The Outpatient Management of Acute Hemorrhoidal Disease*
T. EISENSTAT, M.D., E. P. SALVATI, M.D., R. J. RUBIN, M.D. From the Department of Surgery., University of Maryland Hospital, Baltimore, Maryland, and Divisio~* of Coloyz & Rectal Surger);, Muhlenberg Hospital, PlaiTzfield, NezL*Jersey
ACUTE HEMORRHOIDAL DISEASE represents one of
the most d r a m a t i c p r e s e n t a t i o n s o f all a n o r e c t a l pathology. Although an i n f r e q u e n t occurrence, it is associated with significant morbidity, and is usually associated with p r o l o n g e d convalescence. T h e acute picture is that of irreducible, painful prolapse of the h e m o r r h o i d - b e a r i n g area. Various authors have ref e r r e d to this presentation as acute h e m o r r h o i d a l disease, fourth d e g r e e prolapse with strangulation, or acute strangulated h e m o r r h o i d s . 4'9
h e m o r r h o i d a l plexus. T h e thrombosis is similar to that which is seen in o t h e r parts of the body, with clotted blood seen within dilated vessels. Should the congestion and e d e m a be sufficient to c o m p r o m i s e the blood flow to the superficial areas o f the mucous m e m b r a n e and skin, ulceration will ensue. Left unattended, the natural course of events is one o f slow resolution over a period o f weeks.
Course of Disease T h e majority o f these patients have had longstanding h e m o r r h o i d a l disease o f variable severity; however, the internal h e m o r r h o i d s are usually third or f o u r t h d e g r e e in nature. T h e acute episode is usually incited by straining at stool, which results in e d e m a o f the prolapsed internal hemorrhoids. T h e congestion in the internal venous plexus is then perpetuated by spasm o f the sphincter mechanism. This f u r t h e r contributes to the increasing edema, and a vicious circle ensues. T h e usual course of events leads to e d e m a of the external h e m o r r h o i d a l plexus, which may progress to multiple thromboses. W h e n seen by the physician, the prolapsed tissue a p p e a r s e d e m a t o u s and necrotic, suggesting gang r e n e . T h i s a p p e a r a n c e , in actuality, r e p r e s e n t s u n d e r l y i n g thrombosis of the internal and external venous systems. Occasionally multiple areas o f ulceration may be seen over the congested internal and external venous groups. T h e condition is associated with significant pain, and it is for this that the patient usually consults a physician for relief.
Rationale
Pathologic Features T h e acute condition is one o f e d e m a with or without t h r o m b o s i s within the e x t e r n a l and i n t e r n a l * Received for publication April 6, 1979. Address reprint requests to Dr. Salvati: 1010 Park Avenue, Plainfield, New Jersey 07060.
A review o f the literature ~'4's'9 suggests that most authors advise immediate hospital admission with bed rest, analgesics, compresses applied to the area to aid in subsidence o f the e d e m a , and t h e n i m m e d i a t e h e m o r r h o i d e c t o m y . Despite the spectacular appearance o f this condition, we have f o u n d that appropriate outpatient or office p r o c e d u r e s can alleviate the acute condition and, in the majority of patients, avoid f u r t h e r operative intervention. T h e use o f local anesthetics with hyaluronidase has previously been described for the t r e a t m e n t o f acute h e m o r r h o i d a l disease, s-8 With the advent o f the rubber b a n d ligator in 1958 2,a a n d with i n c r e a s i n g experience with its use, we have developed a comprehensive a p p r o a c h to the treatment of this condition. This a p p r o a c h will decrease the period o f morbidity and length o f convalescence significantly. As previously m e n t i o n e d , f u r t h e r surgical intervention is avoided in the majority o f patients. This o u t p a t i e n t p r o c e d u r e combines modalities that are directed to, (1) relieve pain, (9) decrease edema, (3) treat a p p r o p r i a t e l y the internal hemorrhoidal disease, and (4) treat the external thrombosis, when present.
0012-3706/79/0700/0315/$00.65 9 American Society of Colon and Rectal Surgeons 315
3 16
E I S E N S T A T , ET AL.
Dis. Col. 8,: Rect. Jub,-August I979
\ otumc 22 Number 5
Fxo. 1 (,@per left).
