Complicated haemorrhoids: WSES/AAST updates
M3 India Newsdesk Jun 02, 2022
This article talks about the guidelines from the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) that provide key recommendations for the management of complicated haemorrhoids.
Complicated haemorrhoids
Complicated haemorrhoids can be associated with anal pain or anorectal bleeding. Guidelines from the World Society of Emergency Surgery WSES and the American Association for the Surgery of Trauma AAST provide key recommendations for the management of complicated haemorrhoids. A detailed medical history and a complete physical examination are mandatory to rule out other possible causes of acute anal pain or bleeding. Non-operative management, along with dietary and lifestyle changes, is recommended as the first-line therapy.
Patients with complicated haemorrhoids present with acute anal pain (also called haemorrhoidal crisis) or anorectal bleeding. In both scenarios, a detailed medical history, with a focus on the acute complaint, and a complete physical examination (comprehensive digital rectal examination) are mandatory to rule out other possible causes of acute anal pain or bleeding.
WSES/AAST updates
Guidelines from the World Society of Emergency Surgery WSES and the American Association for the Surgery of Trauma AAST for the management of complicated haemorrhoids are as follows:
1. Clinical examination and biochemical investigations in patients with suspected complicated haemorrhoids
Acute anal pain and the presence of anorectal mass, which is associated with complicated haemorrhoids, can be the clinical manifestation of multiple anal diseases. Acute complicated haemorrhoids could also be the clinical manifestation of a concomitant inflammatory anal and perianal condition such as inflammatory bowel disease (IBD). Hence, a thorough medical history and a complete physical examination are critical during the diagnostic workup of acute anal pain.
Currently, there are no recommendations on the role of biochemical investigations in patients with suspected thrombosed or strangulated haemorrhoids. In patients with suspected bleeding haemorrhoids, a focused medical history should be collected. Next, a complete physical examination including a digital rectal examination should be carried out to rule out other causes of lower gastrointestinal bleeding.
It is important to check the vital signs in patients with suspected bleeding haemorrhoids. This is to determine haemoglobin and hematocrit and to assess coagulation to evaluate the severity of the bleeding. In cases with severe bleeding, blood typing and cross-matching are suggested.
2. Imaging investigations in patients with suspected complicated haemorrhoids
Imaging studies should be carried out when there is suspicion of other diseases. Imaging investigations such as CT scans, MRI, or endoanal ultrasound should be performed only if there is suspicion of concomitant anorectal diseases (sepsis/abscess, inflammatory bowel disease, neoplasm).
3. Endoscopy in patients with complicated haemorrhoids
Endoscopy plays a key role in the diagnosis and management of lower gastrointestinal bleeding. In patients with complicated haemorrhoids, anoscopy should be performed as part of the physical examination, whenever feasible and well-tolerated. Several studies support the use of anoscopy in all patients with complicated haemorrhoids. Compared to flexible endoscopy, anoscopy possesses good accuracy in detecting haemorrhoids and other anorectal lesions. When used in a haemorrhoidal crisis, anoscopy should be carried out using proper sedation.
All cases of painless rectal bleeding should not be considered haemorrhoids as it may be a sign of other diseases such as colorectal cancer, inflammatory bowel disease or other colitis, diverticular disease, or angiodysplasia. In patients with complicated haemorrhoids, colonoscopy should be performed in case of concern for inflammatory bowel disease or cancer arising from the patient personal and family history, or physical examination. It is critical to determine which patients require a full colonoscopy.
4. Pharmacological regimen in patients with complicated haemorrhoids
Pharmacological therapies are widely used for complicated haemorrhoids, with their benefits by multiple studies. Non-operative management is recommended as the first-line therapy, along with dietary and lifestyle changes (i.e., increased fibre and water intake together with adequate bathroom habits).
It is suggested to administer flavonoids to relieve symptoms. The role of flavonoids and phlebotomists has been extensively studied. Phlebotomists are a heterogeneous class of drugs, consisting of plant extracts (i.e., flavonoids) and synthetic compounds (i.e., calcium besylate), mainly used to treat chronic venous insufficiency.
Acute thrombosed external haemorrhoids cause severe anal pain. Internal anal sphincter hypertonicity is both deriving from and causing this excruciating pain. Moreover, the spasm of the anal sphincter worsens the congestion of the prolapsed piles. Hence, in patients with thrombosed or strangulated haemorrhoids, topical muscle relaxants such as topical nitrates and calcium channel antagonists have been suggested.
Currently, there are no recommendations for the role of NSAIDs, topical steroids, other topical agents, or injection of local anaesthetics for complicated haemorrhoids.
5. Role of office-based procedures in patients with complicated haemorrhoids
Currently, no recommendation is made regarding the role of office-based procedures such as rubber band ligation, sclerotherapy, and infrared coagulation in complicated haemorrhoids.
6. Surgery in patients with complicated haemorrhoids
In patients with thrombosed haemorrhoids, the decision between non-operative management and early surgical excision should be based on local expertise and the patient’s preference. The use of incision and drainage of the thrombus is not suggested.
Currently, there are no recommendations on the role of surgery in patients with bleeding haemorrhoids.
7. Angiography in patients with complicated haemorrhoids
Currently, there are no recommendations regarding the role of angiography in complicated haemorrhoids.
The guidelines for the management of anorectal issues by WSES and AAST will be discussed in this series pertaining to different conditions-Click here to read the previous parts-Anorectal abscess: Management guideline updates by WSES and AAST, Managing perineal necrotizing fasciitis: How to manage : WSES/AAST guidelines
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Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.
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