Haemorrhoids: Aetiology to Management

Abstract

The definition of “haemorrhoids” and the epidemiology of these conditions have long been contentious. Unfortunately, we still do not understand the full scope of this phenomenon despite years of studies, discussions, and pathogenetic theories. The ancient Greek words “haema,” which means blood, and “rhoos,” which means flow, are where the name “haemorrhoid” is derived from. The word “piles,” which is derived from the Latin word “pila,” which means anal swelling (round mass), is another term for haemorrhoids. Since the birth of English physician John of Arderne (1307 AD), when haemorrhoids were typically referred to as piles, the term “piles” has become widely used. Haemorrhoids are still used to refer to piles with mass rather than haemorrhagic (bleeding) piles. One of the most common disorders affecting adults in industrialized nations is haemorrhoids. According to published statistics, 60–70% of those over the age of 40 experience haemorrhoid symptoms. In the hierarchy of coloproctological illnesses, haemorrhoids make up roughly 40%. Coloproctologists have already firmly incorporated minimally invasive treatments for haemorrhoids into their routine care in recent years. These treatments have a variety of benefits over surgical approaches, including the capacity to be used as outpatient procedures without causing any impairment, high efficacy in the early stages of the disease, and few complications. Internal and external haemorrhoids are two different types of haemorrhoids. Haemorrhoids may be caused by a low-fibre diet, constipation, prolonged pushing, pregnancy, and obesity. The diagnosis of haemorrhoids must be made after a thorough review of the patient’s medical history, physical examination, and further evaluation. The treatment for haemorrhoids, which includes both medication and surgical options, is dependent on how severe the condition is. In this chapter, we attempt to cover everything from aetiology to the management of haemorrhoids.

1. Introduction

Since the dawn of time and ever since humans learned to walk, haemorrhoids have plagued mankind, and we have yet to discover a permanent cure [1]. It was the same as what we see today and had been haunting humanity for millennia, but it was unclearly comprehended, and names were probably hard to decipher. Even though most illnesses experienced by our ancestors are not explicitly stated in the literature, haemorrhoids and anorectal problems are one set of illnesses that are referenced in the earliest literature. Convincing references can be discovered in both Buddhist and Old Testament literature. Some known mentions of this condition include the existence of physicians attending to haemorrhoids in Egyptian palaces as early as 2500 BC; the treatment records are found in the Edwin Smith and Ebbers Papyri (both 1700 and 1500 BC), as well as in records from India, China, Greece, and Rome [2].

2. Epidemiology

Numerous epidemiological studies over the years have shown how environmental factors might affect the development of haemorrhoidal illness [3].

The prevalence of haemorrhoids varies according to sociocultural factors. For instance, haemorrhoids are extremely uncommon in native Africans, but they are more common in Africans or African Americans exposed to Westernized dietary practices. Both sexes and people of all ages can develop haemorrhoids.

More than a million Americans, or 4.4% of the population, are estimated to experience haemorrhoids yearly in the United States. In addition, haemorrhoids have been reported to cause symptoms in 50% of people over 50.

Race-related differences also exist, with Caucasians being more prevalent. It is challenging to determine the precise prevalence of haemorrhoids because there are far more cases of people who self-diagnose than those with a medical diagnosis.

Just a few years before Burkitt’s theory, Hyams and Philpot were among the pioneers of the contemporary era to investigate the occurrence of haemorrhoids [4]. Age, sex, socioeconomic level, race, religion, bowel habits, and pregnancy were used to categorize the patients. The most significant finding was that haemorrhoidal illness affected one in four people over 30 years of age.

Women may undoubtedly experience haemorrhoids during or after pregnancy, childbirth, or menstruation. Although haemorrhoid tissues include oestrogen receptors, physical rather than hormonal variables, such as increased pelvic pressure, have a bigger impact on the development of haemorrhoids.

The influence of family history is significant, but there is insufficient evidence to conclusively link haemorrhoids to genetics, similar food patterns, or similar lifestyle choices.

Patients presenting with haemorrhoidal disease are more frequently white, from higher socioeconomic status, and in urban areas.

There is no known sex predilection, although men are more likely to seek treatment.

However, pregnancy causes physiologic changes that predispose women to develop symptomatic haemorrhoids. As the gravid uterus expands, it compresses the inferior vena cava, causing decreased venous return and distal engorgement.

External haemorrhoids occur more commonly in young and middle-aged adults than in older adults.

The prevalence of haemorrhoids increases with age, with a peak in persons aged 45–65 years.

3. Anatomy, pathophysiology

The most common anorectal illness is a haemorrhoidal disease (HD) [3, 5, 6, 7, 8, 9], which is characterized by the symptomatic enlargement and/or distal displacement of the typical anal cushions known as haemorrhoids. Haemorrhoids are normal vascular cushions underlying the distal rectal mucosa and they contribute approximately 15–20% of the resting anal pressure and ensure complete closure of the anal canal. External haemorrhoids develop from the external haemorrhoidal plexus, whereas internal haemorrhoids develop from the internal haemorrhoidal plexus. The dentate line is the anatomical line that separates the internal haemorrhoidal plexus from the exterior haemorrhoidal plexus. Three soft engorgements known as anal cushions or “haemorrhoids” make up the normal internal haemorrhoidal plexus. Therefore, if the phrase “internal haemorrhoids” is taken in its precise literal definition, it does not denote a disease state. However, in clinical practice, the term “internal haemorrhoids” is only used to refer to the illness brought on by the abnormal enlargement of anal cushions, or, more specifically, by their metamorphosis into anal nodules. This term is more specifically limited to haemorrhoidal symptoms, i.e., anal cushions are called “haemorrhoids” when they bleed and/or prolapse.

The surgical procedure and haemorrhoid therapies are equally as crucial as having a thorough understanding of pathophysiology. Varicose vein theory, vascular hyperplasia theory, anal lining (cushion) sliding theory, and hyperactivity of the internal sphincter hypothesis are the top established hypotheses up until recently. Although the cushion tissue of haemorrhoids should technically be referred to as “pathologic haemorrhoids” because it is normal tissue, for the sake of simplicity, this chapter will simply refer to them as haemorrhoids.

Thomson [10] compared the varicose vein theory, the vascular hyperplasia theory, and the sliding anal lining theory, the three primary hypotheses for the cause of haemorrhoids, and concluded that the sliding anal lining theory was accurate.

