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Gastric Bezoar

Introduction

Classification

Pathogenesis

Symptoms

Diagnosis

Treatment

Summary and Recommendations

Introduction

Universal antidote against any poison. 

Bezoar ‐ Persian pād‐zahr ‐

literally means "antidote“

Debunked  by Ambroise Pare•Bezoar didn’t save his poisoned chef

Modern science has given renewed credence to the antidote notion•Removal of Arsenic

Classification

Phytobezoar• Persimmon (diospyrobezoar) 

• Psyllium Fruit • Vegetables 

Trichobezoar

Pharmacobezoar• Enteric coated aspirin • Extended release capsules (nifedipine, theophylline) 

• Sucralfate• Others 

Other • Styrofoam • Fungi (candida) • Lactobezoar• Cement • Furniture polish • Shellac

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Phytobezoar

Composed of vegetable matter

>50% of all bezoars

Zhang, R. L.; Yang, Z. L.; Fan, B. G. (2008). "Huge gastric disopyrobezoar: A case report and review of literatures". World journal of gastroenterology : WJG 14 (1): 152–154. 

Diospyrobezoar – Persimmon fruit• Most common culprit• Shiboul chemical forms glue when meets acid

• Have to eat A LOT

Trichobezoar

Balik E, Ulman I, Taneli C, Demircan M. The Rapunzel syndrome: a case report and review of the literature. Eur J Pediatr Surg 1993; 3:171.Pul N, Pul M. The Rapunzel syndrome (trichobezoar) causing gastric perforation in a child: a case report. Eur J Pediatr 1996; 155:18.Singla SL, Rattan KN, Kaushik N, Pandit SK. Rapunzel syndrome‐‐a case report. Am J Gastroenterol 1999; 94:1970.

Hair ball Young female psychiatric patients

Rapunzelsyndrome

Pharmacobezoar

Ingested medications• Extended release nifedipine• Theophylline• Enteric coated ASA• Sodium Alginate

Prisant LM, Carr AA, Bottini PB, Kaesemeyer WH. Nifedipine GITS (gastrointestinal therapeutic system) bezoar. Arch Intern Med 1991; 151:1868.Bernstein G, Jehle D, Bernaski E, Braen GR. Failure of gastric emptying and charcoal administration in fatal sustained‐release theophylline overdose: pharmacobezoar formation. Ann Emerg Med 1992; 21:1388.Bogacz K, Caldron P. Enteric‐coated aspirin bezoar: elevation of serum salicylate level by barium study. Case report and review of medical management. Am J Med 1987; 83:783.Reddy AN. Sucralfate gastric bezoar. Am J Gastroenterol 1986; 81:149.Kaneko H, Tomomasa T, Kubota Y, et al. Pharmacobezoar complicating treatment with sodium alginate. J Gastroenterol 2004; 39:69.

g• Carafate

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Others

Milk curd

Tissue paper

Shellac

Fungus

Evans JR, Mitchell RD. Tissue paper bezoar associated with percutaneously placed gastrostomy tube. Gastrointest Endosc 1988; 34:142.Perttala Y, Peltokallio P, Leiviskä T, Sipponen J. Yeast bezoar formation following gastric surgery. Am J Roentgenol Radium Ther Nucl Med 1975; 125:365.Visvanathan R. Cement bezoars of the stomach. Br J Surg 1986; 73:381.Kamal I, Thompson J, Paquette DM. The hazards of vinyl glove ingestion in the mentally retarded patient with pica: new implications for surgical management. Can J Surg 1999; 42:201.

Fungus

Styrofoam cups

Cement

Vinyl gloves

Pathogenesis

Continued ingestion of cellulose rich or indigestible materials

Rare in healthy subjects •Prior surgery•Not necessarily gastroparesis

Robles R, Parrilla P, Escamilla C, et al. Gastrointestinal bezoars. Br J Surg 1994; 81:1000.KrauszMM, Moriel EZ, Ayalon A, et al. Surgical aspects of gastrointestinal persimmon phytobezoar treatment. Am J Surg 1986; 152:526.White NB, Gibbs KE, Goodwin A, Teixeira J. Gastric bezoar complicating laparoscopic adjustable gastric banding, and review of literature. Obes Surg 2003; 13:948.Calabuig R, Navarro S, Carrió I, et al. Gastric emptying and bezoars. Am J Surg 1989; 157:287.

