*Aneta Obcowska1, Małgorzata Kołodziejczak2
Haemorrhoids – current view on aetiology, pathogenesis and methods of treatment. A review of literature
Choroba hemoroidalna – współczesne poglądy na temat etiopatogenezy oraz metod leczenia. Przegląd piśmiennictwa
1Department of General and Oncological Surgery with the Subunit of Vascular Surgery, Lord’s Transfiguration Hospital, Warsaw
Head of Department: Professor Mariusz Frączek, MD, PhD
2Warsaw Proctology Centre, Saint Elizabeth’s Hospital, Mokotów Medical Centre
Head of Centre: Associate Professor Małgorzata Kołodziejczak, PhD
Choroba hemoroidalna jest najbardziej rozpowszechnioną chorobą proktologiczną. W artykule omówiono współczesne poglądy na temat etiopatogenezy, klasyfikacji i leczenia choroby hemoroidalnej. Etiopatogeneza choroby hemoroidalnej jest wieloczynnikowa i nie jest do końca poznana. Opublikowane w ostatnich latach badania dotyczące tego tematu sięgają do zmian na poziomie molekularnym i wśród nieprawidłowości wymieniają m.in. obniżony stosunek kolagenów typu I/III, w porównaniu z pacjentami bez choroby hemoroidalnej, co sprzyja zmniejszeniu sprężystości tkanki splotów hemoroidalnych. Pomimo dużego rozwoju diagnostyki proktologicznej, nadal podstawową metodą rozpoznania choroby hemoroidalnej jest wywiad i badanie proktologiczne. Z nowości klinicznych na uwagę zasługuje opublikowana w 2015 roku przez autorów z Włoch klasyfikacja opierająca się na ocenie każdego guzka krwawniczego oddzielnie – Single Pile Hemorrhoid Classification (SPHC) oraz skala oceny nasilenia dolegliwości choroby hemoroidalnej, korelująca z oceną jakości życia u pacjentów. Nowości w terapii hemoroidów polegają w większości na modyfikacji stosowanych dotychczas metod. Jedną z ostatnio proponowanych modyfikacji technicznych jest jednoczasowe założenie 2-3 gumowych podwiązek na jeden hemoroid. Modyfikacja ta według autorów zmniejsza odsetek nawrotów, krwawienia i wypadania hemoroidów w III°. Z kolei przedstawiona technika skleroterapii podczas fiberokolonoskopii poza możliwością jednoczasowego zdiagnozowania i usunięcia innych patologii, charakteryzuje się większym bezpieczeństwem iniekcji. Spośród metod klasycznego wycięcia hemoroidów nadal najczęściej wykonywaną procedurą jest operacja Milligana-Morgana. Według aktualnego piśmiennictwa operacje klasyczne z użyciem zaawansowanych urządzeń elektrochirurgicznych, jak LigaSure, nóż harmoniczny, charakteryzują się mniejszymi dolegliwościami bólowymi w przebiegu pooperacyjnym niż operacje wykonane przy użyciu koagulacji monopolarnej.
Haemorrhoids are the most prevalent proctologic disease. In this article we discuss the current view on its etiology, pathogenesis, classification and treatment of hemorrhoids. The etiopathogenesis of haemorrhoids is multifactorial and not fully understood. Recent publications on this topic reach a molecular level, pointing to a decreased ratio between collagen type I/III in comparison to patients without the disease, which promotes a decrease in haemorrhoid tissue elasticity. Despite the recent advancements in diagnostic methods, the mainstay is still patient history and physical examination, including per rectum examination. Worth noting is a classification published in 2015 by Italian authors, based on an individual assessment of each haemorrhoid, the Single Pile Haemorrhoid Classification (SPHC), and haemorrhoidal disease severity scale correlating with the patients’ quality of life. The innovations in the treatment of haemorrhoids are mostly modifications of the well-established methods. A recently proposed modification is binding one haemorrhoid with 2-3 bands simultaneously, thus decreasing recurrence rates, bleeding and degree III prolapses according to its authors. Also the proposed technique of sclerotherapy during fiber optic colonoscopy is characterized by higher safety of injections, while also offering the opportunity for diagnosis as well as treatment of other conditions. Among conventional surgical haemorrhoidectomy methods, the most commonly used technique is the Milligan-Morgan procedure. According to the literature, the use of advanced surgical equipment in conventional haemorrhoid surgeries like electrocautery with LigaSure or harmonic scalpel, is associated with less pain post-op than with the use of monopolar coagulation.
