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Aim: Hemorrhoids are one of the most common anorectal complaints reported in anorectal clinics with an estimated prevalence of 4.4% in the United States and 13-36% in the United Kingdom. It is one of the oldest diseases known to mankind with history seen in the ancient medical writings of every culture, including Babylonian, Hindu, Greek, Egyptian, and Hebrew. According to the Unani system of medicine, the cause of hemorrhoids is morbid Khilt-e- Sauda (black bile). Habb-e-Sandroos has hemostatic, astringent, desiccant, laxative, and anti-inflammatory activity and since ages used by Unani physicians to treat hemorrhoids, hence present study aimed to evaluate its effect in Internal hemorrhoids. Methods: This single-arm open-labelled clinical trial was conducted among 30 male and female patients, aged 20 to 65years, with 1st and 2nd degree hemorrhoids confirmed by proctoscopy. Habb-e-Sandroos, 2 tablets each weighing 0.5g was given thrice a day for 45 days. The efficacy outcome was assessed by an arbitrary grading scale. Results: Significant changes were observed in efficacy outcomes. Follow up assessments were done on every fortnightly for the first forty-five days and monthly follow-up for two months without treatment. Study showed that Habbe- Sandroos produced significant improvement in subjective parameters; bleeding per rectum (p <0.001), prolapse of pile mass (p <0.001), mucus discharge per-rectum (p=0.026), and itching per rectum (p =0.003) at 2 months from the baseline scores. Drug has promising results in Internal hemorrhoids and warrants further studies. Conclusion: The result inferred that the test drug is safe and effective in improving the severity of symptoms of Internal hemorrhoids of 1st and 2nd Grade. It can be used as an alternate to conventional treatment. [ABSTRACT FROM AUTHOR] more...

Background: Milligan Morgan hemorrhoidectomy (open hemorrhoidectomy [OH]) once considered the gold standard surgical technique for hemorrhoids is challenged by stapled hemorrhoidopexy (SH) which claims a better postoperative outcome. The purpose of this study was to compare the outcomes of OH and SH in the Indian context. Materials and Methods: This prospective comparative study included 50 consecutive patients who underwent OH (n = 30) and SH (n = 20) from June 2018 to May 2020 at our institute. The primary outcomes were intra-operative time, postoperative pain assessed by the visual analog scoring system, and duration of stay at the hospital. Patients were clinically assessed at 1 week and 3 months postdischarge, and telephonically interviewed at 3 and 6 months for complications and time taken to resume normal activities. Student t test and chi-square test were used to test the statistical significance of the difference in mean of continuous variables and the difference in the proportion of categorical variables respectively. Results: The mean pain score postOH was found to be significantly higher than post-SH, measured after 3 h (3.47 ± 1.16 vs. 1.90 ± 0.968; P < 0.001), 6 h (5.8 ± 1.4 vs. 3.55 ± 0.99; P < 0.001), and 12 h (5.2 ± 1.7 vs. 1.85 ± 1.387; P < 0.001). The duration of hospital stay post-procedure was higher for OH by 24 h on average (3.1 ± 1.08 days vs. 2.10 ± 1.02 days; P < 0.001). The time that is, taken to resume work after OH was significantly higher (28.3 ± 14.5 vs. 10.85 ± 4.082; P < 0.001). Conclusion: SH has lower post-procedure pain, shorter hospitalization, and faster return to work compared to OH. The incidence of complications was comparable between both groups. more...

Background: Colonoscopy is a critical and frequently used medical procedure that is essential in identifying colonic and rectal cancers on time. It remains the preferred method for visualizing the colonic and rectal mucosae, enabling the detection of conditions like carcinoma, adenoma, and inflammation. Colorectal cancer is the third most common cancer worldwide, and due to its tendency to present late, screening programs that rely on a sensitive tool like colonoscopy are of utmost importance. Objectives: To evaluate the clinical characteristics and colonoscopic findings, including colorectal cancer, among patients referred to the gastro-enterology unit in Al-Imamain Al-Kadhemain Medical City and determine the most common presenting symptoms of colorectal diseases. Patients and Methods: A study was conducted at the GIT unit of Al-Imamain Al-Kadhemain Medical City from November 2022 to March 2023 involving 120 patients who underwent colonoscopy. The study recorded the presenting complaint and colonoscopy results. The mean and standard deviation were used to express continuous variables, while frequency and percentage were used for categorical variables The difference between means was tested using Welch's t-test, and a P-value less than 0.05 was considered statistically significant. Result: The study included a total of 120 participants, with an average age of 46.57 years. The leading indication for colonoscopy was bleeding per rectum (45%), followed by chronic constipation (26.6%) and chronic abdominal pain (21.6%). The most common pathologies observed during colonoscopy were internal hemorrhoid (18.3%), polyposis (15%), and colorectal cancer (13.3%). Conclusion: Rectal bleeding is the primary reason for conducting colonoscopy and is also the most common symptom of colorectal cancer. During colonoscopy, Internal hemorrhoids are frequently observed, which is the most common cause of rectal bleeding. Polyps and colorectal cancer are the next most frequent causes of rectal bleeding. more...

