Advertisement

Hemorrhoids pp 19-33 | Cite as

Classification of Hemorrhoidal Disease and Impact on the Choice of Treatment

  • Amy C. Lord
  • Annabel Shaw
  • Philip H. Pucher
Reference work entry
Part of the Coloproctology book series (COLOPROCT, volume 2)

Abstract

The ideal classification of hemorrhoidal disease remains uncertain, with numerous frameworks proposed. Classification may be based on anatomical findings or symptom severity, with advantages and disadvantages inherent in each. Careful history and examination in an ambulatory setting are required and will be typically coupled with additional investigations to rule out other differentials before a final diagnosis and classification can be reached. Depending on anatomical findings (position of hemorrhoids), various treatment options are recommended which may include lifestyle advice (grade I), ambulatory treatments (grade I–II), or various surgical procedures (grade II–IV). A recommended treatment algorithm is described, but must be considered in the context of symptom severity. Several symptom severity scoring frameworks are described, though validity evidence for these is mixed.

References

  1. Alonso-Coello P, Mills E, Heels-Ansdell D, Lopez-Yarto M, Zhou Q, Johanson JF et al (2006) Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am J Gastroenterol [Internet]. [cited 2017 Jan 24] 101(1):181–188. Available from http://www.ncbi.nlm.nih.gov/pubmed/16405552CrossRefPubMedGoogle Scholar
  2. Bhatti MI, Sajid MS, Baig MK (2016) Milligan–Morgan (open) versus Ferguson haemorrhoidectomy (closed): a systematic review and meta-analysis of published randomized, controlled trials. World J Surg [Internet]. [cited 2017 Jan 27] 40(6):1509–1519. Available from http://www.ncbi.nlm.nih.gov/pubmed/26813541CrossRefPubMedGoogle Scholar
  3. Brown SR, Tiernan JP, Watson AJM, Biggs K, Shephard N, Wailoo AJ et al (2016) Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial. Artic 356. www.thelancet.com
  4. Burch J, Epstein D, Baba-Akbari Sari A, Weatherly H, Jayne D, Fox D et al (2009) Stapled haemorrhoidopexy for the treatment of haemorrhoids: a systematic review. Colorectal Dis [Internet]. [cited 2017 Jan 24] 11(3):233–243. Available from http://www.ncbi.nlm.nih.gov/pubmed/18637932CrossRefPubMedGoogle Scholar
  5. Bursics A, Morvay K, Kupcsulik P, Flautner L (2004) Comparison of early and 1-year follow-up results of conventional hemorrhoidectomy and hemorrhoid artery ligation: a randomized study. Int J Colorectal Dis [Internet]. [cited 2017 Jan 28] 19(2):176–180. Available from http://www.ncbi.nlm.nih.gov/pubmed/12845454
  6. Chung Y-C, Wu H-J (2003) Clinical experience of sutureless closed hemorrhoidectomy with LigaSure™. Dis Colon Rectum [Internet]. Springer. [cited 2017 Jan 27] 46(1):87–92. Available from http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00003453-200346010-00014CrossRefGoogle Scholar
  7. Chung CC, Ha JPY, Tai YP, Tsang WWC, Li MKW (2002) Double-blind, randomized trial comparing Harmonic Scalpel hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scissors excision: ligation technique. Dis Colon Rectum [Internet]. [cited 2017 Jan 27] 45(6):789–794. Available from http://www.ncbi.nlm.nih.gov/pubmed/12072632
  8. De Nardi P, Capretti G, Corsaro A, Staudacher C (2014) A prospective, randomized trial comparing the short- and long-term results of Doppler-guided transanal hemorrhoid dearterialization with mucopexy versus excision hemorrhoidectomy for grade III hemorrhoids. Dis Colon Rectum [Internet]. [cited 2017 Jan 27] 57(3):348–353. Available from http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00003453-201403000-00011
