Bleeding Internal Hemorrhoids Research Articles

S651 Safety and Efficacy of Hemorrhoidal Artery Embolization in Patients Refractory to Conservative Management

Introduction: Endovascular hemorrhoidal artery embolization has emerged as an analogous therapy to Doppler-guided ligation. The purpose of this study was to evaluate the safety and efficacy of outpatient transarterial embolization for symptomatic refractory internal hemorrhoids. Methods: One hundred and twenty-six patients with symptomatic bleeding internal hemorrhoids refractory to prior treatment (e.g., banding, dietary/lifestyle modifications) were treated between August 2021 and May 2022 (62 men and 64 women). The average age was 58.3 +/- 15.8 years with an average Goligher's hemorrhoid grade of 2.2. Patients underwent superior and/or middle rectal artery embolization to the target arteries demonstrating abnormal vascular blush of the hemorrhoidal cushion with spherical embolic particles (500 or 600 micron) and/or microcoils (2-6 mm). Patients were discharged two hours post-procedure and were evaluated at baseline and 1-month for the following standardized outcomes: hemorrhoid related pain (HRP, 0-10), hemorrhoid symptoms score (HSS, 5-20), quality of life (QoL, 0-4), French bleeding score (FBS, 0-9), and hemorrhoid grade (0-4). Results: Femoral (121/126) or radial access (5/126) was performed and successful embolization of the superior and/or middle rectal artery was achieved in 126/126 (100%) patients. Statistically significant improvements in all outcomes were reported at follow-up (baseline vs 1 month): HRP (4.6 vs 1.7, p < 0.001), HSS (10.2 vs 7.1, p < 0.001), QoL (2.4 vs 0.7, p < 0.001), FBS (3.9 vs 1.5, p < 0.001), and hemorrhoid grade (2.0 vs 1.6, p = 0.03). One minor adverse event was reported: post-procedural peri-anal pain that required topical cream, which resolved soon after treatment. No major adverse events were reported. Conclusion: Hemorrhoidal artery embolization is a safe and effective outpatient treatment for refractory symptomatic internal hemorrhoids.

Prospective evaluation of the hemorrhoid energy treatment for the management of bleeding internal hemorrhoids.

BACKGROUNDThe hemorrhoid energy treatment (HET) system is a non-surgical bipolar electrotherapy device, which has previously demonstrated efficacy in the management of bleeding Grade I and II internal hemorrhoids; however, data is limited.AIMTo prospectively assess the safety and efficacy of the HET device.METHODSThis was an IRB-approved prospective study of 73 patients with Grade I or II internal hemorrhoids who underwent HET from March 2016 to June 2019. Patient factors and procedural data were obtained. A post-procedure questionnaire was administered by telephone to all patients at 1-wk and 3-mo following HET to assess for improvement and/or resolution of rectal bleeding and adherence to a stool softener regimen. A chart review was performed to observe recurrent symptoms and durability of response. Statistical analyses were performed using SPSS software (IBM; SPSS Version 25.0).RESULTSSeventy-three patients underwent HET during the study period. Mean post-HET follow-up was 1.89 years. Complete resolution of bleeding was reported in 65% at 1 wk (n = 48), with improvement in bleeding in 97.2% (n = 71) of patients. At 3-mo, resolution and/or improvement in bleeding was reported in 90% (n = 64) of patients. No procedure-related pain or adverse events were reported.CONCLUSIONHET is well tolerated, safe and highly effective in the majority of our patients presenting with Grade I and II symptomatic internal hemorrhoids.

Superior rectal artery embolization for bleeding internal hemorrhoids.

