Haemorrhoids - a collagen disease?

Evaluation of Clinical Manifestations of Hemorrhoidal Disease, Carried Out Surgeries and Prolapsed Anorectal Tissues: Associations with ABO Blood Groups of Patients

Hemorrhoidal disease (HD) is a chronic multifactorial disease. Increased abdominal pressure, along with hyperperfusion, neovascularization, overexpression of inflammatory mediators, and dysbiosis, contributes to the development of HD. The deterioration of the anchoring connective tissue with reduced collagen content and altered collagen ratios, dilatation of blood vessels and thrombosis, muscle injury, and inflammation gradually lead to clinically manifesting prolapse and bleeding from hemorrhoids. The associations of the ABO blood types with a disease have been investigated for the upper gastrointestinal tract only. This study aimed to evaluate HD clinical manifestations, surgeries carried out, and the status of prolapsed anorectal tissues by exploring the associations with the patients' ABO blood groups. Clinical and various morphological methods, combined with extensive bioinformatics, were used. The blood type 0, grade III and IV HD individuals constituted the largest group in a moderately-sized cohort of equally represented males and females studied and submitted to surgical treatment of hemorrhoids. There were significantly more complaints reported by HD females compared to males (p = 0.0094). The Longo technique appeared mostly used, and there were proportionally more surgeries performed below the dentate line for HD individuals with blood type 0 compared to other blood type patients (24% vs. 11%). HD males were found to present with significantly more often inflamed rectal mucosa (p < 0.05). Loosening and weakening of collagenous components of the rectal wall combined with vascular dilation and hemorrhage was found to differ in 0 blood type HD individuals compared to other types. HD males were demonstrated to develop the ruptures of vascular beds significantly more often when compared to HD females (p = 0.0165). Furthermore, 0 blood type HD males were significantly more often affected by a disease manifested with tissue hemorrhage compared to the 0 blood type HD females (p = 0.0081). Collectively, the local status of chronically injured anorectal tissue should be considered when applying surgical techniques. Future studies could include patients with HD grades I and II to gain a comprehensive understanding of the disease progression, allowing for a comparison of tissue changes at different disease stages.

Identification of the microRNA alterations in extracellular vesicles derived from human haemorrhoids

NEW FINDINGS

What is the central question of this study? What are the morphological features and microRNA (miRNA) expression features of extracellular vesicles (EVs) from haemorrhoids (Hae-EVs) and normal tissues? What are the potential functions of the differentially expressed (DE) miRNAs in Hae-EVs? What is the main finding and its importance? We present, for the first time, the morphological features and miRNA profile of human Hae-EVs. Four hundred and forty-seven significant DE-miRNAs were identified. Gene ontology and pathway analysis of the DE-miRNAs indicated diverse roles of the Hae-EVs through different pathways. Our findings provide EV-based pathological features and the underlying mechanism of haemorrhoids.

ABSTRACT

Extracellular vesicles (EVs) play important roles in many pathophysiologies as cell-to-cell communication vehicles. However, the features and potential functions of the EVs in haemorrhoids remain unclear. Therefore, we performed microRNA (miRNA) microarray analysis in EVs derived from haemorrhoid tissue to identify the profile of miRNAs in these EVs and predict their potential functions. We obtained typical EVs from both haemorrhoid and control tissues. Microarray analysis identified 447 miRNAs with significant differential expresssion (DE): 245 upregulated and 202 downregulated. The top three upregulated miRNAs in haemorrhoid EVs (Hae-EVs), namely miR-6741-3p, miR-6834-3p and miR-4254, were detected by RT-qPCR in both Hae-EVs and haemorrhoid tissues. Interestingly, we found a different expression pattern in the haemorrhoid tissues from that in Hae-EVs. The potential target genes of these DE-miRNAs were predicted by the miRWalk and miRDB databases. Gene ontology (GO) analysis of the target genes showed that the DE-miRNAs contributed mainly to protein kinase activity, transcriptional activity and ubiquitin-protein function. KEGG search found that the DE-miRNAs might regulate the MAPK and Ras signalling pathways. These findings revealed, for the first time, the miRNA profiles in Hae-EVs and provided potential targets and pathways involved in the pathological process.

