Background: Hemorrhoids are a common disease that is often considered an easy
problem to solve. Unfortunately, some particular clinical conditions, including Inflammatory Bowel
Diseases (IBD), pregnancy, immunosuppression, coagulopathy, cirrhosis with portal hypertension,
and proctitis after radiotherapy, challenge hemorrhoids management and the outcomes.
Methods: Research and online contents related to hemorrhoids’ treatment in special conditions are
reviewed in order to help colorectal surgeons in daily practice.
Results: There are very limited data about the outcomes of hemorrhoids treatment in these subgroups
of patients. Patients in pregnancy can be effectively treated with medical therapy, reserving
surgical intervention in highly selected and urgent cases. In case of thrombosed haemorrhoids, the
excision allows a fast symptoms’ resolution, with a low incidence of recurrence and a long remission
interval. In case of immunosuppressed patients, there is no consensus for the best treatment,
even in most HIV positive patients, a surgical procedure can be safely proposed when indicated.
There is no sufficient data in the literature related to transplanted patients. The surgical treatment
of hemorrhoids in patients with IBD, especially Crohn’s Disease, can be unsafe, although there is a
paucity of literature on this topic. In case of previous pelvic radiotherapy, it must always be considered
that severe complications, like abscesses and fistulas with subsequent pelvic and retroperitoneal
sepsis, can occur after surgical treatment of hemorrhoids, so a conservative treatment is advocated.
Moreover, caution is recommended in treating patients with coagulopathy, considering
possible complications (mostly bleeding) also after outpatient treatments. In case of portal hypertension
and cirrhosis, a ‘conservative treatment’ is recommended. Bleeding hemorrhoids can be treated
with hemorrhoidectomy when they do not respond to other treatments.
Conclusion: International literature is very scant about the treatment of patients affected by hemorrhoids
in particular situations. A word of caution and concern even about the indication for minor
outpatient procedures must be expressed in these patients, in order to avoid possible life-threatening
complications. The first-line treatment is the conservative medical approach associated with the
treatment of the primary disease.