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
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$209.00 per year
only $17.42 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Gazet, J. C., Redding, W. & Rickett J. W. The prevalence of haemorrhoids. A preliminary survey. Proc. R. Soc. Med. 63 (Suppl.), 78–80 (1970).
Riss, S. et al. The prevalence of hemorrhoids in adults. Int. J. Colorectal Dis. 27, 215–220 (2012).
Morgagni, J. B. Seats and Causes of Disease, 2 letter 32 art. 10, 105–106 (A. Millar, 1769).
Hunter, J. Cases in surgery. Hunterian Manuscripts, ii:95–96.
Verneuil, M. L'anatomie des l'hemorrhoides [French]. Bull. Soc. Anat. 30, 175–177 (1855).
Malgaigne, J. I. Manuel de Medecine Operatoire 10th edn (Germer Bailliere, 1837).
Shezner, F. Die Hamorrhoiden und andere Krankheiten des Corpus cavernosum recti und des Analkanal [German]. Dtsch Med. Wochenschr. 88, 689–696 (1963).
Gass, O. C. & Adams, J. Haemorrhoids: aetiology and pathology. Am. J. Surg. 79, 40–43 (1950).
Thomson, W. H. F. The nature of haemorrhoids. Br. J. Surg. 62, 542–552 (1975).
Willis, S., Junge, K., Ebrahimi, R., Prescher, A. & Schumpelick, V. Haemorrhoids—a collagen disease? Colorectal Dis. 12, 1249–1253 (2010).
Han, W. et al. Pathologic change of elastic fibers with difference of microvessel density and expression of angiogenesis-related proteins in internal hemorrhoid tissues. Zhonghua Wei Chang Wai Ke Za Zhi. 8, 56–59 (2005).
Aigner, F. et al. The vascular nature of hemorrhoids. J. Gastrointest. Surg. 10, 1044–1050 (2006).
Loder, P. B., Kamm, M. A., Nicholls, R. J. & Phillips, R. K. Haemorrhoids: pathology, pathophysiology and aetiology. Br. J. Surg. 81, 946–954 (1994).
Johanson, J. F. & Sonnenberg, A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology 98, 380–386 (1990).
Johanson, J. F. & Sonnenberg, A. Constipation is not a risk factor for hemorrhoids: a case-control study of potential etiological agents. Am. J. Gastroenterol. 89, 1981–1986 (1994).
Altomare, D. F. et al. Red hot chili pepper and hemorrhoids: the explosion of a myth: results of a prospective, randomized, placebo-controlled, crossover trial. Dis. Colon Rectum 49, 1018–1023 (2006).
Gaj, F. & Trecca, A. New “PATE 2006” system for classifying hemorrhoidal disease: advantages resulting from revision of “PATE 2000 Sorrento”. Chir. Ital. 59, 521–526 (2007).
Goligher, J. C. Surgery of the Anus, Rectum and Colon, 93–135 (Balliere & Tindall, 1980).
Sielezneff, I. et al. Is there a correlation between dietary habits and hemorrhoidal disease? Presse Med. 27, 513–517 (1998).
Alonso-Coello, P. et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Systematic Reviews, Issue 4. Art. No.: CD004649. http://dx.doi.org/10.1002/14651858.CD004649.pub2 (2005).
Jensen, S. L., Harling, H., Tange, G., Shokouh-Amiri, M. H. & Nielsen, O. V. Maintenance bran therapy for prevention of symptoms after rubber band ligation of third-degree haemorrhoids. Acta Chir. Scand. 154, 395–398 (1988).
Alonso-Coello, P. et al. Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am. J. Gastroenterol. 101, 181–188 (2006).
Alonso-Coello, P. et al. Meta-analysis of flavonoids for the treatment of haemorrhoids. Br. J. Surg. 93, 909–920 (2006).
Serventi, A. et al. Haemorrhoidal disease: role of conservative outpatient treatments. Ann. Ital. Chir. 82, 341–347 (2011).
Gupta, P. J. Infra red photocoagulation of early grades of hemorrhoids—5-year follow-up study. Bratisl. Lek. Listy. 108, 223–226 (2007).
Filingeri, V., Bellini, M. I. & Gravante, G. The role of radiofrequency surgery in the treatment of hemorrhoidal disease. Eur. Rev. Med. Pharmacol. Sci. 16, 548–553 (2012).
