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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., (Copyright © The ASCRS 2021.)

Background: Hemorrhoids are common and affect mainly the young and middle-aged populations. Current guidelines recommend treating grade I and II hemorrhoids with office-based procedures. These therapies usually require multiple applications. Hemorrhoid energy therapy treats the hemorrhoids at 1 treatment session., Objective: The purpose of this study was to evaluate the safety and efficacy of hemorrhoid energy therapy., Design: This was a prospective pilot study evaluating patients with symptomatic grade I and II internal hemorrhoids., Settings: The study was conducted at a tertiary academic center., Patients: Patients over the age of 18 years with chronic, symptomatic grade I and II internal hemorrhoids who failed 2 weeks of conservative therapy were enrolled between July 2015 and January 2019. Exclusion criteria included patients with grade III or IV internal hemorrhoids, external hemorrhoids, nonhemorrhoidal GI bleeding, active proctitis, and IBD., Interventions: Hemorrhoid energy therapy was administered in clinic, and 2 postprocedure visits were completed. A pretreatment hemorrhoid symptom score was obtained from each patient. A visual analog score was assessed posttreatment., Main Outcome Measures: The primary end point was to evaluate the effect of hemorrhoid energy therapy on hemorrhoid symptoms and its safety. The secondary end point was evaluation of postprocedural pain., Results: A total of 35 patients were enrolled. The mean duration of hemorrhoid symptoms was 3.3 ± 6.4 years, and rectal bleeding and hemorrhoidal prolapse were the most common symptoms. After the procedure, patient hemorrhoid symptom scores decreased from mean 5.5 to 1.4. The mean immediate postprocedural visual analog score was 2.4 ± 2.1 and decreased to <1.0 after 14 days., Limitations: The limitations include lack of comparative groups, single-center design, and small cohort of patients., Conclusions: The application of hemorrhoid energy therapy in the treatment of grade I and II internal hemorrhoids is safe and results in reduction of symptoms, low rate of short-term complications, and minimal pain. See Video Abstract at http://links.lww.com/DCR/B491. EVALUACIÓN DE UN SISTEMA DE COAGULACIÓN BIPOLAR MÍNI-INVASIVA PARA EL TRATAMIENTO DE HEMORROIDES INTERNAS GRADOS I Y II: La enfermedad hemorroidal es muy común y afecta principalmente poblaciones jóvenes y de mediana edad. Las guías actuales recomiendan tratar las hemorroides de grado I y II con procedimientos en el consultorio. Estos tratamientos suelen requerir múltiples aplicaciones. La aplicación de energía para tratar las hemorroides requiere de una sola sesión.Evaluar la seguridad y eficacia del tratamiento hemorroidal con una fuente de energía.Estudio piloto prospectivo que evalúa los pacientes con hemorroides internas de grado I y II sintomáticas.El estudio se realizó en un centro académico terciario.Entre julio de 2015 y enero de 2019 se inscribieron pacientes mayores de 18 años con hemorroides intomáticas internas crónicas grado I y II que fracasaron luego de 2 semanas de tratameinto conservador. Los criterios de exclusión incluyeron pacientes con hemorroides internas de grado III o IV, hemorroides externas, sangrado de orígen gastrointestinal no hemorroidal, proctitis activa y enfermedad inflamatoria intestinal.Se realizó la aplicación de energía sobre las hemorroides en el consultorio y se completó el procedimiento con dos visitas posteriores. Se obtuvo una puntuación analógica de síntomas hemorroidarios en cada paciente antes del tratamiento. Se evaluó la puntuación analógica visual luego del procedimiento.El principal criterio final fué evaluar el efecto de la terapia energética hemorroidaria con relación a los síntomas y la seguridad del dispositivo. El segundo criterio final fué el evaluar el dolor posoperatorio.Se registraron un total de 35 pacientes. La duración media de los síntomas hemorroidarios fué de 3,3 ± 6,4 años, el sangrado rectal y el prolapso hemorroidal fueron los síntomas más frecuentes. Después del procedimiento, las puntuaciones de los síntomas hemorroidarios disminuyeron en una media de 5,5 a 1,4. La puntuación analógica visual media inmediatamente posterior al procedimiento fue de 2,4 ± 2,1 y disminuyó a <1 después de 14 días.Las limitaciones incluyen la falta de grupos comparativos, el diseño de un solo centro y una pequeña cohorte de pacientes.La aplicación de energía como tratamiento de la enfermedad hemorroidal interna grado I y II es segura y da como resultados la reducción de los síntomas, una baja tasa de complicaciones a corto plazo y mínimo dolor. Consulte Video Resumen en http://links.lww.com/DCR/B491. (Traducción-Dr Xavier Delgadillo).

Introduction: Hemorrhoidal disease (HD) is a common and recurrent problem for many adults worldwide. Venoactive drugs, such as micronized purified flavonoid fraction (MPFF; Daflon ® ), have been used to treat HD and their clinical benefits have been demonstrated in previous meta-analyses of clinical trials. The aim of this study was to evaluate the efficacy of MPFF across the broader spectrum of signs and symptoms following treatment of patients with HD., Methods: We performed a systematic review of the literature to identify randomized clinical trials in which MPFF treatment was compared to placebo or no treatment for acute HD or for relief of symptoms after patients had undergone medical management or a surgical procedure to remove hemorrhoids. The main endpoints investigated were bleeding, pain, pruritus, discharge or leakage, and overall improvement. There was no limit on treatment duration., Results: From 351 unique records retrieved, 11 studies reported in 13 articles were included. On the basis of findings from qualitative analysis, MPFF was reported in most studies to be beneficial in treating bleeding, pain, pruritus, anal discharge/leakage, and tenesmus, and in overall improvement. Quantitative meta-analysis of four studies indicated that MPFF treatment provided significant benefits for bleeding (odds ratio [OR] 0.082, 95% confidence interval [CI] 0.027-0.250; P < 0.001), discharge/leakage (OR 0.12, 95% CI 0.04-0.42; P < 0.001), and overall improvement according to patients (OR 5.25, 95% CI 2.58-10.68; P < 0.001) and investigators (OR 5.51, 95% CI 2.76-11.0; P < 0.001). MPFF also tended to decrease pain (OR 0.11, 95% CI 0.01-1.11; P = 0.06)., Conclusion: Taken together, these results suggest that MPFF treatment can improve the most important signs and symptoms of HD.

Case Summary: A 46-year-old otherwise healthy female patient presents with bright red blood during defecation and a lump protruding on defecation that requires manual reduction. She is the mother of 2 children and has a long history of constipation.

