What is Hodgkin's disease?

Hodgkin's disease is one of a group of cancers called lymphomas. Lymphoma is a general term for cancers that develop in the
lymphatic system. Hodgkin's disease, an uncommon lymphoma, accounts for less than 1 percent of all cases of cancer in this
country. Other cancers of the lymphatic system are called non-Hodgkin's lymphomas. Non-Hodgkin's lymphomas are the subject
of another NCI booklet, What You Need To Know About Non-Hodgkin's Lymphoma.
The lymphatic system is part of the body's immune system. It helps the body fight disease and infection. The lymphatic system
includes a network of thin lymphatic vessels that branch, like blood vessels, into tissues throughout the body. Lymphatic vessels
carry lymph, a colorless, watery fluid that contains infection-fighting cells called lymphocytes. Along this network of vessels are
small organs called lymph nodes. Clusters of lymph nodes are found in the underarms, groin, neck, chest, and abdomen. Other
parts of the lymphatic system are the spleen, thymus, tonsils, and bone marrow. Lymphatic tissue is also found in other parts of
the body, including the stomach, intestines, and skin.
Cancer is a group of many related diseases that begin in cells, the body's basic unit of life. To understand Hodgkin's disease, it is
helpful to know about normal cells and what happens when they become cancerous. The body is made up of many types of cells.
Normally, cells grow and divide to produce more cells only when the body needs them. This orderly process helps keep the body
healthy. Sometimes cells keep dividing when new cells are not needed, creating a mass of extra tissue. This mass is called a
growth or tumor. Tumors can be either benign (not cancerous) or malignant (cancerous).
In Hodgkin's disease, cells in the lymphatic system become abnormal. They divide too rapidly and grow without any order or
control. Because lymphatic tissue is present in many parts of the body, Hodgkin's disease can start almost anywhere. Hodgkin's
disease may occur in a single lymph node, a group of lymph nodes, or, sometimes, in other parts of the lymphatic system such as
the bone marrow and spleen. This type of cancer tends to spread in a fairly orderly way from one group of lymph nodes to the
next group. For example, Hodgkin's disease that arises in the lymph nodes in the neck spreads first to the nodes above the
collarbones, and then to the lymph nodes under the arms and within the chest. Eventually, it can spread to almost any other part
of the body. (Please see the non-Hodgkin's lymphoma article.)
The following are some of the risk factors associated with this disease:

Age/Sex -- Hodgkin's disease occurs most often in people between 15 and 34 and in people over the age of 55. It is more
common in men than in women.

Family History -- Brothers and sisters of those with Hodgkin's disease have a higher-than-average chance of developing
this disease.

Viruses -- Epstein-Barr virus is an infectious agent that may be associated with an increased chance of getting Hodgkin's
disease.

People who are concerned about the chance of developing Hodgkin's disease should talk with their doctor about the disease, the
symptoms to watch for, and an appropriate schedule for checkups. The doctor's advice will be based on the person's age, medical
history, and other factors.
Symptoms of Hodgkin's disease
Symptoms of Hodgkin's disease may include the following:

A painless swelling in the lymph nodes in the neck, underarm, or groin

Unexplained recurrent fevers

Night sweats

Unexplained weight loss

Itchy skin

When symptoms like these occur, they are not sure signs of Hodgkin's disease. In most cases, they are actually caused by other,
less serious conditions, such as the flu. When symptoms like these persist, however, it is important to see a doctor so that any
illness can be diagnosed and treated. Only a doctor can make a diagnosis of Hodgkin's disease. Do not wait to feel pain; early
Hodgkin's disease may not cause pain.

X-rays: High-energy radiation used to take pictures of areas inside the body, such as the chest, bones, liver, and spleen.

CT (or CAT) scan: A series of detailed pictures of areas inside the body. The pictures are created by a computer linked to an x-ray
machine.

MRI (magnetic resonance imaging): Detailed pictures of areas inside the body produced with a powerful magnet linked to a computer.

The diagnosis depends on a biopsy. A surgeon removes a sample of lymphatic tissue (part or all of a lymph node) so that a pathologist can
examine it under a microscope to check for cancer cells. Other tissues may be sampled as well. The pathologist studies the tissue and checks for
Reed-Sternberg cells, large abnormal cells that are usually found with Hodgkin's disease.
If the biopsy reveals Hodgkin's disease, the doctor needs to learn the stage, or extent, of the disease. Staging is a careful attempt to find out
whether the cancer has spread and, if so, what parts of the body are affected. Treatment decisions depend on these findings.
The doctor considers the following to determine the stage of Hodgkin's disease:

The number and location of affected lymph nodes;

Whether the affected lymph nodes are on one or both sides of the diaphragm (the thin muscle under the lungs and heart that separates
the chest from the abdomen); and

Whether the disease has spread to the bone marrow, spleen, or places outside the lymphatic system, such as the liver.

In staging, the doctor may use some of the same tests used for the diagnosis of Hodgkin's disease. Other staging procedures may include
additional biopsies of lymph nodes, the liver, bone marrow, or other tissue. A bone marrow biopsy involves removing a sample of bone marrow
through a needle inserted into the hip or another large bone. Rarely, an operation called a laparotomy may be performed. During this operation, a
surgeon makes an incision through the wall of the abdomen and removes samples of tissue. A pathologist examines tissue samples under a
microscope to check for cancer cells
Treatment for Hodgkin's disease
The doctor develops a treatment plan to fit each patient's needs. Treatment for Hodgkin's disease depends on the stage of the
disease, the size of the enlarged lymph nodes, which symptoms are present, the age and general health of the patient, and other
factors. (Treatment for children with Hodgkin's disease is not discussed here. The Cancer Information Service and the other
resources listed under "National Cancer Institute Information Resources" can provide up-to-date information about Hodgkin's
disease in children).
Patients with Hodgkin's disease may be vaccinated against the flu, pneumonia, and meningitis. They should discuss a vaccination
plan with their health care provider.
Hodgkin's disease is often treated by a team of specialists that may include a medical oncologist, oncology nurse, and/or radiation
oncologist. Hodgkin's disease is usually treated with radiation therapy or chemotherapy. The doctors may decide to use one
treatment method or a combination of methods.
Taking part in a clinical trial (research study) to evaluate promising new ways to treat Hodgkin's disease is an important option for
many people with this disease. For more information, see the "Clinical Trials" section.
Getting a second opinion

Before starting treatment, patients may want a second opinion to confirm their diagnosis and treatment plan. Some insurance
companies require a second opinion; others may cover a second opinion if the patient or doctor requests it.
There are a number of ways to find a doctor who can give a second opinion:

The patient's doctor may be able to suggest specialists to consult.