The aim of the present study was to evaluate clinical efficacy and safety of superselective embolization of the superior rectal artery (SRA) for the treatment of internal hemorrhoidal bleeding. Patients with stage II and stage III internal hemorrhoids, treated by interventional embolization of the SRA in our department between January 2017 and June 2019 were retrospectively evaluated. All patients suffering from disabling chronic hematochezia and some with relative contraindications for operation (n = 17) orrejectionofconventional hemorrhoidectomy (n = 15). Superselective SRA branch embolization was performed using gelatin sponge particles (350-560μm) and metallic coils (2-3mm). This treatment process was planned by a multidisciplinary team consisting of proctologist,gastroenterologist and radiologist. The surgical efficacy, postoperative complications and follow-up outcomes were observed. There were 32 patients (18 males, mean age 52 ± 12years, range: 22-78years), 12 (37%) with stage II hemorrhoids and 20 (63%) with stage III hemorrhoids. Embolization was successful in all patients, and bleeding symptoms resolved in 27 (84.4%) patients. The remaining 5 (15.6%) patients underwent either stapled hemorrhoidopexy (n = 4) or sclerotherapy (n = 1). Some patients experienced different degrees of pain (n = 4;12.5%), low fever (n = 11;34.4%), and tenesmus (n = 17;53.1%), which all spontaneously regressed without further treatment. All patients were followed up for at least 1year. There were no serious complications, such as infection, intestinal ischemia or massive hemorrhage. Four patients (14.8%) had rebleeding during the first months of follow-up. All patients with re-bleeding were successfully treated with internal iliac arteriography and branch embolization and did not experience further bleeds after a minimum follow up 3months follow-up. The short-term efficacy of superselective SRA embolization for grade II-III internal hemorrhoids is good, and this method is safe and feasible.

The Effect of Rubber Band Ligation in Bleeding Internal Hemorrhoids.

The Effect of Rubber Band Ligation in Bleeding Internal Hemorrhoids.

Therapeutic effects of endoscopic foam sclerotherapy for bleeding internal hemorrhoids

Objective To evaluate the safety and efficacy of foam sclerotherapy for bleeding internal hemorrhoids. Methods Consecutive adult patients (aged 18-60 years) with bleeding hemorrhoids were prospectively enrolled between March 2017 and March 2018. All patients were randomly assigned to the foam sclerotherapy (FS) group and the liquid sclerotherapy (LS) group. The foam and liquid sclerotherapy of hemorrhoids nucleus was performed by cap-assisted colonic endoscopy. Results A total of 108 patients were enrolled, including 62 males (57.4%) with mean age of 44.0±7.6 years. There was no significant difference in gender, age, or body mass index between the FS (n = 55) group and the LS (n =53) group. The total amount of lauromacrogol injection in the FS group was 3.7±0.9 mL, which was significantly lower than that in the LS group (8.0±2.2 mL, P<0.001). In the LS group, 8 patients (15.1%) developed bleeding after needle removal, which was significantly higher than that in the FS group [5.5%(3/53), P=0.022]. Significant pain was found in 2 patients (3.8%) in the LS group and 0 in the FS group (P= 0.025). The short-term cure rate and effective rate of the FS group were 87.3% (48/55) and 9.1% (5/55), while those were 69.8% (37/53) and 22.6% (12/53) in the LS group, respectively (P=0.046). Conclusion Foam sclerotherapy is safe and effective in the treatment of bleeding internal hemorrhoids. Key words: Hemorrhoids; Sclerosing solutions; Hemostasis, endoscopic; Sclerotherapy

Sa1754 Prospective Evaluation of the Hemorrhoid Energy Treatment in the Management of Bleeding Internal Hemorrhoids

Sa1754 Prospective Evaluation of the Hemorrhoid Energy Treatment in the Management of Bleeding Internal Hemorrhoids

Hemorrhoidal Energy Treatment: A Single-Center Retrospective Analysis of a Novel Technique for Treating Internal Hemorrhoids

Introduction: Internal hemorrhoids are a common cause of rectal bleeding. Traditional first line therapy for Grade I & II bleeding internal hemorrhoids has been conservative management. Various non-surgical and surgical treatment modalities are available for bleeding hemorrhoids. A novel, non-surgical, bipolar electrotherapy probe, the Hemorrhoid Energy Treatment (HET) System, has shown efficacy in the management of bleeding Grade I & II hemorrhoids. Methods: The study included 42 adults with Grade I or II internal hemorrhoids and rectal bleeding who underwent HET from March 2015 to March 2016. Each patient had at least 3-month post treatment follow up. Our retrospective chart review study was IRB approved. 38 subjects out of 42 responded to a telephonic follow-up questionnaire. The questionnaire inquired about post-HET pain, complete resolution of bleeding, improvement in bleeding, and use of stool softeners post-HET. Descriptive analysis was performed. Results: The cohort included 15 males and 23 females, with a mean age of 50±14.8 years. Patients reported average symptom duration of 10.8±10 months, prior to treatment. 36 patients underwent HET under moderate sedation, 1 under general anesthesia, and 1 without any sedation. In 29 patients (76%), HET was performed during flexible sigmoidoscopy; in 9 patients (24%) HET was performed during colonoscopy. The mean procedure time was 13.7±6.1 minutes. Our “modified” HET technique (use of pediatric biopsy forceps and gastroscope assistance) was utilized in 5 subjects and our “standard” HET technique (use of HET and gastroscope guidance only) was used in 33 subjects. None of the patients reported pain or rectal discomfort during the procedure. 33 patients (87%) reported no pain post procedure (Fig 1). 28 patients (74%) reported complete resolution of rectal bleeding (Fig 2). 10 patients reported continued bleeding with 8/10 patients from this group reporting improvement in bleeding post HET treatment. 2 patients (5%) reported no improvement in bleeding symptoms. 19 patients (50%) were able to discontinue stool softener use (Table 1).Figure 1Figure 2Table 1: Responses to Telephonic QuestionnaireConclusion: HET enabled complete resolution of hemorrhoidal bleeding in the majority (74%) of our patient cohort. In addition, most patients reported post-procedure improvement in bleeding. HET is a well-tolerated, safe and effective outpatient procedure for treating rectal bleeding due to hemorrhoids. Our study represents the largest reported HET experience to date.

