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Nonsurgical Management
ofHemorrhoids
“A lifestyle change begins with a vision and a single step.”
Jeff Calloway
5
Key Concepts
• Hemorrhoids can affect people of all age
groups.
• Patients with hemorrhoids may experience
variations in their bowel habits, tenesmus, and
fullness in the anal area.
• Most people are treated by dietary or conservative management.
• Lifestyle modications, relieving constipation, avoiding straining, and uid intake may
help treat and prevent hemorrhoids.
• As the rst-line treatment for symptomatic relief
of grades 1 and 2, the recommended treatment is
Micronized Puried Flavonoid Fraction (MPFF).
• Rubber band ligation of the hemorrhoidal tissue causes ischemia and necrosis of prolapsing mucosa, followed by scar xation.
• Infrared coagulation is a nonoperative procedure
that uses infrared energy for dearterialization,
and submucosal brosis, which results in scar
xation.
• Sclerotherapy using sclerosants results in
contraction and brosis of anal cushions,
which relieves the engorgement of the venous
plexus.
5.1 Introduction
Hemorrhoids have been described from ancient
times. The ancient text narrates numerous treatment options ranging from ointments to surgical
excision and ligation of this common disease.
Insights into ancient text describe that the recommended treatment of hemorrhoids included, following a sensible lifestyle, appeasing Gods of
hemorrhoids, and amulets of dried toads.
5.2 History
The rst recorded mention of hemorrhoids dates
back to 1700BC when an ointment made from
powdered, triturated, and roasted acacia leaves
was used to cure hemorrhoids in an Egyptian
papyrus [1]. In 1200BC, the Egyptian “Chester
Beatty Medical Papyrus” [2] wrote primarily
about this ailment. Hemorrhoids are treated in
four ways according to the ancient Sanskrit scripture Sushruta Samhita (fourth century BC to fth
century BC). They include conservative measures, application of Kshar chemical, heat cau-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
K. Gupta, Lasers in Proctology, https://doi.org/10.1007/978-981-19-5825-0_5
59
60
5 Nonsurgical Management ofHemorrhoids
tery, and surgical excision of hemorrhoids
(Shastrakarma) [3]. Hippocrates (460–377BC),
as evidenced by his dissertations “On Fistula”
and “On Hemorrhoids” [4], talked about anorectal disorders. Hippocrates used two methods to
cure hemorrhoids: hot iron cauterization and
chemical cauterization with alum and copper [3].
In his writings, Celsus (25 BCE–14 BCE) dis-
cussed ligature and ligature with excision procedures [5, 6]. Galen (130–200 AD) wrote
extensively on hemorrhoids and proposed intermittent ligation of hemorrhoids for 2h [6, 7].
In the realm of hemorrhoidal surgery, the
Europeans saw a signicant advancement. Some
of the master surgeons of the European era in the
thirteenth century include Lanfrank of Milan,
John of Arderne, Guy de Chauliac, and Henri de
Mondeville. During that time, however, little has
been documented [6, 7]. Following that, barbers,
also known as “Barber-Surgeons,” took over the
profession of surgery. The barber surgeon’s
period lasted approximately 350years [7].
Sir Astley Cooper, in 1836, advocated only liga-
tion after three of his patients died when hemorrhoids were removed [6, 7]. According to Copeland,
increased anal tone, which was thought to cause
hemorrhoids, was treated with rectal beguinage. In
1871, Mitchell (of Illinois) was the rst to inject carbolic acid into hemorrhoids [7]. After that, the
Whitehead procedure in 1882 stated removing the
area bearing the piles and restoring the mucosal
continuity with the anal skin [8], contributing a little
to hemorrhoidectomy. Salmon created the groundwork for today’s gold standard hemorrhoidectomy
in 1835. Many new surgical procedures, which have
since been modied, have been implemented to
treat hemorrhoids better.
As patients are always fearful of surgery, conser-
vative care remains the primary choice for treating
hemorrhoids. A patient visits a surgeon only after the
disease has progressed to an advanced stage.
5.3 Nonsurgical Management
ofHemorrhoids
Nonsurgical hemorrhoid treatment comprises
conservative management and ofce procedures.
The mainstay of initial therapy includes lifestyle
and dietary modications. If none of these are
effective, the next step is to follow an ofcebased treatment like infrared coagulation, sclerotherapy and rubber band ligation.
