Haemorrhoids – Criteria Led Commissioning Statement

Scope

This commissioning statement refers to:

  • The referral and specialist management of haemorrhoids
  • Haemorrhoids are enlarged vascular cushions in the anal canal and may be external or internal.
  • They are the commonest cause of rectal bleeding Definition of degrees of haemorrhoids:
    • First grade: the haemorrhoids remain inside at all times
    • Second grade: the haemorrhoids extend out of the rectum during a bowel movement but return on their own
    • Third grade: the haemorrhoids extend out during a bowel movement but can be pushed back inside
    • Fourth grade: the haemorrhoid is always outside

This commissioning statement does not refer to:

  • Suspected anal or colorectal cancer - refer using the suspected cancer pathway referral (for an appointment within 2 weeks). See the CKS topic on Gastrointestinal tract (lower) cancers - recognition and referral for detailed information on when to suspect anal or colorectal cancer.
  • Extremely painful, acutely thrombosed external haemorrhoids who present within 72 hours of onset (reduction or excision may be needed).
  • Internal haemorrhoids that have prolapsed and become swollen, incarcerated, and thrombosed (haemorrhoidectomy may be needed).
  • Perianal sepsis (a rare but life-threatening complication).
  • if another serious pathology, such as inflammatory bowel disease or a sexually transmitted infection, is suspected.Refer to an appropriate specialist (using clinical judgement to determine the urgency)

Status

Eligibility Criteria

Referral for non-urgent assessment and treatment

  • Referral for specialist assessment and treatment of haemorrhoids is not routinely commissioned by the CCGs and will only be funded if:
    • The haemorrhoids are prolapsed and incarcerated, and cannot be reduced (Fourth degree haemorrhoids) OR
    • The haemorrhoids are recurrent and associated with persistent bleeding
    • And there is failure of documented conservative management techniques after at least three months.

Conservative management techniques include:

  • Dietary and lifestyle advice (increase fluid and insoluble fibre intake, discourage straining)
  • Bulk forming laxative (or osmotic laxative or stool softener)
  • Non-opioid analgesia and/or topical haemorrhoid preparations for symptomatic relief.

Non-surgical treatment

  • Non-surgical measures (rubber band ligation, injection sclerotherapy or infra-red coagulation) will only be commissioned in the following circumstances:
    • Recurrent haemorrhoids with persistent bleeding and
    • Failure of documented conservative management techniques after at least three months.

Surgical treatment

  • Surgical treatment (haemorrhoidectomy, stapled haemorrhoidopexy or haemorrhoidal artery ligation) will only be commissioned in the following circumstances:
    • Fourth-degree haemorrhoids
    • Third-degree haemorrhoids associated with persistent bleeding that have not responded to non-surgical treatment in line with the above policy statement, or which are too large for non-surgical measures
    • Second-degree haemorrhoids associated with persistent bleeding that have not responded to non-surgical treatment in line with the above policy statement

Lifestyle Factors - Best Practice

Obesity

  • Patients with a BMI >30 should be encouraged by their Clinician to lose weight prior to surgery and signposted to appropriate support to address lifestyle factors that would improve their fitness for surgery and recovery afterwards.
  • There is a clinical balance between risk of surgical complications with obesity and the risk to delaying any surgery.
  • See Weight Management Care Pathways

Smoking

  • In line with 'Healthy Lives, Healthy People; a tobacco control plan for England', local authorities and health professionals are committed to encourage more smokers to quit.
  • Smoking remains the leading cause of preventable morbidity and premature death in England.
  • There is sufficient evidence to suggest that people who smoke have a considerably increased risk of intra- and post-operative complications such as chest infections, lung disorders, wound complications and impaired healing.
  • See Smoking Cessation Care Pathways
Please Note: The life style factors above are not a restriction to the commissioning statements unless otherwise stated


Evidence/Rationale

There is some evidence of longer term efficacy of conventional haemorrhoidectomy over stapled procedure.

Short term efficacy and cost effectiveness is similar.

Stapled haemorrhoidopexy for the treatment of haemorrhoids1

Technology appraisal guidance [TA128]Published date: 26 September 2007

BMJ Clinical Review2 Management of haemorrhoids BMJ2008; 336 doi: http://dx.doi.org/10.1136/bmj.39465.674745.80 (Published 14 February 2008) Cite this as: BMJ 2008;336:380

Cochrane Library3 Stapled versus conventional surgery for hemorrhoids Kathleen J Lumb, Patrick H.D. Colquhoun, Richard Malthaner, Shiva Jayaraman First published: 18 October 2006

American Society of Colon and Rectal Surgeons5 Practice parameters for the management of hemorrhoids (revised 2010). Jama Surgery4

Long-term Outcomes of Stapled Hemorrhoidopexy vs Conventional Hemorrhoidectomy A Meta-analysis of Randomized Controlled Trials Pasquale Giordano, MD, FRCSEd, FRCS; Gianpiero Gravante, MD; Roberto Sorge, PhD; Lauren Ovens, MBChB, MRCS; Piero Nastro, MD, MRCS Arch Surg. 2009;144(3):266-272. doi:10.1001/archsurg.2008.591.

NICE Clinical Knowledge Summaries6

References

  1. Stapled haemorrhoidopexy for the treatment of haemorrhoids https://www.nice.org.uk/guidance/ta128
  2. BMJ Clinical Review - Management of haemorrhoids http://www.bmj.com/content/336/7640/380
  3. Cochrane Library - Stapled versus conventional surgery for hemorrhoids http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005393.pub2/abstract
  4. Jama Surgery - Long-term Outcomes of Stapled Hemorrhoidopexy vs Conventional Hemorrhoidectomy A Meta-analysis of Randomized Controlled Trials. http://archsurg.jamanetwork.com/article.aspx?articleid=404710
  5. American Society of Colon and Rectal Surgeons https://www.guideline.gov/summaries/summary/36076?f=rss
  6. NICE Clinical Knowledge Summaries http://cks.nice.org.uk/haemorrhoids

Assurance & Governance

  • This policy was developed on: 05.2017
  • This policy was approved by: Clinical Strategy Group (NK) and Clinical Cabinet (WK)
  • Date approved: 05.2017
  • Publication Date: 05.2017
  • Review Date: 04.2018
  • Ref No: PA18 - 05.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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