Overview of Hemorrhoid Banding
Hemorrhoids, a common health problem that often causes discomfort, are frequently treated with a simple, minimally invasive procedure called rubber band ligation (RBL). This treatment is especially useful for cases of hemorrhoids that continue to cause symptoms despite other less invasive treatments. It is particularly effective for early to moderate stages of hemorrhoids, known as grade 1, 2, and 3.
The RBL technique has been used successfully for a long time and is recognized for its usefulness in treating internal hemorrhoids, especially when they are not too severe. Rubber band ligation was developed by a doctor called Blaisdel and became popular through another doctor, Barron, in 1963. Due to its effectiveness in relieving symptoms and improving patients’ quality of life, it is widely used in the medical community. In fact, research studies have shown that RBL is more superior than certain other treatments like sclerotherapy (injection treatment) and infrared coagulation (using heat to remove hemorrhoids).
One of the main benefits of RBL is that it’s straightforward and minimally invasive. The procedure is usually done in a doctor’s office and doesn’t require bowel preparation or sedation. This means you can remain awake while the procedure is done. Rubber band ligation involves a small rubber band being placed onto the hemorrhoid. This causes the hemorrhoid to lose its blood supply and eventually become an ulcer, which then detaches and is replaced by scar tissue. The procedure is done on a part of the rectum—the dentate line—that doesn’t feel pain, so it doesn’t cause much discomfort.
The main aim of this kind of treatment is to reduce the symptoms by decreasing the size or the blood supply of the hemorrhoidal tissue and helping scar tissue stick to the rectum wall. This helps minimize problems like prolapse, where the hemorrhoid appears outside the anus, and helps improve the comfort of the patient. While these treatments are usually easy to handle and associated with less pain, it’s essential to consider that there might be a need for repeated procedures and to discuss the possibility of hemorrhoids coming back. It’s always important to discuss these things with your healthcare provider.
Anatomy and Physiology of Hemorrhoid Banding
Hemorrhoids are sorted into three types according to where they form and how they relate to a certain line in the anal canal called the dentate line. These types are internal, external, and mixed hemorrhoids, and each has unique aspects. Recognizing the details of hemorrhoids is essential for spotting and treating the issue.
Internal Hemorrhoids
Internal hemorrhoids are above the dentate line and are essentially cushions made of blood vessels. They consist primarily of flexible and connective tissue and are held in place by a type of supporting band. They are protected by a type of cell layer that doesn’t have much sensitivity to pain or irritation.
These hemorrhoids line up with the ends of certain veins. Internal hemorrhoids drain blood into the liver through the superior rectal vein. These hemorrhoids play a role in building up normal pressure in the rectum and allow you to sense the difference between solids, liquids, and gas in the rectum. They act like arteries, filling up with blood during certain physiological processes, leading to increased rectal pressure.
Internal hemorrhoids are classified by how much they protrude from the anal canal:
– Grade 1 – Does not go below the dentate line and is visible during an examination
– Grade 2 – Comes out of the anal canal but goes back inside automatically
– Grade 3 – Comes out of the anal canal and needs to be pushed back in manually
– Grade 4 – Can’t be pushed back in and could become strangulated
External Hemorrhoids
External hemorrhoids are under the dentate line, usually around the edge of the anus. They are covered by skin and a layer of cells. They communicate with certain nerve branches and are very responsive to pain and irritation. Unlike internal hemorrhoids, external hemorrhoids are mainly composed of veins. They drain blood through the inferior rectal vein into a large vein in the abdomen. They can develop blood clots due to their sluggish blood flow.
Mixed Hemorrhoids
Mixed hemorrhoids are a combination of internal and external hemorrhoids and line up with the dentate line. They connect to the middle rectal vein and allow for blood to flow between the liver and the rest of the body’s blood circulation.
Why Hemorrhoids Develop
Hemorrhoids develop due to triggers like straining during bowel movements, an unhealthy diet and poor bowel habits. These trigger factors could increase blood flow to the area, cause inflammation, increase the tension of the muscles controlling the anus and create an imbalance in connective tissue enzymes. This might deteriorate the supporting band of hemorrhoidal cushions, leading to their displacement downwards. This displacement can cause an increase in blood flow and pooling, leading to the formation of a hemorrhoidal disease.
Why do People Need Hemorrhoid Banding
Choosing between a simple procedure and surgery to treat hemorrhoids, which are swollen blood vessels in the rectum and anus, can be a challenging decision. Surveys show that doctors often have a hard time deciding on the best treatment because each case is unique.
A straightforward procedure known as hemorrhoid band ligation is often used to treat minor to moderate cases of internal hemorrhoids. In this method, your doctor places a small rubber band around the base of a hemorrhoid to cut off its blood supply. This is typically used for hemorrhoids labeled as grade 1, grade 2, or selected cases of grade 3. These labels indicate the severity of the hemorrhoids, with grade 1 being mild and grade 4 being the most severe. Patients usually choose this treatment when they have symptoms like bleeding or hemorrhoids that fall out of the rectum (prolapse).