Nonsurgical hemorrhoids management
includes
• Lifestyle and dietary modications
• Medical management
• Ofce procedures
Indications
• Grade 1 and 2 hemorrhoids
• Nonthrombosed external hemorrhoids
5.3.1 Lifestyle andDietary
Modication
Changes in lifestyle and diet are rst-line treatments for individuals suffering from grade I and
grade 2 internal and nonthrombosed external
hemorrhoids [9]. Increased dietary ber intake,
preventing straining during defecation, and
spending less time on the commode are advised
[9]. According to a recent meta-analysis [10],
ber supplements can moderately reduce overall
bleeding symptoms and should be suggested
early.
According to straining and constipation theory, ber restores normal bowel movement frequency by increasing fecal mass, volume, and
softness. Patients with constipation should consume ber-rich foods such as oats, lentils, ex
seeds, chia seeds, prunes, raisins, broccoli, spinach, gs, pears, grapes, orange, and papaya [11]
(Table 5.1). The recommended dose of ber
intake is about 38g in men and 28g in women.
Fiber supplements help reduce the bleeding and
persisting symptoms risk by nearly 50%.
Table 5.1 Fiber diet chart
Fruits Vegetables
Raspberries Broccoli
Pear with skin Tomato, peas
Apple with skin Carrot, spinach
Banana, black grapes Potato, beans
Orange, mausami, papaya Bhindi, green lasun
Strawberries Green salad
Dried gs, raisins, pulses Plenty of water
5.3 Nonsurgical Management ofHemorrhoids
61
However, they do not improve the itching, pain,
and prolapse [12]. Fibers must be gradually
titrated (for instance, increasing by 5 g each
week) to minimize the gastrointestinal aftereffects (like bloating and atulence) up to
20–30g every day [13].
Lifestyle modications like improving uid
intake, relieving constipation, and avoiding
straining may prevent hemorrhoids [13]. Fluid
intake should be 1L of water for every 20kg of
body weight. Adding bulk to the diet might help
improve bowel habits. Both diarrhea and constipation are clinically potent causes and triggering
factors for symptoms in hemorrhoidal disease,
and their management is as valuable as the treatment of hemorrhoids [13].
Letter from America
Modications in diet are comprised of
acceptable amount of ber and uid con-
sumption and proper instructions of defeca-
tion habits which in general are comprised of
rst-line primary treatment for patients with
hemorrhoids symptomatic disease.
Recommendation Grade: Strong as per
the moderate-quality indications, 1B [14].
5.3.2 Medical Management
Medical management aims to achieve the
following:
Mechanism ofAction
MPFF acts by
• Reducing the inammation
• Decreasing hyperpermeability
• Increasing venous tone
• Facilitating lymphatic drainage [16]
The small size of avonoids increases their
solubility and absorption and shortens the onset
of action. MPFF breaks the vicious cycle of
chronic inammation and protects the hemorrhoidal plexus [16, 17].
Hemorrhoidal Crisis
The hemorrhoidal crisis is a condition when hemorrhoids present with active bleeding, increased hemorrhoidal mass, and inammation. In an acute
hemorrhoidal attack, three tablets of 1000 mg
MPFF can be prescribed daily for 4 days, followed
by two tablets for 3 days. Afterward, one tablet of
1000 mg is recommended daily for 60 days as a
maintenance dose. MPFF is also an effective adjuvant after surgical procedures, reducing lymphostasis [16, 17]. In acute hemorrhoidal disease, a
mixture of avonoids (diosmin, troxerutin, and hesperidin) were shown to control symptoms efciently and manage both congestion and thrombosis
of anal cushions [17]. Other venoactive medicines
like Ginkgo biloba, Euphorbia prostrata, and Calcium dobesilate have not shown optimal results in
managing hemorrhoids [18]. Calcium dobesilate
was found to induce agranulocytosis [18].
• To decrease the inammation
• To re-establish optimal hemodynamic and
microcirculation
5.3.2.1 Role of Flavonoids
As the primary treatment, Micronized Puried
Flavonoid Fraction (MPFF) is suggested for
symptomatic relief of grade 1 and 2 and selected
grade 3 hemorrhoids [15]. Flavonoids have a
unique mode of dual-action. MPFF comprises
10% hesperidin and 90% diosmin [15]. They are
used as oral medication for treating hemorrhoids [15].
Letter from America
Use of MPFF
Cochrane review—benecial effect of
MPFF on bleeding, pruritus, and recurrence [18].
