Professional Documents
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Hemorroides Guias
Hemorroides Guias
Hemorroides Guias
Hemorrhoids
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T
he American Society of Colon and Rectal Surgeons ing the propriety of any specific procedure must be made
(ASCRS) is dedicated to assuring high-quality pa- by the physician in light of all of the circumstances pre-
tient care by advancing the science, prevention, sented by the individual patient.
and management of disorders and diseases of the colon,
rectum, and anus. The Clinical Practice Guidelines Com-
mittee is composed of Society members who are chosen STATEMENT OF THE PROBLEM
because they have demonstrated expertise in the specialty Symptoms related to hemorrhoids are very common in
of colon and rectal surgery. This committee was created to the Western hemisphere and other industrialized societies.
lead international efforts in defining quality care for condi- Although published estimates of prevalence are varied,1,2
tions related to the colon, rectum, and anus. This is accom- it represents one of the most common medical and surgi-
panied by developing Clinical Practice Guidelines based on cal disease processes encountered in the United States, re-
the best available evidence. These guidelines are inclusive sulting in >2.2-million outpatient evaluations per year.3 A
and not prescriptive. Their purpose is to provide informa- large number of diverse symptoms may be, correctly or in-
tion on which decisions can be made rather than to dictate correctly, attributed to hemorrhoids by both patients and
a specific form of treatment. These guidelines are intended referring physicians. As a result, it is important to identify
for the use of all practitioners, healthcare workers, and pa- symptomatic hemorrhoids as the underlying source of the
tients who desire information about the management of anorectal symptom and to have a clear understanding of
the conditions addressed by the topics covered in these the evaluation and management of this disease process.
guidelines. It should be recognized that these guidelines These guidelines address both diagnostic and therapeutic
should not be deemed inclusive of all proper methods of modalities in the management of hemorrhoidal disease.
care or exclusive of methods of care reasonably directed to
obtaining the same results. The ultimate judgment regard-
METHODOLOGY
These guidelines are built on the ASCRS Practice Param-
Supplemental digital content is available for this article. Direct URL ci-
tations appear in the printed text, and links to the digital files are pro- eters for the Management of Hemorrhoids published in
vided in the HTML and PDF versions of this article on the journal’s Web 2011.4 A literature search of MEDLINE, PubMed, and the
site (www.dcrjournal.com). Cochrane Database of Collected Reviews was performed,
expanding on the previous literature search from 1996
Earn Continuing Medical Education (CME) credit online at cme.lww.com.
and updated through April 2017 (see Supplemental Search
Funding/Support: None reported. Strategy, http://links.lww.com/DCR/A532). Key word
combinations included hemorrhoid, internal and external
Financial Disclosure: None reported. hemorrhoids, hemorrhoid disease, thrombosed hemorrhoid,
rubber band ligation, hemorrhoidopexy, procedure for pro-
Correspondence: Scott R. Steele, M.D., 9500 Euclid Ave, A30, Cleveland, lapse and hemorrhoids (PPH), and stapled hemorrhoido-
OH 44915. E-mail: Steeles3@ccforg
pexy, Doppler-guided hemorrhoidopexy, hemorrhoidectomy,
Dis Colon Rectum 2018; 61: 284–292
Milligan–Morgan, and Ferguson. Directed searches of the
DOI: 10.1097/DCR.0000000000001030 embedded references from the primary articles were also
© The ASCRS 2018 performed in selected circumstances. The final source ma-
284 DISEASES OF THE COLON & RECTUM VOLUME 61: 3 (2018)
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
DISEASES OF THE COLON & RECTUM VOLUME 61: 3 (2018) 285
terial used was evaluated for the methodologic quality, the The diagnosis of hemorrhoids is almost always a clinical
evidence base was examined, and a treatment guideline one and should start with a medical history, with great
was formulated by the subcommittee for this guideline. care taken to identify symptoms suggestive of hemor-
When agreement was incomplete regarding the evidence rhoidal disease and risk factors such as constipation,6 fol-
base or treatment guideline, consensus from the commit- lowed by a focused physical examination. The cardinal
tee chair, vice chair, and 2 assigned reviewers determined
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the Grades of Recommendation, Assessment, Develop- toms such as bleeding and prolapse, issues of perineal hy-
ment, and Evaluation system (Table 1).1,5 Members of the giene, and presence or absence of pain. A careful review of
ASCRS Clinical Practice Guidelines Committee worked fiber intake and bowel habits, including frequency, consis-
in joint production of these guidelines from inception to tency, and ease of evacuation, should also be performed,
final publication. Recommendations formulated by the because constipation predisposes patients to hemorrhoid-
subcommittee were then reviewed by the entire Clinical al disease.6,7 A careful assessment of fecal incontinence
Practice Guidelines Committee for edits and recommen- symptoms should also be made, because this may affect