OUTPATIENT MANAGEMENT OF HEMORRHOIDS
Acute hemorrhoidal disease.
Fro. 9 (z@per right). Injection of right side with 0.25 per cent bupivacaine, l : 200,000 epinephrine, and 150 units hyaluronidase sot u tio n.
FIc. 3 (lozcer le))). Injection of left side. Notice that injection is performed directly into edematous hemorrhoid. Flc,. 4 (lower right). disease.
After reduction of acute hemorrhoidal
Procedure With the patient in the prone jack-knife position, .25 per cent bupivacaine with 1 : 200,000 e p i n e p h r i n e and hyaluronidase is infiltrated into the perianal and submucosal tissue (150 units o f h y a l u r o n i d a s e is added to each 10 cc. of .25 per cent bupi~acaine with epinephrine)2 T h e relief of pain is immediate. T h e n , by massage and manual compression the hyaluronidase dissipates the e d e m a and allows complete reduction of the h e m o r r h o i d a l mass. T h e anesthetic is of long-acting variety and affords good pain relief for four to six hours. T h e anesthesia also allows appropriate t r e a t m e n t of the acute h e m o r r h o i d a l disease. Multiple r u b b e r ligatures are then applied to the internal h e m o r r h o i d a l groups as indicated. Sllould any thrombosis be present in the internal h e m o r r h o i d a l plexus, it may be incised prior to ligature. In addition to destroying the internal venous plexus, the scarring which results prevents f u r t h e r mucosal prolapse and r e c u r r e n c e of the condition. Perianal h e m a t o m a s are almost always present and multiple thrombectomies are p e r f o r m e d thro~,gh radial incisions. This may be done t h r o u g h one or a~ many as five separate incisions leaving islands of anod e r m between and taking care not to cross the dentate line. A light compressive dressing is applied and the patient given a prescription for an analgesic which he starts immediately. H e is advised to go h o m e to immediate bed rest. Sitz baths are begun at 12 to 24
g 17
hours and generally the patient may resume normal activities 48 to 72 hours. Alkabutazolidin is prescribed in the dosage o f 100 mg three to four times daily' for 48 to 95 hours only) 's T h e results o f this comprehensive, combined approach to the problems of acute h e m o r r h o i d a l disease has been excellent and extremely gratifying. Hospitalization has been avoided and subsequent h e m o r rhoidectomy "has only rarely been required." No significant anal stenosis has o c c u r r e d and perioperative h e m o r r h a g e has not been a problem.
Summary A p r o c e d u r e for the o u t p a t i e n t m a n a g e m e n t of acute h e m o r r h o i d a l disease is presented. T r e a t m e n t , using local anesthesia with hyaluronidase, is directed to (1) relieve pain, (9) decrease edema, (3) treat appropriately the internal h e m o r r h o i d a l disease, and (4) treat the external thrombosis if present. Adequate t r e a t m e n t of the acute disease will, in a significant p r o p o r t i o n of patients, avoid f u r t h e r surgical intervention. E x p e r i e n c e with results o f this modality of t r e a t m e n t in patients is presented.