Purpose: Symptomatic internal hemorrhoids affect up to 40% of people in Western society. Patients with grade I–III hemorrhoids, who fail lifestyle and medical management, may benefit from office-based procedures. As per the American Society of Colon and Rectum Surgeons (ASCRS), rubber band ligation (RBL) is the first-line office-based treatment. Polidocanol sclerotherapy is a relatively new approach for these patients. The aim of this systematic review is to compare the efficacy of RBL and polidocanol sclerotherapy with the treatment of symptomatic grade I–III internal hemorrhoids. Methods: The systematic review was completed by searching MEDLINE, Embase, and CENTRAL databases from inception to August 2022 for prospective studies comparing RBL and polidocanol sclerotherapy or evaluating the efficacy of polidocanol sclerotherapy alone for adult (> 18 years) patients with grade I–III internal hemorrhoids. Treatments were evaluated for therapeutic success and post-procedure morbidity. Results: Of 155 citations obtained, 10 studies (3 comparative and 7 single-arm studies) and 4 abstracts (2 comparative and 2 single arm) were included in the study. The patients undergoing sclerotherapy had a 93% (151/163) therapeutic success rate compared to 75% (68/91) in the RBL group (OR 3.39, 95% CI 1.48–7.74, p < 0.01). The post-procedure morbidity was 8% (17/200) in the sclerotherapy group and 18% (23/128) in the RBL group (OR 0.53, 95% CI 0.15–1.82, p = 0.31). Conclusion: This study highlights that polidocanol sclerotherapy may be associated with higher therapeutic success in patients with symptomatic grade I–III internal hemorrhoids. Further evaluations in the form of randomized trials are required to evaluate patient populations, which may benefit more from sclerotherapy. [ABSTRACT FROM AUTHOR] more...

Purpose: The purpose of this study was to prospectively evaluate the efficacy and safety of a new, bare platinum, detachable microcoil as a metallic embolization agent in the treatment of hemorrhoidal disease. Material and Methods: This prospective single-center study evaluated a new, bare platinum, electrical, detachable microcoil (Prestige plus coil (Balt Montmorency France)) for use in vascular embolization in patients with hemorrhoidal disease. Between January 2020 and January 2021, 24 embolization procedures were performed in 21 patients (12 males, 9 females; mean age 44.3 ± 7.3). The inclusion criteria were: (a) participants with grade I, II and III hemorrhoidal disease on the Goligher classification; (b) patients older than 18 years of age with a score of greater than 4 on the French bleeding score (FBS) scale; (c) patients with scores greater than 2 on the scale of discomfort proposed by Tradi and Farfallah. (d) patients who underwent treatment that included the use of the new novel coil (Prestige plus coil (Balt)) as an embolic material. The exclusion criteria were participants who failed to provide informed consent and participants diagnosed with rectal bleeding due to other causes (cancer, fissures or others). Participants with severe renal insufficiency, non-correctable coagulation abnormalities and adverse reactions to the contrast medium not correctable with medication were also excluded. The symptoms, technical aspects, the transarterial approach, clinical and technical success complications and short-term outcomes were assessed. Results: Technical success was obtained in 100% of the cases. Seventeen (80.9%) patients experienced improvements in their hemorrhoidal disease. The VAS and QL scores improved by 4 and 1.5 points (81.2% and 87.5%), respectively, after embolization (pV: 0001). Three (14.2%) patients underwent a second embolization due to rebleeding. One patient (4.7%) underwent surgery. No major complications were observed. Three patients had minor complications. The assessment of subjective post-treatment symptoms and QL surveys showed significant differences from the baseline survey. Likewise, the measurement of the degree of satisfaction using a telephone survey at 12 months revealed a high degree of patient satisfaction over 10 points (mean 8.3 ± 1.1). Conclusions: The present study demonstrates that the use of the new, platinum, detachable, electrical microcoil is safe and well-tolerated in the treatment of hemorrhoidal disease. Key points: Catheter-directed hemorrhoidal dearterialization (CDHD) is the procedure of embolization with embolic agents for the treatment of internal hemorrhoids. CDHD is a simple and safe procedure that is accepted by patients and preserves the anal sphincter; it presents few complications when metal devices or microspheres are used as embolic agents. As the recommended embolization agent in treatments, the Prestige electrical, detachable coil is a safe, easy-to-use and effective arterial embolic device. [ABSTRACT FROM AUTHOR] more...

