II. Definitions

  1. Internal Hemorrhoid
    1. Dilation of anorectal vessels above Dentate Line

III. Symptoms

  1. Painless Rectal Bleeding
  2. Incomplete Defecation
  3. Prolapsed rectal mass
    1. Early: Prolapses with straining and then retracts
    2. Later: Prolapses with coughing, sneezing, lifting
      1. Chronic mucus discharge with excessive wetness
      2. Local anal irritation and soils clothes
    3. Irreducible, incarcerated prolapsed Hemorrhoid

IV. Signs: With Anoscopy

  1. Anorectal mass above Dentate Line
    1. Rectal mucosa bulging with reddish-purple mass
  2. Locations
    1. Right Anterior
    2. Right Posterior
    3. Left Lateral

V. Complications

  1. Iron Deficiency Anemia (from heavy bleeding)
  2. Incarcerated prolapsed Hemorrhoid

VI. Grading: Internal Hemorrhoid

  1. Grade I
    1. Present without prolapse
    2. Usually asymptomatic
  2. Grade II
    1. Some prolapse with spontaneous regression
  3. Grade III
    1. Prolapse with manual replacement
  4. Grade IV
    1. Prolapse with inability to replace Hemorrhoid

VII. Management: General

  1. See Hemorrhoid Management
  2. Non-pharmacologic approaches should be incorporated in all Hemorrhoid Management
  3. Colonoscopy should be considered in all patients with anorectal bleeding or presumed Internal Hemorrhoids

VIII. Management: Procedures

  1. Older Techniques
    1. Surgical Excision (Hemorrhoidectomy)
      1. Most effective to decrease recurrent symptoms in Grade 3-4 Internal Hemorrhoids and mixed Hemorrhoids
        1. Removes symptomatic and redundant Hemorrhoidal tissue to reduce pain and complications
        2. Diathermy/ultrasonic adjuncts to procedure: Ligasure, Harmonic Scalpel
      2. Absence from work for up to 4-6 weeks (much longer than with Rubber band ligation)
      3. More painful post-operatively than Rubber band ligation and other procedures (e.g. stapled Hemorrhoidectomy)
      4. Complications: Perianal Skin Tags, Perirectal Abscess, Anal Fistula, anal leakage, anal stenosis and bleeding
    2. Sclerotherapy
      1. Used in Europe but not in United States
      2. Less effective than Rubber band ligation or Hemorrhoidectomy
    3. Cryosurgery
      1. Rectal discharge
  2. Newer Techniques
    1. Rubber Band ligation (Baron Ligation)
      1. Indicated for Grades I to III Internal Hemorrhoid
      2. Highly effective first-line management of Internal Hemorrhoids
    2. Infrared Coagulation (IRC)
      1. Indicated for Grades I to III Internal Hemorrhoid
    3. Bipolar Electrocoagulation (BICAP)
      1. Indicated for Grades I to III Internal Hemorrhoids
      2. Radiofrequency ablation
        1. Apply to Hemorrhoid for 2 seconds
        2. Apply several places along Hemorrhoid
    4. Low-Voltage direct current (Ultroid)
      1. Indicated for Grades I to IV Internal Hemorrhoid
    5. Stapled Hemorrhoidectomy (Stapled Anopexy)
      1. Alternative management of Grade II to IV Hemorrhoids
      2. Interrupts Hemorrhoid blood supply by removing proximal mucosa and submucosa
      3. Staples are placed 4 cm above the Dentate Line circumferentially and bury into the mucosa over time
      4. Revisions are required twice as often as with Hemorrhoidectomy
      5. Common procedure in Europe
      6. High rate of persistent complications (30%)
        1. Pain post-Defecation
        2. Fecal urgency
        3. Awareness of staples in the Rectum for months after the procedure
        4. Bleeding at the staple site
        5. Stenosis (difficult to treat and may result in colostomy)
    6. Hemorrhoidal Artery Ligation (Transanal Hemorrhoidal Dearterialization)
      1. Experimental technique for Grade 2-3 Internal Hemorrhoids
      2. Ligation of superficial artery that lies just proximal to affected Hemorrhoid
      3. von Roon (2009) BMJ Clin Evid 2009: 0415 [PubMed]

IX. Management: Procedure Selection

  1. Grade I-II Internal Hemorrhoids
    1. Rubber Band ligation (Baron Ligation)
    2. Infrared Coagulation (IRC)
    3. Bipolar Electrocoagulation (BICAP)
    4. Low-Voltage direct current (Ultroid)
  2. Grade III-IV Internal Hemorrhoids
    1. Stapled Hemorrhoidectomy (Stapled Anopexy)
    2. Surgical Excision (Hemorrhoidectomy)

X. Management: Postoperative analgesia

  1. NSAIDs
  2. Opioid Analgesics
  3. Compounded preparations that offer post-operative analgesia
    1. Metrogel 10% applied topically three times daily
    2. Glyceryl Trinitrate ointment 0.2% applied twice daily
    3. Topical Nifedipine 0.3% and Lidocaine 1.5% ointment applied twice daily

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