4. Anal cushion

4.1 Vascular part

In the typical surgical anal canal, three primary anal cushions are primarily identifiable. Anal cushions contain a significant component of non-vascular tissue despite being tissues that are mostly of vascular origin. Arterioles, venules, and their functional anastomoses (arteriolar-venular anastomoses) make up the internal haemorrhoidal plexus. The surgical anal canal’s scarlet colour is a result of the presence of veins inside cushions.

The superior (SRA) and middle (MRA) rectal arteries supply blood to the internal haemorrhoidal plexus. Most frequently, a plexus of these arteries develops behind the rectum. This plexus, which is entirely different from the internal haemorrhoidal plexus, typically offers three main terminal branches that penetrate the rectal wall and ultimately terminate submucosally in the anus above the dentate line in three different locations: the left lateral, the right anterior, and the right posterior positions.

The predominant venous branches of the internal haemorrhoid cushions are commonly the superior (SRV) and medium (MRV) rectal veins. While the MRV and the inferior rectal veins are tributaries of the systemic circulation, the SRV drains blood to the inferior mesenteric vein, which is a part of the portal venous circulation [11]. As a result, both portal and systemic circulations drain blood from anal cushions.

Blood flows straight from arterioles to venules inside cushions via numerous arteriolar-venular anastomoses. Since most arteriolar-venular anastomoses lack a muscle wall, they are classified as sinusoids. In an idealized three-way intersection, sinusoidal haemorrhoidal tissue receives arterial blood from the SRA and MRA, oxygenates the cushion’s non-vascular region, and then emits venous blood to the SRV and MRV’s minuscule root venules. The sinusoids are thus filled with a mixture of blood from the arterial, systemic, and portal venous circulations [11].

The development of sinusoidal plexus occurs nearly exclusively in specific locations of the upper anus because of the preferred artery supply to those regions. The anal cushions are situated where the submucosal tissue’s left lateral (3 o’clock), right anterior (11 o’clock), and right posterior (7 o’clock) terminal major artery branches are located (Figure 1) (when looked at with the patient in the lithotomy position, i.e. anterior is 12 o’clock).

Figure 1.

Position of normal anal cushions.

4.2 Non-vascular part

Transitional epithelium, elastic, and collagenous connective tissue, and Treitz muscle make up the cushion’s non-vascular portion. Treitz’s muscle is thought to be one of the most significant pathogenetic elements in the development of haemorrhoids since it tightly holds the cushions in their natural position. The anal submucosal muscle, whose fibres subside submucosally between the sinusoids, fixes the cushions to the “floor” of the haemorrhoids (i.e., to the internal anal sphincter), while the mucosal suspensory ligament (Park’s ligament), which penetrates the internal sphincter, fixes the sinusoids to the conjoined longitudinal muscle.

Despite not being anatomically a part of the anal cushion, the conjoined longitudinal muscle is just as crucial to preventing haemorrhoidal illness as Treitz’s muscle. It appears to work like a backbone that holds the internal and external sphincters in place and secures the anorectum to the pelvis.

Four anatomical safety elements guarantee the firm anchoring of normal anal cushions above the dentate line, the maintenance of their regular size, and the avoidance of their prolapse:

1. the integrity of the accompanying connective tissue, which supports the sinusoids and holds them to the internal sphincter.

2. the Treitz’s muscle and the conjoined longitudinal muscle in their whole anatomically.

3. the structure resembling a sphincter that is seen in the terminal arterioles; and

4. the terminal branches of the supplying arteries are small in diameter.

The reduction in anal cushion size is caused by two additional mechanisms: During defecation, the internal anal sphincter and haemorrhoids work together. The decreasing pressure of the relaxed internal anal sphincter allows blood to flow from the anal cushions to the SRV and MRV, thereby reducing the size of the anal cushions; the submucosal ligament of Treitz’s muscle contracts the anal cushions while the descending stool directly widens the anal canal. Simultaneously, the anal cushions descend, forming anal lips that shield the internal anal sphincter beneath. After faeces, the anal cushions rise to their normal posture, rapidly filling with blood until they are full; thus, faecal soiling is avoided (Figure 2).

Figure 2.

Anatomy of the Anal canal.

5. The theory of varicose veins

From the time of Hippocrates and Galen until recently, the varicose vein theory was thought to be the most significant among the pathophysiology of haemorrhoids since distended vessels were frequently seen in cases of anal tissue or excised haemorrhoidal tissues during surgery. Haemorrhoidal procedures with extensive excision that are based on this hypothesis are being performed, even though it is no longer widely acknowledged. Through resected samples of haemorrhoids, John Hunter et al. were able to see prolonged veins, and they surmised that these veins were pathologic outcomes that are uncommon in healthy individuals.

Although the precise pathophysiology of haemorrhoids is still unknown, it is generally accepted that unusually clogged and descending anal cushions are the primary cause of haemorrhoids [12]. It was believed that several types of anorectal varices included haemorrhoids. However, there is solid proof that anorectal varices and haemorrhoids are two different conditions. Patients with varices and portal hypertension do not experience more haemorrhoids than healthy people do. Due to the multifactorial nature of haemorrhoids, several risk factors, including pregnancy, ageing, constipation, chronic diarrhoea, and internal rectal prolapse, have been linked to their development.

5.1 The theory of sliding anal cushions

According to Thomson [10], the concept of sliding anal cushions or sliding anal canal lining is now widely acknowledged. It suggests that haemorrhoids form when the anal cushion’s supporting tissues break down or degenerate.

This hypothesis was first proposed by Thomson [10], and it has since been expanded upon by Gass, Adams, Hughes, Patey, and Parks. They also believed that haemorrhoids could form from the deterioration of loose and coarse connective tissue.

Elastic fibre, collagen, and subepithelial smooth muscle (also known as the mucosal suspensory ligament or Treitz’s muscle) are the basic components of supporting tissue.

The anal cushions’ elasticity is provided by elastic fibres, and their tensile strength is a result of collagen and smooth muscle.

Anal cushions move downhill due to the tearing of muscle fibres and connective tissue within them because of the shearing force of faecal material, especially hard and bulky stools.

Anal cushions positioned improperly may interfere with venous drainage, causing haemorrhoidal plexus venodilatation.

The cushions are more likely to be forced out of the canal and have their venous return further impeded by increased intraabdominal pressure and strain.

A higher expression of enzymes related to the deterioration of supporting tissues was seen in haemorrhoid specimens, in addition to the direct harm caused by stool passing through anal cushions.

