Infrared Coagulation Research Articles

Interventional treatment of haemorrhoids in anticoagulated patients

Anticoagulants are currently widely used for cardiological reasons, stroke prevention and in other vascular diseases. Colorectal surgeons face patients suffering from haemorrhoids who are put on anticoagulant therapy in their everyday practice. Anticoagulation strategy for patients undergoing interventional treatment of haemorrhoids has not been discussed in detail in the literature so far. Standard management of grade 1-3 haemorrhoids includes rubber band ligation (RBL), sclerotherapy (SCL) and infrared coagulation (IRC) after unsuccessful conservative treatment. The rates of postprocedural bleeding range from 0.9-2.8% after rubber band ligation, 0-2.7% after sclerotherapy and 5% after infrared coagulation. Surgical procedures including dearterialization, haemorrhoidectomy and stapled haemorrhoidopexy are indicated in more advanced degrees as the third line of treatment and are complicated by postoperative bleeding in 1.4-5.9% and 2-7.9% patients, respectively. Haemorrhoidectomy is the best option in grade 4 haemorrhoids and is associated with 6.2-8.4% risk of bleeding. However, closed haemorrhoidectomy, Ligasure technique and/or anal tamponade can reduce this risk. Surgical guidelines recommend continuing acetylsalicylic acid in low bleeding risk procedures, including haemorrhoidal surgery. However, postoperative bleeding after rubber band ligation was more common in the aspirin group. On the other hand, haemorrhage incidence after sclerotherapy did not differ significantly between the group on anticoagulation compared with the group without anticoagulation. Haemorrhoidectomy should be postponed for 6 months in patients receiving dual antiplatelet therapy. According to the guidelines, vitamin K antagonists should be discontinued 5 days before haemorrhoidal surgery. Minimal bleeding risk procedures do not require discontinuation of anticoagulation,but this option seems to be hazardous for patients undertaking rubber band ligation. Sclerotherapy, on the other hand, could not require warfarin discontinuation if the international normalized ratio (INR) is within therapeutic range. Novel oral anticoagulants (NOACs) should be discontinued 1 day before low bleeding risk operations, including haemorrhoidectomy and resumed 1 day after the procedure. In conclusion, all anticoagulants should be ceased prior to operation except for aspirin. There are not clear recommendations on the perioperative protocols for continuation or discontinuation of blood thinners in patients undergoing minimally invasive procedures.

Role of Bhesaja and Shalya Chikitsa in Arsha Roga W.S.R. to Haemorrhoids

Arsha (Hemorrhoids) is an age-old problem involving ano rectal region. It is notorious for its chroniocity recurrences & frequent acute exacerbations. It has been described virtually from the beginning of medical history. Sushruta, the pioneer of ancient Indian Surgery has described Arsha (Hemorrhoids) in detail. Apart from its causes, types, signs and symptoms, he has also described its many folds treatment from which the importance of and prevalence of this disease in the past can be inferred. In today’s modernized world, shift duties, stressful life, eating of unhealthy foods makes people more prone to the ano-rectal diseases such as fissure and haemorrhoid. The dilation of the veins of the internal rectal plexus constitutes the condition of the internal haemorrhoids which are covered by the mucous membrane. Haemorrhoids are commonly occurring in the fourth to sixth decades, however may affect patients of all ages. In India, 1 million new cases are reported annually, 47 per 1000 and increases with age, and it is estimated that in the age group of 45-65 years, 50-85% of people around the world have haemorrhoids. Also, males are more prone to develop haemorrhoids compare to females. Furthermore, due to site of disease, many of the patients hesitate to go to doctor and they delay the examination and treatment which ultimately leads to worsen condition of the disease. According to Modern Surgery, Haemorrhoids is varicosity and dilatation of haemorrhoidal veins of anal-canal. Hemorrhoid is commonly seen in human being due to valve- less structure of haemorrhoidal veins. Hemorrhoid is a disease, which is very specific to human race only due to its erect posture. In the management of haemorrhoids, the procedures, which are in practice at present in modern surgery, are rubber band legation, cryo- surgery, dilatation, infra-red coagulation and haemorrhoidectomy. But not all of them have been uniformly successful. In modern medical science most popular management of haemorrhoids is haemorrhoidectomy, sometimes there is a chance to reoccurring the same disease from the excision area. In Ayurveda the management of Arsha is done as fourfold treatment like- Bhesaja, Kshar Karma, Agnikarma and Shastra Karma according to the clinical manifestation of the disease. In this present review article is an attempt to review the different approach of ayurvedic treatment for the management of Arsha (Haemorrhoids).

