Diagnosis and Treatment of Acute

Hemorrhoidal Disease 30
and the Complications
of Hemorrhoidal Procedures

James M. Tatum and Eric J. Ley

Overview of Hemorrhoids anorectal mucosa above the dentate line proxi-

mally (internal hemorrhoid) and under the somat-
Hemorrhoids, colloquially “piles,” are common ically innervated anoderm distal to the dentate
and range in severity from inconvenience line (external hemorrhoid) [4]. The non-patho-
(Napoleon at Waterloo) to fatal (David Livingston logic hemorrhoid functions as a vascular “cush-
in Africa) [1]. They represent one of medicine’s ion,” both adding mass to the anal canal, serving
oldest problems, one which we are fortunate to maintain continence in time of increased
enough to now understand and possess multiple intraabdominal pressure as they expand during
options for treatment. Valsalva, and functioning in sensing between
solid bowel movement and flatus [2, 3].
The vascular anatomy of the anal canal is par-
Anatomy ticularly important in patients with portal hyper-
tension. There are connections between the
Hemorrhoids are the sinusoidal vascular cush- superior anal vein, which ordinarily has portal
ions composed of the anastomoses of the arteri- drainage, and the middle and inferior rectal veins,
oles of the terminal branches of the superior which drain into the systemic venous circulation,
rectal and hemorrhoidal systems as well as the making the anal canal a notable site for portal
smaller branches of the middle and inferior hem- systemic shunting. The congestion of portal
orrhoidal arteries and their respective venous venous hypertension found in cirrhosis or other
drainage system [2, 3]. There are three hemor- disease of increased portal hypertension can
rhoidal plexuses, predictably found in the anal result in anorectal varicosities of these anastomo-
canal at three positions: laterally on the left and ses [5]. These varices are of clinical concern
on the right at anterior and posterior positions. given their propensity for troublesome bleeding
Each hemorrhoidal plexus extends under both in the cirrhotic patient. It should be clear that
these anorectal varices are clinically and anatom-
ically distinct from hemorrhoids and that confus-
ing them can have fatal consequences for the
patient [5].
A key point to remember about the anatomy
J. M. Tatum · E. J. Ley (*)
of hemorrhoids is that they are not innately
Department of Surgery, Cedars Sinai Medical Center,
Los Angeles, CA, USA pathological; they are not the same as anorectal
e-mail: Eric.Ley@cshs.org varices and are often vaguely described by both

© Springer International Publishing AG, part of Springer Nature 2019 349

C. V. R. Brown et al. (eds.), Emergency General Surgery, https://doi.org/10.1007/978-3-319-96286-3_30
350 J. M. Tatum and E. J. Ley

patients and junior trainees. The perineum mer- Diagnoses and Evaluation

its careful examination by an experienced clini- of Hemorrhoid Disease
cian capable of distinguishing between
prolapse, fissure, mass, papilloma, polyp, Classification
abscess, fistula, melanoma, inflammatory bowel
disease, varices with an acute or chronic pathol- Hemorrhoids are first classified by position rela-
ogy, and any of a variety of other conditions tive to the dentate line, proximal being internal
[2]. The single most important consideration and distal being external. The site of origin deter-
when considering perineal anatomy is that mines the involvement of the superior vs. inferior
someone familiar with it performs or supervises hemorrhoidal plexus, respectively, but more
the clinical examination to avoid misdiagnosis importantly it determines symptoms. External
and mistreatment. hemorrhoids underlie somatically innervated
skin and when thrombosed are associated with
dramatic and incapacitating pain. Internal hemor-
Pathophysiology of Disease rhoids are covered by mucosa and are relatively
painless. Hemorrhoids may involve both the
The hemorrhoid cushions become pathological internal and external components at any of the
and present to the clinician when they experi- three anatomic locations; these are referred to as
ence venous congestion or clot with subsequent “mixed” hemorrhoids.
prolapse with or without incarceration or stran- Internal hemorrhoids are graded on a four-tier
gulation, bleeding from ulceration, thrombosis, scale by severity of prolapse as shown in
or pain [2, 6]. Factors contributing to pathologi- Fig.  30.1. Grade I hemorrhoids are defined by
cal hemorrhoid conditions include habitual non-prolapsing prominent vessels, Grade II as
straining during bowel movements to achieve prolapsing when bearing down with spontaneous
complete rectal emptying. Western low-fiber reduction, Grade III prolapse with bearing down
diets are often linked to this behavior and the requiring manual reduction, and Grade IV as
disease [2]. non-reducible prolapse [4]. Bleeding may occur
from hemorrhoids of any grade.

