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Banding Bulletin – November 2013

Banding Bulletin – November 2013

I hope that this “Thanksgiving Edition” of the Banding Bulletin finds you well! In this edition, we will present a case which focuses on the evaluation and management of your hemorrhoid patients, introduce you to a new member of our training team, and wish you and yours the best for the Holiday Season!

The Holiday Season is Here!

Thanksgiving means that the Holiday shopping season is about to begin …and for physicians that typically means that the “end of the year” rush is about to start as well. Patients suddenly realize that their insurance deductibles have been met for the year, and so want to get the rest of their medical care in before the New Year! Maximizing your office’s efficiency will go a long way in helping you handle this volume most effectively. CRH has developed a number of practice management tools (progress notes, patient consent forms, post-procedure care information etc.) that are available on the website for your use. Please also feel free to contact BRIANNE, as she can arrange for a staff training session in order to address any questions that they may have in regard to these patients and procedures. ANDY and I are also available should any clinical questions pop up.

CRH Expanding Training Program!

Mr. Allen Hansard has been with CRH, serving as Clinical Support Specialist in Georgia for the past year and a half. To date, Allen’s focus has been to provide technical assistance to our Partner Physicians, as well as support to their practices regionally. In the New Year, his role will be expanded to provide those same support services on a national level. We’ll also be announcing some exciting advancements in our training and support programs soon, and Allen will play an important role in this regard moving forward.

Case Study:

The patient presented is a healthy 48 year old male with no significant medical history, is s/p an appendectomy as a teen, takes no meds and has no allergies. He is presents with intermittent anorectal symptoms, including periodic bleeding, swelling, and itching. These symptoms are exacerbated when he has a constipated stool. He relates no significant history of perianal pain. Typically, the symptoms occur every few weeks, and they tend to respond to conservative measures. The patient however, is tired of these episodes and would like to be treated. He is not very symptomatic at the time of presentation — his last bout was a week or so prior to his appointment. He has had a negative colonoscopic examination in the past year.

Exam revealed a bit of a moist perianal erythematous rash, and other than a tiny right-anterior skin tag, there were no other abnormalities. Anorectal examination revealed mild spasm as well as a subtle area of thickening in the posterior midline just inside the anal verge. There was no mass or fullness noted, and when touching the area of scarring, the patient noted that this recreated some of the symptoms that the patient gets during one of his “flare-ups”. No other issues were noted on digital exam, and anoscopy revealed Grade II hemorrhoids in all 3 typical locations.

The patient was diagnosed with Grade II symptomatic hemorrhoids, a partially healed posterior fissure and a mild monilial rash. Supplemental fiber was given (15 – 20 gm/day), along with all of the other conservative measures. Suggestions included stopping the use of wipes, soaps, etc. in the area, a topical anti fungal was given, he was started on topical nitrates for his partially-healed fissure and the first of his bandings was performed.


Several points need to be raised with this patient. He gave a history of “flare-ups” but no real complaint of pain. We’ve found that this part of the patient’s history is unusually unreliable, and in fact, we often find physical signs of a partially healed fissure in patients that do not specifically complain of pain as part of their symptom profile! The literature will tell us that a full 20% of patients with symptomatic hemorrhoids have a fissure as well, and in order to obtain the best outcomes for your patients, ALL of their anorectal issues should be addressed — their hemorrhoids along with rashes, fissures, spasm, etc.! Providing comprehensive care to these patients will improve your patient results in the short term, and the literature hints that it may also improve your long-term results by minimizing the recurrence of any of these issues!

In addition, it is not necessary for the patient to have symptoms at the time of presentation for treatment to be indicated. If the patient has a history of recurrent problems in the face of adequate medical management, and if they desire treatment – then they should be treated! The patient’s next bout of symptoms is likely right around the corner, and these recurrent issues can be successfully treated using the CRH O’Regan System!

Please Call Us if We Can Help!

Andy and I would like to thank all of our Partners for their continued interest and support, and to invite you to contact us if we can help in any way. We are always available should any questions pop up, are happy to head back your way for “refresher” sessions, and to put you in touch with the folks at CRH that might be able to address your specific needs. We are also happy to keep up our “frequent flyer status” by visiting and working with anyone interested in bringing these techniques into their practice! Please let us know how we can help, and have a great Thanksgiving!


Mitchel Guttenplan, MD FACS
Medical Director
CRH Medical Corporation
T: 800.660.2153 x1022 | C: 770.363.0125 | F: 770.825.9015
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