Haemorrhoids are the most common proctologic pathology in western countries, accounting for nearly half of the hospitalization cases in colorectal surgery units (1). It amounts to a social problem, as its symptoms frequently affect young, professionally active people, with some studies indicating as much as 5% of adult population to suffer from the problem (2). Approximately, 40% of patients with pathologically enlarged haemorrhoid plexus are symptomatic.
Haemorrhoidal disease is considered the most common reason for bleeding upon defecation, with bleeding also being its most common symptom (3-5). Other manifestations include itching and prolapsed haemorrhoids. Pain is not a pathognomic presentation of this disease, and only occurs in the case of thrombosed prolapsed haemorrhoids. It may also be associated with the swelling of anoderm, rich in distended, inflamed, and thrombosed venous plexus.
The etiopathogenesis of haemorrhoids remains unclear, yet it is certainly a multi-factor one. The theories on the development of haemorrhoidal disease so far have accounted for the following factors: hyperplasia or increased pressure of the internal anal sphincter (6), excessive dilation of the arteriovenous connections in the haemorrhoidal tissue (7), and age-related deterioration of the anchoring connective tissue system (8, 9).
The current theories on the etiopathogenesis of haemorrhoidal disease
The studies published over the recent years concerning the etiopathogenesis of haemorrhoidal disease have reached as deep as the molecular level. The disorders that have been discussed have included a decrease in type I/III collagen ratio in patients with haemorrhoidal disease as compared to patients without the disease, facilitating reduced tissue elasticity in the haemorrhoidal plexus (10, 11). This is a theory documented in a study published in 2015, where collagen I/III ratio in a group of 57 patients with grade III or IV haemorrhoidal disease was compared against samples collected from human cadavers without haemorrhoidal disease. Another report consistent with this theory has demonstrated the presence of fibrosis in dysplastic smooth muscle fibres in the muscular layer and the submucosa, correlating with symptoms of rectal bleeding and prolapsed haemorrhoids (12). Other theories aimed at explaining the development of haemorrhoidal disease on the molecular layer are concerned with a high level of metalloproteinase VII (13) in the blood serum, as well as with vascular proliferation manifesting with increased expression in endoglin (CD105) (14).
The most popular classification of haemorrhoids is one created by Goligher, based on the assessment of the degree of external haemorrhoid prolapse (15). Other classifications may also be found in literature, yet the majority of them have not been commonly used (16-18).
The newly-proposed classification for haemorrhoidal disease – Single Pile Haemorrhoid Classification (SPHC)
Single Pile Haemorrhoid Classification (SPHC) published in 2015 by Italian authors, based on an individual assessment of every haemorrhoid pile certainly deserves attention. It comprises the assessment of several morphological features of a haemorrhoid pile, including its location (on the face of a clock), Goligher’s classification, and identification of features other than prolapse, characteristic for the severity of haemorrhoidal disease (tab. 1) (19).
Tab. 1. Features assessed according to SPHC
|Number of pathological piles – N||Assessment of internal pile||Assessment of external pile|
|Goligher’s grade I-IV ||Fibrous inelastic pile – F||Congestion of external pile – E||Skin tags – S|
Example: 3IIIFE7–IIIFE11–II3 stands for the presence of 3 piles:
– one grade III pile at 7 o’clock, with visibly fibrous, inelastic internal pile (F) and congested external pile (E),
– one grade III pile at 11 o’clock, with visibly fibrous, inelastic internal pile (F) and congested external pile (E),
– one grade II pile at 3 o’clock.
The advocates of this classification have stressed its greater accuracy in determining disease advancement possible due to describing and highlighting characteristics other than just the prolapse. It is also useful for the assessment of surgical outcome. Nonetheless, it also seems to be quite complex, hence its application in the colorectal surgeon’s daily practice may initially be more challenging.
