What is the optimal inpatient management for hemorrhoids?

From the Guidelines

Inpatient treatment for hemorrhoids should prioritize non-operative management as the first-line therapy, with dietary and lifestyle changes, as recommended by the World Journal of Emergency Surgery in 2021 1. The best inpatient treatment approach involves a combination of conservative measures and, when necessary, surgical intervention. Initially, patients should receive adequate pain control with medications like acetaminophen, NSAIDs, or in severe cases, opioid analgesics. Stool softeners such as docusate sodium (100mg twice daily) and fiber supplements should be administered to prevent constipation. For thrombosed hemorrhoids causing severe pain, surgical excision under local anesthesia provides the most rapid relief, with the decision between non-operative management and early surgical excision based on local expertise and patient’s preference, as suggested by the World Journal of Emergency Surgery in 2021 1. For grade III or IV internal hemorrhoids, procedures like rubber band ligation, sclerotherapy, or surgical hemorrhoidectomy may be performed. The conventional surgical hemorrhoidectomy (Milligan-Morgan or Ferguson technique) remains the gold standard for severe cases, though it requires general anesthesia and has a longer recovery period. Newer techniques like stapled hemorrhoidopexy or Doppler-guided hemorrhoidal artery ligation may offer quicker recovery with less postoperative pain. Post-procedure care includes sitz baths 2-3 times daily, analgesics, stool softeners, and increased fluid and fiber intake. Some key points to consider in the management of hemorrhoids include:

• The American Gastroenterological Association recommends surgical hemorrhoidectomy for patients with symptomatic third-degree, fourth-degree, or mixed internal and external hemorrhoids, or those with concomitant anorectal conditions that require surgery, as stated in their 2004 technical review 1.
• The choice between open and closed hemorrhoidectomy techniques should be based on the individual patient's needs and the surgeon's expertise.
• Postoperative pain management is crucial, and strategies such as limiting the incision, suturing only the vascular pedicle, and using local anesthetics or anal sphincter relaxants may be helpful.
• Complications of hemorrhoidectomy, such as urinary retention, bleeding, anal stenosis, infection, and incontinence, should be carefully managed and prevented when possible.

From the Research

Inpatient Treatment for Hemorrhoids

• The most effective treatment for hemorrhoids in the long term is conventional haemorrhoidectomy, despite its main limitation being post-operative pain 2.
• Other surgical options, such as stapled haemorrhoidectomy and haemorrhoidal artery ligation, are probably less effective but less painful 2.
• Rubber band ligation is effective in 75% of patients in the short term, but does not treat prolapsed haemorrhoids or those with a significant external component 2.
• Bulk laxatives alone may improve symptoms of both bleeding and prolapse and seem as effective as injection sclerotherapy 2.

Conservative Treatment

• Conservative treatment is effective in managing the majority of patients complaining of early stages of the disease 3.
• Dietary and lifestyle modifications are the first therapeutic step necessary to achieve a regular defecation with soft stool 3.
• Oral phlebotonic drugs can help to control symptoms, and the use of topical medications can be beneficial for all patients complaining of hemorrhoidal disease 3.
• Medical management, such as stool softeners, topical over-the-counter preparations, and topical nitroglycerine, are the mainstays of initial therapy 4.

Surgical Options

• Open or closed (conventional) excisional hemorrhoidectomy leads to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures 4.
• Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain 4.
• Stapled hemorrhoidopexy elevates grade III or IV hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue, but has several potential postoperative complications 4.
• Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids because patients may experience less pain and recover more quickly 4.