dations. Final recommendations were approved by the management decisions, to include the possibility of surgi-
ASCRS Clinical Guidelines Committee and ASCRS Execu- cal treatment. Physical examination in the prone, knee–
tive Committee. In general, each ASCRS Clinical Practice chest, or lateral decubitus position should include visual
Guideline is updated every 3 to 5 years. inspection of the anus, as well as digital rectal examina-
tion to evaluate for other anal pathology and sphincter
EVALUATION OF HEMORRHOIDS integrity. In addition, an evaluation of the patient while
straining on the bathroom will assist in the diagnosis of
1. A disease-specific history and physical examination should hemorrhoidal prolapse, as well as exclude full-thickness
be performed, emphasizing degree and duration of symp- rectal prolapse. An anoscopic examination should be per-
toms and risk factors. Grade of Recommendation: Strong formed to assess the anatomy.8 Internal hemorrhoids, lo-
recommendation based on low-quality evidence, 1C. cated above the dentate line, can be assigned a grade based
TABLE 1. The Grades of Recommendation, Assessment, Development, and Evaluation System Grading Recommendations
Description Benefit vs risk and burdens Methodologic quality of supporting evidence Implications
1A Strong Benefits clearly outweigh RCTs without important limitations Strong recommendation, can
recommendation, risk and burdens or vice or overwhelming evidence from apply to most patients in
high-quality versa observational studies most circumstances without
evidence reservation
1B Strong Benefits clearly outweigh RCTs with important limitations Strong recommendation, can
recommendation, risk and burdens or vice (inconsistent results, methodologic apply to most patients in
moderate-quality versa flaws, indirect or imprecise) or most circumstances without
evidence exceptionally strong evidence from reservation
observational studies
1C Strong Benefits clearly outweigh Observational studies or case series Strong recommendation but
recommendation, risk and burdens or vice may change when higher-
low- or very-low- versa quality evidence becomes
quality evidence available
2A Weak Benefits closely balanced RCTs without important limitations Weak recommendation, best
recommendation, with risks and burdens or overwhelming evidence from action may differ depending
high-quality observational studies on circumstances or patient
evidence or societal values
2B Weak Benefits closely balanced RCTs with impo0rtant limitations Weak recommendation, best
recommendations, with risks and burdens (inconsistent results, methodologic action may differ depending
moderate-quality flaws, indirect or imprecise) or on circumstances or patients’
evidence exceptionally strong evidence from or societal values
observational studies
2C Weak Uncertainty in the estimates Observational studies or case series Very weak recommendations;
recommendation, of benefits, risks, and other alternatives may be
low- or very-low- burden; benefits, risks, equally reasonable
quality evidence and burden may be
closely balanced
Adapted with permission from Chest 2006;129:174–181.5
RCT = randomized controlled trial.
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
286 Davis et al: Management of Hemorrhoids
on the definitions in Table 2, which may help to guide TABLE 3. Indications for Complete Colon Evaluation
therapy. Laboratory evaluation is not typically required
for diagnostic purposes. 1. Age ≥50 y if no complete examination within 10 y
2. Age ≥40 y or 10 y younger than the age at diagnosis with history
positive for a single, first-degree relative with colorectal cancer or
advanced adenoma diagnosed at age <60
EVALUATION OF RECTAL BLEEDING
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in select patients with symptomatic hemorrhoids and 4. Positive fecal immunochemical testing (FIT)
rectal bleeding. Grade of Recommendation: Strong rec- 5. Positive FIT-fecal DNA test
ommendation based on moderate-quality evidence, 1B. Source: The Multi-Society Task Force on Colorectal Cancers.11
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
DISEASES OF THE COLON & RECTUM VOLUME 61: 3 (2018) 287
emollients, and/or antiseptics are used commonly, their patients undergoing 2114 RBLs, 25.0% of patients on war-
prolonged use can cause allergic reactions or sensitization, farin bled postprocedure compared with 7.5% taking as-
and there is no strong scientific evidence regarding their pirin or nonsteroidal anti-inflammatory drugs. Of note,
long-term use. only 2.9% of patients bled postprocedure when not taking
any of these products.23
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OFFICE TREATMENT
Sclerotherapy
A variety of techniques and sclerosing agents have been
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Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
288 Davis et al: Management of Hemorrhoids
for grade I and II internal hemorrhoids demonstrated con- patients were treated conservatively with dietary modifi-
trol of symptoms in 81% of patients at 6 months after IRC, cations, stool softeners, oral and topical analgesics, and sitz
whereas 28% of patients required a repeat procedure.34 baths. Resolution of presenting symptoms (pain, bleeding,
and/or lump) was achieved in a mean period of 24 days for
Complications of Office-Based Procedures conservatively managed patients compared with 3.9 days
in the surgically managed group.