Incidence of Recurrent High-Grade Anal Dysplasia in HIV-1-Infected Men and Women Following Infrared Coagulation Ablation: A Retrospective Cohort Study.

This single-center, retrospective cohort study sought to estimate the cumulative incidence in HIV-1-infected patients of biopsy-proven high-grade anal intraepithelial neoplasia (HGAIN) recurrence after infrared coagulation (IRC) treatment. The study was based on data from a prospectively compiled database of 665 HIV-1-infected outpatients who attended a hospital Clinical Proctology/HIV Unit between January 2012 and December 2015. Patient records were checked to see which ones had received IRC treatment but later experienced a recurrence of HGAIN. Cytology samples were also checked for the presence of human papilloma virus (HPV). A total of 81 of the 665 patients (12%, 95%CI: 10–15%), of whom 65 were men and 16 women, were diagnosed with HGAIN and again treated with IRC. Of these 81, 20 (25%) experienced recurrent HGAIN, this incidence being true of both men (16/65, 95%CI: 19–57%) and women (4/16, 95%CI: 10–50%). The median time to recurrence was 6 (2–19) months overall, 6 (2–19) months in men, and 4 (2–6) months in women. HPV infection was detected in all patients except two, with HPV-16 being the most common genotype. This rate of incidence of recurrent HGAIN following IRC treatment is consistent with other reports and highlights the importance of continued post-treatment surveillance, particularly in the first year.

PIPPALYADI TAILA ANUVASAN BASTI IN ARSHA(HEAMORRIED).

Arsha(Haemorrhoid)is one grave disease included AshtaMahagada. According to Sushruta, vitiated VataDosha localizes in Guda Vali and vitiated Twak, Mansa, Meda and Rakta, resulting in the formation of Arsha. The management of Arsha involves AushadhiChikitsa, Kshar Karma, Agnikarma and Shastrakarma. Modern management of Arsha is mainly surgical approach, but the result was found to be less satisfactory. Up to 80% of Haemorrhoidal symptoms can be reduced by conservative treatment. There are many modalities like Haemorrhoidectomy, Sclerotherapy, Infra Red coagulation therapy, Lord’s Dialation Cryosurgery, Rubber band ligation and Stapler haemorrhoidectomy. But the options are limited; concern to their effectiveness in elimination of disease causing pathology. Because surgical approach can’t break Sampraptiof Arsha (pathology). To resolve Samprapti of Arsha, the treatment should be Deepan, Pachan and Vatanulomak. Keeping in mind all the three Karmas to resolve Arsha pathology we searched for the treatment and medicine. Acharya Carak and Vaghat has mentioned PippalyadiTailaAnuvasan Basti as treatment of Arsha. In other side these two Acharya told that Anuvasan Basti is contraindicated in Arsha. Hence, a conceptual study was carried out to explain the mode of action of PippalyadiTailaAnuvasan Basti inArsha.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Anal Squamous Cell Cancers (Revised 2018).

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen

Disparities in the Clinical Evolution of Anal Neoplasia in an HIV-Infected Cohort.

