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D'Alfonso A, De Carolis F, Serva A, Valiyeva S, Guido M, Pietroletti R. Haemorrhoidal disease in pregnancy: results from a self-assessment questionnaire administered by means of a social network. BMC Gastroenterol 2024; 24:150. [PMID: 38698334 PMCID: PMC11064321 DOI: 10.1186/s12876-024-03228-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 04/15/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND The anal symptoms occurring during pregnancy and post-partum, mainly related to Haemorrhoidal Disease (HD), have been reported with in a wide range of incidence in the literature. Although in many cases the course of the disease is mild and self-limiting, sometimes it is severe enough to affect quality of life. METHODS Our study has been conducted through a questionnaire administered via social media with the aim of obtaining epidemiologic data on the incidence of the symptoms of HD in an unselected population of pregnant women. In addition, we looked for the presence of those factors notoriously predisposing or associated to HD (constipation, straining on the toilet, low dietary fibres and fluid intake). RESULTS Out of 133 patients 51% reported symptoms of HD during pregnancy, mainly in the second and third trimester. Constipation, straining on the toilet, low dietary fibres and fluid intake were not significantly related to incidence of HD. Only a previous history of HD was correlated to onset of symptoms of HD in pregnancy and reached a statistical significance (odds ratio = 5.2, p < 0.001). CONCLUSION Although with the limitations posed by the nature of our retrospective study via a self-assessment interview, our results suggest that the occurrence of HD in pregnancy seems not sustained by the classical risk factors observed in the general population. At the moment, specific therapeutic measures are lacking and treatment relies on empiric suggestions concerning diet, fluid intake, bowel care, local ointment. Further studies are needed in order to identify a targeted etiologic treatment.
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Affiliation(s)
- Angela D'Alfonso
- Unit of Obstetrics and Gynaecology, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesca De Carolis
- Surgical Coloproctology, University of L'Aquila, Hospital Val Vibrata, Sant'Omero, TE, Italy
| | - Alessandro Serva
- Unit of Obstetrics and Gynaecology, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Sayali Valiyeva
- Surgical Coloproctology, University of L'Aquila, Hospital Val Vibrata, Sant'Omero, TE, Italy
| | - Maurizio Guido
- Unit of Obstetrics and Gynaecology, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Renato Pietroletti
- Surgical Coloproctology, University of L'Aquila, Hospital Val Vibrata, Sant'Omero, TE, Italy.
- Department of Clinical Sciences and Biotechnology, University of L'Aquila, Surgical Coloproctolgy Hospital Val Vibrata Sant'Omero, 64027, Sant'Omero, TE, Italy.
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Medkova Y, Tulina I, Novikov I, Nikonov A, Ischenko A, Aleksandrov L, Altomare DF, Dezi A, Picciariello A, Tsarkov P. Thrombosed external hemorrhoids during pregnancy: surgery versus conservative treatment. Updates Surg 2024; 76:539-545. [PMID: 38151682 DOI: 10.1007/s13304-023-01741-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 12/19/2023] [Indexed: 12/29/2023]
Abstract
The management of thrombosed external hemorrhoids (TEH) during pregnancy is still under debate because of the fear of potential adverse effects on the fetus. This study aims to compare efficacy and safety of conservative versus surgical treatment of acute TEH in pregnant women. Furthermore, the outcome of two different surgical approaches was evaluated. This is a prospective observational study including a sub-analysis on two randomized groups of pregnant women affected by TEH. The primary outcome measured was the impact of conservative and surgical treatment defined in terms of VAS, clinical patient grading assessment scale (CPGAS) and the SF-12 questionnaire. In a randomized sub-analysis of the surgical treatment, the outcome of local excision (LE) versus thrombectomy (TE) was compared. Fifty-three patients entered the study. Twenty-six patients had conservative treatment and 22 underwent surgery. Within the surgical group, 8 were randomized for TE and 14 for LE. VAS, SF-12 and CPGAS improved in both groups after 3 and 10 days from the treatment. However, physical (PCS) and mental health (MCS) domains of the SF-12 and CPGAS showed a significant difference in favor of surgery on the 10th day (PCS: p < 0.002 and MCS: p = 0.03; CPGAS: p = 0.002). The surgical group showed an earlier significant reduction of pain on the 3rd day (p = 0.0004). In the surgical group, randomization was halted due to ethical concerns arising from a notable difference in the primary end point between subgroups during interim analysis. Specifically, the re-thrombosis rate was 38% (3/8) after TE and 7% (1/14) after LE. No complications occurred for either mothers or fetuses. Both surgical and conservative treatments are safe and effective. However, surgery allows a faster relief of anal pain. Thrombectomy is associated with higher risk of re-thrombosis when compared to local excision (clinicaltrials.gov ID number NCT04588467).