  9. Elmér SE, Nygren JO, Lenander CE (2013) A randomized trial of transanal hemorrhoidal dearterialization with anopexy compared with open hemorrhoidectomy in the treatment of hemorrhoids. Dis Colon Rectum [Internet]. [cited 2017 Jan 27] 56(4):484–490. Available from http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00003453-201304000-00012CrossRefGoogle Scholar
  10. Faucheron J-L, Poncet G, Voirin D, Badic B, Gangner Y (2011) Doppler-guided hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) for the treatment of grade IV hemorrhoids: long-term results in 100 consecutive patients. Dis Colon Rectum [Internet]. [cited 2017 Jan 24] 54(2):226–231. Available from http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00003453-201102000-00017CrossRefGoogle Scholar
  11. Ferguson JA, Heaton JR (1959) Closed hemorrhoidectomy. Dis Colon Rectum [Internet]. [cited 2017 Jan 28] 2(2):176–179. Available from http://www.ncbi.nlm.nih.gov/pubmed/13652788CrossRefGoogle Scholar
  12. Festen S, van Hoogstraten MJ, van Geloven AAW, Gerhards MF (2009) Treatment of grade III and IV haemorrhoidal disease with PPH or THD. A randomized trial on postoperative complications and short-term results. Int J Colorectal Dis [Internet]. Springer. [cited 2017 Jan 24] 24(12):1401–1405. Available from http://link.springer.com/10.1007/s00384-009-0803-2CrossRefPubMedGoogle Scholar
  13. Ganz R (2013) The evaluation and treatment of hemorrhoids: a guide for the gastroenterologist. Clin Gastroenterol Hepatol 11:593–603CrossRefPubMedGoogle Scholar
  14. Garg H, Singh S, Bal K (2011) Approach to the diagnosis of anorectal disorders. J Int Med Sci Acad 24(2):89–90Google Scholar
  15. Gupta PJ, Kalaskar S, Taori S, Heda PS (2011) Doppler-guided hemorrhoidal artery ligation does not offer any advantage over suture ligation of grade 3 symptomatic hemorrhoids. Tech Coloproctol [Internet]. [cited 2017 Jan 28] 15(4):439–444. Available from http://www.ncbi.nlm.nih.gov/pubmed/22033542CrossRefPubMedGoogle Scholar
  16. Johanson JF, Rimm A (1992) Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. Am J Gastroenterol [Internet]. [cited 2017 Jan 27] 87(11):1600–1606. Available from http://www.ncbi.nlm.nih.gov/pubmed/1442682
  17. Kaidar-Person O, Person B, Wexner S (2007) Hemorrhoidal disease: a comprehensive review. J Am Coll Surg 204(1):102–117CrossRefPubMedGoogle Scholar
  18. Kelly SM, Sanowski RA, Foutch PG et al (1986) A prospective comparison of anoscopy and fiberendoscopy in detecting anal lesions. J Clin Gastroenterol 8:658–660CrossRefPubMedGoogle Scholar
  19. Kraemer M, Kara D, Rzepisko M, Sayfan J (2015) A simple tool to evaluate common disorders: validation of a “proctological symptom scale”. Int J Color Dis 30(5):679–682CrossRefGoogle Scholar
  20. Lohsiriwat V (2012) Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol 18(17):2009–2017CrossRefPubMedPubMedCentralGoogle Scholar
  21. Longo A (1998) Treatment of hemorrhoid disease by reduction of mucosa and hemorrhoidal prolapse with a circular suturing device: a new procedure. In: Bologna: Proceedings of the 6th world congress endoscopic surgery, Monduzzi Publishing, Rome, pp 777–784Google Scholar
  22. Lunniss PJ, Mann CV (2004) Classification of internal haemorrhoids: a discussion paper. Color Dis 6(4):226–232CrossRefGoogle Scholar
  23. Macrae HM, Mcleod RS (1995) Surgical Practice Pratique chirurgicale. Comparison of hemorrhoidal treatments: a meta-analysis. Dis Colon Rectum 38(7):687–94Google Scholar
  24. Milligan ETC, Naunton Morgan C, Jones L (1937) Surgical anatomy of the anal canal, and the operative treatment of hæmorrhoids. Lancet 230(5959):1119–1124CrossRefGoogle Scholar
  25. Morinaga K, Hasuda K, Ikeda T (1995) 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 [Internet]. [cited 2017 Jan 28] 90(4):610–613. Available from http://www.ncbi.nlm.nih.gov/pubmed/7717320