Background/aims: An anal fissure (AF) is a linear tear in the distal anal canal and is one of the most common causes of anal pain. Hemorrhoidal disease (HD) is a symptomatic growth and distal displacement of normal anal cushions. Numerous studies have addressed the contributing factors of these conditions, yet the results remain controversial. In this study, we hypothesize that increasing patients' awareness of hidden risk factors could reduce the rate of HD and AF., Materials and Methods: A questionnaire-based controlled study was planned. After power analysis, patients with HD (n=60) and AF (n=60) were enrolled consecutively into the study group and compared with the control group (n=60) of healthy individuals. The survey was designed to assess the participants' toilet and dietary habits and anxiety risk. Odds ratios were calculated and a binary logistic regression model was constructed to identify associated factors., Results: Hard stools, spending more than 5 minutes in the toilet, frequent straining during defecation, and increased spice intake were more frequent in the patients with HD; and hard fecal consistency, time elapsed in toilet greater than 5 min, straining during defecation, and high anxiety risk were more frequent in the patients with AF as compared to the control group (p<0.05)., Conclusion: Possible associations were identified between habitual factors or conditions (i.e., fecal consistency, the time elapsed in the toilet, straining during defecation) and anxiety and benign anorectal diseases (i.e., HD and AF). Patients should be advised about these hidden threats.

Background: There are no adequately validated tools to evaluate symptoms or disease-specific health-related quality of life in hemorrhoidal disease., Objective: The purpose of this study was to assess validity, reliability, and responsiveness of a symptom score of patient-reported pain, itching, bleeding, soiling, and prolapse (Hemorrhoidal Disease Symptom Score). In addition, the study set out to assess reliability and responsiveness of an instrument to measure health-related quality of life in patients with hemorrhoids (Short Health ScaleHD), with 1 item in its 4 dimensions: symptom load, functional status, disease-specific worries, and general well-being., Design: This was a cross-sectional (validity and reliability) and longitudinal (responsiveness) study., Settings: The study was conducted at a single center., Patients: Cohort 1 included 295 patients with hemorrhoids to study validity and 60 patients with test-retest scores to study reliability. Cohort 2 included 128 and 121 patients operated for hemorrhoids to study responsiveness of the Hemorrhoidal Disease Symptom Score and the Short Health ScaleHD., Main Outcome Measures: The study evaluated validity, reliability, and responsiveness. Patient-reported symptom load on a 7-point Likert scale was used as comparator, and receiver operating characteristics curve assessed discriminative validity. Interclass correlation assessed reliability. Receiver operating characteristics curve assessed responsiveness, meaning the ability to discriminate between patients with and without improvement after surgery., Results: The Hemorrhoidal Disease Symptom Score demonstrated the ability to discriminate between patients reporting high or low symptom load (area under the curve = 0.786 (95% CI, 0.725-0.848)). The Hemorrhoidal Disease Symptom Score and the Short Health ScaleHD demonstrated adequate reliability and responsiveness, with interclass correlation of 0.822 (95% CI, 0.715-0.891) and 0.763 (95% CI, 0.634-0.851) and area under the curve of 0.843 (95% CI, 0.756-0.929) and 0.840 (95% CI, 0.752-0.929)., Limitations: We had no gold standard comparator to assess validity and responsiveness., Conclusions: The findings suggest that the Hemorrhoidal Disease Symptom Score is valid, reliable, and responsive and that the Short Health ScaleHD is reliable and responsive. Used together, these tools provide a good overview of symptoms and their impact on patient well-being. See Video Abstract at http://links.lww.com/DCR/A770.

Aim: Current questionnaires designed to evaluate the burden of haemorrhoidal disease ignore symptoms such as bleeding, pain and itching. A specific questionnaire is needed to evaluate the global impact of anal disorders on patients' daily lives., Method: We developed a questionnaire (HEMO-FISS-QoL) to assess the symptom burden of anal disorders and administered it to 256 patients (mean age 46.2 years; men 60.4%) with haemorrhoidal disease (67.2%), anal fissure (29.3%) or both (3.5%). Psychometric properties were evaluated by testing the acceptability, construct validity and reliability of the questionnaire. Principal components and multi-trait analyses were used to identify dimensions and to assess construct validity. Backward Cronbach alpha curves and a graded response model were used to reduce the number of items and modalities. External validity was evaluated against SF-12 and the Psychological Global Well-Being Index (PGWBI) using Spearman's correlation coefficient., Results: Principal component analysis defined four dimensions: physical disorders, psychology, defaecation and sexuality. The number of questions was reduced from 38 to 23. The HEMO-FISS-QoL scores correlated well with those of the SF-12 and PGWBI (P < 0.001). Cronbach's coefficients (all > 0.7) reflected good internal reliability of the different dimensions. The total score increased with the severity of the anal disorders and with their consequences (days off work and personal spending related to the disease)., Conclusion: The HEMO-FISS-QoL questionnaire reliably evaluates the global impact of haemorrhoids and anal fissures on patients' daily lives. This simple tool may prove useful for treatment evaluation in clinical trials and daily practice., (© 2018 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Introduction: This study was conducted to determine the frequency of complaints in a cohort of patients with symptomatic hemorrhoidal disease (HD) treated with micronized purified flavonoid fraction (MPFF, Detralex). MPFF was selected for conservative treatment in this population owing to its proven effects on hemorrhoidal symptoms in a large number of patients., Methods: This multicenter, non-interventional study was part of the international CHORUS survey (Chronic venous and HemORrhoidal diseases evalUation for improvement of Scientific knowledge), conducted in nine centers in different regions of Russia with the participation of 80 coloproctologists. The study enrolled consecutive patients with complaints of hemorrhoids. All were prescribed MPFF-based conservative treatment. The effect of treatment on HD clinical signs and symptoms was assessed at two follow-up visits performed 5-7 days and 25-30 days after enrollment. Surgical and minimally invasive treatment could be performed from day 7 onwards if required., Results: A total of 1952 patients were enrolled. Over the entire period of observation, MPFF-based conservative treatment was effective in 1489 (76.3%) patients in eliminating the main clinical manifestations of disease, i.e., bleeding and prolapse of internal nodes. Invasive treatment was performed in 68 (3.5%) patients with grade IV hemorrhoids and was combined with MPFF conservative treatment in 395 (20.2%) patients with grades I-III hemorrhoids., Conclusion: Conservative therapy with MPFF was beneficial for relieving hemorrhoidal symptoms in the majority of patients. MPFF-based treatment was most effective in patients with grade I and II hemorrhoids before irreversible degenerative changes in ligaments of the hemorrhoidal plexuses have occurred. It was also beneficial in preventing disease relapse in patients with more advanced HD and for promoting optimal conditions in the postoperative period., Funding: Servier.