The effect of source animal age, decellularization protocol, and sterilization method on bovine acellular dermal matrix as a scaffold for wound healing and skin regeneration

BACKGROUND

Healing the full-thickness skin wounds has remained a challenge. One of the most frequently used grafts for skin regeneration is xenogeneic acellular dermal matrices (ADMs), including bovine ADMs. This study investigated the effect of the source animal age, enzymatic versus non-enzymatic decellularization protocols, and gamma irradiation versus ethylene oxide (EO) sterilization on the scaffold.

METHODS

ADMs were prepared using the dermises of fetal bovine or calf skins. All groups were decellularized through chemical and mechanical methods, unless T-FADM samples, in which an enzymatic step was added to the decellularization protocol. All groups were sterilized with ethylene oxide (EO), except G-FADM which was sterilized using gamma irradiation. The scaffolds were characterized through scanning electron microscopy, differential scanning calorimetry, tensile test, MTT assay, DNA quantification, and real-time PCR. The performance of the ADMs in wound treatment was also evaluated macroscopically and histologically.

RESULTS

All ADMs were effectively decellularized. In comparison to FADM (EO-sterilized fetal ADM), morphological, and mechanical properties of G-FADM, T-FADM, and CADM (EOsterilized calf ADM) were changed to different extents. In addition, the CADM and G-FADM were thermally more stable than the FADM and T-FADM. Although all ADMs were noncytotoxic, the wounds of the FADM, T-FADM, and G-FADM groups were contracted to almost 30.0% of the original area on day 7, significantly faster than the CADM (17.5% ± 1.7) and control (12.2% ± 1.59) groups. However, by day 21, all ADMs were mostly closed except for the untreated group (60.1 ± 1.8).

CONCLUSION

Altogether, fetal source and EO-sterilized samples performed better than calf source and gamma-sterilized samples unless in some mechanical properties. There was no added value in using enzymatic treatment during the decellularization process. Our results suggest that the age, decellularization, and sterilization methods of animal source should be selected based on the clinical requirements.

A Morphometric Analysis of Pathological Alterations in Hemorrhoidal Disease Versus Normal Controls: A Controlled Trial

Objective Until today, the true pathophysiology of hemorrhoidal disease (HD) has not yet been unraveled. More and more evidence guides us towards the hypothesis that reduced connective tissue stability is associated with a higher incidence of hemorrhoids. The present study aimed to compare the quantity and quality of collagen, and vessel morphometrics, in patients with symptomatic HD compared with normal controls.

Methods Twenty-two samples of grade III and grade IV HD tissue from patients undergoing a hemorrhoidectomy between January 2004 and June 2015 were included in the study group. Samples of 15 individuals without symptomatic HD who donated their body to science and died a natural death served as controls. The quantity and quality of anal collagen, and anal vessel morphometrics were objectified. The quality of collagen was subdivided in young (immature) and old (mature) collagen.

Results Patients with HD had an increased percentage of total anal collagen (62.1 ± 13.8 versus 18.7 ± 14.5%; p = 0.0001), a decreased percentage of young collagen (0.00009 ± 0.00008 versus 0.0008 ± 0.0008%; p = 0.001), and a smaller surface area of the anal vessels (795.1 ± 1215.9 micrometre2 versus 1219.0 ± 1976.1; p = 0.003) compared with controls. The percentage of old collagen did not differ between the control and study groups (0.588 ± 0.286% versus 0.389 ± 0.242%; p = 0.06).

Conclusion The outcomes of the present study suggest that alterations in anal collagen composition may play a role in the formation of hemorrhoids.

Risk factors for hemorrhoidal disease among healthy young and middle-aged Korean adults

Hemorrhoidal disease is a highly prevalent anorectal condition causing substantial discomfort, disability, and decreased quality of life. Evidence on preventable risk factors for hemorrhoidal disease is limited. We conducted a cross-sectional study of 194,620 healthy men and women who completed a health screening exam including colonoscopy in 2011–2017. We evaluated potential risk factors of hemorrhoidal disease, including lifestyle factors, medical history, birth history, gastrointestinal symptoms, and anthropometric measurements. The prevalence of hemorrhoidal disease was 16.6%, and it was higher in females than in males (17.2 vs. 16.3%; P < 0.001). Compared to men, the prevalence of hemorrhoidal disease was higher in parous women (adjusted odds ratio [OR] 1.06; 95% confidence interval [CI] 1.02–1.10), and lower in nulliparous women (adjusted OR 0.92; 95% CI 0.86–0.98). In the adjusted analyses, older age, female sex, smoking, overweight, and being hypertensive were independently associated with the presence of hemorrhoidal disease. The prevalence of hemorrhoidal disease was positively associated with body mass index and waist circumference in parous women. The prevalence of hemorrhoidal disease was higher in older age, females, ever-smokers, and hypertensive participants. The association of excess adiposity with the prevalence of hemorrhoidal disease differed by sex and parity.

