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41 Benign Anal Disease: Third Degree Hemorrhoids—Who Really Needs Surgery?
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6. Brozek JL, Akl EA, Alonso-Coello P, etal. Grading quality of evidence and strength of recommendations in clinical practice guidelines. Allergy. 2009;64:669–77. CrossrefPubMed
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11. Avital S, Inbar R, Karin E, etal. Five-year follow-up of Doppler-guided hemorrhoidal artery
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12. De Nardi P, Capretti G, Corsaro A, et al. A prospective, randomized trial comparing the
short- and long-term results of Doppler-guided transanal hemorrhoid dearterialization with
mucopexy versus excision hemorrhoidectomy for grade III hemorrhoids. Dis Colon Rectum.
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13. Iyer VS, Shrier I, Gordon PH. Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids. Dis Colon Rectum. 2004;47:1364–70.
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14. Murie JA, Mackenzie I, Sim AJ. Comparison of rubber band ligation and haemorrhoidectomy for second and third degree haemorrhoids: a prospective clinical trial. Br J Surg.
1980;67:786–8. CrossrefPubMed
15. Lewis AAM, Rogers HS, Leighton M.Trial of maximal anal dilatation, cryotherapy and elastic
band ligation as alternatives to haemorrhoidectomy in the treatment of large prolapsing haemorrhoids. Br J Surg. 1983;70:54–6. CrossrefPubMed
16. Shanmugam V, Thaha MA, Rabindranath KS, et al. Systematic review of randomized
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18. Peng BC, Jayne DG, Ho YK.Randomized trial of rubber band ligation vs. stapled hemorrhoidectomy for prolapsed piles. Dis Colon Rectum. 2003;46(3):291–7; discussion 296–7.
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19. Tiernan J, Hind D, Watson A.The HubBLe trial: haemorrhoidal artery ligation (HAL) versus
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with symptomatic hemorrhoids (review). Cochrane Database Syst Rev. 2009;21(1):CD006761.
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22. Wilson MS, Pope V, Doran HE, et al. Objective comparison of stapled anopexy and open
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23. Jayne DG, Botterill I, Ambrose NS, et al. Randomized clinical trial of LigasureTM versus conventional diathermy for day-case haemorrhoidectomy. Br J Surg. 2002;89:428–32.
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24. Kombrorozos VA, Skrekas GJ, Pissiotis CD. Rubber band ligation of symptomatic internal
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Colon Rectum. 1994;37:37–41. CrossrefPubMed
26. Cintron J, Abcarian H.Benign anorectal: hemorrhoids. In: Wolff BG, Fleshman JW, Beck DE,
etal., editors. The ASCRS textbook of colon and rectal surgery. NewYork: Springer; 2007.
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27. Nelson RS, Ewing BM, Ternent C, etal. Risk of late bleeding following hemorrhoidal banding
in patients on antithrombotic prophylaxis. Am J Surg. 2008;196(6):994–9. CrossrefPubMed
28. Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J
Gastroenterol. 2012;18(17):2009–17. https://doi.org/10.3748/wjg.v18.i17.2009.
29. Davis BR etal. The American Society of Colon and Rectal Surgeons Clinical practice guidelines for the management of hemorrhoids. American Society of Colon and Rectal Surgeons
Clinical Practice Guidelines, ASCRS, 2018, https://fascrs.org/ascrs/media/les/downloads/
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30. Shukla S, Maheshwari A, Tiwari B.Randomized trial of open hemorrhoidectomy versus stapled hemorrhoidectomy for grade II/III hemorrhoids. Indian J Surg. 2018;80:574–9. https://
doi.org/10.1007/s12262- 017- 1670- 7.