Vein segmentation is a vascular remodeling process mainly studied in experimental conditions and linked to hemodynamic factors, with clinical implications. The aim of this work is to assess the morphologic characteristics, associated findings, and mechanisms that participate in vein segmentation in humans. To this end, we examined 156 surgically obtained cases of hemorrhoidal disease. Segmentation occurred in 65 and was most prominent in 15, which were selected for serial sections, immunohistochemistry, and immunofluorescence procedures. The dilated veins showed differently sized spaces, separated by thin septa. Findings associated with vein segmentation were: (a) vascular channels formed from the vein intima endothelial cells (ECs) and located in the vein wall and/or intraluminal fibrin, (b) vascular loops formed by interconnected vascular channels (venous-venous connections), which encircled vein wall components or fibrin and formed folds/pillars/papillae (FPPs; the encircling ECs formed the FPP cover and the encircled components formed the core), and (c) FPP splitting, remodeling, alignment, and fusion, originating septa. Thrombosis was observed in some nonsegmented veins, while the segmented veins only occasionally contained thrombi. Dense microvasculature was also present in the interstitium and around veins. In conclusion, the findings suggest that hemorrhoidal vein segmentation is an adaptive process in which a piecemeal angiogenic mechanism participates, predominantly by intussusception, giving rise to intravascular FPPs, followed by linear rearrangement, remodeling and fusion of FPPs, and septa formation. Identification of other markers, as well as the molecular bases, hemodynamic relevance, and possible therapeutic implications of vein segmentation in dilated hemorrhoidal veins require further studies., (© 2018 S. Karger AG, Basel.)

Pelvic floor dysfunction, specifically genital prolapse (GP) and stress urinary inconsistency (SUI) presumably co-occur with other connective tissue disorders such as hernia, hemorrhoids, and varicose veins. Observations on non-random coexistence of these disorders have never been summarized in a meta-analysis. The performed meta-analysis demonstrated that varicose veins and hernia are associated with GP. Disease connections on the molecular level may be partially based on shared genetic susceptibility. A unique opportunity to estimate shared genetic susceptibility to disorders is provided by a PheWAS (phenome-wide association study) designed to utilize GWAS data concurrently to many phenotypes. We searched the PheWAS Catalog, which includes the results of the PheWAS study with P value < 0.05, for genes associated with GP, SUI, abdominal hernia, varicose veins and hemorrhoids. We found pronounced signals for the associations of the SLC2A9 gene with SUI (P = 6.0e-05) and the MYH9 gene with varicose veins of lower extremity (P = 0.0001) and hemorrhoids (P = 0.0007). The comparison of the PheWAS Catalog and the NHGRI Catalog data revealed enrichment of genes associated with bone mineral density in GP and with activated partial thromboplastin time in varicose veins of lower extremity. In cross-phenotype associations, genes responsible for peripheral nerve functions seem to predominate. This study not only established novel biologically plausible associations that may warrant further studies but also exemplified an effective use of the PheWAS Catalog data.

Venous disease is a common but overlooked clinical problem and is an important mortality and morbidity factor depending on the effected vascular territory. Different contributing factors play role on the clinical manifestation of the disease. Peripheral varices of lower extremities, hemorrhoids, varicoceles, pelvic varicose veins are the vasculopathy of veins running toward heart but against gravity. We hypothesize that all these clinical entities share common pathophysiologic steps in terms of vascular wall remodeling and vessel wall damage. A systematic approaches to both arterial and venous dilating disease in further studies and research would increase our understanding on the pathophysiology of dilating vascular disease and would provoke to find out new treatment modalities. Varicose remodeling of veins occurs by a complex interplay of various factors including both physical forces and extracellular matrix remodeling mechanisms. This article focuses on the systematic aspects of dilating venous disease with a focus on pathophysiology under the term of "Dilating Venous Disease"., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Aim: To compare two methods of hemorrhoid treatment., Material and Methods: This prospective study included 240 patients with hemorrhoids stage III-IVA. Stages III and IVA were diagnosed in 156 (65%) and 84 (35%) patients respectively. Randomization was performed using envelopes method in one to one distribution. In group 1 (n=120) Doppler-assisted dearterialization of internal hemorrhoids with mucopexy was performed (DDM), in group 2 (n=120) - hemorrhoidectomy using harmonic scalpel (HE)., Results: Duration of surgery was 17.9±6.1 and 34.5±10.1 minutes in DDM and HE groups respectively (p<0.01). Postoperative pain severity was higher in group 2 (4.8 compared with 2.5 scores of the first group (p<0.01). Narcotic analgesics were used less often in DDM group (1.3 doses compared with 6.1 doses in HE group (p<0.01). Disability period was 14.4±5.2 and 30.3±5.4 days in both groups respectively (p<0.01). Immediate postoperative complications occurred in 9 (7.5%) and 19 (15.8%) patients of DDM and HE groups respectively. Recurrent prolapse of internal hemorrhoids was diagnosed in 2 (1.7%) patients of the 1st group in terms of up to 45 days., Conclusion: DDM is reliable minimally invasive method of hemorrhoids stage III-IVA treatment and has similar efficacy with HE. DDM reduces postoperative pain severity, hospital stay and disability period.

Aim: To compare the clinical efficacies of two surgical procedures for hemorrhoid rectal prolapse with outlet obstruction-induced constipation., Methods: One hundred eight inpatients who underwent surgery for outlet obstructive constipation caused by internal rectal prolapse and circumferential hemorrhoids at the First Affiliated Hospital of Xinjiang Medical University from June 2012 to June 2013 were prospectively included in the study. The patients with rectal prolapse hemorrhoids with outlet obstruction-induced constipation were randomly divided into two groups to undergo either a procedure for prolapse and hemorrhoids (PPH) (n = 54) or conventional surgery (n = 54; control group). Short-term (operative time, postoperative hospital stay, postoperative urinary retention, postoperative perianal edema, and postoperative pain) and long-term (postoperative anal stenosis, postoperative sensory anal incontinence, postoperative recurrence, and postoperative difficulty in defecation) clinical effects were compared between the two groups. The short- and long-term efficacies of the two procedures were determined., Results: In terms of short-term clinical effects, operative time and postoperative hospital stay were significantly shorter in the PPH group than in the control group (24.36 ± 5.16 min vs 44.27 ± 6.57 min, 2.1 ± 1.4 d vs 3.6 ± 2.3 d, both P < 0.01). The incidence of postoperative urinary retention was higher in the PPH group than in the control group, but the difference was not statistically significant (48.15% vs 37.04%). The incidence of perianal edema was significantly lower in the PPH group (11.11% vs 42.60%, P < 0.05). The visual analogue scale scores at 24 h after surgery, first defecation, and one week after surgery were significantly lower in the PPH group (2.9 ± 0.9 vs 8.3 ± 1.1, 2.0 ± 0.5 vs 6.5 ± 0.8, and 1.7 ± 0.5 vs 5.0 ± 0.7, respectively, all P < 0.01). With regard to long-term clinical effects, the incidence of anal stenosis was lower in the PPH group than in the control group, but the difference was not significant (1.85% vs 5.56%). The incidence of sensory anal incontinence was significantly lower in the PPH group (3.70% vs 12.96%, P < 0.05). The incidences of recurrent internal rectal prolapse and difficulty in defecation were lower in the PPH group than in the control group, but the differences were not significant (11.11% vs 16.67% and 12.96% vs 24.07%, respectively)., Conclusion: PPH is superior to the traditional surgery in the management of outlet obstructive constipation caused by internal rectal prolapse with circumferential hemorrhoids.