Yuksel, B. C. et al. Conservative management of hemorrhoids: a comparison of venotonic flavonoid micronized purified flavonoid fraction (MPFF) and sclerotherapy. Surg. Today 38, 123–129 (2008).
Awad, A. E. et al. A prospective randomised comparative study of endoscopic band ligation versus injection sclerotherapy of bleeding internal haemorrhoids in patients with liver cirrhosis. Arab. J. Gastroenterol. 13, 77–81 (2012).
MacRae, H. M. & McLeod, R. S. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis. Colon Rectum. 38, 687–694 (1995).
El Nakeeb, A. M. et al. Rubber band ligation for 750 cases of symptomatic hemorrhoids out of 2200 cases. World J. Gastroenterol. 14, 6525–6530 (2008).
O'Regan, P. J. Disposable device and a minimally invasive technique for rubber band ligation of hemorrhoids. Dis. Colon Rectum 42, 683–685 (1999).
Leicester, R. J., Nicholls, R. J. & Mann C. V. Infrared coagulation: a new treatment for hemorrhoids. Dis. Colon Rectum 24, 602–605 (1981).
Miyamoto, H., Asanoma, M., Miyamoto, H. & Shimada M. ALTA injection sclerosing therapy: non-excisional treatment of internal hemorrhoids. Hepatogastroenterology 59, 77–80 (2012).
Berger, P. L. Haemorrhoids treated by cryotherapy. Ann. R. Coll. Surg. Engl. 66, 73–74 (1984).
Rivadeneira, D. E. et al. Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of hemorrhoids (revised 2010). Dis. Colon Rectum 54, 1059–1064 (2011).
Jayaraman, S., Colquhoun, P. H. & Malthaner, R. A. Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid surgery. Dis. Colon Rectum 50, 1297–1305 (2007).
Morinaga, K., Hasuda, K. & Ikeda, T. A novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler flowmeter. Am. J. Gastroenterol. 90, 610–613 (1995).
Longo, A. Treatment of hemorrhoids disease by reduction of mucosa and hemorrhoidal prolapse with circular suturing device: a new procedure. Proceedings of the 6th World Congress of Endoscopic Surgery (Ed. Monduzzi) 777–784 (Roma, 1998).
Sohn, N., Aronoff, J. S., Cohen, F. S. & Weinstein, M. A. Transanal hemorrhoidal dearterialization is an alternative to operative hemorrhoidectomy. Am. J. Surg. 182, 515–519 (2001).
Avital, S., Inbar, R., Karin, E. & Greenberg, R. Five-year follow-up of Doppler-guided hemorrhoidal artery ligation. Tech. Coloproctol. 16, 61–65 (2012).
Infantino, A. et al. Transanal haemorrhoidal artery echodoppler ligation and anopexy (THD) is effective for II and III degree haemorrhoids: a prospective multicentric study. Colorectal Dis. 12, 804–809 (2010).
Giamundo, P. et al. Doppler-guided hemorrhoidal laser procedure for the treatment of symptomatic hemorrhoids: experimental background and short-term clinical results of a new mini-invasive treatment. Surg. Endosc. 25, 1369–1375 (2011).
Festen, S., van Hoogstraten, M. J., van Geloven, A. A. & Gerhards, M. F. Treatment of grade III and IV haemorrhoidal disease with PPH or THD. A randomized trial on postoperative complications and short-term results. Int. J. Colorectal Dis. 24, 1401–1405 (2009).
Giordano, P., Nastro, P., Davies, A. & Gravante, G. Prospective evaluation of stapled haemorrhoidopexy versus transanal haemorrhoidal dearterialisation for stage II and III haemorrhoids: three-year outcomes. Tech. Coloproctol. 15, 67–73 (2011).
Infantino, A. et al. Prospective randomized multicentre study comparing stapler haemorrhoidopexy with Doppler-guided transanal haemorrhoid dearterialization for third-degree haemorrhoids. Colorectal Dis. 14, 205–211 (2012).
Pucher, P., Sodergren, M., Lord, A., Darzi, A. & Ziprin, P. Clinical outcomes following Doppler-guided haemorrhoidal artery ligation: a systematic review, Colorectal Dis. http://dx.doi.org/10.1111/codi.12205.
