EP249 - Use of Hyaluronidase with Local Anesthetic in the Treatment of Grade IV Internal Hemorrhoids

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Purpose/Background: Acute hemorrhoidal crisis is characterized by the sudden onset of severe pain with irreducible, prolapsed internal hemorrhoids. Typically, Grade III hemorrhoids become incarcerated due to progressive edema from prolapse. This can progress to strangulation, necrosis and gangrene without urgent intervention. While emergent surgical hemorrhoidectomy is recommended, the use of hyaluronidase as an adjunct to reduce hemorrhoidal edema prior to surgical intervention was first suggested in 1956. This has been confirmed by several studies since. Hyaluronidase is an enzyme that catalyzes the hydrolysis of hyaluronic acid, which forms the interstitial space between tissues, thus enhancing the dispersion of local anesthetic and reduces the edema and swelling of the hemorrhoidal tissue. In this paper, we discuss the successful use of hyaluronidase mixed with local anesthetic in the treatment of grade IV prolapsed internal hemorrhoids in two patients that presented to the emergency department with acute hemorrhoidal crisis.

Methods/Interventions: Patient A is a 54-year-old male with no prior hemorrhoid related symptoms who presented with one day of painful, prolapsed grade IV internal hemorrhoids (Figure 1a). Patient B is a 30-year-old male with a prior history of Grade III hemorrhoids who presented with incarcerated grade IV internal hemorrhoids and thrombosed external hemorrhoids (Figure 2a). Both patients were positioned in the prone jackknife position. The perianal region was then prepped with Betadine and draped. A 30 ml solution of 0.25% Marcaine with epinephrine 1:100,000 was mixed with 1 ml of hyaluronidase (150 TR units). This solution was then injected directly into the edematous hemorrhoids circumferentially and as a perianal block using a 10 ml syringe and 25-gauge needle. This was followed by firm massage to the area with pressure held for 5 minutes. Upon re-inspection - this resulted in resolution of the edema and complete reduction of the prolapse in both patients (Figure 1b, 2b).

Results/Outcomes: With normal architecture restored after injection, both patients were able to be discharged from the emergency department and seen in follow up in clinic. Patient A was seen in outpatient follow-up with complete resolution of hemorrhoids and required no further intervention. Patient B underwent Transanal Hemorrhoidal Dearterialization (THD) in an elective outpatient surgery setting (Figure 2c).

Conclusion/Discussion: The use of hyaluronidase mixed with local anesthetic is a safe and effective method to treat Grade IV hemorrhoids and manage an acute hemorrhoidal crisis. This allows resolution of perianal edema and reduction of hemorrhoids. Patients can then proceed to elective office-based interventions (i.e. sclerotherapy, rubber band ligation) or operative interventions.