Purpose: Proctological symptomatology is of little complexity and therefore appears particularly suitable for comparative evaluation by visual scales. We devised a "proctological symptom scale" (PSS) with separate scales for four cardinal proctological symptoms: pain, itching/irritation, discharge/moisture, and bleeding. The objective of this study was to evaluate the PSS among proctological patients and non-proctological controls., Methods: This was a single center non-interventional observational study on 229 proctological patients and 133 controls. The main outcome measures investigated were age- and sex-stratified comparison of the non-proctological cohort and the controls, effect of therapeutic intervention on scale values in a subset of patients with haemorrhoidal disease, and sensitivity of the PSS to detect therapeutic failure in this subset of patients., Results: The PSS was found to significantly differentiate between proctological patients and controls. Gender and age had no significant influence on PSS values in the proctological cohort. The intervention (one session of rubber band ligation in patients with haemorrhoidal disease) was reflected by a significantly improved overall PSS. In 16 cases within this group, the PSS got worse. A case-by-case follow-up of these patients showed that 14 of the 16 patients ended up with surgery (or with the advice to have surgery)., Conclusions: The PSS reliably differentiates proctological patients from non-proctological controls. Following intervention, the PSS reliably differentiated therapeutic success from failure. We find the PSS to be a simple and useful tool in our clinical routine since it provides an easily obtainable and reproducible basis for the visit-by-visit assessment of proctological patients. The PSS may also be suitable for studies to measure and compare symptomatic improvement and success of different therapies in proctology.

Pregnancy and the postpartum period are often associated with many gastrointestinal complaints, including nausea, vomiting, and heartburn; however, the most troublesome complaints in some women are defecatory disorders such as constipation and fecal incontinence, especially postpartum. These disorders are often multifactorial in etiology, and many studies have looked to see what risk factors lead to these complications. This review discusses the current knowledge of pelvic floor and anorectal physiology, especially during pregnancy, and reviews the current literature on causes and treatments of postpartum bowel symptoms of constipation and fecal incontinence.

Allium ampeloprasum subsp iranicum (Leek) has been traditionally used in antihemorrhoidal topical herbal formulations. This study aimed to evaluate its safety and efficacy in a pilot randomized controlled clinical trial. Twenty patients with symptomatic hemorrhoids were randomly allocated to receive the topical leek extract cream or standard antihemorrhoid cream for 3 weeks. The patients were evaluated before and after the intervention in terms of pain, defecation discomfort, bleeding severity, anal itching severity, and reported adverse events. A significant decrease was observed in the grade of bleeding severity and defecation discomfort in both the leek and antihemorrhoid cream groups after the intervention, while no significant change was observed in pain scores. There was no significant difference between the leek and antihemorrhoid cream groups with regard to mean changes in outcome measures. This pilot study showed that the topical use of leek cream can be as effective as a standard antihemorrhoid cream., (© The Author(s) 2015.)

Objectives: To determine the prevalence of haemorrhoids in women with pelvic vein reflux, identify which pelvic veins are associated with haemorrhoids and assess if extent of pelvic vein reflux influences the prevalence of haemorrhoids., Methods: Females presenting with leg varicose veins undergo duplex ultrasonography to assess all sources of venous reflux. Those with significant reflux arising from the pelvis are offered transvaginal duplex ultrasound (TVS) to evaluate reflux in the ovarian veins and internal Iliac veins and associated pelvic varices in the adnexa, vulvar/labial veins and haemorrhoids. Patterns and severity of reflux were evaluated., Results: Between January 2010 and December 2012, 419 female patients with leg or vulvar varicose vein patterns arising from the pelvis underwent TVS. Haemorrhoids were identified on TVS via direct tributaries from the internal Iliac veins in 152/419 patients (36.3%) and absent in 267/419 (63.7%). The prevalence of the condition increased with the number of pelvic trunks involved., Conclusion: There is a strong association between haemorrhoids and internal Iliac vein reflux. Untreated reflux may be a cause of subsequent symptomatic haemorrhoids. Treatment with methods proven to work in conditions caused by pelvic vein incompetence, such as pelvic vein embolisation and foam sclerotherapy, could be considered., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Aim: To compare the effects and postoperative complications between tissue selecting therapy stapler (TST) and Milligan-Morgan hemorrhoidectomy (M-M)., Methods: Four hundred and eighty patients with severe prolapsing hemorrhoids, who were admitted to the Shenyang Coloproctology Hospital between 2009 and 2012, were randomly divided into observation (n=240) and control (n=240) groups. Hemorrhoidectomies were performed with TST in the observation group and with the M-M technique in the control group. The therapeutic effects, operation security, and postoperative complications in the two groups were compared. The immediate and long-term complications were assessed according to corresponding criteria. Pain was assessed on a visual analogue scale. The efficacy was assessed by specialized criteria. The follow-up was conducted one year after the operation., Results: The total effective rates of the observation and control groups were 99.5% (217/218) and 98.6% (218/221) respectively; the difference was not statistically significant (P=0.322). Their were significant differences between observation and control groups in intraoperative blood loss (5.07±1.14 vs 2.45±0.57, P=0.000), pain (12 h after the surgery: 5.08±1.62 vs 7.19±2.01, P=0.000; at first dressing change: 2.64±0.87 vs 4.34±1.15, P=0.000; first defecation: 3.91±1.47 vs 5.63±1.98, P=0.001), urine retention (n=22 vs n=47, P=0.001), anal pendant expansion after the surgery (2.35±0.56 vs 5.16±1.42, P=0.000), operation time (18.3±5.6 min vs 29.5±8.2 min, P=0.000), and the length of hospital stay (5.3±0.6 d vs 11.4±1.8 d, P=0.000). Moreover TST showed significant reductions compared to M-M in the rates of long-term complications such as fecal incontinence (n=3 vs n=16, P=0.003), difficult bowel movement (n=1 vs n=9, P=0.011), intractable pain (n=2 vs n=12, P=0.007), and anal discharge (n=3 vs n=23, P=0.000)., Conclusion: TST for severe prolapsing hemorrhoids is a satisfactory technique for more rapid recovery, lower complication rates, and higher operation security.

