1. 755 Mount Vernon Hwy NE, Ste 350 Atlanta, GA 30328 404-943-9579
2500 Hospital Blvd., Ste 410 Roswell, GA 30076
The Evaluation of Rectal Pain and Bleeding
and
The Non-Operative Treatment of
Hemorrhoids
Anal Fissures
Good morning. For a lot of us our number 1 goal is to wake up in the morning, have a great BM and to make it through the day without experiencing too much pain in our back sides. We belong to a profession of highly anal people so this mornings talk should hit close to everyone’s area of interest. You are going to see a lot of patients with rectal bleeding and or pain through out your careers. Your time and interest in this subject will vary and I hope with a bit of encouragement you can feel comfortable enough with proctology to help your patients find the help they need without going through unnecessary tests and wasting their time on treatments that either do not work or are very painful.
Hemorrhoids © 2007, Alan L. Goldman, M.D., F.A.C.S., all rights reserved

2. Objectives
Office evaluation of rectal pain and bleeding. Not all rectal complaints are due to hemorrhoids.
Signs and symptoms of hemorrhoids and anal fissure.
Etiology and epidemiology of hemorrhoids.
Treatment options.
Colorectal Cancer Screening.

3. Presenting Ano-rectal complaints
Pain-50%
Bleeding-40%
Swelling-25%
Pruritus-24%
Associated with pregnancy, constipation, diarrhea, stress, certain foods, alcohol. Hemorrhoids, anal abscess and fissures, pruritus ani, colorectal cancer, or proctitis.
Ano-rectal complaints in general practitioner visits. Gastroenterol Clin Ciol Dec;30(12):1371-4

4. Hemorrhoids by the numbers
1.Over half the population will have some hemorrhoidal symptoms by age 50 and the incidence peaks between Men and women effected equally but men are more likely to seek treatment million Americans have active hemorrhoids and as many as 5 million seek medical help each year. 3. We spend over 250 million dollars each year on hemorrhoid products. 1.5 million prescriptions. 4. More than 120,000 surgical hemorrhoidectomies are done each year. Most are unnecessary million colonoscopies are done each year.
National Digestive Disease Information Clearinghouse (NDDIC)

5. Normal Anatomy
Rectum is the cm of the lower colon above the dentate line, lined by the mucosa, a mucous secreting columnar epithelial lining. In the rectal ampulla, a space above the dentate line, there are three vascular hemorrhoidal cushions which help the muscles to maintain continence. No pain fibers here, which allows for banding. The dentate line separates the internal hemorrhoids, the anal (Morgagnian) columns, crypts, and papillae above from the anal valves and external hemorrhoids below. At the dentate line the columnar epithelium above transitions to stratified squamous the anoderm which lines the anal canal, the 3-4 cm between the dentate line and anal verge. The nerves in this area help us with continence to discriminate between gas, fluid and solid waste. Fissures occur in the anoderm. Anus or anal verge is the outlet covered by squamous epithelium, true skin rich in nerve endings. The anal canal is surrounded by the internal sphincter, an involuntary muscle, and the voluntary external sphincter. Laterally, there is the Levator Ani composed of the pubococcygeus, puborectalis, the iliococcygeus, and ischiococcygeus. Anal canal starts at proximal margins of sphincters and ends at distal end. Starts where puborectalis sling is palpable and ends as squamous mucocutaneous junction. Junction between anal canal and anal verge and skin is Hilton’s line.

6. Anal Canal
Anal columns of Morgagni: longitudinal folds just distal to dentate line
Anal crypts of Morgagni: minute pockets within anal valves; site of discharge of anal glands
Anal cushions: internal hemorrhoidal blood vessels, connective tissue, and smooth muscle that contribute to continence.
Anal papillae: raised projections of anal columns
Anal sinuses of Morgagni: depressions between anal columns
Anal valves: connection of distal ends of anal columns
Dentate line: midpoint of anal canal formed by the anal valves
Mucosa can absorb medications and lead to systemic levels.

7. What are hemorrhoids?
Internal hemorrhoids are dilated blood vessels and the surrounding tissue above the dentate line. Covered by mucosa. Direct arteriovenous communications of the terminal branches of the superior rectal and superior hemorrhoidal arteries and to a lesser extent the inferior and middle hemorrhoidal arteries. They usually form three anal cushions (right anterior, right posterior, left lateral) that help maintain continence. Symptoms come from dilation of the blood vessels and increased friability, weakening of the surrounding tissue and attachment to rectal wall, injury from passing stool, and prolapse. External hemorrhoids are below the dentate line and are covered with modified squamous epithelium and richly innervated with somatic nerves. Hemorrhoids tend to enlarge over time and prolapse.

8. Anatomy of hemorrhoids
There are internal and external hemorrhoids. Internal hemorrhoids are above the dentate line and covered with insensitive mucosa while externals are below the dentate line and covered by sensitive squamous epithelium. If the outer aspect of a hemorrhoid is covered with skin but the inner side is mucosa than the hemorrhoid is a prolapsed 3rd or 4th grade hemorrhoid. There are no pain fibers above the dentate line but lots below the dentate line. Internal and external hemorrhoids may occur together. The superior hemorrhoidal artery is a branch of the IMA, middle hemorrhoidal artery is a branch of the hypogastric artery, and the inferior hemorrhoidal artery is a branch of the pudendal artery. The superior rectal vein drains to the IMV and portal vein and can be involved with rectal varices from portal hypertension.

9. Grades The severity is graded by the degree of prolapse
Grade 1 -no prolapse and cause painless bleeding.
Grade 2 - prolapse on defecation, go back spontaneously. Seen on straining.
Grade 3 - prolapse and have to be pushed back leading to bleeding and aching pain.
Grade 4 - Can’t be pushed back leading to mucoid discharge, bleeding, pain, necrosis.
This is Banov’s grading described in 1985 and used commonly today

10. Internal Hemorrhoids

11. Prolapsed Hemorrhoids

12. Prolapsed Internal Hemorrhoids
Mucosal prolapse or eversion of the anal mucosa. Radial folds. Anodermal junction also everted.

13. What causes hemorrhoids?
Lack of soluble fiber and enough water in the diet, straining, and sitting longer than 2 minutes on the toilet which promotes prolapse of the anal cushions. Hemorrhoids may be inherited, but it may only be the behaviors and diet habits that are passed along. Failure to eat breakfast. Increase in abdominal pressure e.g. pregnancy, obesity, pelvic tumors, lifting, sitting, coughing, constipation, diarrhea, anal intercourse, aging. Correlation with decreased connective tissue strength as seen in hernias and genitourinary prolapse. Hemorrhoids can be exacerbated by excessive cleaning, rubbing, steroids, and hemorrhoid creams. Enlargement comes from the dragging of the hemorrhoids downward, weakened supporting tissue. Elevated sphincter tone increases straining.
The most common room for reading is the bathroom.
The effect of breakfast on minor anal complaints: a matched case-control study. JR Coll Surg Edinb 1997 Oct; 42(5):331-3
Ahmed SK, Thomson HJ

14. Risk Factors Past history of hemorrhoid symptoms or anal fissure
Age 30-65
Heavy lifting, prolonged sitting
Constipation/Diarrhea
Pregnancy
Failure to eat breakfeast.
Diet-Spicy food, fats, alcohol, smoking, low water intake.
Obesity
Spinal cord injuries
Increased sphincter tone
Risk factors associated with hemorrhoidal symptoms. Gastroenterol Clin Biol Dec;29(12):
Associations between hemorrhoids and other diagnoses. Dis Colon Rectum Dec;41(12):
The effect of breakfast on minor anal complaints: a matched case-control study. JR Coll Surg Edinb Oct;42(5):331-3

15. Hemorrhoid Prevention
Add fiber to prevent constipation and diarrhea
Drink lots of water
Do not ignore the urge to go
Do not strain
Limit time on commode to two minutes
Remove the library from the bathroom
7. Avoid obesity

16. Typical Hemorrhoid Symptoms
Internal Hemorrhoids
External Hemorrhoids
chronic intermittent bright red bleeding with bowel movements. On tissue, in commode, or streaked on stool surface.
Feeling of fullness, swelling, extra tissue, incomplete BM.
Irritation or itching from seepage of mucus, fecal soiling or dermatitis from hemorrhoid creams causes rash.
Pain may occur with prolapse, associated external hemorrhoids or anal fissure. Visceral nerves above dentate line sense pressure not pain.
Rectal pain from stimulation of somatic nerves of anal skin.
Bulge of tissue on anal skin
Blood on toilet tissue.
Thrombosis leading to a hard painful lump.
Skin tags left over after dilated external hemorrhoids, hemorrhoidectomy, or resolved thrombosis. Can trap stool and cause dermatitis and pruritus.

