Post written by Waqar Qureshi, MD, FASGE, from Baylor College of Medicine, Houston, Texas, USA.

With the proper technique, nonsurgical hemorrhoid treatment is safe and effective and performed in the office.

Historically, training of gastroenterologists has lacked focus on benign anorectal disease and its diagnosis and management. Symptomatic hemorrhoids are extremely common, particularly after age 50 and, for most, treatment is nonsurgical and commonly conducted in the office. A proper digital rectal examination and anoscopy are easy to learn and will accurately diagnose most benign anorectal disease in the office setting, where most of the treatment occurs.

The 2 most commonly used modalities to treat symptomatic hemorrhoids in the office setting are rubber band ligation and infrared coagulation. Although the number of studies is scant, rubber band ligation appears to be more effective, but infrared coagulation is more preferred by the patient. With proper technique, both modalities are safe, quick, and effective.

It is my practice to reserve infrared coagulation for patients on antiplatelet agents or anticoagulation because of a bleeding risk when the band falls off a week later when they are back on their anticoagulation or antiplatelet agents.

In addition, infrared coagulation may be more appropriate in young patients with significant irritable bowel syndrome symptoms, as they tend to have more discomfort after band ligation. I also prefer to use infrared coagulation in pregnant patients, as opposed to banding, which can cause lower abdominal discomfort and trigger anxiety for the patient and physician. Unless pregnant patients are very symptomatic, I prefer to treat them only with steroid suppositories until well after the pregnancy, if their symptoms persist.

In about 20% of patients, anal fissures and hemorrhoids will coexist and can present with bleeding after bowel movements. Of course, it is quite easy to distinguish between them because a digital rectal exam causes significant sharp pain in the presence of a fissure, but not with hemorrhoids. In this scenario, one would treat to heal the fissure first, using calcium channel blockers before proceeding with hemorrhoid banding.

During an attempt to band hemorrhoids, placing the bands too close to the dented line can cause significant post-banding discomfort. It is important to identify the dentate line and go at least 2 cm proximal to apply the band. If your patient complains of discomfort postprocedure, you have placed the band too close to the dentate line or have too much mucosa in your band, so that the muscularis layer may be trapped in the band. This is very easy to fix by moving the band up toward the tip of the trapped mucosa with your finger.

Managing benign anorectal disease, which includes hemorrhoids, anal fissures, anal pruritus, and rectal dyssynergia, is well within the domain of the gastroenterologist practice, and you should be doing this.

Retroflexed view of the dentate line (yellow arrow) and the hemorrhoid band (red arrow) to show the distance between the dentate line and the band for a correct technique.

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