Lifestyle and Risk Factors in Hemorrhoidal Disease

Constipation, a low fiber diet, a high Body Mass Index, pregnancy, and a sedentary lifestyle are often assumed to increase the risk of hemorrhoidal disease (HD). However, evidence regarding these factors is controversial. This mini-review aims to examine and critically analyze the association between main risk factors and the prevalence of HD, focusing both on the patient's clinical history and on a tailored treatment. Moreover, some practical suggestions about lifestyle and conservative approaches are given to help clinicians in the management of patients with HD and to obtain the best results from therapy.

Influence of Bowel Habit and Hormonal Changes on the Development of Hemorrhoidal Disease During Pregnancy and the Postdelivery Period: A Prospective Cohort Study

BACKGROUND

Hemorrhoidal disease in women during pregnancy is common in clinical practice. However, prospective data on its real prevalence and women's demographics are scarce.

OBJECTIVE

The aim of this study was to determine the prevalence of hemorrhoidal disease during pregnancy and to assess its impact on quality of life. In addition, this study aimed to identify the relationship between patients' characteristics, bowel habits, hormonal changes, and the presence of symptomatic hemorrhoids.

DESIGN

This is a prospective longitudinal cohort study.

SETTING

This study was conducted in the Obstetrics Department for pregnancy follow-up.

PATIENTS

The patients evaluated were a cohort of pregnant women.

INTERVENTION

The study was designed to follow a homogeneous cohort of women for 15 months. Visits took place in the first and third trimesters of pregnancy, and 3 and 6 months after delivery. Women's demographics (age, medical history, bowel habit, Bristol stool scale) and serum determination of pregnancy-related hormones (estrogen, progesterone, and relaxin) were determined.

MAIN OUTCOME MEASURES

The primary outcome was the development of hemorrhoidal disease.

RESULTS

Overall, 109 women (mean age, 31.2 ± 5.4 years) were included in the study. The prevalence of symptoms and physical findings of hemorrhoidal disease was present in 11% in the first trimester, 23% in the third trimester, 36.2% at 1 month after delivery, and 16.9% at 3 months after delivery. A medical history of hemorrhoidal disease was significantly associated with the diagnosis of hemorrhoids in the first trimester (p < 0.0001) and third trimester (p = 0.005). Symptoms of constipation were associated with this clinical disorder in the first trimester (p = 0.011) and the third trimester of pregnancy (p = 0.022). No association was found between hormonal changes and the development of hemorrhoidal disease.

LIMITATIONS

A larger sample would provide more information.

CONCLUSIONS

The prevalence of women with hemorrhoidal disease increases during pregnancy and after delivery. A history of hemorrhoidal disease and constipation is significantly associated with the diagnosis of symptomatic hemorrhoidal disease. See Video Abstract at http://links.lww.com/DCR/B504.

INFLUENCIA DEL HBITO INTESTINAL Y LOS CAMBIOS HORMONALES EN EL DESARROLLO DE LA ENFERMEDAD HEMORROIDAL DURANTE EL EMBARAZO Y EL PERODO POSTERIOR AL PARTO UN ESTUDIO DE COHORTE PROSPECTIVO