17. Diagnosis of Hemorrhoids
1. History and physical exam including perianal inspection and digital rectal exam. Done in left lateral position. Ask patient to strain. Side viewing anoscopy. Significant pain suggests thrombosis, fissure, spasm, proctitis, abscess. 2. Sigmoidoscopy-rigid vs. flexible to rule out tumors of lower colon and IBD (dull mucosa, absent vascular pattern, friable bleeding mucosa, ulcers, and pseudopolyps. 3. Manometry/endorectal ultrasound-incontinence 4. Colonoscopy for persistent bleeding, polyps, IBD 5. Anal complaints are not always hemorrhoids.
Most patients do not need colonoscopy or physiologic evaluation. Ultrasound and manometry are used before rectal surgery if incontinence, prolapse, or sphincter injury is suspected.

18. History and Physical
Name:_______________________ Date:_____________________________
Weight:______________________ BP:_______________________________
LOS:_________________________ Past RX:___________________________
CC:__________________________ Family Hx:_________________________
ROS:________________________________________________________________________
Bleeding:________________________ Pain:_______________________________
Irritation/Itching:__________________ Swelling:____________________________
Constipation:_____________________ Diarrhea:____________________________
Time on Commode:_________________ Straining:____________________________
OTC RX:__________________________ RX:_________________________________
Abdomen:______________________ Heart:____________________________
Fissure:_________________________ Sentinel Pile:_________________________
Ext Hem:__________________________________ Skin :___________________________
Int Hem: LL___ RA___ RP___ Spasm:_____________________________
Proctosigmoidoscopy;_________________________________________________________
Anoscopy:__________________________________________________________________

19. Rectal Conditions Causing Similar Symptoms
Hemorrhoids or Not?
Rectal Conditions Causing Similar Symptoms
Anal Fissure, Skin tags, pruritus ani, candidiasis.
Fistula in Ano/Perirectal Abscess, Pilonidal Disease, IBD.
3. Rectal Prolapse, Incontinence
4. Carcinoma-Adenocarcinoma, Squamous Cell, Lymphoma, Melanoma.
5. Levator Syndrome, Proctalgia Fugax, Foreign Bodies.
6. STD-Condyloma (HPV), Syphilis, Gonorrhea, Herpes, Chlamydia-LGV, Molluscum Contagiosum, Pediculosis Pubis, Trichomoniasis, Chancroid, CMV, and Scabies. Traumatic proctitis.
7. Rectal varices
Common anorectal conditions. Obstet Gynecol Dec;98(6):1130-9
Diseases of the rectum and anus: a clinical approach to common disorders. Clin Cornerstone. 2002;4(4):34-48
The diagnosis and management of common anorectal disorders. Curr Probl Surg Jul;41(7):
Common anorectal conditions: Part I. Symptoms and complaints. Am Fam Physician Jun 15;63(12):
Common anorectal conditions: Part II. Lesions. Am Fam Physician Jul 1;64(1):77-88
Haemorrhoids are too often assumed and treated. Survey of 548 patients with anal discomfort. Dtsch Med Wochenschr Sep 17;129(38):1965-9
Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma.

20. Anal Fissure
Most common position is posterior.

21. Thrombosed External Hemorrhoid

22. Anal Skin Tag

23. Pruritus Ani

24. Perianal Yeast Infection

25. Perirectal Abscess
Perianal, Ischiorectal, Intersphincteric, Supralevator location.
Caused by infection of mucus-secreting anal glands.
Tender mass at anal verge or on rectal exam.
Fistula in ano may be present. Re-examine in 2-3 weeks.
Incision and drainage may be done under local anesthesia. Limit packing to keep skin edges open.
Antibiotics are of unproven value but should be used in immunocompromised patients, sepsis, or who have valvular heart disease or prosthesis.

26. Perirectal Abscess

27. Perianal Abscess

28. Ischiorectal Absces
Ischiorectal Abscess.

29. Fistula in Ano
Cryptoglandular infections that begin in anal glands and present as abscess and then fistula. Common in Crohn’s disease.

30. Pilonidal Abscess

31. Complete Rectal Prolapse-Procidentia
Full-thickness evagination of the rectal wall with concentric folds. Anus is in normal position.

32. Anal Cancer
Most associated with HPV infections. Not prevented by condoms.

33. Condyloma Accuminata
J Virology, Nov 2004, 78; Mechanisms of Human Papillomavirus-Induced Oncogenesis
CDC MMMWR
Risk factors for anal cancer rectal intercourse, HIV, cervical and vulvar cancer.
Anal cancer
Human papilloma virus (HPV) most common STD, 6.2 million new cases/yr. Types 6,11, and 42 cause raised lesions. Types 16,18, & 31 associated with anal squamous cancer. Transmitted via skin contact, risk reduced but not prevented by condoms. Vaccine for 6,11,16, 18 females age

34. Anal Herpes
May be asymptomatic or proctitis with anal pain, tenderness, discharge, multiple blisters. Urinary retention, weak stream, impotence, and radiating pain to buttocks and thigh may occur.
Groups of small painful sores or blisters caused by herpes simples virus-1 or 2. Transmitted via direct contact leads to chronic infection. Treat with Acyclovir, Famvir, or Valtrex.

35. Rectal Syphilis
STD caused by Treponema pallidum. Can cause proctitis and painful ulcers above the dentate line in primary. Wart like Condyloma lata in second stage. Ulcerated mass may be confused with anal cancer. Bx shows spirochetes. Rx 2.4 million units of benzathine penicillin G.

36. Rectal Gonorrhea
1. Rectal discharge-mucopurulent to bloody. Proctitis with itching or tenesmus. Diarrhea.
2. Thayer-Martin culture positive.
3. Rx-250 mg Cetriaxone IM + doxycycline 100 mg po bid for 7 days.
4. Previously the most common STD affecting the anorectum. Asymptomatic 50% of males and 95% of females.

37. Chlamydia Proctitis
1. Rectal pain, bleeding, and discharge due to proctitis. Asymptomatic in 43% of males and 79% of women. Malaise, fever, chills, joint and muscular pain, vomiting. 2. Friable rectal mucosa without ulceration and matted inguinal lymph nodes. Lymphogranuloma venereum. 3. Chlamydia trachomatis Dx antibody test. 4. Rx with Doxycycline 500 mg bid for one-three weeks or one dose of Azithromycin. 5. May cause late strictures of rectum. 6. Most Common bacterial STD with 2.8 million cases per year in US.
Silent in most. Sx occur within 1-3 weeks of infection. Vaginal discharge, dysuria, PID, penile discharge, itching, pharyngitis.

38. Molluscum Contagiosum
Painless multiple umbilicated pearl-like papular skin lesions caused by a poxvirus. Effects genitals, lower abdomen, inner thighs, and buttocks.
Common infection in children.
STD which has increased in prevalence 2nd to AIDS.
Self-limited disease.
Rx includes cryotherapy, pulsed dye laser, remove the core, podofilox, tretinion cream, antivirals and immunomodulatores.

39. Molluscum Contagiosum

40. AIDS
Ulcerative disease of the anorectum often proximal to the dentate line. May bleed and burrow into muscles causing incontinence and collections of pus. Broad-based cavities with over-hanging edges and occult pockets.
Fissures in HIV secondary to rectal intercourse, diarrhea from infections or side effect of antiretroviral medications.

41. Cytomegalovirus Proctitis
Rectal bleeding, discharge, tenesmus, ulcerations, sinus tracts, enteritis.
Dx-Digene Hybrid Capture (HC) System molecular assay to detect CMV DNA from blood specimens.
CMV is a member of the herpes virus group. Proctitis typically occurs in immunosuppressed patients, including AIDS. May occur with IBD.

42. Levator Syndrome
Episodic intense pain in the high rectum, sacrum, and coccyx due to spasms of the pelvic floor muscles.
Coccydynia, proctalgia fugax (night), proctodynia.
Tender levator muscle on digital exam.
Normal work up other than abnormal EMG. Pain relieved by blocking the area between the rectum and coccyx with marcaine and steroids.
Muscle relaxants, warm baths, biofeedback, NTG, calcium channel blockers, Botox, salbutamol.
Variant is neuralgia of the pudendal nerve.
Treatment of proctalgia fugax with salbutamol inhalation. Am J Gastroenterol Apr;91(4):686-9
Short acting B2 adrenergic receptor agonist used to relieve bronchospasm.
Average attack lasts 15 minutes and stop spontaneously. More common in women around age of 50.
Work up may include manometry, ultrasonography (thickened internal anal sphincter), CT of pelvis, and colonoscopy.