Constipation and haemorrhoids are common complaints after childbirth. The objective of this pilot study was to evaluate impact of fermented milk containing Lactobacillus casei strain Shirota (LcS) on stool consistency and frequency, constipation-related symptoms and quality of life, and incidence of haemorrhoids in women during puerperium. Forty women who had natural childbirth were randomised to group consuming either one bottle/day of fermented milk containing at least 6.5×109 cfu of LcS, or placebo, for 6 weeks after childbirth. Subjects filled in a diary on their bowel habits including number of bowel movement, stool consistency and incidence of haemorrhoids, and answered questionnaires on constipation-related symptoms (PAC-SYM) and quality of life (PAC-QOL) during the study period. The probiotic group showed the better scores on overall PAC-SYM (P=0.013), PAC-SYM subscales of abdominal symptoms (P=0.043) and rectal symptoms (P=0.031), and PAC-QOL satisfaction subscale (P=0.037) in comparison with the placebo group. In the probiotic group, two to four subjects experienced haemorrhoids during the first 3 weeks of treatment. The number decreased in week 4 and no one had haemorrhoids on most days in week 5-6. In the placebo group, on average four subjects had haemorrhoids from the beginning, and no obvious change was observed until week 6. No statistically significant effect was observed on stool consistency and frequency. The study products did not cause any adverse event in the subjects. Results of this study indicate that continuous consumption of fermented milk containing LcS might alleviate constipation-related symptoms, provide satisfactory bowel habit and result in earlier recovery from haemorrhoids in women during puerperium. Nonetheless, there are several limitations in interpretation of the results attributed to the study design, including lack of baseline data. Further study is required in order to confirm the efficacy.

Aims and Background: Tolerance of the anal canal tends to be ignored in patients with cervical cancer undergoing whole pelvic radiotherapy. However, patients with hemorrhoids may be troubled with low radiation dose. We tried to analyze the dose-volume statistics of the anal canal in patients undergoing whole pelvic radiotherapy., Methods: The records of 31 patients with cervical cancer who received definite or postoperative radiotherapy at one institution were reviewed. Acute anal symptoms, such as anal pain and bleeding, were evaluated from radiotherapy start to 1 month after radiotherapy completion. Various clinical and dosimetric factors were analyzed to characterize relations with acute anal complications., Results: The anal verge was located an average of 1.2 cm (range -0.6~3.9) below the lower border of the ischial tuberosity and an average of 2.7 cm (range -0.6~5.7) behind the sacral promontory level. The presence of hemorrhoids before radiotherapy was found to be significantly associated with acute radiation-induced anal symptoms (p = 0.001), and the mean induction dose for anal symptoms was 36.9 Gy. No patient without hemorrhoids developed an anal symptom during radiotherapy. Dosimetric analyses of V30 and V40 showed marginal correlations with anal symptoms (p = 0.07)., Conclusions: The present study suggests a relation between acute anal symptoms following radiotherapy and acute hemorrhoid aggravation. Furthermore, the location of the anal verge was found to be variable, and consequently doses administered to the anal canal also varied substantially. Our results caution careful radiation treatment planning for whole pelvic radiotherapy, and that proper clinical management be afforded patients with hemorrhoids during radiotherapy.

On the basis of great clinical experience, the authors developed the method of choice of optimal surgical aid and suggested an original surgical method of treatment of complicated hemorrhoid. The results obtained were analyzed. There was reliably noted, that the quantity of early postoperative complications decreased, an expression of pain syndrome was lower and there were no relapses during three-year of follow-up. Given technologies allowed an introduction of them as stationary substituting operations on the basis of private medical centers with one day of hospital stay.

While debate continues as to which is the best surgical method for the treatment of hemorrhoids, none of the currently available surgical methods approach the ideal surgical option, which is one that is effective while being safe and painless. In reality, the less painful the procedure, the more likely it is to be associated with recurrence post-op. Where hemorrhoids surgery is concerned, there isn't a "one size fits all" option. Most of the randomized controlled trials performed to date include hemorrhoids of various grades and with a focus on only comparing surgical methods while failing to stratify the outcomes according to the grade of hemorrhoid. We believe that surgery needs to be tailored not only to the grade of the hemorrhoids, but also to the size, circumferential nature of the disease, and prevailing symptomatology.

Background: Milligan-Morgan hemorrhoidectomy (MMH) is the procedure of choice in the management of hemorrhoidal disease. However, this procedure is associated with significant postoperative pain. Tissue selecting technique (TST) is a segmental stapled hemorrhoidopexy, which aims to reduce the postoperative pain, rectovaginal fistula (RVF) and rectal stenosis. The aim of the present study was to compare the clinical outcomes between TST and MMH., Methods: A case-control study was undertaken to investigate the difference in clinical characteristics between the patients treated with TST and those treated with MMH. Intraoperative and postoperative parameters in both groups were collected and compared., Results: One hundred and ninety-five eligible patients underwent either TST (n = 121) or MMH (n = 74). The pain score was significantly less in the TST group than that in the MMH group at the first defecation and at 12 h, day 3 and day 7 postoperatively (P = 0.001). Further analysis revealed that, at the time point of 12 h, day 3, day 7 and during first defecation, the pain score in the TST group and TST + STE group was less than that in the MMH group (P = 0.001). No patient in either group developed postoperative rectal stenosis. Furthermore, no case of RVF was identified in the TST group. The 1-year recurrence rate was 3.3 % (4/121) and 2.7 % (2/74), respectively, in TST and MMH groups (P = 1.0)., Conclusions: The 1-year recurrence rate after TST and MMH for the treatment of patients with grade III-IV hemorrhoids is similar. It is encouraging that TST is associated with less postoperative pain and no RVF or rectal stenosis.

The objective of this research is to evaluate specifications of the surgery, its post-operative period and complications in patients with traditional hemorrhoidectomy which is a procedure performed by using a linear stapler along with a circular resection of prolapsed mucosal and sub-mucosal layers of lower rectal ampulla with the utilization of Longo technique. The study was conducted with the participation of 398 patients with the hemorrhoidal disease accompanied by anal prolapsus of which 338 (84%) were composed of males and 65 (16%) of females. Out of 398 patients, 308 (77%) underwent stapler hemorrohidectomy using linear stapler, 74 (19%) patients had conventional hemorrhoidectomy with the utilization of electric coagulation and 16 (4%) of them received circular hemorroidopexy using Longo technique. According to the data obtained during this research linear stapler use in the treatment of hemorroidal desease, accompanied by anal prolapses is an effective and technically simple solution to the problem. This method is implemented quickly, allows to cover greater part of abnormally changed cavernous tissue and conduct persist lifting of anal canal mucosal layer. It is also a safe method without any disease relapses.

