Review of the medical literature reveals that rubber band ligation is perhaps the most effective office based therapy for symptomatic internal hemorrhoids  In my gastroenterology practice I have found the multiple endoscopic banding (MEB) to be the procedure of choice in the treatment of hemorrhoids.  I currently use the Boston Scientific Speedband Super7 multiple band ligator in conjuction with flexible sigmoidoscopy.  It is a small, clear view ligating unit which is attached to the tip of the endoscope.  The device can deliver multiple rubber bands using a single string deployment apparatus.  The base of the hemorrhoid is suctioned into the clear cup and the rubber band is deployed by turning the dial attached to the endoscope biopsy channel.  The success rate for the multiple band ligation is over 93%.  Potential adverse outcomes can include pain, thrombosed external hemorrhoid (4-12%), bleeding (4%), anal stenosis (4%) and infection.  Having performed over 100 cases of MEB in the past year in the office, the actual complication rates are much lower than those published in the literature above.  The most common complaint in 4-5% of cases is rectal discomfort requiring analgesics beyond Tylenol.

Combining lower gastrointestinal endoscopy with multiple rubber band ligation provides an effective treatment option for patients with symptomatic chronic internal hemorrhoids.  The endoscope projects a large visual field of the rectum on the monitor and the multiple banding device makes the banding procedure more precise. Typically MEB requires two sessions separated by 6-8 week time interval.  The vast majority of patients find the treatment effective without significant side effects.

— Bulent Ender, MD —

HPV is the most common sexually transmitted infection in the U.S.  The prevalence of the virus in women is over 25%.  This virus is ubiquitous and can infect the stratified epithelium of skin and mucous membranes.  Most of these infections are transient and asymptomatic and resolve within a year.  However HPV types 6 and 11 account for 90% cases of genital warts in the population.   The persistence of other “high risk HPV” types within an individual may progress to precancerous lesions and frank carcinoma.  HPV is the cause of nearly all forms of cervical cancer with type 16 and 18 accounting for nearly 75% of cervical cancer cases in the U.S

HPV has also been associated with other types of genital cancer including vaginal, vulvar and penile cancer.  Perhaps up to 40% of cancers in these organs are attributed to HPV infection.  Anogenital transmission of HPV is quite common and does not require sexual intercourse.  It is estimated that 85% of anal cancers are due to HPV infection.  In most cases these are the same virulent strains (type 16 and 18) that cause cervical cancer.  Recent research has also shown an association between orpharyngeal cancer and HPV.  Cancer of the oropharynx is guite prevelant compared to genital cancers.  HPV-16 now appears to be the most common form of oropharyngeal cancer in non-smokers and non-drinkers in the U.S.

There is overwhelming epidemiological evidence which shows that HPV is a significant public health problem in the U.S.  Presently there are two effective vaccines, Gardasil and Cervarix, that can be used to prevent the burden of genital cancers in the general population.

In summary;

1. Gardasil vaccine HPV is not only effective in prevention of infectious genital warts but also one of the first vaccines in cancer prevention.
2. The HPV vaccine needs to be administered prior to virus exposure (early adulthood), in order for it to prevent disease.
3. Vaccination does not preclude patients from undergoing preventive healthcare such as Pap smears to detect premalignant disease
4. In addition to HPV, there are other infectious agents (such as herpes and HIV) that can predispose individuals to cancers of the genitalia.
5. Prevention of infection (vaccination, abstinence, condoms) and early diagnosis is the key to diminishing the incidence of genital cancers in the general population.

Ref:  Br J Cancer. 2007 May 7; 96(9): 1320–1323.

Some patients have family history of diverticular disease and other may have collagen disorders like Marfan’s syndrome which predispose them the diverticulosis.  Other risk factors for this condition include obesity, lack of physical activity, age and stagnant BMs.

The vast majority of patient to not have symptoms from diverticulosis.  However some patients may develop spontanous infections within diverticula resulting in acute diverticulitis which requires antiboitics.  Other complications of diverticular disease include bleeding, stricturing (high grade narrowing), abscess formation and perforation of the large intestine.

So in summary, “What causes diverticulosis?”

1. Aging and associated constipation

2. Genetics and family history

3. Diet and lack of fiber

1. Assessment of nutritional status

Patients with IBD can be deficient in iron, folate, and vitamin D due to their underlying mucosa  disease, prior surgery or current therapy.  Blood level of these micronutrients can be readily assessed to determine deficiency and need for supplementation.

2. Assesment of adherence to medication

Unfortunately adherence to prescribed medication in the setting of chronic disease is typically 50% or less (in spite of patient history).  Lower adherence to medication intake typically results in flare up of inflammitory bowel disease.  The goal of treatment would be to emphasize that patients take at least 80% of their medications 80% of the time to achieve meaningful therapeutic benefit.