Abstract Background Rectovaginal fistula (RVF) following aluminum potassium sulfate hydrate-tannic acid (ALTA) injection therapy for hemorrhoids is a rare complication. We report the first case of RVF after ALTA injection therapy successfully treated by gluteal-fold flap. Case presentation A 49-year-old female suffered from a fever and rectal ulcer after undergoing internal hemorrhoid treatment with a submucosal ALTA injection at a previous clinic. One week after ALTA therapy, she noted obvious passage of flatus and stool through the vagina, and was diagnosed with RVF by anoscope at another clinic. She was referred to our hospital 3 weeks after ALTA therapy. Sigmoid colostomy was performed for fecal diversion as a preliminary step for fistula repair. However, the fistula was scarred and the defect between the rectum and vagina did not improve at all. Ten months after ALTA therapy, we performed fistula repair by gluteal-fold flap. Seven months later, sigmoid-colostomy reversal was performed. The patient has experienced no RVF in the 3 years since sigmoid-colostomy reversal. Conclusions The gluteal-fold flap strategy is a useful option for severe RVF management. more...

In the study, we comment on the article by Qu et al . Internal hemorrhoids are the most common anorectal disorders worldwide with bleeding, prolapse, and difficulty in defecation. Endoscopic rubber band ligation (ERBL) is a safe, convenient, quick, and economical outpatient procedure. The main goal of ERBL is to alleviate prolapse, but the high incidence of recurrence and post-procedural pain are of clinical concern. Polidocanol foam as a local hemostatic and anesthetic agent could reduce the rates of post-procedural pain and bleeding. Endoscopic polidocanol foam sclerobanding (EFSB) is a novel approach that could lift the mucosa for easy ligation and promote increased scarring in the submucosal tissue which translates into long-term relief from prolapse recurrence and reduced 24-h post-procedural pain. The study by Qu et al is a novel multi-center prospective randomized study to compare ERBL and EFSB in patients with grades II and III internal hemorrhoids with one-year follow-up. Results showed that EFSB is a novel therapy for internal hemorrhoids, but future studies with a larger sample, multiple treatment sessions, and long-term follow-up are required to confirm these findings., Competing Interests: Conflict-of-interest statement: We have nothing to disclose for this article., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.) more...

We have read the article by Qu et al with great interest, as it presents an integration of endoscopic polidocanol foam sclerotherapy with rubber band ligation in patients with Grade II-III internal hemorrhoids. The authors conducted a prospective, multicenter, randomized study to evaluate the long-term symptomatic and endoscopic efficacy of this combined intervention. In this discussion, we focus on the procedural steps of this combined strategy and suggest potential avenues for future research., Competing Interests: Conflict-of-interest statement: The authors declare that they have no conflicts of interest., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.) more...