Persimmon fruit•Shibutol→ coagulum

Trichobezoars•Hair denatured by acid → mixes with food → enmeshed mass

Pharmacobezoars•Tums + antichlinergics + opiates + renal failure•Carafate + gastric outlet obstruction•Enteric coating (asa + nifedipine)

Symptoms

Phytobezoars – middle aged men

Trichbezoars – young females

Mostly asymptomatic with insidious symptoms

Bernstein G, Jehle D, Bernaski E, Braen GR. Failure of gastric emptying and charcoal administration in fatal sustained‐release theophylline overdose: pharmacobezoar formation. Ann Emerg Med 1992; 21:1388.Bogacz K, Caldron P. Enteric‐coated aspirin bezoar: elevation of serum salicylate level by barium study. Case report and review of medical management. Am J Med 1987; 83:783.

Mostly asymptomatic with insidious symptoms• Pain, nausea, emesis, wt loss, anorexia, early satiation• Halitosis, alopecia

GI bleeding due to PUD

Rare complications

Overdose 

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Diagnosis

Incidental discovery

Filling defect on imaging

Trichobezoars absorb barium

Gold standard – EGD

Treatment

Chemical dissolution• Phytobezoars with mild symptoms• Most effective if endoscopic not feasible• No prospective studies, but trials and case reports• Various agents

Endoscopy

Kamal I, Thompson J, Paquette DM. The hazards of vinyl glove ingestion in the mentally retarded patient with pica: new implications for surgical management. Can J Surg 1999; 42:201.Robles R, Parrilla P, Escamilla C, et al. Gastrointestinal bezoars. Br J Surg 1994; 81:1000.Zarling EJ, Thompson LE. Nonpersimmon gastric phytobezoar. A benign recurrent condition. Arch Intern Med 1984; 144:959.

Endoscopy• Trichobezoars and diospyrobezoars• Hack away

Surgery• Failed medical therapy• Vinyl gloves

Prevention• 14% recurrence

Chemical Treatment

Cellulase• Preferred, more efficacious

Papain (meat tenderizer)• Side effects

Holloway WD, Lee SP, Nicholson GI. The composition and dissolution of phytobezoars. Arch Pathol Lab Med 1980; 104:159.Walker‐Renard P. Update on the medicinal management of phytobezoars. Am J Gastroenterol 1993; 88:1663.Schlang HA. Acetylcysteine in removal of bezoar. JAMA 1970; 214:1329.Ladas SD, Triantafyllou K, Tzathas C, et al. Gastric phytobezoars may be treated by nasogastric Coca‐Cola lavage. Eur J Gastroenterol Hepatol 2002; 14:801.Kato H, Nakamura M, Orito E, et al. The first report of successful nasogastric Coca‐Cola lavage treatment for bitter persimmon phytobezoars in Japan. Am J Gastroenterol 2003; 98:1662.Chung YW, Han DS, Park YK, et al. Huge gastric diospyrobezoars successfully treated by oral intake and endoscopic injection of Coca‐Cola. Dig Liver Dis 2006; 38:515.Lee BJ, Park JJ, Chun HJ, et al. How good is cola for dissolution of gastric phytobezoars? World J Gastroenterol 2009; 15:2265.Harikumar R, Kunnel P, Sunilraj R. Dissolution of pharmacobezoar using carbonated beverage. Indian J Gastroenterol 2008; 27:245.Winkler WP, Saleh J. Metoclopramide in the treatment of gastric bezoars. Am J Gastroenterol 1983; 78:403.Nomura H, Kitamura T, Takahashi Y, Mai M. Small‐bowel obstruction during enzymatic treatment of gastric bezoar. Endoscopy 1997; 29:424.