A recent meta-analysis suggested that anal intraepithelial neoplasia and invasive anal cancer are more prevalent among black men having sex with men (MSM). We conducted a retrospective cohort of HIV-infected adult patients under care between 2001 and 2012. Disparities in clinical evolution of anal intraepithelial neoplasia to high-grade squamous intraepithelial lesion (HSIL) and invasive anal cancer were evaluated in a three-state Markov model adjusted for cytology misclassification. We studied sociodemographic covariate effects for each state transition using multivariable models controlling for antiretroviral therapy and infrared coagulation treatment of HSIL. Among 2804 patients with a median age of 40years, 78% were MSM and 38% non-white. There were no disparities in HSIL prevalence (14%) by age, sex, race, or risk group. After 4.0years of follow-up, 23 patients developed invasive anal cancer. Females and black patients had lower transition rates from <HSIL→HSIL (HR=0.35 and HR=0.55, respectively); those with age >40 had lower rates of both <HSIL→HSIL progression (HR=0.64) and HSIL→<HSIL regression (HR=0.56); and MSM had higher rates of progression from <HSIL→HSIL (HR=3.30). Controlling for antiretroviral therapy and infrared coagulation (IRC) treatment as time-updated covariates, the univariable effects of sex, black race, and HIV risk factor remained significant. Black race was not associated with prevalent anal intraepithelial neoplasia nor with post-baseline progression of anal intraepithelial neoplasia.

Comparative clinical study of Apamarga Kshara application, infrared coagulation and Arshohara Vati in the management of Arsha (1st and 2nd degree hemorrhoids).

Introduction:In anorectal disorders, incidences of piles and fissures are increasing in Indian population due to western lifestyle. Many surgical methods are available to cure anorectal disorders, but now a days, demand for Ayurveda and herbal preparation is increasing in society.Materials and Methods:In this study, Apamarga Kshara application, infrared coagulation (IRC) procedure and Arshohara Vati (AV) tablet were administered for the management of internal hemorrhoid (Arsha). This study was an open labelled, prospective, interventional study, in which patients of piles [n = 30 (10 each group)] were selected from OPD of Institutional hospital. Apamarga Kshara application (AKA) was done on the internal piles for 1–3 sittings as per requirement, IRC was applied at the base of piles for one sitting and two tablets (500 mg each tablet) of AV were given orally thrice a day for 15 days. In all the three groups, the patients were assessed every week for 1 month and were followed up for another 1 month for relief in signs and symptoms.Results:Obtained results were analyzed and encouraging results were observed after completion of the treatment.Conclusion:The study concluded that Apamarga Kshara application is the most effective treatment for the management of internal hemorrhoid of 1st and 2nd degree in comparison to IRC procedure and administration of Arshohara Vati.

The non-surgical management for hemorrhoidal disease. A systematic review.

The non-surgical treatments for hemorrhoids are cost and time-saving techniques usually performed in patients suffering early hemorrhoidal disease. The most used are rubber band ligation (RBL), injection sclerotherapy (IS), and infrared coagulation (IRC). We performed a systematic review in order to evaluate: do these procedures really help to avoid further more aggressive treatments? What are the common harms? What are the rare harms? How many recurrences there are? A total of 21 RCTs were included in this review: 12 on RBL, 4 on IRC and 5 on IS. In RBL bleeding stops in up to 90% and III degree hemorrhoids improves in 78%-83.8%. IV degree prolapse should have a more invasive treatment. The commonest complications are bleeding and pain (8-80%). IRC related improvement is 78%, 51% and 22% for I, II and III degree. Post-operative pain occurs in 15-100% and post-operative bleeding ranges from 15% to 44%. Recurrence rate is 13% at a three months follow-up. IS brings to the resolution of prolapse in 90%-100% of II degree and allows good results for III degree even if reported only by case series. The post-procedural pain is 36%-49%. Bleeding is a very rare harm. Even if not definitive, these treatments could be an alternative for mild symptomatic patients after a clear explanation of recurrence rates and possible complications.

Treatment of anal dysplasia in HIV-positive men who have sex with men in a large AIDS reference centre

Objectives: Over the last few decades, incidence of anal cancer among HIV-positive men has been on the rise. In this context, programmes of screening and treatment of anal dysplasia which is a precursor of anal cancer have been developed. The aim of our study was to describe the efficiency, side effects and outcome of anal dysplasia treatment in a population of HIV-positive men who have sex with men (MSM).Methods: We performed a retrospective study of HIV-positive MSM who received treatment for anal dysplasia between May 2010 and February 2014 in the Saint-Pierre University Hospital, Brussels. The different treatments used were electrocautery (ECA), infrared coagulation (IRC), surgical treatment and imiquimod.Results: Seventy-three HIV-infected MSM were included in the study, counting 62% of HGAIN. Median age was 41 years. Eighty-one per cent were on HAART. Median CD4 cell count was 525 cell/mm³, and 65% had undetectable viral loads. A total of 139 therapeutic interventions were recorded during the study period, and two-thirds of the enrolled patients received more than one treatment. At 540 days of follow-up, the rate of treatment response was 62%. Fifty per cent of the persistent HGAIN were metachronous lesions. No severe adverse events were recorded but frequent treatment-associated discomfort was reported, such as pain, self-limited bleeding, infection and anal irritation.Conclusion: Treatment of anal dysplasia appears to be safe and to offer short-term efficiency. However, its long-term efficiency remains unknown, especially in the HIV-positive population in which spontaneous clearance is lower and rate of recurrence higher.