The Cancer Information Service, at 1-800-4-CANCER, can tell callers about cancer treatment facilities, including cancer
centers and other programs supported by the National Cancer Institute.

Patients can get the names of doctors from their local medical society, a nearby hospital, or a medical school.

The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training
requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists
lists doctors' names along with their specialty and their educational background. The directory is available in most public
libraries. Also, ABMS offers this information on the Internet at http://www.abms.org. (Click on "Who's Certified.")

Preparing for treatment

Many people with cancer want to learn all they can about their disease and their treatment choices so they can take an active part in
decisions about their medical care. When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings
may make it difficult for people to think of everything they want to ask the doctor. Often, it helps to make a list of questions. To help
remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some people also want to
have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.
Methods of treatment
Radiation therapy and chemotherapy are the most common treatments for Hodgkin's disease, although bone marrow transplantation, peripheral
stem cell transplantation, and biological therapies are being studied in clinical trials.
Radiation therapy (also called radiotherapy) is the use of high-energy rays to kill cancer cells. Depending on the stage of the disease, treatment
with radiation may be given alone or with chemotherapy. Radiation therapy is local therapy; it affects cancer cells only in the treated area.
Radiation treatment for Hodgkin's disease usually involves external radiation, which comes from a machine that aims the rays at a specific area of
the body. External radiation does not cause the body to become radioactive. Most often, treatment is given on an outpatient basis in a hospital or
clinic.

Side effects of treatment for Hodgkin's disease

Treatments for Hodgkin's disease are very powerful. It is hard to limit the effects of therapy so that only
cancer cells are destroyed. Because treatment also damages healthy cells and tissues, it often causes side
effects.
The side effects of cancer treatment depend mainly on the type and extent of the therapy. Side effects may
not be the same for everyone, and they may even change from one treatment to the next. Doctors and
nurses can explain the possible side effects of treatment. They can also lessen or control many of the side
effects that may occur during and after treatment.
Radiation therapy
The side effects of radiation depend on the treatment dose and the part of the body that is treated. During
radiation therapy, people are likely to become extremely tired, especially in the later weeks of treatment.
Rest is important, but doctors usually advise patients to try to stay as active as they can.

It is common to lose hair in the treated area and for the skin to become red, dry, tender, and itchy. There
may also be permanent darkening or "bronzing" of the skin in the treated area.
When the chest and neck are treated, patients may have a dry, sore throat and some trouble swallowing.
Sometimes, they have shortness of breath or a dry cough. Radiation therapy to the abdomen may cause
nausea, vomiting, diarrhea, or urinary discomfort. Often, changes in diet or medicine can ease these
problems.
Radiation therapy also may cause a decrease in the number of white blood cells, cells that help protect the
body against infection, or platelets, cells that help the blood to clot. If that happens, patients need to be
careful to avoid possible sources of infection or injury. The doctor monitors a patient's blood count very
carefully during radiation treatment. If necessary, treatment may have to be postponed to let the blood
counts return to normal.
Although the side effects of radiation therapy can be difficult, they can usually be treated or controlled. It
may also help to know that, in most cases, side effects are not permanent. However, patients may want to
discuss with their doctor the possible long-term effects of radiation treatment on fertility (the ability to
produce children) and the increased chance of second cancers after treatment is over. (The "Followup
Care" section includes more information about the chance for second cancers.) Loss of fertility may be
temporary or permanent, depending on if the testes or ovaries received radiation and the patient's age. For
men, sperm banking before treatment may be a choice. Women's menstrual periods may stop, and they
may have hot flashes and vaginal dryness. Menstrual periods are more likely to return for younger
women. The National Cancer Institute booklet Radiation Therapy and You has helpful information about
radiation therapy and managing its side effects.
Chemotherapy
The side effects of chemotherapy depend mainly on the specific drugs and the doses the patient receives.
As with other types of treatment, side effects may vary from person to person.
Anticancer drugs generally affect cells that divide rapidly. In addition to cancer cells, these include blood
cells, which fight infection, help the blood to clot, and carry oxygen to all parts of the body. When blood
cells are affected, the patient is more likely to get infections, may bruise or bleed easily, and may feel
unusually weak and tired.
Cells in hair roots also divide rapidly; therefore, chemotherapy may lead to hair loss. Hair loss is a major
concern for many patients. Some anticancer drugs only cause the hair to thin out, while others may result
in the loss of all body hair. People may cope with hair loss better if they decide how to handle hair loss
before starting treatment.
Cells that line the digestive tract also divide rapidly, and are often damaged by chemotherapy. As a result,
side effects may include poor appetite, nausea and vomiting, and/or mouth and lip sores.
Most side effects go away gradually during the recovery periods between treatments or after treatment is
over. Sometimes, however, chemotherapy results in a permanent loss of fertility. The National Cancer

Institute booklet Chemotherapy and You has helpful information about chemotherapy and coping with
side effects.
Nutrition during cancer treatment
Eating well during cancer treatment means getting enough calories and protein to help prevent weight loss and
regain strength. Good nutrition often helps people feel better and have more energy.
Some people with cancer find it hard to eat a balanced diet because they may lose their appetite. In addition,
common side effects of treatment, such as nausea, vomiting, or mouth sores, can make eating difficult. Often, foods
taste different. Also, people being treated for cancer may not feel like eating when they are uncomfortable or tired.
Doctors, nurses, and dietitians can offer advice on how to get enough calories and protein during cancer treatment.
Patients and their families also may want to read the National Cancer Institute booklet Eating Hints for Cancer
Patients, which contains many useful suggestions.
Followup care
People who have had Hodgkin's disease should have regular followup examinations after their treatment is over and
for the rest of their lives. Followup care is an important part of the overall treatment process, and people who have
had cancer should not hesitate to discuss it with their health care provider. Patients treated for Hodgkin's disease
have an increased chance of developing leukemia; non-Hodgkin's lymphoma; and cancers of the colon, lung, bone,
thyroid, and breast. Regular followup care ensures that patients are carefully monitored, any changes in health are
discussed, and new or recurrent cancer can be detected and treated as soon as possible. Between followup
appointments, people who have had Hodgkin's disease should report any health problems as soon as they appear .
The nose is a part of the body rich in blood vessels (vascular) and is situated in a vulnerable position as it protrudes
on the face. As a result, trauma to the face can cause nasal injury and bleeding. The bleeding may be profuse, or
simply a minor complication. Nosebleeds can occur spontaneously when the nasal membranes dry out and crack.
This is common in dry climates, or during the winter months when the air is dry and warm from household heaters.
People are more susceptible to bleeding if they are taking medications which prevent normal blood clotting warfarin
(Coumadin), aspirin, or any anti-inflammatory medication]. In this situation, even a minor trauma could result in
significant bleeding.
The incidence of nosebleeds is higher during the colder winter months when upper respiratory infections are more
frequent, and the temperature and humidity fluctuate more dramatically. In addition, changes from a bitter cold
outside environment to a warm, dry, heated home results in drying and changes in the nose which will make it more
susceptible to bleeding. Nosebleeds also occur in hot dry climates with low humidity, or when there is a change in
the seasons. The following factors predispose people to nosebleeds:

Infection

Trauma, including self-induced by nose picking

Allergic and non-allergic rhinitis

Hypertension (high blood pressure)

Use of blood thinning medications

Alcohol abuse

Less common causes include tumors and inherited bleeding problems

How do you stop the common nosebleed?