ANTECEDENTES:La enfermedad hemorroidal en mujeres durante el embarazo es común en la práctica clínica. Sin embargo, hay escasos datos prospectivos sobre su prevalencia real y la demografía de las mujeres.OBJETIVO:El objetivo fue determinar la prevalencia de enfermedad hemorroidal durante el embarazo y evaluar su impacto en la calidad de vida. Además, identificar la relación entre las características de los pacientes, los hábitos intestinales, los cambios hormonales y la presencia de hemorroides sintomáticas.DISEÑO:Estudio prospectivo de cohorte longitudinal.AJUSTE:Este estudio se realizó en el Departamento de Obstetricia para el seguimiento del embarazo.PACIENTES:Una cohorte de mujeres embarazadas.INTERVENCIÓN:El estudio se diseñó para realizar un seguimiento de una cohorte homogénea de mujeres durante 15 meses. Las visitas se realizaron en el primer y tercer trimestre del embarazo, y a los 3 y 6 meses después del parto. Se determinaron los datos demográficos de las mujeres (edad, antecedentes médicos, hábito intestinal, escala de heces de Bristol) y la determinación sérica de hormonas relacionadas con el embarazo (estrógeno, progesterona y relaxina).PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue el desarrollo de enfermedad hemorroidal.RESULTADOS:Se incluyó en el estudio a 109 mujeres (edad media, 31,2 ± 5,4 años). La prevalencia de síntomas y hallazgos físicos de enfermedad hemorroidal estuvo presente en 11% en el primer trimestre, 23% en el tercer trimestre, 36,2% 1 mes después del parto y 16,9% 3 meses después del parto. Un historial médico previo de enfermedad hemorroidal se asoció significativamente con el diagnóstico de hemorroides en el primer trimestre (p <0,0001) y tercer trimestre (p = 0,005). Los síntomas de estreñimiento se asociaron con este trastorno clínico en el primer trimestre (p = 0,011) y el tercer trimestre del embarazo (p = 0,022), respectivamente. No se encontró asociación entre los cambios hormonales y el desarrollo de enfermedad hemorroidal.LIMITACIONES:Una muestra más grande proporcionaría más información.CONCLUSIONES:La prevalencia de mujeres con enfermedad hemorroidal aumentó durante el embarazo y el posparto. El antecedente de enfermedad hemorroidal y estreñimiento se asociaron significativamente con el diagnóstico de enfermedad hemorroidal sintomática. Consulte Video Resumen en http://links.lww.com/DCR/B504.

Changes in the proportions of types I and III collagen in hemorrhoids: the sliding anal lining theory

Objective This study aims to determine changes in the proportions of types I and III collagen in hemorrhoids and to verify the sliding anal canal lining theory.

Patients and method The study is focused on a sample of 17 patients, 9 females and 8 males (age range: 30–70 years), with grade III and grade IV hemorrhoids. Tissue from 4 fetuses (age: 16 weeks of gestation) was used as control sample. All the participants gave their informed consent. Samples were gathered in 2014. All patients underwent open hemorrhoidectomy by using the technique described by Milligan and Morgan, published in Lancet journal in 1937. The hemorrhoid samples were stained with hematoxylin–eosin for the histologic study to confirm the hemorrhoidal tissue diagnosis. The picrosirius red staining protocol was used after the histologic analysis. The method used for image processing is described in the text. Images were imported to the Image Tool for Windows software. The same process was used on the embryonic tissue. Data resulting from the analysis of images were processed using STATISTICA, a software for statistical analysis.

Results When compared, it was found that the two tissues presented very different values, with hemorrhoids containing the highest type III collagen values.

Conclusion Our results seem to imply that hemorrhoids have a larger proportion of type III collagen than fetal tissue. They also suggest a possible age-related deterioration of the tissue.

Perioperative Adverse Events in Women Undergoing Concurrent Hemorrhoidectomy at the Time of Urogynecologic Surgery

OBJECTIVE

The aim of this study was to describe the incidence and trends of outcomes after concurrent surgeries for symptomatic hemorrhoids and pelvic floor disorders.

METHODS

This was a retrospective matched cohort study. Women who underwent concurrent vaginal urogynecologic and hemorrhoid surgery between 2007 and 2017 were identified by their surgical codes and matched to a cohort of women who underwent vaginal urogynecologic surgery only. The medical record was queried for demographic and perioperative data.

RESULTS

Thirty-three subjects met the inclusion criteria; 198 subjects were matched accordingly (N = 231). Mean age and body mass index were 57 ± 12 years and 28.9 ± 5.6 kg/m, respectively. Subjects who underwent concurrent hemorrhoidectomy were more likely to have had previous prolapse surgery (27.3% vs 15.2%, P = 0.09) and preoperative fecal incontinence (27.3% vs 13.6%, P = 0.05). Concurrent cases were more likely to have unplanned office visits (27.2% vs 12.6%, P = 0.03) and phone calls (range, 1-7 vs 0-10; P = 0.001), mostly for pain complaints. Reoperation was higher in combined cases (3% vs 0%, P = 0.01); however, the overall rate of serious perioperative adverse events was low and not different between groups. Concurrent cases were more likely to be discharged home with a Foley (42.4% vs 18.2%, P = 0.002) and to have a postoperative urinary tract infection (33.3% vs 10.6%, P = 0.005). In the concurrent group, 33.3% of the patients experienced severe rectal pain.