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Affiliation(s)
- Yuliia Medkova
- Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Inna Tulina
- Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ivan Novikov
- Department of Hearth Rhythm Disorders, Federal State Budget Organization "National Medical Research Center of Cardiology" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Andrey Nikonov
- Snegirev Clinic of Obstetrics and Gynecology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Anatoliy Ischenko
- Snegirev Clinic of Obstetrics and Gynecology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Leonid Aleksandrov
- Snegirev Clinic of Obstetrics and Gynecology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Donato F Altomare
- Department of Precision and Regenerative Medicine and Ionian Area and Inter-Department Research Center for Pelvic Floor Disease (CIRPAP), University "Aldo Moro" of Bari, Piazza G. Cesare, Bari, Italy
| | - Agnese Dezi
- Department of Precision and Regenerative Medicine and Ionian Area and Inter-Department Research Center for Pelvic Floor Disease (CIRPAP), University "Aldo Moro" of Bari, Piazza G. Cesare, Bari, Italy
| | | | - Petr Tsarkov
- Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
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Chen YY, Chang CY, Lin CH, Cheng LY, Shih WT, Chen KJ, Yang YH. Prevalence, Characteristics, and Treatment of Hemorrhoids During Pregnancy: A Nationwide Population-Based Cohort Study in Taiwan. J Womens Health (Larchmt) 2023; 32:1394-1401. [PMID: 37582215 DOI: 10.1089/jwh.2023.0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023] Open
Abstract
Background: Hemorrhoids, a gastrointestinal tract disorder, are common during pregnancy. However, large-scale epidemiological studies on hemorrhoids during pregnancy are limited. Therefore, this study used analyzed data from a nationwide population-based database to investigate the prevalence, characteristics, and treatment of hemorrhoids in Taiwan. Materials and Methods: This retrospective population-based study used data from the National Health Insurance Research Database and Taiwan Birth Certificate Application to collect the medical records of women who were pregnant at any time during 2009-2018. Hemorrhoids was defined by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) (455. X) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) (K64.X, O22.4X) with related treatment. Results: We enrolled 1,608,804 deliveries in 1,070,708 women. The proportion of hemorrhoids increased with age in both primipara and multipara women. Of the pregnant women, 31% received oral medication, and 93.2% used the topical ointment to treat their hemorrhoids. Few patients (1.8%) required procedure or surgery during pregnancy, and 41.4% of those patients underwent procedure or surgery in their first trimester. The cumulative incidence of hemorrhoids during pregnancy was significantly higher in women with a history of hemorrhoids and those with multifetal pregnancies. No significant difference in the incidence of hemorrhoids was observed between multiparous and primiparous women. Conclusion: Women with a history of hemorrhoids or those carrying multiple fetuses had an increased risk of hemorrhoids during pregnancy. The most commonly used treatment for hemorrhoids during pregnancy was topical ointments, with only a small proportion (1.8%) of patients requiring procedure or surgery.
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Affiliation(s)
- Yu-Ying Chen
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Puzi, Taiwan
| | - Chao-Yang Chang
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Puzi, Taiwan
| | - Chih-Hsuan Lin
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Puzi, Taiwan
| | - Ling-Yun Cheng
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Puzi, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wei-Tai Shih
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Puzi, Taiwan
| | - Ko-Jung Chen
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Puzi, Taiwan
| | - Yao-Hsu Yang
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Puzi, Taiwan
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Puzi, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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4
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Luo H, He X, Wang M, Zheng X, Peng R, Wang C, Li Q, Yang B. Comparision of Ligasure hemorrhoidectomy and conservative treatment for thrombosed external hemorrhoids (TEH) in pregnancy. BMC Surg 2023; 23:15. [PMID: 36658522 PMCID: PMC9850810 DOI: 10.1186/s12893-023-01910-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/10/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Ligasure hemorrhoidectomy for thrombosed external hemorrhoids in pregnancy has been rarely studied. OBJECTIVE The purpose of this article is to study the efficacy and safety of Ligasure hemorrhoidectomy comparing with conservative treatment for thrombosed external hemorrhoids in pregnancy. DESIGN This was a retrospective cohort study. SETTING The patients were treated at a tertiary referral center in China. PATIENTS 94 pregnant patients hospitalized for thrombosed external hemorrhoids from September 2020 to December 2021. INTERVENTIONS Ligasure hemorrhoidectomy treatment or conservative treatment according to the patient's wishes. MAIN OUTCOME MEASURES Symptom relief, recurrence and satisfaction of thrombosed external hemorrhoids in pregnancy with different interventions. RESULTS There were no differences between groups in maternal age, gestational age, body mass index, parity, constipation and a prior history of thrombosed external hemorrhoids. The pain scores were less in surgical group than in conservative group in post-treatment days 1 and 7. Time to return to normal activities was shorter in surgical group than in conservative group (6.51 vs. 13.52 days, P < 0.001). Post-treatment complications were mild in surgical group and there were no significant differences concerning the rate of abortion, preterm birth, cesarean delivery and weight of fetus. Recurrence rate was significantly lower in surgical group (8.57% vs. 30.43%, P = 0.017). The patient satisfaction scores were significantly higher in surgical group than in conservative group (Z = - 2.979, P = 0.003). LIMITATIONS This was a retrospective study with a limited number of patients, the data was obtained from only one center. CONCLUSIONS Comparing with conservative treatment, Ligasure hemorrhoidectomy for TEH in pregnancy results in more rapid pain relief, shorter time to return to normal activities, lower incidence of recurrence, and better patient satisfaction. This type of surgery has low and mild postoperative complications, is not attended by any risk to the mother or her fetus.
