Hemorrhoids Pathophysiology To Treatment
Hemorrhoids Pathophysiology To Treatment
Hemorrhoids Pathophysiology To Treatment
REVIEW
Varut Lohsiriwat
Varut Lohsiriwat, Division of Colon and Rectal Surgery, De- Several surgical approaches for treating hemorrhoids
partment of Surgery, Faculty of Medicine Siriraj Hospital, Ma- have been introduced including hemorrhoidectomy and
hidol University, Bangkok 10700, Thailand stapled hemorrhoidopexy, but postoperative pain is
Author contributions: Lohsiriwat V was the sole contributor invariable. Some of the surgical treatments potentially
to literature review, acquisition, analysis of data and manuscript cause appreciable morbidity such as anal stricture and
preparation.
incontinence. The applications and outcomes of each
Supported by Faculty of Medicine Siriraj Hospital, Mahidol
treatment are thoroughly discussed.
University, Bangkok, Thailand
Correspondence to: Varut Lohsiriwat, MD, PhD, Division of
2012 Baishideng. All rights reserved.
Colon and Rectal Surgery, Department of Surgery, Faculty of
Medicine Siriraj Hospital, Mahidol University, Prannok Road,
Bangkok 10700, Thailand. [email protected] Key words: Hemorrhoids; Pathophysiology; Treatment;
Telephone: +66-0-24198077 Fax: +66-0-24115009 Management; Outcome
Received: September 12, 2011 Revised: January 10, 2012
Accepted: February 8, 2012 Peer reviewer: Rasmus Goll, MD, Department of Gastro-
Published online: May 7, 2012 enterology, University Hospital of North Norway, 9038 Tromso,
Norway
venous dilatation and distortion in hemorrhoids, dys- increases shearing force on the anal cushions. However,
regulation of the vascular tone might play a role in recent evidence questions the importance of constipa-
hemorrhoidal development. Basically, vascular smooth tion in the development of this common disorder[14,16,17].
muscle is regulated by the autonomic nervous system, Many investigators have failed to demonstrate any signif-
hormones, cytokines and overlying endothelium. Im- icant association between hemorrhoids and constipation,
balance between endothelium-derived relaxing factors whereas some reports suggested that diarrhea is a risk
(such as nitric oxide, prostacyclin, and endothelium- factor for the development of hemorrhoids[16]. Increase
derived hyperpolarizing factor) and endothelium-derived in straining for defecation may precipitate the develop-
vasoconstricting factors (such as reactive oxygen radicals ment of symptoms such as bleeding and prolapse in pa-
and endothelin) causes several vascular disorders[11]. In tients with a history of hemorrhoidal disease. Pregnancy
hemorrhoids, nitric oxide synthase, an enzyme which can predispose to congestion of the anal cushion and
synthesizes nitric oxide from L-arginine, was reported to symptomatic hemorrhoids, which will resolve spontane-
increase significantly[8]. ously soon after birth. Many dietary factors including
Several physiological changes in the anal canal of pa- low fiber diet, spicy foods and alcohol intake have been
tients with hemorrhoids have been observed. Sun et al[12] implicated, but reported data are inconsistent[1].
revealed that resting anal pressure in patients with non-
prolapsing or prolapsing hemorrhoids was much higher CLASSIFICATION AND GRADING OF
than in normal subjects, whereas there was no significant
change in the internal sphincter thickness. Ho et al[13] per- HEMORRHOIDS
formed anorectal physiological studies in 24 patients with A hemorrhoid classification system is useful not only to
prolapsed hemorrhoids and compared with results in 13 help in choosing between treatments, but also to allow
sex- and age-matched normal subjects. Before operation, the comparison of therapeutic outcomes among them.
those with hemorrhoids had significantly higher resting Hemorrhoids are generally classified on the basis of
anal pressures, lower rectal compliance, and more perineal their location and degree of prolapse. Internal hemor-
descent. The abnormalities found reverted to the normal rhoids originate from the inferior hemorrhoidal venous
range within 3 mo after hemorrhoidectomy, suggesting plexus above the dentate line and are covered by mu-
that these physiological changes are more likely to be an cosa, while external hemorrhoids are dilated venules of
effect, rather than the cause, of hemorrhoidal disease. this plexus located below the dentate line and are cov-
ered with squamous epithelium. Mixed (interno-external)
EPIDEMIOLOGY AND RISK FACTORS OF hemorrhoids arise both above and below the dentate
line. For practical purposes, internal hemorrhoids are
HEMORRHOIDS further graded based on their appearance and degree of
Although hemorrhoids are recognized as a very com- prolapse, known as Golighers classification: (1) First-
mon cause of rectal bleeding and anal discomfort, the degree hemorrhoids (grade): The anal cushions bleed
true epidemiology of this disease is unknown because but do not prolapse; (2) Second-degree hemorrhoids
patients have a tendency to use self-medication rather (grade ): The anal cushions prolapse through the anus
than to seek proper medical attention. An epidemiologic on straining but reduce spontaneously; (3) Third-degree
study by Johanson et al[14] in 1990 showed that 10 million hemorrhoids (grade ): The anal cushions prolapse
people in the United States complained of hemorrhoids, through the anus on straining or exertion and require
corresponding to a prevalence rate of 4.4%. In both manual replacement into the anal canal; and (4) Fourth-
sexes, peak prevalence occurred between age 45-65 years degree hemorrhoids (grade ): The prolapse stays out
and the development of hemorrhoids before the age of at all times and is irreducible. Acutely thrombosed, incar-
20 years was unusual. Whites and higher socioeconomic cerated internal hemorrhoids and incarcerated, throm-
status individuals were affected more frequently than bosed hemorrhoids involving circumferential rectal mu-
blacks and those of lower socioeconomic status. How- cosal prolapse are also fourth-degree hemorrhoids[18].