Background: Hemorrhoid is a common anorectal lesion. Goligher’s system classified the internal hemorrhoids into (4) grades, however, it did not provide any information about the severity of the disease. There is limited data about the role of the colonoscopy in the diagnosis and evaluate the severity of the internal hemorrhoids. Objective: The study to compare the difference between both colonoscopy and standard Goligher’s grading in their relation to the symptoms and complications in the same patient and to prove which grading system is better for the diagnosis of internal hemorrhoids. Patients and Methods: This cross-sectional study was done in the elective gastrointestinal endoscopy unit, Internal Medicine Department, Faculty of Medicine, Zagazig University from March 2021 to Augustus 2021, and including 300 consecutive Egyptian patients who underwent a flexible colonoscopy were enrolled in this study for different reasons. Results A significant increase in the proportion of patients who had grade IV colonoscopy classification with an increase in the size and presents of RCS, also there is a significant increase in the proportion of patients who had RCS with increasing the size of internal hemorrhoids, (P<0.05). The chronic anemia, lower GI bleeding, are the most independent risk factors for the development of internal hemorrhoids in patients undergoing colonoscopy grading, (P < 0.001). Conclusions: The use of retroflexed colonoscopy is accurate and effective in diagnosing and evaluating internal hemorrhoids. The colonoscopy grading is more accurate in describing the relationship between the degree of hemorrhoids and complaints than Goligher's grading. [ABSTRACT FROM AUTHOR] more...

Background: Endoscopic rubber band ligation (ERBL) is a nonsurgical technique for the treatment of symptomatic internal hemorrhoids but is limited by recurrence and post-procedural pain., Aim: To evaluate satisfaction, long-term recurrence, and post-procedural pain in managing internal hemorrhoids using a combination of polidocanol foam sclerotherapy and ERBL., Methods: This was a prospective, multicenter, randomized study. A total of 195 consecutive patients diagnosed with grade II-III internal hemorrhoids were enrolled from four tertiary hospitals and randomly divided into a cap-assisted endoscopic polidocanol foam sclerobanding (EFSB) or an ERBL group. All patients were followed-up for 12 months. Symptom-based severity and post-procedural pain were assessed using a hemorrhoid severity score (HSS) and a visual analog scale (VAS). Continuous variables were reported as medians and interquartile range., Results: One hundred and ninety-five patients were enrolled, with 98 in the EFSB group. HSS was lower in the EFSB group than in the ERBL group at 8 weeks [4.0 (3.0-5.0) vs 5.0 (4.0-6.0), P = 0.003] and 12-month [2.0 (1.0-3.0) vs 3.0 (2.0-3.0), P < 0.001] of follow-up. The prolapse recurrence rate was lower in the EFSB group at 12 months (11.2% vs 21.6%, P = 0.038). Multiple linear regression analysis demonstrated that EFSB treatment [B = -0.915, 95% confidence interval (CI): -1.301 to -0.530, P = 0.001] and rubber band number (B = 0.843, 95%CI: 0.595-1.092, P < 0.001) were negatively and independently associated with the VAS score 24 hours post-procedure. The median VAS was lower in the EFSB group than in the ERBL [2.0 (1.0-3.0) vs 3.0 (2.0-4.0), P < 0.001]., Conclusion: Cap-assisted EFSB provided long-term satisfaction and effective relief from the recurrence of prolapse and pain 24 hours post-procedure., Competing Interests: Conflict-of-interest statement: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.) more...

Background: Rectovaginal fistula (RVF) following aluminum potassium sulfate hydrate-tannic acid (ALTA) injection therapy for hemorrhoids is a rare complication. We report the first case of RVF after ALTA injection therapy successfully treated by gluteal-fold flap. Case presentation: A 49-year-old female suffered from a fever and rectal ulcer after undergoing internal hemorrhoid treatment with a submucosal ALTA injection at a previous clinic. One week after ALTA therapy, she noted obvious passage of flatus and stool through the vagina, and was diagnosed with RVF by anoscope at another clinic. She was referred to our hospital 3 weeks after ALTA therapy. Sigmoid colostomy was performed for fecal diversion as a preliminary step for fistula repair. However, the fistula was scarred and the defect between the rectum and vagina did not improve at all. Ten months after ALTA therapy, we performed fistula repair by gluteal-fold flap. Seven months later, sigmoid-colostomy reversal was performed. The patient has experienced no RVF in the 3 years since sigmoid-colostomy reversal. Conclusions: The gluteal-fold flap strategy is a useful option for severe RVF management. [ABSTRACT FROM AUTHOR] more...

Colorectal cancer (CRC) is the second most diagnosed cancer and the second leading cause of cancer-related deaths in the United States. Rectal cancers, specifically, are the second most common cancer of the large intestine. Although once perceived as a disease of the elderly, the incidence of early-onset CRC (EO-CRC), classified as occurring in individuals less than 50 years old, has been paradoxically increasing. Although the incidence of rectal cancers has increased, the digital rectal exam (DRE) continues to be an underutilized physical exam maneuver when a patient presents with red-flag symptoms. Here, we present a case of a 38-year-old male from West Virginia who was referred to general surgery for complaints of rectal bleeding attributed to internal hemorrhoids. After undergoing a colonoscopy, the patient was found to have a rectal mass consistent with adenocarcinoma. We describe the importance of identifying red-flag signs to keep colorectal malignancy in the differential diagnosis in a young patient and highlight the importance of performing rectal exams to identify rectal cancers early to expedite treatment., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Ramanathan et al.) more...