References 1, Archambault R, Archambault P: Hemorrhoids: Their treatment in the acute stage. J Int Coll Surg 30: 814, 1958 2. Barron J: Office ligadon of internal hemorrhoids. Am J Surg 105: 563, 1963 3. Blaisdell PC: Scientific exhibit, AM'A, San Francisco. 1954 4. Goligher JC, Duthie HL, Nixon HH: Surgery of the Anus, Rectum and Colon. Ed 3, London, Bailli~re Tindall. 1975, 1164 pp 5. Ramalho LD, Salvati EP, Rubin RJ: Bupivacaine, a long-acting local anesthetic, in anorectal surgery. Dis Colon Rectum 19: 144, 1976 6. Salvati EP, Hamandi wJ, Kratzer GL: Acute hemorrhoidal disease. J Int Coll Surg 34: 662, 1960 7. Salvati EP, Kratzer GL: Advantages of local over spinal anesthesia in anorectal surgery, Surg GynecoI Obstet 103: 434, 1956 8. Schneider HC: H,valuronidase with Local anesthesia in anorectal surgery. A m J Surg 88: 703, I954 9. Turell R: Diseases of the Colon and Anorectum. Ed 2, Philadelphia, W B Saunders Company, t969, 1340 pp
T. EISENSTAT, M.D., E. P. SALVATI, M.D., R. J. RUBIN, M.D. From the Department of Surgery., University of Maryland Hospital, Baltimore, Maryland, and Divisio~* of Coloyz & Rectal Surger);, Muhlenberg Hospital, PlaiTzfield, NezL*Jersey
ACUTE HEMORRHOIDAL DISEASE represents one of
the most d r a m a t i c p r e s e n t a t i o n s o f all a n o r e c t a l pathology. Although an i n f r e q u e n t occurrence, it is associated with significant morbidity, and is usually associated with p r o l o n g e d convalescence. T h e acute picture is that of irreducible, painful prolapse of the h e m o r r h o i d - b e a r i n g area. Various authors have ref e r r e d to this presentation as acute h e m o r r h o i d a l disease, fourth d e g r e e prolapse with strangulation, or acute strangulated h e m o r r h o i d s . 4'9
h e m o r r h o i d a l plexus. T h e thrombosis is similar to that which is seen in o t h e r parts of the body, with clotted blood seen within dilated vessels. Should the congestion and e d e m a be sufficient to c o m p r o m i s e the blood flow to the superficial areas o f the mucous m e m b r a n e and skin, ulceration will ensue. Left unattended, the natural course of events is one o f slow resolution over a period o f weeks.
Course of Disease T h e majority o f these patients have had longstanding h e m o r r h o i d a l disease o f variable severity; however, the internal h e m o r r h o i d s are usually third or f o u r t h d e g r e e in nature. T h e acute episode is usually incited by straining at stool, which results in e d e m a o f the prolapsed internal hemorrhoids. T h e congestion in the internal venous plexus is then perpetuated by spasm o f the sphincter mechanism. This f u r t h e r contributes to the increasing edema, and a vicious circle ensues. T h e usual course of events leads to e d e m a of the external h e m o r r h o i d a l plexus, which may progress to multiple thromboses. W h e n seen by the physician, the prolapsed tissue a p p e a r s e d e m a t o u s and necrotic, suggesting gang r e n e . T h i s a p p e a r a n c e , in actuality, r e p r e s e n t s u n d e r l y i n g thrombosis of the internal and external venous systems. Occasionally multiple areas o f ulceration may be seen over the congested internal and external venous groups. T h e condition is associated with significant pain, and it is for this that the patient usually consults a physician for relief.
Rationale
Pathologic Features T h e acute condition is one o f e d e m a with or without t h r o m b o s i s within the e x t e r n a l and i n t e r n a l * Received for publication April 6, 1979. Address reprint requests to Dr. Salvati: 1010 Park Avenue, Plainfield, New Jersey 07060.
A review o f the literature ~'4's'9 suggests that most authors advise immediate hospital admission with bed rest, analgesics, compresses applied to the area to aid in subsidence o f the e d e m a , and t h e n i m m e d i a t e h e m o r r h o i d e c t o m y . Despite the spectacular appearance o f this condition, we have f o u n d that appropriate outpatient or office p r o c e d u r e s can alleviate the acute condition and, in the majority of patients, avoid f u r t h e r operative intervention. T h e use o f local anesthetics with hyaluronidase has previously been described for the t r e a t m e n t o f acute h e m o r r h o i d a l disease, s-8 With the advent o f the rubber b a n d ligator in 1958 2,a a n d with i n c r e a s i n g experience with its use, we have developed a comprehensive a p p r o a c h to the treatment of this condition. This a p p r o a c h will decrease the period o f morbidity and length o f convalescence significantly. As previously m e n t i o n e d , f u r t h e r surgical intervention is avoided in the majority o f patients. This o u t p a t i e n t p r o c e d u r e combines modalities that are directed to, (1) relieve pain, (9) decrease edema, (3) treat a p p r o p r i a t e l y the internal hemorrhoidal disease, and (4) treat the external thrombosis, when present.
0012-3706/79/0700/0315/$00.65 9 American Society of Colon and Rectal Surgeons 315
3 16
E I S E N S T A T , ET AL.
Dis. Col. 8,: Rect. Jub,-August I979
\ otumc 22 Number 5
Fxo. 1 (,@per left).
OUTPATIENT MANAGEMENT OF HEMORRHOIDS
Acute hemorrhoidal disease.
