Approach to Hemorrhoids

  • Varut LohsiriwatEmail author
Large Intestine (B Cash, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Large Intestine


Hemorrhoids are a very common anorectal disorder defined as the symptomatic enlargement and abnormally downward displacement of anal cushions. The current pathophysiologies of hemorrhoids include the degenerative change of supportive tissue within the anal cushions, vascular hyperplasia, and hyperperfusion of hemorrhoidal plexus. Low-grade hemorrhoids are easily and effectively treated with dietary and lifestyle modification, medical intervention, and some office-based procedures. An operation is usually indicated in symptomatic high-grade and/or complicated hemorrhoids. Whilst hemorrhoidectomy has been the mainstay of surgical treatment, more recently other approaches have been employed including Ligasure hemorrhoidectomy, stapled hemorrhoidopexy, and doppler-guided hemorrhoidal artery ligation. Post-procedural pain and disease recurrence remain the most challenging problems in the treatment of hemorrhoids. This article deals with modern approaches to hemorrhoids based on the latest evidence and reviews of the literature. The management of hemorrhoids in complicated situations is also discussed.


Hemorrhoids Treatment Hemorrhoidectomy Stapled hemorrhoidopexy Doppler-guided hemorrhoidal artery ligation 


Compliance with Ethics Guidelines

Conflict of Interest

Varut Lohsiriwat declares no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Thomson WH. The nature and cause of haemorrhoids. Proc R Soc Med. 1975;68:574–5.PubMedGoogle Scholar
  2. 2.
    Riss S, Weiser FA, Schwameis K, et al. The prevalence of hemorrhoids in adults. Int J Color Dis. 2012;27:215–20.CrossRefGoogle Scholar
  3. 3.
    Gralnek IM, Ron-Tal Fisher O, Holub JL, et al. The role of colonoscopy in evaluating hematochezia: a population-based study in a large consortium of endoscopy practices. Gastrointest Endosc. 2013;77:410–8.PubMedCrossRefGoogle Scholar
  4. 4.
    • Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012;18:2009–17. This article highlights the emerging pathophysiologies of hemorrhoids which are applicable to current and novel treatment of hemorrhoids. The applications and outcomes of each therapeutic modality are thoroughly discussed.PubMedCrossRefGoogle Scholar
  5. 5.
    Aigner F, Gruber H, Conrad F, et al. Revised morphology and hemodynamics of the anorectal vascular plexus: impact on the course of hemorrhoidal disease. Int J Color Dis. 2009;24:105–13.CrossRefGoogle Scholar
  6. 6.
    Perera N, Liolitsa D, Iype S, et al. Phlebotonics for haemorrhoids. Cochrane Database Syst Rev. 2012;8, CD004322.PubMedGoogle Scholar
  7. 7.
    Lohsiriwat V, Scholefield JH, Dashwood MR, et al. Pharmacological characteristics of endothelin receptors on sheep rectal blood vessels. Pharmacol Res. 2011;63:490–5.PubMedCrossRefGoogle Scholar
  8. 8.
    Morinaga K, Hasuda K, Ikeda T. A novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler flowmeter. Am J Gastroenterol. 1995;90:610–3.PubMedGoogle Scholar
  9. 9.
    The American Gastroenterological Association Clinical Practice Commitee. American gastroenterological association medical position statement: diagnosis and treatment of hemorrhoids. Gastroenterology. 2004;126:1461–2.CrossRefGoogle Scholar
  10. 10.
    Alonso-Coello P, Mills E, Heels-Ansdell D, et al. Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am J Gastroenterol. 2006;101:181–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, et al. Meta-analysis of flavonoids for the treatment of haemorrhoids. Br J Surg. 2006;93:909–20.PubMedCrossRefGoogle Scholar
  12. 12.
    Johanson JF, Rimm A. Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. Am J Gastroenterol. 1992;87:1600–6.PubMedGoogle Scholar
