Internal hemorrhoids are a common problem that afflict a large proportion of the United States population over the age of 50. Hemorrhoids, correctly called anal cushions, are normal anatomy of the anal canal and are usually asymptomatic. Symptomatic hemorrhoids, nonetheless, result in nearly 3.5 million physician visits per year at an estimated cost of $500 million. It is thus important for primary care physicians, gastroenterologists, and surgeons to be able to accurately diagnose and effectively treat hemorrhoids. This educational DVD will focus on the safe, effective, and well-tolerated endoscopic therapy of symptomatic hemorrhoids. Specifically, we will first describe the anatomy, classification and grading, symptomatology, and evaluation of hemorrhoids, and then demonstrate the endoscopic treatment principles and techniques. Internal hemorrhoids are located in the subepithelial space of the anal canal. They consist of connective tissue cushions surrounding the direct arteriovenous communications between the terminal branches of the superior rectal arteries and the superior, middle, and inferior rectal veins. Anal subepithelial smooth muscle arises from the conjoined longitudinal muscle layer. It passes through the internal anal sphincter and inserts into the subepithelial vascular space. The suspended smooth muscle creates a hemorrhoid cushion that, in turn, contributes to resting anal pressure. Increases in redundant tissue results in progressive hemorrhoidal protrusion below the dentate line. The pathogenesis of enlarged, prolapsing cushions is generally unknown. Proposed contributing factors include increased intra-abdominal pressure, redundant mucosal prolapse, low-fiber diet, family history of hemorrhoids, and pregnancy. Patients with symptomatic hemorrhoids commonly present with one or more complaints of rectal bleeding, prolapse or protrusion, perianal itching, swelling, mucoid discharge or soiling, and pain. Enlarged internal hemorrhoids cause most of these symptoms. Abnormal swelling of the anal cushions, stretching of suspensory muscles, and dilation of the submucosal arterial venous plexus result in the prolapse of upper anal and lower rectal tissue through the anal canal. This tissue is easily traumatized, leading to bright red bleeding that may frequently drip into the toilet bowl or onto tissue paper. Bleeding is thus the most common symptom. Prolapse of the rectal mucosa may lead to deposition of mucus on the perianal skin. This may cause perianal itching due to inadequate hygiene, minor incontinence, or perianal dermatitis. External hemorrhoids classically present with pain that is associated with a thrombosed external hemorrhoid. Understanding of the hemorrhoidal anatomy is critical in its treatment. Hemorrhoids are defined as internal or external according to their position relative to the dentate line. The dentate line is the junction of skin and mucosa located a few centimeters into the anus. It is the site of the white anal papillae. The anoderm below the dentate is highly innervated and is exquisitely sensitive to mechanical, electrical, or thermal painful stimuli. External hemorrhoids arise from the inferior hemorrhoidal plexus and are located beneath the dentate line. They are covered with squamous epithelium, which contains numerous pain receptors. External skin tags may be confused with external hemorrhoids. Skin tags represent the residual excess skin associated with prior thrombosis of external hemorrhoids, not the hemorrhoids themselves. Internal hemorrhoids are located in the subepithelial space of the anal canal. The rectal mucosa of internal hemorrhoids have no sensory perception. This area feels pressure and heat, but not pain. Hemorrhoids are further defined in terms of their grading. Accurate classification of hemorrhoids is important in order to guide optimal treatment decisions. There is no widely used classification system for external hemorrhoids. Internal hemorrhoids are classified according to their degree of prolapse. Internal hemorrhoids that are not prolapsed, but bleed, are designated as grade 1. Those that prolapse out of the anal canal with defecation or straining, but are able to be reduced spontaneously, are grade 2 hemorrhoids. Prolapsed hemorrhoids that require manual reduction into their normal position are grade 3 hemorrhoids. Prolapsed internal hemorrhoids that cannot be reduced are grade 4. They usually include both internal and external components and are confluent from skin tag to inner anal canal. Acutely thrombosed incarcerated internal hemorrhoids involving circumferential rectal mucosal prolapse are classified as grade 4 hemorrhoids as well. Endoscopic treatment is generally targeted to patients with symptomatic grades 2 to 3 hemorrhoids who do not respond to conservative medical management. It is also recommended that patients should undergo either flexible sigmoidoscopy or colonoscopy to exclude other causes of hemorrhoidal symptoms. Rectal varices caused by portal hypertension are distinct from hemorrhoids. Bleeding can also be seen in proctitis, radiation proctopathy, inflammatory bowel disease, or neoplasm. Hemorrhoid protrusion must be distinguished from rectal prolapse or condyloma. Eczema or fungal infections may also cause perianal itching. Anal fissures, fistulas, perianal abscess, or infection may similarly present with rectal pain. Beyond grading based on prolapse, it is important to endoscopically recognize the different hemorrhoidal stigmata. Hemorrhoids may be intermittently symptomatic, and therefore endoscopic appearance may vary. Endoscopically, hemorrhoids may be visualized by active bleeding, hemorrhoidal ulceration or erosion, or they may show prominent capillaries or hyperemia. Standard medical recommendations for hemorrhoids are to add dietary fiber and fluids in order to bulken stool and avoid straining. Over-the-counter topical agents and suppositories are used empirically. Additional treatment aims to optimize anal hygiene. Patients are