CONCLUSIONS

Patients undergoing concurrent hemorrhoidectomy at the time of vaginal urogynecologic surgery are at higher risk of minor events such as postoperative urinary tract infection and need for discharge home with a Foley, as well as risk of pain that may be greater than urogynecologic surgery alone.

Rethinking What We Know About Hemorrhoids

Although hemorrhoids are responsible for considerable economic cost and personal suffering, they have received surprisingly little research attention. In the United States, hemorrhoids are the third most common outpatient gastrointestinal diagnosis with nearly 4 million office and emergency department visits annually. The etiology of hemorrhoids is speculative. A low-fiber diet and constipation have historically been thought to increase the risk for hemorrhoids, but not proven. Symptoms commonly attributed to hemorrhoids include bleeding, pain, pruritus, fecal seepage, prolapse, and mucus discharge. Research has found that these symptoms were equally reported by patients with and without hemorrhoids. Medical therapies for hemorrhoids have not been formally studied except for fiber where the results have been inconsistent. A number of office-based interventions such as rubber band ligation and infrared coagulation are widely used and economically favorable for practitioners. Surgical procedures are effective at eliminating hemorrhoids but may be painful. Given the burden of disease and numerous gaps in our understanding, the time has come for targeted research to understand the cause, symptoms, and best treatment for patients with symptomatic hemorrhoids.

[Common sense of diosmin administration in combined treatment of hemorrhoids]

Flavonoids are herbal medicines and widely used for chronic venous diseases and hemorrhoids. Flavonoid diosmin in both micronized and non-micronized form is a part of various drugs. According to literature data, flavonoids are able to reduce venous stasis, suppress local inflammation, improve venous tone and lymphatic outflow. It should be noted that biological models of in vivo trials have certain limitations while available data of different researches are contradictory. However, flavonoids were recommended for hemorrhoids in view of meta-analysis of 14 trials comparing flavonoids (diosmin, micronized purified flavonoid fraction and rutosides) with placebo in 1514 patients with hemorrhoids and Cochrane review of 24 randomized controlled trials (2,334 participants). These drugs should be administered as a part of complex therapy. At the same time, there is no conclusive evidence to prefer only one of these medicines. There are also no data confirming the benefits of daily dosage of 3000 mg per day of micronized fraction of flavonoids compared with 1800 mg of purified diosmin per day for treatment of acute hemorrhoids.

A Randomized Controlled Trial Comparing Suture-Fixation Mucopexy and Doppler-Guided Hemorrhoidal Artery Ligation in Patients with Grade III Hemorrhoids

Background. We aimed to evaluate the effectiveness of a suture-fixation mucopexy procedure by comparing with Doppler-guided hemorrhoidal artery ligation (DGHAL) in the management of patients with grade III hemorrhoids. Methods. This was a randomized controlled trial. One hundred patients with grade III hemorrhoids were randomly assigned to receive suture-fixation mucopexy (n = 50) or DGHAL (n = 50). Outcome assessments were performed at 2 weeks, 12 months, and 24 months. Assessments included resolution of clinical symptoms, postoperative complications, duration of hospitalization, and total costs. Results. At 2 weeks, one (2%) patient in suture-fixation group and four (8%) patients in DGHAL group had persistent prolapsing hemorrhoids. Postoperative bleeding was observed in two patients (4%) in suture-fixation group and one patient in DGHAL group. There was no significant difference in short-term recurrence between groups. Postoperative complications and duration of hospitalization were comparable between the two groups. Rates of recurrence of prolapse or bleeding at 12 months did not differ between groups. However, recurrence of prolapse at 24 months was significantly more common in DGHAL group (19.0% versus 2.3%, p = 0.030). Conclusions. Compared with DGHAL, the suture-fixation mucopexy technique had comparable short-term outcomes and favorable long-term outcomes.

Hemorrhoids and matrix metalloproteinases: A multicenter study on the predictive role of biomarkers

INTRODUCTION

An association between hemorrhoidal disease and matrix metalloproteinases (MMPs) has been described previously. MMPs regulate extracellular structural proteins and tissue remodeling. Neutrophil gelatinase-associated lipocalin (NGAL) is involved in the regulation of MMP activity. The aim of this work was to study the relationship between tissue immunoreactive levels of MMPs and NGAL and different stages of hemorrhoids.