Symptom-based severity score f or haemorrhoidal disease
Another study by other authors, published in 2015, presented a scale for the assessment of haemorrhoidal disease severity, correlated with the assessment of the patient’s quality of life. Surprisingly, the authors cite bleeding to be poorly correlated with deteriorated quality of life. In its opening part, the questionnaire asks the physician whether the patient suffers from rectal bleeding and whether any other reasons potentially underlying the reported symptoms have been considered and ruled out. It is only when both questions have been answered affirmatively that the questionnaire is addressed at the patient. Interestingly, the applied point score is not proportionate to the frequency with which the symptoms occur, and varies depending on their character (tab. 2) (20).
Tab. 2. Scale assessment of the severity of symptoms of haemorrhoidal disease. Based on (20)
|Have you considered or ruled out other pathologies?|
Does your patient suffer from rectal bleeding?
Fill in the questionnaire only when the answers to the questions above are affirmative.
Please answer the questions below as concerns your symptoms over the last month.
|How severe/persistent is the itching or irritation?||0 – not at all/no symptoms|
1 – mild/does not bother me
3 – moderately severe
5 – very severe
|How severe is the pain/discomfort when relaxing?||0 – not at all/no symptoms|
1 – mild/does not bother me
3 – moderately severe
5 – very severe
|How severe is pain/discomfort when defecating?||0 – not at all/no symptoms|
1 – mild/does not bother me
3 – moderately severe
5 – very severe
|How often do you notice a prolapsed haemorrhoid pile?||0 – never|
1 – less often than once a month
2 – more often than once month
3 – more often than once a week
4 – every day
|Final score: 0-14 points|
As the questionnaire may be repeated, it allows the physician to assess the therapeutic outcome and the potential progress of the disease, hence it may find wider application among colorectal surgeons.
Regardless of the substantial advancements in diagnostic methods, patient history and physical examination remain the mainstay of haemorrhoidal disease diagnosis. When taking patient history, it is crucial to cover questions concerning the presence of contributing factors such as constipation, wrong dietary choices, and sedentary lifestyle alongside the ones regarding the symptoms as such.
Physical examination includes abdominal examination, inspection of the perineum, digital rectal examination, and anoscopy. In patients over 50 years old reporting rectal bleeding, as well as in every patient reporting any other alarming symptoms raising the suspicion of cancer or IDB a colonoscopy must be performed. For patients who are not in the group at greater risk from colorectal cancer, flexible fiberosigmoidoscopy (FFS) is recommended.
Even though in most cases of non-prolapsed haemorrhoids elevated maximum resting anal pressure is revealed, anorectal manometry is not commonly employed. This test is recommended to facilitate a better planning of surgery in patients with recurring haemorrhoids, incontinence, and decreased sphincter tone suggested by the examining colorectal surgeon.
Aside from several specific situations, conservative treatment remains the initial stage in the management of haemorrhoidal disease. It encompasses the right nutrition to prevent constipation, including fibre supplements, as well as oral medication and topical anti-inflammatory agents and myorelaxants.
There have been multiple reports confirming the beneficial effect of dietary fiber administered at a dosage of 20-30 g/d. The advantages have been listed to include decreased bleeding and itchiness (21, 22). Stool-softeners, e.g. paraffin-based agents, may also be used as an adjuvant.
Among the orally administered medications, at present flavonoids are the most commonly used. They are agents with anti-oxidant, anti-inflammatory, anti-allergic and vasodilating properties. Their mechanism of action consists in inhibiting enzymes such as hyaluronidase, elastase and collagenase which cause increased pericapillar permeability. A meta-analysis of numerous studies has determined the effectiveness of flavonoids for the suppression of bleeding and haemorrhoidal prolapsing (23-26). In the periods of acute symptomacity, when there is severe pain caused by the spasm of the internal anal sphincter, in the course of strangulated and thrombosed prolapsed haemorrhoids, substances that reduce the tone of the internal sphincter are applied (pharmacological sphincterotomy). As recently as several years ago, 0.5% nitroglycerin ointment was commonly ordered, yet owing to its side-effects (headaches) it is now only sporadically used. Currently, 0.3% nifedipine ointment is in use, being also very effective for relieving post-operative pain (28). In our practice, we have found 2% dilitiazem ointment to be effective, administered b.i.d rectally for a period of several weeks. Similarly to nifedipine, this is also an agent that reduces sphincter tone, thus providing analgesic effect in the post-operative course following haemorrhoidectomy. Transient chemical denervation of the internal sphincter may also be produced with botulinum toxin, a method that has been available for many years, currently regaining its popularity (29).