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Affiliation(s)
- Huihua Luo
- grid.410745.30000 0004 1765 1045Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China ,grid.33199.310000 0004 0368 7223Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Xiaojun He
- grid.33199.310000 0004 0368 7223Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Min Wang
- grid.410745.30000 0004 1765 1045Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Xiaosong Zheng
- grid.33199.310000 0004 0368 7223Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Rong Peng
- grid.33199.310000 0004 0368 7223Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Chenwei Wang
- grid.33199.310000 0004 0368 7223Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Qiu Li
- grid.33199.310000 0004 0368 7223Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Bolin Yang
- grid.410745.30000 0004 1765 1045Department of Colorectal Surgery, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
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5
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Constipation, Hemorrhoids, and Anorectal Disorders in Pregnancy. Am J Gastroenterol 2022; 117:16-25. [PMID: 36194029 DOI: 10.14309/ajg.0000000000001962] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/23/2022] [Indexed: 11/05/2022]
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Bužinskienė D, Sabonytė-Balšaitienė Ž, Poškus T. Perianal Diseases in Pregnancy and After Childbirth: Frequency, Risk Factors, Impact on Women's Quality of Life and Treatment Methods. Front Surg 2022; 9:788823. [PMID: 35252326 PMCID: PMC8894587 DOI: 10.3389/fsurg.2022.788823] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 01/07/2022] [Indexed: 11/13/2022] Open
Abstract
Hemorrhoids and anal fissures occur in about 40% of pregnant women and women during postpartum period. Usually they occur during the third trimester of pregnancy and 1–2 days after giving birth. Constipation during pregnancy, perianal diseases during previous pregnancy and childbirth, instrumental delivery, straining duration of more than 20 min, and weight of the newborn more than 3,800 g are associated with hemorrhoids. Perianal diseases reduce the quality of life of both pregnant and postpartum women. In the absence of acute conditions, surgical treatment of hemorrhoids is delayed after pregnancy, childbirth, and lactation. Thrombosed internal hemorrhoids and perianal thrombosis are to be treated conservatively in most instances by prescribing adequate pain relief, oral, and topical flavonoid preparations.
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Affiliation(s)
- Diana Bužinskienė
- Clinic of Obstetrics and Gynecology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Tomas Poškus
- Clinic of Gastroenterology, Nephrourology, and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
- *Correspondence: Tomas Poškus
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Prentice R, Al-Ani A, Cherry T, Dixon-Douglas J, Eccles-Smith J, Matheson J, Tie J, Thevathasan I, McCormick JJ, Christensen B. Evaluation and management of rectal bleeding in pregnancy. Med J Aust 2021; 215:377-382. [PMID: 34601746 DOI: 10.5694/mja2.51267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rectal bleeding occurs in about 40% of pregnant women, and is predominantly attributed to benign perianal pathology (haemorrhoids or anal fissures). More sinister causes of rectal bleeding may be heralded by key red flag clinical and biochemical features. These features should be evaluated in all women with rectal bleeding. Imaging investigations or flexible sigmoidoscopy may be warranted. The latter can be performed safely by experienced operators in pregnant women. Women with evidence of haemodynamic compromise, elevated inflammatory markers, significant anaemia, signs of intestinal obstruction or compromise to the fetus should be evaluated urgently. Providers must be mindful of the changes in normal ranges for common haematological and biochemical parameters in pregnancy compared with the non-pregnant state. Faecal calprotectin is an established tool for identification of intestinal inflammation and is valid in pregnancy. An elevated faecal calprotectin level (≥ 50 µg/g) signifies a need for further diagnostic evaluation. Inflammatory bowel disease may present initially, or with worsening disease activity, in pregnancy. Expedient diagnosis with the use of faecal calprotectin, sigmoidoscopy with or without intestinal ultrasound, exclusion of alternative or compounding infective aetiologies, and institution of appropriate therapy are critical. Medical therapies for management of inflammatory bowel disease can be safely instituted in pregnancy. Colorectal cancer incidence is increasing in younger age groups, but fortunately remains rare. When diagnosed in pregnancy, colorectal cancer can be successfully and safely managed with a collaborative multidisciplinary team approach. Early diagnosis is key to optimising outcomes.