Most people who develop nose bleeding can handle the problem without the need of a physician if they follow the
recommendations below:
1.

Pinch all the soft parts of the nose together between your thumb and index finger.

2.

Press firmly toward the face - compressing the pinched parts of the nose against the bones of the face.

3.

Lean forward slightly with the head tilted forward. Leaning back or tilting the head back allows the blood
to run back into your sinuses and throat and can cause gagging or inhaling the blood.

4.

Hold the nose for at least five minutes. Repeat as necessary until the nose has stopped bleeding.

5.

Sit quietly, keeping the head higher than the level of the heart. Do not lay flat or put your head between
your legs.

6.

Apply ice (wrapped in a towel) to nose and cheeks.

How do you prevent the nose from bleeding again?

1.

Go home and rest with head elevated at 30 to 45 degrees.

2.

Do not blow your nose or put anything into it. If you have to sneeze, open your mouth so that the air will
escape out the mouth and not through the nose.

3.

Do not strain during bowel movements. Use a stool softener (for example, Colace).

4.

Do not strain or bend down to lift anything heavy.

5.

Try to keep your head higher than the level of your heart.

6.

Do not smoke.

7.

Stay on a soft, cool diet. No hot liquids for at least 24 hours.

8.

Do not take any medications that will thin the blood [aspirin, ibuprofen, clopidogrel bisulfate (Plavix) or
warfarin (Coumadin)]. If these have been prescribed by your physician, you need to contact them regarding
stopping these medications.

9.

Your doctor may recommend some form of lubricating ointment for the inside of the nose (see below).

10. If re-bleeding occurs, try to clear the nose of clots by sniffing in forcefully. You can temporarily use a nasal
decongestant spray, such as Afrin or Neo-Synephrine. These types of sprays constrict blood vessels.

(NOTE: If used for many days at a time, these can cause addiction and do not use if you have high blood
pressure.)
11. Repeat the steps above on how to stop the common nose bleed. If bleeding persists, call the doctor and/or
visit to the emergency room.
How do you stop the common nosebleed?
Most people who develop nose bleeding can handle the problem without the need of a physician if they follow the
recommendations below:
1.

Pinch all the soft parts of the nose together between your thumb and index finger.

2.

Press firmly toward the face - compressing the pinched parts of the nose against the bones of the face.

3.

Lean forward slightly with the head tilted forward. Leaning back or tilting the head back allows the blood
to run back into your sinuses and throat and can cause gagging or inhaling the blood.

4.

Hold the nose for at least five minutes. Repeat as necessary until the nose has stopped bleeding.

5.

Sit quietly, keeping the head higher than the level of the heart. Do not lay flat or put your head between
your legs.

6.

Apply ice (wrapped in a towel) to nose and cheeks.

How do you prevent the nose from bleeding again?

1.

Go home and rest with head elevated at 30 to 45 degrees.

2.

Do not blow your nose or put anything into it. If you have to sneeze, open your mouth so that the air will
escape out the mouth and not through the nose.

3.

Do not strain during bowel movements. Use a stool softener (for example, Colace).

4.

Do not strain or bend down to lift anything heavy.

5.

Try to keep your head higher than the level of your heart.

6.

Do not smoke.

7.

Stay on a soft, cool diet. No hot liquids for at least 24 hours.

8.

Do not take any medications that will thin the blood [aspirin, ibuprofen, clopidogrel bisulfate (Plavix) or
warfarin (Coumadin)]. If these have been prescribed by your physician, you need to contact them regarding
stopping these medications.

9.

Your doctor may recommend some form of lubricating ointment for the inside of the nose (see below).

10. If re-bleeding occurs, try to clear the nose of clots by sniffing in forcefully. You can temporarily use a nasal
decongestant spray, such as Afrin or Neo-Synephrine. These types of sprays constrict blood vessels.

(NOTE: If used for many days at a time, these can cause addiction and do not use if you have high blood
pressure.)
11. Repeat the steps above on how to stop the common nose bleed. If bleeding persists, call the doctor and/or
visit to the emergency room.
What precautions can you take to prevent nose bleeding?
The most common cause of a nose bleeds is drying of the nasal membranes. If you are prone to recurrent nosebleeds, it is often helpful to try
lubricating the nose with an ointment of some type. This can be applied gently with a Q-tip or your fingertip up inside the nose, especially on the
middle portion (the septum). Many patients use A & D ointment, Mentholatum, Polysporin/Neosporin ointment, or Vaseline. Saline mist nasal
spray is often helpful (Ocean Spray).

What is epistaxis?

Epistaxis (ep-i-STAK-sis), also known as a nosebleed, is a condition where there is active bleeding from the nose.
This occurs when the blood vessels inside the nose are injured or damaged. Epistaxis can be located either anteriorly
(front) or posteriorly (back). Anterior nosebleed is usually from the front and lower part of the nose. The most
common site of anterior bleeding is in the nasal septum (bridge of the nose). Posterior nosebleed happens when the
bleeding starts from the higher and deeper back portion of the nose. The blood usually drains down the back of the
throat instead of coming out the nostrils (nose openings). Epistaxis is usually not life-threatening, but prompt
treatment is needed to prevent prolonged bleeding and further problems.
The nose is the main gateway to the respiratory (breathing) system. The inside of the nose is covered with mucosa
(moist, soft tissues) that has a rich blood supply. This warms and moistens the air we breathe. Air passes to and from
the lungs through the nostrils. A thin flexible wall called a nasal septum separates the two nostrils.

What causes epistaxis?

The following may cause epistaxis or increase your risks of having one:
Extreme temperatures:
Very cold, dry air during winter or very hot, dry air during summer. This may make the inside of the nose dry, crack,
and bleed easily.
Heavy alcohol drinking:
Drinking too much alcohol and too often. Alcohol is found in beer, wine, liquor, such as vodka and whiskey, or other
adult drinks. Talk to your caregiver if you drink alcohol.

