Tag: hemorrhoids

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Instructions For Hemorrhoidal Banding

INSTRUCTIONS FOR HEMORRHOIDAL BANDING

You have been booked to have internal hemorrhoids banded in my office on________________at
________________. No anesthetic is required for this procedure.

It is very important that you keep this appointment. We reserve the right to bill you for not showing up. Please phone our office 3 days before your appointment to confirm that you will be coming for the procedure.

HOW TO PREPARE FOR HEMORRHOIDAL BANDING?

1. Buy a Fleet enema to be used rectally two hours before the procedure.

2. Normally you may not need a ride going home but if you are very anxious about this procedure then
have somebody bring you here and take you home. Normally there is minimal discomfort during the
procedure.

An internal hemorrhoid is inside the lower part of the rectum near the beginning of the anal canal. An external hemorrhoid is a swollen vein further down at or just inside the anal opening. Usually there are three internal hemorrhoids at 3, 7 and 11 o’clock position. There may be other minor internal hemorrhoids as well.

Usually one to two internal hemorrhoids are banded at one sitting. Therefore you may need more than one appointment to complete the banding of all the internal hemorrhoids. Banding is not done for external hemorrhoids. If external hemorrhoids are bothersome then they need to be cut out under local anesthetic in the office.

WHAT TO DO AFTER HEMORRHOIDAL BANDING?

1. Take pain killers which you are familiar with if there is discomfort or pain.

2. Keep your bowels regular, soft and bulky with dietary fiber, oral fluids, fiber supplements, exercise
and stool softeners if required.

3. Sit in the hot bath for 20 – 30 minutes twice a day and this will relieve pain and provide comfort.

4. You can use hemorrhoidal ointment which has been prescribed to you.

ARE THERE ANY COMPLICATIONS ASSOCIATED WITH THIS PROCEDURE?

Usually the complication rate is very small. Except for some pressure and discomfort most of the time things go very well. Complications to look for are:

1. Delayed bleeding at 5 to 10 days (less than 1%)

2. Pain (less than 5% – may need to remove the band)

3. Discomfort (30%)

4. Thrombosis (clotting of the hemorrhoidal vessels – very rare)

5. Fissure (very rare)

6. Infection (usually rare but can be very serious). In case of persistent pain then please phone
my office.

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Hemorrhoids

“What’s up, Dave? You don’t look happy!”

“Doc, its my hemorrhoids again!”

Dave has had symptoms of haemorrhoids for sometime. His main complaints have been bright rectal bleeding on the toilet paper and itching. About five years ago he was investigated for other colon and rectal problems and nothing abnormal was found.

He has been able to control the symptoms by using high fibre diet, having regular bowel movements, application of ointment, taking care of local hygiene and hot baths. He resists any temptation to strain at defecation.

Generally speaking, when patients complain about hemorrhoids, they really mean they have a problem in the rectal area. Besides hemorrhoids, one has to keep in mind conditions like: fissure, fistula, infection (abscess), inflammation of the rectum (proctitis), polyps, and cancer.

Like a good detective, the physician can eliminate these conditions by taking a careful history and do a physical examination – including the dreaded digital rectal examination. Patients also need tests like flexible sigmoidoscopy (examination of the rectum and distal colon) and in some instances colonoscopy (full examination of the colon).

“So Dave, what has changed?

This time Dave has painless bright rectal bleeding not only on the toilet paper but also outside of the stool. Blood drips after a bowel movement. Dave has been advised in the past not to ignore any bleeding from the rectum. Painless bright rectal bleeding (usually with or following bowel movements) immediately warns a physician to check for cancer.

“Doc, does every patient with rectal bleeding require colonoscopy to rule out cancer?”

No. I use age 40 as a cut off point. Patients under 40, who have no personal or family history of colon polyps or cancer or their bleeding is not associated with diarrhoea then I advise them to have flexible sigmoidoscopy as the first line of investigation. This is an office procedure requiring less bowel preparation and no sedation. It examines 60-cm. of distal colon and rectum.

Five years ago, Dave had a flexible sigmoidoscopy and this was normal except for internal hemorrhoids. Now Dave is over 40, and should undergo colonoscopy. This is a same day procedure in hospital, requiring full bowel preparation a day before, and sedation during the procedure.

Dave returns to the office after the colonoscopy. This is normal except for internal hemorrhoids. Since Dave continues to bleed off and on, he requires more than conservative (high fibre diet, no straining, local hygiene, ointment, hot bath) management.