43. Diagnosis of Hemorrhoids
History and physical exam including perianal inspection and digital rectal exam. Done in left lateral position. Ask patient to strain. Side viewing anoscopy. Significant pain suggests thrombosis, fissure, spasm, proctitis, abscess.
2. Sigmoidoscopy-rigid vs. flexible to rule out tumors of lower colon and IBD (dull mucosa, absent vascular pattern, friable bleeding mucosa, ulcers, and pseudopolyps.
3. Manometry/endorectal ultrasound-incontinence
4. Colonoscopy for persistent bleeding, polyps, IBD
5. Anal complaints are not always hemorrhoids.
Most patients do not need colonoscopy or physiologic evaluation. Ultrasound and manometry are used before rectal surgery if incontinence, prolapse, or sphincter injury is suspected.

44. Hypertrophic Anal Papillae

45. Colorectal Polyp

46. Rectal Villous Adenoma

47. Colorectal Cancer

48. Rectal Cancer
About 2% of patients in the Cleator series and CRC.

49. Inflammatory Bowel Disease
A. Dull mucosa and lack of normal vascular pattern. B. After Rx

50. Crohn’s Disease
Friable, bleeding, ulcers. Pseudopolyps with intervening normal mucosa.

51. Ulcerative Colitis
Diffuse mucosal chronic inflammation without intervening areas of normal mucosa.
Asacol 400 mg po QID
Fecal Lactoferrin elevated

52. Rectal Varices

53. Rectal Hemangioma
Rare cause of painless rectal bleeding. Do not biopsy. Bluish mass with dilated veins. Ct scan may show mass with pelvic phlebolites. MR may show abnormal blood flow. Rx complete resection.

54. Radiation Proctitis
Cellular injury leading to proctitis with tenesmus, mucoid rectal discharge, rectal bleeding, constipation, and decrease stool caliber. Rectal mucosal hypervascularity.

55. Raise your level of suspicion
Hemorrhoids or Not?
Raise your level of suspicion
Recent changes in bowel habits, constipation, diarrhea, small caliber.
Abdominal Pain
Weight Loss
Anemia
Family history of Colo-rectal cancer
HIV infection, genital warts-HPV, rectal sex, cigarette smoking and increased risk of anal cancer
First-degree-only hemorrhoids.
Proctitis
6. Anal cancer incidence: genital warts, anal fissure or fistula, hemorrhoids, and smoking. J Natl Cancer Inst Nov 15;81(22):

56. Bloody Stools-Lower GI Hemorrhage in Adults
Melena-Black Tarry stools due to digested blood from upper digestive tract, esophagus, stomach, and jejunum. Esophagitis, varices, gastritis, gastric ulcer, peptic ulcer, angiodysplasia, jejunal diverticulum. Rarely from a slow bleeding right colon lesion. Black licorice, lead, iron, bismuth medicines-Pepto Bismol can also cause black stools.
Hematochezia-Red or maroon-colored stools frequently foul smelling. Diverticulosis, angiodysplasia, inflammatory bowel disease, anorectal disease such as hemorrhoids, anal fissure, fistula in ano, colorectal polyps or cancer, ischemic colitis, infectious colitis, radiation enteritis, coagulopathy, aortoenteric fistula, post-polypectomy, post-hemorrhoidectomy, hemobilia, or massive UGI bleeding. Massive lower GI bleeding causes shock and may require transfusion. Diverticulosis is the most common cause of major lower GI bleeding. Blood mixed with stool, shorter duration of sx, and more episodes per month are more common with cancer, polyps, IBD when compared to hemorrhoids.
Rectal Bleeding from Hemorrhoids or Anal Fissure-Blood on tissue, on outside of formed stool, or drips into commode after bowel movement. Blood is bright red in color. Typically mild and intermittent but occasionally massive. Hemorrhoids are the most common cause of chronic intermittent minor or non-massive lower GI bleeding associated with bowel movements.
The outpatient evaluation of hematochezia. Am J Gastroenterol Feb;93(2):179-82

57. Medical Management of Hemorrhoids
Add 15 grams of fiber and drink 6-8 glasses of water each day. Avoid constipation and diarrhea. Rx IBS.
Avoid straining and prolonged sitting on commode. Remove reading materials from bathroom. Weight loss. Moderate exercise but avoid heavy lifting and strenuous exercise.
Tub baths with warm water
Keep area clean with warm water and avoid scented or colored tissue
Lubricating ointment-Vaseline
Generic 2.5% HC + 1% Pramoxine HCL-$10 limit to two weeks.
Long airline flights aggravate hemorrhoids.
Micronized, purified flavonoid fraction. Not approved by FDA
Hemorrhoid products can reduce symptoms of itching or minor discomfort but will not help significant bleeding, prolapse, or cure the problem.
Coffee, strong spices, beer, cola, excess salt may exacerbate symptoms.
Pregnant patients should lie on their side whenever possible.
Avoid alcohol and low fiber foods on airplanes. Drink water and get up and move around.

58. Fiber
1. Trials of fiber show a consistent beneficial effect for symptoms and bleeding in the treatment of symptomatic hemorrhoids. Fiber for the treatment of hemorrhoids complication: a systematic review and meta-analysis. Am J Gastroenterol Jan;101(1): About a 50% decrease in symptoms.

59. Fiber in food
A healthy diet should include 30 grams of fiber. The typical western diet contains 15 grams. Low fiber diets can cause smaller harder stools leading to hemorrhoids and diverticulosis. Fiber is an indigestible polysaccharides found in plant cells. Soluble fibers (Gums, Pectin, Hemicelluloses) dissolve in water and form a thick jelly like substance, where insoluble fibers (Cellulose and Lignin) do not. Soluble fiber improves stool bulk and water content and is the important component for proper function of the colon. Also stays in stomach longer and reduces glycemic load and cholesterol levels. Bulkier stools preventing each end of lengths of the colon closing off with the normal segmentation movement of the colon preventing rise in colonic pressure and results in less cramps and lower rectal pressure on vessels. Try a variety of fibers, increase slowly, and wait up to six weeks to see benefit.
Most foods are a combination of soluble and insoluble fibers.
Psyllium, Fresh fruit, citrus fruits, leafy vegetables, oatmeal, oat bran, figs, nuts, dried peas, beans, lentils, apples, pears, strawberries, blueberries, whole grains, wheat bran are good sources of soluble fiber.
Whole wheat, whole grain, vegetables, bran, cabbage, cauliflower, onions, spinach, carrots, peas, green beans, wax beans, broccoli, cucumber skins, peppers, berries, prunes, bananas, cherries, plums, pears, apple skins, carrots, celery, eggplant, radishes have insoluble fiber.
Bloating and increased gas may occur. Citrucel may give less gas.

60. Low Fiber Diet
Fiber has been removed during the refining of food particularly bread and starches. The typical diet has 15 grams of fiber.
Low fiber contributes to obesity and disturbance of the enteroinsular axis and in many the onset of NIDDM.
Adding fiber slows digestion, lowers cholesterol and blood sugar, decreases risk of cardiovascular disease, and may help reduce the risk of CRC.
Non insulin dependent diabetes is the commonest form of diabetes and weight reduction of 10 to 15 kilograms results in improvement in 90% of those affected

61. Fiber Products-Bulk Forming Laxatives
Fibersure-vegetable fiber inulin from chicory roots-5gms/tsp, $20/ 20.6 oz
Benefiber-Guar gum-3gms/2 teaspoons- $18/ 17 oz.
Psyllium-Plantago ovata, Fiberall, Metamucil $14/ 29 oz., Hydrocil, Alramucil, Konsyl, Reguloid, Serutan
Fiberone Cereal-14 grams per 4 oz.
Fiber Choice Tablet-4 grams $12/90
Citrucel-Methylcellulose $15/ 30 0z. Less gas production
Fibercon- Polycarbophil- $18/ 140 caplets
Side effects-allergic reaction-breathing problems, swelling, difficulty swallowing, skin rash, or itching. Side effects may include abdominal pain, nausea, or vomiting. May interfere with absorption of medications.

62. Laxatives Stool softeners-Docusate (Colace, Surfak), Poloxamer 188
Hyperosmotic-Lactulose, Polyethylene glycol, Magnesium Citrate, Sodium Phosphate (Fleets), MOM
Lubricants-Mineral Oil
Stimulants-Bisacodyl (Ducolax, Correctol), Cascara, Castor Oil, Senna (X prep), Sennosides (Senokot, Ex-Lax), Casanthranol
Combinations- Perdiem (Psyllium and Senna), Pericolace (Casanthranol and Docusate)
Fiber, methylcellulose, fibercon, metamucil, bran, ispaghula (Fybogel), senna, colace, mom, cascara safe in pregnancy. Avoid ducolax, correctol, castor oil, ex-lax, mineral oil.