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Affiliation(s)
- Ralley Prentice
- Monash Health, Melbourne.,St Vincent's Hospital Melbourne, Melbourne, VIC
| | | | | | | | | | | | - Jeanne Tie
- Peter MacCallum Cancer Centre, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | | | - Jacob J McCormick
- Royal Melbourne Hospital, Melbourne, VIC.,Peter MacCallum Cancer Centre, Melbourne, VIC
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8
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Story L, Rafique S, Samadi N, Mawdsley J, Singh B, Banerjee A. Lower gastrointestinal bleeding in pregnancy: Differential diagnosis, assessment and management. Obstet Med 2021; 14:129-134. [PMID: 34646340 PMCID: PMC8504301 DOI: 10.1177/1753495x20948300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/15/2020] [Accepted: 07/15/2020] [Indexed: 12/16/2022] Open
Abstract
Rectal bleeding is a common symptom experienced by pregnant women. Although the majority of cases are attributable to benign conditions such as haemorrhoids and anal fissures, other more serious diagnoses such as inflammatory bowel disease and malignancy should not be overlooked. Most investigations are safe during pregnancy and these should not be withheld as significant implications on both fetal and maternal morbidity may result. In these cases, a multidisciplinary team approach is essential. This review explores the differential diagnosis, investigation and management of rectal bleeding during pregnancy.
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Affiliation(s)
- L Story
- Department of Women and Children's Health King's College, London, UK.,Women's Services, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - S Rafique
- King's College London Medical School, London, UK
| | - N Samadi
- King's College London Medical School, London, UK
| | - J Mawdsley
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - B Singh
- Department of Surgery, University Hospitals Leicester, Leicester, UK
| | - A Banerjee
- Women's Services, Guy's and St Thomas' NHS Foundation Trust, London, UK
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9
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Garmanova TN, Markaryan DR, Kazachenko EA, Tsar'kov PV. PERSONALIZED APPROACH TO ACUTE PERIANAL VENOUS THROMBOSIS TREATMENT DEPENDING ON CLINICAL MANIFESTATIONS. SURGICAL PRACTICE 2020. [DOI: 10.38181/2223-2427-2020-3-11-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Aim: to investigate the time period and reasons for seeing a doctor of patients with acute thrombosis and to assess treatment satisfaction.Methods: The main complaints, symptom duration, pain severity and pathological process characteristics of patients with acute perianal venous thrombosis were recorded. The treatment strategy was determined by the doctor and the patient: the surgical thrombosed hemorrhoid removal or conservative treatment with analgesics, venotonics, drugs for stool softening. Pain severity on days 3, 7, 30 and overall satisfactions on day 30 were evaluated.Results: 62 patients were included. The main symptoms were pain (69.4%) and discomfort (16.1%). During the first 72 hours from the disease onset 21.5% of patients saw a doctor and 66.7% of all patients underwent the surgery, on day 4–7 — 50% saw a doctor and 77% underwent the surgery, > 8 days — 28.5% and 33% respectively. During the appointment pain was 4 points according to VAS, 3 days after surgery — 5.9 points, 4–7 days — 3.9 points, > 8 days — 2.5 points. 64% of patients underwent the surgery with average pain level of 5 points, in the conservative group — of 4.5 points (p = 0.014). On day 30 80.6% of all patients were completely satisfied. Having the pain severity > 4points nobody was satisfied with conservative treatment, while 80% of surgical patients were satisfied.Conclusion: Considering the symptom duration, pain continuing > 3 days, perianal discomfort ora «bump» the treatment tactics should be accepted by the doctor and the patient together for achieving a high treatment satisfaction.