NICE. Haemorrhoidal artery ligation. NICE National Institute for Health and Care Excellence [online], (2010).
Bursics, A., Morvay, K., Kupcsulik, P. & Flautner, L. Comparison of early and 1-year follow-up results of conventional hemorrhoidectomy and hemorrhoid artery ligation: a randomized study. Int. J. Colorectal Dis. 19, 176–180 (2004).
Gupta, P. J., Kalaskar, S., Taori, S. & Heda, P. S. Doppler-guided hemorrhoidal artery ligation does not offer any advantage over suture ligation of grade 3 symptomatic hemorrhoids. Tech. Coloproctol. 15, 439–444 (2011).
Schuurman, J. P., Borel Rinkes, I. H. & Go, P. M. Hemorrhoidal artery ligation procedure with or without Doppler transducer in grade II and III hemorrhoidal disease: a blinded randomized clinical trial. Ann. Surg. 255, 840–845 (2012).
Schuurman, J. P. & Go, P. M. N. Y. H. Anal duplex fails to show changes in vascular anatomy after the haemorrhoidal artery ligation procedure. Colorectal Dis. 14, 330–334 (2012).
Allegra, G. Experiences with mechanical staplers: hemorrhoidectomy using a circular stapler. G. Chir. 11, 95–97 (1990).
Altomare, D. F. et al. Long-term effects of stapled haemorrhoidectomy on internal anal function and sensitivity. Br. J. Surg. 88, 1487–1491 (2001).
Pescatori, M., Favetta, U., Dedola. F. & Orsini, S. Transanal stapled excision of rectal mucosal prolapse. Tech. Coloproct. 1, 96–98 (1997).
Tjandra, J. J. & Chan, M. K. Systematic review on the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy). Dis. Colon Rectum 50, 878–892 (2007).
Ommer, A., Hinrichs, J., Möllenberg, H., Marla, B. & Walz, M. K. Long-term results after stapled hemorrhoidopexy: a prospective study with a 6-year follow-up. Dis. Colon Rectum 54, 601–618 (2011).
Burch, J. et al. Stapled haemorrhoidopexy for the treatment of haemorrhoids: a systematic review. Colorectal Dis. 11, 233–243 (2009).
Burch, J. et al. Stapled haemorrhoidectomy (haemorrhoidopexy) for the treatment of haemorrhoids: a systematic review and economic evaluation. Health Technol. Assess. 12, 1–193 (2008).
Grigoropoulos, P. et al. Early and late complications of stapled haemorrhoidopexy: a 6-year experience from a single surgical clinic. Tech. Coloproctol. 15, S79–S81 (2011).
Cirocco, W. C. Life threatening sepsis and mortality following stapled hemorrhoidopexy. Surgery 143, 824–829 (2008).
Pescatori, M. & Gagliardi, G. Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures. Tech. Coloproctol. 12, 7–19 (2008).
Ganio, E., Altomare, D. F., Gabrielli, F., Milito, G. & Canuti, S. Prospective randomized multicentre trial comparing stapled with open haemorrhoidectomy. Br. J. Surg. 88, 669–674 (2001).
Ortiz, H., Marzo, J. & Armendariz, P. Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy. Br. J. Surg. 89, 1376–1381 (2002).
Boccasanta, P. et al. Randomized controlled trial between stapled circumferential mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with external mucosal prolapse. Am. J. Surg. 182, 64–68 (2001).
Shalaby, R. & Desoky, A. Randomized clinical trial of stapled versus Milligan–Morgan haemorrhoidectomy. Br. J. Surg. 88, 1049–1053 (2001).
Slim, K. Long-term outcome of a multicentre randomized clinical trial of stapled haemorrhoidopexy versus Milligan–Morgan haemorrhoidectomy. Br. J. Surg. 94, 1306–1307 (2007).
Ganio, E., Altomare, D. F., Milito, G., Gabrielli, F. & Canuti, S. Long-term outcome of a multicentre randomized clinical trial of stapled haemorrhoidopexy versus Milligan–Morgan haemorrhoidectomy. Br. J. Surg. 94, 1033–1037 (2007).
Ommer, A., Hinrichs, J., Möllenberg, H., Marla, B. & Walz, M. K. Long-term results after stapled hemorrhoidopexy: a prospective study with a 6-year follow-up. Dis. Colon Rectum 54, 601–608 (2011).