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Infrared Coagulation of Benign Erosions of Cervix

ABSTRACT Cervical erosion is the commonest problem encountered in gynecological practice. Various methods have been used uptil now to treat benign cervical erosion, such as electrocautery, cryotherapy and laser. All have some advantages and disadvantages. Aim: To evaluate the utility of infrared coagulator in conservative treatment of benign cervical erosions. Methods and results This is a study of 1000 cases. Nine hundred and seventy cases (97%) were done on outpatient basis. Healing was much faster and postprocedure discharge was minimal. Out of above cases only 20 (2%) required repeat procedure due to polyp like ectopias. In 30 cases (3%) of cases concomitant endocervical erosion was treated with electrocautery under short GA. Conclusion Infrared coagulation is at the moment the best suited method. In this necrosis is not caused by electric current but rather by heat of infrared light energy. This treatment is practically painless, does not require anesthesia and can be performed on outpatient basis. Healing time is short and postprocedure secretions are minimal. How to cite this article Sortey K. Infrared Coagulation of Benign Erosions of Cervix. J South Asian Feder Obst Gynae 2014;6(2):104-106.

Minimally Invasive Treatments of Hemorrhoidal Disease

Infrared coagulation (IRC), Direct current Electrotherapy (DCE), and Sclerotherapy. Results: Upon the articles, 881 were treated with RBL, 454 with IRC, 1203 with DCE, and 2372 with sclerotherapy. Postoperative pain, which is a common complication of hemorrhoidectomy, was 3-25% in RBL, 2.13-4.3% in DCE, and 1.8-7% in sclerotherapy. Pain was mild to moderate and rarely needed analgesic. Postoperative rectal bleeding was seen in 1.26-32.4% of patients treated with RBL. Recurrence of preoperative symptoms was 1.9-39% for RBL, 6.9-21% for sclerotherapy, and 2.9-3% for DCE. Postoperative complications were minor in all procedures and for sclerotherapy it was seen in 6.9-21% of patients. Success rate was 69.4-96.4% in RBL, 80% in IRC, 89.3-99.7% in sclerotherapy, and 98.2% in DCE. Patient ’ s satisfaction was 98% for DCE versus 99% for RBL and IRC. Operation time for each tag of hemorrhoid was 4.5-10 minutes for DCE, regarding different amplitudes of currency and degrees of hemorrhoid, and 13 minutes for sclerotherapy and not reported for other methods. Conclusions: Minimally invasive procedures are used depending on surgeon ’ s experience and preference. These modalities are comparable from different aspects. The cost of treatment and availability of equipment may affect the choice of modality. All of these techniques could be used in patients resulting in maximum success rate and minimum complications.

Long-term effectiveness of infrared coagulation for the treatment of anal intraepithelial neoplasia grades 2 and 3 in HIV-infected men and women