Aceytlcysteine

Coca‐Cola

Metoclopramide• In conjunction with endoscopy or enzymes

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Lee et al 2009

• Complete dissolution in 24%• 3L cola lavage• Phytopbezoars and pharmacobezoars

MOA unknown

• Low pH, high sodium bicarb, CO2 bubbles

Summary & Recommendations

3 major types ‐ phytobezoars, trichobezoars, and pharmacobezoars

Mostly asymptomatic for years ‐ develop symptoms insidiously

Incidental findingIncidental finding

Phytobezoar – treat with cellulase or Cola• Maybe papain, acetylcystein, reglan• 3L CocaCola over 12 hours

Trichobezoars + diospyrobezoars – endoscopy + surgery

Surgery – failed medical therapy or obstruction

IntroductionIntroduction

Anatomy and classificationAnatomy and classification

Hemorrhoids

PathogenesisPathogenesis

Clinical manifestationsClinical manifestations

TreatmentTreatment

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Eternal pain in the ass

1772 BC. Code of Hammurabi. Ancient Babylonian law code inscribed on stone. On display in The Louvre.

Moses, on doing wrong:"The Lord will smite thee with the botch of Egypt, and with the emerods, and with the scab, and with the itch, whereof thou canst not be healed" (Deuteronomy 28; vs. 27, King James Version).

“Having placed the man over two round stones upon his knees, examine, for you will find the parts near the anus between the buttocks inflated, and blood proceeding from within. If, then, the condyloma below the cover be of a soft nature, bring it away with the finger, for there is no more difficulty in this than in skinning a sheep

Hemorrhoid:Greek: heamor and rhoid = blood flowing

difficulty in this than in skinning a sheep,to pass the finger between the hide and the flesh. And this should be accomplished without the patient's knowledge, while he is kept in conversation. When the condyloma is taken off, streaks of blood necessarily flow from the whole of the torn part. It must be speedily washed with a decoction of galls, in a dry wine”.

Saint Fiacre ‐ Patron saint of hemorrhoids

Hemorrhoids – “Fiacre’s curse” 

Severe case of prolapsed hemorrhoids.

Prayed while sitting on a stone ‐miraculous cure.

Hemorrhoid imprint remains on stone.  

H h id ff il i FHemorrhoids suffers pilgrimage to France.  

King Henry V of England ransacked St. Fiacre’s tomb.

Later died of hemorrhoids on St. Fiacre Day.  

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NapoleonNapoleon Jimmy CarterJimmy Carter George Brett.George Brett.Napoleon Bonaparte.

Battle of Waterloo lost due to hemorrhoids?

Napoleon Bonaparte.

Battle of Waterloo lost due to hemorrhoids?

Jimmy Carter.Emergency hemorrhoid treatment during 1978 White House Christmas party.

Jimmy Carter.Emergency hemorrhoid treatment during 1978 White House Christmas party.

George Brett.Minor hemorrhoid surgery during World Series.  Returned to play in the next game, “my problems are all behind me”

George Brett.Minor hemorrhoid surgery during World Series.  Returned to play in the next game, “my problems are all behind me”

Anatomy

Hemorrhoids = Normal occurring specialized, highly vascularized cushions forming discrete masses of thick submucosa containing blood vessels, smooth muscle, and elastic and connective tissue.

Symptoms of internal hemorrhoids arise as they enlarge and protrude b l th d t t libelow the dentate line.  

External or internal based upon whether they are below or above the dentate line, (often coexist)

Anatomy of Hemorrhoids

•From the superior hemorrhoidal cushion 

•3 primary locations • left lateral•right anterior •right posterior

•Overlying mucosa is rectal•Innervation is visceral

Internal hemorrhoids 

•From the inferior hemorrhoidal plexus

•Covered with squamousepithelium

•Somatic pain receptors

External hemorrhoids 

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ClassificationInternal hemorrhoids are 

graded according to degree of prolapse.

Internal

Grade I – no prolapse

Grade II – Prolapsewith spontaneous 

reduction

G d III P lHemorrhoids

Grade III – Prolapserequiring digital 

reduction

Grade IV –Prolapsed, cannot be 

reduced

External

Pathogenesis• → deteriora on of connec ve  ssue (anchors hemorrhoids to the underlying sphincter)  → hemorrhoids begin to bulge, and "slide" into the anal canal → progressive symptoms

Advancing age 

• → pushes hemorrhoid plexus against the internal sphincter → more subject to trauma from fecal bolus → symptoms

Hypertrophy of the internal anal  j y p

sphincter

• → vascular engorgement of  ssue → more prone to trauma from fecal bolus. 

• In support of this hypothesis: hemorrhoids regress following ligation of the hemorrhoidal arteries.

