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Day care management of grade I and II bleeding hemorrhoids

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Background: Hemorrhoids occur in up to 80% of the population, involving any age and affecting males and females equally1 First and second-degree hemorrhoids can be treated conveniently on an out-patient basis by sclerotherapy and rubber band ligation 2. This study aims at comparing outcomes of these modalities for the treatment of grade I and II bleeding hemorrhoids.Methods: In NKP Salve institute of Medical Sciences and Research Centre hospital based nonrandomized comparative study, patients clinically diagnosed as Grade I and II bleeding hemorrhoids were included. Subjects were divided in into two groups i.e Barron’s banding and Injection of Sclerosant. The post procedural complications for the first 24 hrs were recorded, follow up was taken at regular intervals and any complications were recorded.Results: A total of 50 patients were enrolled with mean age 42.01 years and a male preponderance, with 31 males and 19 females. Barron’s banding was carried out in 25 subjects and the 25 subjects were subjected to Injection of sclerosant the mean duration taken for Injection of sclerosant was 13.6 min and in Barron’s banding 16.4 min. In the first 24hrs post procedural bleeding was observed in 40% subjects in the Barron’s banding group and 52% in the injection of sclerosant group. For post procedural pain the mean VAS score in the Barron’s group was 1.84 and 0.96 in injection of sclerosant group, follow up at 3rd month showed 16% recurrence of bleeding and 32% in injection of sclerosant group.Conclusions: Injection of sclerosant is better than Barron’s banding procedure in terms of post procedural pain.
International Surgery Journal | August 2019 | Vol 6 | Issue 8 Page 2916
International Surgery Journal
Trivedi B et al. Int Surg J. 2019 Aug;6(8):2916-2920
http://www.ijsurgery.com
pISSN 2349-3305 | eISSN 2349-2902
Original Research Article
Day care management of grade I and II bleeding hemorrhoids
Bhushan Trivedi, T. R. V. Wilkinson*, Murtaza Akhtar
INTRODUCTION
Haemorrhoidal disease is probably one of the oldest ills
known to man, perhaps since the time he assumed the
upright position.1 It leads to discomfort, and decreased
quality of life. Haemorrhoids are vascular cushions
within the anal canal and are ubiquitous.1,2 The term
haemorrhoids is derived from the Greek word
haimorrhois meaning flow of blood while the word pile
comes from Latin pila meaning a pill or ball thus
indicating the two cardinal symptoms namely bleeding
and prolapsing mass per rectum. The two terms
haemorrhoids and pile have been misused over time, they
have been used by the lay people for many condition and
symptoms associated with the perianal region,
Haemorrhoids are classified into external and internal
haemorrhoids, internal haemorrhoids are further
classified into first, second, third and fourth degree of
internal haemorrhoids.2,3
Thickened cushions of mucosa and submucosa appears to
the right anterior, right posterior and left posterior with
the possible variations and secondary cushions.
ABSTRACT
Background:
Hemorrhoids occur in up to 80% of the population, involving any age and affecting males and females
equally1 First and second-degree hemorrhoids can be treated conveniently on an out-patient basis by sclerotherapy
and rubber band ligation 2. This study aims at comparing outcomes of these modalities for the treatment of grade I
and II bleeding hemorrhoids.
Methods:
In NKP Salve institute of Medical Sciences and Research Centre hospital based nonrandomized
comparative study, patients clinically diagnosed as Grade I and II bleeding hemorrhoids were included. Subjects were
divided in into two groups i.e Barron’s banding and Injection of Scl erosant. The post procedural complications for the
first 24 hrs were recorded, follow up was taken at regular intervals and any complications were recorded.
Results:
A total of 50 patients were enrolled with mean age 42.01 years and a male preponderance, with 31 males and
19 females. Barron’s banding was carried out in 25 subjects and the 25 subjects were subjected to Injection of
sclerosant the mean duration taken for Injection of sclerosant was 13.6 min and in Barron’s banding 16.4 min. In the
first 24hrs post procedural bleeding was observed in 40% subjects in the Barron’s banding group and 52% in the
injection of sclerosant group. For post procedural pain the mean VAS score in the Barron’s group was 1.84 and 0.96
in injection of sclerosant group, follow up at 3rd month showed 16% recurrence of bleeding and 32% in injection of
sclerosant group.
Conclusions: Injection of sclerosant is better than Barron’s banding procedure in terms of post procedural pain.