Inflammation:
Inflammation (swelling) of the nose may be due to infections, such as colds or allergies. The more your nose is
stuffy, the more likely the blood vessels may widen and bleed. This may also make you frequently blow your nose
too hard and cause further damage.
Medicines:
Some medicines may make the blood thinner or clot longer. These may include anticoagulants (clot busters), nonsteroidal anti-inflammatory drugs, such as aspirin and ibuprofen, or steroids.
Smoking or illegal drug use:
Cigarette smoking or sniffing cocaine may irritate your nose and cause thinning of the lining of the nose.
Trauma:
Nosebleeds may be caused by an injury or direct blow to the nose. This may occur during a fight, physical abuse, car
accident, or contact sports. An object stuck in the nose or frequent picking of the nose may also cause epistaxis.
Others:
High blood pressure, bleeding problems, abnormal blood vessels in the nose, and tumors.

What are the signs and symptoms of epistaxis?

Dark or bright red bleeding from one or both nostrils is the most common sign of epistaxis. You may also have
trouble breathing, smelling, or talking if blood clots block your nostrils. If you swallow blood, your stool (bowel
movements) may look black. Other symptoms include headache, dizziness, and weakness, especially when you lose
a lot of blood.

How is epistaxis diagnosed?

Your caregiver will check your health history. This may include details of any injury or present medicines you may
be taking. You may also need any of the following:
Nasal speculum exam:
Caregivers will use bright light and an instrument called a speculum to check the inside of your nose. This gently
spreads open your nostrils to look for any blood clots or swelling. He may also locate where the bleeding is coming
from.
Nasal endoscopy:
This procedure, also known as anterior rhinoscopy, uses a scope to see the inside of your nose. A scope is made of a
long, bendable tube with a light on the end of it. During a nasal endoscopy, pictures are taken by a small camera
attached to the scope.

Blood tests:
You may need blood taken for tests. The blood can be taken from a blood vessel in your hand, arm, or the bend in
your elbow. It is tested to see how your body is doing. It can give your caregivers more information about your
health condition. You may need to have blood drawn more than once.
Angiography:
This test looks for problems with your arteries in the face, especially around the nose. Before the x-ray, a dye is put
into a thin tube through a small cut in your groin. The groin is the area where your abdomen (stomach) meets your
upper leg. The dye helps the arteries show up better on these x-ray pictures. People who are allergic to iodine or
shellfish (lobster, crab, or shrimp) may be allergic to this dye. Tell your caregiver if you are allergic to shellfish,
dyes, or any medicines.

How is epistaxis treated?

Treatment for epistaxis aims to control bleeding and treat the underlying cause. You may have any of the following:
Medicines:
Caregivers may directly apply medicines to your nose to relieve congestion, decrease pain, and stop bleeding. Other
medicines may also be given to treat the cause of your nosebleed. These may include medicines for high blood
pressure, bleeding problems, and kidney and liver diseases.
Nasal packing:
Caregivers may pack your nose with gauze (bandage) strips to control bleeding and prevent infection. These strips
are moistened (wet) with salt solution or antibiotic ointment. A balloon device or rubber tube may also need to be
placed at the back of your nose. This may be left in place until the bleeding has stopped.
Cautery:
This uses an electrical device or a chemical, such as silver nitrate, to seal the injured blood vessels.
Embolization:
A special substance will be injected into the bleeding vessel. This blocking agent will stop the blood flow.
Laser therapy:
Laser therapy uses intense light to destroy abnormal blood vessels that cause the bleeding.
Surgery:
You may need surgery to tie an artery if the bleeding does not stop. Surgery may also be needed to correct a
deformity or fix damaged tissues in the nose. Blood clots in the nose may also be removed to prevent infection.
Injury to the other parts of the nose, nerves, or blood vessels may also be treated with surgery.

What first aid may be done for epistaxis?

You may do the following when your nose bleeds:

Lean forward to keep blood from going down the back of your throat, and breathe through your mouth.
Pinch the lower soft part of your nose tightly using your thumb and index finger for 5 to 20 minutes.
While pinching your nose, apply ice to the bridge of your nose to slow down the bleeding.
After pinching your nose, release it to check if there is still bleeding. If your nose is still bleeding, repeat pinching
your nose and applying ice.
Seek emergency medical help if your nose bleeding does not stop.
PRE-PROCEDURE
INDICATIONS

CONTRAINDICATIONS

EQUIPMENT
ENT chair
Headlamp
Nasal speculum
Bayonet forceps
Emesis basin

4 4 gauze
Antibiotic ointment

Umbilical clamps
ANATOMY

PROCEDURE

The full content of this section includes:

Step-by-step text instructions for performing the procedure
Clinical pearls providing practical clinical tips from medical experts
Patient safety guidelines consistent with Joint Commission and OHSA standards
Links to medical evidence and related procedures

POST-PROCEDURE
CARE
Patients with anterior packing should follow-up with an otolaryngologist and begin treatment with penicillin or a
first-generation cephalosporin to prevent toxic shock syndrome.

All patients with posterior packing should be managed in consultation with otolaryngology and merit admission
to the hospital.
Instruct the patient to avoid blowing the nose and to refrain from strenuous activity or activities prone to
injuring the nose.

Continue anticoagulation therapy if INR is in the therapeutic range.

Apply antibiotic ointment to the interior nose to reduce recurrence.

COMPLICATIONS

Failure to control bleeding

Toxic shock syndrome

Anatomic blockage of the nasal passages

Airway obstruction due to dislodged packing

Nasovagal reflex

What are anal fissures?