Successful Colonoscopic Sclerotherapy for Bleeding Internal Hemorrhoids with Lauromacrogol

Background and aim: Inspired by the success of endoscopic sclerotherapy for the treatment of bleeding gastric varices, we investigated a new minimally invasive method for the treatment of bleeding internal hemorrhoids. Patients and methods: From 2009 to 2013, 110 outpatients with 2- or 3-degree bleeding internal hemorrhoids underwent colonoscopic sclerotherapy with Lauromacrogol. Patients with mixed hemorrhoids, fistula and fissure were excluded in this study. All patients were visited after 1 week and followed up through a telephone interview after 1 month, 6 months, 1 years and 2 years. 93 patients were performed colonoscopy examination after 1 year or 2 years. Results: As shown in this study, no patient had immediate complications. Mild postoperative pain occurred in 13 cases (12%) after the initial treatment, but could be alleviated spontaneously without pain medication. 26 patients (23.6%) showed mild self-limiting rectal bleeding one week after the treatment. All patients displayed pelvic infection, rectal prolapse and urinary retentions. Three months later, 95.5% of patients (105/110) were effectively treated. 5 patients carried out another sclerotherapy with injection of Lauromacrogol due to recurrent hemorrhage. A total of 93 patients (85%) were contacted by telephone for a follow-up to document results of the treatment after 1 month, 6 months, 1 year and 2 years. Among them, 70 cases (75%) showed no symptoms. 23 cases (25%) had some residual symptoms including occasional bleeding and prolapse, however, there were no requirements for further treatment. No patients experienced fecal incontinence. The duration of the operation in our study is 16.3±5.1minutes. The total cost of this sclerotherapy with Lauromacrogolis 2536±167.8 Yuan.

