sclerotherapy is a widely available technique, the most common sclerosant being 5% phenol in almond oil, and is particularly useful for bleeding piles. The sclerosant induces an inflammatory reaction causing changes both in the haemorrhoidal mass and affecting the underlying architecture. Haemorrhoids are again identified by proctoscopy and then injected well above the dentate line. As long as the injections are appropriately directed there is no pain experienced by the patient. Although this is a seemingly easy, reproducible procedure, there are as many reported problems with it as advantages. High failure rates accompanied by misplaced injections have led many surgeons to abandon this office procedure.

There are certain contraindications for banding and injecting piles such as patients being on formal anticoagulant medication and coagulopathies, but there are no guidelines discouraging the use of a combination of procedures under these circumstances. One large study has shown that by using a combination of sclerotherapy, rubber band ligation and infrared coagulation over a period of 2 months on average, satisfaction rates of around 90% were achieved with less than 10% requiring surgical intervention. (20)

Cyrotherapy appears to have fallen out of favour. With the use of a specialised probe, the haemorrhoidal mass is ablated, and can be repeated over time. Potential problems include ulceration and discharge as a consequence of impaired healing following application of the cyro-probe. (21)

Photocoagulation requires the use of specific infrared optical equipment. The procedure is similar to sclerotherapy in that direct visualisation of the haemorrhoid with a procotscope is required. Once the coagulator device is primed, the base of the haemorrhoidal tissue is targeted and necrosis ensues. The subsequent healing of the mucosa leads to shrinkage of the piles and ulcer formation. It has been most commonly used for internal haemorrhoids and has been shown to be a superior technique to sclerotherapy with fewer complications (22).

Surgical Options

Excision Haemorrhoidectomy

Haemorrhoidectomy has remained the centre of all the surgical procedures for symptomatic haemorrhoids of high grade or those failing office procedures. Although the exact details of the operation and its variants are beyond the scope of this review, haemorrhoidectomy has been shown to be the most effective treatment for haemorrhoids (23). Originally described by Whitehead in the late part of the 19th century, its modification, the Milligan-Morgan operation (24) was later reserved for prolapsing haemorrhoids of grade III and IV. This involves excision of the internal and external components of each haemorrhoid, leaving the skin open in a 3-leaf clover pattern and allowing healing to occur by secondary intention. Over the years newer, more efficient surgical procedures have been developed with the operation being performed with either an open (as described above) or closed technique where the haemorrhoid component is excised and the wounds closed primarily (25). The theory behind the closed or Ferguson haemorrhoidectomy was that this would lead to better healing, less scaring and pain. This technique has been shown to have better patient satisfaction and fewer long-term problems, previously associated with the traditional open haemorrhoidectomy and in particular anal continence (26). Diathermy haemorrhoidectomy and LigaSureTM (Valley-lab, Boulder) haemorrhoidectomy are also varieties of operation which have the common theme of excising haemorrhoidal tissue, the latter using a specialised surgical instrument to minimise tissue trauma and confer faster wound healing. At present the LigaSureTM haemorrhoidectomy has been shown to more efficacious than conventional haemorrhoidectomy (27).

Unfortunately, complication rates have traditionally been higher in surgery than office procedures with post-operative pain being the most common, though this is not necessarily the case with newer techniques (28). A number of trials have attributed this to be the main factor preventing patients from an early return to normal life, and have suggested time-frames of between 2 and 4 weeks before patients return to work (29-31). Other complications include urinary retention, sepsis, incontinence and anal stenosis (32, 33).

Figure 6 – Photograph of Milligan-Morgan Haemorrhoidectomy (34)

Stapled Anopexy

This procedure has recently gained a reputation for being the Gold-standard for prolapsed haemorrhoids (grade III and IV) with encouraging results regarding postoperative recovery and comparable complication to traditional haemorrhoidectomy (35). First introduced by Longo in 1998, it uses as stapling device which has been modified from the circular stapling instrument used for low rectal anastomoses (36). It involves circumferential excision of redundant mucosa, and reduction and fixation of prolapsed haemorrhoidal tissue. Not only does this procedure allow suspension of the prolapsing haemorrhoidal tissue back within the anal canal, it also interrupts the arterial inflow that traverses the excised segment. It does not however deal with skin tags when compared with excisional haemorrhoidectomy. This is an important point as many patients regard their skin tags as actual haemorrhoids.

One of the largest single centre studies has shown it to be a safe and effective procedure with relatively few complications (37). The first major randomized controlled studies which compared this technique with traditional excision haemorrhoidectomy demonstrated decreased operative time, as well as decreased pain, and subsequent quicker return to daily activities (38, 39, 40). Most surgeons would perform this procedure under general anaesthetic, but recent trials in the use of local anaesthetic and mild sedation have been encouraging with the benefits of more fully realized (41).  It must be remembered that it is appropriate for grade IV and some grade III conditions but not for less severe haemorrhoids. However, despite promising results from a number of trials, there are some important complications which have been recorded including rectal perforation (42), retroperitoneal and pelvic sepsis (43). Furthermore, histological analysis of the surgical specimens have revealed fibres from the internal anal sphincter as well as more proximal rectal wall (44). This could have potentially disastrous functional consequences.

Figure 7 – Photograph of stapled anopexy device being used.

Doppler-Guided Haemorrhoidal Artery Ligation (DG-HAL)

The newest treatment modality which is gaining considerable popularity is Doppler-guided haemorrhoidal artery ligation. Although essentially a surgical procedure, it is far less traumatic than traditional surgical options and does not involve the excision of haemorrhoidal tissue and their associated complications. This technique was first described more than decade ago and involves the use of a specialised proctoscope coupled with a Doppler probe (45). It can be performed with or without general anaesthesia depending on the patient and clinical circumstances. It has been performed on grades II-IV, but is thought to be most useful for grades II and III. The procedure works on the principle that arterial flow through local arteriovenous anastamoses maintains the haemorrhoidal mass. Ligating these vessels ultimately leads to haemorrhoid shrinkage with consequent reduction and cessation of bleeding.

Figure 8 – Cast of haemorrhoid with arterial supply displayed (46)

 
Using the proctoscope to identify terminal branches of the superior rectal artery and haemorrhoidal artery, the vessels are subsequently ligated by placing haemostatic sutures (Figure 9). The patients are cautioned that bleeding will resolve over a period of up to 6 weeks. Early results have been promising with satisfaction rates superceeding all other modalities and complications reported as extremely low and success rates of almost 95% (47, 48). However, it is important to note that this procedure is still in its infancy with no longer-term studies available at present.

Figure 9 – The DG-HAL technique


An even newer technique which aims to act on grade IV haemorrhoids with rectal mucosa prolapse is the DG-HAL recto-anal repair (RAR). It uses the same method as DG-HAL but additionally applies a vertical running suture which retracts the prolapsed mucosa. There are no large series’ published on this treatment, however it could be potentially a rival to stapled anopexy.

The Future

The resurgence in the treatment of haemorrhoids has led to the introduction of more efficient variants of traditional techniques and novel surgical procedures all aimed to increase efficacy, reduce complications and promote better healing and higher satisfaction. With greater understanding of the anatomy and pathophysiology of the condition, it may be possible to limit treatment to a few interventions relating directly to an appropriate classification system. It is highly improbable that there will be one all-encompassing optimal treatment modality for haemorrhoids, as the condition represents a spectrum of severity. However, the important message is that whichever treatment is used, it must be safe and efficient.