Hemorrhoidal disease affects an estimated 10 million people in the United States and is a leading outpatient gastrointestinal diagnosis. The condition can cause bleeding, pain, itching, swelling, and tissue prolapse, and treatment is guided by symptom severity, as well as classification as internal, external, or mixed disease. Jean H. Ashburn, MD, of Atrium Wake Forest Baptist Health in Winston-Salem, North Carolina, summarized the current evidence from a 25-year literature search on the pathophysiology, treatment, and more in this recently published review. Highlights are included here.
Internal hemorrhoids arise above the dentate line and are graded from I to IV based on prolapse severity. Grade I hemorrhoids remain inside the rectum, while grade IV cannot be manually reduced. External hemorrhoids occur below the dentate line and may cause acute pain if thrombosed. Mixed hemorrhoids involve both internal and external components.
First-line treatment for symptomatic disease includes increasing dietary fiber to 20 to 30 g daily, getting adequate hydration (5 to 6 glasses daily), and minimizing straining during defecation. Patients are also advised to avoid prolonged toilet sitting and to establish regular bowel habits. Fiber supplementation reduces rectal bleeding but may not improve prolapse, pain, or itching.
Phlebotonics, including plant-based flavonoids, may decrease bleeding, itching, and leakage, though their effect on complete pain relief is less certain. Symptom recurrence up to 80% is common within 3 to 6 months after discontinuation.
When conservative therapy fails, office-based treatments are recommended for internal hemorrhoids grades I to III. Rubber band ligation is preferred because most patients can achieve symptom resolution: In a large prospective study, Dr. Ashburn found, more than 85% of patients were symptom-free at 8 weeks, though recurrence occurred in about 15% of patients at 2 years. Complications can include pain and bleeding, and bleeding risk is higher in patients who take anticoagulants. Repeated banding is also needed in up to 20% of patients, Dr. Ashburn noted.
Sclerotherapy and infrared coagulation are alternatives that can improve bleeding and prolapse but often require additional treatments compared with rubber band ligation. Sclerotherapy generally causes less postprocedure discomfort but has lower long-term remission rates—only one-third of patients. Both interventions have between 70% to about 80% success rates.
Excisional hemorrhoidectomy is recommended for grade III to IV internal hemorrhoids, mixed disease, or thrombosis that does not respond to less invasive options. One analysis in the review found that the procedure is more effective than rubber band ligation for grade III hemorrhoidal disease, but not for grade II. It has a low recurrence rate (2% to 10%) but requires longer recovery and carries risks such as postoperative pain, bleeding, urinary retention, and fecal incontinence. Open and closed techniques have similar outcomes. Bleeding can occur within 7 to 10 days of the procedure "due to suboptomal hemostasis or wound breakdown," Dr. Ashburn wrote, "and fecal incontinence...may be temporary due to postoperative inflammation and edema that interferes with proper approximation of sphincter muscles or persistent due to sphincter injury, particularly in patients with preoperative incontinence."
Transanal hemorrhoidal dearterialization is a less invasive surgical option with reduced postoperative discomfort but higher recurrence rates than excisional hemorrhoidectomy. For acute thrombosis within 72 hours, outpatient clot evacuation can shorten symptom duration and reduce recurrence risk. After 72 hours, conservative management with stool softeners, analgesics, and sitz baths is preferred.
Dr. Ashburn noted that this review was not systematic, and the quality of included evidence was not formally assessed. The number of randomized trials was limited, and some relevant studies may have been missed.
Full disclosures can be found in the published study.
Source: JAMA Network