Hemorrhoids

Functional constipation in patients with hemorrhoids: a systematic review and meta-analysis

Hemorrhoids are common anorectal pathology, with high recurrence rates after surgical treatment. It is hypothesized that high straining forces during paradoxical contractions and inadequate relaxation are causally related to hemorrhoids. This review aimed to assess the coprevalence of functional constipation and dyssynergic defecation in a population with hemorrhoids. Moreover, the effects of rubber band ligation (RBL) were analyzed. Sources included Pubmed, Embase and CENTRAL . Randomized trials, cohort and case-control studies that investigated the prevalence of constipation in patients with hemorrhoids or the prevalence of hemorrhoids in patients with constipation compared to healthy subjects were included. Manometric studies were also eligible. Quality assessment was performed by using the Newcastle Ottawa Quality Assessment Scale. The primary outcome was the prevalence of functional constipation or dyssynergic defecation in patients with hemorrhoids. Nineteen studies were included. Prevalence of constipation was significantly higher in patients with hemorrhoids compared to controls [OR (odds ratio), 2.09; 95% CI (confidence interval), 1.27-3.44]. No significant difference in the prevalence of hemorrhoids between patients with constipation compared to controls was found (OR, 2.37; 95% CI, 0.67-8.44). Anal pressures in patients with hemorrhoids were significantly higher compared to healthy controls in all manometric studies. After RBL, these pressures remained significantly higher in patients with hemorrhoids ( P  = 0.001). Functional constipation, dyssynergic defecation and higher basal anal pressures are more prevalent in patients with hemorrhoids compared to controls. Improvement of therapy for functional constipation, especially dyssynergic defecation patterns, might lead to better long-term outcomes and reduce recurrence.

Somatosensory stimulation treatments for postoperative analgesia of mixed hemorrhoids: Protocol for a systematic review and network meta-analysis

BACKGROUND

Pain after hemorrhoidal surgery bothers both clinicians and patients. Somatosensory stimulation treatments have shown promising effect on the pain after hemorrhoidal surgery, but the comparative effectiveness between them has not been studied. We aim to determine the relative effectiveness among these treatments on pain relief after hemorrhoidal surgery by using network meta-analysis.

METHOD

We will search the following electronic databases: MEDLINE, EMBASE, the Cochrane library, Chinese Biomedicine database (CBM), China National Knowledge Infrastructure (CNKI). We will include randomized controlled trials (RCTs) that examine the effect of somatosensory stimulation treatments on pain after hemorrhoidal surgery. The primary outcome will be the responder rate after treatment. The secondary outcomes will include the assessments with pain intensity scales (visual analog scale, numeric rating scale, or other scales) on day 1 to 7 after surgery. Two independent reviewers will extract needed information from eligible trials using standardized electronic forms. Network meta-analysis will be performed using a frequentist framework based on electrical network theory. The relative effectiveness of the treatments will be ranked by using P score, which is the mean probability of a treatment ranking the best in all treatments. Meta-regression will be performed to assess the impact of surgery type, anesthesia methods, and funding source on the treatment ranking. The quality of the eligible RCTs will be evaluated by the Cochrane risk of bias tool.

ETHICS AND DISSEMINATION

The result of this network meta-analysis will clarify which is the relatively best somatosensory-stimulation treatment in relieving postoperative pain caused by hemorrhoidal surgery, and the review will, therefore, guide the management of postoperative pain after hemorrhoidal surgery for clinicians and patients. This review does not require ethical approval and will be reported in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42018115558.

The Evaluation and Office Management of Hemorrhoids for the Gastroenterologist

PURPOSE OF REVIEW

Hemorrhoid disease is extremely common, and seldom requires surgical intervention. The vast majority of patients can be cared for in the office setting and by the gastroenterologist. This piece aims to summarize the epidemiology and pathophysiology of hemorrhoid disease, along with the proper evaluation and office-based treatment of these patients.

RECENT FINDINGS

Most GI fellowship training programs spend little time on these topics, and the recommendation has been made to include anorectal care in the GI's "core curriculum." The use of the anoscope and a proper anorectal examination are keys to evaluating these patients, and the techniques available to treat these patients are described. Often overlooked in these patients are other anorectal issues that occur alongside hemorrhoidal issues very commonly-the most common being anal fissure. Comprehensive management of all of these issues will allow all but the most severely affected patients to avoid the expense and morbidity of surgical intervention. The anatomy, etiology, pathophysiology, diagnosis, and non-surgical treatment of hemorrhoid disease are presented with the gastroenterologist in mind.

