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Banding Bulletin – March 2012

Banding Bulletin – March 2012

We hope that this month’s edition of the “Banding Bulletin” finds you well! In this edition, we’d like to touch a bit on the topic of ansocopy – an issue over which we’ve received a number of inquires. We’ll also bring you up to date on a few happenings with the company.

Visit us at upcoming meetings!

CRH is happy to be participating in the 2012 GI Roundtable Conference in Knoxville, TN from March 30-31 ( We’ll then be at DDW in San Diego, CA in May, where we will participate in the “Learning Center” as well as in the Exhibition Hall. If you will be attending either of these meetings, please come by and say “hello”!

Hemorrhoids – Office Management and Review for Gastroenterologists.

Bob Ganz and I recently had the above piece published, reviewing many of the topics discussed in our presentations, and we have a link to that paper HERE. I’m certain that if my grandmother were still alive, she would tell you that it is the best paper ever written on the topic – if not the best paper written about anything! She was not a gastroenterologist…or a doctor…but she was my grandmother!

To Anoscope or Not to Anoscope . . . . .

Questions regarding the need for anoscopy are among the most frequent that we receive. It is clear that prior to treating your patients for hemorrhoids, some sort of visualization of the patient’s disease is indicated. There are several options available to accomplish this – from evaluating the anorectum as a part of a colonoscopy or flexible sigmoidoscopy to the performance of a dedicated anoscopic exam. This visualization will not only help to identify the patient’s hemorrhoids, but also (particularly in the case of the flex sig or colonoscopy), rule out other clinical entities. This discussion pertains only to the anorectal portion of that evaluation.

When evaluating the patient endoscopically, particularly when you are in “retroflexion” and insufflated, that insufflation tends to cause the internal hemorrhoids to “hide” (as a result of the distension of the rectum). In order to better characterize the internal hemorrhoidal disease (those changes which are proximal to the dentate line), the rectum must be partially decompressed to “expose” the extent of the internal disease, otherwise the majority of the abnormalities exposed are at and distal to the dentate line (and so “external” by definition). The location of the hemorrhoids can be a bit awkward to describe in retroflexion as well, but the easiest way to do this would be to squirt some irrigant into the rectum. The “puddle” will be on the left (assuming the patient is in the left lateral position), and then you are able to “do the math” in order to identify the right-anterior and right-posterior bundles.

Another way to examine the patient not in need of one of the more comprehensive exams is to do a simple anoscopy. This can be done in the office, without prep or significant discomfort or expense (the disposable anoscope that we use is less than $1.00!), and it affords you a lot of information regarding the extent and position of the patient’s hemorrhoids, in addition to several other anorectal issues. Anoscopy does not “need” to be performed each time you see and treat a patient, but it certainly comes in quite handy before initiating treatment for hemorrhoids as well as after the treatment has been completed if you are checking for residual disease.

There are several types of anoscopes on the market, typically categorized as “slotted” and “non-slotted”. Like most things in life, each has its “pros” and “cons”. Andy and I typically utilize a non-slotted scope, which affords a 360-degree view of the rectum without the need for rotation or repeated passages of the scope, but there are other options out there as well.

If you have any questions regarding the above, or if you would like to feel more comfortable in the performance of your anoscopic exams, Andy and I will be happy to head back your way to reinforce ANY of the techniques that we’ve discussed in the past. CRH will provide “refresher” trainings for you at no cost, just as it does initial trainings – please contact ME if you’d like to arrange a visit or have any questions!



Mitchel Guttenplan, MD, FACS

Medical Director

CRH Medical Corporation

T: 800.660.2153 x1022 | C: 770.363.0125 | F: 770.475.9953

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