Everything you wanted to know about hemorrhoids and anal fissures, but were afraid to ask.
This is the second installment of a piece based on an interview by Dr. Rob Orman with Dr. Megan Cavanaugh, a colorectal surgeon in Portland, Oregon. Although many of Dr. Cavanaugh’s recommendations are not based on controlled trials, listeners nonetheless found the interview very helpful. Her advice is straightforward and practical, with a good measure of humor mixed in. Last month, we discussed perianal abscesses. This month, we cover hemorrhoids and fissures.
We will deal with painful external hemorrhoids first. One of the questions that emergency physicians face frequently is whether an external hemorrhoid should be incised or not. According to Dr. Cavanaugh, many so-called thrombosed hemorrhoids are actually acute flares that do not require surgical intervention. If the overlying skin is not taught and purple and a hard mass cannot be palpated inside, incision is likely to cause more pain and discomfort than the patient already has. Moreover, if symptoms have been present for more than 2-3 days, the chances of retrieving a clot are greatly diminished and conservative management with warm baths and a prescription steroid cream is more prudent. In these cases, it will often take a few weeks for the inflammation and pain to completely resolve.
In those patients who do qualify for an incision and clot removal, Dr. Cavanaugh uses the following technique:
Begin with a local anesthetic mixture that includes lidocaine, bupivicaine and bicarbonate to decrease the burning associated with injection.
Use a very small needle (28 gauge) to do the injecting and only instills analgesic in the area of the planned incision.
The incision itself is elliptical, made with scissors after gently lifting the skin over the area of maximum tension with forceps.
Remove this piece of overlying skin along with any underlying clotted material. Despite the inherently robust bacterial milieu of the region, antibiotics are not generally necessary after this procedure and patients typically heal uneventfully in a couple of weeks.
Bleeding hemorrhoids, most commonly internal, are the most common cause of rectal bleeding. The typical history is of intermittent bright red blood per rectum with defecation, on the toilet paper or on the outside of stools. Although a digital rectal examination is imperative in the evaluation of patients with rectal bleeding to palpate for a malignancy, only with anoscopy can one visualize internal hemorrhoids. To facilitate anoscopy, it is helpful to use a generous amount of lubrication and ask the patient to bear down during insertion of the anoscope. As the anoscope is then slowly and gently removed, the clinician visualizes the mucosa using a good direct light source. Interestingly, even when patients present with a history of recent bleeding, it is unusual to actually see a bleeding hemorrhoid on anoscopic examination. It is more common to see the hemorrhoids themselves creeping over the verge of the anoscope as it is slowly withdrawn.
Visualization of hemorrhoids is sufficient to initiate treatment, which consists of a high fiber diet and plenty of fluids, similar to the treatment of fissures discussed below. If bleeding is severe or does not respond to these conservative measures, patients should be referred for surgical treatment (typically banding) and consideration of further investigation to rule out more proximal and serious sources of bleeding. For bleeding external hemorrhoids, Dr. Cavanaugh will often inject the site of bleeding with an epinephrine containing lidocaine solution and in some cases there may be a role for cauterization.
Anal fissures typically present with sharp, searing pain upon defecation. Although fissures are small and can be difficult to visualize, many practitioners give up too early during their examination. Because of the spasm associated with fissures, it is important to spread the buttocks fully and have the patient as relaxed as possible. Fissures can often be found adjacent to an anal skin tag. Most fissures are in the midline posteriorly. A minority are anterior. Fissures that are in neither of these two locations should raise suspicion of an associated disease process such as Crohn’s disease or even a malignancy and warrant referral.
Treatment of fissures requires completely softening the stools. This is best achieved by the use of bulking agents (fiber), combined with at least 8 glasses of water per day. Although most practitioners use psyllium based products such as Metamucil®, Dr. Cavanaugh prefers methylcellulose (Citrucel®) because it does not produce gas and is therefore better tolerated. She also recommends taking the fiber in a suspension with water to help ensure that adequate fluid is consumed. Without adequate water, fiber can cause paradoxically hard stools. Magnesium, in the form of tablets or as a dose of milk of magnesia can also be helpful, especially in patients taking calcium or other agents that cause constipation.
To relieve the spasm and break the cycle of constipation and painful defecation associated with anal fissures, nitroglycerin ointment (0.2%) applied perianally three times daily can be very helpful. By relieving the spasm of the involuntary internal anal sphincter, blood flow to the two torn sides of the fissure are better able to heal. Unfortunately, many patients get headaches as a side effect. For this reason, Dr. Cavanaugh prefers using a calcium channel blocker initially, such as topical diltiazem. She also tells patients to continue all of these therapies concurrently for several weeks after the symptoms improve to prevent recurrence.
Dr. Swadron is the vice-chair for education in the department of EM at the LA County/USC Medical Center. He is an assoc. prof. of clinical EM at the Keck School of Medicine. EM:RAP is a monthly audio program that can be found at www.EMRAP.org
If you haven't seen it yet, check out the VIDEO from last month's EM:RAP, part 1 of this series.