Rubber band ligation (RBL) using rigid anoscope is a commonly recommended therapy for grade I-III symptomatic internal hemorrhoids. Severe complications of RBL include pain, hemorrhage and sepsis. Flexible endoscopic RBL (ERBL) is now more commonly used in RBL therapy but few severe complications have been reported. Here we report on a case of massive bleeding after ERBL.

A 31-year-old female was admitted to the department of gastroenterology with a chief complaint of discontinuous hematochezia for 2 years. No previous history, accompanying diseases or drug use was reported. Physical examination and colonoscopy showed grade II internal hemorrhoids. The patient received ERBL therapy. Five days after ligation, the patient presented with mild hematochezia. On days 7 and 9 after ligation, she presented with a large amount of rectal bleeding, dizziness and weakness. Emergency colonoscopy revealed active bleeding and an ulcer in the anal wound. The patient received two sessions of hemoclipping on days 7 and 9 to treat the bleeding. No further bleeding was reported up to day 15 and she was discharged home. Although the hemorrhoid prolapse disappeared after ERBL, she was dissatisfied with the subsequent complications.

ERBL therapy is an effective treatment for symptomatic internal hemorrhoids with satisfactory short and long-term recovery. Pain and anal bleeding are the most frequently reported postoperative complications. Coagulation disorders complicate the increased risk of bleeding. Although rarely reported, our case reminds us that those patients without coagulation disorders are also at risk of massive life-threatening bleeding and need strict follow-up after ligation.

Hemorrhoids are one of the most common diseases of the anorectal region. Previously, treatment for hemorrhoids included conservative treatment, outpatient treatment, and surgical treatment. The development of flexible reversible endoscopes has provided precise controllability and imaging, enabling further improvement and development of various endoscopic techniques to treat hemorrhoids. This article discusses several of these endoscopic techniques: rubber band ligation, sclerotherapy, and electrocoagulation. The development, efficacy, and advantages of these treatments are summarized and evaluated. It is expected that going forward, endoscopic technology will be further applied in clinical practice and may become the first-line method for the treatment of hemorrhoids.

Endoscopic treatment of anorectal bleeding can be challenging. We report use of the endoscopic over-the-scope clip (OTSC) to treat massive bleeding from the transitional zone of the anorectum. The aim of this retrospective study was to assess the clinical outcome and efficacy of the OTSC and to describe the technique of its use in acute severe bleeding occurring at the transitional zone of the anorectum.

We treated 5 consecutive patients (age range, 36-79 years, 5 men) with severe bleeding from the transitional zone of the anorectum caused by hemorrhoid therapy, digital trauma, and a Dieulafoy lesion. We analyzed the efficacy, safety, and outcome of endoscopic treatment using the OTSC.

Primary hemostasis was successfully achieved in all the patients using a single OTSC. The OTSC deployment technique was adapted from the endoscopic band ligation of hemorrhoids. There was no immediate or late rebleeding. We observed that there were no adverse events from OTSC placement in the anorectum.

This case series provides evidence that OTSCs may be effective in controlling bleeding from the transitional zone of the anorectum. Although use of OTSCs for bleeding elsewhere in the GI tract has been described, this case series is the first to show its application in the transitional zone of the anorectum.

Internal hemorrhoids often present with bleeding, prolapse, and other symptoms. Currently used nonsurgical treatment modalities have limited effectiveness and usually require several treatment sessions.

To evaluate effectiveness and safety of a novel endoscopic device for nonsurgical treatment of internal hemorrhoids.

Retrospective study.

Single center.

This study involved 23 patients with actively bleeding internal hemorrhoids.

The HET Bipolar System is a modified anoscope, with a treatment window, light source, and tissue temperature monitor. The device is inserted into the rectum under direct observation. The tissue carrying superior hemorrhoidal branches and the apex of the internal hemorrhoid is positioned inside the treatment window, clamped with incorporated tissue forceps, and treated with bipolar energy to ligate hemorrhoidal feeding vessels.

Rate of hemorrhoidal bleeding after the treatment.

The mean age of the patients was 64.3 ± 9.9 years (range 44-79 years). Eleven patients (47.8%) had grade I hemorrhoids and 12 patients (52.2%) had grade II hemorrhoids. In 18 patients (78.3%), treatment with the HET System was performed with the patient under conscious sedation. Five patients (21.7%) were treated without sedation. All patients tolerated treatment without complaints. The average follow-up period was 11.2 ± 4.7 months. No bleeding or prolapse occurred after the procedure in any of the treated patients.

Retrospective study.

The newly developed HET System is easy to use, safe, and highly effective in eliminating bleeding in grade I and II internal hemorrhoids and prolapse in grade II internal hemorrhoids.

