"Everyone has hemorrhoids," said Rajat Parikh, MD, president of Birmingham Gastroenterology Associates. "That's a common misconception among patients and many physicians."
And for those with problems severe enough to require treatment, surgery can be effective, but recovery is difficult. "Over the past few decades a lot of work has been put into treating hemorrhoids with medicine, which had pluses and minuses. They've been quite equivocal in my experience," Parikh said.
When possible, Parikh prefers to treat patients with two nonsurgical therapies, hemorrhoidal banding or ligation, and hemorrhoidal energy therapy (HET). "Surgery is required when someone has a clot -- or thrombosis hemorrhoid," he said. "But many people have chronic symptoms such as bleeding, pain, itching, rectal leakage or prolapse, and these are the symptoms we are trying to treat without surgery.
"First we will address lifestyle modification and make sure the problem is not confused with another disease such anal or rectal cancer, or IBD. We never assume hemorrhoidal bleeding and want to make sure there isn't another cause. We'll increase fiber and hydration and try to normalize bowel movements. All physicians do that, but patients often require something beyond that, and that is when these therapies come into play."
The banding procedure can be done in a physician's office and requires no prep on the part of the patient. "We have a device that can be used with or without an anoscope to visualize the hemorrhoidal vessels feeding the hemorrhoids," Parikh said. "Almost everyone has three vessels feeding the hemorrhoidal plexus. We pass the hemorrhoidal ligator through the anus to just above the internal hemorrhoids and band the vessel. We're actually not even touching the hemorrhoidal plexus. We are banding the vessel feeding the hemorrhoid, decimating the blood flow to it."
Three bands are required, one on each vessel, to complete the therapy. Most patients experience pain and other discomforts when all three bands are placed at the same time, so one band is placed every two to three weeks until all are in place. Each procedure takes only two to three minutes and is done without sedation. "It's well tolerated and quite effective," Parikh said.
The other procedure, HET, can also be performed without sedation, although most patients choose to have it. The patient preps in much the same way as for a standard sigmoidoscopy, and the procedure is performed in an endoscopy center. As with the banding procedure, the goal is to eliminate blood flow to the internal hemorrhoid. "Under sedation we are able to pass an anoscope and forceps to carry out a bipolar ablation cautery of the tissue above the vessels leading to the internal hemorrhoids," Parikh said. "We aim for 5 to 10mm above the apex of the internal hemorrhoids, proximal to the dentate line (where the rectum becomes the anus). Tissue is folded in the forceps, clamped, heated to 55 degrees Celsius and released. We do this for 360 degrees until all the tissue is ablated."
Both procedures have proven to have long term benefits, even if the patient is not particularly compliant with the recommended lifestyle changes. "Recurrence is possible," Parikh said. "But that number is small."
No post-procedure pain medications are required for either procedure.
"Both techniques are excellent," Parikh said. "I leave it up to the patient to choose which procedure they prefer. The HET is done in one procedure but requires patient prep and sedation. The banding can be done in the office without prep, but the patient has to come three times to complete the therapy. Both have good long term data."
Four grades of hemorrhoids
Hemorrhoids originate from the superior hemorrhoidal plexus.
Grades 3 and 4 will usually require surgical attention. Hemorrhoidal banding and HET are generally reserved for Grade 1 and 2 hemorrhoids.