Hemorrhoid band ligation might also be a beneficial treatment for patients with severe (grade 4) hemorrhoids who cannot have surgery. For instance, if a patient has cirrhosis (liver disease) and portal hypertension (high blood pressure in the vein that carries blood from the digestive organs to the liver), and is also experiencing severe blood loss that’s causing anemia. In such cases, this straightforward procedure can be a helpful alternative to surgery.
When a Person Should Avoid Hemorrhoid Banding
Rubber Band Ligation (RBL), a treatment used for hemorrhoids, is not recommended under certain conditions:
This treatment might not benefit people with large, advanced hemorrhoids. If someone has significant inflammation or infection around the anus – for example, if they have an abscess (an infected, pus-filled area), inflammation of the colon (colitis), or diseases like Crohn’s – they might not be eligible for RBL. Doctors typically suggest more gentle treatments for these patients because there’s a higher chance of complications and there’s a possibility that the condition could get better on its own. Sometimes, in very specific cases, the option of surgery could be considered, but the final decision has not been made yet.
RBL is not recommended for people with a rapidly forming blood clot in a hemorrhoid (acutely thrombosed hemorrhoids) or a long-lasting tear or break in the skin of the anus (chronic anal fissure). Surgery is typically a better option for chronic anal fissures.
People with a swollen growth around their anus (hypertrophied anal papilla) and not enough tissue for the ligator device to grasp and pull should not undergo this treatment. If someone is on medication that prevents blood clotting (anticoagulated state), or if they are unlikely to return for further appointments, RBL might also not be recommended.
Equipment used for Hemorrhoid Banding
A medical device called an anoscope or proctoscope can be used by doctors to examine the inside of the anus. This helps in seeing the hemorrhoids (swollen blood vessels in the rectum) and a landmark called the dentate line inside your rectum.
We have various tools to work with when treating this condition called, ‘Rubber Band Ligation (RBL)’. Some use a tool to grab the hemorrhoids, while others apply suction to pull the swollen blood vessels into the ligation instrument. Two types of suction systems are available:
Endoscopic Suction Ligator:
- This technique pulls the hemorrhoid into a special drum, which is attached to an instrument called an endoscope, using suction. The endoscope has a tiny camera at the end that allows the doctor to see inside your rectum. A band is then placed around the base of the hemorrhoid through a mechanism triggered via the endoscope.
- This technique may require fewer treatment sessions to be effective.
- There is also a simpler and more affordable device that can do the job successfully, which only requires the use of one hand and doesn’t need an endoscope.
Wall Suction Ligator:
- This technique works by using a vacuum suction, which is connected to a wall outlet.
- This method can be done in less time and may need fewer sessions than the standard method.
- No extra person is required to assist the doctor while using this device.
Who is needed to perform Hemorrhoid Banding?
Depending on the type of tool used for a procedure known as Rubber Band Ligation (RBL), the doctor might do it by themselves or get help from another medical professional. RBL is a procedure used to treat conditions like hemorrhoids, where small rubber bands are used to cut off the blood supply, causing them to fall off.
Preparing for Hemorrhoid Banding
Getting Ready for the Procedure
Preparing for this operation is typically simple and straightforward. While some doctors may recommend a cleansing procedure like an enema before the operation, it’s not always needed. Similarly, there is usually no requirement for antibiotics to be given through an IV before the operation. When performed correctly, the procedure doesn’t need any anesthesia meaning no local or IV anesthetics are needed.
Gathering Equipment
The specific tools for this procedure should be prepared beforehand. These tools include an anoscope or proctoscope (devices used to view the inside of the rectum and anus), a banding system which includes a ligator and rubber bands. The area where the treatment will be performed should be well-lit so that the doctor can clearly see during the operation.
Assessing the Patient
The first thing the doctor will do is evaluate the patient’s symptoms related to hemorrhoids, and specifically look for any severe or concerning issues like acute bleeding. Then, they’ll establish the size, position, and severity of the hemorrhoids. The most significant hemorrhoid will be chosen for the initial treatment.
They’ll also assess which position would be the safest and most comfortable for the patient during the procedure. This can differ for each patient and depends on factors like the doctor’s preference, the patient’s body size and shape, and any other health conditions they might have. Some of the possible positions include the prone jackknife, lithotomy, or lateral decubitus positions. For example, patients who have severe obesity may need to be in the lithotomy position instead of the jackknife for their comfort and safety. The doctor will always consider what’s best for the individual patient.
How is Hemorrhoid Banding performed
Rubber band ligation (RBL) is a non-surgical treatment for hemorrhoids that are in the early to mid-stages (grades 1, 2, and 3). The procedure can often be done in a doctor’s office instead of a hospital.