Epidemiology
Symptoms
Many people suffer from enlarged hemor-
rhoids although the exact number is unknown Hemorrhoids are asymptomatic in more than
as it is often a self-limited condition or one for 40% of people with pathological hemorrhoids.
which patients do not seek medical care. The The most common symptoms are bleeding and
prevalence is estimated to be more than 4% of pain [8].
the adult US population [7]. Hemorrhoids are
more common in Caucasians with the highest  ymptoms of Internal Hemorrhoids
S
prevalence between ages 45 and 65  years. Grades I–III internal hemorrhoids often present
Hemorrhoids in the young are uncommon, and with complaints of bleeding on toilet paper or
alternative explanations for bleeding must be spotting in the toilet after a bowel movement.
dutifully sought if the diagnosis is not Other symptoms include pruritus, incontinence,
certain. difficulty cleaning the perineum after bowel
30  Diagnosis and Treatment of Acute Hemorrhoidal Disease and the Complications of Hemorrhoidal 351

Fig. 30.1  Illustration of

Grades I–IV internal
hemorrhoids

Grade I: Non-prolapsing
prominent vessels

Grade II: Prolapsing with

valsalva, spontaneous
reduce

Grade III: Prolapse with

valsalva, require manual
reduction

Grade IV: Prolapsed, non-

reducible
352 J. M. Tatum and E. J. Ley

movement, or concern of prolapse. Grade IV Table 30.1 American Society of Colon and Rectal
Surgeons practice parameters
internal hemorrhoids present with more promi-
nent complaints of the same symptoms. 1. The evaluation of patients with hemorrhoids should
include a directed history and physical examination
Thrombosed internal hemorrhoids can present
Grade of recommendation: strong recommendation
with pain or more commonly symptoms of dis- based on low-quality evidence 1Ca
comfort, difficulty completely evacuating, or anal Source: Rivadeneira et al. [7]
leakage. The prolapsed Grade IV hemorrhoid can a
Recommendations made using GRADE system [9]
become incarcerated or strangulated with subse-
quent thrombosis, necrosis, and bleeding.
nosis [7]. These examinations are aided by proper
 ymptoms of External Hemorrhoids
S patient positioning: knee to chest while in prone
External hemorrhoids are not graded. In the jackknife or left lateral position [3] (Table 30.1).
absence of thrombosis, external hemorrhoids
often go unnoticed in the absence of bleeding.  iagnostic Procedures, Imaging,
D
Thrombosis of an external hemorrhoid (TEH) is and Laboratory Testing
excruciating. If not evacuated, the TEH pains will Laboratory tests are not indicated unless there is
generally abate over a few days [2, 8]. a clinical concern of anemia from blood loss,
concern for pelvic sepsis, or diagnostic uncer-
tainty regarding soft tissue infection or abscess of
Initial Evaluation the perineum. We do recommend coagulation
tests in patients with end-stage liver disease or on
Hemorrhoids can usually be diagnosed with an oral anticoagulants and will also consider them in
oral history and a physical examination. In gen- pregnant patients with bleeding from pathologi-
eral, any anorectal condition, especially those cal hemorrhoids.
involving bleeding, require a digital rectal exami- Imaging is rarely indicated in the setting of
nation and often anoscopy on first presentation. uncomplicated hemorrhoidal disease, and when
The one exception to this rule is in patients with indicated it is used to aid in the evaluation of pel-
prominent pain and no external signs of throm- vic sepsis or to evaluate for diagnoses other than
bosed or prolapsing hemorrhoids. Provided these hemorrhoids such as abscess, necrotizing soft tis-
patients have minimal signs of bleeding, infec- sue infection, or rectal malignancy. Imaging
tion, or inflammatory bowel disease, the diagno- studies to be considered in this setting include CT
sis of anal fissure can be considered. If anal scan of the abdomen and pelvis, intrarectal ultra-
fissure is the most likely diagnosis from history sonography, or barium enema.
and visual examination, the DRE may be delayed
until a later date and treatment of the fissure has Endoscopy
commenced. Care must always be taken in per- Formal endoscopic (colonoscopy or sigmoido-
forming DRE or anoscopy on patient with end- scopic) evaluation of the colon is indicated in
stage liver disease as it may cause intractable selected patients with hemorrhoidal bleeding
bleeding. All other patients require a DRE +/− including those with iron deficiency anemia, +
anoscopy for the initial diagnosis of hemorrhoids. fecal occult blood test, age ≥ 50 years in patients
Anoscopy is superior to flexible sigmoidoscopy without colonoscopy within 10  years, and
for initial diagnosis as the hollow barrel of the age ≥ 40 years in those with a concerning family
side-viewing endoscopy which allows hemor- history and no recent colonoscopy and those with
rhoids to be viewed from the sidewall which symptoms or signs concerning for inflammatory
facilitates careful inspection and a specific diag- bowel disease or malignancy [7] (Table 30.2).
30  Diagnosis and Treatment of Acute Hemorrhoidal Disease and the Complications of Hemorrhoidal 353