Giordano, P., Gravante, G., Sorge, R., Ovens, L. & Nastro, P. Long-term outcomes of stapled hemorrhoidopexy vs. conventional hemorrhoidectomy: a meta-analysis of randomized controlled trials. Arch. Surg. 144, 266–272 (2009).
Jayaraman, S., Colquhoun, P. H. & Malthaner, R. A. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Systematic Reviews, Issue 4. Art. No.: CD005393. http://dx.doi.org/10.1002/14651858.CD005393.pub2 (2006).
Shao, W. J. et al. Systematic review and meta-analysis of randomized controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy. Br. J. Surg. 95, 147–160 (2008).
NICE. Circular stapled haemorrhoidectomy. NICE National Institute for Health and Care Excellence [online], (2003).
McDonald, P. J., Bona, R. & Cohen, C. R. Rectovaginal fistula after stapled haemorrhoidopexy. Colorectal Dis. 6, 64–65 (2004).
Brown, S., Baraza, W. & Shorthouse, A. Total rectal lumen obliteration after stapled haemorrhoidopexy: a cautionary tale. Tech. Coloproctol. 11, 357–358 (2007).
Bufo, A., Galasse, S. & Amoroso, M. Recurrent postoperative bleeding after stapled hemorrhoidopexy requiring emergency laparotomy. Tech. Coloproctol. 10, 62–63 (2006).
Pescatori, M., Spyrou, M., Cobellis, L., Bottini, C. & Tessera, G. The rectal pocket syndrome after stapled mucosectomy. Colorectal Dis. 8, 808–811 (2006).
Pérez-Vicente, F. et al. Prospective randomised clinical trial of single versus double purse-string stapled mucosectomy in the treatment of prolapsed haemorrhoids. Int. J. Colorectal Dis. 21, 38–43 (2006).
Boccasanta, P., Venturi, M. & Roviaro, G. Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse. A randomized controlled trial. Int. J. Colorectal Dis. 22, 245–251 (2007).
Caviglia, A. et al. Single Stapler Parachute Technique (SSPT): a new procedure for large hemorroidal prolapse. G. Chir. 32, 404–410 (2011).
Giuratrabocchetta, S. et al. Safety and short term effectiveness of EEA stapler vs PPH stapler in the treatment of III degree haemorrhoids. Prospective randomised controlled trial. Colorectal Dis. 15, 354–358 (2012).
Altomare, D. F., Roveran, A., Pecorella, G., Gaj, F. & Stortini, E. The treatment of hemorrhoids: guidelines of the Italian Society of Colorectal Surgery. Tech. Coloproctol. 10, 181–186 (2006).
Rosa, G. et al. Submucosal reconstructive hemorrhoidectomy (Parks' operation): a 20-year experience. Tech. Coloproctol. 9, 209–214 (2005).
Whitehead, W. Three hundred consecutive cases of haemorrhoids cured by excision. BMJ 26, 449–451 (1887).
Milligan, E. T., Morgan, C. N., Jones, L. E. & Officer, R. Surgical anatomy of the anal canal and the operative treatment of hemorrhoids. Lancet 2, 1119–1124 (1937).
Chen, J. S. & You, J. F. Current status of surgical treatment for hemorrhoids—systematic review and meta-analysis. Chang Gung Med. J. 33, 488–500 (2010).
Gravante, G. & Venditti, D. Postoperative anal stenoses with LigaSure hemorrhoidectomy. World J. Surg. 31, 245 (2007).
Ferguson, J. A. & Heaton, J. R. Closed hemorrhoidectomy. Dis. Colon Rectum 2, 176–179 (1959).
Arbman, G., Krook, H. & Haapaniemi, S. Closed vs. open hemorrhoidectomy—is there any difference? Dis. Colon Rectum 43, 31–34 (2000).
Jóhannsson, H. O., Påhlman, L. & Graf, W. Randomized clinical trial of the effects on anal function of Milligan–Morgan versus Ferguson haemorrhoidectomy. Br. J. Surg. 93, 1208–1214 (2006).
Arroyo, A. et al. Open versus closed day-case haemorrhoidectomy: is there any difference? Results of a prospective randomised study. Int. J. Colorectal Dis. 19, 370–373 (2004).