To assess the effectiveness and safety of infrared coagulation (IRC) for the ablation of anal intraepithelial neoplasia (AIN) and to provide data on the prevalence of AIN in HIV-infected patients. We performed a single-center, retrospective cohort study based on data collected from a prospectively compiled database of outpatients attended in the Clinical-Proctology-HIV-Unit (first visit). The effectiveness (normal anal cytology after 12 months of IRC) and safety of IRC were estimated. Between January 2005 and December 2011, a total of 69 (5%) patients with biopsy-proven AIN-2 or AIN-3 from among 1518 patients (1310 men; 208 women) were treated with IRC. The prevalence of cytological abnormalities was 49.5% [751/1518; (atypical squamous cells of unknown significance, 14%; low-grade squamous intraepithelial lesions, 27.5%; high-grade squamous intraepithelial lesions, 8%)]. High-resolution anoscopy revealed intra-anal condylomata in 31% of patients (236/751), nonvisualized lesions in 30% (227/751), and visualized lesions (from which biopsy specimens were taken) in 38% (288/751). The histological diagnosis was: AIN-1, 52% (151/288); AIN-2, 15% (44/288); AIN-3, 9% (25/288); normal, 19% (56/288); and nonevaluable, 4% (12/288). IRC was applied in-office in 66 patients (three refused to undergo treatment). At 12 months, all patients (n = 56) had a normal anal cytology result. Seven (13%) patients had biopsy-proven recurrence [mean (range) time-to-recurrence, 30 (18-43) months]. High-risk-human papilloma virus (HPV) infection was detected in all anal lesions (HPV-16 was the most common genotype). Agreement between cytological and histological results was poor. A high prevalence of AIN was found in both HIV-infected men and HIV-infected women. Although randomized clinical trials are lacking, IRC ablation of AIN-2 and AIN-3 lesions without concomitant condylomata could help prevent anal squamous cell carcinoma.

13. Long-term effectiveness of intra-anal high-grade dysplasia ablation and near 100% prevention of progression to anal cancer

Background High-grade dysplasia (HSIL) is the anal squamous cell carcinoma (ASCC) precursor. Ablation with surgery, electro cautery (ECA) and infrared coagulation (IRC) might prevent ASCC. We endeavoured to determine long-term effectiveness of HSIL ablation and progression to ASCC. Methods: A retrospective chart review of patients undergoing HSIL ablation by any modality between February 1998 until May 2012. Results: In 456 HIV+ MSM (mean age 45 ± 9 years) and 271 HIV– MSM (mean age 41 ± 11years) followed for a mean of 3 (range 0.2–13) years, 1673 HSILs were treated by laser, IRC and/or ECA. ASCC developed in 5 (0.7%) MSM but only one (0.1%) was undergoing active treatment. For HIV+ MSM, recurrence after 1st, 2nd, 3rd and 4th treatment was 66%, 64%, 62% and 54%, respectively. For HIV– MSM, HSIL recurrence after the 1st, 2nd, 3rd and 4th treatment was 59%, 44%, 46% and 50%, respectively. Median number of recurrent lesions was never greater than 2 for HIV+ MSM and 1 for HIV– MSM. The cure rate of lesions treated once in HIV+ and HIV– MSM was 73% and 84%, respectively. KM curves demonstrate that most recurrence occurs within the first 12 months after treatment. Recurrence increased with HIV infection (HR 1.3; 95% CI: 1.1–1.6) and each additional lesion treated (HR 1.6; 95% CI: 1.1–1.2). Age and treatment modality did not affect recurrence. Conclusions: Patients undergoing active ablation for cure of intra-anal HSIL appear to have limited progression to ASCC. Recurrence remains high but falls over time and repeated treatment.

Comparative Study of Infra-red Coagulation vs Haemorrhoidectomy in Patients of Haemorrhoids

Hemorrhoid disease is the most common reason patients seek evaluation by a colon and rectal surgeon. The majority of hemorrhoids can be managed nonoperatively with medical management or as day care procedures. Even though Milligan Morgan Hemorrhoidectomy(MMH) & Minimal Invasive Procedure for Hemorrhoid (MIPH) is the gold standard for hemorrhoids, but newer techniques like INFRA-RED Coagulation(IRC) for 1st, 2nd & 3rd degree hemorrhoids are showing promising results because of minimal complications, ease of procedure and a day care procedure most of the time. Besides that many patients are not ready for a definite surgical procedure and they can be benefitted by IRC.