“Doc, what are my options?”

Dave’s options depend on the size and the type of the hemorrhoids. External hemorrhoids usually require no treatment unless there is a painful blood clot in the blood vessels. This can be drained in the office under local anaesthetic with almost instant relief.

Internal hemorrhoids vary in size and symptoms. Grade 1 internal hemorrhoids do not prolapse. Grade 2 internal hemorrhoids prolapse on defecation but reduce spontaneously. Grade 3 internal hemorrhoids prolapse and require manual reduction. Grade 4 internal hemorrhoids prolapse and cannot be reduced.

Barron’s rubber band ligation is recommended as a first line treatment for Grades 1 and 2 and Grade 3 that do not respond to diet or local preparations, says an article in the Canadian Journal of Surgery. It says that rubber band application is an office procedure that does not require general anaesthetic and time off work. It is associated with fewer complications and less pain.

Surgical removal of hemorrhoids under general anaesthetic should be reserved for Grade 4 and some Grade 3 patients who do not respond to rubber band ligation. Recovery period is prolonged and more painful than rubber band ligation.

Dave has Grade 2 internal hemorrhoids and has successful rubber band ligation in the office. Dave is a happy man again!


This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Rectal Bleeding and Hemorrhoids

“Hello doctor, I am Maggie, Susan’s mother. I have been passing blood in my stool. Do you think it is hemorrhoids? Dave and Susan think it could be cancer.”

Maggie is sixty seven. She has been bleeding rectally for the last two years. Over-the-counter medications for local application have not helped. Has she got colon or rectal (colorectal) cancer?

Colorectal cancer affects men and women equally. It is the fourth most common cancer site. It is the second leading cause of cancer deaths in men and women combined ( A Snapshot of Cancer in Alberta-1996).

Do we know what causes colorectal cancer? No. If we did then prevention and cure would be easy. But we do know the risk factors.

Like breast cancer, age is a significant factor. Before the age of forty, the incidence is pretty low. But by the age of fifty, the risk begins to increase dramatically.

What about lifestyle and nutrition?

Studies have shown that death from colorectal cancer can decrease with increased intake of fiber, fruits, and vegetables. Decrease in fat intake also helps.

Increased physical activity, aspirin and avoiding cigarette smoking may be beneficial.

Heredity and genetics is now recognized as a risk factor for this disease. Studies have shown that if there is a family history of colorectal cancer in a parent or a sibling , then a person’s lifetime risk of colorectal cancer jumps from 1.8 fold to 8.0 fold.

Previous history of colorectal cancer or polyps, inflammatory bowel disease and exposure to radiation are other significant risk factors.

With this information in the back of my mind, I take a full history from Maggie and do a thorough physical examination.

The physical examination is normal. A digital rectal examination reveals no suspicious lumps. A proctosigmoidoscopy ( a hollow tube with a light at one end to examine the rectum) shows internal hemorrhoids but no lumps to suggest a new growth of tissue.

Although Maggie has internal hemorrhoids, there are about fifty percent chances that the blood could be coming from higher up in the colon. This may or may not be due to cancer. But she requires further investigation like colonoscopy.

Examination of the entire colon by colonoscopy (a thin, flexible tube made of fibers that transmit light) is the most important test for looking, taking biopsies and when possible, removing growths. Maggie agrees to have the test done as soon as possible.

Maggie has to take laxatives to clean the colon completely of waste products the day before the procedure. The test is done at the hospital as day surgery and under sedation.

A polyp (new growth of tissue) is discovered and removed during colonoscopy. This is sent to the lab for testing to see if it is benign or malignant. In the meantime, she makes an appointment to see me in the office for the results.

Susan accompanies Maggie to make sure her Mom understands the results and its implications. Susan also wants to know how the findings will affect her (Susan’s) health in the future.

“Maggie, I have good news for you. The polyp is benign in nature but it’s a type which can come back and turn into cancer if not picked up early and removed.”

“Dr. B, thank you for the good news. Now I have the same old question for you. How can my mom and I stay one step ahead of the game?” Susan asks with a sense of relief.

Eat less fat. Eat more fiber-containing foods. Have a digital rectal examination and annual stool test for hidden blood and colonoscopy every 3 to 5 years. Report to your doctor earlier if there is any change in bowel habit.

Maggie and Susan are happy that this is all over. As they leave the examination room, I overheard Maggie say to Susan, “I hope now you will listen to your mother and start eating bran flakes cereal in the morning!”

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!