31. Dekker L, Han-Geurts IJM, Rørvik HD, etal. Rubber band ligation versus haemorrhoidectomy for the treatment of grade II–III haemorrhoids: a systematic review and meta-analysis
of randomised controlled trials. Tech Coloproctol. 2021;25:663–74. https://doi.org/10.1007/
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32. Brown SR, Tiernan JP, Watson AJM, Biggs K, Shephard N, Wailoo AJ, Bradburn M, Alshreef
A, Hind D.Haemorrhoidal artery ligation versus rubber band ligation for the management
of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre,
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33. Xia W, Manning JPR, Barazanchi AWH, Su’a B, Hill AG.Metronidazole following excisional
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34. Zhang L, Xie Y, Huang D, Ma X, Wang W, Xiao H, Zhong W. LigaSure hemorrhoidectomy versus the procedure for prolapse and hemorrhoids: a meta-analysis of randomized controlled trials. Medicine (Baltimore). 2022;101(3):e28514. https://doi.org/10.1097/
MD.0000000000028514. PMID: 35060505; PMCID: PMC8772652
35. Balciscueta Z, Balciscueta I, Uribe N. Post-hemorrhoidectomy pain: can surgeons reduce
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36. Aibuedefe B, Kling SM, Philp MM, etal. An update on surgical treatment of hemorrhoidal
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org/10.1007/s00384- 021- 03953- 3.
37. Kuiper SZ, Dirksen CD, Kimman ML, Van Kuijk SMJ, Van Tol RR, Muris JWM, et al.
Effectiveness and cost-effectiveness of rubber band ligation versus sutured mucopexy versus
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protocol for a multicentre randomized controlled trial. Contemp Clin Trials. 2020;99:106177.
38. Wang JY, Lu CY, Tsai HL, Chen FM, Huang CJ, Huang YS, Huang TJ, Hsieh JS.Randomized
controlled trial of LigaSure with submucosal dissection versus Ferguson hemorrhoidectomy for prolapsed hemorrhoids. World J Surg. 2006;30(3):462–6. https://doi.org/10.1007/
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39. Tan EK, Cornish J, Darzi AW, Papagrigoriadis S, Tekkis PP.Meta-analysis of short-term outcomes of randomized controlled trials of LigaSure vs conventional hemorrhoidectomy. Arch
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40. Tjandra JJ, Chan MKY. Systematic review on the procedure for prolapse and hemorrhoids
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E. Soto and J. Laryea
Management Options forBleeding
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Hemorrhoids inPatients
42
onAnticoagulation
JohnKonen andKarimAlavi
PICO table
Patients
Patients with bleeding
hemorrhoids in
anticoagulation
Hemorrhoids are part of the normal anatomy of the anal canal and are comprised
of arterio-venous connections and broelastic connective tissue within the submucosa. They are important for maintaining continence as well as reducing the trauma
from passage of stool. Hemorrhoids typically occur at three locations—left lateral,
right anterolateral, and right posterolateral. Most patients, however, have variations
of this ‘classic’ distribution pattern. Hemorrhoids are classied in relation to the
dentate line. Mucosa proximal to the dentate is endodermal in origin and is lined
with columnar epithelium, while mucosa distal to the dentate is from the ectoderm,
and is lined with squamous epithelium. Appreciation of this demarcation is critical,
as innervation proximal to the dentate is by the autonomic nervous system, while
mucosa distal to the dentate is somatically innervated and sensitive to pain. Internal
hemorrhoids, which are proximal to the dentate line, are further subclassied into
four grades based on the degree of prolapse, while external hemorrhoids are distal
Intervention Comparator
Ofce-based
procedures
Surgical
procedures
Outcome
Cessation of bleeding,
recurrence, complications
J. Konen (*)
Rush University Medical College, Department of Surgery, Division of Colon & Rectal
Surgery, Chicago, IL, USA
e-mail: John_Konen@rush.edu
K. Alavi (*)
UMass Chan Medical School, Department of Surgery, Division of Colon & Rectal Surgery,
Worcester, MA, USA
e-mail: Karim.Alavi@umassmemorial.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_42
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to the dentate. “Mixed”-type hemorrhoids straddle the dentate line and contain both
components. Chronic straining and irregular bowel movements leads to engorgement of the arterio-venous connections and development of symptomatic hemorrhoids characterized by bleeding, prolapse, pain, and/or itching.