The protrusion of anal cushions and the development of haemorrhoids may be partially caused by anomalies in the composition and metabolism of collagen. Researchers have looked at the kind and quantity of collagen fibres in haemorrhoid sufferers.

5.2 The theory of vascular abnormality

Based on the histologic findings of marked venodilatation in haemorrhoid specimens and the bleeding symptoms of prolapsing and “non-prolapsing” haemorrhoids, vascular abnormality, and the dysregulation of blood supply to, from, and within anal cushions may be linked to the development of haemorrhoids. The anorectal blood flow is regulated by several mechanisms. Some processes, such as intrinsic vascular tone and endothelial factors, come from within blood vessels, while others, like cytokines and hormones, come from the surrounding tissue. Dysregulation of vascular tone is brought on by an imbalance between vasoconstrictor and vasodilator chemicals.

Haemorrhoids showed a rise in powerful vasodilatory chemicals including nitric oxide. Haemorrhoid tissue exhibited an upregulation of inducible nitric oxide synthase.

When compared to healthy controls, patients with haemorrhoids had significantly greater peak velocities and acceleration velocities of afferent arteries, according to a trans perineal colour Doppler ultrasound examination of the anorectal vascular plexus as demonstrated by Aigner. Patients with haemorrhoids also had significantly increased arterial blood flow. Patients with haemorrhoids had terminal branches of the superior rectal artery that supplied the anal cushion that was noticeably larger than those in healthy individuals. The severity of haemorrhoids was oddly well linked with an increase in artery calibre and flow.

5.3 The theory of rectal redundancy

Haemorrhoids may have a pathogenesis that extends beyond the anal cushions. Many medical professionals say internal rectal prolapse or rectal redundancy is linked to circumferential prolapsing haemorrhoids. The correct anchoring of supporting tissue within anal cushions to the rectal wall may be hampered by rectal redundancy. Straining and frequent stool passing, which result in clogged and prolapsed haemorrhoids, are two signs of blocked defecation that are frequently caused by high-graded internal rectal prolapse. Using a trans anal circular stapler, the stapled haemorrhoidopexy or procedure for prolapse and haemorrhoids (PPH) repositions prolapsing haemorrhoids back up into the anal canal by removing a ring of redundant anorectal mucosa just above the haemorrhoids. The blood flow to haemorrhoid tissue is also decreased with stapled haemorrhoidopexy, leading to the shrinkage of haemorrhoids.

5.4 The theory of increased pressure on the anorectal vascular plexus

According to Palit et al., defecation requires the integration and coordination of the sensorimotor functions of the colon, rectum, anal canal, pelvic floor muscle, and its associated nerve supply. In real life, a reflex expulsion will happen if intrarectal pressure is over 50 mmHg, such as when faeces are present in the rectal ampule. The voluntary contraction of the abdominal muscles and the adoption of the squatting position have an impact on the efficacy of defecation as well. Both movements raise the intraabdominal pressure, which then raises the intrarectal pressure. According to Morio et al., people with functional constipation or blocked defecation condition have noticeably high intrarectal pressure. Anal cushion venous engorgement & haemorrhoids are caused by abnormally high intraabdominal and intrarectal pressures that interfere with the venous drainage of the anorectal vascular plexus. Haemorrhoids are thought to be caused by several conditions that raise intraabdominal pressure, or they may aggravate acute haemorrhoid symptoms. Pregnancy, persistent cough, abdominal obesity, constipation, straining, vigorous activity, and weightlifting are some of these conditions.

6. The causes of haemorrhoids

• Low-fibre diet and constipation.

• Prolonged Straining with defecation.

• Diarrhoea.

• Hereditary predisposition.

• Pregnancy.

• Occupation.

• Sports.

• Leisure activities.

• Psychological disorders.

• Spinal Paralysis.

6.1 Classification of haemorrhoids

A disease classification system helps compare the numerous treatment choices that are available as well as select the best course of action for a certain class. Haemorrhoids are often classified according to where they are located and how much prolapsed they are. However, none of the classification systems for haemorrhoids is complete enough to provide a detailed clinicopathological description of haemorrhoids in a specific patient.

1. Goligher’s classification of haemorrhoids is the one that is most frequently used. Internal haemorrhoids are further rated according to the degree of prolapse in Goligher’s classification.

   • Grade I: haemorrhoids do not prolapse even though they bleed.

   • Grade II: haemorrhoids prolapse when the patient strains, but they reduce spontaneously.

   • Grade III: haemorrhoids prolapse but need to be repositioned manually; and

   • Grade IV: haemorrhoids prolapse and are not reducible (Figure 3).

     Drawbacks of Goligher’s classification: the inadequacy of not considering the related symptoms and extension (dynamic evolution) of this classification to the complete haemorrhoidal system (internal and external), to get around the basic differentiation between internal and external haemorrhoids.

     • Basic irreducible haemorrhoids and acutely thrombosed, incarcerated internal haemorrhoids are both classified as fourth-degree haemorrhoids.

     • This classification does not specify:

       • the number of haemorrhoidal columns involved,

       • the size of the haemorrhoids, or

       • whether they are circumferential or isolated.

2. Depending on the relation to the dentate line,

   • Internal – the internal haemorrhoids are covered by mucosa (columnar or cuboidal epithelium) and originate above the dentate line.

   • External – the external haemorrhoids arise below the dentate line and are covered by anoderm (squamous epithelium).

   • Mixed – Mixed (interno-external) haemorrhoids arise both above and below the dentate line.

3. Based on the anatomical locations of haemorrhoids,

   • Primary – Primary haemorrhoids occur at the three primary positions of the anal cushions, which have been classically described,

   • Secondary – Secondary haemorrhoids arise in between the primary anal cushions, and

   • Circumferential.

4. Based on symptoms,

   • Prolapsing, and (Figure 4)

   • Non-prolapsing.

5. Depending on the number of haemorrhoids and the presence of circumferential haemorrhoids or thrombosis, each primary Goligher grade (I to IV) of haemorrhoids is further categorized by using the suffixes (a to d), as mentioned below [13].

   1. Single pile mass

   2. Two piles but with <50% circumference

   3. Circumferential piles occupying >50% circumference of the anal canal.

   4. Thrombosed or gangrenous piles (complicated)

Figure 3.

Grades of Haemorrhoids.

Figure 4.

Prolapsing Grade IV haemorrhoids.