Swelling of the hemorrhoidal

cushions 

Pathogenesis of HemorrhoidsSeveral associations:

Advancing age, diarrhea, pregnancy, pelvic tumors, prolonged sitting, straining, and chronic constipation. 

Chronic constipation, however, was not supported in a large epidemiologic study.1

1. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology 1990; 98:380.

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• Painless bleeding usually associated with BM; typically coats the stool at the end of defecation; may also drip into the toilet or stain toilet paper. 

• Chronic blood losses from hemorrhages can be substantial enough to induce iron deficiency. 

• Painful bleeding during defecation should prompt Bleeding investigation for other causes such as anorectal fissures.• Visible or occult bleeding should not be attributed to hemorrhoids until other potential bleeding sites have been excluded by endoscopic testing.

• Flexible sigmoidoscopy or anoscopy in low‐risk younger patients or colonoscopy in most other patients

Bleeding

• Itching, irritation or mild incontinence are common. • Prolapse of internal hemorrhoids → leakage of rectal contents → local irrita on

• Hemorrhoids may be difficult to clean → prolonged contact of fecal material with the perianal skin → local irritation.

• Pa ents with leakage may clean too aggressively → i l i i i

Pruritusperianal irritation.  

Pain (ra

re)

Pain is usually the results 

from thrombosis

Thrombosis occurs in both internal and external 

hemorrhoids

Internal usually less severe; unless strangulated → 

gangrene → surgical emergency

Thrombosis of external hemorrhoids 

Overlying perianal skin is highly innervated

→ excrucia ng pain.   Easily visible, purple, elliptical mass 

extending from the anal to the perianal 

skin. 

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TreatmentConservative medical treatment is recommended for both internal and 

external hemorrhoids.1

• Fiber• Sitz baths• Topical nitroglycerin• Topical steroids• Topical calcium channel blocker

Even thrombosed external hemorrhoids:  

• If diagnosed early (<72 hours), consider surgical excision under local anesthesia.  

• However, excision not required for patients whose symptoms are improving (pain resolves in 7‐10 days)

1. AGA Medical Position Statement: Diagnosis and Treatment of Hemorrhoids. Gastroenterology 2004; 126: 1461-1462.

improving (pain resolves in 7‐10 days). 

Fiber

Cochrane meta analysis re: Fiber and hemorrhoids

• 7 controlled trials enrolling a total of 378 participants to fiber or a non‐fiber control 

Psyllium vs methylcellulose 

• Neither had particular advantage over the other in treating hemorrhoidal disease.  

1. Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev 2005; :CD004649.

were identified• Significant and consistent benefit in improving bleeding.1

g• 20‐30g per day• May help prevent recurrence; continued use indefinitely

Fiber

Psyllium Methylcellulose

Bulk‐K [OTC];Fiberall® [OTC];Fibro‐Lax [OTC];Fibro‐XL [OTC];Genfiber™ [OTC] [DSC];Hydrocil® Instant [OTC];Konsyl D™ [OTC];

Citrucel [OTC]

1. Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev 2005; :CD004649.

Konsyl‐D  [OTC];Konsyl® Easy Mix™ [OTC];Konsyl® Orange [OTC];Konsyl® Original [OTC];Konsyl® [OTC];Metamucil® Plus Calcium [OTC];Metamucil® Smooth Texture [OTC];Metamucil® [OTC];Natural Fiber Therapy Smooth Texture [OTC];Natural Fiber Therapy [OTC];Reguloid [OTC]

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Other Medical Treatment

•Helps relieve irritation and pruritus. •Warm water 2‐3 times per day. Sitz Baths

•FDA approved Rectiv (0.4%) ointment for anal fissures. Topical •Small series supports its use for analgesia in hemorrhoids.1Nitroglycerin

•Small controlled trial suggested benefit.2

•Topical nifedipine (50 pts) 0.3% + 1.5% lidocaine bid x 14 days vs. control (48 pts) 1.5% lidocaine bid x 14 days.

•Complete relief of pain in 43 patients (86%) of the nifedipine‐treated group vs 24 patients (50%) of the control (P<0.01)

Topical Nifedipine

1. Gorfine SR. Treatment of benign anal disease with topical nitroglycerin. Dis Colon Rectum 1995; 38:453.2. Perrotti P, Antropoli C, Molino D, et al. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum 2001; 44:405.