63. Hemorrhoid Products
Anorectal preparations may temporarily help relieve anal itching or irritation. Will not cure the problem of rectal bleeding and prolapse. Patients prefer creams over suppositories.
Local anesthetics
Vasoconstrictors
Protectants or emollients
Astringents
Antiseptics
Keratolytics
Antipruritics
Corticosteroids
Natural wound healers

64. Local Anesthetics
Relieves mild discomfort, burning, and itching by blocking nerve conduction, but can cause allergic reaction (burning and itching) and aggravate symptoms.
Benzocaine-5 to 20% Americaine, Lanacane. External use only.
Benzyl alcohol-5 to 20%
Dibucaine-.25% to 1.0% Nupercainal
Dyclonine-.5 to 1%
Lidocaine-2 to 5%
Pramoxine-1%-Anusol, Fleet Pain Relief, Procto Foam non-steroidal, Tronolane, Preparation H Cream with Maximum Strength Pain Relief.
Tetracaine-.5% to 5%
Nupercainal-1% Dibucaine $6/1 oz.
Americaine Spray-Benzocaine $5.50/2 oz.
Americaine Ointment-20% benzocaine $5.50/1 oz.
Tronolane- Pramoxine-$7/ 2 oz.
Prep H Max-Glycerin, Phenylephrine HCL, Pramoxine HCL, Petrolatum, aloe barbadensis leaf extract, BHA, carboxymethylcellulose sodium, cetyl alcohol, citric acid, edetate disodium, glyceryl stearate, laureth-23, methylparaben, mineral oil, panthenol, propyl gallate, propylene glycol, propylparaben, purified water, sodium benzoate, steareth-2, steareth-20, stearyl alcohol, tocopherol, vitamin E, xanthan gum May be rapidly absorbed via the rectal mucosa causing elevated systemic levels.
Methemoglobinemia with benzocaine.

65. Vasoconstrictors
Constricts blood vessels by stimulating alpha and beta receptors. May reduce swelling but will not stop bleeding. May reduce itching and mild discomfort. Topical use has a low risk of aggravating angina, arrhythmias, hypertension, hyperthyroidism, diabetes, or BPH. May cause nervousness, tremor, or insomnia. Contact dermatitis.
Ephedrine sulfate - .1 to 1.25%
Epinephrine-.005% to .01%
Phenylephrine HCL- .25% in Medicone Suppository, Preparation H, Rectacaine
Preparation H Suppositories-Cocoa butter, Shark Liver Oil, Phenylephrine Hydrochloride $12/24
Preparation H Ointment-Petrolatum, Mineral Oil, Shark Liver Oil, Phenylephrine HCL $10/2 oz.
Preparation H Cream-Petrolatum, Glycerin, Shark Liver Oil, Phenylephrine HCL $10/1.8 oz.
Tronolane Suppositories-Hard fat and Phenylephrine HCL $5/12
May interact with BP meds, MAO inhibitors, Tricyclic Antidepressants.

66. Protectants or Emollients
Coats the skin with a physical barrier and lubricates it to decrease irritation, burning, and drying of skin. Present as a base in many products. Applied after bowel movements.
Aluminum hydroxide-Absorbent
Cocoa butter-emolient
Glycerin-emolient
Kaolin-emolient
Lanolin-emolient
Mineral oil-Balneol, Preparation H ointment
White petrolatum-Vaseline-emolient
Starch-emolient
Zinc oxide or calamine when combined with above-emolient
Cod liver oil or shark liver oil with vitamin A when combined with above
Preparation H Suppositories-Phenylephrine HCL, shark liver oil, methylparaben, propylparaben, starch $12/24
Preparation H Ointment- Phenylephrine HCL, mineral oil, Yeast cell extract, shark liver oil, paraffin, wool fat, wool alcohols, thyme oil red, glycerin, chlorhexidine acetate $10/2 oz. May be used internally.
Preparation H Cream-Petrolatum, Glycerin, Shark Liver Oil, Phenylephrine HCL $10/1.8 oz.
Fleet Rectal Pads-12% Glycerin and 1% Pramoxine HCL $6/100
Tronolane Suppositories-Hard fat and Phenylephrine HCL $5/12

67. Astringents
Coagulates skin proteins, decreases cell volume and secretions. Decreases irritation, burning, and itching but not pain.
Calamine- 5 to 25%
Zinc oxide- Calmol 4, Nupercainal, Tronolane
Witch hazel- Fleet Medicated, Tucks, Witch Hazel Hemorrhoidal Pads-external use only. May cause contact dermatitis.
Preparation H medicated wipes-Witch hazel and Aloe $5/48
Clear Gel-Witch hazel, phenylephrine hcl, Hydroxyethylcellulose, propylene glycol, sodium citrate, methyl hydroxybenzoate, disodium edetate, propyl hyroxybenzoate, citric acid, Hamamelis Water-external use only.
Tucks Pads-Witch hazel-$4/40
Dickinson’s Towelettes- Witch hazel $3.50/20

68. Antiseptics
No proven advantage over soap and water to prevent infection. Present in many products as preservatives.
Boric acid
Hydrastis
Phenol
Benzalkonium chloride-Tucks/Fleet Medicated Wipes
Cetylpyridinium chloride
Benzethonium chloride
Resorcinol-used for psoriasis, acne and eczema

69. Keratolytics
Removes skin exposing tissue to therapeutic agents. May help itching. Do not use near open wounds around the anus. For external hemorrhoids only. Found in naturopathic ointments.
1. Aluminum chlorhydroxy allantoinate-alcloxa-.2 to 2%
2. Resorcinol- 1 to 3%. Methemoglobinemia
3. Do not use near open wounds.

70. Antipruritics
Causes a feeling of comfort, cooling, tingling that distracts from the feeling of irritation and itching.
1. Menthol-not safe. Allergic reactions, laryngospasm, dyspnea & cyanosis.
2. Camphor-not safe
3. Turpentine oil-not safe
4. Juniper tar

71. Herbs and Natural Wound Healers
FDA ruled in 1990 which ingredients are allowed in OTC products.
Local anesthetics, analgesics, vasoconstrictors, lubricants, astringents, and Keratolytics allowed. Benzyl alcohol, cocoa butter, witch hazel may be used.
Live yeast cell derivative, goldenseal, mullein, tannins, menthol, camphor-not approved by FDA for OTC products
Balsam Peru, pilewort (Ranunculus ficaria) and skin respiratory factor or SRF, no proven effectiveness.
Plantain (Plantago), Butcher’s broom (Ruscus acu-leatus), alumroot, slippery elm bark.
Topical calendual, camomile, yarrow, plantain, St. John’s-wort, almond oil, witch hazel, aloe
Avoid Horse Chestnut & Corn Cockle-toxic. Comfrey-veno-occlusive disease of the liver.

72. Corticosteroids
Anti-inflammatory, lysosomal membrane stabilization, antimitotic, and vasoconstrictive to reduce itching and swelling. OTC products containing hydrocortisone are not FDA approved for internal anorectal use. Prolonged use can weaken tissue, promote infection, cause allergic reaction.
Tucks/Anusol-1.12% hydrocortisone acetate $6/.7 oz.
Preparation H Anti-Itch Cream Hydrocortisone 1%-1% hydrocortisone, BHA, carboxymethylcellulose sodium, cetyl alcohol, citric acid, edetate disodium, glycerin, glyceryl oleate, glyceryl stearate, lanolin, methylparaben, petrolatum, propyl gallate, propylene glycol, propylparaben, simethicone, sodium benzoate, sodium lauryl sulfate, stearyl alcohol, water, xanthan gum

73. Rectal Steroid Concerns
Prolonged use of higher concentrations can lead to systemic effects and weaken skin.
1. Do not use with associated fistula or abscess 2. Allergic reactions to steroid or emollients 3. Not proven to be safe in pregnancy or breast feeding 4. May increase blood sugar in diabetics. 5. May exacerbate Glaucoma, Myasthenia gravis, Osteoporosis 6. Serum levels may increase in hypothyroidism or cirrhosis 7. May lead to increased gastric acid levels 8. May cause slower wound healing and increased infections. 9. May worsen acute psychosis. 10. Weight gain, swelling, acne, sweating, increased hair.