Fro. 9 (z@per right). Injection of right side with 0.25 per cent bupivacaine, l : 200,000 epinephrine, and 150 units hyaluronidase sot u tio n.
FIc. 3 (lozcer le))). Injection of left side. Notice that injection is performed directly into edematous hemorrhoid. Flc,. 4 (lower right). disease.
After reduction of acute hemorrhoidal
Procedure With the patient in the prone jack-knife position, .25 per cent bupivacaine with 1 : 200,000 e p i n e p h r i n e and hyaluronidase is infiltrated into the perianal and submucosal tissue (150 units o f h y a l u r o n i d a s e is added to each 10 cc. of .25 per cent bupi~acaine with epinephrine)2 T h e relief of pain is immediate. T h e n , by massage and manual compression the hyaluronidase dissipates the e d e m a and allows complete reduction of the h e m o r r h o i d a l mass. T h e anesthetic is of long-acting variety and affords good pain relief for four to six hours. T h e anesthesia also allows appropriate t r e a t m e n t of the acute h e m o r r h o i d a l disease. Multiple r u b b e r ligatures are then applied to the internal h e m o r r h o i d a l groups as indicated. Sllould any thrombosis be present in the internal h e m o r r h o i d a l plexus, it may be incised prior to ligature. In addition to destroying the internal venous plexus, the scarring which results prevents f u r t h e r mucosal prolapse and r e c u r r e n c e of the condition. Perianal h e m a t o m a s are almost always present and multiple thrombectomies are p e r f o r m e d thro~,gh radial incisions. This may be done t h r o u g h one or a~ many as five separate incisions leaving islands of anod e r m between and taking care not to cross the dentate line. A light compressive dressing is applied and the patient given a prescription for an analgesic which he starts immediately. H e is advised to go h o m e to immediate bed rest. Sitz baths are begun at 12 to 24
g 17
hours and generally the patient may resume normal activities 48 to 72 hours. Alkabutazolidin is prescribed in the dosage o f 100 mg three to four times daily' for 48 to 95 hours only) 's T h e results o f this comprehensive, combined approach to the problems of acute h e m o r r h o i d a l disease has been excellent and extremely gratifying. Hospitalization has been avoided and subsequent h e m o r rhoidectomy "has only rarely been required." No significant anal stenosis has o c c u r r e d and perioperative h e m o r r h a g e has not been a problem.
Summary A p r o c e d u r e for the o u t p a t i e n t m a n a g e m e n t of acute h e m o r r h o i d a l disease is presented. T r e a t m e n t , using local anesthesia with hyaluronidase, is directed to (1) relieve pain, (9) decrease edema, (3) treat appropriately the internal h e m o r r h o i d a l disease, and (4) treat the external thrombosis if present. Adequate t r e a t m e n t of the acute disease will, in a significant p r o p o r t i o n of patients, avoid f u r t h e r surgical intervention. E x p e r i e n c e with results o f this modality of t r e a t m e n t in patients is presented.
References 1, Archambault R, Archambault P: Hemorrhoids: Their treatment in the acute stage. J Int Coll Surg 30: 814, 1958 2. Barron J: Office ligadon of internal hemorrhoids. Am J Surg 105: 563, 1963 3. Blaisdell PC: Scientific exhibit, AM'A, San Francisco. 1954 4. Goligher JC, Duthie HL, Nixon HH: Surgery of the Anus, Rectum and Colon. Ed 3, London, Bailli~re Tindall. 1975, 1164 pp 5. Ramalho LD, Salvati EP, Rubin RJ: Bupivacaine, a long-acting local anesthetic, in anorectal surgery. Dis Colon Rectum 19: 144, 1976 6. Salvati EP, Hamandi wJ, Kratzer GL: Acute hemorrhoidal disease. J Int Coll Surg 34: 662, 1960 7. Salvati EP, Kratzer GL: Advantages of local over spinal anesthesia in anorectal surgery, Surg GynecoI Obstet 103: 434, 1956 8. Schneider HC: H,valuronidase with Local anesthesia in anorectal surgery. A m J Surg 88: 703, I954 9. Turell R: Diseases of the Colon and Anorectum. Ed 2, Philadelphia, W B Saunders Company, t969, 1340 pp