Objective: To observe clinical effect, feasibility and security of preconditioning of thermopaste application at Shenque (CV 8) for relieving stretch reflex induced by procedure for prolapse and hemorrhoids (PPH)., Methods: A total of 100 cases of mixed hemorrhoids (stage III and IV) patients were randomized into 1.0 h, 0.5 h, 0 h and control (no application) groups (n = 25 in each group) according to a random number table. Thermopaste was applied to Shenque (CV 8) 1.0 h and 0.5 h before PPH or conducted simultaneously with PPH. The mean arterial pressure, heart rate, blood oxygen saturation of patients before and after anastomose operation, and the incidence of adverse reactions within 24 hours after the procedure were monitored and recorded. The patient's pain degree was assessed by using visual analogue scale., Results: After the preconditioning, of the 25 patients in the 0.5 h group (0.5 h G), 14 experienced marked improvement (in the stretch reflex during PPH), 10 had an improvement, and 1 was invalid, respectively. The markedly effective rate and the total effective rate were 56% and 96%, respectively. The therapeutic effects for inhibiting stretch reflect being from the better to the poorer were 0.5 h G > 1.0 h G > 0 h G >NG. The heart rate and blood pressure from more stable to lesser stable were 0.5 h G> 1.0 h G > 0 h G > NG. The patients' pain reaction during operation and their adverse effects of nausea, vomiting, abdominal distention and abdominal pain, etc. occurred during operation also presented the same tendency in the 4 groups., Conclusion: Thermopaste application to Shenque (CV 8) can effectively prevent and control visceral reflex in patients undergoing PPH, which effect is significantly better when conducted 0.5 hour before the operation.

Hemorrhoids are a very common anorectal disorder defined as the symptomatic enlargement and abnormally downward displacement of anal cushions. The current pathophysiologies of hemorrhoids include the degenerative change of supportive tissue within the anal cushions, vascular hyperplasia, and hyperperfusion of hemorrhoidal plexus. Low-grade hemorrhoids are easily and effectively treated with dietary and lifestyle modification, medical intervention, and some office-based procedures. An operation is usually indicated in symptomatic high-grade and/or complicated hemorrhoids. Whilst hemorrhoidectomy has been the mainstay of surgical treatment, more recently other approaches have been employed including Ligasure hemorrhoidectomy, stapled hemorrhoidopexy, and doppler-guided hemorrhoidal artery ligation. Post-procedural pain and disease recurrence remain the most challenging problems in the treatment of hemorrhoids. This article deals with modern approaches to hemorrhoids based on the latest evidence and reviews of the literature. The management of hemorrhoids in complicated situations is also discussed.

The Miligan-Morgan's operation has long been considered to be the "golden standard" of hemorrhoids' stage I-III treatment. The invention of distal branches of the upper rectal artery' suture ligation with mucopexia and lifting of the anal canal mucosa discovered new possibilities for hemorrhoids surgery, though there are still some questions considering long-term results. 151 cases of recurrence within 1-6 months were analyzed. The use of CT-angiography with 3D reconstruction of the upper rectal artery allowed to chose the operative technique more relevant and thus improve the treatment results.

Aim: The procedure for prolapse and haemorrhoids (PPH) is an effective surgical therapy for symptomatic haemorrhoids. Compared with haemorrhoidectomy, meta-analysis has shown PPH to be less painful, with higher patient satisfaction and a quicker return to work, but at the cost of higher prolapse recurrence rates. This is the first report describing predictors of prolapse recurrence after PPH., Method: A cohort of patients with symptomatic haemorrhoids, treated with PPH in our hospital between 2002 and 2009, was retrospectively analysed. Multivariate analysis was performed to identify patient-related and perioperative predictors associated with persisting prolapse and prolapse recurrence., Results: In total, 159 consecutively enrolled patients were analysed. Persistence and recurrence of prolapse was observed in 16% of the patients. Increased surgical experience showed a trend towards lower recurrence rates. Multivariate analysis identified female gender, long duration of PPH surgery and the absence of muscle tissue in the resected specimen as independent predictors of postoperative persistence of prolapse of haemorrhoids. The absence of prior treatment with rubber band ligation (RBL) as well as increased PPH experience at the hospital showed a trend towards a higher rate of prolapse recurrence., Conclusion: In order to reduce recurrence of prolapse, PPH should be performed by a surgeon with adequate PPH experience, patients should be treated with RBL prior to PPH and a resection of mucosa with underlying muscle fibres should be strived for., (© 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.)

This review discusses the pathophysiology, epidemiology, risk factors, classification, clinical evaluation, and current non-operative and operative treatment of hemorrhoids. Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions. The most common symptom of hemorrhoids is rectal bleeding associated with bowel movement. The abnormal dilatation and distortion of the vascular channel, together with destructive changes in the supporting connective tissue within the anal cushion, is a paramount finding of hemorrhoids. It appears that the dysregulation of the vascular tone and vascular hyperplasia might play an important role in hemorrhoidal development, and could be a potential target for medical treatment. In most instances, hemorrhoids are treated conservatively, using many methods such as lifestyle modification, fiber supplement, suppository-delivered anti-inflammatory drugs, and administration of venotonic drugs. Non-operative approaches include sclerotherapy and, preferably, rubber band ligation. An operation is indicated when non-operative approaches have failed or complications have occurred. Several surgical approaches for treating hemorrhoids have been introduced including hemorrhoidectomy and stapled hemorrhoidopexy, but postoperative pain is invariable. Some of the surgical treatments potentially cause appreciable morbidity such as anal stricture and incontinence. The applications and outcomes of each treatment are thoroughly discussed.

Objective: The aims of this study were to identify groups of symptoms experienced by women during midlife and to determine the main profiles or trajectories for each of these symptom groups through the menopausal transition., Methods: The study uses data from the middle-aged cohort of women from a large community-based longitudinal study. Groups or patterns of symptoms are determined using factor analysis. Latent class analysis based on age and age at menopause is used to identify profiles for each of the symptom patterns., Results: Of the four symptom patterns identified, "somatic," "urogynecological," and "physical" symptoms have a constant profile through midlife. Vasomotor symptoms vary through menopause: 11% of women have the "early severe" profile of symptoms that begin at premenopause, whereas 29% have the "late severe" profile, with symptoms peaking during postmenopause and persisting more than a decade after menopause. The remaining women with the "moderate" or "mild" profiles report occasional symptoms that tend to peak around menopause., Conclusions: Identifying the profile of vasomotor symptoms could help health professionals to tailor their advice to women going through menopause.

Stapled hemorrhoidectomy (SH) and Ligasure hemorrhoidectomy (LH) are standard for hemorrhoidal disease treatment, but the surgical principle is different. This randomized clinical trial compared the 2 methods. We included 98 patients with grade 3 hemorrhoidal disease: 46 patients treated by SH and 52 patients by LH. Incidence of complications, recurrence, postoperative pain, wound healing time, and time off everyday activity were observed. The follow-up period was 24 months. We found that LH has a significantly shorter wound healing time. The recurrence rate and the overall postoperative complication rate was higher after SH but not significantly (recurrence LH vs. SH: 1.9% vs. 11.1%; complications LH vs. SH: 13.5% vs. 23.9%). Postoperative pain level, analgesic consumption, and time off everyday activity were practically the same in both groups. Both procedures can be used to treat grade 3 hemorrhoidal disease with the same efficacy, but analysis of recurrence after SH is necessary.