ever, this association may reflect differences in health- Some authors proposed classifications based on ana-
seeking behavior rather than true prevalence. In the tomical findings of hemorrhoidal position, described as
United Kingdom, hemorrhoids were reported to affect primary (at the typical three sites of the anal cushions),
13%-36% of the general population[1,15]. However, this secondary (between the anal cushions), or circumferen-
tial, and based on symptoms described as prolapsing and
estimation may be higher than actual prevalence because
non-prolapsing[19]. However, these classifications are in
the community-based studies mainly relied on self-
less widespread use.
reporting and patients may attribute any anorectal symp-
toms to hemorrhoids.
Constipation and prolonged straining are widely CLINICAL EVALUATION OF
believed to cause hemorrhoids because hard stool and
increased intraabdominal pressure could cause obstruc- HEMORRHOIDS
tion of venous return, resulting in engorgement of the The most common manifestation of hemorrhoids is
hemorrhoidal plexus[1]. Defecation of hard fecal material painless rectal bleeding associated with bowel move-
ment, described by patients as blood drips into toilet tary and lifestyle modification to radical surgery, depend-
bowl. The blood is typically bright red as hemorrhoidal ing on degree and severity of symptoms[21,22]. The cur-
tissue has direct arteriovenous communication[3]. Positive rent management of internal hemorrhoids is illustrated
fecal occult blood or anemia should not be attributed in Table 1. In addition, selected meta-analyses showing
to hemorrhoids until the colon is adequately evaluated various treatment options of hemorrhoidal disease are
especially when the bleeding is atypical for hemorrhoids, shown in Table 2[23-32].
when no source of bleeding is evident on anorectal
examination, or when the patient has significant risk fac- Dietary and lifestyle modification
tors for colorectal neoplasia[18]. Since shearing action of passing hard stool on the anal
Prolapsing hemorrhoids may cause perineal irritation mucosa may cause damage to the anal cushions and lead
or anal itching due to mucous secretion or fecal soiling. to symptomatic hemorrhoids, increasing intake of fiber
A feeling of incomplete evacuation or rectal fullness is or providing added bulk in the diet might help eliminate
also reported in patients with large hemorrhoids. Pain is straining during defecation. In clinical studies of hemor-
not usually caused by the hemorrhoids themselves unless rhoids, fiber supplement reduced the risk of persisting
thrombosis has occurred, particularly in an external hemor- symptoms and bleeding by approximately 50%, but did
rhoid or if a fourth-degree internal hemorrhoid becomes not improve the symptoms of prolapse, pain, and itch-
strangulated. Anal fissure and perianal abscess are more ing[26]. Fiber supplement is therefore regarded as an ef-
common causes of anal pain in hemorrhoidal patients. fective treatment in non-prolapsing hemorrhoids; how-
The definite diagnosis of hemorrhoidal disease is ever, it could take up to 6 wk for a significant improve-
based on a precise patient history and careful clinical ment to be manifest[33]. As fiber supplements are safe
examination. Assessment should include a digital exami- and cheap, they remain an integral part of both initial
nation and anoscopy in the left lateral position. The peri- treatment and of a regimen following other therapeutic
anal area should be inspected for anal skin tags, external modalities of hemorrhoids.
hemorrhoid, perianal dermatitis from anal discharge or Lifestyle modification should also be advised to any
fecal soiling, fistula-in-ano and anal fissure. Some physi- patients with any degree of hemorrhoids as a part of
cians prefer patients sitting and straining in the squatting treatment and as a preventive measure. These changes
position to watch for the prolapse. Although internal include increasing the intake of dietary fiber and oral
hemorrhoids cannot be palpated, digital examination will fluids, reducing consumption of fat, having regular ex-
detect abnormal anorectal mass, anal stenosis and scar, ercise, improving anal hygiene, abstaining from both
evaluate anal sphincter tone, and determine the status straining and reading on the toilet, and avoiding medica-
of prostatic hypertrophy which may be the reason for tion that causes constipation or diarrhea.