• Helps relieve irritation and pruritus.• Cream applied bid for max of 7 days due to risk of potential thinning of perianal and anal mucosa and risk of injury.  

Topical Steroids

Other Medical Treatment

Minimally InvasiveReserved for selected patients:• Continued symptoms despite medical treatment.• Grade I‐III internal hemorrhoids • NOT external hemorrhoids• Most (excluding acute thrombosis) are managed medically

• NOT grade IV and symptomatic grade III• Require surgical treatment• Require surgical treatment

Ambulatory procedures with minimal morbidity.  

Fundamentally similar mechanism:• Remove or cause sloughing of excess hemorrhoidal tissue.• Subsequent healing and scarring fixes residual tissue to underlying anorectalmuscular ring.

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Minimally Invasive

Rubber band ligation

Coagulation (infrared and laser)

Sclerotherapy

Cryosurgery

Choice among procedures often depends on availability and local expertise.  

Minimally Invasive

• Rubber‐band ligation is recommended as the initial mode of therapy for grades 1 to 3 hemorrhoids unresponsive to conservative measures.  Hemorrhoidectomy showed better response, however it was associated with more complications and pain than rubber‐band ligation. 

MacRae et al. 1997.1 18 trials.  

• Rubber‐band ligation superior to other non‐surgical options (infrared coagulation, sclerotherapy), but may have higher side effects

Johanson et al. 1992.2 5 trials, 863 patients. 

1. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatments: a meta-analysis. Can J Surg 1997; 40:14.2. Johanson JF, Rimm A. Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy.

Am J Gastroenterol 1992; 87:1600.

Rubber Band Ligation

RBL is the most widely used minimally invasive procedure for hemorrhoids refractory to conservative treatment.  

Available since the 1960s.  

Several different techniques:

•Forceps applicator•Suction ligator•Endoscopic•Anoscopic•Blind

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Rubber Band Ligation

• Success rate of 71% (no symptoms for median 1200 days).• Low complication rate, bleeding (2.8 %), thrombosedexternal hemorrhoids (1.5%), and bacteremia (0.09%).  

Iyer et al.  2004.  804 patients underwent 2114 ligations.1

• Pain is most common complication; occurring in ~ 8% of cases.Wechter et al. 1987.2

1. Iyer VS, Shrier I, Gordon PH. Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids. Dis Colon Rectum 2004; 47:1364.2. Wechter DG, Luna GK. An unusual complication of rubber band ligation of hemorrhoids. Dis Colon Rectum 1987; 30:137.

Rubber Band Ligation

Attempt to stay >5mm proximal to dentate line.

Usually only one column of hemorrhoids is treated in a single session, but up to three bands on a single column may be safely applied.1

Treatments are repeated at 4‐6 week intervals until all symptoms are controlled and all hemorrhoids are gone. 

1. Khubchandani IT. A randomized comparison of single and multiple rubber band ligations. Dis Colon Rectum 1983; 26:705.

Rubber Band Ligation

Contraindications to rubber band ligation

1. Jutabha R. ASGE Clinical Update: Endoscopy for Internal Hemorrhoids. ASGE 2009. 17,1: 1-5

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Forceps applicator• Internal hemorrhoid is grasped with forceps through anoscope and pulled into drum of ligator.

• Rubber bands then advanced down to the neck of the hemorrhoid.  

Rubber Band Ligation

Suction ligator:• Endoscopic: internal hemorrhoid is suctioned into the ligating drum which is attached to an endoscope.1

• Anoscopic: (non‐endoscpopic devices) Anoscope + wall suction + ligator.• Marketed as KillRoid (AstraTech), ShortShot (Cook Medical)

• Blind: single use disposable ligator

Rubber Band Ligation

g p g• Marketed as CRH O’Regan System

1. Berkelhammer C, Moosvi SB. Retroflexed endoscopic band ligation of bleeding internal hemorrhoids. Gastrointest Endosc 2002; 55:532.

Blind suction ligator:• CRH O’Regan System

Rubber Band Ligation

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Other Minimally Invasive Treatment

• Application of modality (current, infrared, laser) to cause coagula on and necrosis → fibrosis in submucosal layer.  

• Generally effective for grade I‐II internal hemorrhoids.

Coagulation ‐bipolar or infrared.1‐2

• Specialized needles inject sclerosing agents directly into hemorrhoidal ssue → intense inflammatory reac on destroys redundant submucsoal tissue associated with hemorrhoids.