An anal fissure is a cut or tear occuring in the anus (the opening through which stool passes out of the body) that
extends upwards into the anal canal. Fissures are a common condition of the anus and anal canal and are responsible
for 6-15% of the visits to a colonic and rectal (colorectal) surgeon. They affect men and women equally and both the
young and the old. Fissures usually cause pain during bowel movements that often is severe. Anal fissure is the most
common cause of rectal bleeding in infancy.
Anal fissures occur in the specialized tissue that lines the anus and anal canal, called anoderm. At a line just inside
the anus--referred to as the anal verge or intersphincteric groove--the skin (dermis) of the inner buttocks changes to
anoderm. Unlike skin, anoderm has no hairs, sweat glands, or sebaceous (oil) glands and contains a larger number of
somatic sensory nerves that sense light touch and pain. (The abundance of nerves explains why anal fissures are so
painful.) The hairless, gland-less, extremely sensitive anoderm continues for the entire length of the anal canal until
it meets the demarcating line for the rectum, called the dentate line. (The rectum is the distal 15 cm of the colon that
lies just above the anus and rectum and just below the sigmoid colon.)
What causes anal fissures?
Anal fissures are caused by trauma to the anus and anal canal. The cause of the trauma usually is a bowel movement,
and many patients can remember the exact bowel movement during which their pain began. The fissure may be
caused by a hard stool or repeated episodes of diarrhea. Occasionally, the insertion of a rectal thermometer, enema
tip, endoscope, or ultrasound probe (for examining the prostate gland) can result in sufficient trauma to produce a
fissure. During childbirth, trauma to the perineum (the skin between the posterior vagina and the anus) may cause a
tear that extends into the anoderm.
The most common location for an anal fissure in both men and women (90% of all fissures) is the midline
posteriorly in the anal canal, the part of the anus nearest the spine. Fissures are more common posteriorly because of
the configuration of the muscle that surrounds the anus. This muscle complex, referred to as the external and internal
anal sphincters, underlies and supports the anal canal. The sphincters are oval-shaped and are best supported at their
sides and weakest posteriorly. When tears occur in the anoderm, therefore, they are more likely to be posterior. In
women, there also is weak support for the anterior anal canal due to the presence of the vagina anterior to the anus.
For this reason, 10% of fissures in women are anterior, while only 1% are anterior in men. At the lower end of
fissures a tag of skin may form, called a sentinal pile.
When fissures occur in locations other than the midline posteriorly or anteriorly, they should raise the suspicion that
a problem other than trauma is the cause. Other causes of fissures are anal cancer, Crohn's disease, leukemia as well
as many infectious diseases including tuberculosis, viral infections (cytomegalovirus or herpes), syphilis, gonorrhea,
chlamydia , chancroid (Hemophilus ducreyi), and human immunodeficiency virus (HIV). Among patients with

Crohn's disease, 4% will have an anal fissure as the first manifestation of their Crohn's disease, and half of all
patients with Crohn's disease eventually will develop an anal ulceration that may look like a fissure.
Studies of the anal canal in patients with anal fissures consistently show that the muscles surrounding the anal canal
are contracting too strongly (they are in spasm), thereby generating a pressure in the canal that is abnormally high.
The two muscles that surround the anal canal are the external anal sphincter and the internal anal sphincter (already
discussed). The external anal sphincter is a voluntary (striated) muscle, that is, it can be controlled consciously.
Thus, when we need to have a bowel movement we can either tighten the external sphincter and prevent the bowel
movement, or we can relax it and allow the bowel movement. On the other hand, the internal anal sphincter is an
involuntary (smooth) muscle, that is, a muscle we cannot control. The internal sphincter is constantly contracted and
normally prevents small amounts of stool from leaking from the rectum. When a substantial load of stool reaches the
rectum, as it does just prior to a bowel movement, the internal anal sphincter relaxes automatically to let the stool
pass (that is, unless the external anal sphincter is consciously tightened).
When an anal fissure is present, the internal anal sphincter is in spasm. In addition, after the sphincter finally does
relax to allow a bowel movement to pass, instead of going back to its resting level of contraction and pressure, the
internal anal sphincter contracts even more vigorously for a few seconds before it goes back to its elevated resting
level of contraction. It is thought that the high resting pressure and the "overshoot" contraction of the internal anal
sphincter following a bowel movement pull the edges of the fissure apart and prevent the fissure from healing.
The supply of blood to the anus and anal canal also may play a role in the poor healing of anal fissures. Anatomic
and microscopic studies of the anal canal on cadavers found that in 85% of individuals that the posterior part of the
anal canal (where most fissures occur) has less blood flowing to it than the other parts of the anal canal. Moreover,
ultrasound studies that measure the flow of blood showed that the posterior anal canal had less than half of the blood
flow of other parts of the canal. This relatively poor flow of blood may be a factor in preventing fissures from
healing. It also is possible that the increased pressure in the anal canal due to spasm of the internal anal sphincter
may compress the blood vessels of the anal canal and further reduce the flow of blood.
What are the symptoms of anal fissures?
Patients with anal fissures almost always experience anal pain that worsens with bowel movements. The pain following a bowel
movement may be brief or long lasting; however, the pain usually subsides between bowel movements. The pain can be so severe
that patients are unwilling to have a bowel movement, resulting in constipation and even fecal impaction. Moreover, constipation can
result in the passage of a larger, harder stool that causes further trauma and makes the fissure worse. The pain also can affect
urination by causing discomfort when urinating (dysuria), frequent urination, or the inability to urinate. Bleeding in small amounts,
itching (pruritus ani), and a malodorous discharge may occur due to the discharge of pus from the fissure. As previously mentioned,

anal fissures commonly bleed in infants.

How are anal fissures diagnosed and evaluated?
A careful history usually suggests that an anal fissure is present, and gentle inspection of the anus can confirm the
presence of a fissure. If gentle eversion (pulling apart) the edges of the anus by separating the buttocks does not
reveal a fissure, a more vigorous examination following the application of an anesthetic to the anus and anal canal
may be necessary. An cotton-tipped swab may be inserted into the anus to gently localize the source of the pain.
An acute anal fissure looks like a linear tear. A chronic anal fissure frequently is associated with a triad of findings
that includes a tag of skin at the edge of the anus (sentinel pile), thickened edges of the fissure with muscle fibers of
the internal sphincter visible at the base of the fissure, and an enlarged anal papilla at the upper end of the fissure in
the anal canal.