Patients with symptomatic hemorrhoids comprise a signicant percentage of
annual ofce visits in the United States. Recent data estimate three million visits at
an annual cost of over 770 million dollars [1]. However, this cost may be a gross
under-estimation as many patients self-medicate or seek alternative treatment options
on the internet [2]. In fact, the top trending health issue in the United States in 2012
was “hemorrhoids” according to Google’s annual roundup of the world’s search
trends [3]. Unfortunately, the quality of online information on hemorrhoids is variable, and nearly 50% of websites are graded as poor quality [4]. This makes it imperative that physicians treat patients with hemorrhoids using evidence-based medicine.
J. Konen and K. Alavi
Medical Treatment
Treatment options of hemorrhoids are generally guided by the severity of the chief
complaints of the patient, which are usually a combination of the following four
symptoms: pruritus and/or discomfort, bleeding, pain (thrombosis), or prolapse. In
general, the higher the grade of internal hemorrhoids, the more likely it is that banding and/or surgery will play a signicant role, and the less likely that a conservative
treatment paradigm will be successful. Regardless, all patients should be counseled
on dietary and lifestyle modications as a rst-line approach to treatment and prevention of recurrence. Conservative measures include ingestion of 20–30g of ber
daily, which has been shown in several studies to reduce bleeding events in patients
with hemorrhoids [5, 6]. A recent Cochrane meta-analysis, examined 378 patients
who were enrolled in randomized controlled trials (RCTs) and showed that ber
supplementation resulted in a signicant risk reduction in bleeding (RR 0.50, 95%
CI 0.28 to 0.89) [7]. Additionally, it is also important to counsel patients to avoid
straining and to limit time on the toilet, as these habits have been shown to be more
frequent among patients with symptomatic hemorrhoids [8]. Regular physical activity and increased water intake promote stool regularity, although the exact efcacy
of these recommendations have not been scientically validated.
In terms of topical therapies, high-quality evidence supporting their use is lacking. The one exception are phlebotonics—a class of venoactive medications thought
to increase venous tone, strengthen vascular wall integrity, improve capillary permeability, facilitate lymphatic drainage, and have anti-inammatory properties. A
2012 Cochrane review examined twenty RCTs with a total of 2334 patients, of
which two trials and a total of 99 patients examined bleeding as an outcome measure. Pooled analysis demonstrated a statistically signicant benecial effect of
phlebotonics in treating symptomatic bleeding hemorrhoids compared to controls
(OR 0.12; 95% CI 0.04 to 0.37, P=0.0002) [9]. They also showed similar signicant benet of phlebotonics over controls for pruritus (OR, 0.23; 95% CI, 0.07–0.79)
and for prevention of drainage/leakage (OR, 0.12; 95% CI, 0.04–0.42). Unfortunately,
42 Management Options forBleeding Hemorrhoids inPatients onAnticoagulation
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routine use and availability of phlebotonics for hemorrhoids in the U.S. is limited
compared to Asia and Europe. In general, if patients are receiving symptomatic
relief from topical agents, it is reasonable to continue their use, for at least a brief
period with the caveat that these products have not been rigorously tested for efcacy. Steroid-containing products should be discontinued beyond 7days, as they
can lead to thinning and subsequent erosion of the anoderm. Lastly, sitz baths using
hot tap water soaks, or application of moist heat to the perianal area have been
shown to provide relaxation of the anal sphincters and symptomatic relief [10].
