1. Evans, Luke MBBS, FRCS
  2. Manley, Kate MBBS, MRCS
  3. Rooney, Liz RGN

Article Content

The diagnosis and management of hemorrhoids comprises a significant proportion of the general surgery outpatient workload. Although the exact prevalence of hemorrhoids in the general adult population is hard to quantify given the reluctance of many patients to seek medical attention, epidemiologic studies have estimated rates of up to 38.9%.1



The submucosa of the anal canal contains fibrovascular "cushions"-areas of thickened tissue that play a role in continence by providing an additional seal above the anus. These cushions are notable in that they are a site of communication between the arterial and venous system. The anal cushions are surrounded by a supportive framework of connective tissue. The breakdown or damage of this framework (which may occur with aging, high body mass index, or during pregnancy) can lead to erosion, bleeding, and prolapse of tissue. In practice, the severity of hemorrhoids can be graded from I-IV depending on the degree of prolapse during defecation.2 (See Internal and external hemorrhoids.)


The most common presenting symptom of hemorrhoids is bright red bleeding per rectum, but patients may also complain of perianal swelling, pain, or itching.2-4 It is of vital importance to note that other, more serious pathologies (such as colorectal malignancy) should always be excluded in this patient population with careful history, exam, and if necessary, further investigation.


The management of hemorrhoids should be largely guided by the severity of symptoms experienced by the patient. Initial management generally involves dietary and lifestyle changes with referral to the general surgery outpatient clinic for further assessment and discussion of nonsurgical/surgical intervention if symptoms do not improve. More invasive surgical intervention, such as a hemorrhoidectomy, is usually reserved for higher-grade hemorrhoids or for cases refractory to conservative and nonsurgical interventions. Of the nonsurgical interventions available, rubber band ligation is a well-established, efficient, and effective outpatient management of symptomatic hemorrhoids. Rubber bands can be applied to hemorrhoids by general or colorectal surgeons, gastroenterology physicians, or specialist nurse practitioners. The main aims, as described by the American Society of Colon and Rectal Surgeons, are to decrease hemorrhoid vascularity, reduce redundant tissue, and promote hemorrhoid fixation to the rectal wall through promotion of an inflammatory reaction.4


Evidence has shown comparable complication and recurrence rates when compared with other techniques, such as bipolar coagulation, with some studies demonstrating superior success rates with rubber-band ligation.5 This, in addition to the obvious cost-effectiveness and speed of the procedure, has resulted in widespread use in the outpatient setting.



Suction banding is frequently utilized in the management of hemorrhoids in the General Surgical outpatient department of the authors' tertiary referral center in Norwich, United Kingdom. A recurrent problem was noted whereby the first band fired immediately fell off after application. Further investigation into the cause of this persistent failure revealed that clinic staff had been preloading the rubber bands onto the applicator several weeks in advance in attempt to reduce the time taken for each procedure, and thus, the efficiency of the clinic.


Although never recommended by the manufacturer, preloading of rubber bands had not resulted in complications prior to the widespread use of latex-free bands. These have a greater memory, and therefore, if prematurely loaded onto the applicator and left for a period of time at maximum stretch, will quickly lose their elasticity. In order to test this hypothesis, an investigation was conducted by members of the general surgical outpatient team to investigate the effects of prolonged stretch on the rubber bands used for outpatient ligation of hemorrhoids.

Figure. Internal and... - Click to enlarge in new windowFigure. Internal and external hemorrhoids
Figure. Band stretch... - Click to enlarge in new windowFigure. Band stretching


Images were taken and compared of fired bands after having been preloaded at different time intervals: immediately prior to firing; at 1 week; and at 4 weeks prior to firing (see Band stretching). Six bands in total (two in each category) were examined. The internal diameter of each band was measured after firing in each case, and the average internal diameters were found to be 1 mm prior to firing, 3 mm after 1 week, and 4 mm after 4 weeks. It can clearly be seen that preloading leads to a permanent change in circumference of the band, thus, demonstrating a decrease in elasticity proportional to the length of time of preloading.



Although there is a drive to reduce exposure to natural rubber latex among patients and healthcare workers, this is not always without problems, as the alternative bands (composed of synthetic polyisoprene instead of natural rubber latex) inherently have less elasticity and greater shape-memory. Loss of elasticity is not merely a problem of immediate failure; if the band is unable to induce pressure necrosis, the hemorrhoid will become edematous and could act as a source of sepsis, pain, and/or bleeding. Rubber band ligation of hemorrhoids is not a procedure free from potential complications.6 While clinic efficiency is important, every effort should be made to optimize technique where possible to improve patient outcomes.




1. Riss S, Weiser FA, Schwameis K, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012;27(2):215-220. [Context Link]


2. Fox A, Tietze PH, Ramakrishnan K. Anorectal conditions: hemorrhoids. FP Essent. 2014;419:11-19. [Context Link]


3. Madoff RD, Fleshman JW. Clinical Practice Committee and American Gastroenterological Association. American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology. 2004;126(5):1463-1473.


4. Rivadeneira DE, Steele SR, Ternent C, et al. Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum. 2011;54(9):1059-1064. [Context Link]


5. Jutabha R, Jensen DM, Chavalitdhamrong D. Randomized prospective study of endoscopic rubber band ligation compared with bipolar coagulation for chronically bleeding internal hemorrhoids. Am J Gastroenterol. 2009;104(8):2057-2064. [Context Link]


6. Watson NF, Liptrott S, Maxwell-Armstrong CA. A prospective audit of early pain and patient satisfaction following out-patient band ligation of Haemorrhoids. Ann R Coll Surg Engl. 2006;88(3):275-279. [Context Link]