If rectal bleeding is present, an endoscopic evaluation using a rigid or flexible viewing tube is necessary to exclude
the possibility of a more serious disease of the anus and rectum. A sigmoidoscopy that examines only the distal part
of the colon may be reasonable in patients younger than 50 years of age who have a typical anal fissure. In patients
with a family history of colon cancer or age greater than 50 (and, therefore, at higher risk for colon cancer), a
colonoscopy that examines the entire colon is recommended. Atypical fissures that suggest the presence of other
diseases, as discussed previously, require other diagnostic studies including colonoscopy and upper gastrointestinal
(UGI) and small bowel x-rays.
How are anal fissures treated?
The goal of treatment for anal fissures is to break the cycle of spasm of the anal sphincter and its repeated tearing of
the anoderm.
General treatment. In acute fissures, medical (nonoperative) therapy is successful in the majority of patients. Of
acute fissures, 80-90% will heal with conservative measures as compared with chronic (recurrent) fissures, which
show only a 40% rate of healing. Initial treatment involves adding bulk to the stool and softening the stool with
psyllium or methylcellulose preparations and a high fiber diet. Additionally, patients are advised to avoid "sharp"
foods that may not be well-digested (i.e., nuts, popcorn, tortilla chips), increase their liquid intake, and, at times, take
stool softeners (docusate or mineral oil preparations). Sitz baths (essentially soaking in a tub of warm water) are
encouraged, particularly after bowel movements, to relax the spasm, to increase the flow of blood to the anus, and to
clean the anus without rubbing the irritated anoderm.
Anesthetics and steroids. Topical anesthetics (e.g., Xylocaine, lidocaine, tetracaine, pramoxine) are recommended
especially prior to a bowel movement to reduce the pain of defecation. Often, a small amount of a steroid is
combined in the anesthetic cream to reduce inflammation. The use of steroids should be limited to two weeks
because longer use will result in thinning of the anoderm (atrophy), which makes it more susceptible to trauma. Oral
medications to relax the smooth muscle of the internal sphincter have not been shown to aid healing.
Nitroglycerin. Because of the possibility that spasm of the internal sphincter and reduced flow of blood to the
sphincter play roles in the formation and healing of anal fissures, ointments with the muscle relaxant, nitroglycerin
(glyceryl trinitrate), have been tried and found to be effective in healing anal fissures. Glycerin trinitrate
(nitroglycerin) has been shown to cause relaxation of the internal anal sphincter and to decrease the anal resting
pressure. When ointments containing nitroglycerin are applied to the anal canal, the nitroglycerin diffuses across the
anoderm and relaxes the internal sphincter and reduces the pressure in the anal canal. This relieves spasm of the
muscle and also may increase the flow of blood, both of which promote healing of fissures. Unlike Nitropaste, a
2.0% concentration of nitroglycerin that is used on the skin for patients with heart disease and angina, the
nitroglycerin ointment used for treating anal fissures contains a concentration of nitroglycerin of only 0.2%. One
randomized, controlled trial has demonstrated the healing of anal fissures in 68% of patients with nitroglycerin as
compared to 8% of patients treated with placebo (inactive treatment). Other studies have shown a 33-47%
recurrence rate of fissures following treatment with nitroglycerin. The presence of a sentinel pile is associated with a
lower healing rate with nitroglycerin treatment.
The dose of nitroglycerin often is limited by side effects. The usual side effects are headache (due to dilation of
blood vessels in the head) or light-headedness (due to a drop in blood pressure). This author recommends that a
small amount of ointment be applied to a cotton-tipped swab with the swab then inserted into the anus only for the
depth of the cotton-tipped portion of the swab. Smearing ointment around the outside of the anus does not allow the
ointment to reach the anoderm where its effects are important, yet the nitroglycerin will be absorbed and produce
side effects.

Nitroglycerin is more rapidly absorbed if blood flow in the anoderm is high. For this reason, it is recommended that
nitroglycerin not be applied within 30 minutes of a bath since the warm water of the bath enlarges (dilates) the blood
vessels in the skin and anoderm and increases their flow of blood. Additionally, the first application of nitroglycerin
should be at bedtime while the patient is lying down in order to prevent falls due to light-headedness.
The side effects of nitroglycerin often are self-limited, that is, they become less with repeated use. Caffeine can help
reduce or prevent headaches. However, if side effects are pronounced, nitroglycerin should be discontinued. Drugs
for impotence (e.g., sildenafil (Viagra)), should not be used together with nitroglycerin since they increase the risk of
developing low blood pressure.
Calcium channel blocking drugs. As is the case with nitroglycerin, ointments containing calcium channel blocking
drugs (e.g., nifedipine (Adalat) or diltiazem (Cardizem)) relax the muscles of the internal sphincter. They also
expand the blood vessels of the anoderm and increase the flow of blood. Nifedipine ointment (2%) is applied in a
manner similar to nitroglycerin ointment, but seems to produce fewer side effects. Although healing of chronic
fissures has been reported in up to 67% of patients treated with calcium channel blockers, they are most effective
with acute fissures.
Botulinum toxin. Botulinum toxin (Botox) relaxes (actually paralyzes) muscles by preventing the release of
acetylcholine from the nerves that normally causes muscle cells to contract. It has been used successfully to treat a
variety of disorders in which there is spasm of muscles, including anal fissures. The toxin is injected into the
external sphincter, the internal sphincter, the intersphincteric groove (an indentation just inside the anus that
demarcates the dividing line between external and internal sphincters), or into the fissure itself. The dose is not
standardized and has varied from 2.5 to 20 units of toxin in two locations (usually on either side of the fissure). The
cost of a 100 unit vial of toxin is several hundred dollars and unused toxin cannot be saved. Thus, the expense for a
single injection of toxin is high. In some series of patients but not all, the frequency of healing of fissures with
botulinum toxin is high. When fissures recur after treatment, they usually heal again with a second injection. One
representative study found that fissures healed in 87% of patients by six months after treatment with botulinum
toxin. By 12 months, however, the healing rate had fallen to 75% and by 42 months to 60%. The primary side effect
of botulinum toxin is weakness of the sphincters with varying degrees of incontinence (leakage of stool) that usually
is transient. Other side effects are not common.
There is a great variability in the medical literature with respect to the effectiveness of drugs and botulinum toxin in
the healing of anal fissures. Healing may be temporary and fissures may return with a hard bowel movement.
Recurrent fissures often require a change to another form of treatment. Patients need to balance the effectiveness of
treatment, short and long-term side effects, convenience, and expense in choosing their treatment. When patients are
intolerant or unresponsive to non-surgical treatments, surgery becomes necessary.
Surgical treatment. The Standard Task Force of the American Society of Colon and Rectal Surgeons has
recommended a surgical procedure called partial lateral internal sphincterotomy as the technique of choice for the
treatment of anal fissures. In this procedure, the internal anal sphincter is cut starting at its distal most end at the anal
verge and extending into the anal canal for a distance equal to that of the fissure. The cut may extend to the dentate
line, but not farther. The sphincter can be divided in a closed (percutaneous ) fashion by tunneling under the
anoderm or in an open fashion by cutting through the anoderm. The cut is made on the left or right side of the anus,
hence the name "partial lateral internal sphincterotomy." The posterior midline, where the fissure usually is located,
is avoided for fear of accentuating the posterior weakness of the muscle surrounding the anal canal. (Additional
weakness posteriorly can lead to what is called a keyhole deformity, so called because the resulting anal canal
resembles an old fashioned skeleton key. This deformity promotes soilage and leakage of stool.)