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10
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van Tol RR, Kleijnen J, Watson AJM, Jongen J, Altomare DF, Qvist N, Higuero T, Muris JWM, Breukink SO. European Society of ColoProctology: guideline for haemorrhoidal disease. Colorectal Dis 2020; 22:650-662. [PMID: 32067353 DOI: 10.1111/codi.14975] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 01/03/2020] [Indexed: 12/15/2022]
Abstract
AIM The goal of this European Society of ColoProctology project was to establish a multidisciplinary, international guideline for haemorrhoidal disease (HD) and to provide guidance on the most effective (surgical) treatment for patients with HD. METHODS The development process consisted of six phases. In phase one we defined the scope of the guideline. The patient population included patients with all stages of haemorrhoids. The target group for the guideline was all practitioners treating patients with haemorrhoids and, in addition, healthcare workers and patients who desired information regarding the treatment management of HD. The guideline needed to address both the diagnosis of and the therapeutic modalities for HD. Phase two consisted of the compilation of the guideline development group (GDG). All clinical members needed to have affinity with the diagnosis and treatment of haemorrhoids. Further, attention was paid to the geographical distribution of the clinicians. Each GDG member identified at least one patient in their country who could read English to comment on the draft guideline. In phase three review questions were formulated, using a reversed process, starting with possible recommendations based on the GDG's knowledge. In phase four a literature search was performed in MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews. The search was focused on existing systematic reviews addressing each review question, supplemented by other studies published after the time frame covered by the systematic reviews. In phase five data of the included papers were extracted by the surgical resident (RT) and checked by the methodologist (JK) and the GDG. If needed, meta-analysis of the systematic reviews was updated by the surgical resident and the methodologist using Review Manager. During phase six the GDG members decided what recommendations could be made based on the evidence found in the literature using GRADE. RESULTS There were six sections: (i) symptoms, diagnosis and classification; (ii) basic treatment; (iii) outpatient procedures; (iv) surgical interventions; (v) special situations; (vi) other surgical techniques. Thirty-four recommendations were formulated. CONCLUSION This international, multidisciplinary guideline provides an up to date and evidence based summary of the current knowledge of the management of HD and may serve as a useful guide for patients and clinicians.
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Affiliation(s)
- R R van Tol
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - J Kleijnen
- Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - A J M Watson
- Department of Surgery, Raigmore Hospital, Inverness, UK
| | - J Jongen
- Department of Surgical Proctology, Proktologische Praxis Kiel,, Kiel, Germany
| | - D F Altomare
- Department of Emergency and Organ Transplantation, University of Aldo Moro of Bari, Bari, Italy
| | - N Qvist
- Surgical Department A, Odense University Hospital, Odense C, Denmark
| | - T Higuero
- Clinique Saint Antoine, Nice, France
| | - J W M Muris
- Department of Family Medicine/General Practice, Research Institute CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - S O Breukink
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
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11
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Zhang J, Peng P, Cao D, Yang J, Shen K. Clinicopathological features and maternal and foetal management of pregnancy‑complicating Krukenberg tumours. Mol Clin Oncol 2020; 12:581-587. [PMID: 32337041 DOI: 10.3892/mco.2020.2025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/21/2020] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jingjing Zhang
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Dongcheng, Beijing 100730, P.R. China
| | - Peng Peng
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Dongcheng, Beijing 100730, P.R. China
| | - Dongyan Cao
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Dongcheng, Beijing 100730, P.R. China
| | - Jiaxin Yang
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Dongcheng, Beijing 100730, P.R. China
| | - Keng Shen
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Dongcheng, Beijing 100730, P.R. China
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12
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Garmanova TN, Bredikhin MI, Tulina IA, Medkova YS, Alekberzade AV, Tsarkov PV. [Choice of optimal treatment strategy for acute perianal thrombosis. Results of online survey]. Khirurgiia (Mosk) 2020:39-47. [PMID: 32105254 DOI: 10.17116/hirurgia202002139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To study the factors influencing the physicians' choice of treatment strategy in patients with acute perianal thrombosis. MATERIAL AND METHODS A survey was conducted among 124 Russian colorectal surgeons. RESULTS This survey showed that the choice of treatment strategy varies between private and state clinics. Conservative approach is preferred in government clinics (p=0.024). The time factor is more important for professionals. Hemorrhoidectomy is preferred in private clinicians, thrombectomy - in public clinics. The majority of physicians note that pregnancy significantly affects choice of treatment tactics. The most important factors to refuse surgery are pregnancy (r=0.796), age over 70 years (r=0.655), duration of thrombosis over 4 days (r=0.791). Large thrombosed node (2-3 cm), severe pain syndrome (r=0.858) and duration of disease less than 3 days (r=0.901) determine preferable surgical approach. CONCLUSION The choice of treatment of acute perianal thrombosis depends on not only duration of disease, severity of pain syndrome, age and pregnancy, but also on the type of the hospital. Conservative treatment is preferable in the majority of national state hospitals. Moreover, most surgeons prefer less aggressive treatment options in the state clinics. Further research is needed to determine any important factors limiting more effective surgical treatment besides pain and patient's attitude toward the disease.