Bessa, S. S. Diathermy excisional hemorrhoidectomy: a prospective randomized study comparing pedicle ligation and pedicle coagulation. Dis. Colon Rectum 54, 1405–1411 (2011).
Chung, C. C., Ha, J. P., Tai, Y. P., Tsang, W. W. & Li, M. K. Double-blind, randomized trial comparing Harmonic Scalpel hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scissors excision: ligation technique. Dis. Colon Rectum 45, 789–794 (2002).
Kwok, S. Y., Chung, C. C., Tsui, K. K. & Li, M. K. A double-blind, randomized trial comparing Ligasure and Harmonic Scalpel hemorrhoidectomy. Dis. Colon Rectum 48, 344–348 (2005).
Milito, G., Cadeddu, F., Muzi, M. G., Nigro, C. & Farinon, A. M. Haemorrhoidectomy with LigaSure vs conventional excisional techniques: meta-analysis of randomized controlled trials. Colorectal Dis. 12, 85–93 (2010).
Bessa, S. S. LigaSure vs. conventional diathermy in excisional hemorrhoidectomy: a prospective, randomized study. Dis. Colon Rectum 51, 940–944 (2008).
Nienhuijs, S. & de Hingh, I. Conventional versus LigaSure hemorrhoidectomy for patients with symptomatic Hemorrhoids. Cochrane Database Systematic Reviews, Issue 1. Art. No.: CD006761. http://dx.doi.org/10.1002/14651858.CD006761.pub2 (2009).
Ratto, C. et al. Transanal haemorrhoidal dearterialization (THD) for selected fourth-degree haemorrhoids. Tech. Coloproctol. 15, 191–197 (2011).
Zacharakis, E. et al. Long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids: a prospective study with median follow-up of 6 years. Tech. Coloproctol. 11, 144–147 (2007).
Carapeti, A., Kamm, M. A., McDonald, P. J. & Phillips, R. K. Double-blind randomised controlled trial of effect of metronidazole on pain after day-case haemorrhoidectomy. Lancet 351, 169–172 (1998).
Chaudhary, N. D., Rivadeneira, D. E., Ranire-Maguire, M. & Corman, M. L. Topical sucralfate post-hemorrhoidectomy: an affordable and feasible treatment option. Dis. Colon Rectum 51, 1857 (2008).
Ala, S., Saeedi, M., Eshghi, F. & Mirzabeygi, P. Topical metronidazole can reduce pain after surgery and pain on defecation in postoperative hemorrhoidectomy. Dis. Colon Rectum 51, 235–238 (2008).
Al-Mulhim, A. S., Ali, A. M., Al-Masuod, N. & Alwahidi, A. Post hemorrhoidectomy pain. A randomized controlled trial. Saudi Med. J. 27, 1538–1541 (2006).
Nicholson, T. J. & Armstrong, D. Topical metronidazole (10 percent) decreases posthemorrhoidectomy pain and improves healing. Dis. Colon Rectum 47, 711–716 (2004).
Balfour, L. et al. A randomized, double-blind trial of the effect of metronidazole on pain after closed hemorrhoidectomy. Dis. Colon Rectum 45, 1186–1190 (2002).
Chauhan, A., Tiwari, S., Mishra, V. K. & Bhatia, P. K. Comparison of internal sphincterotomy with topical diltiazem for post-hemorrhoidectomy pain relief: a prospective randomized trial. J. Postgrad Med. 55, 22–26 (2009).
Singh, B. et al. Botulinum toxin reduces anal spasm but has no effect on pain after haemorrhoidectomy. Colorectal Dis. 11, 203–207 (2009).
Franceschilli, L. et al. Role of 0.4% glyceryl trinitrate ointment after haemorrhoidectomy: results of a prospective randomised study. Int. J. Colorectal Dis. 28, 365–369 (2013).
Haas, E., Onel, E., Miller, H., Ragupathi, M. & White, P. F. A double-blind, randomized, active-controlled study for post-hemorrhoidectomy pain management with liposome bupivacaine, a novel local analgesic formulation. Am. Surg. 78, 574–581 (2012).
La Torre, F. & Nicolai, A. P. Clinical use of micronized purified flavonoid fraction for treatment of symptoms after hemorrhoidectomy: results of a randomized, controlled, clinical trial. Dis. Colon Rectum 47, 704–710 (2004).