Keywords: Barron’s banding, Haemorrhoids, Injection of sclerosant
DOI: http://dx.doi.org/10.18203/2349-2902.isj20193342
Department of Surgery, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India
Received: 24 April 2019
Revised: 15 June 2019
Accepted: 17 June 2019
*Correspondence:
Dr. T. R. V. Wilkinson,
E-mail: rajuwilk@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
Trivedi B et al. Int Surg J. 2019 Aug;6(8):2916-2920
International Surgery Journal | August 2019 | Vol 6 | Issue 8 Page 2917
Haemorrhoids consist of the venous plexus and the
arterial supply embedded in a stroma of connective
tissue, smooth muscle and nerves.4,5 The pathogenesis of
haemorrhoids is not yet finally elucidated. However
environmental factors like low fibre diet, constipation,
repeated and prolonged straining, hard stool, chronic use
of laxatives, have been identified to support the
development of haemorrhoids.6,7
Hippocrates described the treatment of haemorrhoids in
400 BC by the use of cautery and ligation. This
enunciated basic principles for surgical treatment of
haemorrhoids and all the modern techniques of
haemorrhoidectomy are based on the same principal viz
ligation and excision of piles. This condition is a common
ailment among the adults. More than the men and women
aged 50 years will experience haemorrhoid symptoms at
least once during their lifetime.12,13 However, there have
been incidences where children and the elderly have also
been diagnosed with this condition. Haemorrhoid disease
is said to be the fourth leading outpatient gastrointestinal
diagnosis, accounting for 3.3 million ambulatory care
visits in the United States.14
The treatment of haemorrhoids is directed towards
eliminating or controlling the symptoms caused by them.
Treatment has always been fraught with considerable
confusion, and treatment of this common disease with
relatively unknown aetiology has been varied, it ranges
from fancy applications to medications and suppositories,
Both the conservative and operative measures for the
symptoms bears testimony to the confusion. Traditional
treatment of the haemorrhoids falls into 2 categories, one
being less invasive techniques like the rubber band
ligation and the injection of sclerosant which tend to
produce minimal pain, different techniques like bipolar
diathermy, cryosurgery, infrared photocoagulation,
haemorrhoid artery ligation are also being used for the
treatment of haemorrhoids, there are more radical
techniques like excisional haemorrhoidectomy which are
inherently more painful.
In this study an attempt was made to study the outcomes
of two such modality i.e. rubber band ligation and
injection of sclerosant for the treatment of grade I and II
bleeding haemorrhoids, thus helping to understand the
effectiveness and to assess the better procedure to be
done in a day care surgery.
METHODS
This nonrandomized comparative study was conducted in
a NKP Salve Institute of medical sciences and Research
centre in Central India, over a period of 24 months from
September 2016 to October 2018. In this study, 50
patients clinically diagnosed with Grade I and II bleeding
hemorrhoid were enrolled. Patients with co-existing
anorectal conditions like symptomatic anal fissures/anal
fistulas, patients not willing for any treatment were
excluded from the study. Various study factors were
recorded in the study and were compared, demographic
factors like age, gender were recorded, Chief complains
of the patient like bleeding per rectum, reducible mass
coming out of the anus were recorded along with the
duration of the onset. Subjects were allocated the
following two interventions i.e. Barron’s banding and
Injection of sclerosant, Intervention allotted to the patient
were based on the choice of the surgeon in a non
randomized manner. Subjects were divided into two
groups of 25 subjects in each group. Both the procedure
were carried out as a day care procedures.
In Barron’s banding, protcoscope was introduced into the
anal canal and haemorrhoids were visualized. The
haemorrhoid was grasped with help of forceps. The
haemorrhoidal tissue was pulled into a double-sleeved
cylinder and was ligated by discharging bands from the
cylinder. Patient was then observed for the next 24 hours
for any complications.
In injection of sclerosant an protcoscope is passed into
the anal canal for visualization of the haemorrhoids, a
lumbar puncture needle (no 23) attached to 5ml syringe
loaded with Inj askerol (polidocanol 3%) is passed
through the proctoscope and injected into the base of the
haemorrhoids, patients were then observed for the next
24 hours for any complications.
The outcome factors present in the study were post
procedural outcomes in first 24 hours: These include the
following-
Post procedural bleeding: Any episode of post
procedural bleeding, 24hrs after the procedure was
recorded.
Post procedural pain: Any episode of post procedural
fullness or discomfort experienced by the patient within
the first 24 hours was recorded.
Pain was assessed for the first 24 hours. by a visual
analogue scale (VAS) from 0-10 where 0 meant no
complaints of pain and 10 is equal to intense pain.
Follow up of the patients were taken at regular intervals
at 1st and 3rd month for any post procedural
complications.
