Here’s hoping that this month’s “Banding Bulletin” finds you enjoying your summer! In this edition, we will draw your attention to some additional educational resources which have recently become available, as well provide a case study in order to help illustrate a point or two in the care of your hemorrhoid patients.
Doctor Robert A. Ganz has just had a great review piece published in the June issue of Clinical Gastroenterology and Hepatology –which can be found HERE. This paper is geared towards gastroenterologists and summarizes the epidemiology, anatomy, pathophysiology, diagnosis and treatment of hemorrhoids. Congratulations to Dr. Ganz for a job well done! We’d like to strongly encourage you to have a look at the piece, as it contains great information that will be helpful to your practice and your patients.
If you were at DDW last month in Orlando, you might have seen this CME associated video playing in the ASGE’s “Learning Center”. I was fortunate to participate in the development of the video with Bob Ganz, and hope that it will be a valuable resource to you. The DVD is available through the ASGE, and you can find a description of it at: http://portal.asge.org/products/details.aspx?catid=68&prodid=268
While we are on the topic of videos, I’d like to bring your attention back to another lecture that is available online, and which also grants CME credit. The presentation is part of the ACG Universe, and has a title that I only wish that I had stolen for my own talks! It was given by Dr. Lawrence J. Brandt at the 2011 ACG Western Regional Postgraduate Course, and can be found by creating an account and logging onto the Universe at: http://universe.gi.org. Dr. Brandt presents a great summary of the topic, and the “ACG Universe” is a great portal for a host of CME topics. If you do a “title seach” using the word “hemorrhoid” within the portal, you will also find a piece featuring Dr. Harry Sarles, and a presentation that I did as well.
An otherwise healthy 50-year old gentleman presented with a history of intermittent hemorrhoidal symptoms including itching, swelling, bleeding, burning as well as a long history of “hemorrhoid flare-ups” occurring every several weeks to several months. The patient had been seen at 2 week intervals, where the LL, RA and RP hemorrhoids were banded. It is now approximately 4 weeks after the last banding, the patient is still complaining of bleeding, and he just reported another “flare-up” after a hard bowel movement 3-4 days prior to this latest appointment.
A physical exam revealed no rashes, lesions, fistulae or anything other than the same anterior skin tag that has been present since the original presentation. The digital exam revealed a bit of tenderness at the anal orifice anteriorly associated with a fairly subtle linear thickening felt most easily in the intersphincteric groove. Anoscopy showed that each of the internal hemorrhoidal areas had some scarring present from their previous bandings, and that they were each “grade I” in appearance.
This is actually a scenario that both Andy and I have seen during visits to some of our Partners’ offices as part of our “refresher training sessions”, and serves as a reminder for a number of clinical points to keep in mind.
This patient has an anterior anal fissure with an associated “sentinel tag”, which is partially healed and so not clearly visible, but yet sufficient to periodically cause symptoms. While it is certainly possible that a patient may need a 4th banding for persistent hemorrhoidal tissue not completely controlled by the classic 3 bandings — from our experience at these sessions, it seems as if the most frequent cause of persistent bleeding after a patient has had their hemorrhoids treated is a missed anal fissure. I’d like to reinforce a few points regarding these patients below:
• Internal hemorrhoids don’t hurt! While there are exceptions, such as a patient with true “grade IV” disease, if the patients have pain as part of their symptom profile, then there is either infection (abscess, fistula, etc.), or “spasm” (fissure, thrombosis, proctalgia, etc.)
• “Flare-ups” = fissures! Patient histories are notoriously unreliable in these circumstances — some patients will not relate any history of pain, but when you palpate one of these partially,or mostly, healed fissures, the patient will admit to some discomfort. Often only then are they forthcoming with a whole host of other symptoms that they failed to report in the first place!
• Not all fissures are tender or are obviously visible. Most fissures are in various stages of healing, and may have been superficially re-epithelialized. If these patients still have deeper, non-healed tissue, then they still have a fissure! YOU DO NOT NEED TO SEE A FISSURE TO KNOW THAT IT IS THERE! In fact, by looking for a fissure too vigorously, the patient may wind up with a fissure that they didn’t have when they walked into your office!!!!! Fissures and the resulting spasm can be palpated during a proper digital ano-rectal exam, and you should act clinically based upon those findings.
• 20% of patients with symptomatic hemorrhoids have fissure disease as well! This is the number given in the literature, and it may well be a conservative one. In order to get the greatest benefit for your patients, make sure that BOTH the hemorrhoids and the fissures are attended to during your clinical interactions.
The treatment for these patients may include several steps in order to help control the patients’ spasm and fissure disease as you treat their hemorrhoids. I should note here that if the patient has a more severe fissure and is very tender, then we will obviously start by treating the fissure, “cooling them off”, and then attacking the hemorrhoids in a couple of weeks. The vast majority of patients have partially or mostly-healed fissures, are not terribly tender to examination, and you can easily treat both problems concurrently.
These treatments include:
• Conservative Medical Treatment — 15-20 gm of supplemental fiber per day, increased fluid intake, minimizing the time spent on the commode, warm sitz baths, etc.
• Topical Medications — our favorites are topical nitrates, but the use of calcium channel blockers have also been described.
• Botulinum Toxin injection for resistant cases.
• Surgery for the most resistant cases (lateral internal sphincterotomy). Surgery IS the most effective treatment for fissure disease (>90%), BUT it also is accompanied by at least a 2 – 4% risk of post-surgical incontinence – all reasons to fully utilize the conservative measures at your disposal prior to taking the patient to surgery!
ANDY and I would like to thank each of our Partners for filling out our recent survey! We are always trying to improve our training and support resources, and your feedback is crucial to these efforts. We would also like to invite any of you who might be interested in being trained in the use of the technology to contact ME or SHAUN GERRITS for more information. There is no cost to you or your practice for a training or refresher session, and both Andy’s wife and mine are happy to get us out of the house — so please let us know if we can help!
Mitchel Guttenplan, MD, FACS
CRH Medical Corporation
C: 770.363.0125 F: 770.475.9953