Background: Doppler-guided ligation of hemorrhoidal vessels is being proposed as a treatment of grade 2 and 3 hemorrhoids. Many researchers are coupling this procedure with mucopexy or lifting of hemorrhoids to control the prolapse more effectively. The present study was conducted in patients with 3rd-degree hemorrhoids to determine the usefulness of Doppler-guided hemorrhoidal artery ligation compared to mucopexy of prolapsing hemorrhoids and to compare it with mere mucopexy of the hemorrhoids., Materials and Methods: A double-blind, randomized controlled study was conducted on 48 consecutive patients with grade III hemorrhoids requiring surgery. The patients were randomized into two groups. Half of them were treated with ligation and mucopexy [SL], while the remaining patients underwent a Doppler-guided hemorrhoidal artery ligation followed by ligation and mucopexy [DSL]. The patients were examined by a blinded independent observer at 2, 4, and 6 weeks and at the end of 1 year after the operation to evaluate postoperative pain scores, amount of analgesics consumed, and complications encountered. The observer also assessed recurrence of hemorrhoids after 1 year., Results: Operative time was significantly longer in the DSL group (31 min vs. 9 min P < 0.003). The postoperative pain score was significantly higher in the Doppler group [4.4 vs. 2.2, P < 0.002 (visual analogue scale)]. The mean total analgesic dose and duration of pain control using analgesics were greater and longer for the Doppler group than for the SL group (17 vs. 11 tablets, and 13 days vs. 9 days, respectively; P < 0. 01). Complications were similar in both the groups. At 1-year follow-up, the recurrence of hemorrhoids was not statistically significant in either group (4 patients in SL group and 3 patients in DSL group; P < 0.93)., Conclusions: Suture ligation of hemorrhoids is a simple, cost-effective, and convenient modality for treating grade 3 hemorrhoids. Doppler assistance in ligating the hemorrhoidal vessels prior to hemorrhoidal mucopexy offers no advantage and is a time-consuming procedure.

Hemorrhoidal disease is the first cause of proctological consultation although epidemiology is poorly documented. Pathophysiology is complex and involves a fragmentation of supporting tissues as well as vascular changes with hypervascularization and/or impaired venous return. The only complication of external hemorrhoids is thrombosis, which is responsible for acute anal pain irrespective of bowel movements. Internal hemorrhoids most frequently cause prolapse and/or bleeding which is easily recognizable. Physical examination always confirms the diagnosis and a colonoscopy is required after 40 or 45 in order to rule out colorectal cancer., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Background and Objective: The aim of this prospective controlled trial was to evaluate the long-term clinical and manometric results of stapled hemorrhoidopexy performed by expert surgeons in a selected group of patients for the treatment of chronic hemorrhoids., Settings: This study took place in the outpatient clinic and at the Day Surgery Unit attached to the University Hospital of Elche., Patients: From March 2003 to May 2005, 200 consecutive patients with third-degree hemorrhoids and treated with double-pursestring stapled hemorrhoidopexy with a PPH33-03 stapler were included in the study., Main Outcome Measures: Demographic, manometric, and clinical features were analyzed, as well as the variables related to surgery, postoperative course, and follow-up. Manometry was repeated at the 6-month, 1-year, and 5-year follow-up., Results: Median follow-up was 110 months. Four patients (2%) reported daily rectal bleeding. One patient with active rectal bleeding was taken for reoperation within the first 12 postoperative hours. Seventy percent of patients reported pain ≤ 2 on the first postoperative day, 85% on the fourth postoperative day, and 95% on the seventh postoperative day. Pain was measured with a linear analog scale from 0 to 10 (0 = no pain; 10 = unbearable pain). Seventeen patients (8.5%) reported tenesmus during the first week. Eight patients (4%) reported persistent pain: in 5 patients, the pain resolved within the next 6 months; 2 patients presented with anal fissure; and 1 patient required the removal of the staples. Two patients (1%) reported residual soiling at the 5-year revision. Fourteen patients (7%) experienced recurrence with symptomatic prolapse. Six (3%) underwent further surgery: stapled hemorrhoidopexy was indicated again in 2 patients, and 4 patients underwent a Milligan-Morgan open hemorrhoidectomy, because they did not have a uniform prolapse. Six patients required treatment with rubber band ligation. There were no statistically significant differences between preoperative and postoperative manometric values., Conclusions: The new PPH33-03 stapler, the learning process of the modified surgical procedure, and the correct selection of patients will overcome the main objections to stapled hemorrhoidopexy.

Introduction: Rectal bleeding is a very common clinical sign. It is often caused by haemorrhoids. However, it can be a symptom of other pathology in the rectum or colon. There are little data coincidental pathology in patients with haemorrhoids and rectal bleeding., Objective: To examine coincidental pathology in patients with rectal bleeding and haemorrhoids, especially with respect to age., Methods: Prospectively, 290 consecutive patients presenting with bleeding and haemorrhoids were analysed. All patients had an endoscopic examination. All significant endoscopic findings (diverticuli, polyps, cancer, angiodysplasia and varices or colitis) were recorded., Results: The patients were divided into two groups. Group 1 consisted of patients with only haemorrhoids (n = 129, % male: 41.1, mean age: 53.6 +/- 12.7 years). Group 2 consisted of patients with haemorrhoids and coincidental pathology (n = 161, % male: 46.6, mean age: 67.3 +/- 13.7 years). There was no difference in gender or in the type of endoscopy. However, patients in Group 2 were significantly older., Conclusion: It can be concluded that in cases of rectal bleeding and haemorrhoids, coincidental pathology occurs in a large proportion of patients, especially the elderly. Omitting endoscopy in these patients can lead to major doctors delay.

Haemorrhoids are varicose veins of the rectum covered by mucosa at or near the anal canal. They are normally asymptomatic, can occur at any age and affect both males and females. In this review, we address the issue of the approach of the obstetrician to haemorrhoids and their management. Haemorrhoids are common in young women and commoner during pregnancy and the puerperium. Obstetricians and gynaecologists should be familiar with haemorrhoids, a proctological disease, diagnosis and their treatment, but they have little experience regarding the impact of pregnancy on haemorrhoids. The obstetrician must be able to relieve symptoms in patients who are pregnant, or who have just delivered.

