Improved Outcomes in Colon and Rectal Surgery part 20. Written by many of the worlds leading colorectal surgeons, this evidence-based text investigates the risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions, the authors identify the best practices for patient safety and positive outcomes to ensure that physicians correctly recognize potential problems and carefully manage complications | 18 Nonoperative therapy for hemorrhoid disease Kerry Hammond and Charles B Whitlow CHALLENGING CASE A 50-year-old male otherwise healthy presents to your office and after evaluation is diagnosed with grade 3 internal hemorrhoids. Rubber band ligation is performed and is well-tolerated. Fortyeight hours later he develops urinary retention and worsening anal pain. CASE MANAGEMENT The patient s symptoms are suggestive of pelvic or postbanding sepsis. The patient should be examined urgently admitted started on broad-spectrum intravenous antibiotics and intravenous fluids. A foley catheter should be placed and blood work CBC metabolic profile etc obtained. A CT scan of the abdomen and pelvis should be considered. If the initial exam including anoscopy is not adequate or demonstrated necrotic perianal tissue the patient should receive an exam under anesthesia and debridement of any necrotic tissue. INTRODUCTION Hemorrhoids are among the most frequent presenting complaints of patients evaluated in the outpatient setting by colon and rectal surgeons. In a 1990 review of data from the National Center for Health Statistics Johanson and Sonnenberg determined a prevalence of symptomatic hemorrhoids in the . population. l In a subsequent study of data collected by the National Hospital Discharge Survey the same authors found that the annual number of surgical hemorrhoidectomies performed in the United States had decreased from a peak of 117 per 100 000 patients in 1974 to a nadir of 37 per 100 000 in 1987. 2 This decrease in operative procedures is likely the result of improvements in nonoperative therapies for symptomatic internal hemorrhoids. ANATOMY AND PATHOPHYSIOLOGY Hemorrhoids are cushions ofvascular and connective tissue located in the subepithelial space lining the anal canal. Arteriovenous sinusoids between the terminal branches of the superior rectal arteries and the superior middle and inferior rectal veins are encompassed by these cushions. These sinusoids .
