Endoscopic Ligations of Hemorrhoids

Hemorrhoids are swollen blood vessels in the lower rectum. They are among the most common causes of anal pathology, and subsequently are blamed for virtually any rectal complaint by patients and medical professionals alike. It can be found in both men and women and it is calculated that over 50% of ages over 50, suffer from it.

Common situations that increase pressure within the hemorrhoidal blood vessels and lead to abnormalities include the following: Straining to have a bowel movement (may be due to constipation or diarrhea), prolonged sitting (including on the toilet), lack of exercise, obesity, pregnancy, colon cancer and many others. If the hemorrhoids are small, they usually have no symptoms or you might notice some bleeding in your stools. In serious cases though, we are facing Anal Abscess,Rectal Pain, and Rectal Bleeding.

Hemorrhoids may be classified into four grades:

  • Grade I, hemorrhoids protrude into the anal canal but do not prolapse
  • Grade II, hemorrhoids prolapse with straining or defecation but reduce spontaneously (see the image below)
  • Grade III, hemorrhoids prolapse and usually require manual reduction
  • Grade IV, hemorrhoids are prolapsed and cannot be reduced and are thus at risk of strangulation and thrombosis

A doctor may be able to see diagnose if you have external hemorrhoids simply by looking. Tests and procedures to diagnose internal hemorrhoids may include examination of your anal canal and rectum:

  • Digital examination.During this exam can suggest to your doctor whether further testing is needed.
  • Visual inspection.Because internal hemorrhoids are often too soft to be felt during a rectal exam, your doctor may also examine the lower portion of your colon and rectum with a proctoscope .

You can often relieve the mild pain, swelling and inflammation of hemorrhoids with simple treatments. Often these are the only treatments needed:an over-the-counter hemorrhoid cream or suppository containing hydrocortisone, Soak your anal area in plain warm, painkillers and anti-inflammatory pills. You can also use a high in fibers diet and plenty of fluids.

Types of Hemorrhoides

  • Thrombosed hemorrhoids can be very painful. If you have one, it can hurt to walk, sit, or go to the bathroom.
  • Anal Fissures: they are indicated by sharp pain in the anal area during bowel movements
  • Skin Tags: if a blood vessel near the anus swells or becomes enlarged, it can result in a skin tag. This is because the extra skin remains even after the swelling has gone down.

Minimally Invasive techniques

Sclerotherapy: Sclerotherapy describes a procedure when a chemical is injected into the hemorrhoid, which causes it to scar and decrease in size.

Cryosurgery: In this procedure, your physician will first use local anesthesia to numb the area before applying either nitrous oxide or liquid nitrogen with a cryoprobe to freeze internal or external hemorrhoids. The physician may also tie them off (ligate) before freezing them. The hemorrhoids shrink and fall off in 2-3 weeks. There tends to be more pain after this type of treatment, and there are increased risks, such as infection and bleeding. Cryosurgery was once very common, but most physicians now opt for a different treatment due to the many potential complications of this procedure.

Infrared Coagulation: Coagulation techniques use laser or infrared light or heat. They cause small, bleeding, internal hemorrhoids to harden and shrivel. While coagulation has few side effects and may cause little immediate discomfort, it’s associated with a higher rate of hemorrhoids coming back (recurrence) than is the rubber band treatment.

Anal Dilation: Parks in the 1960’s shared his belief that hemorrhoids might be caused to a small anal canal. Anal and distal rectal dilation is the act of opening, widening, or stretching the anus with tools called anal dilators. It is often done after surgical procedures on the anus to restore the area to its normal state. Anal dilation can make passing stool more comfortable. This technique will give you an immediate relief but will not last for long.

Lateral Internal Sphincterotomy: This is a minimal and very effective operation through a very small wound. During this procedure, the surgeon partially cuts the lower third of the relatively insignificant internal sphincter through a tiny incision. This cut is made on the left or right side of the anus and it may extend to the dentate line, but not farther. In the past, surgeons preferred the stretch of anal sphincters, as an option. However, this operation can result in trauma to anal sphincters and fecal incontinence (loss of stool).

Surgical Treatments

Surgical intervention is usually required in low-graded hemorrhoids refractory to non-surgical treatment, high-graded symptomatic hemorrhoids, and hemorrhoids with complication such as strangulation and thrombosis. An operation for hemorrhoids may be performed if patient has other concomitant anorectal conditions requiring surgery, or due to patient’s preference.

An ideal operation for hemorrhoids should remove internal and external component of hemorrhoids completely, have minimal postoperative pain and complication, demonstrate less recurrence, and are easy to learn and perform. Unfortunately, none of the currently available operation achieves all the ideal conditions. So far, excisional hemorrhoidectomy is the mainstay operation for grade III-IV hemorrhoids and complicated hemorrhoids. Of note, closed (Ferguson) hemorrhoidectomy and open (Milligan-Morgan) hemorrhoidectomy were equally effective and safe, but the Ferguson method was superior to the Milligan-Morgan method in term of long time patient satisfaction and continence. Nevertheless, both techniques may lead to severe postoperative pain.

In order to minimize or avoid post-hemorrhoidectomy pain, more recent approaches including Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation and stapled hemorrhoidopexy have been adopted into the surgical treatment of hemorrhoids. In addition, perioperative care for hemorrhoids has been significantly improved. Although the endoscopic methods of band ligation, injection therapy, and bipolar cautery are familiar to most gastroenterologists, application of these techniques in the anorectal area to hemorrhoids is not part of many training programs. In conclusion, endoscopic hemorrhoid ligation is an important progress in the treatment of symptomatic internal hemorrhoids.

Endoscopic hemorrhoid ligation is simple, safe, and effective. Multiple bands can be applied in one session, and further bands can be applied in subsequent sessions if a single session fails to completely eradicate the internal hemorrhoids. The treatment success rate is high, and the long-term recurrence rate is low.Knowledge of anorectal anatomy, proper patient selection, and the management of immediate and delayed adverse events are essential.

Do they reappear?

That depends on the technique that will be used and the grade of the hemorrhoids, during the surgery. In minimally invasive treatments, there is a great chance of reoccurrence, after months or years. But even with the surgery technique, that might happen as well.

Most important role is that of a healthy diet and stay in good physical health by exercising often. Hard stools, constipation and great pressure in the area during defecation, can cause a relapse. Prevention is the most important thing when it comes to hemorrhoids.

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