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Conservative and surgical treatment of haemorrhoids

Abstract

The management of haemorrhoids has evolved rapidly during the past few decades. Several new treatments have been proposed with the aim of reducing patients' postoperative pain, time to return to normal life, risk of early and late complications, and recurrence rate. Although conservative treatment based on dietary and lifestyle changes can help the majority of patients, and rubber band ligation and phlebotonic drugs can effectively treat grade I and II haemorrhoids, surgery is required for the most advanced stages. Milligan–Morgan haemorrhoidectomy is considered to be the gold-standard approach for grade IV haemorrhoids. An increasing number of minimally invasive treatment options, including mucopexy with or without mucosal resection and haemorrhoid artery ligation, have now been proposed for the management of grade III haemorrhoids. These approaches aim to correct the underlying pathophysiological mechanisms involved in the aetiology of haemorrhoids. An increased risk of recurrence is the price to pay for these minimally invasive and less painful treatments, but the sparing of the sensitive anoderm and a rapid return to normal life without pain are greatly appreciated by patients. An algorithm for the management of haemorrhoids using evidence-based medicine is also presented here.

Key Points

  • Haemorrhoid treatment must be tailored to the severity of disease and the patient's expectation

  • Conservative (including dietary, hygienic and medical) treatment is effective in managing patients during the early stages of haemorrhoids

  • Several new minimally invasive surgical options, including stapled mucopexy and Doppler-guided haemorrhoid artery ligation, are now being offered to patients with grade III haemorrhoids

  • Patients with grade IV haemorrhoids need to undergo a haemorrhoidectomy, the outcome of which is improved by the use of radiofrequency vessel sealing devices

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Figure 1: Evidence-based algorithm for the management of haemorrhoids.

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Altomare, D., Giuratrabocchetta, S. Conservative and surgical treatment of haemorrhoids. Nat Rev Gastroenterol Hepatol 10, 513–521 (2013). https://doi.org/10.1038/nrgastro.2013.91

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