Rigid proctoscopy, the gold standard for detecting hemorrhoids, has become a neglected procedure in the era of flexible endoscopy. Evaluation of hemorrhoids is often done with the retroflexed fiberoptic colonoscope. The aim of this study was to evaluate the technique of videoanoscopy in comparison with retroflexion of colonoscope in the rectum to detect hemorrhoids and to correlate objective findings of hemorrhoids and their relation to bleeding.

In total, 544 patients were screened and 358 patients were evaluated by the technique of videoanoscopy and retroflexion of colonoscope in the rectum. The video images of both the procedures were independently analyzed by two observers for the presence or absence of hemorrhoids. The videoanoscopy images were also analyzed for number of columns of hemorrhoids, size and presence of red-color sign.

Videoanoscopy detected hemorrhoids in a significantly higher number of subjects when compared with retroflexion of colonoscope in the rectum by both observers (P < 0.05). The average kappa value was 0.637 and 0.779 for retroflexed colonoscopy and videoanoscopy, respectively. Red-color sign was present in 80.5% of patients with bleeding compared with only 30.3% in the non-bleeding group. The majority (71%) of patients in the bleeding group had larger hemorrhoids. Red-color sign and size of hemorrhoidal columns correlated with bleeding (P < 0.05).

Videoanoscopy is a simple technique with increased sensitivity to detect hemorrhoids compared with intrarectal retroflexion of colonoscope and yields valuable objective information about the presence and condition of hemorrhoids. It should be performed as an extension of standard colonoscopy.

Elastic band ligation by means of a rigid proctoscope is the treatment of choice for patients with symptoms caused by internal hemorrhoids of grade 2 to 3. In contrast to the flexible videoendoscope, the rigid proctoscope has limited maneuverability, has a narrower field of view, and does not allow adequate documentation. Therefore, a randomized trial was conducted to compare the safety and the efficacy of conventional elastic band ligation with videoendoscopic elastic band ligation.

A total of 100 consecutive patients (mean age 47 [12] years) with chronically bleeding grade 2 or 3 internal hemorrhoids were randomized to elastic band ligation or videoendoscopic elastic band ligation. For videoendoscopic elastic band ligation, a reusable multiband ligator was attached to the end of a therapeutic upper videoendoscope. From one to 3 bands were placed per session in both groups. Re-treatment was performed every 2 to 3 weeks in both groups until cessation of bleeding and eradication of the hemorrhoids (at least grade 2) were achieved. Thereafter, the patients were followed to assess complications and efficacy. Recurrent bleeding was considered a treatment failure.

To achieve the desired therapeutic aims, a significantly lower number of treatment sessions was required in the videoendoscopic elastic band ligation group (1.8 [0.8] vs. 2.4 [0.9]; p < 0.01) and the total number of bands applied was significantly less (2.8 [1.1] vs. 3.7 [1.4]; p < 0.01). Pain was noted after ligation by 25% of patients in the elastic band ligation group compared with 27% of those who had videoendoscopic elastic band ligation. However, analgesic medications were required in only 7% after elastic band ligation and 9% after videoendoscopic elastic band ligation (NS). Post-ligation bleeding that had to be treated endoscopically occurred in 3.5% of the patients of the elastic band ligation group and 3.2% of those in the videoendoscopic elastic band ligation group (NS). Blood transfusion was not required. At a median follow-up of 12 months, there was no recurrence of bleeding in 40 patients (80%) in the conventional elastic band ligation group vs. 43 (86%) in the videoendoscopic elastic band ligation (NS).

The long-term efficacy and safety of conventional elastic band ligation and videoendoscopic elastic band ligation are highly comparable. However, when videoendoscopic elastic band ligation is performed, significantly fewer treatment sessions are required.

The ideal therapy for early stages of hemorrhoids is always debated. Some are more effective but are more painful, others are less painful but their efficacy is also lower. Thus, comfort or efficacy is a major concern. In the present randomized study, a comparison is made between infrared coagulation and rubber band ligation in terms of effectiveness and discomfort. One hundred patients with second degree bleeding piles were randomized prospectively to either rubber band ligation (N = 54) or infrared coagulation (N = 46). Parameters measured included postoperative discomfort and pain, time to return to work, relief in incidence of bleeding, and recurrence rate. The mean age was 38 years (range 19-68 years). The mean duration of disease was 17.5 months (range 12 to 34 months). The number of male patients was double that of females. Postoperative pain during the first week was more intense in the band ligation group (2-5 vs 0-3 on a visual analogue scale). Post-defecation pain was more intense with band ligation and so was rectal tenesmus (P = 0.0059). The patients in the infrared coagulation group resumed their duties earlier (2 vs 4 days, P = 0.03), but also had a higher recurrence or failure rate (P = 0.03). Thus, we conclude that band ligation, although more effective in controlling symptoms and obliterating hemorrhoids, is associated with more pain and discomfort to the patient. As infrared coagulation can be conveniently repeated in case of recurrence, it could be considered to be a suitable alternative office procedure for the treatment of early stage hemorrhoids.