Repeat colonoscopy’s value in gastrointestinal bleeding

To assess the diagnostic yield and clinical value of early repeat colonoscopies for indications other than colorectal cancer (CRC) screening/surveillance. A retrospective review of patients who had more than one colonoscopy performed for the same indication within a three year time frame at our tertiary care referral hospital between January 1, 2000 and January 1, 2010 was conducted. Exclusion criteria included repeat colonoscopies performed for CRC screening/surveillance, poor bowel preparation, suspected complications from the index procedure, and incomplete initial procedure. Primary outcome was new endoscopic finding that led to an endoscopic therapeutic intervention or any change in clinical management. Clinical parameters including age, sex, race, interval between procedures, indication of the procedure, presenting symptoms, severity of symptoms, hemodynamic instability, duration between onset of symptoms and when the procedure was performed, change in endoscopist, withdrawal time, location of colonic lesions and improvement of quality of bowel preparation were analyzed using bivariate analysis and logistic regression analysis to examine correlation with this primary outcome. Among 19 772 colonoscopies performed during the above mentioned period, 947 colonoscopies (4.79%) were repeat colonoscopies performed within 3 years from the index procedure. Out of these repeat colonoscopies, 139 patient pairs met the inclusion criteria. The majority of repeat colonoscopies were for lower gastrointestinal bleeding (88.4%), change in bowel habits (6.4%) and abdominal pain (5%). Among 139 eligible patient pairs of colonoscopies, only repeat colonoscopies that were done for lower gastrointestinal bleeding and abdominal pain produced endoscopic findings that led to a change in management [25 out of 123 (20.33%) and 2 out of 7 (28.57%), respectively]. When looking at only recurrent lower gastrointestinal bleeding cases, new endoscopic findings included 8 previously undetected hemorrhoid lesions (6.5%), 7 actively bleeding lesions requiring endoscopic intervention, which included 3 bleeding arterio-venous malformations (2.43%), 2 bleeding radiation colitis (1.6%), and 2 bleeding internal hemorrhoids (1.6%), 5 previously undetected tubular adenomas [4 were smaller than 1 cm (4.9%) and 1 was larger than 1 cm (0.8%)], 3 radiation colitis (2.43%), 1 rectal ulcer (0.8%), and 1 previously undetected right sided colon cancer (0.8%). Of the 25 new endoscopic findings, 18 (72%) were found when repeat colonoscopy was done within the first year after the index procedure. These findings were 1 rectal ulcer, 3 radiation colitis, 4 new hemorrhoid lesions, 3 previously undetected tubular adenomas, and 7 actively bleeding lesions requiring endoscopic intervention. Of all parameters analyzed, only the interval between procedures less than one year was associated with higher likelihood of finding a clinically significant change in repeat colonoscopy (odds ratios of interval between procedures of 1-2 year and 2-3 year compared to 0-1 year were 0.09; 95%CI 0.01-0.74, P = 0.025 and 0.26; 95%CI 0.09-0.72, P = 0.010 respectively). No complications were observed among all 139 colonoscopy pairs. There is clinical value of repeating a colonoscopy for recurrent lower gastrointestinal bleeding, especially within the first year after the index procedure.

Su1543 A Prospective Randomized Comparative Study of Endoscopic Band Ligation and Sclerotherapy of Bleeding Internal Hemorrhoids in Egyptian Patients With Liver Cirrhosis

Endoscopic band ligation (EBL) is a safe and effective method for treating symptomatic second and third degree hemorrhoids [1].Takahiro et al. [2], in their retrospective study, concluded that endoscopic injection sclrotherapy (EIS) is superior to EBL with regard to long-term effectiveness and complications. The aim of our study was to evaluate the effectiveness and complications of EBL compared to EIS in the treatment of bleeding internal hemorrhoids in Egyptian patients with liver cirrhosis.

Flexible Video-Endsocopic Injection Sclerotherapy for Second and Third Degree Internal Hemorrhoids

ABSTRACT Background and objectives: Bleeding from hemorrhoids is the commonest cause of rectal bleeding in adults. Injection sclerotherapy of internal hemorrhoids is one of the non-surgical treatments, and is simple, safe and feasible. Conventionally sclerotherapy is performed with rigid proctoscope which has limitations of maneuverability, narrower field of vision and documentation compared to flexible videoendoscope. Therefore, we assessed the efficacy and safety of video-colonoscopic sclerotherapy for bleeding internal hemorrhides. Methods: Seventy-nine patients of bleeding internal hemorrhoids were subjected to colonoscopic sclerotherapy using 1.5% polidocanol in retroflexed or forward viewing positions. Success of treatment was defined as cessation of bleeding for six weeks. Patients were observed for complications and were followed up regularly for 3 months. Results: A total of 79 evaluable patients, 61 had grade II and 18 had grade III hemorrhoids. There was no statistically significant differences in achieving excellent or good results for control of bleeding between patients with grade II and grade III hemorrhoids (100% vs 94,5%; p&gt;0.05). The number of sessions of sclerotherapy required were significantly more in grade II than grade III hemorrhoids (1.1 ± 0.3 vs 1.3 ± 0.7; p = 0.04). No significant complications were noted except for bloating in ten patients (12.6 %) and rectal pain in 6 (7.6%) patients. Median time taken for the procedure was 30 minutes. Conclusions: Video-endoscopic sclerotherapy is safe, well-tolerated and effective treatment for bleeding internal hemorrhoids.(J Dig Endosc 2011;2(1):1-5)

Endoscopic Rubber Band Ligation of Internal Hemorrhoids in a Community GI Practice: A Patient Validated Survey of Clinical Efficacy