Table 30.2 American Society of Colon and Rectal Table 30.3 American Society of Colon and Rectal
Surgeons practice parameters Surgeons practice parameters
2. Complete endoscopic evaluation of the colon is 3. Dietary modification consisting of adequate fluid
indicated in select patients with hemorrhoids and and fiber intake is the primary first-line nonoperative
rectal bleeding therapy for patients with symptomatic hemorrhoid
Grade of recommendation: strong recommendation disease
based on moderate-quality evidence 1Ba Grade of recommendation: strong recommendation
Source: Rivadeneira et al. [7] based on moderate-quality evidence 1Ba
a
Recommendations made using GRADE system [9] Source: Rivadeneira et al. [7]
a
Recommendations made using GRADE system [9]

Nonoperative Treatment use of micronized and purified flavonoid with or

of Hemorrhoid Disease without anti-inflammatory medications to treat
hemorrhoid symptoms [4]. These medications
Hemorrhoids amenable to nonoperative therapy are not approved by the Food and Drug
rarely present to the acute care surgeon as their Administration for use in the United States.
acute management and disposition are well
within the scope of practice of the emergency
room physician or primary care provider. On the Topical Treatments
occasion when nonoperative hemorrhoids pres-
ent to the surgeon, there are multiple noninvasive Multiple over-the-counter remedies exist to treat
options that can be considered and recommended; hemorrhoids and hemorrhoid symptoms. There
these interventions are also part of the treatment are no studies that support the use of over-the-
of those who do require an acute intervention. counter therapy to reduce either bleeding or pro-
lapse; however, some have been shown to reduce
symptoms and inflammation [4]. Topical cortico-
Lifestyle Modifications steroids can be used, with caution, over a short
duration to reduce inflammation. Other over-the-
The avoidance of constipation with adequate counter devices, creams, ointments, or gels may
hydration and fiber intake is of paramount impor- be recommended for use at the patients’ discre-
tance both in preventing trauma to the hemor- tion, and we have found, anecdotally, that gels
rhoidal plexus and preventing prolapse [2, 4]. with a local anesthetic do improve patients’
Diarrhea can be equally problematic for those with symptoms. The most effective topical therapy is
Grades III–IV as continence is compromised as is warm water during a sitz bath or shower to main-
the ability to maintain good hygiene. Adequate tain good hygiene and minimize trauma.
dietary fiber is again of paramount importance.
Sitz baths are an equally important mechanism of
hygiene, especially in those with Grades III–IV or Operative Treatment of External
external hemorrhoids (Table 30.3). Hemorrhoid Disease

Thrombosed External Hemorrhoids (TEH)

Oral Medications
TEH frequently present as an acutely painful,
Oral fiber supplements should be recommended sometimes bleeding, anal mass. Thrombosis gen-
at a dose that optimizes stool consistency and erally occurs after unusually intense straining
regularity. European studies have examined the from lifting, prolonged sitting, or constipation.
354 J. M. Tatum and E. J. Ley