Statistical method
A pre-designed proforma was used to record the study
factors and data recorded was entered into an excel sheet
and analysed using statistical software STATA version
10.1.2011. The data was presented as mean, standard
deviation, range and percentage for descriptive statistics
of age, gender and clinical manifestations. Comparison of
parameters between Barron’s banding and injection of
sclerosant was done using student t-test, nonparametric
for continuous data and chi square test and Fischer test
for categorical variables. The statistical software used in
Trivedi B et al. Int Surg J. 2019 Aug;6(8):2916-2920
International Surgery Journal | August 2019 | Vol 6 | Issue 8 Page 2918
the analysis was SPSS version 20, EPI Info software
version 7. Statistical significance was set at p<0.05.
RESULTS
The mean age of the patients was 42.01±16.51 years with
a range from 18years to 80 years. On observing decade-
wise distribution, haemorrhoids were most commonly
observed in the age group of 20-30 years accounting for
22% and 30-40years age group accounting for 20% of the
cases. Out of 50 patients, 30 (65%) were males and 20
(35%) were females. Male: Female Ratio was found to be
1.5:1, Bleeding per rectum was the most common
complaint given by all 50 (100%) patients, 19 patients
(38%) complained of reducible mass protruding per anus,
2 (4%) came with complaint of discomfort while
defecation.
On proctoscopic examination around 18 patients (34%)
presented with Grade I haemorrhoids and 32 patients
(66%) presented with Grade II haemorrhoids (Table 1).
Table 1: Grade wise distribution.
Grade of
hemorrhoids
Number of
patients
Percentage (%)
Grade I
18
34
Grade II
32
66
Total
50
100
Grade I haemorrhoid were seen at 3 o’clock position in 13
patients, 7 o’clock position in 4 patients, and 11 o’clock
position in 6 patients. Grade II haemorrhoid was seen at 3
o’clock position in patients, 7 o’clock position in 18
patients and 11 o’clock position in 13 patients. (Table 2).
Table 2: Position of haemorrhoids.
Grade I
Grade II
Total
13
6
19
4
18
22
6
13
19
Out of the 50 patients 25 patients underwent Barron’s
banding procedure and rest 25 patients underwent
injection of sclerosant. In the Barron’s banding group 10
patients (40%) developed post procedural bleeding in the
first 24 hrs. Similarly in the sclerosant group 13 patients
(52%) had post procedural bleeding (Table 3).
Subjects in both the groups were assessed with a visual
analogue score for pain which had a scale from 0-10, 0
means no pain and 10 meaning excruciating pain, In the
Barron’s banding group the mean score was of 3.06 with
a standard deviation of 0.67 and in the Injection of
sclerosant group the mean score was 2.18 with a standard
deviation of 0.71 (Table 4).
Table 3: Comparing post procedural bleeding in the
first 24 hrs.
Post procedural
bleeding in 24 hrs
Procedure
Banding
Sclerosant
No.
%
No.
%
Yes
10
40
13
52
No
15
60
12
48
Total
25
100
25
100
𝑥2=0.7246; P value=0.395; not significant.
Table 4: Comparision of pain by VAS score
in both groups.
Procedure
Barron’s
banding
Injection of
sclerosant
Vas score (24 hours)
3.06±0.67
2.18±0.71
Patients were followed up after a period of 1 month to
observe for any complaints. Out of the 50 patients who
came for follow up 25 patients had underwent
sclerotherapy, out of them 3 (12%) patients complained
of episodes of bleeding after the procedure, in the
Barron’s banding group 5 (20%) patients out of 25
patients who came for follow up complained of episodes
of bleeding per rectum. In the Barron’s banding group 3
(12%) had complaints of discomfort, and in the sclerosant
group 2 patients complained of pain in the 1 month
period, on 3rd month follow up 4 patients in the banding
group had recurrence of bleeding as compared in
sclerosant group were 8 patients had the similar
complaints. In the banding group 2 patients had
complains discomfort while in the sclerosant group 1
patient had this complaints, In the present study
procedural time for both procedures were recorded, the
time taken for each procedure were noted and were
compared, in the Barron’s banding group the mean
procedural time was 16.44 mins with standard deviation
of ±3.84 SD, while in the Injection of sclerosant group
mean procedural time was 13.6 mins with standard
deviation of ±3.39 (Table 5).
Table 5: Mean comparison of procedural time
of both groups.
Procedure
Mean
SD
Banding
16.44
3.84
Sclerosant
13.6
3.39
P value: 0.0079; significant.
DISCUSSION
Haemorrhoids arises from congestion of internal or
external vascular plexuses around anal canal. They are
classified into four degrees based on their severity. A
majority of cases of haemorrhoidal disease can be treated
by dietary modification, topical medication and warm
water bath.