The way it works is that the patient is positioned carefully, and a small medical device called a scope is inserted into the rectum. This allows the doctor to find the dentate line (a line inside your rectum) and the hemorrhoids. The hemorrhoids are essentially swollen veins, and the biggest ones are treated first.
The rubber band ligation involves putting small rubber band rings onto the internal hemorrhoids. This is done using a handheld device. A pair of forceps can be used to hold the hemorrhoid steady while the bands are applied. These instruments are designed to be as gentle as possible to minimize discomfort.
If you feel any pain during the procedure, it’s crucial to tell your doctor. They will then adjust the placement of the forceps and the bands. The aim is to put the bands around 5 mm above the dentate line, because that part of your body doesn’t feel pain. If a band is placed too low and it hurts, it will need to be removed immediately.
Usually, only one hemorrhoid is treated at a time to prevent too much tissue necrosis (tissue death). However, if the discomfort you feel is minimal, your doctor might choose to treat multiple hemorrhoids in the same session. If more sessions are needed, they can take place every 3 to 4 weeks. Your doctor will record every detail of the procedure, including your responses.
After the procedure, the rubber bands cause the hemorrhoid to form a clot (thrombosis), which then leads to localized scarring under the mucous membrane lining your rectum. The bands cause the hemorrhoidal tissues to lose blood supply (ischemia) and die off (necrosis) within 3 to 5 days. This creates an ulcer, which usually heals completely after several weeks.
Your doctor will give you clear instructions about how to manage any pain after the procedure and things you need to be careful of. You might feel some tightening in your anus or rectum, but that’s normal. A follow-up appointment will be scheduled so your doctor can monitor your recovery and see how effective the RBL treatment was.
Possible Complications of Hemorrhoid Banding
Getting rubber band ligation (RBL) treatment for hemorrhoids can sometimes cause problems. These problems can be minor or severe. Common minor issues include mild bleeding, pain, and delayed bleeding which usually occurs 8 to 14 days after banding as the tissue naturally breaks down. This bleeding usually stops on its own. Other minor complications you might experience include feeling faint, bands slipping off, prolonged erection (priapism), trouble urinating, tears in the anal skin (anal fissure), and long-lasting sores (chronic longitudinal ulcers).
Severe complications are less common but can include heavy bleeding, swollen and painful hemorrhoids, severe pain, inability to urinate (which may need a catheter to drain urine), a severe infection in the pelvic region (pelvic sepsis), a fistula (an abnormal opening), and in very rare cases, death.
Pelvic sepsis, though rare after RBL, is a serious complication as it could be life-threatening. It’s important to be aware of this so that you can get medical help quickly if needed. Signs to look out for include increasing pain, fever, or trouble urinating. The usual treatment for this kind of infection includes intravenous or IV fluids and antibiotics, removing the rubber band, and possibly removing dead tissue in an operation. Early treatment is important to prevent the infection from spreading and turning into more serious conditions like necrotizing soft tissue infection or Fournier gangrene.
In comparison to surgical removal of hemorrhoids, you’re less likely to have severe bleeding, trouble urinating, loss of bowel control, and narrowing of the anal canal after rubber-band ligation treatment.
What Else Should I Know About Hemorrhoid Banding?
Rubber band ligation (RBL) is a common and affordable treatment for hemorrhoids, which are swollen blood vessels in your rectum or anus. This treatment involves placing tiny rubber bands around the base of the hemorrhoids to cut off their blood supply, causing them to shrink and fall off. It works well, has few severe side effects, and people generally tolerate it well. An added bonus is that it can help to prevent hemorrhoids from coming back.
Numerous studies have researched RBL. In one study, 805 people underwent 2,114 rubber band procedures on average. Good outcomes (the treatment worked) were observed in 71% of these people, regardless of the severity of their hemorrhoids. However, the authors discovered that if they used four or more bands in one treatment, it was less likely to work.
Other research has suggested that RBL can successfully stop bleeding in up to 90% of patients. One report showed that 84% of those with severe hemorrhoids experienced symptom relief. Interestingly, an extensive case series on RBL involved 750 consecutive patients with moderate to severe hemorrhoids – a whopping 93% were completely cured and only 11% experienced a recurrence or return of hemorrhoids after two years, irrespective of the severity of their hemorrhoids.
A comprehensive review compared the efficacy of RBL and surgical removal of hemorrhoids (excisional hemorrhoidectomy) based on the severity of the condition. The review concluded that for severe hemorrhoids, surgical removal was superior to RBL in terms of effectiveness. However, for moderate hemorrhoids, no significant difference was observed.
Overall, the effectiveness of RBL makes it a valuable option when you are dealing with the discomfort of hemorrhoids.