These are sometimes amenable to conservative Non-thrombosed External

treatment with oral analgesia, sitz baths, and the Hemorrhoids
application of topical anesthetics +/− topical
nifedipine. Pain will generally resolve over a In the absence of thrombosis or frank hemor-
2–3-day period and swelling will resolve in rhage, external hemorrhoids should not be oper-
7–10 days [10]. ated on in an acute setting. Large or troubling
If the patient presents within 72  h (ideally external hemorrhoids may be considered for
≤48 h) of thrombosis, surgical evacuation may be excision in an elective setting, usually by a
considered. Patients with severe ulceration and colorectal surgeon experienced in this nonstan-
bleeding, rupture, or signs concerning for infec- dard procedure.
tion should undergo excision within 72  h of
symptom onset. This procedure should be per-
formed through an elliptical incision overlying Operative Treatment of Internal
the thrombosed hemorrhoid in a radial orienta- Hemorrhoids (Fig. 30.2)
tion to the anus after a four-finger stretch of the
anus and rectum [6]. The thrombosed hemor- Thrombosed Internal Hemorrhoids
rhoidal plexus is ligated and excised. We prefer to
perform this procedure in the operating room Thrombosis of internal hemorrhoids may occur,
under general anesthesia. The wound is generally usually as a complication in a prolapsed Grades
left open and the specimen is always sent to III–IV hemorrhoid. Surgery is rarely recom-
pathology. Antibiotics can be prescribed at the mended unless there is true strangulation.
discretion of the surgeon; we recommend them Surgical treatment if necessary is a formal exci-
when there is concern of infection prior to sur- sion hemorrhoidectomy of some, or all, of the
gery as well as in patients with diabetes and in diseased hemorrhoidal plexuses.
those with obvious poor hygiene. Bedside inci-
sion and evacuation of the TEH do provide symp-
tomatic relief if done early. This relief is Internal Hemorrhoids
frequently complicated by recurrence or re-
bleeding; however, rates of recurrence after Office-Based Procedures
excision and incision considered together are
­ Sclerotherapy: Sclerotherapy of Grades I–II
lower than after conservative management [10]. internal hemorrhoids is accomplished in the non-
Rubber band ligation of a TEH will result in anesthetized patient with no other anal or rectal
excruciating pain on the part of the patient. pathology by the application of a variety of scle-
Rubber band application to an external hemor- rosing agents into the hemorrhoid while avoiding
rhoid is contraindicated in all cases. the hemorrhoidal vein [2]. Potential complica-
Patients with resolved TEH often develop skin tions include abdominal pain, impotence, nerve
tags which can be troubling in terms of hygiene injury, and hepatic abscess. We do not recom-
or appearance. These may be excised by a non- mend that this procedure be performed in an
acute care surgeon in an elective setting acute setting by a non-expert.
(Table 30.4). Infrared coagulation: Heat is applied to Grades
I–II internal hemorrhoid resulting in coagulation
Table 30.4 American Society of Colon and Rectal and eventual obliteration. If an external compo-
Surgeons practice parameters nent is present, then anesthesia is required.
5. Most patients with thrombosed external Rubber band ligation: Application of a rubber
hemorrhoids benefit from surgical excision within band at the base of the internal hemorrhoid results
72 h of the onset of symptoms
in ischemic necrosis and amputation of the
Grade of recommendation: strong recommendation
based on low-quality evidence 1Ca plexus. The procedure can be accompanied by
Source: Rivadeneira et al. [7] pain, increasing in amount as proximity to the
a
Recommendations made using GRADE system [9] dentate line increases. Rubber bands may not be
30  Diagnosis and Treatment of Acute Hemorrhoidal Disease and the Complications of Hemorrhoidal 355

