Hemorrhoid therapy for patients on medications altering coagulation

Symptomatic hemorrhoids represent an extremely common disorder, affecting essentially all age groups. A variety of office and surgical procedures have been developed to treat this condition. A recognized complication of all treatments for hemorrhoids is late bleeding secondary to mucosal ulceration or sloughing of the vascular pedicle. This event usually occurs while the patient is at home and can be life threatening. For this reason, medications that alter normal coagulation are typically discontinued prior to treatment of the symptomatic hemorrhoids if it is deemed safe to do so. An increasing number of patients are taking medications that alter coagulation. These medications, which include aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), thienopyridines (clopidogrel and ticlopidine), and warfarin, inherently increase the potential for intraoperative and postoperative hemorrhage. They are indicated for treatment and risk reduction for coronary artery disease (CAD), atrial fibrillation (AF), mechanical heart valves, and deep vein thrombosis (DVT). Because of the underlying diseases, discontinuation of anticoagulant/ antiplatelet medications in these patients is not without risk. The management of hemorrhoids in patients on medications altering coagulation requires careful clinical decision making. Strategies must account for the severity of hemorrhoidal disease, the severity of medical conditions, and the risk related to the (dis)continuation of medications. Literature specifically addressing hemorrhoidal therapy in patients on coagulation-altering drugs is lacking. Therefore, it is important to understand the concepts of management and tailor the approach to the patient. Due to the complexity of somemedical conditions, communication with primary care physicians and cardiologists is critical to insure appropriate management. The purpose of this chapter is to discuss the issues involved with the management of patients with hemorrhoidal disease who are taking medications that alter coagulation. Bleeding risks related to specific hemorrhoidal treatment modalities are addressed. Next, the mechanisms of action of the medications are reviewed. Their use for the treatment of specific conditions and the effects of cessation of use are addressed. Finally, we will propose recommendations addressing the optimalmanagement of patients with symptomatic hemorrhoids taking medications altering coagulation.