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DISEASES OF THE COLON & RECTUM VOLUME 61: 3 (2018) 289
in a cephalad relocation of the anal cushions and inter- was treated by low anterior resection. Despite surgical
ruption of the feeding arteries. Although effective for treatment and resuscitation, there were 4 deaths.49
internal prolapsing disease, it does not address external
hemorrhoids. Early cohort and smaller nonrandomized Doppler-Guided Hemorrhoidectomy
trials reported stapled hemorrhoidopexy to be associated Doppler-guided/assisted hemorrhoid artery ligation
with less pain and faster recovery when compared with
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stapled hemorrhoidopexy and 388 patients to undergo possibly less pain. A mucopexy has also been described for
traditional excisional surgery. Stapled hemorrhoidopexy patients with symptomatic prolapse. In general, prospec-
was less painful than excisional hemorrhoidectomy in the tive studies using HAL have demonstrated favorable short-
short term, and surgical complication rates were simi- term results.50 A systematic review evaluating 28 studies,
lar between groups. The excisional hemorrhoidectomy including 2904 patients with grade I to IV hemorrhoids,
group had significantly better quality-of-life scores than demonstrated a recurrence rate that ranging between
the hemorrhoidopexy group. In the stapled hemorrhoid- 3.0% and 60.0% (pooled recurrence rate = 17.5%), with
opexy group, 32% of patients reported that their symp- the highest rates for grade IV hemorrhoids. Postoperative
toms had recurred compared with 14% in the excisional analgesia was required in 0% to 38% of patients. Overall
hemorrhoidectomy group (OR = 2.96 (95% CI, 2.02– postoperative complication rates were low, with an overall
4.32); p < 0.0001), and this difference was maintained at bleeding rate of 5.0% and an overall reintervention rate of
24 months.45 A Cochrane review demonstrated that pa- 6.4%. The operative time ranged from 19 to 35 minutes.51
tients with stapled hemorrhoidopexy were significantly In a randomized prospective trial comparing RBL
more likely to have recurrent hemorrhoids in long-term with HAL for the treatment of grade II and III hemor-
follow-up at all of the time points compared with those rhoids, the recurrence rates at 1 year postprocedure were
who underwent excisional hemorrhoidectomy (12 trials, 49% (87/176) in the RBL group and 30% (48/161) in the
955 patients, OR = 3.22 (95% CI, 1.59–6.51); p = 0.001). HAL group (adjusted OR = 2.23 (95% CI, 1.42–3.51);
Furthermore, a significantly higher proportion of pa- p = 0.0005). The main reason for this difference was the
tients who underwent hemorrhoidopexy reported the number of additional procedures required in the RBL
symptom of prolapse at all time points (13 studies, 1191 group to alleviate symptoms (32% in the RBL group
patients, OR = 2.65 (95% CI, 1.45–4.85); p = 0.002).45 Pa- and 14% in the HAL group). Recurrence rates, symptom
tients undergoing hemorrhoidopexy were also more like- scores, complications, 5-level EQ-5D version (ie, a widely
ly to require an additional operative procedure compared used quality-of-life assessment instrument), and conti-
with those who underwent excisional hemorrhoidectomy nence score were similar, although patients had more pain
(8 articles, 553 patients, OR = 2.75 (95% CI, 1.31–5.77); in the early postoperative period after HAL. HAL was also
p = 0.008). When all of the symptoms were considered, more expensive and was not found to be cost-effective
patients undergoing excisional hemorrhoidectomy sur- compared with RBL in terms of incremental cost per qual-
gery were more likely to be asymptomatic (12 trials, 1097 ity-adjusted life-year.52
patients, OR = 0.59 (95% CI, 0.40–0.88)). Nonsignificant
trends in favor of stapled hemorrhoidopexy were seen Complications of Surgical Hemorrhoidectomy
in pain, pruritus ani, and fecal urgency. All of the other Complications after surgical hemorrhoidectomy are low,
clinical parameters showed trends favoring excisional with the most common being postprocedure hemorrhage
hemorrhoidectomy.46 In another systematic review of all and most larger series reporting an incidence between 1%
surgical techniques for the operative treatment of hemor- and 2%.41 Acute urinary retention has been reported to
rhoids, recurrence of hemorrhoidal symptoms was more occur between 1% and 15% and is the most common rea-
common after stapled hemorrhoidopexy than after exci- son for failure of surgical patients to be discharged from
sional operations.47 an ambulatory setting.53 The incidence is higher after spi-
Stapled hemorrhoidopexy has been associated with nal anesthesia and after HAL procedures. The risk may be
several unique complications (ie, rectovaginal fistula, sta- mitigated with decreasing volume of intravenous fluids
ple line bleeding, and stricture at the staple line). A sys- and through judicious use of local anesthesia.54
tematic review of 784 articles including a total of 14,232
patients found a median complication rate of 16.1%, with 2. Patients undergoing surgical hemorrhoidectomy
5 mortalities documented.48 Between 2000 and 2009, there should use a multimodality pain regimen to reduce
were 40 published cases in the literature of rectal perfora- narcotic usage and promote a faster recovery. Grade of
tion after stapled hemorrhoidopexy. Thirty-five patients Recommendation: Strong recommendation based on
required a laparotomy with fecal diversion, and 1 patient moderate-quality evidence, 1B.