Trivedi B et al. Int Surg J. 2019 Aug;6(8):2916-2920
International Surgery Journal | August 2019 | Vol 6 | Issue 8 Page 2919
In Grade I & II bleeding haemorrhoids day care
procedures can be advised to the patient for relieving of
symptoms, these procedures can be carried out as an OPD
procedure and thus is routinely done. The present study
aims to compare the outcomes of these day care
procedure i.e. Barron’s banding and Injection of
sclerosant.
While evaluating the clinical presentation of the patients
in the present study, the most common symptoms on
presentation was bleeding per rectum which was present
in all the 50 patients, (100%) who participated in the
study. This presentation is consistent with different
studies seen in the literature. The other symptoms which
patient presented initially were constipation with bleeding
per rectum which was seen in 80% of the subject group
and mass coming out of the anus which was seen in 38%
of the subject group, In the study done by Mukhopadhyay
et al they observed bleeding per rectum in 91.3%
patients, while a study conducted by Jadhav et al, 2016
observed 100% of their subjects with the complaints of
bleeding per rectum on initial presentation.
In the present study post procedural bleeding during first
24 hrs. was 40% in Barron’s banding group as compared
to 52% in Injection of sclerosant group. On subsequent
follow up taken at 1 month and 3rd month interval patient
in the Injection of sclerosant group had more complaints
of recurrence of bleeding (32%) as compared to Barron’s
banding group were complaints of recurrence of bleeding
per rectum was 16%. Outcomes from different studies in
literature give comparable results. In a study by Sarmund
et al, 56% patients in the Barron’s banding group had
post procedural bleeding within the first 24hrs as
compared to 26% in the injection of sclerosant group. On
comparing post procedural pain in the two groups,
patients in the Barron’s banding group experienced more
complaints of pain than the injection of sclerosant group.
This can be due to improper placement of the band. Post
procedural pain was observed using a visual analogue
scale (VAS) scale. On comparing the VAS scores of the
two group, mean score in the Barron’s banding group was
1.84±1.62 SD as compared to the injection of sclerosant
group in which mean score was 0.96±1.20 SD this
difference was statistically significant with a p value of
0.034. In a study done by Rahman et al, VAS score
(mean) in the rubber banding group was 0.76±0.97.
In present study the mean time taken for banding
procedure was 16.44 min with a standard deviation of
3.84, while in injection of sclerosant group the mean
procedural time taken was 13.6 min with a standard
deviation of 3.39 mins. In a study done by Vaghasiya et
al, the mean procedural time for banding procedure was
12 mins as compared to 20 mins taken in the injection of
sclerosant group. This can be attributed to the
instrumentation and time taken for loading the band while
carrying out the banding procedure.
CONCLUSION
This study shows both procedures to be comparable with
respect to post procedural bleeding but with terms to post
procedural pain injection of sclerosant is better than
Barron’s banding procedure. In the delayed
complications, Barron’s banding shows more
improvement than the injection of sclerosant group and
can be used to treat grade I and II bleeding haemorrhoids
in a day care setting.
ACKNOWLEDGEMENTS
Authors would like to thank Dr. Kajal Mitra, Dean
NKPSIMS, Nagpur for permitting us to publish this
research.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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Cite this article as: Trivedi B, Wilkinson TRV,
Akhtar M. Day care management of grade I and II
bleeding hemorrhoids. Int Surg J 2019;6:2916-20.
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BACKGROUND: Hemorrhoids are one of the most common complaints that coloproctologists must evaluate. Polidocanol is widely used as a sclerosing agent for the treatment of hemorrhoids. OBJECTIVES: To study the efficacy and safety of polidocanol for sclerotherapy in the treatment of hemorrhoids. METHODS: A prospective study of 58 patients over a period of one year. The treatment details, efficacy and adverse effects were studied. RESULTS: In our study the male to female ratio was 1.52:1. The age ranged from 22 to 60 years. Out of 58 patients, 36(62.07%) patients were having first degree haemorrhoids and 22(37.93%) patients had early second degree haemorrhoids. In our study, after three doses of injection (89.66%) patients had satisfactory results. After the first dose of injection 39(67.24%) patients had satisfactory results. Rest 19 patients were given second dose of injection, of which 11(57.89%) patients had satisfactory results. Third dose of injection given to the remaining 8 patients proved satisfactory only in 2 cases. After three doses of injection, 6(10.34 %) cases failed to show any response. All the six cases had early second degree haemorrhoids. CONCLUSION: Polidocanol is an effective sclerosant for the treatment of early hemorrhoids.
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