Grade of recommendation: weak
according to the evidence, 2B.
5.3.2.2 Topical Treatment
ofHemorrhoids
There are various over-the-counter (OTC) hemorrhoidal remedies like astringents, topical
62
5 Nonsurgical Management ofHemorrhoids
anesthetics, corticosteroids, and zinc oxide (protectants). There is a lack of evidence supporting
these OTC products’ effectiveness. Topical ointment of nitroglycerin (0.4%) reduces rectal pain.
However, it is used commonly in anal ssures
[19]. Long-term usage of topical products, specically preparations that contain steroids, must
be avoided as they can cause allergy [20] (Grade
of recommendation 2B).
5.3.2.3 Sitz Bath
Sitz baths often reduce itching, burning, and pain
after a bowel movement for a temporary period.
This relatively simple procedure involves lling
up the bathtub with warm water (Fig.5.1). The
water used should be tap water and lukewarm
(not exceeding 40–42 °C) [21]. The patient is
asked to sit in the tub for around 15–20min [21].
Shak theorized that a warm Sitz bath via a neural pathway eased the pain by relaxing the internal anal sphincter [22]. This procedure minimizes
the pain by reducing the anal pressure, increasing
vasodilatation, and reducing edema [22].
5.3.3 Ambulatory Treatment (Oce
Procedures)
The commonly used ofce treatment procedures
are:
• Infrared coagulation (IRC)
• Sclerotherapy
• Rubber band ligation (RBL)
The ofce procedures aim to relieve the symptoms by reducing the vascularity or size of hemorrhoidal tissue and increasing the hemorrhoidal tissue
xation in the rectal wall by scar brosis [23].
5.3.3.1 Infra-Red Coagulation
Infra-red coagulation was introduced as the
mainstay procedure for treating hemorrhoids.
Popularly known as IRC, this procedure was rst
described by Nieger [24] (Fig.5.2). It is a painless, noninvasive, safe, and easy procedure that
gives optimal results compared to other ambulatory treatment procedures.
Principle
Infrared energy is used to induce protein denaturation, leading to dearterialization. The shrinkage
of the hemorrhoidal tissue occurs following submucosal brosis and scar xation [25].
Indications
Grade 1 and 2 hemorrhoids.
Contraindications
Prolapsing hemorrhoids.
Technique
The tip of the infrared coagulator is pressed
against the mucosa at the apex of the hemorrhoids, and the energy is released through the
window of the proctoscope. The radiation is
released in pulses. The duration of each pulse is
1.5s, given three times to each hemorrhoid. The
penetration depth of infrared energy is approxi-
Fig. 5.1 Sitz bathtub
Fig. 5.2 Infrared equipment
5.3 Nonsurgical Management ofHemorrhoids
Fig. 5.3 (a) Activation of IRC beam at the apex of the hemorrhoids. (b) White eschar formation at the apex
63
mately 3mm. A white round spot, equivalent to
the diameter of the infrared probe, appearing at
the application site indicates eschar formation
due to tissue coagulation (Fig.5.3a, b). Minor
discomfort is felt after the completion of the
procedure. All three hemorrhoidal masses can
be simultaneously treated. If necessary, the procedure can be repeated after 2–3weeks [25, 26].
Success Rate
The success rate following IRC is shown in
Table5.2. In a study conducted by Mohammad
Reza Nikshoar, the postoperative pain score after
infrared coagulation was less than the conventional surgery (2 vs. 6, respectively) [26]. In a
comparative study between the two procedures,
rubber band ligation versus infra-red coagulation
for hemorrhoids, the visual analog score for rubber band ligation was more than the infrared
coagulation [27].
Complications
If the thermal energy from the infrared beam is
released at the dentate line, the patient would feel
severe pain, and bleeding may occur due to
sloughing.
Opinion
I prefer to do infrared coagulation in patients
with symptomatic grade 1 hemorrhoids. The
principle of IRC is protein denaturation leading
to dearterialization. As the position of the superior hemorrhoidal artery branches is not con-
Table 5.2 Success rate of infrared coagulation
Success
Journal
Brastisl Lek
Listy
P.J. Gupta [27]
J Laser Med Sci
Mohammad
Reza Nikshoar
[26]
rate (%) Bleeding
80 15% (7 out of 46 had
bleeding after IRC)
80 IRC-5%
Closed
hemorrhoidectomy 30%
[26]
stant, it is better to palpate the vessels before
releasing energy. This approach will achieve
better efcacy. To palpate the vessels, one
needs to insert a half-cut proctoscope under
general anesthesia (Propofol). The procedure is
similar to nger- guided hemorrhoidal artery
ligation, which will be discussed under laser
hemorrhoidoplasty.
