Office treatement of Internal Hemorrhoids

Effective Treatment of Hemorrhoids in GI Practice

Internal hemorrhoids are one of the most common causes of rectal complaints and bleeding in medical practice. In spite of conservative management and topical creams, often patients tend to have recurrent symptoms.  Although many patients are referred to surgeons, 98% of internal hemorrhoids can be readily treated in the office setting and do not need excisional surgery.   Internal hemorrhoids are classified as follows:

Grade 1      Small internal hemorrhoid which do not prolapse below the dentate line

Treated with topical medication, Infrared coagulation (IRC), electrocautery

Grade 2     Hemorrhoids which prolapse with defecation, but spontaneously reduce

Treated with IRC, Electrocautery, Rubber band ligation (RBL)

Grade 3    Spontaneously prolapsing hemorrhoids which require manual reduction

Treated with RBL, or occasionally with surgery

Grade 4    Prolapsed internal hemorrhoids that are not reducible

Treated with excisional surgery

Infrared coagulation (IRC)

IRC is an office based procedure that uses a probe to deliver several two-second pulses of light energy to the base of a hemorrhoid.  This energy coagulates vessels and tethers the mucosa to the submucosal tissue resulting in superficial sclerosis and interruption of the blood supply to the hemorrhoid, causing it to shrink and recede.  The procedure is very quick and essentially painless.  It is considered one of the safest treatment modalities for treatment of internal hemorrhoids.  The IRC is ideal for Grade 1 and 2 internal hemorrhoids.

Rubber Band Ligation (RBL)

I’ve been using the O’Regan Disposable Hemorrhoid Banding System for ligation of internal hemorrhoids since January 2009. This highly effective (99%), minimally invasive procedure is performed in our offices in less than a minute, and most patients return to work that same day. Typically, we treat one hemorrhoid at a time in separate visits.

During the brief procedure, the tissue just above the internal hemorrhoid is suctioned into a specialized syringe-like apparatus and ligated with a small rubber band. This eventually causes mucosal ulceration with resultant interruption of blood flow and obliteration of the internal hemorrhoid.

Within the first 24 hours after the procedure, some patients may experience a feeling of fullness or a dull ache in the rectum. This can typically be relieved with an over-the-counter pain medication. However, most patients treated with this modality do not have significant post-procedure pain or need for analgesics.  With recent design improvements, this procedure has a ten-fold reduction in complications compared to traditional banding. We are also performing elastic band ligation of internal hemorrhoids atthe time of lower GI endoscopy.  This facilitates treatment of symptomatic hemorrhoids at the time of diagnostic colonoscopy or sigmoidoscopy.  The rubber band ligation therapy is optimal for Grade 2 and 3 internal hemorrhoids.