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
290 Davis et al: Management of Hemorrhoids
In a review of 115,775 patients undergoing surgery, pain re- 2. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clini-
ported after hemorrhoidectomy was ranked 23rd of 529 well- cal guideline: management of benign anorectal disorders. Am J
defined surgical procedures.55 A number of modifications Gastroenterol. 2014;109:1141–1157, (Quiz) 1058.
in surgical and postoperative management have attempted 3. Peery AF, Crockett SD, Barritt AS, et al. Burden of gastroin-
testinal, liver, and pancreatic diseases in the United States.
to reduce this pain.56 Topical 2% Diltiazem ointment has
Gastroenterology. 2015;149:1731–1741.e3.
been shown to reduce narcotic usage and pain scores after
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ectomy and treated with topical nitroglycerin demonstrated the management of hemorrhoids (revised 2010). Dis Colon
significant pain reduction as well. Patients also appeared to Rectum. 2011;54:1059–1064.
resume routine activities earlier than those in the control 5. Guyatt G, Gutterman D, Baumann MH, et al. Grading strength
group.59 Studies evaluating surgical sphincterotomy (LIS) of recommendations and quality of evidence in clinical guide-
also demonstrate efficacy in reducing postoperative pain lines: report from an american college of chest physicians task
and need for analgesics after excisional hemorrhoidectomy. force. Chest. 2006;129:174–181.
LIS also managed to decrease the incidence of postoperative 6. Arora G, Mannalithara A, Mithal A, Triadafilopoulos G, Singh
urinary retention and anal stenosis. The negative aspect of G. Concurrent conditions in patients with chronic constipa-
adding LIS to excisional hemorrhoidectomy was the risk of tion: a population-based study. PLoS One. 2012;7:e42910.
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rhoids on screening colonoscopy. PLoS One. 2015;10:e0139100.
instances was temporary.60 Three RCTs have investigated 8. Harish K, Harikumar R, Sunilkumar K, Thomas V.
botulinum toxin A after hemorrhoidectomy. Postoperative Videoanoscopy: useful technique in the evaluation of hemor-
pain appeared to be reduced for <1 week after excisional rhoids. J Gastroenterol Hepatol. 2008;23(8 pt 2):e312–e317.
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continence to flatus, was comparable to placebo.61 The use colonoscopy in evaluating hematochezia: a population-based
of oral metronidazole was evaluated in a recent meta-anal- study in a large consortium of endoscopy practices. Gastrointest
ysis and found to be no better than placebo in controlling Endosc. 2013;77:410–418.
postoperative pain.62 Liposomal bupivacaine (LB) has been 10. Siminoff LA, Rogers HL, Harris-Haywood S. Missed oppor-
evaluated in 2 RCTs. In the first, 189 patients undergoing ex- tunities for the diagnosis of colorectal cancer. Biomed Res Int.
cisional hemorrhoidectomy were randomly assigned to LB 2015;2015:285096.
versus placebo. Pain intensity scores were significantly lower 11. Rex DK, Boland CR, Dominitz JA, et al. Colorectal cancer
screening: recommendations for physicians and patients from
in the LB group (141.8 vs 202.5; p < 0.0001). More patients
the US Multi-Society Task Force on Colorectal Cancer. Am J
in the LB group remained opioid free from 12 hours (59%)
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TONE concept can help avoid surgery in most patients with
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