74. Prescription Hemorrhoid Products
Generic 2.5% HC + 1% Pramoxine HCL-$10
Proctocort/Dermol HC- 1% hydrocortisone cream-$73-28 gm
2. Proctofoam-1 % hydrocortisone and pramoxine HCL-$65-10 gm can
3. Analpram HC- 1% hydrocortisone and 1 % pramoxine HCL-$48-30 gm
4. ProctoCream HC-2.5% hydrocortisone cream-$44-30 gm
5. Anusol HC Cream-2.5% hydrocortisone cream - $42-30 gm
Proctosol HC-2.5% hydrocortisone cream-$22-35 gm
Analpram 2.5% hydrocortisone, 1% Pramoxine HCL-$54-30 gm
Suppositories-Anucort-HC, Anumed HC, Anusol-HC, Proctocort
OTC Hydrocortisone Acetate 1% cream, Cortizone 10 plus Aloe - $ gm
Suppositories or foams have no advantage over creams and have worse patient compliance.
Cortizone 10 Plus Moisturizers or Aloe - 1% Hydrocortisone, Vit. A, D, E, Aloe, Petrolatum-$9-2 oz. for external anal usage

75. Micronized Flavonoids
1. Phlebotropic drug derived from Rutaceae aurantieae, a small orange from Spain, North Africa, and China. 2. Daflon 500 mg -Micronized Purified Flavonoid Fraction (MPPF). Reduced particles to allow digestion. 90% micronized diosmin and 10% hesperidin. 3. Used in chronic venous disease to improve venous tone, reduce capillary hyperpermeability, edema, and inflammatory mediators tablets per day for chronic hemorrhoids, up to 6 per day for acute attacks. About $1 per pill. 5. May help reduce pain and bleeding. 6. Not approved by the FDA and trials have given mixed results. 7. May be safe in pregnancy.
Diosmin differs molecularly from hesperidin by the presence of a double bond between two carbon atoms in the central carbon ring.
- Application to DHHS, FDA
Meta-analysis of flavonoids for the treatment of haemorrhoids. Br J Surg Aug;93(8):

76. Complications of Hemorrhoids
Bleeding - can be severe but rarely life threatening unless the patient is taking meds like Warfarin.
Severe Pain-anal fissure with spasm of the sphincter is often associated with hemorrhoids and the hemorrhoids can thrombose (clot), prolapse, or incarcerate (become trapped) and then are very painful and can become infected or gangrenous.
Relief of the spasm by local anesthetic injection can relax the spasm and give immediate improvement.

77. Hemorrhoid Procedures
Hemorrhoidectomy: Milligan-Morgan(open), Ferguson(closed) days in hospital. Anesthesia required. Effective but more expense, pain, complications, and disability compared to office treatments. Its reputation causes many to avoid effective Rx and to buy ineffective hemorrhoid creams.
PPH-Procedure for Prolapse and Hemorrhoids. Introduced in Lower pain than above but may have higher recurrence rate and similar complication rate. Learning curve. Perforations, stenosis, bleeding, or chronic pain may occur.
Rubber Band Ligation causes ischemic necrosis and scarring, which results in shrinkage of tissue and fixation to rectal wall. Office procedure with minimal pain and complications. Low recurrence rate which can be Rx with rebanding.
IRC-infrared coagulation requires 5-7 Rx, is more expensive than banding, higher recurrence rate, and may make external disease worse. Coagulates and scleroses tissue with heat. Less painful than old banders but more painful than CRH bander.
Sclerotherapy-Phenol or vegetable oil, urea hydrochloride or hypertonic salt injected into base. Out of favor 2nd to complications and high recurrence rate.
Bipolar diathermy-Coagulates and fibroses with heat.
Direct-current electrotherapy-Coagulates and fibroses with heat.
Doppler ligation-more expensive and no proven advantage over banding.
Cryosurgery and anal stretch no longer recommended because of complications
Rubber band ligation is more effective than IRC for bleeding. SGO 1987 Dec;165(6):479-82
Rubber band ligation is more effective than IRC for Grade III and IV. Rev Esp Enferm Dig Apr;93(4):239-47
PPH-Ethicon Endo-Surgery. Stapled hemorrhoidopexy. Circumferential band of mucosa and submucosa removed and area stapled. Interrupts blood supply and fixes tissue to rectal wall. Does not treat external disease. Avoid in pts. with sphincter injury/incontinence.
Harmonic Scalpel-Ethicon Endo-Surgery. Uses ultrasonic waves that reduces lateral heat damage.
LigaSure-Valleylab, Tyco Health. Bipolar device that limits lateral damage.
These two devices may decrease postoperative pain but results are inconsistent and adds to expense of procedure.

78. Procedure for Prolapsing Hemorrhoids - PPH
Stapled hemorrhoidectomy offers less pain than traditional hemorrhoidectomy but leaves persistent tags, higher recurrence rate, and rarely severe complications not usually seen.
Learning curve may contribute to complications.
4% bleeding. Staple line bleeding to uncontrollable bleeding.
Reoperation %
Pain with BM or Urge to defecate for several weeks. 5-14%
Pain, anal fissure, missed polyps
Recurrence
Perforations, Stenosis, Retained staples
Pelvic Sepsis, Urinary retention
Rectovaginal fistula, incontinence
Inflammatory polyps causing late bleeding-11 %
Uncontrollable intra-abdominal bleeding necessitating low anterior resection of the rectum after stapled hemorrhoidopexy Surg Today 2007;37(3):254-7
Stapled hemorrhoidopexy. Complications and 2-year follow-up. Chir Ital Nov-Dec;58(6)753-60
Reinterventions after complicated or failed stapled hemorrhoidopexy. Dis Colon Rectum 2004 Nov;47(11):
Inflammatory polyps: a cause of late bleeding in stapled hemorrhoidectomy. Dis Colon Rectum Dec;49(12):1910-3
Prospective randomized clinical trial comparing two different circular staplers for mucosectomy in the treatment of hemorrhoids
PPH33-03 is a new stapler reported to have fewer complications.

79. Rubber Band Ligation vs Hemorrhoidectomy
Minor Bleeding %
Major Bleeding %
Significant pain %
Thrombosis %
Urinary Retention 0-1%
Pelvic Sepsis %
Perianal Infection %
Rectal Stenosis %
Incontinence/Soiling 0%
Reoperation %
Total Complications %
Effectiveness %
Recurrence %
Death %
Hemorrhoidectomy
2-25%
1-2%
3-80% 1%
1-16%
.5%
1.6-3%
7%/21%
.4-8%
20-40%
85-97%
10-20%
0-.2%
Lower complication rate when banding done one at a time and constipation increases recurrence-Rubber Band ligation of hemorrhoids and rectal mucosal prolapse in constipated patients. Dis Colon Rectum 1989 May;32 (5): Mattana C
Prospective randomized clinical trial on suction elastic band ligator versus forceps ligator in the treatment of haemorrhoids. Asian J Surg Oct;28(4): Suction band ligation is superior to forceps ligation for the treatment of second and third-degree haemorrhoids in terms of pain tolerance, amount of analgesia consumed and intra-procedure bleeding.

80. CRH-O’Regan Ligation System
1963 Barron report on 150 patients banded in office.
1999 Dr. Patrick O’Regan develops a disposable ligation system featuring gentle suction instead of metal grasper.
2003-Dr. Iain Cleator, Professor Emeritus of Surgery, University of British Columbia, opens Cleator Clinic.
Dr. Cleator reports on 5,424 bandings on 1,852 patients. Complication rate of .3%, 99.1% effective, 2 year recurrence rate of 5%. No pain medication and immediate return to normal activities.
CRH opens offices in Chicago, Atlanta, Las Vegas, San Francisco, Los Angeles.
Ligator has now been proven safe and reliable in over 15,000 applications.
7. Banding normalized the size of hemorrhoidal cushions.
8. Inflammation reattaches tissue to surrounding muscles.
8. External disease improves but skin tags may be left behind.
Barron J. Office ligation treatment of hemorrhoids. Dis Colon Rectum 1963; 6:
US Gastroenterology Review 2005, April Banding Hemorrhoids Using the O’Regan Disposable Bander: Cleator, IGM., Cleator, M.
Diseases of the Colon & Rectum.1999 May; 42(5), Disposable device and a minimally invasive technique for rubber band ligation of hemorrhoids.

81. Who can be banded
All grades of hemorrhoids can be banded. Grade I may respond to conservative measures but should be considered for CRC screen using FIT.
Grade IV cases can be reduced with NTG and topical Lidocaine or a pudendal block. Banding done later after swelling reduced. Rx associated fissures and encourage sitz baths and supine position. Consider Flagyl Rx.
External disease can not be banded but will frequently shrink and be retracted by banding.
Associated symptomatic skin tags can be removed as a separate office procedure under local anesthesia. Less than 10% of cases.

82. Hemorrhoidectomy Indications
Failed Banding
Not capable of tolerating office procedure
Large external hemorrhoidal disease?
Grade III to IV hemorrhoidal disease?
We have treated all grades of hemorrhoids and have not referred anyone to surgery to date.

