The following is a quick summary of treatment for internal hemorrhoids by grade:
Grade I hemorrhoids are treated with conservative medical therapy and avoidance of nonsteroidal anti-inflammatory drugs and spicy or fatty foods
Grade II and grade III hemorrhoids are initially treated with nonsurgical procedures
Very symptomatic grade III and grade IV hemorrhoids are best treated with surgical hemorrhoidectomy
Treatment of grade IV internal hemorrhoids or any incarcerated or gangrenous tissue requires prompt surgical consultation
External hemorrhoid symptoms are generally divided into problems with acute thrombosis and hygiene/skin tag complaints. The former respond well to office excision (not enucleation), whereas operative resection is reserved for the latter. Remember that therapy is directed solely at the symptoms, not at aesthetics. Treatment of thrombosed hemorrhoids is then aimed at pain relief. If symptoms are minimal, mild analgesics, sitz baths, proper anal hygiene, and bulk-producing agents suffice. Regulation of diet and avoidance of prolonged straining at the time of defecation comprise the initial treatment of mild symptoms of bleeding and protruding hemorrhoids. A high-fiber diet (≥ 25-35 g daily) with raw vegetables, fruits, whole-grain cereals, and hydrophilic bulk-forming agents can reduce and often alleviate all symptoms. However, if pain is severe, excision of the thrombosed hemorrhoids may be beneficial.
When performed well, operative hemorrhoidectomy should have a 2%-5% recurrence rate. Nonoperative techniques, such as rubber band ligation, produce recurrence rates of 30%-50% within 5-10 years. However, these recurrences can usually be addressed with further nonoperative treatments.
Acutely thrombosed external hemorrhoids may be safely excised in the emergency department in patients who present within 48-72 hours of symptom onset. Infiltration of a local anesthetic containing epinephrine is followed by elliptical incision and excision of the thrombosed hemorrhoid, its accompanying vein, and overlying skin. Simple incision and clot evacuation is inadequate therapy and should not be performed.
Occasionally, the internal hemorrhoidal tissue may be incarcerated outside the anal canal, resulting in spasm of the anal sphincter, massive local edema, and severe pain. In such circumstances, the edematous tissue may be injected with a local anesthetic containing epinephrine. Dissipation of the edema by manual compression then can be achieved, allowing reduction of the prolapsed tissue. Observation and use of stool softeners with tub soaks usually allow the acute episode to resolve without surgery because the hemorrhoidal vessels have been naturally thrombosed. The thrombosed internal hemorrhoids sclerose and may not require surgery. If symptoms persist or recur, three-quadrant hemorrhoidectomy may be necessary.
The circular stapled hemorrhoidectomy is a new technique indicated for the elective treatment of circumferential third-degree and fourth-degree hemorrhoids that are not permanently prolapsed.
For more on the treatment of hemorrhoids, read here.
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