Early hemorrhoid disease will frequently present as painless bleeding noted as streaking on toilet paper. It is important to differentiate hemorrhoids from other pathological conditions including fi ssure, polyps, IBD, or cancer. It is uncommon for bleeding hemorrhoids to present with anemia and all other conditions should be ruled out prior to treating the hemorrhoids. As stated earlier, hemorrhoidal grading is determined by protrusion. Enlarged hemorrhoids that do not protrude below the dentate line are considered grade 1. Factors leading to development of hemorrhoids include hard stools from a low-fi ber diet, limited fl uid intake, straining to pass bowel movements, and prolonged sitting during bowel movements. With distention of the hemorrhoid vessels within the anal canal, irritation from passage of stool and wip­ing can lead to excoriation and bleeding. As the anoderm above the dentate line is largely insensate, patients will not present with pain as an initial symptom.

A 52-year-old male presents with a history of bright red blood per rectum. The patient reports blood dripping in the toilet as well as on the toilet paper with bowel movements. He can feel swelling at his backside that subsides about 30 min after defecation; he occasionally will need to push on the swelling to achieve resolution. He has a history of congestive heart failure treated with diuretics and seasonal aller­gies treated with intermittent antihistamines. He reports regular bowel movements and does not strain on the toilet. His wife reports that he will sometimes spend 15–20 min in the bathroom.

Grade 2/3 internal hemorrhoids

Progression of hemorrhoid disease to grade 2 or 3 is defi ned by protrusion of inter­nal hemorrhoids below the dentate line with spontaneous reduction in grade 2 or manual reduction in grade 3 (Fig. 10.3 ). Again, painless bleeding will frequently be

First described in 1963 by Barron, banding is performed during anoscopy [ 5 ]. Conventional banding uses an atraumatic clamp and a bander to deploy a rubber band gathering redundant mucosa above the hemorrhoidal column. A purpose-built suction bander serves a similar function and can be operated with one hand. The bander is placed within the anal canal above the prominent hemorrhoid column. The anorectal mucosa is drawn into the device. A trigger deploys the rubber band to permanently gather this tissue. Banding proximally tethers the hemorrhoid columns within the anal canal preventing protrusion. Over the following 3–5 days, the banded tissue will strangulate, necrose, and pass with a bowel movement occasionally her­alded by a brief episode of self-limited bleeding. Most patients can achieve cure with this intervention at success rates of 75% [ 6 ] (Figs. 10.4 and 10.5 ). Some patients may require repeat banding depending on the severity of their hemorrhoids. Recurrence is prevented by continued adherence to dietary and behavioral modifi ca­tions. Complications of rubber band ligation include pain, thrombosis, bleeding, and potential life-threatening pelvic sepsis. In our experience, most patients will experience a dull ache for 24–48 h. Symptomatic relief is provided by Tylenol or ibuprofen and sitting in a warm tub. Any patient who develops urinary retention with severe pelvic pain and fever should be promptly evaluated for pelvic sepsis. Early intervention with possible removal of the band, IV antibiotics, and careful observation are important steps to prevent further complications.

Another option for treatment of grade 2 or 3 hemorrhoids is sclerotherapy . Historically, this was performed prior to the advent of rubber band ligation. This process involves injection of a caustic agent to decrease the blood fl ow and induce fi brosis. Many different solutions have been used for sclerotherapy, but most clini­cians now use a commercially available 5–10 % phenol solution with oil. Using a 25-gauge needle, the submucosa 1 cm above the dentate line is infi ltrated with 1–2 mL of solution. Long-term results are very similar to banding in grade 1 and 2 hemorrhoid patients [ 7 ].

Because pain is the largest barrier to hemorrhoid surgery, many new devices have come to market which purport to give the same long-term improvement in symp­toms with less post-procedural pain. These include Doppler-guided transanal hem­orrhoid devascularization (THD™, AMI™), stapled hemorrhoidectomy or procedure for prolapsed hemorrhoids (PPH), and the hemorrhoid energy therapy (HET™) bipolar system.

The stapled hemorrhoidectomy was introduced for hemorrhoids in 1998. First, an anal dilator is used to secure a circumferential purse-string stitch 2–4 cm above the dentate line. A modifi ed EEA stapler is then inserted into the anal canal and the purse-string stitch draws redundant mucosa into the head of the stapler. The stapler is then fi red excising a ring of redundant tissue and creating a circumferential staple line above the dentate line. Most long-term studies show no difference in pain when compared to conventional hemorrhoidectomy, but recurrence rates appear to be higher. Additionally, there are several unique complications associated with stapled hemorrhoidectomy including fi stula, staple-line bleeding, and chronic pain [ 11 ].

Treatment of thrombosed external hemorrhoids is dictated by the time between onset of symptoms and the patient’s presentation to the outpatient clinic or emer­gency department. If diagnosed and treated within 48–72 h of onset, then an ellipti­cal excision of overlying skin with evacuation of the thrombosed clot can provide signifi cant symptomatic relief from pain and pressure. Topical or injectable 1 % lidocaine with 1:100,000 epinephrine can provide procedural analgesia and assist with hemostasis. Care must be taken to fully unroof the overlying skin to prevent re-closure and potential abscess formation. Post-procedural sitz baths three times daily and with soiling will allow for healing by secondary intention and a low inci­dence of postoperative abscess formation. If diagnosed beyond 72 h, treatment is conservative with warm packs and appropriate hygiene as pain and tenderness resolve over the following 5–7 days. Topical and systemic analgesics are appropri­ate for symptomatic relief during this period [ 13 ].