5.3.3.2 Sclerotherapy
John Morgan rst attempted this procedure in 1896
using persulfate of iron [28]. In 1928, Blanchard recommended injecting 3–5 mL of almond oil with
phenol (5%) above the pile mass and not into it [29].
Turell (1959) and Later Bacon (1949) came up with
a method of directly injecting urea hydrochloride
and quinine solution into the piles [30, 31].
Principle
Chemical agents create a scar xation of the mucosa
by brosis [32]. The principle is known as “Chemical
Ablation.” An inammatory focus is created by
64
injecting the sclerosant solution into the submucosal
tissue of internal hemorrhoids. It decreases vascularity, intravascular thrombosis, contraction, and brosis of the hemorrhoidal mass with cushion xation in
its normal anatomical position [23].
Indications
First- and second-degree internal hemorrhoids.
Contraindications
• External hemorrhoids
• Thrombosed internal hemorrhoids
• Gangrenous hemorrhoids
5 Nonsurgical Management ofHemorrhoids
Common Reagents Used
• Sodium tetradecyl sulfate (Setrol)
• Polidocanol 3%
• Phenol with almond oil
• Aluminum potassium sulfate/Tannic acid
(Latest in Japan) [33]
Technique
A sclerosant solution of about 0.5mL is injected
into the submucosal tissue of each internal hemorrhoidal mass, creating an inammation focus.
The patient is placed in the left lateral position.
While injecting, make sure there is a wheal formation and not a bleb. If it is a bleb, it means the
injection is very supercial. If there is no wheal
formation, the needle has entered the sphincter
complex while injecting the solution.
Foam sclerotherapy, popularly known as
Tessari’s method [34], is a procedure where 1mL
of solution is mixed with 4 mL of air [35, 36]
(Fig.5.4). The foam is then injected into the hemorrhoids. With foam, there is better diffusion using
less quantity of the sclerosant. These days, phenol
with almond oil is not used due to the large volume
injected into each pile mass, and the results with
this sclerosant are not satisfactory [35].
Complications
• Thrombosis and necrosis
• Burning
• Local abscess
• Bacteremia and sepsis
• Portal pyemia
Fig. 5.4 Tessari’s method
• Mild pain
• Pressure
• Bleeding
Injections into the deeper plane may lead to
infection and abscess formation. Sloughing can
be there:
• If the injection is too supercial
• Too much solution is injected into single hem-
orrhoid, or
• A second injection is given into hemorrhoids
too soon after the rst
Ideally, the injection should be repeated after
3 weeks. Failure to respond after three injections
is an indication of surgical intervention.
Precautions
• During the procedure, one should always stay
above the dentate line. While injecting the
solution, always withdraw the syringe’s piston
to ensure that the solution is not inserted into
the blood vessel.
It is worth mentioning that sclerotherapy
for varicose veins is done by injecting a sclerosant directly into the vein that converts the
vein into a string of connective tissue in a process known as sclerosis [37]. The sclerosant
destroys the endothelium of the vein, and the
5.3 Nonsurgical Management ofHemorrhoids
65
vein gets absorbed into the surrounding tissue
and disappears over time [37]. In contrast, the
sclerosant in hemorrhoids is directly injected
into the pile mass, which leads to scarring and
brosis.
• If injections are given too deep, they can lead
to infection, prostatitis, urethral irritation,
perirectal brosis, or severe sepsis [38].
• The injection should be given directly into the
pile mass. Some authors recommend that the
injection be given into the submucosa at the
base of the hemorrhoidal tissue and should
never be given in the hemorrhoids, as it may
cause pain in the upper abdomen [32].
Success Rate
The success rate of sclerotherapy has been mentioned in Table5.3.
5.3.3.3 Rubber Band Ligation
Barron, in 1964, modied the technique as an
improvement of the outpatient ligature method,
which was designed and practiced originally by
Blasdell [40, 41] (Fig.5.5a, b).
Table 5.3 Success rate of injection sclerotherapy
Journal Success rate
Int J Surg Investig
Kanellos [39]
Journal of Investigative
Surgery
Pierluigi Lobasico [38]
57.6%
78.8% (after a single
session)
86% (after two sessions)
Principle
Hemorrhoidal tissue banding leads to ischemia of
prolapsing mucosa followed by rectal wall scar
xation [41].