METHODS

In a multicenter, open-label, prospective study, the population under investigation consisted of 2 groups: group I (with symptomatic hemorrhoids; Goligher grade I-IV) and group II (healthy volunteers).

RESULTS

We enrolled 97 patients with hemorrhoids: 21 with grade I hemorrhoids, 37 with grade II, 14 with grade III, and 25 with grade IV. Finally, 90 healthy volunteers (53 males and 37 females; age range, 19-70 years; median, 56) were enrolled in group II. Enzyme-linked immunosorbent assay and Western blot analysis revealed greater levels of immunoreactive MMPs and NGAL in all patients with hemorrhoids. We recorded significantly greater levels of MMP-1 and MMP-3 in grade I and II patients compared with control, and greater levels of MMP-3, MMP-7, MMP-8, and MMP-9 in grade III compared with grade II. MMP-9 and NGAL were particularly increased in patients with grade IV especially in case of thrombosed hemorrhoids.

CONCLUSION

These results provide potentially important insights into the understanding of the natural history of hemorrhoids. MMPs and NGAL play a role in development of disease and may represent molecular markers for the complications such as hemorrhoidal thrombosis.

Abnormalities in collagen composition may contribute to the pathogenesis of hemorrhoids: morphometric analysis

Purpose

While hemorrhoidal disease is common, its etiology remains unclear. It has been postulated that disturbances in collagen lead to reduced connective tissue stability, and in turn to the development of hemorrhoidal disease. We aimed to compare the quality and quantity of collagen in patients with hemorrhoidal disease versus normal controls.

Methods

Specimens from 57 patients with grade III or IV internal hemorrhoids undergoing hemorrhoidectomy between 2006 and 2011 were evaluated. Samples from 20 human cadavers without hemorrhoidal disease served as controls. Quality of collagen was analyzed by collagen I/III ratio, and quantity of collagen was determined by collagen/protein ratio. The study group was subdivided into gender and age subgroups.

Results

The male:female ratios in the study and control groups were 30:27 and 10:10, respectively. Median age was significantly less in the study group [46.9 years (range 20–69)] compared to the control group [76 years (range 46–90)] with P < 0.05. Tissues from patients in the study group had significantly lower collagen I/III ratio as compared to the control group (4.4 ± 1.1 vs. 5.5 ± 0.6; P < 0.0001). Nevertheless, despite a trend toward lower collagen/protein ratio in the study group, it did not reach statistical significance (57 ± 42.4 vs. 73 ± 32.5 g/mg; P = 0.167). There was no difference in collagen I/III or collagen/protein ratios among different age groups and genders.

Conclusions

Hemorrhoidal tissues from patients with hemorrhoidal disease appear to have reduced mechanical stability as compared to normal controls.

Ehlers-danlos syndrome-hypermobility type and hemorrhoids

Ehlers-Danlos syndrome-hypermobility type (EDS-HT) is a connective tissue disorder associated with chronic musculoskeletal pain. The diagnosis is based on simple clinical examination, although it is easily overlooked. Herein we present a case of EDS-HT associated with hemorrhoids and suggest that there may be an association between the two conditions.

Matrix Metalloproteinases in Pathogenesis of Hemorrhoidal Disease

The aim of this study is to investigate the accuracy of serum matrix metalloproteinase (MMP) levels in an effort to find a reliable factor that may play an important role in pathogenesis of hemorrhoidal disease. Twenty control subjects and 21 Grade I, 19 Grade II, 20 Grade III, and 21 Grade IV patients with internal hemorrhoid were included in this prospective study. The mean ages of control subjects were 47.65 ± 6.71 standard deviation (SD) years (range, 37 to 60 years). The mean age of internal Grade I, Grade II, Grade III, and Grade IV patients with internal hemorrhoid were 48.85 ± 6.44, 47.20 ± 6.75, 44.90 ± 6.13, and 42.95 ± 3.49 SD years (ranges, 38 to 58, 38 to 60, 34 to 55, and 38 to 50 years), respectively. Ten milliliters of blood was taken from all subjects. Enzymelinked immunosorbent assay (ELISA) for MMP-1, -2, -7, and -9 levels were performed using an ELISA kit (R&D Systems) following the manufacturer's instructions. There was an important difference between Grade I and Grade II groups in the serum levels of MMP-9 ( P < 0.01). Patients with Grade III hemorrhoidal disease had significantly higher serum levels of all MMP than patients with Grade I and Grade II hemorrhoidal disease ( P < 0.001). Also, patients with Grade 4 hemorrhoidal disease had higher serum levels of MMP-7 and -9 according to Grade I, II, and III groups ( P < 0.01, 0.001). High serum levels of MMP are present in patients with hemorrhoids, suggesting the possible mechanism in the pathogenesis of hemorrhoids.