485
Office-Based Procedures
Ofce-based procedures should be considered for patients with recalcitrant disease
after a trial of conservative treatments. Patients with mixed-type hemorrhoids
refractory to medical treatment should proceed directly to surgery as ofce-based
procedures will not address their symptoms. Ofce-based procedures include: rubber band ligation, sclerotherapy, and infrared coagulation. Rubber band ligation
(RBL) is the most commonly utilized method and has been shown to be more effective, require fewer treatment sessions, and have better patient outcomes compared
to sclerotherapy and infrared coagulation [11, 12] The most recent Clinical Practice
Guidelines on hemorrhoid management published by the American Society of
Colorectal Surgeons, considers RBL in the setting of anticoagulation or antiplatelet
therapy a contraindication [13]. This recommendation is based on the theoretical
increased risk of bleeding at the 5–7 post-procedure day range, at which the hemorrhoidal tissue necroses and the rubber band falls off. A large retrospective review of
805 patients demonstrated that 25% of patients on warfarin had post-procedure
bleeding, statistically higher compared to 7.5% taking aspirin or NSAIDs, compared to only 2.9% in patients not taking these medications [14]. The overall number of bleeding complications was small (only 8 patients taking warfarin and 40
taking ASA/NSAIDs) and the authors did not comment on the clinical signicance
of the bleeding and if intervention was necessary. Marshman etal. examined 241
patients who underwent RBL, of which only two had had bleeding, both of whom
required hospitalization and clot evacuation. Both patients were on oral anticoagulation [15]. Conversely, a recent retrospective case-control study of 82 patients
showed no difference in bleeding for patients on clopidogrel versus controls (3.75%
vs 2.78%, p=0.74) [16].
The greatest risk of bleeding is 5–7days post-banding, thus holding antithrombotic medication such as aspirin, clopidogrel, and coumadin at the time of banding
allows for a reduction in their potency at the most critical time [17]. Additionally,
time off these medications will be reduced by not stopping the medication for a
predetermined amount of time before the procedure, limiting complications such as
stroke, acute myocardial infarction (AMI), or DVT/PE.Nelson etal. reviewed their
experience with this approach in 364 patients who had RBL while on antithrombotic medication (NSAIDs, aspirin, clopidogrel, and warfarin) and stopping the
medication at the time of banding for 7–10days [18]. They instructed patients to
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J. Konen and K. Alavi
hold NSAIDs, aspirin, and clopidogrel for 10days, and warfarin for 7days postprocedure before restarting. Only 3.7% (23 patients) of patients had a bleeding episode, the majority of whom were considered insignicant (i.e. requiring no further
therapy), and only 0.9% (6 patients) required emergency evaluation, admission, or
transfusion. The authors concluded that these rates were not different compared to
rates reported in the literature of post-procedural bleeding from RBL in patients not
taking antithrombotic therapy (1.7–2.9%) [14, 19, 20]. They also reported average
post-band bleeding occurred on day 6.5, whereas patients taking clopidogrel bled
later, on post-band day 9.5 [18].
Several studies examined the risk of stroke and AMI following abrupt discontinuation of antithrombotic medications. In a study examining frequency of stroke
occurring after discontinuation of antiplatelet medication in neurology wards,
4.49% of all strokes were related to stopping antiplatelet drugs, with events happening between 6–10days after stopping the medications [19]. The authors also postulated this was an underestimate, as patients who developed a post-operative stroke
were not likely to be referred to a neurology ward. Another study looking at cessation of clopidogrel following treatment of AMI with either medical management or
with percutaneous coronary intervention identied that AMI occurred in 17.1% and
7.9% of patients, respectively, and there was a signicant rebound effect with events
occurring more frequently in the rst 90days following cessation [20]. These ndings suggest that the risk of potential bleeding following placement of a hemorrhoidal band should be carefully weighed against potential risk of stroke, AMI, or
other thrombotic issue.