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Affiliation(s)
- T N Garmanova
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - M I Bredikhin
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - I A Tulina
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - Yu S Medkova
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - A V Alekberzade
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
| | - P V Tsarkov
- Sechenov First Moscow State Medical University of the Ministry of Health of Russia, Moscow, Russia
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Gallo G, Martellucci J, Sturiale A, Clerico G, Milito G, Marino F, Cocorullo G, Giordano P, Mistrangelo M, Trompetto M. Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease. Tech Coloproctol 2020; 24:145-164. [PMID: 31993837 PMCID: PMC7005095 DOI: 10.1007/s10151-020-02149-1] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/06/2020] [Indexed: 02/07/2023]
Abstract
Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.
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Affiliation(s)
- G Gallo
- Department of Surgical and Medical Sciences, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
- Department of Colorectal Surgery, Santa Rita Clinic, Vercelli, Italy
| | - J Martellucci
- Department of General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
| | - A Sturiale
- Proctological and Perineal Surgical Unit, Cisanello University Hospital, Pisa, Italy
| | - G Clerico
- Department of Colorectal Surgery, Santa Rita Clinic, Vercelli, Italy
| | - G Milito
- Department of General Surgery, Tor Vergata University, Rome, Italy
| | - F Marino
- Operative Unit of General Surgery, IRCCS de Bellis, Castellana Grotte, Bari, Italy
| | - G Cocorullo
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - P Giordano
- Department of Colorectal Surgery, Whipps Cross University Hospital, Barts Health, London, UK
| | - M Mistrangelo
- Department of General and Minimally Invasive Surgery, University of Turin, Turin, Italy
| | - M Trompetto
- Department of Colorectal Surgery, Santa Rita Clinic, Vercelli, Italy.
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Trompetto M, Clerico G, Cocorullo GF, Giordano P, Marino F, Martellucci J, Milito G, Mistrangelo M, Ratto C. Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement. Tech Coloproctol 2015; 19:567-75. [PMID: 26403234 DOI: 10.1007/s10151-015-1371-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 09/05/2015] [Indexed: 02/07/2023]
Abstract
Hemorrhoids are one of the most common medical and surgical diseases and the main reason for a visit to a coloproctologist. This consensus statement was drawn up by the Italian society of colorectal surgery in order to provide practice parameters for an accurate assessment of the disease and consequent appropriate treatment. The authors made a careful search in the main databases (MEDLINE, PubMed, Embase and Cochrane), and all results were classified on the basis of the grade of recommendation (A-C) of the American College of Chest Physicians.
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Affiliation(s)
- M Trompetto
- Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy.
| | - G Clerico
- Department of Colorectal Surgery, S. Rita Clinic, Vercelli, Italy
| | - G F Cocorullo
- Unit of Emergency and General Surgery, Department of Surgical Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy
| | - P Giordano
- Department of Colorectal Surgery, Barts Health, London, UK
| | - F Marino
- Department of General Surgery, "A. Perrino" Hospital, Brindisi, Italy
| | - J Martellucci
- General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
| | - G Milito
- Department of General Surgery, Tor Vergata University, Rome, Italy
| | - M Mistrangelo
- Department of General and Minimally Invasive Surgery, University of Turin, Turin, Italy
| | - C Ratto
- Proctology Unit, University Hospital "A Gemelli", Catholic University, Rome, Italy
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Abstract
INTRODUCTION Although the acute thrombosis and strangulation of haemorrhoids is a common condition, there is no consensus as to its most effective treatment. METHODS A PubMed search was undertaken for papers describing the aetiology and treatment of the acute complications of haemorrhoids. RESULTS The anatomy and treatments for strangulated internal haemorrhoids and thrombosed perianal varices are discussed. Studies of the effectiveness and complications of conservative and operative treatments are reviewed. CONCLUSIONS Ambiguities exist in the terminology used to describe the two separate pathologies that make up the acute complications of haemorrhoids. These complications have traditionally been treated conservatively. There is evidence that early operative intervention for strangulated internal haemorrhoids is safe and effective. A suggested algorithm for treatment is given, based on the published literature.
