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Nonoperative hemorrhoids treatment
For most people, high fiber diet and increasing water intake, will improve or completely treat hemorrhoids. However, if conservative measures fail, then additional options could be considered. There are numerous nonoperative methods available to treat internal hemorrhoids. Nonsurgical options include the RBL technique (Rubber Band Ligation), infrared coagulation (IRC), direct-current electrotherapy (DC electrotherapy), sclerotherapy and cryotherapy. These procedures are often called office-based because they can be done on outpatient basis. This is possible because there are no somatic nerves above the linea dentata. Many analyses show that there is no perfect method and the efficiency of these office procedures is very similar. Most of them are only effective in low-grade hemorrhoids (I-II grade), and in some cases in uncomplicated III-grade hemorrhoids. The choice should depend on the surgeon’s experience and the personal preference of the patient.
Rubber Band Ligation for treatment of internal hemorrhoids
Rubber band ligation (RBL) is the most common procedure for symptomatic piles performed in the United States and throughout the world. The reason for this is that it’s relatively safe and very cost effective method. A similar technique has been used since ancient times. In 50s Blasdell described the ligation of internal hemorrhoids with a rubber band. Later the technique was improved by Barron. Since then RBL has been used as first-line treatment of symptomatic internal hemorrhoids (I-III grade).
The procedure in brief: The surgeon ligates the apex of the hemorrhoid. The idea is that the redundant hemorrhoidal tissue will fall in 5-7 days, leaving an ulcer at the site. This will naturally cause fibrosis, which will then retract and fixate the hemorrhoid back to its normal position.
Before the procedure, the patient should clear his bowel. The surgeon will conduct an evaluation with an anoscope and then he will use a special banding ligator to grasp the redundant tissue. A small rubber band is applied at the base. Patients with several hemorrhoids may require multiple visits or the surgeon might choose to band several of them at once. This approach has been proven risky and some patients might not be able to tolerate several bandings. Since the area below linea dentata has many nerves, it is important to apply the band at least 2 cm above the line. No anesthesia is required for this procedure.
If you feel pain during the intervention, the band should be removed. Rubber band ligation should cause a minimal degree of pain. You should be able to resume normal activities in a day. The band will fall in about a week and you might experience blood, but it shouldn’t lead to massive bleeding (hemorrhage). It’s important not to take any NSAID drugs for several days prior and after the procedure.
Complications after Rubber band ligation are rare. Most commonly patients complain of mild pain and discomfort during the first 24-48 h. after the procedure. The pain could be treated with analgesics (prescribed by the physician) and sitz baths. More serious complications are urinary retention, thrombosis, bleeding, abscess and pelvic sepsis. The last one is extremely uncommon, but potentially fatal. If you feel extreme pain, fever and urinary retention, you should seek medical help on time.
RBL has shown to be very effective for I-II degree internal hemorrhoids, less so in large prolapsed hemorrhoids. Since RBL only resolves the symptom, but not the cause, hemorrhoids recurrence is quite common in the long run. The good news is that the procedure is relatively safe and can be repeated.
Infrared coagulation for treatment of internal hemorrhoids
Another popular office-based treatment for symptomatic internal hemorrhoids is infrared (photo)coagulation. During the procedure, infrared radiation is used to generate heat and create an ulcer formation that will subsequently scar and fix the hemorrhoid back to its place. This can take up to ten days or more. The downside is that the method usually requires several applications and several patient visits. The radiation should be applied above the linea dentata to avoid extreme pain. Application of energy might lead to some bleeding. However, complications are extremely rare. Infrared coagulation is best suited for patients with low-grade (I-II) hemorrhoids.
Several clinical trials have compared infrared coagulation with RBL and the results are similar, with some advantage given to Rubber band ligation in the long run. Physicians might also purpose bipolar diathermy or direct-current electrotherapy as alternatives to infrared coagulation. Both procedures are very similar methods of fixation. These procedures are less common and there isn’t enough data on their efficacy.
Sclerotherapy for treatment of internal hemorrhoids
Sclerotherapy utilizes chemical agents to create fibrosis, which will retract and fixate the hemorrhoid. The chemical agent usually consists of different solutions, such as 5% phenol in an oil base, hypertonic saline solution, and others. The procedure is minimally invasive. The physician inserts a thin spinal needle and injects the sclerosant near the base of the hemorrhoid (above linea dentata). The sclerosant should go inside the submucosal space, and not into the mucosa or the internal sphincter. Otherwise, the patient might feel excruciating pain. The drawback of this method is that it’s not advisable for multiple attempts. Complications are rare but could cause dangerous inflammatory reaction, abscess and even impotence. Sclerotherapy is indicated for smaller I-II grade hemorrhoids. Sclerotherapy is not performed as often nowadays. Clinical trials have shown that it’s less effective than RBL in the long run. However, new sclerosant agents are being actively developed. Scientists in Japan have developed a new sclerosant called ALTA (aluminum potassium sulfate and tannic acid). The results look promising, but additional research is needed.
Cryotherapy for treatment of internal hemorrhoids
Cryotherapy is an alternative method for fixation of internal hemorrhoids. It utilizes freezing to destroy the redundant hemorrhoidal tissue and fixate the hemorrhoid back to its place. To achieve that the surgeon uses a special probe, which is then applied to the desired location. This method is largely abandoned, since it’s expensive, time-consuming and could lead to serious complications. It could cause damage to the sphincter muscles and this is not always easy to prevent.