Myofibrotic malformation vessels: unique angiodysplasia toward the progression of hemorrhoidal disease

Background

The etiology and pathogenesis of hemorrhoids is unclear, although hemorrhoids are a worldwide disease in men and women, with peak prevalence at 45–65 years of age. Hemorrhoidal cushions as the anal venous plexi are normal anatomical structures from infancy. This study attempts to reveal the angiodysplasia and other pathological changes in association with different degrees of symptomatic hemorrhoids.

Materials and methods

A total of 281 patients with internal hemorrhoids from degree I to IV underwent hemorrhoidectomy. The vascular changes were analyzed by microscopic assessment and software analysis, with Masson’s trichrome, CD34, and smooth muscle actin.

Results

The hemorrhoidal tissues exhibited abnormal vessels in the mucosae and submucosae that we termed them as myofibrotic malformation vessels (MMVs). MMVs are not ascribed to arteries or veins because they exhibit enlarged and tortuous lumens with smooth muscle dysplasia and fibrotic deposition in the walls without overlying mucosal ulceration. The muscularis mucosae also showed smooth muscle dysplasia and fibrosis, even if it were interrupted by the intruding MMVs. The statistical data indicated that the severity of all the changes correlate positively with the progression of hemorrhoids (P<0.001). Hemorrhoidal patients are prone for reoccurrence even with prolapsing hemorrhoid when compared with the conventional hemorrhoidectomy. Multiple logistic regression analysis showed that MMVs in mucosal propria, mean thickness of mucosal muscularis layer, and fibrotic changes in MMV were independent risk factors for MMVs in hemorrhoidal disease.

Conclusion

MMVs and muscularis mucosae dysplasia reciprocally contribute to hemorrhoidal exacerbation. The novel findings of this study propose that the characteristic features of MMVs and muscularis mucosae dysplasia of the anorectal tube ultimately cause symptomatic hemorrhoids, which could affect the clinical management of hemorrhoidal disease through the use of surgery to target the malformed vessels.

Vascular Z-shaped ligation technique in surgical treatment of haemorrhoid

AIM

To present the effectiveness of minimal invasive vascular zet ligation in the surgical treatment of haemorrhoidal disease (HD).

METHODS

Among 138 patients with 2(nd)-4(th) grade internal HD having several complaints and operated at our hospital between 2003-2013; 116 patients who regularly attended 1-year control were included in the study. Operation times, postoperative early period pain, satisfaction score, complications and relapse details were obtained from computer records retrospectively. Visual Analogous Scale (VAS) scores were used for patient satisfaction on the 3(rd), 7(th) and 21(st) days. Technique; fixed suture which is constituted by the first leg of the Z-shaped suture (to pass by the mucosa and muscular layer) was put in the pile root in order to ensure vascular ligation and fixation. The second leg of the Z-shaped suture is constituted by mobile suture and it passes by the pile mucosa and submucosa which prolapses 5-10 mm below the first suture.

RESULTS

Seventy-five of the patients (65%) were male, 41 of them (35%) were female and their age average was 41. The mean operation time was 12 ± 4.8 min. VAS/satisfaction score was found as 2.2/4.3, 1.8/4.0, 1.2/4.4 respectively on the 3(rd), 7(th), and 21(st) days. Four of the patient (3.5%) had relapse.

CONCLUSION

This technique is an easily applicable, cost efficient way of operation which increases patient satisfaction.

Recent advances in the management of hemorrhoids

Hemorrhoids are considered one of the most common anorectal diseases with a prevalence of 4.4% up to 36.4% of the general population, and a peak incidence between 45 and 65 years. Hemorrhoidal disease presents with a prolapsed lump, painless bleeding, discomfort, discharge, hygiene problems, soiling, and pruritus. Sliding anal canal lining theory is the most accepted theory as a cause of hemorrhoidal disease; however, it is also associated with hyper-vascularity, and, recently, with several enzymes or mediators involved in the disintegration of the tissues supporting the anal cushions, such as matrix metalloproteinase. A comprehensive search in published English-language literature till 2013 involving hemorrhoids was performed to construct this review article, which discusses advances in the management of hemorrhoids. This includes conservative treatment (life style modification, oral medications, and topical treatment), office procedures (rubber band ligation, injection sclerotherapy, infrared and radiofrequency coagulation, bipolar diathermy and direct-current electrotherapy, cryosurgery, and laser therapy), as well as surgical procedures including diathermy hemorrhoidectomy, LigaSure hemorrhoidectomy, Harmonic scalpel hemorrhoidectomy, hemorrhoidal artery ligation, stapled hemorrhoidopexy (SH), and double SH. Results, merits and demerits of the different modalities of treatment of hemorrhoids are presented, in addition to the cost of the recent innovations.