6.2 Symptoms

• Bleeding – Fresh red blood during or after defecation, the level of haemoglobin may fall with long-term bleeding, dark red blood along with stool points to colonic disease, and tar-like dark-coloured blood suggests bleeding from the upper GI Tract.

• Prolapse – Apart from bleeding, prolapse is the second most important symptom of haemorrhoids. Goligher classification is based on the degree of prolapse. Patients with third-or fourth-degree haemorrhoids frequently complain of something coming out of their anus, as well as inflamed tissue in the perianal region.

• Pain – Internal haemorrhoids are not painful except for the ones that have been forcibly reduced or are incarcerated. Anal conditions such as thrombosed external haemorrhoids or anal fissures, which are distal to the dentate line of the anal canal, usually cause pain.

• Itching – Itching around the anus is a common complaint among patients with internal haemorrhoids. Mucosal prolapse causes an increase in perianal discharge, which irritates the perianal skin and causes itching. Pruritus ani may also be brought on by mycosis, allergic dermatitis, contact dermatitis, psoriasis, benign tumours, malignancies, oxyuriasis, and diabetes, among other conditions.

• Discharge – Typically, the mucosa proximal to the dentate line is where the mucoid secretion occurs. Prolapsed haemorrhoids may also cause mucoid discharge. Apart from prolapsed haemorrhoids, mucoid discharge is a symptom of several illnesses, including rectal polyps, anal fistulas, ulcerative colitis, Crohn’s disease, and irritable bowel syndrome.

• Soiling – Some individuals with third and fourth-degree haemorrhoids have soil in the form of mucus discharge due to an impairment of the fine regulation of continence.

6.3 Differential diagnosis

Because most patients who complain of haemorrhoids have a variety of anorectal symptoms, it is crucial to rule out alternative causes of haemorrhoid symptomatology.

All aspects of the differential diagnosis are based on the patient’s symptoms.

The causes of discomfort, such as fissures, abscesses, fistulas, external haemorrhoid thrombosis, or prolapsed thrombosed internal haemorrhoids, are nearly often detected in pathologies distal to the dentate line when anal pain is the patient’s primary complaint.

6.4 Acute pain

• Anorectal abscess

• Acute anal fissure

• Anorectal fistula

• Impaction

• Rectal trauma

• Thrombosed haemorrhoid.

6.5 Chronic pain

• Anorectal abscess

• Anal fissure

• Anorectal fistula

• Anal stenosis

• Crohn’s disease affecting the anal canal

• Thrombosed haemorrhoid.

6.6 Bleeding per rectum

• Fissure in ano

• Inflammatory bowel disease

• Malignancy

• Polyps

• Proctitis

• Ruptured thrombosed haemorrhoids

• Pruritus Ani

• Anogenital warts (condyloma acuminata)

• Anal incontinence

• Eczema

• Fistula

• Fungal infection

• Infections (sexually transmitted diseases — STDs)

• Rectal prolapse

6.7 Swelling or lump

• Abscess

• Anal tumour

• Rectal tumour

• Rectal polyp

• Rectal prolapse

• Thrombosed haemorrhoids.

6.8 Haemorrhoids, portal hypertension and rectal varices

Anorectal varices must be distinguished from bleeding haemorrhoids since they require very distinct treatments. Magnetic resonance imaging and endoscopic ultrasonography are non-invasive techniques for diagnostic and post-treatment control.

The trans anal suture technique, transhepatic inferior mesenteric venography and embolization, or any of the portal-systemic shunting and decompression techniques can all be used to treat bleeding from varices.

6.9 Examination, workup, and diagnosis

Patients with haemorrhoid complaints should undergo the following examinations: [once you have assured the patient and thoroughly explained what you are going to accomplish.]

Inspection: Gently spread the buttocks to facilitate a thorough examination of the following areas: – The squamous section of the anal canal - The perianal, Genital, Perineal, and Sacrococcygeal regions.

Palpation: The key to diagnosis is palpation, which helps to localize symptoms, including pain, soreness, induration, swelling, lumps, and growths.

Digital rectal examination: This is the fundamental assessment for each patient with anorectal pathology.

Anoscopy/Proctoscopy: The simplest tool for visualizing the interior haemorrhoidal cushions and anoderm. Proctoscopy or flexible sigmoidoscopy must be carried out when symptoms indicate a need to check for neoplasms and inflammatory bowel disease in the rectum and lower colon.

It is usually recommended that all individuals who have anorectal symptoms undergo an anoscopy, rigid proctosigmoidoscopy, and/or flexible sigmoidoscopy.

Additional evaluation and workup may be scheduled based on the results of the physical examination, the patient’s age, and his or her medical history.

In the following circumstances, a colonoscopy or barium enema to examine the colon is advised:

• The anorectal examination is inconclusive.

• The bleeding does not indicate haemorrhoids.

• Anaemia is present.

• There is positive occult blood in stool; and

• There are significant risk factors for colonic neoplasia present (family history, personal joint pathology, pulmonary disease, significant abdominal symptoms, weight loss, change in bowel habits, age older than 50 years, or other risk factors for colonic malignancy).

Describe anatomically where each anal pathology is located (e.g., anterior, posterior, left, right, etc.) or by the numbers that go around a clock’s face in a clockwise direction.

6.10 Laboratory investigations

A CBC could be a helpful indicator of anaemia & infection.

Haemorrhoidal bleeding can sometimes cause anaemia, and on rare occasions, the presence of such anaemia should suggest a different diagnosis.

6.11 Imaging studies and manometry

Rectal prolapse may require a defecography. The sphincter complex and its mechanism of action can be assessed using endoanal ultrasonography and anorectal manometry. This is crucial in the evaluation before haemorrhoid intervention since it could affect the type of intervention the surgeon chooses based on the possibility of developing incontinence following surgery.

6.12 Treatment and management

An old saying about haemorrhoids asserts that if you take care of your bowels, your haemorrhoids will take care of themselves. A simple and frequent defecation of soft stool can help to prevent, or at least limit, anal mucosal prolapse; thus, it is important to consider all medical and hygienic suggestions for the control of haemorrhoid symptoms.

The management of haemorrhoids has undergone a facelift with better and safer modalities available for different grades of haemorrhoids, with less postoperative complaints. These modalities range from reassurance to surgical hemorrhoidectomy to newer minimally invasive modalities [14].

