Hemorrhoids: A range of treatments

Cleveland Clinic Journal of Medicine. 2019 September;86(9):612-620 | 10.3949/ccjm.86a.18079
September 3, 2019|Cleveland Clinic Journal of Medicine
Turgut Bora Cengiz, MD;Emre Gorgun, MD, FACS, FASCRS
Author and Disclosure Information

Turgut Bora Cengiz, MD
Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic

Emre Gorgun, MD, FACS, FASCRS
Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Address: Emre Gorgun, MD, FACS, FASCRS, Department of Colorectal Surgery, A30, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; gorgune@ccf.org

Release date: September 1, 2019
Expiration date: August 31, 2020
Estimated time of completion: 1 hour

Click here to start this CME/MOC activity.

ABSTRACT

Hemorrhoids are a common reason for office visits. Each patient is unique, and with a range of treatments available, treatment can be individualized. This article reviews the diagnosis and decision-making process for individualized treatment.

KEY POINTS

  • Hemorrhoids account for more than 3.5 million office visits annually.
  • Most patients present with painless rectal bleeding, but this can also be a sign of colorectal cancer, which needs to be ruled out.
  • Fiber supplements along with dietary and lifestyle changes are recommended for all patients with hemorrhoids regardless of symptom severity.
  • Hemorrhoids are graded on a scale of I (least severe) through IV (most severe). Office-based treatments are effective for grades I, II, and some grade III hemorrhoids. Surgical excision is the standard for high-grade hemorrhoids.

NO ‘BEST’ TREATMENT

There is no best treatment for hemorrhoids. Every patient is different, and the physician and patient need to understand each other’s expectations, weigh the risks and benefits, and arrive at a mutual decision. A good patient-doctor relationship is essential.

Figure 5. Algorithm for hemorrhoid management.
A thorough history and physical examination will enable the practitioner to understand the patient’s problem (Figure 5).

Given the variety of available treatments, head-to-head comparisons are difficult. Moreover, the efficacy and applicability of each technique changes with the grade of the lesion or lesions and the skill of the practitioner. Lacking comprehensive studies comparing conservative, office-based, and surgical management, no decisive statements can be made based on current evidence.

Patients with compounding conditions

Pregnant patients often develop hemorrhoids as intra-abdominal pressure increases, particularly during the third trimester.36 Also, acute episodes of pain and bleeding are common in pregnant women with preexisting hemorrhoids.

,

Conservative treatment is the main approach in pregnant patients because most hemorrhoids regress after childbirth. This includes increased dietary fiber, stool softeners, and sitz baths, which are safe to use for external hemorrhoids. Any office-based or surgical intervention should be postponed until after childbirth, if possible. Kegel exercises and lying on the left side are also recommended to relieve symptoms. In cases of severe bleeding, anal packing appears to be useful.

Immunosuppressed patients and those on anticoagulant therapy are more prone to serious complications such as sepsis and profuse bleeding. Thus, conservative management should be used in these patients as well. Injection sclerotherapy may be beneficial, as it has been shown to decrease bleeding. Of note, patients on immunosuppressive agents should stop taking them and start taking an antibiotic, and patients on anticoagulant or antiplatelet medications should be instructed to stop them 1 week before any intervention.

Crohn disease. Some patients with Crohn disease may have hemorrhoids, though this is rare. Eglinton et al,37 in a series of 715 patients with Crohn disease, reported that 190 (26.6%) had symptomatic perianal disease. Of these, only 3 (1.6%) had hemorrhoids. Treatment is always conservative and directed at the Crohn disease rather than the hemorrhoids.

Patients with portal hypertension (eg, due to cirrhosis) are prone to have anorectal varices that may resemble hemorrhoids. Anorectal varices can be treated with vascular ligation, whereas sclerotherapy is the preferred method for hemorrhoids in this group, in whom coagulopathy is common.

TAKE-HOME MESSAGES

Hemorrhoidal disease is common in the United States, and with our diet and lifestyle, the incidence is likely to increase. (A national survey found that overall dietary quality improved modestly in children and adolescents in the United States from 1999 to 2012 but remained far below optimal.38) Practitioners need to carefully assess hemorrhoidal symptoms and complete any necessary screening tests before establishing a diagnosis. This helps to avoid missing any underlying disease.

Fiber supplements along with dietary and lifestyle changes constitute the baseline of the management regardless of the disease grade. Office-based interventions are beneficial for grade I and II hemorrhoids and for some grade III hemorrhoids. Repeated interventions can increase the success rate. In patients with high-grade, symptomatic hemorrhoids, surgical hemorrhoidectomy is the most effective modality with the lowest recurrence rates, although it causes more pain than conservative methods.