Modern management of hemorrhoidal disease

Complaints secondary to hemorrhoidal disease have been treated by health care providers for centuries. Most symptoms referable to hemorrhoidal disease can be managed nonoperatively. When symptoms do not respond to medical therapy, procedural intervention is recommended. Surgical hemorrhoidectomy is usually reserved for patients who are refractory to or unable to tolerate office procedures. This article reviews the pathophysiology of hemorrhoidal disease and the most commonly used techniques for the nonoperative and operative palliation of hemorrhoidal complaints.

Stapled hemorrhoidopexy - Initial experience from a general surgery center

BACKGROUND

Stapled hemorrhoidopexy is gaining popularity as a relatively painless alternative to conventional excisional hemorrhoidectomy. The initial experience from a service hospital is presented along with review of literature.

METHODS

40 cases were managed by stapled hemorrhoidopexy (SH) over a period of two and half years. The primary outcome measures assessed were the analgesic requirement in the post-operative period and the time taken to resume Activities of Daily Living (ADL). Additional outcome measures studied were; presence of bleeding per rectum, prolapse of mass per rectum, incontinence to flatus/stool, post-operative urinary retention, requirement of a repeat procedure, presence of post-operative anal stenosis, and residual external haemorrhoids at 1 week, 1, 3 and 6 months and 1 year after surgery.

RESULTS

40 patients with grade II, III and IV hemorrhoids underwent SH under spinal anesthesia. In the first 24 h 17 patients required a single dose of Injection Diclofenac Sodium while 19 patients required two doses and 4 patients had to be given three doses. 14 patients (35%) achieved Katz Index of Independence in Activities of Daily Living score of 6 on the first post-operative day and another 17 (42.5%) on the second post-operative day. By the fourth post-operative day all patients had achieved a score of 6. One patient had a rectal perforation as a complication of the procedure and another required a second procedure for excision of thrombosed external hemorrhoids.

CONCLUSION

Stapled hemorrhoidopexy is associated with less post-operative pain and early resumption of ADL. Although the procedure appears simple to perform, it can be associated with serious complications and still cannot be considered the standard of care for the operative treatment of internal hemorrhoids.

Quality of life after stapler haemorrhoidectomy evaluated by SF-36 questionnaire

OBJECTIVE

Hemorrhoids are normal elements of the anal canal anatomy and they become symptomatic with potential factors such as gravity or strain. When symptomatic, hemorrhoidal disease can be costly measured in time away from productive activities. The aim of the study was to assess changes in the quality of life of patients after hemorrhoidectomy using Short Form-36.

MATERIAL AND METHODS

Thirty patients, 24 male and 6 female (age 28 to 65), who were diagnosed with grade III and IV internal hemorrhoidal disease at the general surgery outpatient clinic and treated with stapled hemorrhoidectomy were enrolled in the study. They filled out Short Form-36 a week before surgery and four weeks after surgery. Post-Hoc tests were evaluated with Bonferroni correction after Kruskal Wallis analysis. Wilcoxon test, Student-t-test and Mann-Whitney U test were used for statistical analysis using SPSS 15.

RESULTS

Physical health (Physical functioning, Physical role restriction, Bodily pain) scores were significantly improved after surgery.

CONCLUSION

Success of hemorrhoidectomy operations can be evaluated by postoperative recovery, incidence of complications or relapses. Quality of life questionnaires are another method to evaluate the success of the treatment from the patient's perspective.