An alternative ofce-based procedure for patients on anticoagulation is sclerotherapy. This involves injecting 1–1.5mL of a sclerosing agent into the base of the hemorrhoid in the submucosal layer using a 21-gauge spinal needle, causing brosis and
xating the hemorrhoid. Anesthesia is not necessary. Injection into the submucosa is
crucial, as supercial injection can cause mucosal necrosis, and deep injection can
cause pain, abscess/stula, or sepsis, although this is exceedingly rare [21–23].
Commonly used sclerosants include: hypertonic saline and 5% phenol in vegetable
oil, or polidocanol foam, and sodium tetradecyl sulfate (Sotradecol), among others.
While there are no randomized data to support use in anticoagulated patients, the
American Society of Colorectal Surgeons’ (ASCRS) Clinical Practice Guidelines and
the ASCRS textbook both assert its safety in these patients. A Japanese case-matched
study of 37 patients who underwent sclerotherapy on antiplatelet therapy (aspirin,
ticlopidine, clopidogrel, and cilostazol), anticoagulant therapy (warfarin), or both,
showed no difference in efcacy to improve bleeding symptoms or post-procedure
bleeding rates between patients on antithrombic medication versus case-matched controls. The authors concluded that this provided evidence supporting its use and safety
in patients on antithrombotic medications [24]. Efcacy at controlling hemorrhoidal
bleeding has been quoted at 75–89% [25, 26], and a recent systematic review found
resolution of bleeding in 69–88% of rst degree hemorrhoids and prolapse resolution
in 90–100% of second degree hemorrhoids, with subjective ‘excellent improvement’
rating in 80% of rst degree hemorrhoid patients [27]. Recurrent bleeding was low
(1.5–29%), and 36–49% of patients reported post-procedural pain.
42 Management Options forBleeding Hemorrhoids inPatients onAnticoagulation
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Finally, infrared coagulation (IRC) is considered an alternative to RBL in patients
who are on antithrombotic medications given the lower bleeding risk. IRC involves
using a tungsten-halogen lamp as an energy source to deliver light converted to heat
energy at the apex of an internal hemorrhoid to cause tissue coagulation, though
high initial investment costs may be a barrier to use. A small prospective randomized crossover study of 94 patients comparing IRC to RBL demonstrated less pain
and bleeding in the IRC group compared to the RBL group in the rst 24hours following the procedure (6.8% vs. 10.2%, respectively; p<0.01) [28]. A systematic
review of IRC found one RCT identied improvement in bleeding symptoms in
78%, 51%, and 22% for grade I, II, and III hemorrhoids, respectively, while two
other RCTs reported 81% to 93% ‘moderate improvement’ rates [27]. An RCT of
RBL vs IRC demonstrated equal efcacy of the two treatments, but higher pain
reports after RBL, but slightly more patients required additional procedures after
IRC [29], and the exact same trends were found in a meta-analysis [11]. While no
ofce-based procedure has been consistently shown to be superior, it is important to
note that there are no studies examining the safety and efcacy of IRC in patients on
antithrombotic medications.
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Surgical Management
Surgical hemorrhoidectomy may be necessary for patients who are on anticoagulation and continue to bleed despite all conservative measures. Hemorrhoidectomy
eliminates the potential need for repeat ofce-based procedures and the risk of
bleeding associated with each of those procedures. Additionally, patients with grade
III-IV hemorrhoids or “mixed-type” hemorrhoids will be undertreated or inappropriately treated with an ofce procedure and should be considered for hemorrhoidectomy. This needs to be balanced with the increased risk of pain and higher
complication rates in surgical approaches, especially in the setting of chronic anticoagulation [11]. Hemorrhoid artery ligation (HAL) may also be an alternative to
traditional hemorrhoidectomy. This approach involves specialized equipment
including a doppler probe-integrated anoscope followed by suture mucopexy to
both ablate the inow hemorrhoidal arteriole and pexy the hemorrhoid column.