3. Metabolic bone disease

Chronic IBD has been associated with premature osteopenia and osteoperosis in 15% of patients, with higher prevalance of metabolic bone disease seen in older individuals.  Medications such as steroids and immunodulators can increase bone loss in these predispose patients.  Furthermore smoking, decreased physical activity and surgical menopause can be additional risk factors for osteoperosis.  Dexa scanning to assess bone density in patients with IBD are usefull in diagnosing asymptomatic metabolic bone disease.

4. Preventive immunization.

Compliance with adult immunization rates in the U.S. are unfortunately very low (<30%) due to lack of awareness of patients and physicians.   Important vaccination that need to be assessed and provided in the clinic are Tetanus, Influenza, Pneumonia, Hepatitis A/B HPV and Zoster.   These vaccines should be administer at an early age to minimize morbidity in case the patient becomes immunodeficient at a later date.  In fact certain live virus vaccines sucha as zoster and MMR need to be avoided in individuals that are currently immunocompromised.

5. Assessment for depression.

Patients with IBD are 4-5 times at risk for anxiety and depression than the general population.  Regular screening of these patients in the clinic and appropriate medical interventions can minimize the impact of these conditions.

6. Colorectal cancer screening.

Patients with Ulcerative colitis and Crohn’s colitis have significantly increased risk of colon cancer based on duration of their illness, extend of their disease and their current age.  Baseline screening examination with 8-10 years of the original diagnosis and surveillance colonoscopy with biopsies every 1-3 years is appropriate for early diagnosis of dysplasia and colon cancer.

1) CECAL INTUBATION RATE OF GREATER THAN 95%.  The goal of colonoscopy is the perform a thorough and complete evaluation of the large intestine.  This is achieved by demonstration of the cecum where the small bowel empties into the large intestine.  We look for anatomic landmarks such as the ileocecal valve, cecal strap and the appendiceal orifice in confirming the cecum.  Most experienced gastroenterologist are able to reach the cecum in greater than 98% of cases and (when indicated) able to intubate the terminal ileum in > 70% of cases.

2) DETECTION OF ADENOMAS IN > 20% OF SCREENING PROCEDURES.   The primary goal of colorectal cancer screening is the detection of adenoma which are precursor lesions to adenocarcinomas.  The consensus is that an experience gastroenterologists should be able to detect adenomas in approximately 20 % of cases.  Although the very diminutive polyps and flat lesions can be difficult to ascertain, lesions greater the 2 mm should be detectable in patients with adequate bowel preps.  High definition endoscopes appear to increase adenoma detection rates

3) WITHDRAWAL OF ENDOSCOPY FROM THE COLON SHOULD BE GREATER THAN SIX MINUTES.   Most gastroenterologist diagnose polyps during the withdrawal of the colonoscope from the cecum to the rectum.  Spending adequate time for inspection and detection of colon polyps is important in maximizing the yield of the examination.   Studies have shown that the minimal withdrawal time (on average) for colonoscopic examination should be six minutes in order to minimize the likelihood of missing an adenomatous polyp.   Prior surgical colon resection and anatomical variability can have impact on individual cases of colonoscopy.

4) COLON POLYPS < 2 CM IN SIZE SHOULD NOT BE SENT FOR SURGICAL RESECTION PRIOR TO ATTEMPTED ENDOSCOPIC POLYPECTOMY.  Most experienced gastroenteorlogists feel confterable in resection and removal of colon polyps < 2.5 cm in size.  These lesions can be removed through various techniques and if necessary in piecemeal fashion.

5) COMPLICATIONS OF COLONOSCOPY AND THERAPEUTIC COLONOSOCPY SHOULD BE KEPT TO A MINIMUM ESPECIALLY IN SCREENING CASES.   Most gastroenterologists have perforation rates well below 1 in 2,000 cases of screening colonoscopies, with some less than 1 in 5,000 cases.   Similarly, post colonoscopy bleeding should be less than 10% after polyp removal and well less than 1% in screening cases.  The size of the polyp and the use of electrocautery tendS to affect complication rates of colonoscopy.  Over 95% of cases of pos-polypectomy bleeding can be managed conservatively without resorting to surgical intervention.