Purpose: Endoscopic treatment of internal hemorrhoids is directed at relieving symptoms of rectal bleeding. In this study its efficacy in a community GI practice was judged by a survey of patients' symptoms after treatment. Methods: 137 patients who underwent endoscopic rubber band ligation of bleeding internal hemorrhoids at United Hospital System between 2/1/05 to 2/1/10 were sent a symptom survey in March of 2010. The patients were asked the following questions. 1) Satisfaction with the treatment on a scale of 0 to 10. 2) Current presence of rectal bleeding and its magnitude if still present. 3) Endorsement of this treatment for someone with rectal bleeding from internal hemorrhoids. Results: 53 patients filled out and returned the survey. There were 30 males and 23 females. The mean age was 60 years. The mean time from the last treatment to the survey was 33.4 months. The mean no. of rubber band ligation sessions per patient was 1.3 with 42 patients undergoing only one session. The number of patients with none or minimal bleeding was 43. The number of patients endorsing this treatment was 43. The mean satisfaction score for all patients was 7.4. This jumped to 8.8 in patients with none or minimal bleeding. Conclusion: Endoscopic Rubber Band Ligation of bleeding internal hemorrhoids was highly effective in a majority of patients after one session only with a high satisfaction score.

Randomized Prospective Study of Endoscopic Rubber Band Ligation Compared With Bipolar Coagulation for Chronically Bleeding Internal Hemorrhoids

Randomized Prospective Study of Endoscopic Rubber Band Ligation Compared With Bipolar Coagulation for Chronically Bleeding Internal Hemorrhoids

Randomized Prospective Study of Endoscopic Rubber Band Ligation Compared With Bipolar Coagulation for Chronically Bleeding Internal Hemorrhoids

Our purpose was to compare the efficacy, complications, success rate, recurrence rate at 1 year, and crossovers of rubber band ligation (RBL) with those of bipolar electrocoagulation (BPEC) treatment for chronically bleeding internal hemorrhoids. A total of 45 patients of mean age 51.5 years, who had rectal bleeding from grade II or III hemorrhoids and in whom intensive medical therapy failed, were randomized in a prospective study comparing RBL with BPEC. Treatment failure was predefined as continued bleeding, occurrence of a major complication, or failure to reduce the size of all internal hemorrhoidal segments to grade I in < or =3 treatments. Patients were followed up for 1 year. With similar patients, rectal bleeding and other symptoms were controlled with significantly fewer treatments of RBL than of BPEC (2.3+/-0.2 vs. 3.8+/-0.4, P<0.05), and RBL had a significantly higher success rate (92% vs. 62%, P<0.05). RBL had more cases of severe pain during treatment (8% vs. 0%, P<0.05), but significantly fewer failures and crossovers (8% vs. 38%). Symptomatic recurrence at 1 year was 10% RBL and 15% BPEC. For patients with chronically bleeding grade II or III internal hemorrhoids that are unresponsive to medical therapy, safety and complication rates of banding and BPEC were similar. The success rate was significantly higher with RBL than with BPEC. Symptom recurrence rates at 1 year were similar.

Endoscopic hemorrhoidal sclerotherapy using 50% dextrose water: a preliminary report

Injection sclerotherapy has a prominent role in the treatment of bleeding hemorrhoids. The commonly used sclerosants are not available or very expensive in Nigeria. We prospectively evaluated 50% dextrose water, used as a nonallergenic sclerosant, in the treatment of bleeding internal hemorrhoids. Forty consenting adult patients (median age 50 years [range 35-67]; 22 women) with bleeding hemorrhoids, seen over a 2-year period, were offered injection sclerotherapy with 50% dextrose water. They were assessed for response, tolerance and complications. The duration of symptoms before presentation was 3 months to 15 years. The bleeding stopped after the injection in all patients. No patient needed a repeat procedure. No complication was recorded during follow up which ranged from 2 months to 12 months. We conclude that endoscopic hemorrhoidal sclerotherapy using 50% dextrose water offers a simple, safe and effective modality of treatment if properly utilized.