6.12.1 Lifestyle modifications

Every patient should get lifestyle recommendations for both initial therapy and to lower the likelihood of recurrence in those who need additional intervention. These recommendations include improving anal hygiene; increasing dietary fibre and fluid intake; avoiding foods and beverages like nuts, coffee, spicy foods, and alcohol; avoiding straining during defecation; avoiding delaying the urge to urinate; avoiding spending too much time on the toilet seat; and avoiding constipation or diarrhoea.

The use of sitz baths and refraining from straining when using the toilet may also be advised, albeit there is scant scientific evidence to support this.

In a small number of situations, the symptoms can be alleviated by changing the patient’s defecatory behaviours, such as advising them to refrain from reading on the toilet and sitting in a particular position on the toilet. Symptoms are anticipated to improve to some extent with conservative treatment for all types of haemorrhoids, whether they are in an early stage or an advanced stage.

Therefore, regardless of the severity, conservative treatment should be advised as a first line of management. Early internal or external haemorrhoids may be treated using the following conservative measures:

• A warm sitz bath

• Medicine

• Diet

• Defecation advice

6.12.2 Conservative treatment

1. Sitz Bath: It is essential for the conservative treatment of benign anal disorders such as haemorrhoids and anal fissures, postoperative management, and prevention. Sitz baths reduce pain by lowering anal pressure, assisting in keeping the anus clean and enhancing anal blood circulation, which reduces congestion and oedema.

2. Timed Toilet Training: If possible, patients should be advised to initiate their defecation after breakfast and to finish their bowel movement within 3 minutes, even if they feel like they need to defecate more. If someone has a propensity to go to the toilet shortly after waking up, they should be told to drink one to two cups of water to trigger the gastrocolic reflex. Teach people to rinse with water rather than using tissue after defecating. If a tissue is required, tell people to use it only after soaking it in water.

3. Medical Therapy: To maintain soft stools and prevent straining, medical therapy may involve the use of laxatives, which are typically fibre-based.

Although there are several topical medications in the form of creams, ointments, and suppositories in the market, there is no strong proof that they work.

These include various combinations of corticosteroids, vasoconstrictors, local anaesthetics, antiseptics, and astringents. They might offer some symptomatic relief in the short term, but prolonged usage is not advised, especially with corticosteroid-containing treatments, because it may lead to ulceration and skin thinning. Again, there is scant support for these agents.

The role of oral medicines in the treatment of haemorrhoids is either as a preventative measure for early stages where prolapse is not significant or as a crucial means of controlling severe bleeding until definite office procedures or surgery can be performed. Despite the lack of clear data, phlebotonics (such as oral flavonoids) [15] may have some role in the management of acute symptoms and may help ease symptoms following surgical therapy.

A heterogeneous group of medications known as phlebotonics are made utilizing plant-derived substances like calcium dobesilate or flavonoids, which can be either manufactured or taken from plants like Euphorbia prostrata, Gingko Biloba, etc. Because of their abilities to strengthen blood vessel walls, increase venous tone, promote lymphatic drainage, normalize capillary permeability, and their antagonistic effects on the molecular mediators of inflammation, they treat acute and chronic haemorrhoidal diseases. Their precise mode of action, however, is not completely understood. These medications are nevertheless routinely utilized in patients with symptomatic haemorrhoidal illness despite concerns about their efficacy due to methodological study limitations, heterogeneity, and potential publication bias.

Diosmin was isolated in 1925 from the plant Scrophularia nodosa and was first introduced as a therapeutic agent in 1969. Micronized Purified Flavonoid Fraction, which contains 10% hesperidin and 90% diosmin, has shown promise in the treatment of haemorrhoids.

Patients with grade I and II haemorrhoids who received MPFF-based treatment prior to irreversible degenerative changes in the ligaments of the haemorrhoidal plexuses experienced the best results. It also helped promote ideal conditions during the postoperative phase and avoid symptom relapse in patients with more severe haemorrhoidal disease [16].

Symptomatic haemorrhoids appear to respond favourably to therapy with flavonoids. Flavonoids reduce the risk of not getting well or having persistent symptoms by 60%, and they also appear to considerably reduce the risks of bleeding, chronic discomfort, and itching. However, each of these outcomes exhibits significant variation. With conflicting outcomes in multiple trials, it is still unclear whether supplementing treatment with fibre with a flavonoid is advantageous. Flavonoids are sometimes taken at doses that are higher than those that are generally recommended.

In conclusion, medical therapies can alleviate symptoms of haemorrhoids at any stage; those who do not respond, however, should receive additional care.

6.12.3 Office procedures

1. Sclerotherapy: Haemorrhoids were successfully treated with sclerosing agent injections 200 years ago. Molgan published the first account of the injection-based use of iron sulphate in England in 1869. Michael utilized a mixture of olive oil and phenol (2:1) in 1871 and reported positive results. Inflammation and fibrosis, which result in vascular compression, hemostasis, and fixation of prolapsed haemorrhoid tissues in the anal canal, are the fundamental principles of sclerotherapy.

   1. Indications and Contraindications – Indicated in first andd second-degree non-prolapsing haemorrhoids. Contraindicated for thrombosed external haemorrhoids, concomitant anal diseases such as fistulas, tumours, anal fissures, and skin tags.

   2. Procedure: Sclerotherapy is commonly performed without anaesthesia; however, with the availability of topical local anaesthetic sprays, the patient’s anxiety can be decreased by their use.

   3. Depending on the surgeon’s preference, the procedure can be readily carried out with the patient in a lithotomy or prone jackknife position.

   4. The rectal ampulla is reached by inserting the anoscope or proctoscope through the anal canal. The scope is then slowly dragged out until the mucosa “prolapses” over its opening. Once the haemorrhoidal tissue has been located, inject 5 ml of your selected sclerosant into the submucosa at the haemorrhoid’s base.

   5. Complications: Injecting the sclerosant solution can result in momentary, acute precordial and upper abdominal pain. Other known complications are sloughing, thrombosis and necrosis, burning, local abscess and paraffinoma, bacteraemia and sepsis.

2. Rubber band ligation: The most often used non-invasive treatment for haemorrhoids is rubber band ligation. Using a rubber band to stop the blood flow, promotes ischaemic necrosis to remove the haemorrhoidal tissue. This procedure can be done in an outpatient clinic without the need for anaesthesia, and it can also be used to remove relatively minor piles that are left behind after the primary, larger pile has been removed.