Bleeding/painful/incarcerated hemorrhoid

<72 h evacuate

Strangulated internal hemorrhoid Thrombosed external hemorrhoid

(TEH) >72 h non-operative management
<72 h >72 h non-operative management

If possible complete or partial If not possible/reasonable

hemorrhoidectomy non-operative management

Fig. 30.2  Decision algorithm for acute painful hemorrhoids

Table 30.5 American Society of Colon and Rectal consultation of a colorectal surgeon first.
Surgeons practice parameters Antibiotics are not required prior to the perfor-
4. Most patients with grades I, II, and III hemorrhoid mance of hemorrhoidectomy; however, we do
disease in whom medical treatment fails may be administer them to patients with signs of infec-
effectively treated with office-based procedures, such tion, diabetics, and smokers as hemorrhoidec-
as banding, sclerotherapy, and infrared coagulation.
Hemorrhoid banding is typically the most effective tomy in these patients is associated with a higher
option risk of postoperative complications [11].
Grade of recommendation: strong recommendation Closed Hemorrhoidectomy: Local anesthesia
based on moderate-quality evidence 1Ba mixed with epinephrine is used to infiltrate the
Source: Rivadeneira et al. [7] anal submucosa. A plane is developed between
a
Recommendations made using GRADE system [9] the internal sphincter and the hemorrhoidal tissue
which is then excised and the pedicle ligated. All
applied distal to (or ideally within 1 cm of) the incisions are closed both internally and on the
dentate line. There is a risk of hemorrhage as the skin. Complications may include incontinence,
banded hemorrhoid sloughs 1–2 weeks post pro- pelvic sepsis, or hemorrhage.
cedure. Rubber band ligation requires only sim- Open Hemorrhoidectomy: It is similar to
ple mechanical equipment which is intuitive to closed hemorrhoidectomy without submucosal
use and should be part of the scope of practice of or skin closure. Both procedures have a risk of
the acute care surgeon. This is our preferred subsequent stenosis of the anal canal, and care
method of intervention if called to address bleed- must be taken to leave bridging tissue between
ing internal hemorrhoids. hemorrhoid plexuses. Open hemorrhoidectomy
Other local interventions have been described is sometimes indicated in a subacute setting to
including cryotherapy and diathermy. These treat necrotic hemorrhoids or those with intrac-
treatments are beyond the scope of an acute care table bleeding not amenable to other interven-
surgery text (Table 30.5). tions. You must remember to liberally dilate the
anal canal before performance of these proce-
Operative Treatment of Internal dures to reduce the risk of subsequent stenosis.
Hemorrhoids Harmonic/LigaSure Hemorrhoidectomy:
Multiple Procedures for the Operative Treatment Planes are developed in the same fashion as the
of Internal or Mixed Hemorrhoids: Each requires above procedures, and dissection/resection is
specialized knowledge, and each has potentially achieved with the energy device of the surgeons
devastating complications to the surrounding tis- choosing. This is our preferred method to treat
sue and patient. Catastrophic bleeding from an intractable bleeding of necrotic internal hemor-
internal hemorrhoid should nearly always be rhoids in the acute setting.
amenable to local therapies such as banding or Stapled Hemorrhoidopexy: Use of modified
simple open hemorrhoidectomy. Attempting to circular stapler is used to resect a segment of the
perform a complex operative procedure in an rectal mucosa and submucosa after approxima-
acute setting is not recommended without the tion with a purse-string suture. We do not recom-
356 J. M. Tatum and E. J. Ley

Table 30.6 American Society of Colon and Rectal necrosis, or pelvic abscess. Any of these compli-
Surgeons practice parameters
cations can be rapidly fatal if not diagnosed early
6. Surgical hemorrhoidectomy should be reserved for and treated aggressively. Prompt diagnosis,
patients who are refractory to office procedures, who
are unable to tolerate office procedures, who have
resuscitation, and treatment which may include
large external hemorrhoids, or who have combined operative exploration, drainage and/or, resection
internal and external hemorrhoids with significant may be necessary. A high index of suspicion
prolapse (grades III to IV) should be maintained by the acute care surgeon
Grade of recommendation: strong recommendation when consulted on the patient who recently
based on moderate-quality evidence 1Ba
underwent operative hemorrhoidectomy.
Source: Rivadeneira et al. [7]
a
Recommendations made using GRADE system [9]
Acknowledgments  We would like to acknowledge Rex
mend this device for use in the acute setting or by Chung, MD of the Department of Surgery at Cedars-Sinai
Medical Center, for his contribution of illustrations to this
a non-colorectal surgeon. The procedure can lead chapter.
to incontinence or infection. If the patient’s hem-
orrhoids are accompanied by significant rectal
prolapse, the patient deserves to have consulta-
tion with a colorectal surgery prior to any non- References
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