Although many surgeons decline to cut out the fissure itself during lateral sphincterotomy, this author feels that this
reluctance to remove the fissure is not always appropriate, and characteristics of the fissure itself should be taken
into account. If the fissure is hard and irregular, suggesting anal cancer, the fissure should be biopsied. If the edges
and base of the fissure are heavily scarred, there may be a problem after surgery with anal stenosis, a condition in
which additional scarring narrows the anal canal and interferes with the passage of stool. In this case, it may be
better to cut out the scarred fissure so that there is a chance for the wound to heal with less scarring and chance of
stenosis. Finally, an associated large anal papilla or a large hemorrhoidal tag may interfere physically with wound
healing, and removing them may promote healing.
Following surgery, 93-97% of fissures heal. In one representative study, healing following surgery occurred in 98%
of patients by two months. At 42 months following surgery, 94% of patients were still healed. Recurrence rates after
this type of surgery are low, 0-3%.
Failure to heal following surgery often is attributed to reluctance on the part of the surgeon to adequately divide the
internal anal sphincter; however, other reasons for failure to heal, such as Crohn's disease should be considered as
well. The risk of incontinence (leakage) of stool following surgery is low. It is important to distinguish between
short-term and long-term incontinence. In the short-term (under six weeks), the sphincter is weakened by the
surgery, so leakage of stool is not unexpected. Long-term incontinence should not occur after partial lateral internal
sphincterotomy because the internal sphincter is less important than the external sphincter (which is not cut) in
controlling the passage of stool. It is important to distinguish between incontinence to gas, a minimal amount of
stool that, at most, stains the underwear (soiling), and loss of stool that requires an immediate change in underwear.
In a large series of patients followed for a mean of five years after surgery, 6% were incontinent of gas, 8% had
minor soiling, and 1% experienced loss of stool.
Anal surgical stretch. Several surgeons have described procedures that stretch and tear the anal sphincters for the
treatment of anal fissures. Though anal stretching often is successful in alleviating pain and healing the fissure, it is a
traumatic, uncontrolled disruption of the sphincter. Ultrasonograms of the anal sphincters following stretching
demonstrate trauma that extends beyond the desired area. Because only 72% of fissures heal and there is a 20%
incidence of incontinence of stool, stretching has fallen out of favor.
Hemorrhoids (AmE), haemorrhoids (BrE), emerods, "h-drops" or piles are swelling and inflammation of veins in the rectum and
anus. The anatomical term "hemorrhoids" technically refers to "cushions of tissue filled with blood vessels at the junction of the
rectum and the anus".[1] However, the term is popularly used to refer to varicosities of the hemorrhoid tissue. Perianal hematoma are
sometimes misdiagnosed and mislabeled as hemorrhoids, when in fact they have different causes and treatments.[2]

[edit] Classification

Direct view of hemorrhoid seen on sigmoidoscopy

(I84.3-I84.5) External hemorrhoids are those that occur outside the anal verge (the distal end of the anal
canal). Specifically they are varicosities of the veins draining the territory of the inferior rectal arteries,
which are branches of the pudendal artery. They are sometimes painful, and by swelling and irritation.
Itching, although often thought to be a symptom of external hemorrhoids, is more commonly due to skin
irritation.
o

(I84.3) External hemorrhoids are prone to thrombosis: if the vein ruptures and/or a blood clot
develops, the hemorrhoid becomes a thrombosed hemorrhoid.[3]

(I84.0-I84.2) Internal hemorrhoids are those that occur inside the rectum. Specifically they are varicosities
of veins draining the territory of branches of the superior rectal arteries. As this area lacks pain receptors,
internal hemorrhoids are usually not painful and most people are not aware that they have them. Internal
hemorrhoids, however, may bleed when irritated.

(I84.1) Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and
strangulated hemorrhoids:
o

Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they are pushed outside
the anus.

If the anal sphincter muscle goes into spasm and traps a prolapsed hemorrhoid outside the anal
opening, the supply of blood is cut off, and the hemorrhoid becomes a strangulated hemorrhoid.

Degree of prolaspes

Grading of Internal Hemorrhoids

o

Grade I: The hemorrhoids do not prolapse.

Grade II: The hemorrhoids prolapse upon defecation but spontaneously reduce.

Grade III: The hemorrhoids prolapse upon defecation, but must be manually reduced.

Grade IV: The hemorrhoids are prolapsed and cannot be manually reduced.

Symptoms
Many anorectal problems, including fissures, fistulae, abscesses, anal melanoma or irritation and itching,
also called pruritus ani, have similar symptoms and are incorrectly referred to as hemorrhoids.
Hemorrhoids are usually not dangerous or life threatening. In most cases, hemorrhoidal symptoms will go
away within a few days.
Although many people have hemorrhoids, and hemorroidial radiation, not all experience symptoms. The
most common symptom of internal hemorrhoidial radiation is bright red blood covering the feces
(hematochezia), on toilet paper, and/or in the toilet bowl. However, an internal hemorrhoid may protrude

through the anus outside the body, becoming irritated and painful. This is known as a protruding
hemorrhoid.
Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus that
results when a blood clot forms. This condition is known as a thrombosed external hemorrhoid.
In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding
and/or itching, which may produce a vicious circle of symptoms. Draining anal mucus, produced by the
dentate line may also cause itching.
Causes

Sitting for long periods of time can start the hemorrhoidic process. [citation needed]
Increased straining during bowel movements caused by constipation or diarrhea may lead to hemorrhoids.
[6]
It is thus a common condition due to constipation caused by water retention in women experiencing
premenstrual syndrome or menstruation.[citation needed]
Hypertension, particularly portal hypertension, can also cause hemorrhoids because of the connections
between the portal vein and the vena cava which occur in the rectal wallknown as portocaval
anastomoses.[7]
Obesity can be a factor by increasing rectal vein pressure. Poor muscle tone or poor posture can result in
too much pressure on the rectal veins.[citation needed]
Pregnancy may lead to hypertension and increase strain during bowel movements, so hemorrhoids are
often associated with pregnancy.[citation needed]
Insufficient liquid can cause a hard stool, or even chronic constipation, which can lead to hemorrhoidal
radiation.[citation needed] An excess of lactic acid in the stool, a product of excessive consumption of dairy
products, such as yogurt, can cause radiation; reducing such consumption can bring relief. [citation needed]
Vitamin E deficiency is also a common cause.[citation needed] Eating spicy food does not cause hemorrhoids,
though spicy foods may aggravate the condition.[citation needed]
Prevention of hemorrhoids includes drinking more fluids, eating more dietary fiber (such as fruits,
vegetables and cereals high in fiber), exercising, practicing better posture, and reducing bowel movement
strain and time. Wearing tight clothing and underwear may also contribute to irritation and poor muscle
tone in the region and promote hemorrhoid development. [citation needed]
Women who notice they have painful stools around the time of menstruation would be well-advised to
begin taking extra dietary fiber and fluids a couple days prior to that time.