83. Rectal Examination Inspect for rash, skin tags, externals, fissure.
Use adequate lubrication and gentle palpation. If pain and spasm present consider NTG and lidocaine ointment.
Rigid Sigmoidoscopy to asses lower 15 cm.
Side viewing anoscope, rotate handle to banding area, remove obturator.
Insert ligator and apply suction 1-2 cm above dentate line. Rotate ligator, lock, and fire if no pain.
Check position with finger and roll up band if painful or too tight and muscle is caught in band.
Order of LL, RA, RP may be adjusted to avoid an external thrombosis, fissure, or to band a bleeding hemorrhoid.

84. CRH Banding via Slotted Anoscope
Banding may be done via side viewing anoscope. Band is placed 1.5 to 2 cm above dentate line to decrease pain. 90 then reverse 180 degree turn of bander is done to check for pain prior to placement of rubber band. Device allows locking of suction handle for ease of use by one operator. After band is applied it is digitally checked for position and comfort. Avoid banding too deeply which can include the underlying muscles which could lead to muscle necrosis and pelvic sepsis. Device may be reloaded if position incorrect or band does not atach properly.

85. CRH Banding - by position
The CRH-O’Regan ligator may be used without the anoscope, the so called “blind technique”, which is less painful and is easier for the patient if a fissure or anal spasm is also present. Use finger to help guide ligator into rectum and line up anal skin with area between the two lines on barrel. Angle ligator and then proceed as before. Older metal grasper instrument was not disposable, more traumatic, more complications, and required two operators. Banding is done above the dentate line. Do not pick up the anoderm or the underlying muscle in the band.

86. Rubber Band Ligation

87. Pre-banding Preparation
No laxatives, bowel preparation, enemas are needed.
Prophylactic antibiotics should be given in patients with valvular heart disease, stents, prosthesis, or those with decreased immunity. Amoxicillin or Biaxin plus Flagyl if neutropenic.
Stop aspirin and anticoagulants if possible for 5 days before and after banding.
Three hemorrhoids will require three bands in most patients. Appointments are two weeks apart.

88. After care
Patients may resume normal activities after the banding but should avoid strenuous activities till next day.
There may be a feeling of heaviness or fullness for 1-2 days.
Avoid constipation. Continue with fiber and fluids.
Bleeding may occur which may be from associated fissure or other hemorrhoids. Lie down on side, drink fluids, apply ice to anal area, and if persists call physician. Apply AgNO4, stop NTG for 2 days.
Call physician for urinary retention, fever, myalgia, flu like symptoms. Flagyl and Levaquin should be promptly started and hospitalization considered for suspected sepsis.
The band will fall off and pass in 1-7 days.
Fourth visit 3 weeks after last band for FIT.

89. Contraindications to Banding
Anticoagulants such as Coumadin, Plavix, or aspirin are a relative contraindication to hemorrhoid treatment and if possible it is best to stop them for 5 days before and after banding. Dr. Cleator has banded patients on coumadin (30 times in 10 patients) and had only one moderate bleed which resolved with lying down. In portal hypertension the rectal varices are treated by treating the portal hypertension. Rx fissures with NTG. In pregnancy try to avoid rectal procedures to avoid the rare complication of pelvic sepsis or the liability of abortion. Anal fissures may be treated with NTG.

90. FIT-Immunochemical Fecal Blood Test
At the end of the treatment a screening test for human blood in the stool is performed – the FIT, fecal immunochemical testing. Two-three stool samples are brushed. Tests for intact human hemoglobin from lower GI tract. Twice the yield of cancer and polyps compared to Hemocult II Sensa. Detects 80-94% of cancers and larger adenomas. No preparation required. InSure, HemeSelect. More expensive. Avoid test for hematuria, menstrual period, cuts on hands. About 2% of patients with typical symptoms of hemorrhoids turn out to have cancer or large polyps. Treating the hemorrhoids first decreases the rate of positive FIT and the need for colonoscopy to less than 10%.
FIT detects 94.1 % of cancerous lesions and 67% of polyps-Ann Intern Med 2007 Feb 20:146(4): A quantitative immunochemical fobt for colorectal neoplasia
FIT detects 96% of cancers-Gut 2007 Feb 19
A comparison of fecal occult-blood test for colorectal-cancer screening. N Engl J Med Jan 18;334(3):155-9

91. FOBT
Fecal occult blood test is noninvasive test for fecal blood to be done at home. Preferred-Sensitive guaiac Hemoccult II Sensa.
Guaic based test-wood resin of Guajacum tree
Hemoccult II, Hemoccult II Sensa - guaic smear test done on three samples and developed with hydrogen peroxidase.
EZ Detect, ColoCARE-flushable reagent pads for home test uses chromogenic dye and not affected by meat or vitamin C. Patients prefer ease of use but not as sensitive (21 vs. 72%)
Stop aspirin, NSAIDs, Vitamin C. No red meat, horseradish, cantaloupe/melon, grapefruit, figs, raw turnips, broccoli, cauliflower, red radishes, and parsnips for 3-5 days.
Annual screening reduces death from colon cancer by 33%.
45% false positives. Hemorrhoids, diverticulosis, PUD, fissure.
Ann Intern Med 2005 Jan 18;142(2):81-5. Accuracy of screening for fob on a single stool sample by digital rectal examination
Am J Gastroenterol Dec;90(12): Colocare self-test versus Hemoccult II Sensa for FOBT
Am J Med 2004;117: The Effect of Aspirin and NSAID Use on Fecal Occult Blood Testing Results. They did not cause increase false-positives.
Tumors may bleed intermittently. Three samples increases detection rate.

92. FIT vs. FOBT
HemeSelect, InSure, Flexsure use monoclonal or polyclonal antibodies to detect globin protein. Globin does not survive passage from upper GI tract.
FIT true-positive. CRC 87.5% vs. 54.2%. Significant adenomas (high grade dysplasia, villous change, >10mm) 42-47% vs. 23 %.
Reduces false positives and the need for colonoscopy
No need to modify diet or avoid aspirin.
Cost $5 for Hemoccult II Sensa vs $75 for FIT
Cancer 2006 Nov 1;107(9): Comparison of a brush-sampling FIT for hemoglobin with a sensitive guaiac-based fobt in detection of colorectal neoplasia.
Aliment Pharmacol Ther May 1;23(9): A quantitative immunochemical fobt is more efficient for detecting significant colorectal neoplasia than a sensitive guaic test.

93. ACS Advisory Group Recommendations FIT
Immunochemical tests have advantages over guaiac tests….these tests offer enhanced specificity in colorectal cancer screening compared with guaiac-based testing.
“in comparison with guaiac-based tests for the detection of occult blood, immunochemical tests are more patient-friendly, and are likely to be equal or better in sensitivity and specificity.”

94. Rectal Bleeding and Colonoscopy
Bright red rectal bleeding with bowel movements is a common complaint. Benign lesions are the most common cause.
Incidence of Colon Cancer in patients with chronic intermittent rectal bleeding that is typical of hemorrhoids with no abdominal pain, change in bowel habits and rectal cancer not present on anoscopy is %. In those under the age of 50 it is 0-3%. Other causes include polyps, fissures, diverticulosis, IBD.
The average approved reimbursement for colonoscopy is approximately $2200 compared to $1200 for banding.
Complications occur in 1-5% including perforation at a rate of % and bleeding at a rate of .1-2%.
Colonoscopy misses 2-6% of colon cancers
Factors identifying higher risk rectal bleeding in general practice. Br J Gen Pract Dec; 55(5210:949-55
‘One stop’ rectal bleeding clinic: the coventry experience. Int Surg 2006 Sep-Oct;91(5):288-90
Investigating chronic, bright red, rectal bleeding. ANZ J Surg Dec;71(12):720-2
An approach to haemorrhoids. Colorectal Dis Mar;7(2):143-7
Rectal bleeding in patients less than 50 years of age. Dig Dis Sci Jul;40(7):1520-3
Complications of colonoscopy in an integrated health care delivery system. Ann Intern Med Dec 19;145(12):880-6
Rates of new or missed colorectal cancers after colonoscopy. Gastroenterology 2007 Jan;132(1):96-102

95. Do All Patients with Rectal Bleeding Typical of Hemorrhoids Need Colonoscopy
Yes. Symptoms are unreliable and significant pathology is found in 20-40%; CRC, polyps, IBD, fissure, diverticulosis, angiodysplasia, rectal ulcers or proctitis, infectious or ischemic colitis. No. Having an effective office hemorrhoid treatment changes the approach. Banding the hemorrhoids first and restricting colonoscopy to those with positive FIT post banding is safe, cost effective, provides effective treatment, and avoids colonoscopy in over 90% of patients.
Incidence and causes of rectal bleeding in general practice as detected by colonoscopy. Br J Gen Pract Mar;46(404):161-4
Consider colonoscopy for young patients with hematochezia. J Fam Pract 2004 Nov;53(11):879-84
Colonoscopic evaluation of rectal bleeding in young adults. Am Surg 1994 Nov;60(11):903-6
Colonoscopic findings in patients with lower gastrointestinal bleeding sent to a hospital for their study. Rev Esp Enferm Dig Jan;88(1):16-25
Prolonged rectal bleeding associated with hemorrhoids: the diagnostic contribution of colonoscopy. South Med J Mar;80(30):313-4
Banding Hemorrhoids Using the O’Regan Disposable Bander. Business Briefing: US Gastroenterology Review 2005, Iain G M Cleator

96. Indications for Colonoscopy in Evaluation of Hemorrhoids
History or physical findings suggestive of cancer or IBD. Abdominal pain, weight loss, change in bowel habits, no obvious source of bleeding.
Iron deficiency anemia
Positive FIT/after RX
Age over 40 with 1st degree relative with CRC or adenoma<60 and no BE or colonoscopy within 10 years.
Age over 40 with two 1st degree relatives and no evaluation within 3-5 years.