Studies have shown favorable short-term results with a recent systematic review
showing an overall bleeding rate reported at 5% and an overall reintervention rate
was 6% [30]. Although there is limited long-term follow-up data, HAL has increased
residual disease and symptom recurrence rates compared to hemorrhoidectomy.
Studies of HAL have reported recurrence rates between 6% and 22%, and especially
higher rates in advanced disease grades, with a range as high as 50–60% in grade IV
hemorrhoids [30–33]. Atallah etal. examined their experience with HAL in patients
on anticoagulation and found no difference in post-operative bleeding between
patients who were continued on anticoagulants before and after the procedure
(except for the day Surgical hemorrhoidectomy may be necessary for patients who
are on anticoagulation and continue to bleed despite all conservative measures.
Hemorrhoidectomy eliminates the potential need for repeat ofce-based procedures
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J. Konen and K. Alavi
and the risk of bleeding associated with each of those procedures . Additionally,
patients with grade III-IV hemorrhoids or “mixed-type” hemorrhoids will be undertreated or inappropriately treated with an ofce procedure and should be considered
for hemorrhoidectomy. This needs to be balanced with the increased risk of pain and
higher complication rates in surgical approaches, especially in the setting of chronic
anticoagulation [11]. Hemorrhoid artery ligation (HAL) may also be an alternative
to traditional hemorrhoidectomy. This approach involves specialized equipment
including a doppler probe-integrated anoscope followed by suture mucopexy to
both ablate the inow hemorrhoidal arteriole and pexy the hemorrhoid column.
Studies have shown favorable short-term results with a recent systematic review
showing an overall bleeding rate reported at 5% and an overall reintervention rate
was 6% [30]. Although there is limited long-term follow-up data, HAL has increased
residual disease and symptom recurrence rates compared to hemorrhoidectomy.
Studies of HAL have reported recurrence rates between 6% and 22%, and of surgery) and those not on any anticoagulation. Patients on anticoagulation included:
aspirin, clopidogrel, warfarin, apixaban, fondaparinux, enoxaparin, and dipyridamole. The study was limited by small sample size (106 patients), and the majority of
the anticoagulated cohort (55.6%) were on monotherapy low-dose aspirin alone.
Additionally, complications from stopping anticoagulation in these patients were
not reported [34].
A nal consideration is management of antithrombotic medications surrounding surgical hemorrhoidectomy. In the only prospective study of hemorrhoidal surgery on patients with antithrombotic medication, evaluation of 980 patients
undergoing hemorrhoid surgery without interruption of antithrombotic medication
(aspirin, clopidogrel, oral anticoagulants, or patients “bridged” to low molecular
weight heparin (LMWH) peri-operatively) revealed the overall rate of post-operative bleeding to be 6.5% [35]. On multivariate analysis, patients who stopped warfarin and were bridged with LMWH had the highest rate of bleeding (57%,
RR=42), compared to those who remained fully anticoagulated during their hemorrhoidectomy (23%, RR=5.8). Patients on clopidogrel also had a signicantly
higher rate of bleeding (15%, RR = 10). No difference was detected in postoperative bleeding in patients taking aspirin compared to those not on aspirin
(5.6% vs 3.5%, P=0.373). This data suggests that for patients undergoing hemorrhoidectomy, it is safe to continue aspirin perioperatively, and that continuing antithrombotic medications may be an appropriate alternative strategy to bridging,
which seems to increase bleeding risk to an unacceptably high level. In addition,
clopidogrel seems to signicantly increase risk of bleeding, and if the patient’s
condition allows, stopping it perioperatively should be seriously considered. In
general, studies investigating the impact of antithrombic agents following hemorrhoid procedures are limited by small sample size, lack of generalizability, and
poor study quality. Based on the lack of available high quality evidence guiding
physicians, management of patients on antiplatelet or anticoagulant medications
who undergo hemorrhoidectomy should be individualized with early involvement
of physicians managing these medications to help weigh the risk of bleeding versus
the cardiovascular benet of these medications.
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489
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