Complications
Rectal bleeding is a characteristic feature of symptomatic hemorrhoids. At times the bleeding can be excessive or massive, or may be the etiology of symptomatic anemia, especially in patients taking oral anticoagulation medications.[37]
Patients with continuous bleeding or those who develop symptomatic anemia require early endoscopic evaluation (colonoscopy).[2][13] This evaluation is followed by definitive hemorrhoid treatment after more proximal pathology is eliminated.
Acute thrombosis of a hemorrhoid manifests as the sudden onset of perianal pain and the appearance of a tender nodule adjacent to the anal canal.[1] The thrombosis often follows a period of vigorous activity.
The treatment of an acute thrombosis involves the relief of pain, which is the predominant symptom. Nonsurgical treatment consists of warm tub soaks. Mild oral analgesia and stool softeners can be offered.[1] The thrombus will be gradually resorbed over 1 to 2 weeks.
Early surgical deroofing or excision can be considered when symptoms are severe; this will also result in faster resolution of symptoms.[1][13][29]
Prolapsing hemorrhoidal tissue can become incarcerated and be unable to be reduced into the anal canal causing severe pain.
The treatment for incarcerated hemorrhoids is traditionally urgent surgical hemorrhoidectomy. Adjuncts to reduce the swelling and to facilitate conservative excision include hyaluronidase injection into the swollen hemorrhoidal tissue.
Considerable risk of some degree of impaired continence, usually to flatus (52%) and liquid stool (40%) has been reported following surgical hemorrhoidectomy.[36] Severe incontinence is rare; women are at greater risk. Grade of hemorrhoids does not appear to influence risk of fecal incontinence. Rubber band ligation was not associated with fecal incontinence in one review.[36] Network meta-analyses suggest that stapled hemorrhoidectomy and open hemorrhoidectomy are associated with the highest risk of bowel incontinence.[24][38]
Clinically disproportionate rectal pain, urinary retention, abdominal pain, and pyrexia are often warning signs.
Technically difficult procedures, high and incomplete staple line with full thickness excision should raise suspicion.
Immunocompromised patients including people with diabetes, those on long-term corticosteroids may be at risk.
Imaging (plain chest x-ray, abdominal x-ray, or computed tomography scan) may reveal free air in the peritoneum or retroperitoneum, and may be diagnostic.
Sepsis can progress rapidly to multi-organ failure and shock, and is often fatal. Survival is dependent on early recognition and immediate intervention with empiric broad-spectrum antibiotic therapy, which should be administered within 1 hour of recognition of suspected sepsis. Urgent surgical evaluation is warranted.
Increased incidence with extensive, circumferential excision. Severe longstanding stenosis is rare.
Meticulous attention to technical details, including preservation of skin bridges in between excised pedicles, should prevent occurrence of stenosis.
Minor fibrotic stenosis is treated by dilation in outpatient clinics followed by self-dilation. Significant stenosis will require surgical correction.
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