also advised to avoid increased risk of bleeding by eliminating blood thinning agents. The goals of endoscopic or surgical hemorrhoidal therapy are to reduce mucosal prolapse by removing excess tissue or by inducing secondary fibrosis, as well as obliterate venous plexus. Various endoscopic and endoscopic treatments for internal hemorrhoids that are refractory to medical therapy are available. They include band ligation, coagulation therapy with heater or gold probe or BICAP therapy, injection sclerotherapy, infrared coagulation, cryotherapy, and radiofrequency ablation. This educational DVD will focus on endoscopic treatment with band ligation and coagulation therapy with gold probe, as well as anoscopic therapy with injection sclerotherapy and infrared coagulation. These treatments should not be performed in patients who are immunocompromised, have rectal prolapse, inflammatory bowel disease diagnosis, anal or rectal carcinoma, portal hypertension, coagulopathy, or thrombocytopenia. Treatment of pregnant or immediate postpartum patients must be approached with great caution. Endoscopic band ligation is a well-established, safe, and effective technique for grades 1 to 3 hemorrhoids. Band ligation has been compared to other anoscopic or endoscopic hemorrhoidal treatment modalities, such as infrared coagulation or injection sclerotherapy, and has been shown to be more effective in fewer treatment sessions. It has become the mainstay of endoscopic treatment for bleeding or prolapsing internal hemorrhoids that are unresponsive to medical therapy. The technique is an extension of the application of esophageal variceal band ligation. It relies on the tightening of redundant tissue mucosa, connective tissue, and blood vessels to induce submucosal fibrosis and scarring. Redundant rectal mucosal tissue is suctioned into the banding device, and bands are then released by pulling a wire at the tip of the endoscope. Treatments can be performed with both an end-on antiflex view within the anal canal above the dentate line, or in a retroflex position within the rectum above the dentate line. A diagnostic upper endoscope is preferable to a sigmoidoscope because retroflexion is easier to perform and the procedure is better tolerated with a smaller diameter instrument. Studies have demonstrated that deployment of up to three bands is safe. If the patient experienced pain with the endoscopic suctioning, then the band should not be deployed, as it is likely that squamous epithelium is involved in the suction. The following is a case demonstration of endoscopic band ligation of hemorrhoids. The 78-year-old man presents with daily rectal bleeding. And here we are just completing the colonoscopy, examining the distal rectum very closely. And here's the image on rectal flexion. We typically perform banding using the Clear-Q banding equipment. This is the standard banding accessory that we typically use to perform esophageal-parietal banding. Here we are just going to use a diagnostic upper endoscope. And standard placement of the banding accessory is used. It is important to place the banding cap snugly to the tip of the endoscope. And the pulling wire should be in a slightly diagonal direction from 10 to about 5 o'clock. And the banding equipment has now been placed in the endoscope. In order to perform banding of hemorrhoids, we typically do not lock the controller of the banding. So we let it loose. This is important as we will perform the banding in a rectal flexion queue. If we had locked the bander, then there is a tendency for the banding to be released prematurely. So here we are inserting the banding equipment. Relax. And now the banding has a lot of lubricant. This can be accomplished easily. So at this point, we would retroflex the endoscope similarly as we would perform examination of the distal rectum. So here we are ready to perform banding. And typically we would band slightly proximal to the dented line. Care is given not to include the dented line. So here we are just looking for areas with more visible hemorrhoidal plexi. And you can appreciate the dented line in the far end of the view. And we will place the band here. At this point, we would ask the patient whether he had felt any pain sensation. Sir, do you have any pain? No? We would then lock the banding equipment and we would place one band. And one band had been deployed. Typically, there would be slight bleeding as the banding caused a sudden increase in the blood pressure of the capillaries and caused a rupture. But this bleeding usually is self-controlled. So let's watch. Typically, we would perform two or three bandings in one session. So we have put one nice band at that location. And we are looking for another area. And here we are about to deploy the second band. Sir, do you have any pain? No. Two bands have been deployed. Again, the same effect was seen. Minimal bleeding is typically seen. And a nice polyploid structure has been formed by the band. And we are going to perform another banding here. Again, care is given not to bend the dented line or the squamous mucosa. Again, we can see the dented line at the top part of the bander. So we are going to push the endoscope slightly. And then suction. Sir, do you have any pain? No. And here three bands have been safely deployed without causing any pain. Do you have any pain at all? None. And we typically would stop. We would then ask our patients to return to our endoscopy unit in about two to three weeks, but not to return if there is no further bleeding. So three bands have been deployed, and we are going to stop the procedure at this point. On an anterflexion view, it can be appreciated that the bands have been deployed proximal to the dented line. So one band at 2 o'clock, another band at 12, and another band at 9 o'clock. They were all slightly proximal to the dented line. It is anticipated that patients may experience a dull ache or fullness due to banded hemorrhoidal tissue within the rectum. Patients should be