Interventions for anal canal intraepithelial neoplasia

Anal canal intraepithelial neoplasia (AIN) is a pre-malignant condition of the anal canal transitional epithelium that is associated with human papillomavirus (HPV) infection. The incidence and prevalence of AIN and anal cancer are increasing rapidly in HIV-positive men who have sex with men (MSM). Other groups like HIV-negative MSM, immunosuppressed patients and people affected by other HPV diseases like genital warts and cervical intraepithelial neoplasia (CIN) may also develop AIN. The condition is complicated by its multicentric and multifocal nature and high rates of relapse and morbidity. Targeted excisions using ablative treatments such as cautery, infrared coagulation (IRC) and cryotherapy have been used as first-line therapeutic strategies, and there are many other options. There is no consensus about the optimal management of AIN. To evaluate the effects of therapeutic interventions for anal canal intraepithelial neoplasia (AIN). We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2011, Issue 4), MEDLINE and EMBASE (to October 2011). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies, and contacted experts in the field and manufacturers of any AIN and HPV-specific treatments. Randomized controlled trials (RCTs) that assessed any type of intervention for AIN. Two review authors independently abstracted data and assessed risk of bias. If it was possible, the data were synthesised in a meta-analysis. We found only one RCT, which included 53 patients, that met our inclusion criteria. This trial reported data on imiquimod versus placebo. There was no statistically significant difference in the risk of disease cure but there was a trend for imiquimod to downgrade the AIN to a low-risk stage. The lack of statistical power of the trial may be due to the small number of patients in each group. The risk of bias was estimated as moderate. The included trial failed to demonstrate any statistically significant efficacy of imiquimod in the management of anal intraepithelial neoplasia (AIN). The absence of reliable evidence for any of the interventions used in AIN precludes any definitive guidance or recommendations for clinical practice. Prospective cohort studies and retrospective studies have not been included in this review as they are considered to provide lower quality evidence. Well designed RCTs are needed.

Comparative Analysis of Doppler Guided Hemorrhoidal Artery Ligation (DG-HAL) &amp; Infrared Coagulation (IRC) in Management of Hemorrhoids

Both Doppler-guided hemorrhoidal artery ligation (DG-HAL) and infrared coagulation (IRC) are well-established techniques in the management of hemorrhoids. The aim of the study is to compare the clinical outcomes of DG-HAL and IRC in the patients with grade 1 and 2 hemorrhoids. A total of 296 patients were registered for the study, but 51 patients were lost in follow-up; hence, finally 245 patients were included in the analysis. Patients were randomized into two groups (mean age, 42years; range, 19-60years). Group A (n = 116) was treated with DG-HAL and group B (n = 129) was treated with IRC. Patients were examined at 1week, 1month, and 6months after the procedure. Mean time taken for HAL was 21min and for IRC, 12min. The cost of the DG-HAL procedure was 1,440 rupees ($31.53) and that of IRC was 376 rupees ($8). The mean duration of hospital stay after HAL was 6h and after IRC, 2h. Control of symptoms with HAL was 96%, whereas with IRC, 81%. Postoperative complication rate for HAL was 2%, whereas for IRC, 13%. Requirement of repeat procedure with HAL was 9% and with IRC, 28%. Both the procedures are minimally invasive, associated with minimal discomfort, and suitable for day care surgery. IRC requires lesser procedure time, lesser postoperative hospital stay, and has lower procedure cost, whereas DG-HAL is more effective in controlling symptoms of hemorrhoids, has lower post operative complication rate, and has lesser requirement of repeat procedure.

A retrospective clinical study of the treatment of high-grade anal dysplasia by infrared coagulation in a population of HIV-positive men who have sex with men

HIV-positive men who have sex with men (MSM) are at high risk of developing human papillomavirus-associated anal squamous cell cancer. Similar to the management of cervical dysplasia, clinicians are treating high-grade anal dysplasia to prevent progression to cancer. Initial treatments such as cold scalpel excision and electrofulguration have shown limited efficacy in a HIV-positive population. Infrared coagulation (IRC) is an outpatient treatment for high-grade anal dysplasia. This retrospective clinical study reports on 68 HIV-positive MSM with 78 biopsy proven high-grade anal lesions. Each lesion was treated with the IRC with re-biopsy of the treatment site a mean of 140 days later. Of the 74 evaluable lesions; 39 had anal intraepithelial neoplasia (AIN) 1, 20 had AIN 2, seven had AIN 3, and eight had normal epithelium. The IRC showed 64% efficacy per treated lesion and shows promise as a treatment modality for high-grade anal dysplasia in this population.