  26. National Institute for Health and Clinical Excellence (2015) Suspected cancer recommendation and referral. NICE guideline (NG12). Available from https://www.nice.org.uk/guidance/ng12/chapter/1-recommendations-organised-by-site-of-cancer#lower-gastrointestinal-tract-cancers
  27. Nisar PJ, Scholefield JH (2003) Managing haemorrhoids. Br Med J 327(7419):847–851CrossRefGoogle Scholar
  28. O’Boyle CA (1992) Assessment and quality of life in surgery. Br J Surg 79(5):395–398CrossRefPubMedGoogle Scholar
  29. Perera N, Liolitsa D, Iype S, Croxford A, Yassin M, Lang P et al (2012) Phlebotonics for haemorrhoids. In: Perera N (ed) Cochrane database of systematic reviews [Internet]. Chichester: Wiley. [cited 2017 Jan 24]. p CD004322. Available from http://www.ncbi.nlm.nih.gov/pubmed/22895941
  30. Pucher PH, Sodergren MH, Lord AC, Darzi A, Ziprin P (2013) Clinical outcome following Doppler-guided haemorrhoidal artery ligation: a systematic review. Colorectal Dis [Internet]. [cited 2017 Jan 28] 15(6):e284–e294.  https://doi.org/10.1111/codi.12205CrossRefPubMedGoogle Scholar
  31. Pucher PH, Qurashi M, Howell A-M et al (2015) Development and validation of a symptom-based severity score for haemorrhoidal disease: the Sodergren score. Color Dis 17(7):612–618CrossRefGoogle Scholar
  32. Ratto C, Parello A, Donisi L, Litta F, Doglietto GB (2011) Anorectal physiology is not changed following transanal haemorrhoidal dearterialization for haemorrhoid disease: clinical, manometric and endosonographic features. Color Dis 13(8):243–245CrossRefGoogle Scholar
  33. Ratto C, Parello A, Veronese E, Cudazzo E, D’Agostino E, Pagano C et al (2015) Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial. Colorectal Dis [Internet]. [cited 2017 Jan 28] 17(1):O10–O19.  https://doi.org/10.1111/codi.12779CrossRefGoogle Scholar
  34. Riss S, Weiser FA, Riss T, Schwameis K, Mittlbock M, Stift A (2011) Haemorrhoids and quality of life. Color Dis 13(4):48–52CrossRefGoogle Scholar
  35. Sailer M, Brussen D, Debus ES, Fuchs KH, Thiede A (1998) Quality of life in patients with benign anorectal disorders. Br J Surg 85:1716–1719CrossRefPubMedGoogle Scholar
  36. Sanchez C, Chinn BT (2011) Haemorrhoids. Clin Colon Rectal Surg 24(1):5–13CrossRefPubMedPubMedCentralGoogle Scholar
  37. Schrock TR (1991) Hemorrhoids: nonoperative and interventional management. In: Advanced therapeutic endoscopy. Raven Press, New YorkGoogle Scholar
  38. Schuurman J-P, Rinkes IHMB, Go PMNYH (2012) Hemorrhoidal artery ligation procedure with or without Doppler transducer in grade II and III hemorrhoidal disease. Ann Surg [Internet]. [cited 2017 Jan 28] 255(5):840–845. Available from http://www.ncbi.nlm.nih.gov/pubmed/22504188CrossRefPubMedGoogle Scholar
  39. Simillis C, Thoukididou SN, Slesser AAP, Rasheed S, Tan E, Tekkis PP (2015) Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg [Internet]. Wiley. [cited 2017 Jan 27] 102(13):1603–1618.  https://doi.org/10.1002/bjs.9913CrossRefPubMedGoogle Scholar
  40. Thomson JPS, Leicester RJ, Smith LE (1992) Haemorrhoids. In: Coloproctology and the pelvic floor, 2nd edn. Springer. pp 373–393Google Scholar
  41. Walega P, Krokowicz P, Romaniszyn M, Kenig J, Sałówka J, Nowakowski M et al (2010) Doppler guided haemorrhoidal arterial ligation with recto-anal-repair (RAR) for the treatment of advanced haemorrhoidal disease. Colorectal Dis [Internet]. Blackwell Publishing. [cited 2017 Jan 28] 12(10 Online):e326–e329.  https://doi.org/10.1111/j.1463-1318.2009.02034.xCrossRefGoogle Scholar
  42. Yeung TM, D’Souza ND (2013) Quality analysis of patient information on surgical treatment of haemorrhoids on the internet. Ann R Coll Surg Engl 95(5):341–344CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Croydon University Hospital NHS TrustLondonUK
  2. 2.St Mary’s Hospital, Imperial College LondonLondonUK

Personalised recommendations