Diagnostic screening of high risk patients to evaluate for the presence of HBV-surface antigen remains an important aspect of early diagnosis, since most patients with the virus are asymptomatic throughout much of their disease state.  Populations considered at high risk for CHB infection that need screening include:

1. Foreign born and second generation Asian Americans
2. Illicit drug users and homosexual men
3. Hemodialysis patients
4. Patients with recurrent, STDs, those with HIV and HCV virus
5. Incarcerated individuals and those recently discharged from prisons

In addition, patients with ALT > 19 (females) and ALT > 30 (males) should routinely have viral serologies performed for both HBV and HCV.  Unfortunately most chemistry laboratories, including our own clinic, have normal range for ALT/AST that is between  45-60, which results in under diagnosis of chronic liver disease.

CHB remains a complex disease with multiple host-viral life cycles and an inactive carrier state.  The hepatitis B virus can also develop mutations in its genome resulting in resistance to antiviral therapy.   Once HBV-surface antigen is documented in the non-acute hepatitis B infected patient, additional biochemical evaluation consists of checking the HBV-e antigen (which correlates with active viral replication) and HBV-DNA level.  Higher viral load of HBV-DNA (> 20,000 IU/ml) warrant antiviral therapy [This DNA threshold for treatment may be much lower  in the HBV-e antigen negative patient or a patient with active necroinflammitory disease or other risk factors disease progression].   Although some clinicians also perform baseline HBV genotyping, HBV mutation profiles and routine liver biopsy, these studies are not essential to initiate therapy.

Treatment of most patients with CHB can be readily handled in the primary care setting. However most of these individuals are referred to gastroenterologists for care.  Majority of GI physicians in our community prefer not to manage patients with CHB.  Although there are several oral antiviral treatments available for CHB, two agents ,  entacavir (Baraclude) and tenofovir (Viread) appear to be the most effective in viral suppression and disease management.    Both medications are taken once a day on a long term basis, and are well tolerated.  Although a true cure for CHB is difficult, effective suppression of viral load can result in i) decrease incidence of cirrhosis ii) decrease rates of HCC and iii) lower the mortality of CHB disease.

Surveillance of patients with CHB is important since 70% of deaths directly attributed to complication of chronic HBV infection is from hepatocellular carcinoma.  HBV virus is known to integrate to the genome of the host hapatocyte and is considered a potent oncogenic agent.  The current standard surveillance protocol involves laboratory testing for alpha feto protein (AFP) level and liver ultrasound, both performed on 6-month intervals.  This surveillance regimen also needs to be undertaken for inactive carriers of the HBV virus that have no evidence of active liver disease.

One last note:   Since 1998 North Carolina students have been mandated to receive HBV vaccination.   It is now time to vaccinate all adult patients in our care for HBV and minimize the impact of chronic hepatitis B on our community —– Vaccination saves lives.

Reference:  Keepffe, E.B.,  Dieterich, D.T., Han, S.B.    Clinical Gastroenteorology and Hepatology 2008;6:1315-1341.   A Treatment Algorithm for the Management of Chronic Hepatitis B Virus Infectino in the United States:  2008 Update

1) Endoscopic evaluation of the lower GI tract (flexible sigmoidoscopy or colonoscopy),  in conjunction with band ligation, provides  additional diagnostic benefit to the patient and can readily exclude colitis, neoplasm, rectal ulceration, fistula and other mucosal diseases that may mimic hemorroidal bleeding.

2) Endoscopy provides great visual field of the anal canal and rectal anatomy compared to anascopy.  The images from the videoendoscope can be readily projected to a large screen monitor for real-time examination and photodocumentation.  In the retroflexed view of endoscopy, the layout of the hemorrhoidal complex and the dentate line is visualized in great detail.  Furthermore the endoscope provides more precise delivery of the rubber band at the time of ligation.

3) In the setting the of colonoscopy, the patient is prepped, sedated and comfortable throughout the procedure and typically has no recollection of the rubber band ligation.

4) Endoscopic band ligators provide for multiple hemorrhoidal banding capability.   This is in contrast to office based rubber band ligation, which is typically  performed on one hemorrhoid per session.   Hence patients typically need 1-2 sessions of endoscopic band ligation as opposed to 3-4 sessions of traditional rubber band ligation.

5) Charges for the hemorroidectomy (via endoscopic band ligation) when performed in conjunction with colonoscopy, is actually less expensive compared to office based rubber band ligation, due to the fact that the banding procedure is discounted by the insurance company in the setting of colonoscopy.

In spite of widespread use of endoscopy in the diagnosis and management of digestive disorders, fecal occult testing still plays an important role in medical practice.   The conventional quaiac based stool testing has been present for over three decades.  However these traditional “hemoccult” tests have low sensitivity and poor specificity in detecting colorectal neoplasms or actual human blood in the stool.  Recently, several commercial laboratories have introduced immunochemical fecal occult blood (iFOB) tests.  These newer generations of tests use anti-hemoglobin antibodies (immmunochemical tests) to detect minute amounts of human hemoglobulin in the stool.  By detecting blood proteins, these assays are both more sensitive and specific, especially for colonic GI blood loss.  Brand names include Hemosure, Quickvue Quidel, Hema-screen.