Refractory Rectal Ulcer Secondary to Infrared Coagulation Treated with Canasa Suppository

Purpose: Rectal ulcer is an uncommon rectal disorder that can present with bleeding, passage of mucus, and sense of incomplete evacuation. Solitary rectal ulcer is the most common type of rectal ulcer. Other less common causes include infection, ischemia, idiopathic, radiation, malignancy or medications. Here we report two cases of rectal ulcers secondary to hemorrhoid treatment, treated successfully with Canasa suppository. Methods: Two patients with grade II internal hemorrhoid treated with Infrared coagulation (IRC). Both patients developed rectal ulcer at the site of the application with intermittent bleeding. Initially they were treated conservatively with stool bulking agents and Anusol suppository, unsuccessfully. Canasa suppository were applied QHS for one month. Both achieved complete healing of there ulcers and symptoms. Results: Both patients achieved complete healing of there ulcers and symptoms. Repeat flexible sigmoidoscopy showed complete healing of the ulcer. No further treatment was required. Conclusion: Nonsurgical therapy for hemorrhoidal disease grades I and II with infrared photocoagulation, banding, bipolar and laser coagulation is a good alternative to surgery; it is painless, suitable as an outpatient procedure and its cost is low. These treatment are complicated occasionally with delayed rectal bleeding, urinary retention, pain, and fever. Treating this complication is very important for the practicing Gastroenterologist. Canasa is a new addition to our armamentarium for treating refractory rectal ulcers secondary to such hemorrhoidal treatment.

Early results of the treatment of internal hemorrhoid disease by infrared coagulation and elastic banding: a prospective randomized cross-over trial

Rubber band ligation (RBL) is probably the most commonly performed nonsurgical therapy for hemorrhoidal disease. Infrared coagulation (IRC) is one of the most recent advances based on the use of "heat". Recent studies have demonstrated similar efficacy for both modalities. This prospective randomized crossover trial compared IRC and RBL for pain, complications, effectiveness, and patient satisfaction and preference in the treatment of internal hemorrhoids (IH). Patients were randomized to receive either RBL (Group A) or IRC (Group B) for treatment of the first hemorrhoid; in a second procedure two weeks later, patients underwent the other procedure on the second hemorrhoid, thereby serving as their own control. The procedure preferred by the patient was employed two weeks later for the third hemorrhoid. Post-treatment pain was evaluated on a visual analog scale and on the basis of the percentage of patients requiring analgesics. Bleeding and early outcome of treatment were also recorded, together with the patient's satisfaction. A total of 94 patients were included in this study (47 patients in each group). At 30 minutes and 6 hours after treatment, pain scores were significantly higher in patients treated with RBL than in those treated with IRC (p<0.01). There was no significant difference in pain scores between the two procedures immediately and 24 hours after the procedures (p<0.05). After 72 hours and one week, the pain scores for RBL and IRC were similar. The percentage of patients using analgesics was significantly higher in RBL group than in IRC group at 6 hours (29.6% vs. 19.2%, respectively; p<0.05) and 24 hours (22.5% vs. 13.5%, respectively; p<0.05) after treatment. However, significant differences were not noted at 72 hours (12.7% vs. 6.4%; p<0.05) and one week (5.6% vs. 7.1%; p>0.05) after the procedures. There were significantly higher incidences of bleeding immediately, 6 hours, and 24 hours after RBL compared to IRC (immediate: 32.4% vs. 4.3%; 6 hours: 13.4% vs. 3.6%, 24 hours: 26.8% vs. 10.2%, respectively; p<0.01). However, there were no significant differences noted regarding the incidence of bleeding between the two groups at 72 hours. Complications were more likely after RBL than IRC, however this difference was not significant (p>0.05). Overall, 91 patients (96.8%) were successfully treated and 93 patients (99%) were very satisfied with the treatment. In the third treatment session, 50% of patients selected RBL and 50% chose IRC. Both RBL and IRC were well-accepted and highly efficacious methods for the treatment of IH; in addition, both procedures were associated with relatively minor complications. However, RBL was associated with more pain than IRC in the 24-hour postoperative period.