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Affiliation(s)
- A Hardy
- Abertawe Bro Morgannwg University Health Board, UK
| | - CRG Cohen
- University College London Hospitals NHS Foundation Trust, UK
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Thomas GP, dos Santos IM, Ouro SM, Thomas-Gibson S, Vaizey CJ. Colorectal disorders during pregnancy: a review. Br J Hosp Med (Lond) 2013; 74:625-30. [PMID: 24220524 DOI: 10.12968/hmed.2013.74.11.625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- G P Thomas
- Research Fellow, Sir Alan Parks Department of Physiology, St Marks Hospital and Academic Institute, Harrow
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Moore JS, Seah AS, Hyman N. Management of hemorrhoids in unusual circumstances. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2013.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Hemorrhoid disease is the most common reason patients seek evaluation by a colon and rectal surgeon. The majority of hemorrhoids can be managed nonoperatively with medical management or office-based procedures. The authors review the anatomy, pathophysiology, presentation, and management of hemorrhoids.
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Affiliation(s)
- Caroline Sanchez
- Division of Colon and Rectal Surgery, University of Medicine and Dentistry–Robert Wood Johnson Medical School, Edison, New Jersey
| | - Bertram T. Chinn
- Division of Colon and Rectal Surgery, University of Medicine and Dentistry–Robert Wood Johnson Medical School, Edison, New Jersey
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Abstract
Haemorrhoids are varicose veins of the rectum covered by mucosa at or near the anal canal. They are normally asymptomatic, can occur at any age and affect both males and females. In this review, we address the issue of the approach of the obstetrician to haemorrhoids and their management. Haemorrhoids are common in young women and commoner during pregnancy and the puerperium. Obstetricians and gynaecologists should be familiar with haemorrhoids, a proctological disease, diagnosis and their treatment, but they have little experience regarding the impact of pregnancy on haemorrhoids. The obstetrician must be able to relieve symptoms in patients who are pregnant, or who have just delivered.
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Affiliation(s)
- A F Avsar
- Department of Obstetrics and Gynecology, Atatürk Education and Research Hospital, Ankara, Turkey
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Haemorrhoidectomy by vessel sealing system under local anaesthesia in an outpatient setting: preliminary experience. Colorectal Dis 2010; 12:236-40. [PMID: 19508547 DOI: 10.1111/j.1463-1318.2009.01833.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM This prospective study was designed to assess the feasibility of local anaesthesia for LigaSure haemorrhoidectomy in an outpatient setting. METHOD From April 2006 to March 2007, 207 consecutive patients (median age 42, 126 males) with grade III (147) and grade IV (60) haemorrhoids, underwent Milligan-Morgan haemorrhoidectomy with LigaSure under local anaesthesia (lidocaine 1%, mean dose 27 +/- 1.7 ml) in an outpatient setting. Postoperative pain was assessed by a visual analogue scale (VAS). RESULTS Two, three and four files were removed in 120, 51 and 36 patients. Mean operative time was 12 +/- 5.2 min and mean blood loss was 3.4 +/- 3.9 ml. The mean postoperative pain scores were 6.2 +/- 2.1 for the maximal pain intensity and 6.1 +/- 2.5 for the pain on defecation. All patients left hospital after surgery within 2 h and 33 (15.9%) required analgesics. They returned to normal daily activity after 12.2 +/- 7.9 days including work (12.1 +/- 7.8 days). The wounds had healed by 32.2 +/- 9.1 days. At a follow-up of at least 6 months, only six cases of major bleeding had occurred and 24 patients had skin tags. The median satisfaction score was +2 (-2 to +3). CONCLUSION LigaSure haemorrhoidectomy under local anaesthesia in the outpatient setting is safe and effective.
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Affiliation(s)
- Shauna Lorenzo-Rivero
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, Tennessee
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24
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Martel G, Boushey RP. The Treatment of Hemorrhoids in Unusual Situations and Difficult Circumstances. SEMINARS IN COLON AND RECTAL SURGERY 2007. [DOI: 10.1053/j.scrs.2007.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Madoff RD, Fleshman JW. American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology 2004; 126:1463-73. [PMID: 15131807 DOI: 10.1053/j.gastro.2004.03.008] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Hemorrhoids remain one of the most common colorectal complaints. They are defined as a pathologic engorgement of the submucosal vascular plexus. Although they are often asymptomatic, hemorrhoids may cause bleeding, prolapse and, less commonly, pain. This review gives an update on various treatment options for symptomatic hemorrhoids, which include conservative treatments, office interventions, and surgical procedures, depending on the individual constellation of symptoms. Objective findings and expectations are also addressed. Recent advances (eg, stapled hemorrhoidectomy and use of alternate energy sources) are emphasized, and treatment under special circumstances (HIV, pregnancy, inflammatory bowel disease, and liver disease) is outlined.