Indications
Internal hemorrhoids—Grades 1, 2, and a few
grade 3 cases.
Contraindications
• External hemorrhoids
• Patients with hypertrophied anal papillae
• Strangulated hemorrhoids
• Internal thrombosed hemorrhoids
• Patient with large grade 4 hemorrhoids
• Patients on anticoagulants
Technique
The patient is placed in either the left lateral or
jackknife posture as per the surgeon’s preference.
The procedure can be carried out with an endoscope with a retroection or forward-view or done
without the endoscope using a forceps ligator or a
suction elastic band ligator. When a ligator is
placed accurately, a rubber band is employed at the
internal hemorrhoid base. It is vital to position the
band 1–2cm above the dentate line. The zone of
anal transition includes a considerate amount of
innervation, and placing the band in this area can
cause a considerable amount of pain. In severe
pain, it is advisable to remove the bands immediately. The number of bands placed may be from 1
ab
Fig. 5.5 (a) Rubber band ligation. (b) Barron band ligator
66
5 Nonsurgical Management ofHemorrhoids
to 3 at any given time. Using multiple bands may
lead to vasovagal reactions, urinary retention, and
pain.
By applying a rubber band at the hemorrhoidal
tissue base, the hemorrhoids are xed high in the
anal canal, rectifying the prolapse. By interrupting the blood ow, the size of the hemorrhoids
decreases.
In the case of small hemorrhoids, the normal
saline solution is injected into the banded pile
mass to increase its volume. This tightens the
noose around the neck and prevents the band
from slipping [42]. Bulk agents or stool softeners
are added. The patient should be informed that a
few drops of blood may be seen for 5–7 days
after the banding. After 2–4weeks, an appointment should be made to evaluate the success of
banding [42]. Patients can resume their regular
diet after the procedure.
Complications ofRubber Band Ligation
• Pain—This is attributed to the placement of
the rubber band near the dentate line and pressure exerted by the bands on the somatic
nerves. Pain is ill-dened, throbbing, and
might increase 4–6 h after the banding [43].
Sometimes the pain may be due to multiple
bandings. Pain may worsen after a few days;
in that case, a re-evaluation of the patient is
required. Pain may be eased by mild analgesics, a warm Sitz bath, and avoiding hard stool
by consuming bulk-forming or mild laxatives.
Trichow etal. [44] recommended injecting a
solution of local anesthesia into a hemorrhoidal bundle after rubber band ligation.
Severe pain indicates that the band has
been placed over the dentate line. Go for
immediate band removal [45].
• Slippage of Bands—To prevent slippage, one
may inject 1mL of normal saline into the pile
mass once the band is released [42].
• Thrombosis.
• Massive Bleeding—Incidence was reported
in 7.5% of patients on anticoagulants [46].
• Vasovagal Symptoms.
• Delayed Hemorrhage—Approximate 1% of
the patients may experience late bleeding [42].
Table 5.4 Results of rubber band ligation
Journal Success rate
World journal of
Gastrointest Surg
Albuquerque A. [42]
Dis Colon Rectum
Indru Khubchandani
[45]
Dis Colon Rectum
V.S.Iyer [46]
69%
80.1% (multiple ligation)
71.9% (single ligation)
80.2%
All three hemorrhoids can be banded in one
session. However, the patient may require
repeated sessions in grade 2 and a few cases of
grade 3 hemorrhoids. The most prominent hemorrhoid is tackled rst.
Precautions
Skin tags and hypertrophied anal papillae should
not be treated by rubber band ligation.
Postprocedure Care
The patient should not strain while defecating.
A ber-rich diet should be advised to the
patient.
Success Rate
The success rate of rubber band ligation is shown
in Table5.4.
5.4 A Word About Cryotherapy
Principle
“Ablation of the hemorrhoidal tissue with a freezing cryoprobe” at a temperature of minus 160°C,
using liquid nitrogen [47].
Advantages
It causes less pain as the sensory nerve endings
are destroyed at very low temperatures. It was
found that cryotherapy was linked to prolonged
foul-smelling discharge [47]. This procedure has
almost been abandoned now.
A comparative study between IRC, sclerotherapy, and rubber band ligation is shown in
Table5.5.