Safety and efficacy of colonoscopy after myocardial infarction: an analysis of 100 study patients and 100 control patients at two tertiary cardiac referral hospitals

The purpose of this study is to analyze the risks vs. the benefits of colonoscopy soon after myocardial infarction. A total of 100 consecutive patients undergoing colonoscopy within 30 days after myocardial infarction at two large tertiary cardiac referral hospitals were studied. The study group was compared with 100 control patients with neither myocardial infarction nor unstable angina during the preceding 6 months (matched for age, colonoscopy indication, and colonoscopist) who underwent colonoscopy. Indications for colonoscopy were bleeding per rectum (37 patients), fecal occult blood (36 patients, hematocrit < 30% in 25), iron deficiency anemia (11 patients, hematocrit < 25% in 9), and other (16 patients). Colonoscopy was performed at a mean of 15.5 (8.3) days after myocardial infarction. Two patients underwent colonoscopic colonic decompression. Colonoscopy was diagnostic in 46 (47%) of the study patients vs. 41% of the control patients ( p = 0.47, chi-square test). The relative rate of ischemic colitis was significantly higher in study vs. control patients (14 vs. 2, p < 0.005). Other diagnoses in study patients were the following: colon cancer (8), bleeding internal hemorrhoids (5), pseudomembranous colitis (5), high-risk adenomatous polyp (large or villous histopathology) (4), and other (10). Urgent colonoscopy was diagnostic in 63% of cases. Twenty-three patients had a major therapeutic benefit consequent to colonoscopy, including colon cancer surgery in 5. Study patients were significantly sicker than control patients (APACHE II score 9.9 [4.3] vs. 7.4 [2.8], p < 0.0001) and suffered significantly more colonoscopic complications compared with control patients (9 vs. 1; OR 5.2: 95% CI [1.2, 9.8], p < 0.03). Minor complications without clinical sequelae occurred in 8 study patients (asymptomatic hypotension or bradycardia). One major complication occurred in this group that was probably not procedure related. Colonoscopy in patients with a recent myocardial infarction is associated with a higher rate of minor, transient, and primarily cardiovascular complications compared with control patients but is relatively infrequently associated with major complications. Colonoscopy is beneficial and indicated after myocardial infarction, despite a higher risk, in certain circumstances. The relative frequency of ischemic colitis was relatively high in study patients.

HEMORRHOIDS CAN BE A SOURCE OF OBSCURE GI BLEEDING THAT REQUIRES TRANSFUSION

Hemorrhoidal bleeding typically manifests as bright red rectal bleeding that does not cause anemia or require transfusion. We report 3 patients with obscure GI bleeding severe enough to require repeated blood transfusions whom were cured by surgical hemorrhoidectomy. Case 1: 72 year old woman with a two year history of GI bleeding requiring a total of 20 units of blood. She had multiple non-diagnostic endoscopic procedures performed, including capsule endoscopy (VCE). Unprepared sig-moidoscopy was performed while she was bleeding, revealing bleeding internal hemorrhoids and no evidence for proximal bleeding. EUA revealed large bleeding internal hemorrhoids. After hemorrhoidectomy, no further bleeding has been seen for 6 months. Case 2: 54 year old woman with a diagnosis of chronic anemia due to obscure GI bleeding. She required 14 units of blood over the last three years and had an extensive workup performed, including VCE. During a subsequent episode of rectal bleeding, an unprepared flexible sigmoidoscopy demonstrated bleeding internal hemorrhoids with no proximal bleeding. She had an EUA followed by hemorrhoidectomy. She has not needed further transfusions during 4 months of follow-up. Case 3: 30 year old woman with a 16 month history of hematochezia attributed to internal hemorrhoids seen on sigmoidoscopy. She began bleeding daily and colonoscopy demonstrated internal hemorrhoids. Bleeding continued and her hematocrit fell to 20% and she was transfused 2 units of blood. Repeat colonoscopy was performed, showing hemorrhoids. She continued to bleed, and was treated by hemorrhoidectomy. After surgery she has not had any further bleeding for two years. These 3 patients show that hemorrhoidal bleeding can require transfusions. This demonstrates the truism that any GI bleeding that causes anemia or requires transfusion cannot be a hemorrhoidal bleed is not correct. Diagnosis requires a careful history and urgent unprepared sigmoidoscopy during bleeding. This will confirm that the bleeding is ano-rectal in origin and that there is no proximal source. Treatment is surgical. Relevant literature review demonstrated few studies on this topic. Kluiber and Wolff estimated the incidence of hemorrhoidal bleeding causing anemia to be 0.5 patients per 100,000 of the population. We agree that the incidence of clinically significant hemorrhoidal bleeding may be low, but it is more prevalent than commonly thought.