Objective: To compare the efficacy of injections Sclerotherapy (IST) and rubber band ligation (RBL) for the treatment of 2nd degree haemorrhoids in terms of improvement in symptoms severity score (SS score) in OPD patients. Study Design: Randomized controlled trial. Place and Duration of Study: It was conducted in surgical OPD of CMH Kohat, from 15th October 2010 to 10th April 2011 Material and Methods: A total of 116 patients with symptomatic 2nd degree haemorrhoids were randomly divided into two groups, RBL and IST (58 patients each) respectively and a baseline symptoms severity score was noted for each patient. Patients in RBL group were treated with RBL while in IST group were treated with IST. The outcome measures were relief of symptoms and improvement in SS score. Results: In RBL group, baseline SS score was 4.67 ± 2.01 which reduced to final mean SS score of 1.34 ± 0.96 whereas in IST group the baseline SS score was of 4.31 ± 2.13 which reduced to a final mean SS score of 1.6 ± 0.97. 44 (75.95%) patients had complete recovery and control of bleeding in RBL group; whereas in IST group 32 (55.1%) of the patients had this response by the end of two weeks. Conclusion: Rubber band ligation was found to have better patient outcomes as compared to injections sclerotherapy in treatment of 2nd degree hemorrhoids. [ABSTRACT FROM AUTHOR] more...

Copyright of West Indian Medical Journal is the property of West Indian Medical Journal (WIMJ) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.) more...

A 45 years female presented with a complain of something coming out through her anus since one year, which comes on straining and reduces only after manual intervention. She had also, a history of constipation with occasional blood and mucus discharge in the stool. On examination, she was found to have full thickness rectal prolapse, which comes out on straining and reduces only after pushing it manually. With a diagnosis of complete rectal prolapse grade III, she underwent abdominal suture rectopexy and now she is doing well after six months of follow-up. One of the very close differential diagnosis of complete rectal prolapse is prolapsed internal hemorrhoid. Both can present with similar symptoms with similar clinical grading, but management is completely different. Diagnosis of both these conditions is critical and mostly based on clinical findings. The differentiating point between a rectal prolapse and internal hemorrhoid lies in the orientation of the mucosal folds. Rectal prolase usually has circular folds (A,B) where as internal hemorrhoids have radial folds (C). This is because, hemorrhoids are collections of submucosal, fibrovascular, arterio-venous sinusoids mostly seen in the left lateral, right anterolateral and right posterolateral region of anal canal. While rectal prolapse is the intussusception of whole circumference of the rectal wall through the anal canal which presents with circular folds of rectal mucosa. This image presents a classic case of complete rectal prolapse with an image of a prolapsed internal hemorrhoid to understand the differentiating points of these two very common clinical conditions. more...

A 66-year-old male patient came to the anorectal clinic, Outpatient department, AVT Institute for Advanced Research, Coimbatore, Tamil Nadu, with complaints of prolapsing pile mass during defecation and bleeding while passing stool. The case was diagnosed as "Raktarsha" - 11 & 7 ′o′ clock position II degree internal hemorrhoids, deeply situated, projecting one and caused by pitta and rakta; with bleeding tendency. Kshara karma (application of caustic alkaline paste) intervention was done in this case to internal hemorrhoids under local anesthesia. The pile mass and per rectal bleeding resolved in 8 days and the patient was relieved from all symptoms within 21 days. No complications were reported after the procedure. The patient was followed up regularly from 2004 onward till date and proctoscopic examination did not reveal any evidence of recurrence of the hemorrhoids. more...

Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy is increasingly popular for treating internal hemorrhoids. This injectable compound incites inflammation to dampen hemorrhoidal blood flow and inflict secondary fibrosis. Herein, we detail the implications of ALTA treatment for laparoscopic low anterior resection of rectal cancer. A 72-year-old man receiving ALTA sclerotherapy for internal hemorrhoids thereafter required laparoscopic low anterior resection for newly discovered early rectal cancer. Observed changes of anal canal resembled those of radiochemotherapy and proved problematic. There was mural thickening and sclerosis at the planned resection site. To ensure proper removal, the bowel was compressed and stapled slowly. A two-shot resection took place (without straining), anastomosis was performed, and a covering stoma was constructed. Recovery was uneventful, allowing discharge on postoperative Day 10. The ileostomy was closed at a later time. Although little information is available on long-term rectal pathology after ALTA therapy, existing data suggest that sclerosis persists well beyond injection timeframes. Hence, caution is required in dissecting and debriding sclerotic remnants. We have identified only four earlier reports in this setting, the present case providing added perspective. Colonoscopy is highly advisable prior to ALTA therapy. A thorough work-up before rectal surgery is also essential, documenting any past treatments for anorectal disease, especially ALTA. • Rectal surgery after ALTA therapy requires caution due to mural thickening. • ALTA-induced tissue fibrosis is sustained for at least 5 years. • Careful preoperative histories of prior anorectal treatments are essential. • Colonoscopy is strongly recommended prior to treatment of anorectal disease. [ABSTRACT FROM AUTHOR] more...

Background: Several minimally invasive technologies are available to treat common soft tissue lesions including symptomatic hemorrhoids. The use of energy to deliver heat and coagulate target lesions is commonly practiced. This study compares the histologic effects produced on intestinal tissues by two energy-based systems which employ different approaches of heat delivery. Methods: Two heat delivery systems were evaluated in vivo in a single porcine subject: infrared coagulator and bipolar tissue ligator utilizing constant tissue compression and temperature guidance. Eighteen treatment sites divided into three groups of six were assessed. Treatment site temperature was measured and the effects of thermal treatment in the mucosa, submucosa, submucosal vessels, and muscularis layer were scored. Lateral thermal spread beyond the energy application site was also assessed. Results: Treatment site temperatures were much lower in the bipolar ligator group than in the infrared coagulator group. The mucosal and submucosal tissue changes observed in tissues treated with infrared energy and bipolar energy at 55°C were similar. Both the mucosal and submucosal tissue changes with bipolar energy at 50°C were significantly less. Conclusion: Both devices achieved similar histologic results. However, the unique design of the bipolar ligator, which allows consistent capture, constant compression, and temperature monitoring of target tissue, accomplished the desired histologic changes with less muscular damage at much lower temperatures than the infrared coagulator. The use of bipolar ligation could offer clinical advantages such as reduced patient pain and a minimized chance of heat-related collateral tissue damage. [ABSTRACT FROM AUTHOR] more...

Anorectal bleeding is the second most common site of lower gastrointestinal bleeding. Colonoscopy remains the gold standard test to localize sources of lower gastrointestinal bleeding, but it can miss left-sided colon pathologies such as diverticula, rectal varices, and internal hemorrhoids. We report an unusual case of a male cirrhotic patient with massive hemorrhoidal bleeding which went undiagnosed despite multiple imaging and endoscopic evaluations. He underwent urgent sigmoidoscopy that identified grade III internal hemorrhoids and sclerotherapy which resolved the hematochezia. Decompensated cirrhosis complicates patient candidacy for surgical hemorrhoidectomy, but sclerotherapy is a viable option even for high-risk patients. Urgent sigmoidoscopy during active bleeding should be considered if hemorrhoidal bleeding is suspected but inconclusive by colonoscopy., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Morrison et al.) more...

Background: Rubber band ligation (RBL) using rigid anoscope is a commonly recommended therapy for grade I-III symptomatic internal hemorrhoids. Severe complications of RBL include pain, hemorrhage and sepsis. Flexible endoscopic RBL (ERBL) is now more commonly used in RBL therapy but few severe complications have been reported. Here we report on a case of massive bleeding after ERBL., Case Summary: A 31-year-old female was admitted to the department of gastroenterology with a chief complaint of discontinuous hematochezia for 2 years. No previous history, accompanying diseases or drug use was reported. Physical examination and colonoscopy showed grade II internal hemorrhoids. The patient received ERBL therapy. Five days after ligation, the patient presented with mild hematochezia. On days 7 and 9 after ligation, she presented with a large amount of rectal bleeding, dizziness and weakness. Emergency colonoscopy revealed active bleeding and an ulcer in the anal wound. The patient received two sessions of hemoclipping on days 7 and 9 to treat the bleeding. No further bleeding was reported up to day 15 and she was discharged home. Although the hemorrhoid prolapse disappeared after ERBL, she was dissatisfied with the subsequent complications., Conclusion: ERBL therapy is an effective treatment for symptomatic internal hemorrhoids with satisfactory short and long-term recovery. Pain and anal bleeding are the most frequently reported postoperative complications. Coagulation disorders complicate the increased risk of bleeding. Although rarely reported, our case reminds us that those patients without coagulation disorders are also at risk of massive life-threatening bleeding and need strict follow-up after ligation., Competing Interests: Conflict-of-interest statement: All authors declare that they have no conflicts of interest., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.) more...