Haemorrhoids, rectal prolapse, anal fissure, peri-anal fistulae and sexually transmitted diseases

Anorectal disorders like haemorrhoids, rectal prolapse, anal fissures, peri-anal fistulae and sexually transmitted diseases are bothersome benign conditions that warrant special attention. They, however, can all be diagnosed by inspection or proctoscopy (sexually transmitted proctitis). Constipation can play an underlying role in haemorrhoids, rectal prolapse and anal fissures, and it is important to treat these conditions in order to avoid recurrences. Haemorrhoids and anal fissures are generally treated conservatively and surgery is seldom required. Rectal prolapse and cryptoglandular peri-anal fistulae are treated surgically. In a recurrent peri-anal fistula, the fistular tract needs to be visualised with anal ultrasound or magnetic resonance imaging (MRI). There are different techniques available for this evaluation, and care must be taken not to damage the anal sphincter. Peri-anal fistulae in Crohn's disease are treated conservatively and surgery is only required in cases with abscesses. Sexually transmitted proctitis needs to be adequately recognised and treated according to the infectious agent.

Hemorrhoids and fissure in ano

Hemorrhoids and anal fissures are common benign anorectal conditions that form a significant part of a colorectal surgeon's workload. This review summarizes and evaluates the current techniques available in their management.

Two-center experience in the treatment of hemorrhoidal disease using Doppler-guided hemorrhoidal artery ligation: functional results after 1-year follow-up

INTRODUCTION

Doppler-guided hemorrhoidal artery ligation (DGHAL), as a method of treating hemorrhoidal disease, is currently used in many centers across Europe, Asia, and Australia. The aim of our study was to evaluate the clinical effectiveness and functional results of DGHAL as estimated by means of anorectal manometry.

MATERIALS AND METHODS

Between 2000 and 2006 the DGHAL procedure was performed on 507 patients with II-IV degree hemorrhoids in two centers (Poland and Austria). Three hundred eight patients were included in the initial phase of the study, designed to estimate the method's effectiveness. During the second phase (199 patients) selected functional results were also assessed. Patients were classified as having grade II (144), III (319), and IV (44) hemorrhoids.

RESULTS

There were no intra- and immediate postoperative complications. Good results were reported by 351 patients (69.2%), and were acceptable in a further 75 cases (4.8%). When the patients were grouped according to the stage of hemorrhoidal disease, 133 out of 144 patients (92.4%) with grade II and 272 out of 324 (84%) with grade III had very good or good results. Only 18 out of 44 patients (41%) with grade IV were satisfied with the operation. Fifty-nine patients after anorectal folds, fissure or anal canal polyp excision required analgesics for 1-2 days. Apart from lower contraction amplitude and contraction speed after 1 month there were no differences in anorectal functional tests.

CONCLUSION

Based on our results we may conclude that DGHAL is a safe and effective method and may offer an important alternative to operative hemorrhoidectomy with no risk of postoperative stool incontinence, minimal postoperative pain, and early return of patients to their normal activities. Nevertheless, this is a fairly new procedure with a short-term follow-up. Until 5-year observations of large, multicenter, randomized trials are published we cannot recommend this method as a gold-standard procedure, although it still can offer significant benefits to patients.

Telephone follow-up following office anorectal surgery

INTRODUCTION

Patients with minor anorectal conditions are frequently reviewed at an 8-week out-patient appointment (OPA). This study was designed to assess whether telephone follow-up could reduce OPA numbers whilst maintaining patient satisfaction.

PATIENTS AND METHODS

Over an 11-month period, 46 patients (23 male) underwent banding of haemorrhoids and 14 were prescribed medical treatment for fissure-in-ano (3 male). All were telephoned at 6 weeks and were offered an 8-week OPA if they had continuing problems. Patients were telephoned at a later date by a member of the hospital's patient panel to assess satisfaction.

RESULTS

Overall, 88% were contacted at 6 weeks, 60% at the first attempt; 40% required two or more attempts. Of those who underwent banding, 68% were asymptomatic, 17% requested an OPA for re-banding and 15% requested an OPA for a different problem. Of fissure patients, 25% were cured; the remainder were prescribed either second-line medical treatment (8%), anorectal physiology (42%) or surgery (25%). All avoided an OPA. Of a potential 60 OPAs, 47 were saved by telephone follow-up. None of 7 non-contactable patients accepted a written offer of an OPA. Overall, 89% of patients were contacted by the patient panel; of these patients, 93% reported a high level of satisfaction.

CONCLUSIONS

Telephone follow-up can reduce the number of OPAs following out-patient treatment of minor anorectal conditions whilst maintaining a high level of patient satisfaction. However, it requires considerable consultant time. This process could be developed into either a nurse-led service with booked telephone appointments or a patient-led service to a dedicated hotline.