   1. Indications and Contraindications: Indicated in early second and third-degree haemorrhoids, haemorrhoids in patients with comorbidities of heart, liver, and lung where corrective surgery is not possible, residual piles after hemorrhoidectomy, removal of a rectal polyp. Contraindicated in patients on anticoagulants.

   2. Procedure: The patient should normally be positioned in the left lateral decubitus posture to facilitate the procedure. Equipment that is suited for the procedure and has adequate lighting is also necessary. Few medical professionals recommend placing the band on the redundant mucosa above the haemorrhoid. Thus, the benefits of maintaining the anal cushions and ensuring that the ligations are well above the dentate line, thereby reducing the possibility of post-ligation pain, are provided. Some experts recommend placing two bands on the same column in one sitting. Although ligating three columns in one sitting has been documented, it is better to only ligate one to two columns at a time to save the patient the unpleasant experience of severe discomfort and pain.

   3. Complications: Delayed bleeding, External haemorrhoidal thrombosis, Ulceration Slippage of the ligature, severe pain, nagging abdominal pain, urinary retention, sepsis and rarely death.

3. Infrared Coagulation: An effective therapy option for internal haemorrhoids that are low-grade and symptomatic is infrared coagulation. It can be performed with a specialized device and the probe inserted through an anoscope. Infrared coagulation involves the direct application of infrared light at the haemorrhoid’s base, where it is converted to heat. This causes tissue destruction to a depth of 3 mm, protein denaturation, and inflammation, resulting in fibrosis and subsequent scarring, shrinkage, and fixation of the redundant haemorrhoid tissue to the muscular layer beneath (Figure 5).

   1. Advantages: Modern, user-friendly technology that is quick and painless to use, instantaneous coagulation without smoke or odour, works even in wet fields, less painful and less complicated than rubber band ligation, and cross-contamination elimination without the need for disinfection.

   2. Complications: The postoperative recovery is excellent, except for tolerable pain. Occasionally, a patient may complain of severe pain if the coagulation is performed at the mucocutaneous junction. Some patients may bleed during the first week. This bleeding does not require treatment other than assurance.

4. Radiofrequency coagulation and excision: What Is the Basic? The basic principle behind radiosurgery is to deliver radio waves between 5.0 and 6.0 MHz through a radiofrequency electrode while keeping the temperature low. Radiofrequency coagulation can be used for first and second-degree haemorrhoids and radiofrequency excision for grade III and grade IV haemorrhoids (Figure 6).

   1. Advantages: Advantages of the procedure include: No postoperative stay is necessary; Easy learning curve; Patient can return to work the following morning; It can be done as an outpatient treatment; It can be done under local anaesthesia, regional anaesthesia, or short general anaesthesia.

5. Embolization [17]: In response to the hypothesis that haemorrhoids become arterially vascularized, a novel approach has recently been introduced. The idea is to permanently restrict blood flow to the haemorrhoids by embolizing the main feeding arteries of the piles. The treatment involves pushing 2–3 mm fibre coils with a microcatheter through a right femoral route to the distal branches of the superior rectal arteries while under local anaesthesia. The primary indication appears to be a patient who has a haemorrhoidal illness with disabling chronic bleeding, a medical contraindication to surgery, or who has not responded to instrumental or surgical treatment.

Figure 5.

Infrared coagulator.

Figure 6.

Radiofrequency.

6.12.4 Surgical procedures

1. Conventional hemorrhoidectomy [18, 19]: Hemorrhoidectomy is one of the most frequently performed anorectal operations, with two well-established methods, the “open” Milligan-Morgan excision and the “closed” Ferguson technique, being used by most colorectal surgeons. Hemorrhoidectomies have historically served as the gold standard for surgical care and are taught as such. Both procedures carry the risk of postoperative bleeding, urinary retention, and late anal stenosis, and the convalescence is similarly long and challenging after both operations. The complication rate must be kept in mind, and modern management asks for diverse approaches. When patients are asked to consent, it is appropriate to inform them that hemorrhoidectomy delivers the best long-term efficacy with the worst pain control in the first two weeks following surgery, meaning a longer recovery period before returning to work. Modern energy sealing devices that are employed for dissection during hemorrhoidectomy contribute to better outcomes for pain management. A partial list of possible complications from surgical hemorrhoidectomy includes the following: Pain, haemorrhage, urinary retention, urinary tract infection, constipation, faecal impaction, anal tags, mucosal prolapse, mucosal ectropion, rectal stricture, anal stenosis, anal fissure, pseudo polyps, epidermal cysts, anal fistula, pruritus ani, faecal incontinence, and recurrent haemorrhoids.

2. Stapled hemorrhoidectomy: Prof. Longo first discussed this in 1998 [20]. The upper anal canal’s mucosa and submucosal tissue were removed and anastomosed using a circular stapler. Even though the haemorrhoidal piles are not removed, the haemorrhoids are successfully treated. It was once believed that blocking the blood supply to haemorrhoids was the mode of this treatment, but it now appears to be due to the lifting of the anal canal caused by the removal and suturing of redundant mucosa and submucosal tissue. This procedure was designed to manage pain and discomfort following a haemorrhoid operation, and it conceptually altered how surgical treatment was done. While not addressing any exterior components, a circumferential mucosectomy performed well above the dentate line helps reduce haemorrhoidal cushion prolapse by restoring anatomy to the anorectal junction (Figure 7).

   With the main advantage of being less painful, haemorrhoidopexy has been advocated as an alternative to traditional hemorrhoidectomy. The most specific indication would be circumferential prolapsed haemorrhoids, always maintaining that any exterior components would need extra operations either concurrently or during a second operation. Stapled haemorrhoidopexy is contraindicated in cases of infection, preoperative stenosis, any degree of incontinence, or sphincter injury. Concerns and Issues Other than in Conventional Hemorrhoidectomy:

   Anal intercourse (male or female); Anal fissure; Anal fistula; Skin tags; Hypertrophied anal papillae; Thrombosis; Preexisting sphincter injury or loss; Excessive rectal mucosal prolapse.