Fluids emitted by the intestinal tract may contain irritants that may increase the fissures associated with
hemorrhoids. Washing the anus with cool water and soap may reduce the swelling and increase blood
supply for quicker healing and may remove irritating fluid.
Kegel exercises for the pelvic floor may also prove helpful.
Many people do not get a sufficient supply of dietary fiber (20 to 25 grams daily), and small changes in a
person's daily diet can help tremendously in both prevention and treatment of hemorrhoids.
Use of squat toilets
Based on their very low incidence in the underdeveloped world, where most people squat for bodily
functions, hemorrhoids have been attributed to the use of the "sitting" toilet. [8][9] Dr. Berko Sikirov
published a study in 1987 testing this hypothesis by having hemorrhoid sufferers convert to squat toilets.
[10]
Eighteen of the 20 patients were completely relieved of their symptoms (pain and bleeding) with no
recurrence, even 30 months after completion of the study. This chart summarizes the results. This study
was undertaken in a very small number of people, when compared to the numbers involved in recognized
high-quality trials. Therefore, the results, while highly suggestive, cannot be assumed to provide a firm
conclusion.
No follow-up studies have ever been published. The American Society of Colon & Rectal Surgeons is
silent regarding the therapeutic value of squatting.
Examination

Endoscopic image of internal hemorrhoids seen on retroflexion of the flexible sigmoidoscope at the anorectal junction
After visual examination of the anus and surrounding area for external or prolapsed hemorrhoids, a doctor
may conduct a digital examination. In addition to probing for hemorrhoidal bulges, a doctor may also
look for indications of rectal tumor or polyp, enlarged prostate and abscesses.
Visual confirmation of hemorrhoids can be done by doing an anoscopy, using a medical device called an
anoscope. This device is basically a hollow tube with a light attached at one end that allows the doctor to
see the internal hemorrhoids, as well as polyps in the rectum.

If warranted, more detailed examinations, such as sigmoidoscopy and colonoscopy can be performed. In
sigmoidoscopy, the last 60 cm of the colon and rectum are examined whereas in colonoscopy the entire
large bowel (colon) is examined.
A pathologist will look for dilated vascular spaces which exhibit thrombosis and recanalization.
Treatments
Treatments for hemorrhoids vary in their cost, risk, and effectiveness. Different cultures and individuals
approach treatment differently. Some of the treatments used are listed here in increasing order of
intrusiveness and cost.
Home treatments
Temporary relief from symptoms can be provided by:

Hydrotherapy with a bathtub, bidet, or extend-able shower head. Especially in the case of external
hemorrhoids with a visible lump of small size, the condition can be improved with warm bath
causing the vessels around the rectal region to be relaxed. [citation needed]

Cold compress.[citation needed]

Topical analgesic (pain reliever), such as cinchocaine or pramocaine.

Systemic (pill-form) analgesic (pain reliever).

Topical corticosteroid such as hydrocortisone. (May weaken the skin and may contribute to
further flare-ups.)[citation needed]

Topical vasoconstrictor such as phenylephrine.

Topical moisturizer.

Topical astringent, such as witch hazel

Topical medicines may be delivered as an ointment or suppository. Some hemorrhoid-specific

medications contain a mixture of multiple ingredients, such as Preparation H, Proctosedyl, and Faktu.
Surgical and non-medicinal treatments

Rubber band ligation, sometimes called Baron ligation. Elastic bands are applied onto an internal
hemorrhoid to cut off its blood supply.[11] Within several days, the withered hemorrhoid is
sloughed off during normal bowel movement.

Hemorrhoidolysis, desiccation of the hemorrhoid by electrical current.

Sclerotherapy, sclerosant or another hardening agent is injected into hemorrhoids. This causes the
vein walls to collapse and the hemorrhoids to shrivel up.

Cryosurgery, a frozen tip of a cryoprobe is used to destroy hemorrhoidal tissues.[12] Rarely used
anymore because of side effects.

Hemorrhoidectomy, a surgical excision of the hemorrhoid. Has possible correlation with

incontinence issues later in life; in addition, many patients complain that pain during recovery is
severe. For this reason it is often now recommended only for severe (grade IV) hemorrhoids.

Transanal Hemorrhoidal Dearterialization (THD-HP) is a minimally invasive treatment for

hemorrhoids and hemorrhoidal prolapse [13][14][15]. THD uses an ultrasound doppler to accurately
locate the arterial blood inflow. With simple suture, these arteries are tied off and the prolapsed
tissue is sutured back to anatomical position without excision of tissue. THD is performed above
the nerve bundles, or dentate line. Because of this, there is very little pain. THD is typically
performed in an out-patient setting and return to normal activities is within a few days.

Stapled hemorrhoidectomy, a resection of soft tissue proximal to the dentate line, which disrupts
the blood flow to the hemorrhoids. It is generally less painful than complete removal of
hemorrhoids and also allows for faster recovery times. It's meant for hemorrhoids that fall out or
bleed and is not helpful for painful outside conditions.

Doppler guided hemorrhoidal artery ligation, which cuts the artery that delivers blood to the
hemorrhoid. It is the best treatment for bleeding piles, as the bleeding stops immediately.[16]

Natural treatments

Eating fiber-rich diets, as well as drinking lots of water, help to create a softer stool that is easier
to pass, to lessen the irritation of existing hemorrhoids. [17]

Using the squatting position for bowel movements.[10]

Dietary supplements can help treat and prevent many complications of hemorrhoids, and natural
botanicals such as Butchers Broom, Horse-chestnut, Hem-eez and bioflavonoids can be an
effective addition to hemorrhoid treatment.[18]

Butcher's Broom extract, or Ruscus aculeatus, contains ruscogenins that have anti-inflammatory
and vasoconstrictor effects that help tighten and strengthen veins. Butcher's Broom has
traditionally been used to treat venous problems including hemorrhoids and varicose veins. [19][20]
[21]

Horse-chestnut extract, or Aesculus hippocastanum, contains a saponin known as aescin, that has
anti-inflammatory, anti-edema, and venotonic actions. Aescin improves tone in vein walls,
thereby strengthening the support structure of the vein. Double blind studies have shown that
supplementation with horse-chestnut helps relieve the pain and swelling associated with chronic
venous insufficiency.[22][23]

Diseases with similar symptoms

Symptoms associated with rectal cancer, anal fissure, anal abscess, anal fistula, perianal hematoma, and
other diseases may be similar to those produced by hemorrhoids and may be reduced by the topical
analgesic methods described above. For this reason, it is a good idea to consult with a physician when

these symptoms are encountered, particularly for the first time, and periodically should the problem
continue. In the US, colonoscopy is recommended as a general diagnostic for those over age 50 (40 with
family history of bowel cancers)