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Out-Patient Treatment of Haemorrhoids

Out-Patient Treatment of Haemorrhoids. David Jones Consultant General and Colorectal Surgeon Wythenshawe Hospital. Piles of Defeat Napoleon at Waterloo Welling et al Dis Colon Rectum 1988;31:303. Was Napoleon beaten by Wellington or his Piles?. Piles matter!. Piles. Cancer.

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Out-Patient Treatment of Haemorrhoids

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  1. Out-Patient Treatment of Haemorrhoids David Jones Consultant General and Colorectal Surgeon Wythenshawe Hospital

  2. Piles of DefeatNapoleon at WaterlooWelling et al Dis Colon Rectum 1988;31:303 Was Napoleon beaten by Wellington or his Piles?

  3. Piles matter! Piles Cancer

  4. Abnormal bowel habit • “If the patient is obviously infringing the rules of common sense it is reasonable to try and correct an error of bowel habit alone.” Keighley and Williams

  5. “Errors of bowel habit” Insistence on having at least one bowel motion a day Neglecting the first urge to defecate Insistence on trying to pass the last piece of stool in the rectum

  6. Dietary manipulation • Correcting constipation seems logical • Evidence is lacking

  7. Topical preparations Shark liver oil Yeast cell extract

  8. Prescription for Topical preparationsSouth Manchester PCT: Nov 05 –Oct 06“Top 5”

  9. “Invasive” out-patient treatment Aim is to cause mucosal fixation and prevent prolapse

  10. Do you have to treat haemorrhoids? • “Conservative forms of treatment to reduce the degree of prolapse of the anal cushions, such as injection, photocoagulation or band ligation, are so safe and simple…… that it is seldom justifiable for a proctologist who has been referred a patient with bleeding or prolapse to withhold these forms of treatment until after a trial of the effects of advice alone.” Surgery of the Anus, Rectum and Colon, Keighley and Williams, 1999

  11. How have I managed rectal bleeding?Flexible sigmoidoscopy for rectal bleeding:May 2001 – April 2002: n = 125 • Haemorrhoids: no intervention 57 • Haemorrhoids: RBL 9 • Haemorrhoidectomy 2 • “Normal” 20 • Fissure 5 • IBD 10 • Polyps 13 • Cancer 9

  12. Comparison of Hemorrhoidal Treatment Modalities: A meta-analysisMacRae, Dis Colon Rectum 1995, 38:687 • MEDLINE 1966 - 1994 • Clinical trials • Multicentre studies • Randomized, controlled trials • Textbooks • 16 Trials for analysis • 1952 patients enrolled, 1597 completed trial • 4.4% of population have “haemorrhoids”

  13. Meta-analysis: conclusions • Injections and photocoagulation are similar • Better response after RBL compared to IS or IRC (p=0.005) • Less need for further treatment after RBL (p 0.03) • Pain was greater after RBL

  14. Haemorrhoidectomy vs Banding • Haemorrhoidectomy better overall response rate (p = 0.001) • Greater risk of complications after haemorrhoidectomy (p=0.02) • Greater pain after haemorrhoidectomy (p<0.0001)

  15. Systematic review of randomized trials comparing rubber band ligation with excisional haemorrhoidectomyShanmugam et al. BJS 2005 92, 1481 • Complete remission of symptoms better after haemorrhoidectomy • Fewer patients require retreatment after haemorrhoidectomy • Anal stenosis, postoperative bleeding and incontinence to flatus more common after haemorrhoidectomy • Haemorrhoidectomy produces better long-term results but is associated with more post-operative complications

  16. Practice Parameters for the Management of Hemorrhoids (revised), Disease of Colon and Rectum 2005; 48: 189 Literature search: PubMed & Medline 1990-2003 www.fascrs.org

  17. Out-Patient treatment • Banding is most effective Office treatment • 65-85 % short to medium term success • Complications • Band slippage • Post band ulcer • Urinary retention • Anal pain • Haemorrhage • Pelvic infection

  18. Where to band? Pain occurs if bands are placed too low

  19. Where to band? 1.5 to 2cm above dentate line

  20. Where to band?

  21. Where to band? a b c d e f

  22. Look to see where you have banded

  23. Injections and photocoagulationWhich area do you treat?

  24. Life threatening sepsis following treatment for haemorrhoids: a systematic reviewMcCloud, Jameson, Scott, Colorectal Disease Nov 2006 • 10 papers • 17patients with sepsis • 10 deaths • Look out for • Severe perineal or abdominal pain • Urinary retention • Fever and leucocytosis

  25. Alternative treatments “Cool rectal spa therapy: From your freezer to your anus; Pleasure and relief in minutes”

  26. Most patients could be managed in Primary Care?

  27. Beattie GC. Rao MM. Campbell WJ. Secondary haemorrhage after rubber band ligation of haemorrhoids in patients taking clopidogrel--a cautionary note. [Case Reports. Journal Article] Ulster Medical Journal. 73(2):139-41, 2004 Nov.No longer taken (check catalogue for availability of issues) UI: 15651778 Authors Full NameBeattie, G C. Rao, M M. Campbell, W J.

  28. Vasotopic agents Reduce swelling and have anti-inflammatory properties • Flavonidic fraction vs RBL • Relieves bleeding • Ho et al, Dis Colon Rectum. 2000; 43: 66

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