3. Doppler-guided haemorrhoidal artery ligation & recto anal repair [21]: In 1995, a Japanese surgeon named Kazumasa Morinaga developed a novel method of treating haemorrhoids. Using a Doppler (ultrasound) approach, he identified the haemorrhoidal arteries. He created a special device with a Doppler transducer and a window that allowed the surgeon to identify the haemorrhoidal arteries and ligate them by ligating a suture (stitch) around them. This is a straightforward method that quickly alleviated the majority of haemorrhoidal symptoms, including bleeding and protrusion. When dealing with prolapse, a mucopexy is added to the artery ligation, and this approach, which is extremely respectful of the anorectal architecture, is genuinely non-excisional. It is ideal for individuals with grades II to III who need surgery because of bleeding [22]. If there is no fibrosis preventing cushions from being lowered to their anatomical place, grade IV haemorrhoids can also be treated in this manner. Sclerotherapy recipients may not be good candidates for mucopexy in that regard. Emergency bleeding management in high-risk patients taking antiplatelet medication has also been effective. A specific characteristic of this operation is the possibility to adapt it to the specific symptoms of each patient (Figure 8).

   Adding mucopexy to more or fewer locations is tailored to individual clinical presentations. The cost issue also compares favourably to other operations. The need for Doppler to guide the location of arteries has been questioned and could also have cost implications. Lower postoperative pain and complications as well as comparatively reduced costs even with a higher rate of recurrence are criteria to propose arterial ligation and mucopexy as a possible first step before considering more aggressive treatments.

4. Laser haemorrhoidoplasty: Laser Hemorrhoidoplasty (LHP) is a novel therapeutic option for haemorrhoids. Lasers were first described for use in haemorrhoid disease over 30 years ago but have only been utilized recently. There are two main laser approaches to haemorrhoidal disease. Laser haemorrhoidoplasty (LH) involves an incision at the base of haemorrhoid, via which the haemorrhoidal tissue is coagulated using the laser probe [23]. A haemorrhoidal laser procedure utilizes a Doppler ultrasound probe to identify the terminal branches of the superior rectal artery, which are first ligated, and then the haemorrhoidal tissue is coagulated using the laser probe. Some authors use finger-guided haemorrhoidal artery ligation of the superior haemorrhoidal arteries followed by coagulation of haemorrhoidal tissue using a laser probe. Although LHP is an effective treatment for grade II to grade IV haemorrhoids, individuals with grade IV haemorrhoids run a substantial risk of bleeding and re-intervention (Figure 9).

   Laser haemorrhoidoplasty offers significantly lower pain scores, defecation pain scores, and opioid analgesia use in the early postoperative period, there is statistically significant symptom resolution and improvement in symptom-related patient QoL on long-term follow-up. Laser therapy for haemorrhoids results in less tissue damage and good hemostasis, as well as shorter surgical times and shorter hospital stays. Despite all the advantages, using lasers in therapy necessitates specialized training and safety precautions. Further head-to-head studies comparing LH to other haemorrhoid therapies with larger sample sizes and the utilization of objective postoperative symptom scores are required to determine the most efficacious therapeutic approach for this common condition. Complications include pain, bleeding at the site of entry of fibre, burning pain and itching, postoperative oedema, thrombosis, infection, bleeding, sloughing of mucosa in inexperienced hands, and abscess.

5. Transanal suture rectopexy [24]: Introduced by Dr Chivte from India in 2012. Indicated for grade II to grade IV haemorrhoids, The theory is based on dearterialization, whereby vessels are blocked at two locations, 2 and 4 cm above the dentate line, hence preventing the creation of collaterals and their subsequent recurrence. The learning curve is quite low for trans anal suture rectopexy for haemorrhoids. All grades of haemorrhoids have an identical rate of success, and different surgeons have demonstrated comparable outcomes. Haemorrhoids’ mass, prolapse, and recurrence can be successfully managed by the operation. To be acknowledged as an acceptable painless treatment for haemorrhoids, the novel approach still needs extensive follow-up.

Figure 7.

Stappled haemorrhoidectomy.

Figure 8.

Preoperative Image – Immediate Post DGHAL-RAR.

Figure 9.

1470 nm diode laser - the glow of the laser in the submucous plane.

7. Management in specific situations

1. Thrombosed external haemorrhoids [25, 26]: Hematoma from venous rupture and clotting caused by excessive squeezing during defecation are thrombosed haemorrhoids. Commonly occurring on external haemorrhoids, it may occur on internal haemorrhoids also. A painful palpable lump around the anus is the commonest symptom. The size of the lump may vary, the smaller size of the lump, the more easily the pain subsides. Pain itself should be differentiated from the perianal abscess and anal fissure. Anal ultrasound is often used for differential diagnosis.

   The treatment is divided into conservative and surgical treatment [27]. If the lump is less than the size of a pea, it can be treated conservatively. Sitz baths, laxatives, anti-inflammatory drugs, and ointments are used for conservative treatment. Usually, the pain settles down within 3–4 days, and the hematoma sometimes ruptures spontaneously; in some cases, it can last for more than 1 month to dissolve completely. The leftovers from the hematoma’s complete dissolution frequently manifest as a skin tag (Figure 10).

   A hematoma that covers more than 30% of the anal circumference is better treated surgically. Even with a lesser thrombosed haemorrhoid, if it frequently reoccurs and is typically accompanied by increasing anal pressure or an anal fissure, then, surgical removal of blood clots is advised together with lateral internal sphincterotomy to lower anal pressure.

2. Thrombosed internal haemorrhoids: Internal haemorrhoids that are acutely thrombosed or strangulated typically manifest in patients as extremely painful, untreatable haemorrhoids. Haemorrhoids that are confined may necrotize and drain. Treatment for this condition can be challenging, especially if there has been significant strangling, thrombosis, or if there is an underlying circumferential prolapse of high-grade haemorrhoids. Pain and tissue congestion may be lessened by manually decreasing the haemorrhoid masses, either with or without intravenous analgesics or anaesthesia. In these cases, an urgent hemorrhoidectomy is frequently necessary. Mucosa and anoderm should be preserved as much as possible to avoid postoperative anal stricture unless the tissues are necrotic. In skilled hands, the surgical results of an urgent hemorrhoidectomy were on par with those of an elective procedure.