5.6 Which Is theBest Oce Procedure Out ofSclerotherapy, Infrared Coagulation, andRubber Band…
67
Table 5.5 Comparative results of IRC, sclerotherapy,
and rubber band ligation
Procedure Success rate
IRC [49] 46%
Sclerotherapy [38] 21.2% (single ST session)
14% (after the second
session)
Rubber band ligation [49] 73%
Letter from America
Ofce Procedures
Most patients were suffering from
Grade-I/II and other selected patients with
Grade III internal hemorrhoidal conditions
who have undergone failed medical treatment could be treated with ofce-based
procedures like infrared coagulation (IRC),
sclerotherapy, and banding.
Grade of recommendation: Strong as
per the high-quality evidence, 1A [48].
5.5 Discussion
Nonsurgical hemorrhoid treatment, which
includes lifestyle and dietary modications, is
still the primary line of management of hemorrhoids. Hemorrhoids are most commonly
caused by constipation and straining. Drinking
enough liquids and eating a high-ber diet help
patients improve their condition. Changing
bowel habits, sitting in the toilet for long periods, and converting toilets into libraries should
be avoided.
Nugroho in 2011 [50] and Sitti in 2017 con-
cluded that 66.6% of patients with hemorrhoids
consumed low-ber foods [51]. High-ber foods
can bind water in the colon to soften the stool’s
consistency, make the volume of the stool big, and
stimulate the rectum nerves, resulting in a desire
for defecation. The stool becomes easier to pass,
and constipation and straining are reduced [14].
MPFF is a highly tolerated therapeutic option
for internal hemorrhoids, and it is advised in
patients with rst-degree hemorrhoids and postoperatively [17].
All ofce procedures are performed above the
dentate line [52], and the underlying principle is
scar brosis. In infrared coagulation, dearterialization results in the reduction of hemorrhoids.
Sclerotherapy leads to chemical ablation followed by scar xation of the mucosa by brosis
[53]. In the rubber band, ligation of the hemorrhoidal tissue results in necrosis or ischemia of
prolapsing mucosa, followed by scar xation in
the rectal wall [52].
Studies have shown that rubber band ligation
has advantages over other ofce procedures for
treating grade 1 and 2 hemorrhoids. In comparison to rubber band ligation, infrared coagulation
causes only small tissue coagulation resulting in
minimal tissue injury of 2–3mm depth [54]. This
decrease in depth presumably causes less tissue
xation and scarring, increasing the possibility of
recurrence and chances of offending tissue being
incompletely destroyed [54]. Infrared coagulation has been linked to fewer complications [54,
55]. A comparative study by Johanson et al.
reported that rubber band ligation had lasting
efciency but higher pain incidence after the procedure [54]. Marques etal. conducted a random
crossover trial to compare the two procedures,
RBL and IRC [55]. The complications, patient
satisfaction, effectiveness, pain, and preference
to treat the internal hemorrhoids were studied.
They reported higher bleeding incidence immediately or 6/24 h after the rubber band ligation
procedure than the infrared coagulation. The
number of patients using analgesics were considerably higher in the rubber band ligation group
than in the infrared coagulation group 24h after
treatment [56].
5.6 Which Is theBest Oce
Procedure Out
ofSclerotherapy, Infrared
Coagulation, andRubber
Band Ligation?
Research by Johansson etal. and MacRae [57]
showed that rubber band ligation led to the
least recurrent hemorrhoid symptoms and the
lowest rate of repeat treatment [57]. As a result,
68
5 Nonsurgical Management ofHemorrhoids
rubber band ligation is advised as a primary
nonoperative option for treating grade 1 and 2
hemorrhoids [57].
Rubber band ligation is the most common surgical process performed in the British assessment of
over 900 colorectal and general surgeons, followed
by sclerotherapy and hemorrhoidectomy [56].
Take-Home Message
• The avonoids are quite effective for patients
with one to two episodes of mild bleeding in
grade 1 hemorrhoids. Although mentioned in
the literature, I have never treated any patient
with profuse active bleeding on avonoids
alone. Always an ofce procedure has been
carried out along with prescribing
avonoids.
• As far as ofce procedures are concerned, the
overall results mentioned in the literature favor
rubber band ligation over infrared coagulation
and sclerotherapy. However, I prefer sclerother-
apy or infrared coagulation for grade 1 and 2
hemorrhoids, and the results are promising.
• Failed medical management of grade 2 and 3
hemorrhoids is an absolute indication for sur-
gical intervention.
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