Retroflexed endoscopic band ligation of bleeding internal hemorrhoids

Background: Elastic band ligation is a well-established nonoperative method for treatment of bleeding internal hemorrhoids, stages II-III. Usually, one or two bands are placed at a single session by using rigid instruments. The aim of this study was to assess the feasibility, tolerability, safety, and efficacy of multiple band ligation of internal hemorrhoids performed in one session by using a flexible endoscope with an attached band ligation device in the retroflexed position. Methods: Eighty-three patients with chronically bleeding and/or prolapsing internal hemorrhoids were treated by retroflexed endoscopic band ligation. From 1 to 6 bands were placed in a single session. Bands were targeted at the apex and proximal body of the internal hemorrhoid so that final band placement was entirely proximal to the dentate line. Malpositioned bands were removed by using a novel method. Patients were followed prospectively to assess tolerance, complications, and efficacy. Retreatment was offered if the desired result was not achieved. Results: A mean of 3.0 (SD 1.2) bands (range 1-6) were placed in a single session. Five percent of bands were malpositioned and removed. Patients were followed for 26 (17) months (range 1-52 months). An excellent result was achieved in 80% of patients with stage II hemorrhoids. Patients with stage II hemorrhoids were more likely to have an excellent result compared with patients with stage III hemorrhoids (80% vs. 54%, p < 0.01). Retroflexed endoscopic band ligation was well tolerated overall. The rate of major, nonfatal complications was 4%. Conclusions: Retroflexed endoscopic band ligation is a feasible, well-tolerated, effective, and safe for treatment of bleeding stage II internal hemorrhoids. A novel method of endoscopic band removal is described. (Gastrointest Endosc 2002;55:532-7.)

Current medical, anoscopic, endoscopic, and surgical treatments for bleeding internal hemorrhoids

Internal hemorrhoids are extremely common in adults and are the most frequent cause of self-limited hematochezia in ambulatory adults. Most patients with gastrointestinal bleeding from internal hemorrhoids have bright red blood per rectum that stops and is not associated with anemia. However, approximately 15% to 20% of patients with bleeding internal hemorrhoids have more severe bleeding that requires hospitalization and transfusion for severe anemia. In a CURE Hemostasis Research Group study of patients with severe hematochezia, internal hemorrhoids represented the second most common colorectal cause of severe hematochezia. Bleeding internal hemorrhoids are most effectively diagnosed by slotted anoscopy; however, in adults, other colonic lesions need to be excluded by colonoscopy. Endoscopic and anoscopic techniques for treatment of bleeding internal hemorrhoids include sclerotherapy, banding, direct current probe, infrared coagulator, bipolar probe, and heater probe. Endoscopic diagnosis, treatment techniques, results, and complications are presented in this report, and medical and surgical treatments are discussed.

3638 Randomized, prospective trial of endoscopic rubber band ligation compared to bipolar coagulation for bleeding internal hemorrhoids

Internal hemorrhoids are the most common cause of recurrent hematochezia (BRB) in ambulatory adults.We compared the efficacy and safety of bipolar coagulation (BICAP) with endoscopic rubber band ligation (RBL) for hemostasis of bleeding internal hemorrhoids (IH). Methods: This was a randomized prospective trial of patients with IH bleeding, documented by anoscopy and colonoscopy, who continued to have BRB inspite of at least 60 days of medical therapy (bulk agents, suppositories, stool softeners). Exclusions were rectal fissures, AIDS, inflammatory disease, or incidental IH and another source of bleeding found. After grading of IH with a slotted anoscope, patients were randomized to anoscopic treatment with BICAP (16W, 1 secs pulses) or RBL (via videoendoscope) and treatments were applied above the dentate line on 3 IH segments/session. Endpoints were control of BRB, severe complication or refusal to continue the treatment, and reduction of all IH segments to grade ≤ 1 in ≥ 3 treatment sessions. Failures were crossed over to other therapies. Results: 37 patients with mean age of 51 and chronic IH symptoms for ≤ 9 yrs were treated, 18 with BICAP and 19 with RBL. See table for results. Significantly fewer treatment sessions with RBL were required for control of BRB. Conclusions: For patients with chronic internal hemorrhoids and recurrent hematochezia unresponsive to medical therapy: 1) bipolar coagulation and rubber band ligation were similar in efficacy and safety for hemostasis, 2) non-significantly more bipolar than RBL patients had treatment failures and were crossed-over to other treatments, and 3) RBL required significantly fewer sessions to control hematochezia and reduce the size of internal hemorrhoids than bipolar coagulation. Funded in part by NIH DK41301 (Human Studies Core), American Digestive Health Foundation Endoscopy Research Award, and NIH-GCRC M01-RR008658.