Settings where fecal occult blood can be useful:

1)     Evaluation of patients with abdominal pain.  Digital rectal exam should be a routine part of a physical exam in patients who present with acute abdominal pain; especially those with altered BMs.  Guaiac based tests are routinely used to detect blood in the GI tract which may be due to peptic ulcer disease, gastritis, gastrointestinal (GI) neoplasm, and intestinal lesions including regional enteritis, colitis or NSAID induced mucosal disease.  A positive iFOB is useful in further localizing bleeding originating from the colon such as Inflammatory Bowel disease (IBD), infectious colitis and ischemic colitis.

2)     Patients with diarrhea also benefit with fecal occult blood testing.  Positive test results may suggest more serious pathology beyond simple viral intestinal infections.  Further endoscopic work-up is typically undertaken in these circumstances to evaluate patients for IBD, neoplasia, mucosal GI disease and invasive pathogens.

3)     Work-up of anemia and suspected occult GI blood loss.  Positive iFOB is beneficial in the work-up of patients with anemia as it tends to localize the source of GI blood loss to the colon.   Guaiac based tests are less specific with higher false positive results.  Nonetheless repeated negative iFOB and hemoccult test results (in the presence of negative panendoscopy) tent to be reassuring and may sway the physician to pursue alternative work-up of anemia beyond GI sources

4)     Colorectal screening. Colonoscopy has become the standard of care in screening for colorectal cancer in the community.  Patients without colon polyps are advised to return in 10 years for repeat examination.   However this long time interval has not been documented to be the optimal screening period.  Therefore some physicians use in-home iFOB testing, starting 5 years after the last colonoscopy, to evaluate for microscopic blood loss from colonic neoplasia.  This may turn out to be an inexpensive option for screening asymptomatic patients in-between routine colon examinations.

Further comments to follow……..

Aside from colorectal cancer (CRC) screening, rectal bleeding is one of the most common indications for referral of patients for colonoscopy.  In the vast majority of these cases the source of bleeding is typically internal hemorrhoids.  However once a diagnosis is rendered by the gastroenterologist, the management of internal hemorrhoids with topical creams is typically of limited benefit.   The most beneficial, simple and widely implemented in-office treatment of internal hemorrhoids is rubber band ligation (RBL).  In the office setting this has typically required multiple visits for ligation of each of the three major columns of internal hemorrhoids.  With the advent of endoscopic band ligation it is possible to consolidate this treatment to a single procedure.

Since most of the diagnostic colonoscopies are performed to evaluate rectal bleeding, and internal hemorrhoids are the most common cause of such bleeding (especially in younger patients), it makes sense to treat the source of the bleeding at the time of the colonoscopy.  As the patient is already prepped, sedated and monitored during the colonoscopy, ligation of internal hemorrhoids only adds another 5-10 minutes to the endoscopic procedure.  Hence this combined one-step procedure provides both diagnostic and therapeutic benefit to the patient with hemorrhoidal disease.

There are multiple medical devices available for hemorrhoidal banding in the setting of colonoscopy.  I’ve found that the Boston Scientific Speedband Superview Super7 Multiple Band Ligator to be the most efficient.  It is a small, clear view ligating unit which is attached to the tip of the endoscope.  The device can deliver up to 7 rubber bands using a single string deployment apparatus.  During the endoscopic procedure, the base of the hemorrhoid is suctioned into the clear cup and the rubber band is deployed by turning the dial at the endoscope biopsy channel.  The apparatus is virtually identical to the multiple rubber band ligator used for treatment of esophageal variceas. 

A recent article using an alternative ligator, showed that combined colonoscopy and 3-guadrant hemorrhoidal ligation in 500 patients was 93% effective in the resolution of symptoms attributed to internal hemorrhoids over a three year period.  Additional 6.6% of these patients had repeat RBL treatment with benefit and only 2.2% required hemorrhoidectomy.  None of these patients experienced post-ligation hemorrhage and only a small minority had significant pain.  (Davis, KG et. al.  Dis Colon Rectum 2007; 50: 1445-1449).

Combined colonoscopy with multiple rubber band ligation provides an effective treatment option for patients with symptomatic internal hemorrhoids.  The procedure is safe, convenient and cost effective for both the patient and the physician.  This combined modality could be readily offered to patients who present with painless rectal bleeding or chronic symptomatic hemorrhoidal disease.