We hope that this edition of the Banding Bulletin finds you well! In this edition, we’ll utilize a case study to help illustrate the benefit of taking a comprehensive approach to caring for your patients with hemorrhoidal symptoms, mention a few things about our new website, and update you on our upcoming conference attendance.
Case study – Patient presenting with multiple hemorrhoidal symptoms including pain
A 52 year old, otherwise healthy male, presents complaining of “hemorrhoids”. His symptoms include swelling, itching, bleeding and periodic burning and pain, particularly when his hemorrhoids “flare up” every few weeks. He has had a negative colonoscopy as part of his evaluation, except for the finding of hemorrhoids, is not on any medication, has no allergies, and seeks care for his problems.
At the time of his first banding, a digital exam was only minimally uncomfortable for the patient and an anoscopy was performed revealing Grade II internal hemorrhoids. The Left Lateral, Right Anterior and Right Posterior columns were ligated at 2-week intervals without complication. Routine post-banding instructions were given, and the patient did extremely well until about 5 weeks after the last session, at which time, the patient had a “flare-up” after a constipated stool. He returned to the clinic while we were visiting for a “refresher” session. A physical exam revealed only a couple of skin tags externally, but on digital rectal exam, a very subtle scar could be palpated in the posterior midline, just inside the anal verge. The area was a bit tender when palpated, and was most consistent with a partially-healed fissure. He was recommended to continue with his post-banding dietary and behavioral modifications (fiber, fluid, sitz baths, avoid straining, minimizing his time on the commode, etc.), and topical nitroglycerin ointment 0.125% was prescribed. Within 2 weeks, his pain and “flare-up” had completely resolved!
Discussion:
A large percentage of “hemorrhoid patients” have associated issues along with their hemorrhoids. Commonly, we see perianal dermatitic reactions, anal spasm, and very frequently, an anal fissure. From our perspective, the diagnosis of a fissure is a clinical one and not necessarily one dependent upon “seeing” the fissure — often you can “feel” a partially healed fissure. In fact, if the patient is tender in the posterior, or less likely the anterior midline, in an area between the dentate line and the anal verge (and if they don’t have an abscess or a fistula) — they probably have a fissure!
A very liberal definition of a fissure, along with an aggressive use of topical treatments, will improve your clinical outcomes dramatically. Our favorite topical is 0.125% NTG as this concentration provides a high level of effectiveness, without the headache problems which tend to accompany stronger NTG concentrations. The 0.125% NTG is “off label” and must be compounded, but we have found it to be very helpful to our patients. For more information on our NTG treatment protocols, please take a look at our Clinical Pearls as well as our Nitroglycerin Instruction Sheet for patients.
For the most part — INTERNAL HEMORRHOIDS DO NOT HURT, and when we hear the words “flare-up”, more often than not we find small fissures, and so will treat these in conjunction with their hemorrhoids. Remember, not all fissures will cause a patient to jump off of the exam table when you touch them! There are many more fissures that are in various stages of healing not visible to the naked eye. If you treat both these partially healed fissures along with the hemorrhoids, we are confident that you will be thrilled with the outcomes you will see!
Website Changes
In case you haven’t noticed, CRH has recently launched a new PATIENT-ORIENTED WEBSITE as well as a PHYSICIAN-ORIENTED SITE. Please have a look, and let us know if you’d like any other information made available to you on the web!
Come Visit Us!
We will be out in force for the American College of Surgeons’ Clinical Congress in the exhibition hall from October 1 – 3 in Chicago, and then again in Las Vegas for the American College of Gastroenterology’s Annual Scientific Meeting from October 21-23.
We would also like to welcome Ed Harris and Barbara Wener to the CRH team. Ed and Barbara are clinical sales specialists based out of Miami and San Francisco, respectively. Please feel free to contact them if you’re in their area. If not, we hope to have a rep for your area in the future; in the meantime, you’re stuck with ME!
If you would like additional information on the tools you can use to build your banding practice, contact Brianne Brody. Have a great day, and we hope to catch up with you soon.
Best,
Mitch
Mitchel Guttenplan, MD, FACS
Medical Director
CRH Medical Corporation
T: 800.660.2153 x1022 | C: 770.363.0125 | F: 770.475.9953