3. Haemorrhoids in pregnancy: Haemorrhoidal issues are frequently an issue for women in the latter stages of pregnancy. Under the effect of progesterone, haemorrhoids and constipation are likely to occur often throughout pregnancy. Drugs should be avoided as much as possible in the early stages of pregnancy. Haemorrhoids are uncommon throughout the middle stages of pregnancy, but during the latter stages, increased abdominal pressure and hunched posture make them prolapse easily. Most of these issues can be effectively managed with sitz baths and bowel control (such as laxatives and stool softeners). Thrombosed haemorrhoids can be surgically removed as usual. In managing haemorrhoids in pregnant women, MPFF is a safe and efficient medical therapy (use is contraindicated in the first trimester) [15]. Maintaining treatment with MPFF during the prenatal stage decreases the incidence and length of relapses of acute haemorrhoid symptoms. For individuals who do not improve after receiving conservative treatment, surgical or non-surgical techniques may be recommended. Only thrombosed or strangulated haemorrhoids should be treated surgically, and this should be done under local anaesthesia.

4. Haemorrhoids in children: Although they are uncommon, haemorrhoids can occur in infants. Most infant haemorrhoids do not require surgical treatment. Children with haemorrhoids should receive prompt treatment and be closely observed to avoid the spread of infections. Children’s haemorrhoids are frequently caused by constipation, prolonged chair use, a low-fibre diet, poor toilet training, and prolonged sitting. The most typical symptom is rectal bleeding. Controlling constipation, consuming more fibre while eating less spicy and fatty food, using haemorrhoidal cream, taking sitz baths, and using anti-pruritic medications are conservative treatments for haemorrhoids in children.

5. Haemorrhoids in patients on anticoagulants [28]: In patients with haemorrhoids, anticoagulant or antiplatelet medications may encourage anorectal bleeding and raise the risk of bleeding after surgery or banding. Because most bleeding episodes are self-limited and end spontaneously, stopping antithrombotic medication may not be essential unless the bleeding is continuous or severe. The mainstay of treatment for these patients is, consequently, a conservative approach. When medical treatment is ineffective for bleeding, low-grade haemorrhoids, injection sclerotherapy is the preferred option. The danger of subsequent bleeding makes rubber band ligation contraindicated in individuals taking anticoagulant or antiplatelet medications at the time. It is advised to stop using anticoagulant or antiplatelet medications 5–7 days before and after haemorrhoid banding or any other type of surgery for haemorrhoids.

6. Haemorrhoids in patients with portal hypertension [29]: The bleeding from an anorectal varicose vein and the bleeding from haemorrhoids should be differentiated in patients with portal hypertension. Haemorrhoids are purple, do not collapse under digital pressure, do not extend proximally to the dentate line, and may prolapse during proctoscopy. Rectal varices, on the other hand, are dark blue, extend more than 4 cm above the anal margin, and collapse on digital pressure but do not prolapse. Varices originate from the rectum, anal canal, and perianal area. These three locations can be managed by suturing continually at three to four points from the upper rectum to the perianal area. RBL is typically not advised for patients with severe cirrhosis due to the possibility of postoperative secondary bleeding. In these cases, conservative therapy and coagulopathy correction should be suggested. Patients with concurrent bleeding haemorrhoids and cirrhosis can be effectively and safely treated with injection sclerotherapy. Suture ligation of the bleeder or hemorrhoidectomy may be suggested in a refractory situation.

7. Haemorrhoids in HIV Patients: Approximately 19.7% of HIV-positive patients also have perianal conditions, such as haemorrhoids. As a result, it is important to carry out an effective and safe procedure on these individuals. Numerous studies have found that patients with HIV infection had poor anorectal wound healing. The primary line of treatment for persons with HIV who have symptomatic haemorrhoids should be conservative. If conservative treatment is unsuccessful, surgical methods should be made available along with good CD4 count maintenance and preventative antibiotics. Particularly for HIV-positive patients, TRSRP – DGD MP are safe procedures with a low complication risk and few technical issues [30]. HIV-positive patients have a high level of satisfaction with these procedures.

8. Haemorrhoids in patients with inflammatory bowel disease: In patients with inflammatory bowel disease, or for that matter with any infectious or non-infectious colitis, an exacerbation of haemorrhoidal problems is not at all uncommon. Treatment of haemorrhoids in these situations should be as conservative as possible [31]. Any procedure done on the anus or perianal skin in inflammatory bowel disease patients should be confined to the very minimum necessary to address the patient’s complaint. Such patients may experience delayed healing or non-healing after receiving definitive or intensive surgical therapy for any anorectal issue, leaving them more disabled than they were before the procedure. Hemorrhoidectomy is occasionally a reasonable way to cure bleeding or protrusion of haemorrhoids when the illness is dormant and sepsis, fistula formation, and scarring are absent.

9. Recurrent haemorrhoids: A past excisional hemorrhoidectomy may have a significant impact on how recurrent disease is managed. Reevaluating all the baseline features is necessary, and this includes changing one’s lifestyle, losing weight, and reassessing if a colonoscopy is necessary. It is also necessary to receive the initial consultation and operation reports. Before advising the best course of treatment, it is essential to consider any previously acknowledged elements that may be influencing the symptoms of bleeding. These factors might be as straightforward as noncompliance or as complicated as undiagnosed bleeding diatheses or initial misdiagnosis. Depending on the severity of the issue, the recurrence may now be treatable with non-invasive hybrid procedures or, in rare circumstances, a guided hemorrhoidectomy, if enough anoderm is preserved to prevent stricture.

Figure 10.

Thrombosed external haemorrhoids.

When, what, and what not in the management of haemorrhoids

1. There is no “one size fits all” approach to treating haemorrhoids.

2. Although there is an ongoing debate on the optimal surgical technique for treating haemorrhoids, none of the techniques that are currently in use come close to the ideal surgical solution, research is ongoing for a technique that is efficient while being painless and safe.

   In actuality, the less painful the surgery, the higher the likelihood of post-op recurrence.

3. The ideal haemorrhoid surgery should be successful with a low recurrence rate, have minimum postoperative pain to allow for an early return to regular activities, and be safe with minimal morbidity. If recurrence is the primary concern, conventional hemorrhoidectomy (CH) remains the “gold standard.” It is, however, accompanied by substantial postoperative pain.

4. Anyone managing patients with colorectal issues will frequently have to deal with people who have haemorrhoidal illnesses. We leave you with a few closing remarks even though it is challenging to summarize all you will run against.

5. Recurrence and other complications following therapy for haemorrhoidal disease are very common, although they are frequently preventable with careful patient selection, preoperative planning, and intervention according to the patient’s needs.

6. Technical issues following surgical intervention may have a long-term detrimental effect on patient quality of life. It is crucial that you, as the surgeon, are skilled, knowledgeable about the technical details of the treatments you provide, and familiar with the frequency and treatment of procedural-specific complications.