  13. 13.
    MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum. 1995;38:687–94.PubMedCrossRefGoogle Scholar
  14. 14.
    El Nakeeb AM, Fikry AA, Omar WH, et al. Rubber band ligation for 750 cases of symptomatic hemorrhoids out of 2200 cases. World J Gastroenterol. 2008;14:6525–30.PubMedCrossRefGoogle Scholar
  15. 15.
    Shanmugam V, Thaha MA, Rabindranath KS, et al. Systematic review of randomized trials comparing rubber band ligation with excisional haemorrhoidectomy. Br J Surg. 2005;92:1481–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Tiernan J, Hind D, Watson A, et al. The HubBLe trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for haemorrhoids. BMC Gastroenterol. 2012;12:153.PubMedCrossRefGoogle Scholar
  17. 17.
    • Nienhuijs S, de Hingh I. Conventional versus LigaSure hemorrhoidectomy for patients with symptomatic Hemorrhoids. Cochrane Database Syst Rev 2009; CD006761. This meta-analysis demonstrates that Ligasure hemorrhoidectomy results in significantly less postoperative pain (up to 14 days) and shorter operating time, with similar efficacy to conventional hemorrhoidectomy. Google Scholar
  18. 18.
    Lohsiriwat D, Lohsiriwat V. Outpatient hemorrhoidectomy under perianal anesthetics infiltration. J Med Assoc Thail. 2005;88:1821–4.Google Scholar
  19. 19.
    Lohsiriwat V, Lohsiriwat D. Ambulatory anorectal surgery under perianal anesthetics infiltration: analysis of 222 cases. J Med Assoc Thail. 2007;90:278–81.Google Scholar
  20. 20.
    Patti R, Almasio PL, Muggeo VM, et al. Improvement of wound healing after hemorrhoidectomy: a double-blind, randomized study of botulinum toxin injection. Dis Colon Rectum. 2005;48:2173–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Siddiqui MR, Abraham-Igwe C, Shangumanandan A, et al. A literature review on the role of chemical sphincterotomy after Milligan-Morgan hemorrhoidectomy. Int J Color Dis. 2011;26:685–92.CrossRefGoogle Scholar
  22. 22.
    Gupta PJ, Heda PS, Kalaskar S, et al. Topical sucralfate decreases pain after hemorrhoidectomy and improves healing: a randomized, blinded, controlled study. Dis Colon Rectum. 2008;51:231–4.PubMedCrossRefGoogle Scholar
  23. 23.
    Ala S, Saeedi M, Eshghi F, et al. Topical metronidazole can reduce pain after surgery and pain on defecation in postoperative hemorrhoidectomy. Dis Colon Rectum. 2008;51:235–8.PubMedCrossRefGoogle Scholar
  24. 24.
    •• Burch J, Epstein D, Sari AB, et al. Stapled haemorrhoidopexy for the treatment of haemorrhoids: a systematic review. Colorectal Dis. 2009;11:233–43. This systematic review shows that, compared to conventional hemorrhoidectomy, stapled hemorrhoidopexy is associated with less postoperative pain and a shorter convalescence, but a higher rate of prolapse and re-intervention for prolapse.PubMedCrossRefGoogle Scholar
  25. 25.
    Chen JS, You JF. Current status of surgical treatment for hemorrhoids–systematic review and meta-analysis. Chang Gung Med J. 2010;33:488–500.PubMedGoogle Scholar
  26. 26.
    Satzinger U, Feil W, Glaser K. Recto Anal Repair (RAR): a viable new treatment option for high-grade hemorrhoids. One year results of a prospective study. Pelviperineology. 2009;28:37–42.Google Scholar
  27. 27.
    Giordano P, Overton J, Madeddu F, et al. Transanal hemorrhoidal dearterialization: a systematic review. Dis Colon Rectum. 2009;52:1665–71.PubMedCrossRefGoogle Scholar
  28. 28.
    Sajid MS, Parampalli U, Whitehouse P, et al. A systematic review comparing transanal haemorrhoidal de-arterialisation to stapled haemorrhoidopexy in the management of haemorrhoidal disease. Tech Coloproctol. 2012;16:1–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand

Personalised recommendations