Abramowitz, L. & Batallan, A. Epidemiology of anal lesions (fissure and thrombosed external hemorroids) during pregnancy and post-partum. Gynecol. Obstet. Fertil. 31, 546–549 (2003).
Abramowitz L. et al. Anal fissure and thrombosed external hemorrhoids before and after delivery. Dis. Colon Rectum 45, 650–655 (2002).
Staroselsky, A., Nava-Ocampo, A. A., Vohra, S. & Koren, G. Hemorrhoids in pregnancy. Can. Fam. Physician 54, 189–190 (2008).
Quijano, C. E. & Abalos, E. Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium. Cochrane Database Systematic Reviews, Issue 3. Art. No.: CD004077. http://dx.doi.org/10.1002/14651858.CD004077.pub2 (2005).
Titapant, V., Indrasukhsri, B., Lekprasert, V. & Boonnuch, W. Trihydroxyethylrutosides in the treatment of hemorrhoids of pregnancy: a double-blind placebo-controlled trial. J. Med. Assoc. Thai. 84, 1395–1400 (2001).
Wijayanegara, H., Mose, J. C., Achmad, L., Sobarna, R. & Permadi, W. A clinical trial of hydroxyethylrutosides in the treatment of haemorrhoids of pregnancy. J. Int. Med. Res. 20, 54–60 (1992).
Vohra, S. et al. The effectiveness of Proctofoam-HC for treatment of hemorrhoids in late pregnancy. J. Obstet. Gynaecol. Can. 31, 654–659 (2009).
Ebrahimi, N. et al. The fetal safety of hydrocortisone-pramoxine (Proctofoam-HC) for the treatment of hemorrhoids in late pregnancy. J. Obstet. Gynaecol Can. 33, 153–158 (2011).
Abramowitz, L. et al. Haemorrhoidal disease in pregnancy. Presse Med. 40, 955–959 (2011).
Jeffery, P. J., Parks, A. G. & Ritchie, J. K. Treatment of haemorrhoids in patients with inflammatory bowel disease. Lancet 21, 1084–1085 (1977).
Karin, E., Avital, S., Dotan, I., Skornick, Y. & Greenberg, R. Doppler-guided haemorrhoidal artery ligation in patients with Crohn's disease. Colorectal Dis. 14, 111–114 (2012).
Morandi, E., Merlini, D., Salvaggio, A., Foschi, D. & Trabucchi, E. Prospective study of healing time after hemorrhoidectomy: influence of HIV infection, acquired immunodeficiency syndrome, and anal wound infection. Dis. Colon Rectum 42, 1140–1144 (1999).
Pattana-arun, J. et al. A comparison of early postoperative results between urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoids and elective closed hemorrhoidectomy. J. Med. Assoc. Thai. 92, 1610–1615 (2009).
Greenspon, J., Williams, S. B., Young, H. A. & Orkin, B. A. Thrombosed external hemorrhoids: outcome after conservative or surgical management. Dis. Colon Rectum 47, 1493–1498 (2004).
Chan, K. K. & Arthur, J. D. External haemorrhoidal thrombosis: evidence for current management. Tech. Coloproctol. 17, 21–25 (2013).
Bellomo, R. & Bagshaw, S. M. Evidence-based medicine: classifying the evidence from clinical trials—the need to consider other dimensions. Crit. Care 10, 232 (2006).
Author information
Authors and Affiliations
Contributions
Both authors contributed equally to all aspects of this article.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing financial interests.
Rights and permissions
About this article
Cite this article
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
Published:
Issue Date:
DOI: https://doi.org/10.1038/nrgastro.2013.91
This article is cited by
-
Excisional haemorrhoidectomy in Crohn’s disease — is it time to question an old dogma?
Irish Journal of Medical Science (1971 -) (2023)
-
Pressure dressings versus nonpressure dressings after hemorrhoidectomy: study protocol for a randomized controlled trial
Trials (2021)
-
Local Anaesthesia Alone Versus Regional or General Anaesthesia in Excisional Haemorrhoidectomy: A Systematic Review and Meta‐Analysis
World Journal of Surgery (2020)
-
Topical analgesia following excisional haemorrhoidectomy: a systematic review and meta-analysis of randomised controlled trials
International Journal of Colorectal Disease (2020)
-
Hemorrhoids and the recurrent attempts to destroy them
Techniques in Coloproctology (2017)