straining as this aggravates descent of the anal cushions
during micturition. Hemorrhoidal size, location, severity Medical treatment
of inflammation and bleeding should be noted during Oral flavonoids: These venotonic agents were first de-
anoscopy. Intrarectal retroflexion of the colonoscope or scribed in the treatment of chronic venous insufficiency
transparent anoscope with flexible endoscope also allow and edema. They appeared to be capable of increasing
excellent visualization of the anal canal and hemorrhoid,
vascular tone, reducing venous capacity, decreasing capil-
and permit recording pictures[20].
lary permeability[34], and facilitating lymphatic drainage[35]
as well as having anti-inflammatory effects[36]. Although
MANAGEMENT OF HEMORRHOIDAL their precise mechanism of action remains unclear, they
are used as an oral medication for hemorrhoidal treat-
DISEASE ment, particularly in Europe and Asia. Micronized puri-
Therapeutic treatment of hemorrhoids ranges from die- fied flavonoid fraction (MPFF), consisting of 90% dios-
Table 2 Selected meta-analyses showing various treatment options for hemorrhoidal disease (in order of publication year)
1
With available detailed data on the patients enrolled. IC: Infrared coagulation; IS: Injection sclerotherapy; RBL: Rubber band ligation; SH: Stapled hemor-
rhoidopexy; TCMH: Traditional Chinese medicinal herbs.
min and 10% hesperidin, is the most common flavonoid to cure the disease. Thus, other therapeutic treatments
used in clinical treatment[27]. The micronization of the could be subsequently required. A number of topical
drug to particles of less than 2 m not only improved its preparations are available including creams and supposi-
solubility and absorption, but also shortened the onset tories, and most of them can be bought without a pre-
of action. A recent meta-analysis of flavonoids for hem- scription. Strong evidence supporting the true efficacy
orrhoidal treatment, including 14 randomized trials and of these drugs is lacking. These topical medications can
1514 patients, suggested that flavonoids decreased risk contain various ingredients such as local anesthesia, cor-
of bleeding by 67%, persistent pain by 65% and itching ticosteroids, antibiotics and anti-inflammatory drugs[41].
by 35%, and also reduced the recurrence rate by 47%[27]. Topical treatment may be effective in selected groups
Some investigators reported that MPFF can reduce rec- of hemorrhoidal patients. For instance, Tjandra et al[42]
tal discomfort, pain and secondary hemorrhage follow- showed a good result with topical glyceryl trinitrate 0.2%
ing hemorrhoidectomy[37]. ointment for relieving hemorrhoidal symptoms in patients
with low-grade hemorrhoids and high resting anal canal
Oral calcium dobesilate: This is another venotonic pressures. However, 43% of the patients experienced
drug commonly used in diabetic retinopathy and chronic headache during the treatment. Perrotti et al[43] reported
venous insufficiency as well as in the treatment of acute the good efficacy of local application of nifedipine oint-
symptoms of hemorrhoids[38]. It was demonstrated that ment in treatment of acute thrombosed external hemor-
calcium dobesilate decreased capillary permeability, in- rhoids. It is worth noting that the effect of topical applica-
hibited platelet aggregation and improved blood viscos- tion of nitrite and calcium channel blocker on the symp-
ity; thus resulting in reduction of tissue edema[39]. A clin- tomatic relief of hemorrhoids may be a consequence of
ical trial of hemorrhoid treatment showed that calcium their relaxation effect on the internal anal sphincter, rather
dobesilate, in conjunction with fiber supplement, provid- than on the hemorrhoid tissue per se where one might an-
ed an effective symptomatic relief from acute bleeding, ticipate a predominantly vasodilator effect.
and it was associated with a significant improvement in Apart from topical medication influencing tone of
the inflammation of hemorrhoids[40]. the internal anal sphincter, some topical treatment tar-
gets vasoconstriction of the vascular channels within
Topical treatment: The primary objective of most topi- hemorrhoids such as Preparation-H (Pfizer, United
cal treatment aims to control the symptoms rather than States), which contains 0.25% phenylephrine, petrola-
tum, light mineral oil, and shark liver oil. Phenylephrine and wavelength of the coagulator[51]. The necrotic tissue
is a vasoconstrictor having preferential vasopressor ef- is seen as a white spot after the procedure and eventu-
fect on the arterial site of circulation, whereas the other ally heals with fibrosis. Compared with sclerotherapy,
ingredients are considered protectants. Preparation-H is infrared coagulation (IRC) is less technique-dependent
available in many forms, including ointment, cream, gel, and avoids the potential complications of misplaced
suppositories, and medicated and portable wipes[44]. It sclerosing injection[22]. Although IRC is a safe and rapid
provides temporary relief of acute symptoms of hemor- procedure, it may not be suitable for large, prolapsing
rhoids, such as bleeding and pain on defecation. hemorrhoids.
Table 3 Summary of different philosophies regarding the pathogenesis of hemorrhoids and related surgical approaches
tive methods for the treatment of hemorrhoids. 22 Kaidar-Person O, Person B, Wexner SD. Hemorrhoidal
disease: A comprehensive review. J Am Coll Surg 2007; 204:
102-117
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