Pharmacological treatment of hemorrhoids: a narrative review

INTRODUCTION

Hemorrhoid disease is the cause of most proctologic complaints and hundreds of medical and surgical therapies have been proposed to relieve symptoms. However, the role and the correct indication of medical treatments are still controversial. Further, the utility of conservative measures are rarely scientifically supported by adequate trials.

AREAS COVERED

This narrative review is based on the search and analysis of full papers in English language selected from PubMed in the past 30 years using the following MeSH Editing: hemorrhoids, conservative treatment, medical treatment and hemorrhoids, pregnancy and hemorrhoids, thrombosed hemorrhoids, randomized trials and hemorrhoids, postoperative pain and hemorrhoids.

EXPERT OPINION

Early stages (I/II degrees) of this disease could be effectively managed conservatively with several approaches as lifestyle changes, fiber supplement, topical ointments and phlebotonic drugs. The more advanced hemorrhoid stages (III/IV degrees) need some type of surgery, but medical therapy is still useful to minimize anal symptoms as a bridge-to-surgery treatment. Further, post-hemorrhoidectomy pain, hemorrhoidal crisis even in pregnancy could benefit from the adjunct of local and systemic medical treatment. This expert opinion, based also on long-lasting clinical practice, also supports the use of medical treatment in symptoms relief in patients with hemorrhoid disease.

Conservative and surgical treatment of haemorrhoids

The management of haemorrhoids has evolved rapidly during the past few decades. Several new treatments have been proposed with the aim of reducing patients' postoperative pain, time to return to normal life, risk of early and late complications, and recurrence rate. Although conservative treatment based on dietary and lifestyle changes can help the majority of patients, and rubber band ligation and phlebotonic drugs can effectively treat grade I and II haemorrhoids, surgery is required for the most advanced stages. Milligan-Morgan haemorrhoidectomy is considered to be the gold-standard approach for grade IV haemorrhoids. An increasing number of minimally invasive treatment options, including mucopexy with or without mucosal resection and haemorrhoid artery ligation, have now been proposed for the management of grade III haemorrhoids. These approaches aim to correct the underlying pathophysiological mechanisms involved in the aetiology of haemorrhoids. An increased risk of recurrence is the price to pay for these minimally invasive and less painful treatments, but the sparing of the sensitive anoderm and a rapid return to normal life without pain are greatly appreciated by patients. An algorithm for the management of haemorrhoids using evidence-based medicine is also presented here.

Direct and recurrent inguinal hernias are associated with ventral hernia repair: a database study

BACKGROUND

A systemically altered connective tissue metabolism has been demonstrated in patients with abdominal wall hernias. The most pronounced connective tissue changes are found in patients with direct or recurrent inguinal hernias as opposed to patients with indirect inguinal hernias. The aim of the present study was to assess whether direct or recurrent inguinal hernias are associated with an elevated rate of ventral hernia surgery.

METHODS

In the nationwide Danish Hernia Database, a cohort of 92,457 patients operated on for inguinal hernias was recorded from January 1998 until June 2010. Eight-hundred forty-three (0.91 %) of these patients underwent a ventral hernia operation between January 2007 and June 2010. A multivariate logistic regression analysis was applied to assess an association between inguinal and ventral hernia repair.

RESULTS

Direct (Odds Ratio [OR] = 1.28 [95 % CI, 1.08-1.51]) and recurrent (OR = 1.76, [95 % CI, 1.39-2.23]) inguinal hernias were significantly associated with ventral hernia repair after adjustment for age, gender, and surgical approach (open or laparoscopic).

CONCLUSIONS

Patients with direct and recurrent inguinal herniation are more prone to ventral hernia repair than patients with indirect inguinal herniation. This is the first study to show that herniogenesis is associated with type of inguinal hernia.