Hemorrhoidal therapy at the time of colonoscopy

 

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.