• Less effective than rubber band ligation 3

Sclerotherapy• Less effective than rubber band ligation.

• Applica on of liquid nitrogen probes to hemorrhoid →necrosis and fixation of hemorrhoidal cushion.  Supplanted by other methods.  Not recommended.    

Cryosurgery

1. Iwagaki H, Higuchi Y, Fuchimoto S, Orita K. The laser treatment of hemorrhoids: results of a study on 1816 patients. Jpn J Surg 1989; 19:658.2. O'Connor, JJ. Infrared coagulation of hemorrhoids. Practical Gastroenterology 1986; 10:8.3. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatments: a meta-analysis. Can J Surg 1997; 40:14.4. Buls JG, Goldberg SM. Modern management of hemorrhoids. Surg Clin North Am 1978; 58:469.

•No advantage over others and expensive with serious complications.Lasers ‐ done with 

ND:YAG or CO2 laser.1

•Specialized proctoscope (Moricorn) uses Doppler transducer to identify and ligate hemorrhoidal arteries.  

•Improvement in pain, prolapse, and bleeding in 78‐96% of pts (116).

Doppler guided hemorrhoidal artery 

ligation.2

Other Minimally Invasive Treatment

1. Buls JG, Goldberg SM. Modern management of hemorrhoids. Surg Clin North Am 1978; 58:469.2. 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 1995; 90:610.

Surgical Treatment

Only recommended for a small minority of patients:• Failure of medical and non‐operative therapy• Symptomatic grade III or grade IV hemorrhoids• Strangulated internal hemorrhoids

Various techniques:Various techniques:• Closed hemorrhoidectomy• Open hemorrhoidectomy with excision and ligation• Stapled hemorrhoidectomy• Lateral internal sphincterotomy

Usually require general or spinal anesthesia.  

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Closed hemorrhoidectomy•Most common surgical procedure done for internal hemorrhoids• Elliptical incision is made to remove hemorrhoidal tissue.  Crosses the dentate line.  Closed with sutures.  95% success rate.  

Surgical Treatment

Open hemorrhoidectomy• Some surgeon advocate no mucosal closure to reduce infection risk.• A modified version (semi‐open) was associated with more rapid healing and lower postoperative complications (300 pts).1

Stapled hemorrhoidectomy (hemorrhoidopexy)• Intraluminal stapling device excises a circumferential column of mucosa and 

Surgical Treatment

p gsubmucosa from upper anal canal → reduces hemorrhoids and fixes their position.   

1. Reis Neto JA, Quilici FA, Cordeiro F, Reis Júnior JA. Open versus semi-open hemorrhoidectomy: a random trial. Int Surg 1992; 77:84.2. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev 2006; :CD005393.

Lateral internal sphincterotomy• Used for patients with internal hemorrhoids and high resting internal anal sphincter pressures.

• Used frequently for patients with 1

Surgical Treatment

concomitant fissure disease.1

1. Arabi Y, Alexander-Williams J, Keighley MR. Anal pressures in hemorrhoids and anal fissure. Am J Surg 1977; 134:608.

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Pain following hemorrhoidectomy is nearly universal. • Long acting bupivicaine injected during procedure.• Some benefit with: • Diltiazem (2%) ointment tid x 7 days• Botox

Other complications:1

Surgical Treatment

• Urinary retention (30%)• UTI (5%)• Delayed hemorrhage (1‐2%)• Fecal impaction (usually related to opiod use due to pain)

1. Bleday R, Pena JP, Rothenberger DA, et al. Symptomatic hemorrhoids: current incidence and complications of operative therapy. Dis Colon Rectum 1992; 35:477.

Summary and RecommendationsRemember the hemorrhoid grading (grade I‐IV)

Dietary modification for all patients• adequate fluid and fiber intake (~30g fiber/day)

Medical therapy: sitz (if itching) +/‐medications (ccb, nitro, steroids)

Minimally invasive proceduresMinimally invasive procedures • Reserved for grade I‐III after failed medical therapy• Rubber band ligation preferred over others

Surgical hemorrhoidectomy• Reserved for small minority of patients• grade IV and some grade III • failed minimally invasive approaches• mixed internal and external• strangulated internal• acute thrombosed external