Introduction: Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking., Methods: A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020., Results: Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids., Conclusions: The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management., (© Acta Gastro-Enterologica Belgica.) more...

Hemorrhoidal disease is a fairly common and debilitating clinical entity. Despite centuries' of attempts to shed light on its pathophysiology, to cure those affected and to improve sufferers' quality of life, many aspects of the disease remain elusive. Individual beliefs and historical legends, accompanied by undocumented theories, have established and perpetuated the confusion regarding the mechanisms leading to the development of the disease and the rules governing its treatment. Hemorrhoids are classified as internal or external and are viewed as a disease when they become symptomatic. Returning to basic medical sciences, this mini-review focuses on internal hemorrhoids and aims to define the histology and anatomy of the normal and abnormal internal hemorrhoidal plexus and to encourage clinicians to comprehend the pathophysiology of the disease. If doctors can understand the pathophysiology of hemorrhoidal disease, they will be able to clarify the nature of the associated symptoms and complications and to make the correct therapeutic decision., Competing Interests: Conflict of Interest: None more...

The article presents a case study of a 45 years female with a complain of something coming out through her anus; history of constipation with occasional blood and mucus discharge in the stool; and diagnosis of complete rectal prolapse is prolapsed internal hemorrhoid. more...

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. more...

Background: Several minimally invasive technologies are available to treat common soft tissue lesions including symptomatic hemorrhoids. The use of energy to deliver heat and coagulate target lesions is commonly practiced. This study compares the histologic effects produced on intestinal tissues by two energy-based systems which employ different approaches of heat delivery., Methods: TWO HEAT DELIVERY SYSTEMS WERE EVALUATED IN VIVO IN A SINGLE PORCINE SUBJECT: infrared coagulator and bipolar tissue ligator utilizing constant tissue compression and temperature guidance. Eighteen treatment sites divided into three groups of six were assessed. Treatment site temperature was measured and the effects of thermal treatment in the mucosa, submucosa, submucosal vessels, and muscularis layer were scored. Lateral thermal spread beyond the energy application site was also assessed., Results: Treatment site temperatures were much lower in the bipolar ligator group than in the infrared coagulator group. The mucosal and submucosal tissue changes observed in tissues treated with infrared energy and bipolar energy at 55°C were similar. Both the mucosal and submucosal tissue changes with bipolar energy at 50°C were significantly less., Conclusion: Both devices achieved similar histologic results. However, the unique design of the bipolar ligator, which allows consistent capture, constant compression, and temperature monitoring of target tissue, accomplished the desired histologic changes with less muscular damage at much lower temperatures than the infrared coagulator. The use of bipolar ligation could offer clinical advantages such as reduced patient pain and a minimized chance of heat-related collateral tissue damage. more...

Hemorrhoids are normal vascular structures underlying the distal rectal mucosa and anoderm. Symptomatic hemorrhoidal tissues located above the dentate line are referred to as internal hemorrhoids and produce bleeding and prolapse. Thrombosis in external hemorrhoids results in painful swelling. Symptomatic internal hemorrhoids that fail bowel management programs may be amenable to in-office treatment with rubber band ligation or infrared coagulation. Internal hemorrhoids that fail to respond to these measures or complex internal and external hemorrhoidal disease may require a surgical hemorrhoidectomy, either open or closed. A stapled hemorrhoidopexy treats symptomatic internal hemorrhoids and should be employed with care and only after thorough training of the surgeon because of the risk of rare, severe complications. The choice of procedure should be based on the patient's symptoms, the extent of the hemorrhoidal disease, and the experience of the surgeon. more...