Corticosteroid ointments of anti-inflammatory and anti-itch properties are also still in use in conservative treatment of haemorrhoidal disease, however when applied on a long-term basis (for many weeks), they are believed to have a thinning effect on the mucosa, thus putting it at an increased risk of damage.
Streptokinase administered in the form of intrarectal suppositories (2000 000IU) has been found to be effective in management of prolapsed haemorrhoids. THERESA-2 and THERESA-4 studies demonstrated streptokinase administered for 5 days to reduce pain and bleeding accompanying prolapsed and strangulated haemorrhoids in a statistically significant manner. The above mentioned study found the therapy to be more effective than 25 mg Hydrocortisone suppositories, without causing any significant adverse effects (30, 31).
For their drying effect, zinc oxide ointments still tend to be used, as well as topical analgesics .
Another method used adjunctively to relieve haemorrhoidal pain are warm sitz baths (hip baths), with warm water sitz baths being equally effective to herbal ones (e.g. chamomile) (32) in our practice.
The majority of currently used instrumental methods have been known for years, some have had a historic impact.
Instrumental techniques are used in patients with symptomatic stage I and II haemorrhoids resistant to conservative treatment, but also in some patients with stage III haemorrhoids, particularly if just one haemorrhoid pile is affected. Particular methods are most commonly chosen according to their availability at a given treatment center. The idea at the core of the majority of the available techniques consists in destroying the haemorrhoid tissue by ligating the pile’s blood supply, thus causing local necrosis. In effect, in the course of healing a scar forms that anchors the remnants of the haemorrhoid tissue to the sphincters.
Modifications may be related to the equipment used, for instance automatic ligators allowing several rubber bands to be released and applied one by one.
One of the proposed changes in the technique consists in applying 2-3 bands laterally, starting 4 cm above the dentate line, and finishing at the haemorrhoid pile as such. This modification is said to allow for a reduction in the bleeding and prolapse recurrence rates of grade III haemorrhoids (fig. 1) (33).
Fig. 1. Rubber bands applied vertically onto one haemorrhoidal column. Based on (33)
Contraindications for rubber band ligation include coagulopathies, long-term anticoagulant and antiplatelet therapy (with the exception of 75 mg acetosalicylic acid therapy) (34). Owing to the existing risk of septic complications, this method is also contraindicated in patients with a lowered immune response (chemotherapy, HIV+, AIDS). Colorectal comorbidities such as an anal fissure or fistula, as well as any inflammatory conditions with accompanying anismus constitute relative contraindications.
Rubber band ligation (banding) for haemorrhoids has been in common practice for several dozen years and still remains popular among colorectal surgeons. The procedure is a relatively simple one, however some complications may still occur, including the following:
– pain – in 8% (35),
– bleeding: 2-4 days after banding (when the band falls off), and 5-7 days after banding (due to the exfoliation of the mucosa),
– thrombosis of a haemorrhoid located distally to the site where the band was applied on the same haemorrhoidal column,
– infectious complications, such as development of an anal abscess or sepsis.
In comparison to other instrumental methods, rubber band ligation proves more effective but is also associated with a higher complication rate. When compared with a conventional haemorrhoidectomy, rubber banding is associated with a higher recurrence rate, while involving less pain and fewer complication. In a large study conducted in a group of 805 patients, a 70% effectiveness of treating grade I-III haemorrhoids with this technique was demonstrated, regardless of their grade. Ligation using more than 4 bands (in the course of the entire therapy) was also noted to statistically significantly correlate with an inferior treatment outcome (35). Another retrospective study evaluating the effectiveness of this method in over 300 patients with grade II and III haemorrhoids over a period of 11 years after the application of the therapy determined an equally high effectiveness rate, and no haemorrhoid recurrence in 70% of the studied patients (36).
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