Death resulting from fournier gangrene secondary to thrombosis of very large hemorrhoids: report of a case

A 53-year-old male was admitted with a two-day history of abdominal pain, anal bleeding, fever, diarrhea, vomiting, and mental confusion. A diagnosis of thrombosis of very large hemorrhoids (Grade 4) was made. On the day of admission, he underwent an exploring laparotomy followed by abdominoperineal resection. The peritoneal cavity was filled with pus and blood clots. Because rectal necrosis was involved, sigmoid colostomy was imperative. Twenty-eight hours after surgery, the patient demonstrated signs of soft-tissue perineal necrosis associated with progressive pain and fever. He developed a rapidly progressive gangrene of the lower limbs and scrotum followed by acute renal and respiratory failure, and he died of sepsis. At autopsy, the cadaver showed jaundice and a large gangrene of the perineum and lower limbs. The internal organs showed features secondary to sepsis complications. To the best of our knowledge, this is the first autopsy study of a patient who died because of complications of hemorrhoids.

Managing haemorrhoids

Increased understanding of the anatomy of haemorrhoids has led to the development of new procedures to treat them. Among the surgical options for intractable prolapsed haemorrhoids, formal haemorrhoidectomy now competes with stapled haemorrhoidopexy, which is less painful and allows a shorter convalescence but may have a higher recurrence rate and needs further long term evaluation

Micronised purified flavonoid fraction: a review of its use in chronic venous insufficiency, venous ulcers and haemorrhoids

Micronised purified flavonoid fraction (MPFF) [Daflon 500 mg], an oral phlebotropic drug consisting of 90% micronised diosmin and 10% flavonoids expressed as hesperidin, improves venous tone and lymphatic drainage, and reduces capillary hyperpermeability by protecting the microcirculation from inflammatory processes. The absorption of diosmin is improved by its micronisation to particles with a diameter <2 microm. Compared with placebo, MPFF 500 mg twice daily significantly decreased ankle or calf circumference, and improved many symptoms of chronic venous insufficiency (CVI) and plethysmographic parameters in two randomised, double-blind, 2-month studies. Improvement in symptoms was parallelled by an improvement in health-related quality of life in a nonblind, 6-month trial. Significantly more venous leg ulcers </=10 cm in diameter completely healed with MPFF 500 mg twice daily plus standard management (compression and local treatment) for 2-6 months than with standard management alone or with placebo in a nonblind and a double-blind trial. The addition of MPFF to standard management was cost effective in a retrospective pharmacoeconomic analysis of the 6-month trial. Compared with placebo, the duration and/or intensity of individual symptoms of grade 1 or 2 acute internal haemorrhoids improved significantly with 3 tablets of MPFF 500 mg twice daily for 4 days then 2 tablets of MPFF 500 mg twice daily for 3 days. Two tablets of MPFF 500 mg daily for 60 or 83 days reduced the frequency, duration and/or severity of acute haemorrhoidal symptoms and improved the overall signs and symptoms of chronic (recurrent) haemorrhoids compared with placebo. Compared with a control group, MPFF significantly reduced the risk of secondary bleeding after elective haemorrhoidectomy. In clinical trials, MPFF had a tolerability profile similar to that of placebo; the most frequently reported adverse events were gastrointestinal and autonomic in nature. In conclusion, MPFF is a well established and well tolerated treatment option in patients with CVI, venous ulcers, or acute or chronic internal haemorrhoids. MPFF is indicated as a first-line treatment of oedema and the symptoms of CVI in patients in any stage of the disease. In more advanced disease stages, MPFF may be used in conjunction with sclerotherapy, surgery and/or compression therapy, or as an alternative treatment when surgery is not indicated or is unfeasible. The healing of venous ulcers </=10 cm in diameter is accelerated by the addition of MPFF to standard venous ulcer management. MPFF may reduce the frequency, duration and/or intensity of symptoms of grade 1 or 2 acute internal haemorrhoids, and also the severity of the signs and symptoms of chronic haemorrhoids.

Hemorrhoids

Technologic advances have contributed to numerous diverse approaches to the management of hemorrhoid disease over the past centuries. Better understanding of the pathophysiology and anatomy of the anal canal has also added to the increased success in the treatment of hemorrhoids. This article reviews the clinical and pathological aspects of hemorrhoid disease, emphasizing new therapeutic modalities.