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Affiliation(s)
- Swarna Balasubramaniam
- Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street, Suite 5400, Los Angeles, CA 90033, USA.
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Abstract
Gastrointestinal disorders during pregnancy that require surgery often mimic the symptoms and signs of conditions that do not require surgery. Anatomic and physiologic changes of pregnancy can alter the usual clinical presentation of gastrointestinal disorders that require surgery. These alterations can be a challenge to diagnosis. Prompt treatment is critical to successful management. Most elective and urgent operations can be performed during pregnancy with minimal maternal and fetal risk. The condition of the mother should always take priority because proper treatment of the mother usually benefits the fetus as well.
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Affiliation(s)
- Mark A Malangoni
- Department of Surgery, Case Western Reserve University, MetroHealth Medical Center Campus, 2500 MetroHealth Drive, H-914, Cleveland, OH 44109, USA.
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Abstract
Constipation, diarrhea, and symptomatic hemorrhoids are disorders common in the general population, particularly in women. These conditions, if mild, often are self-treated with various home remedies or nonprescription preparations. Few of these patients, moreover, are referred to gastroenterologists, as primary care providers generally are confident managing these conditions, unless they are severe, refractory to conventional management, or require additional diagnostic studies.
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Affiliation(s)
- Arnold Wald
- University of Pittsburgh Medical Center, Division of Gastroenterology, Hepatology and Nutrition, PUH, Mezzanine Level, C-Wing, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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Affiliation(s)
- S Argov
- Elisha and Horev Medical Centers, POB 8744, 31087, Haifa, Israel.
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Abstract
Understanding of hemorrhoidal pathology and treatment has come a long way. The theory of a sliding anal canal lining and the knowledge that hemorrhoidal cushions are a normal part of the anal anatomy should encourage symptom control rather than radical removal of tissue. Techniques that fix the cushions back in position can be performed in outpatients with reasonable success rates. When required, surgery should be aimed at symptomatic hemorrhoids. It is hoped that new developments such as circular stapling and better pain management will promote increased day surgery, better pain control, and less time off work for patients.
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Affiliation(s)
- M Hulme-Moir
- Department of Colorectal Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland.
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Abstract
Gastrointestinal surgical problems often mimic symptoms and signs of nonsurgical conditions that occur during pregnancy. This mimicry presents a particular challenge to diagnosis because avoiding a delay in treatment is critical to successful management. Some of these conditions, such as acute appendicitis and biliary colic, are common in younger women; however, the anatomic and physiologic changes of pregnancy can alter their usual manner of presentation. Many elective and urgent operations can be performed during pregnancy with minimal risk to the mother and fetus. The mother's condition should always take priority because her proper treatment usually benefits the fetus as well.
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Affiliation(s)
- M S Firstenberg
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Medich DS, Fazio VW. Hemorrhoids, anal fissure, and carcinoma of the colon, rectum, and anus during pregnancy. Surg Clin North Am 1995; 75:77-88. [PMID: 7855720 DOI: 10.1016/s0039-6109(16)46535-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The pregnant patient afflicted with a variety of colorectal conditions merits special consideration for reasons related to the safety and timeliness of operation while preserving fetal viability and fertility. The literature is scanty with respect to hemorrhoids, fissures, and colorectal and anal carcinoma. Therefore, the patient has to have a forthright discussion with her physician(s) about the pros and cons of operative and nonoperative approaches, which can result in either therapeutic abortion and timely surgery versus preserving the fetus and taking on the unknown factor of whether delay in treatment will cause an adverse outcome. This underscores the need for a frank discussion with the patient with regard to anticipated outcomes. In benign conditions, there is more latitude to adopt a conservative approach, as the patient's ability to tolerate the symptoms of her condition would dictate the need for definitive operative therapy. In the patient with malignancy, delaying surgical or radiation therapy carries an unknown risk to the patient. Here, the patient's personal views regarding abortion and future fertility dictate the timing of definitive treatment.
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Affiliation(s)
- D S Medich
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio
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Abstract
The histological features of haemorrhoids are detailed in this study with special attention to the mucosal changes. These include significant crypt distortion, with stromal hyperplasia which bear a remarkable resemblance to the changes seen in mucosal prolapse syndrome. We propose that the mucosal prolapse syndrome should include haemorrhoids as part of the spectrum.
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Affiliation(s)
- S M Kaftan
- Department of Histopathology, University Hospital of South Manchester, UK
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