97. American Cancer Society Colorectal Cancer Screening Guidelines
Beginning at age 50 (45 for African Americans), men and women who are at average risk for developing colorectal cancer should have 1 of the 5 screening options below:
a fecal occult blood test (FOBT)* or fecal immunochemical test (iFOBT or FIT)* every year**, OR
flexible sigmoidoscopy every 5 years, OR
an FOBT* or FIT* every year plus flexible sigmoidoscopy every 5 years**, OR (Of these first 3 options, the combination of FOBT or FIT every year plus flexible sigmoidoscopy every 5 years is preferable.)
double-contrast barium enema every 5 years**, OR
colonoscopy every 10 years
*For FOBT or FIT, the take-home multiple sample method should be used.
**Colonoscopy should be done if the FOBT or FIT shows blood in the stool, if sigmoidoscopy results show a polyp, or if double-contrast barium enema studies show anything abnormal. If possible, polyps should be removed during the colonoscopy.
FIT is 2-3 times more sensitive and has less false positives, added in 2003.
37 % of Americans are current with their testing. J Womens Health 2007 Jan-Feb;16(1):57-65
Colonoscopists that take longer than 6 minutes detect more than twice as many lesions: NEJM 2006 Dec 14;355(24):
New horizons include virtual colonoscopy and methods to detect genetic analysis of stool for mutations in tumor cells.

98. 2007 ACS Current Guidelines
iFOBT was added in 2003.
Postpolypectomy and Postcolorectal cancer resection surveillance revised.
Follow-up intervals were often shorter than recommended, raising cost and complications.
Single FOBT in the office is not recommended because of low sensitivity.
Cancer Screening in the United States, A Review of Current Guidelines, Practices, and Prospects. Cancer J Clin 2007;57:90-104

99. Risk Category Age to Begin Recommendation Comments Increased Risk
ACS Guidelines on Screening and Surveillance for the Early Detection of Colorectal Adenomas and Cancer
Risk Category Age to Begin Recommendation Comments Increased Risk
Single <1cm adenoma years later Colonoscopy If normal resume average risk
Multiple adenomas, Within 3 years Colonoscopy If normal repeat in 5 years, if >1cm, villous, normal resume average risk
High grade dysplasia
S/P Curative Resection months then Colonoscopy If normal repeat in 3 years, if year normal then repeat every 5 years
or more often for HNPCC
Colorectal cancer or Age 40 or 10 yrs Colonoscopy Every 5-10 years
Adenomatous polyps, in before youngest
1st degree relative <60, case
or 2 or more 1st degree
relatives at any age
(not a hereditary syndrome)
Three or more adenomas, high-grade dysplasia, villous features, adenoma>1cm 3 years
1-2 small adenoma, no dysplasia-5-10 years
Hyperplastic polyps-10 years
5% of colon cancers are found in patients who have had a colonoscopy within 5 years and no cancer was found. 27% at polypectomy site.
24% of adenomas are missed on colonoscopy. Most under 1 cm.
Colonoscopy completion rates are 85-98%. Poor prep, difficult anatomy, obstruction, pain, sever inflammation.
Rectal cancers should have ultrasound or flexible sigmoidoscopy at 3-6 month intervals for two years.
Guidelines for Colonoscopy Surveillance after Cancer Resection. CA Cancer J Clin 2006;56:

100. Risk Category Age to Begin Recommendation Comments High Risk
ACS Guidelines on Screening and Surveillance for the Early Detection of Colorectal Adenomas and Cancer
Risk Category Age to Begin Recommendation Comments High Risk
Family hx FAP Puberty Endoscopy and + genetic test, colectomy
Genetic testing
Family hx of Age 21 Colonoscopy genetic test or if not done
HNPCC counseling every 1-2 yrs till age 40 then
for Genetic testing annually.
Ulcerative Colitis yrs after Colonoscopy Every 1-2 years
Or Crohn’s disease onset of pancolitis or years after left sided colitis
Familial adenomatous polyposis
HNPCC-Hereditary nonpolyposis colon cancer
Low dose aspirin, COX-2 inhibitors, folate may reduce risk of polyps and CRC
5-ASA may decrease CRC in IBD
Obesity, physical inactivity, smoking, heavy alcohol consumption, diet high in red or processed meat, and inadequate fiber from fruits and vegetables increase risk.

101. Screening for CRC
Ideal screening should be safe, easy, reliable, inexpensive.
Current compliance for CRC screening is 35%
4-7% of people develop CRC during lifetime. Screening colonoscopy will result in no benefit to over 90% of us but subject us to the expense and morbidity of the exam.
Sufficient colonoscopic and economic resources not available in most areas.
Colonoscopy misses 5% of cancers and 20% of polyps.
FIT is a reasonable recommendation in the average risk group.

102. CT Colonography
1. Helical CT scan creates two and three-dimensional images. Prepare with phospha-soda and bisacodyl. Air insufflation. 2. Accurate in detection of polyps greater than 10 mm and colon cancer. 3. False positives 15% unnecessary colonoscopy from retained stool, diverticular disease, thick or complex haustral folds, metal or motion artifacts. 4. May miss flat adenomas which are more aggressive. 5. Non therapeutic. 6. More expensive and not covered by insurance.
CA Cancer J Clin 2003;53; Emerging Technologies in Screening for Colorectal Cancer.

103. DNA Stool Testing Screening Stool for DNA Mutations
Still under investigation.
Only one sample required.
Non-invasive, no preparation. Requires entire bowel movement be sent to lab.
May be more specific for cancer and polyps
Expensive at over $400 per test.
K-ras, APC, p53, Bat-26, and long DNA tested.
Emerging Technologies in Screening for Colorectal Cancer. CA Cancer J Clin 2003; 53:44-55

104. Research Opportunity
4-7% of people develop CRC during their lifetime.
A prospective study on the diagnosis and treatment of rectal bleeding typical of hemorrhoids. The role of hemorrhoidal banding, FIT, and colonoscopy.
A cooperative project of primary care providers, GI specialists, and the Center for Colorectal Health.
Patients with rectal bleeding typical of hemorrhoids will be evaluated, banded, undergo FIT, and then colonoscopy.
When is colonoscopy indicated? Age, sex, length or type of symptoms.
Colon cancer is the third most common cancer, 112,000 cases per year, Rectal cancer 41,000 per year, Deaths 52,000 per year. Death rate is declining.
3,690 cases per year and 1,340 deaths in GA. 2nd to lung cancer at 4,500 deaths per year. Breast 1120.
Five year survival from CRC has increased from 50% to 63% over the past 15 years.
Incidence has been decreasing, 2.1 per year partly due to screening. 90 % occur in patients over the age of 50.
5-year survival for Stage I is 90% but only 39% diagnosed at this stage. 68% for positive nodes. 10% for distant mets.
Incidence Prostate, Lung, Breast, Colon
Death Lung, Colon, Breast, Pancreas, Prostate
CA Cancer J Clin Jan-Feb;57(1):43-66

105. Thrombosed External Hemorrhoid

106. Thrombosed External Hemorrhoids
Typical presentation is acute rectal pain and mass.
Associated with heavy lifting, straining, sitting, diarrhea.
Rx warm baths, stool softeners, Lidocaine ointment, analgesics, supine position, Nifedipine, NTG, or diltiazem ointment.
Surgical excision best done within first 72 hrs. for severe pain, ulceration, rupture. Open vs. closed excision.
When associated with 3-4th degree hemorrhoids will require pudendal block and reduction of prolapse. Avoid surgery if possible.
Up to 50% will experience further hemorrhoid problems. After acute episode resolves proceed with anoscopy and banding.
Look for associated fissure.
Supine position helps recovery. Pudendal block may be rarely required.