instructed to avoid straining, as this may lead to tissue prolapse, rectal spasm, or pain. The most common complication of endoscopic band ligation is pain, which is reported in 5 to 60 percent of treated patients. Pain following the procedure tends to be relatively minor, however, and can be satisfactorily managed with sitz baths and over-the-counter analgesics. Pain associated with high fever and urinary tension following endoscopic band ligation, however, is of great concern, suggesting necrotizing pelvic sepsis. Such patients require emergency examination under general anesthesia with radical debridement of all necrotic tissue. This complication is rare, and there is no standard recommendation for empiric antibiotic use post-banding at this time. Other potential complications include urinary retention, band slippage, prolapse, and thrombosis of adjacent hemorrhoids, and bleeding. Self-limited intermittent bleeding up to 3 to 5 days after treatment is expected. Severe bleeding requiring intervention, however, may occasionally occur when the eschar from the band sloughs. This usually occurs 1 to 2 weeks post-treatment. This is an example of a patient who presented 10 days following an endoscopic band ligation procedure with rectal bleeding. There was a large rectal ulcer visualized with a visible vessel at the prior band ligation site. An endoscopic endoclip was successfully deployed with resolution of the patient's bleeding. Coterie techniques rely on the coagulation, occlusion, and obliteration of the hemorrhoidal plexus. The bipolar generator setting is between 12 to 16 watts with 1 second pulse duration. The base of the internal hemorrhoid segment around the dentate line is coagulated with 4 to 7 pulses per hemorrhoid segment. Three hemorrhoid segments are treated at each session in the different quadrants. The treatment is repeated every 4 to 6 weeks for generally 3 to 5 treatment sessions until all internal hemorrhoid segments are obliterated or reduced to grade 1 in size with symptom control. Patients may experience a mild stinging sensation during application of the gold probe but is otherwise well tolerated. Sclerotherapy has been successfully used for grades 1 to 2 internal hemorrhoids. A submucosal injection of 5 milliliters of sclerosants at the base of the hemorrhoidal complex can cause acute vessel thrombosis, sclerosis of connective tissue, and subsequent fibrosis and fixation of the overlying mucosa. Complications are rare and include pain, hematoma, impotence, and abscess. Infrared photocoagulation focuses infrared radiation from a tungsten halogen lamp via a polymer probe tip. The patient is never exposed to electrical current and does not have to be grounded. The infrared coagulation light is generated by a 15-volt tungsten halogen lamp and transmitted down the solid quartz glass light guide. The treatment wand is covered by a disposable cover which eliminates the possibility of transmission of infectious diseases. Infrared energy coagulates and seals this venous plexus and tethers the mucosa to the muscularis, thereby reducing blood flow to the hemorrhoid. This reduced blood flow causes the hemorrhoid to shrink and prevents future prolapse. Hemorrhoids are usually found in three of the four quadrants. Multiple hemorrhoids can be treated in each visit. The patient should be placed in the knee chest or left lateral position with the knees elevated towards the chest. A thorough evaluation should be made of the anorectum. Using gloves, the anal area is lubricated and the anoscope is carefully inserted. The bevel or slide inside the anoscope is designed to maximize exposure to the quadrant faces. Therefore, rotation of the anoscope is required in order to observe all four quadrants. The obturator is placed prior to each rotation to minimize patient discomfort. Treatment with the infrared coagulator does not involve application to the hemorrhoid itself, but rather to the bulging mucosa above the hemorrhoid. Two patterns of treatment are widely used. The four-point diamond pattern or the three-to-four-point semicircle. Either is effective. The distal tip of the light guide is angled and can be rotated 360 degrees within the hand applicator to ensure proper placement. Although the procedure is essentially painless, with each exposure, the patient may experience a brief sensation of heat and should be informed of this before starting. The timer should be set at 1 to 1 1⁄2 seconds, just enough to achieve coagulation as evidenced by a uniform whitish circular eschar. The first exposure is made by depressing the trigger and not releasing it until the lamp goes off completely, a function of the timer. It is essential to maintain face-to-face contact between the tip and the mucosa using light mechanical pressure until the light goes out completely. The tip should not be embedded in the tissue. Allow 5 to 10 seconds between exposures to avoid overheating the lamp. Any adherent debris can be wiped from the tip with a damp gauze pad between exposures. Subsequent exposures can be made by leaving a gap of 2 to 3 millimeters between treatment areas. At 1 1⁄2 seconds exposure time, the depth of coagulation is 1 1⁄4 millimeters. Most symptomatic internal hemorrhoids respond to medical management alone. Various nonsurgical treatments, such as described in this educational DVD, are available for bleeding or protrusion grades 1 to 3 internal hemorrhoids that remain symptomatic despite medical therapy. They have established safety and efficacy. External hemorrhoids and grade 4 internal hemorrhoids are usually not amenable to endoscopic or anoscopic treatment and require surgical intervention for severe or persistent symptoms. Surgery should also be considered in patients whose symptoms are refractory despite the aforementioned therapies, when nonsurgical treatments are contraindicated, or if they are unable to adhere to multiple treatment sessions.

anatomy

classification

symptomatology

evaluation

treatment

internal hemorrhoids