107. Fissure
Fissures often cause pain and itch and spasms of the muscles around the anal canal

108. Anal Fissure
For unusual location consider syphilis, tuberculosis, leukemic infiltrates, carcinoma, herpes, AIDS, IBD, occult abscess.
Acute posterior anal fissure producing pain on digital exam. Sphincter tone increased. Exam limited by pain that may respond to NTG and Lidocaine.

109. Anal Fissures
A linear tear in the skin of the anal canal caused by passage of a hard stool, diarrhea, straining, sitting too long. May be seen in IBD or after rectal surgery. Increased sphincter tone.
Deep fissures expose underlying internal sphincter, white color.
Spasm, irritation, itching, pain after BM, and bleeding.
Acute fissures may heal with sitz baths, fiber, brief Rx steroid cream, leading to thin skin and sentinel pile. Pile may shrink after Rx. If persists may be excised after Rx of fissure completed.
Associated hemorrhoids are common.
NTG, Lidocaine ointment, fiber, fluids, no straining, banding.
Infected fissures Rx Flagyl.
Lateral internal sphincterotomy is 90% effective with a 10% risk of some degree of incontinence.
Lateral Internal Sphincterotomy is Superior to Topical NTG for Healing Chronic Anal Fissure and doe not Compromise Long-Term Fecal Continence. Dis Colon Rectum Feb 13.
Nonsurgical Approaches for the Treatment of Anal Fissures. Am J Gastroenterol Mar 31. Over 60% cured.

110. Anal Fissure Rx
6 weeks of twice a day intra-rectal NTG ointment, .12%, then 6 weeks of once a day NTG. Watch for headaches, tachycardia, or light headiness. Do not use NTG in patients on Viagra or Cialis. Recurrences require repeat NTG Rx and increasing fiber. 5% Lidocaine ointment as needed.
2 % Diltiazem, calcium channel blocker. ointment is an alternative in those with headaches and is used three time per day and may take longer.
Botox effectively paralyzes internal sphincter but costs $600 per vial and may cause incontinence. May be used in combination with NTG.
Surgery is effective but has a 10% incontinence rate.
Pudendal block may be rarely required for pain relief.
NTG .12% ointment applied twice a day for six weeks and then once a day for six weeks. Pea size drop applied inside of rectum.
Side effects include headache and dizziness. More common in the beginning because of increased absorption through tear.
Dosage and strength may be increased for persistent cases.
Botox injection of units via #22 needle on either side of fissure into internal sphincter. May be repeated in 2 days if no relief.
Randomized clinical trial comparing botulinum toxin injections with .2% NTG. Br J Surg Feb;94(2):162-7.

111. NTG
Nitroglycerin relaxes smooth muscle, decreases resting pressure, and improves blood supply.
Side effects: hypotension, bradycardia, tachycardia, headache, rash, dizziness, dyspepsia, flushing, blurred vision, dry mouth, fainting.
Avoid with congestive heart failure, calcium channel blockers, beta blockers, Viagra, Cialis.
Has been used in pregnancy without difficulty so far but has not been adequately tested.

112. Diltiazem
Calcium-channel blocker relaxes smooth muscle and increases blood supply.
Side effects: dizziness, lightheadedness, flushing, headache, tiredness, bradycardia, dyspepsia, nausea, vomiting, diarrhea, constipation, abdominal pain, dry mouth, edema, nervousness, insomnia.
Allergic reactions may occur.
2% ointment of Cardizem, Dilacor, Tiazac.
Avoid in heart block, beta-blockers, heart failure.
May increase Digoxin or Tegretol levels.
Tagamet increases blood levels.

113. CRH Rx of Fissures
The combined therapy at CRH of using fiber, bathroom behavior modification, NTG, and banding of internal hemorrhoids heals a high percentage of anal fissures while avoiding the expense, pain, disability, and risk of internal sphincterotomy and hemorrhoidectomy.

114. Skin tags
Skin tags are extra folds of skin around the anal verge. Caused by stretching of skin from dilated external hemorrhoids. May interfere with cleaning and add to pruritus ani. Cosmetic issue to some.
Skin tag and can be removed or left alone depending on preference.
Removal requires local anesthesia and office excision. Takes 15 minutes and leads to 2-3 days of discomfort.
Often the patient thinks of the skin tags as hemorrhoids

115. Associated skin tags
Skin is prepared with EMLA or Lidocaine cream. Area injected with Lidocaine and Marcaine plus NaHCO3. Base is clamped, tag removed with scissors, and wound closed with chromic catgut to close off dead space and decrease bleeding. Limit to one tag per visit.

116. Pruritus Ani Chronic itching and rash around the anus.
Caused by leakage of stool and mucous leading to inflammation of skin, dermatitis.
Hemorrhoids, fissures, and poor hygiene may lead to itch.
Fungal infections may occur, more common in DM.
Contact dermatitis may occur from soap, perfumes, dye in toilet paper, or hemorrhoid creams or wipes.
Citrus fruits, grapes, tomatoes, spices, beer, milk, tea, or coffee may exacerbate condition.
Laxatives, colpermin, and antibiotics may cause itch.
Keep area clean and dry at all times. Loose pants and cotton underwear. Balneol and Lotrimin or Lotrisone Rx. Band hemorrhoids and treat fissure.

117. Pruritus Ani

118. Balneol INDICATIONS: Perianal cleanser for Pruritus Ani
Balneol is specially formulated to cleanse and soothe the perianal and external vaginal areas. INGREDIENTS: Water, Mineral Oil, Propylene Glycol, Glyceryl Stearate, PEG-100 Stearate, PEG-40 Stearate, Laureth 4, PEG-4 Dilaurate, Lanolin Oil, Sodium Acetate, Carbomer 934, Triethanolamine, Methylparaben, Dioctyl Sodium Sulfosuccinate, Fragrance, Acetic Acid. DIRECTIONS: To reduce discomfort while cleansing after each bowel movement, spread a small amount of BALNEOL on cotton or tissue and wipe skin around perianal area. Also use between bowel movements and at bedtime for additional comfort. WARNINGS: In all cases of rectal bleeding, consult physician promptly. If irritation persists or increases, discontinue use and consult physician. Keep this and all medications out of the reach of children. For External Use Only.

119. Irritable Bowel Syndrome
Lower abdominal cramping, abdominal pain, bloating, associated with diarrhea and or constipation and relieved by bowel movement. Straining, urgency, hemorrhoids, fissures. 15 percent of adults have IBS. More common in women and starts before the age of 35 in 50 %. Altered motility, visceral hypersensitivity, abnormal brain-gut interaction, autonomic dysfunction, and immune activation. Disturbed gut flora Rx with probiotics or enteric coated peppermint oil (Colpermin 1 po 3-4 per day). Elevated Serotonin levels. Alosetron improves diarrhea(1mg bid). High fiber low fat diet, small meals, stress management, antispasmodics (Colofac), IgGfood elimination diet can help. R/O Celiac disease and inability to digest gluten.
Bleeding, fever, weight loss, and persistent abdominal pain suggest other diagnosis.
Eradication of small intestinal bacterial overgrowth reduces symptoms of IBS. Am J Gastroenterol Dec;95(12): Lactulose hydrogen breath test.
Enteric-coated peppermint-oil capsules in the treatment of IBS. J Gastroenterol Dec;32(6):765-8.
Fatty foods, milk products, chocolate, alcohol, caffeine, carbonated drinks may need to be avoided. Elevated IgG4 and IgE to wheat, beef, pork, lamb.
Efficacy and safety of alosetron in women with IBS. Lancet 2000 Mar 25;355(9209):
Fiber, Lomotil or Imodium, antispasmodics (Colofac MR 200 mg bid-mebeverine hcl, Levsin or Bentyl), antidepressants, Librax.
Zelnorm has been removed by FDA.
Gluten found in wheat, rye, and barley. Also in vitamins, medicines, and envelope adhesive. IgA, tTGA (anti-tissue transglutaminase), AEA (IgA anti-endomysium antibodies. Small bowel biopsy may be done to diagnose Celiac disease.

120. IBS RX with Probiotics
Fecal flora shows decreased Bifidobacterium, and Lactobacillus and increased Enterobacteriaceae. Probiotics help normalize the gut flora and immune system. Bifidobacterium infantis 35624, Lactobacillus. Further randomized studies needed.

121. Final Questions
What is the role of hemorrhoidal creams or suppositories for rectal pain, bleeding or prolapse?
What is the role of colonoscopy in the evaluation of rectal bleeding after bowel movements?
Who should be referred for the office based non-surgical treatment of hemorrhoids or anal fissures?
What is the role of surgery in hemorrhoidal disease and anal fissure?

122. Being regular is a good thing
Being regular is a good thing. Thank you And Do not Forget 15 grams of Fiber a Day Keeps the Proctologist Away