Hemorrhoidal disease is a common problem that is managed by various physicians, ranging from primary care providers to surgeons. This article reviews the pathophysiology, clinical presentation, and updated treatment of hemorrhoids, including nonoperative options, office-based procedures, and surgical interventions from standard excision to stapled hemorrhoidopexy and Doppler-guided ligation. The article also covers complications and provides guidance for special circumstances, such as pregnancy, hemorrhoidal crisis, and inflammatory bowel disease., (Copyright 2010 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to determine whether overactivity of the anal sphincter in patients with hemorhhoids is primary or secondary and thus assess indication of lateral internal sphincterotomy to surgical treatment of hemorrhoids. Tonic contraction of the sphincter muscle in patients with advanced stages of hemorrhoids is considered by many authors as a primary cause, and therefore, they complete hemorrhoid surgery with lateral internal sphincteroomy. If hypertension of anal sphincter is secondary during hemorrhoid disease, lateral internal sphincterotomy is not indicated. Although examinations made immediately after sphincterotomy proved no changes of anal continence, certain sequelae of lateral internal sphincterotomy cannot be excluded and may later negatively affect patient's anal continence., Patients and Methods: The prospective study comprised 385 patients treated in 2002-2006 by Hemoron or surgery according to Milligan-Morgan or Longo. Patients with history of another disease of the anal canal, radiotherapy of pelvis, Crohn's disease or ulcerous colitis were excluded. Manometry was performed before and after surgery at intervals of 1, 3, 6 and 12 months after operation using a perfusion flow method, six-channels catheter with radial arrangement of channel tips., Results: In all three groups (Hemoron, sec. Milligan-Morgan, sec. Longo), there were 60-65% of patients with third degree hemorrhoids. Normal resting anal pressure before surgery was recorded in only 25% of men and 30% of women. Patients with advanced hemorrhoid degrees were found to have significant hypertension of the anal sphincter. The most significantly improved state of sphincter overactivity was observed after surgery according to Longo and application of Hemoron. After surgery, according to Milligan-Morgan, recovery of anal sphincter tension was the longest; even 6 months after operation, a mean increased resting anal pressure persisted (91-110 mmHg) in 25% of men and 19% of women. After 12 months, recovery of anal tension occurred in this group also--mean increased anal pressure was recorded in only three patients (1.67%)., Conclusion: Overactivity of the anal sphincter in patients with hemorrhoids is secondary and according to our results. Hypertension of the sphincter muscle in patients with hemorrhoids is significantly increased in patients with advanced degrees of hemorrhoids. Therefore, it is not recommended to postpone surgery and indicate patients with advanced degrees of hemorrhoids to hemorrhoidectomy.

Vascular diseases are a major threat to human health nowadays. Hypertension, cardiovascular disease and varicose vain disease including hemorrhoids, are now increasingly recognized as inflammatory diseases. The role of inflammation cytokines in the pathogenesis of these diseases is very important. The lamina propria in the nasal mucosa is rich in blood vessels and humoral mediators. Recurrent epistaxis from Kiesselbach's area syndrome (REKAS) was first mentioned as early as 1985. It has been found that 90% of patients suffering from recurrent epistaxis from Kiesselbach area syndrome simultaneously suffered from hemorrhoids. Clinical observations suggest a possible mutual pathophysiologic relationship between Kiesselbach's and anorectal venous plexus. This relationship is also suggested in the reverse direction: significantly more than two thirds of primarily hemorrhoidal patients (83.01%) showed simultaneous vascular dilatations within their Kiesselbach plexuses, but none of these patients had ever have recurrent nose bleeds. There is one more thing they did not have (contrary to REKAS group)--anterior septal deformity. Furthermore, REKAS and hemorrhoidal disease, despite being different clinical entities, frequently appear in the primarily REKAS patients or their closest relatives (more than 90% out of all!). At the same time, all of REKAS patients did have a certain degree of the anterior septal deformity, which primarily hemorrhoidal patients did not have at all. Therefore we presume that Kiesselbach's vascular plexus in the Little's area of the nasal septum belongs to the same group as anorectal venous plexus does (others of this group are brain, esophagus, and lower leg venous system). We also presume that the anterior septal deformity is a crucial factor for the onset of the inflammation of the nasal vestibule skin (vestibulitis nasi), while vestibulitis nasi precipitates the onset of typical recurrent nose bleeds from the Kiesselbach's plexus.

Introduction: In a previous uncontrolled study, a reduction of rectal distensibility and volume thresholds for sensations have been related to the occurrence of fecal urgency and/or increased stool frequency after stapled hemorrhoidopexy., Aim of the Study: The aim of this study was to compare rectal symptoms and sensory-motor function after stapled hemorrhoidopexy and Milligan-Morgan hemorrhoidectomy., Methods: The clinical records of 12 (four women) and ten patients (four women) with third- and fourth-degree hemorrhoids, respectively, who underwent stapled hemorrhoidopexy or Milligan-Morgan's hemorrhoidectomy, were evaluated. One week before and 6 months after surgery, rectal motor and sensory response to distension was assessed by an electronic barostat, and bowel and rectal symptoms were recorded by means of a 7-day diary and Bristol Index scale and psychological symptoms with SCL-90 questionnaire., Results: Rectal distensibility and volume thresholds for sensations were significantly lower after surgery (P < 0.02) in the stapled group. Increased stool frequency and/or fecal urgency arose in 41% of patients in the stapled group and associated with altered rectal distensibility. No difference within and between groups could be demonstrated in SCL-90 score., Conclusions: Rectal distensibility and volume thresholds for sensations decrease after stapled hemorrhoidopexy. Altered rectal distensibility was associated with rectal urgency and/or increased stool frequency.

Objectives: The aim of the present study is to determine anion and cation contents of the herbals used in Turkish folk remedy to explore the rationale of their use in hemorrhoid treatment in the context of the vasoactivity of these elements., Design: Herbs used in the treatment of hemorrhoid were determined by the way of literature search. These herbs were obtained from certified herb sellers. Ground herb samples were placed in individual tubes containing methanol and incubated for 48 hours at 30 degrees C. At the end of the incubation, supernatants were analyzed for their ion concentrations by using ion chromatography., Results: The difference between ion levels between systemic and locally used herbs, was not statistically significant (p>0.05). Anion concentrations (except nitrate) of locally used herbs were slightly higher than systemically used herbs (p>0.05). Cation levels (except magnesium) of systemically used herbs were slightly higher than locally used herbs (p>0.05). It was shown that the concentration of vasoconstrictor effective ions was higher than the concentration of vasodilator effective ions (p<0.001). While vasoconstrictor ion concentration of systemically used herbs was 88.06 +/- 147.42 mg, vasodilator ion concentration of locally used herbs was 90.15 +/- 136.94 mg. The difference between vasodilator concentrations of groups was more evident; 5.39 +/- 9.80 mg and 14.32 +/- 66.48 mg for locally and systemically used herbs respectively., Conclusions: This study showed that herbal remedies used for the treatment of hemorrhoid in Turkey contain vasoactive and especially vasoconstrictor ions. Vasoconstrictor agents could amplify each others' effects as it has been previously shown, therefore, it is probable that the vasoconstrictor ion contents could contribute to the curative effects of herbals in the treatment of hemorrhoids.

Purpose: The pathogenesis of hemorrhoidal disease is based mainly on the vascular hyperplasia theory. The aim of this study was to reassess the morphology and the functional mechanisms of the anorectal vascular plexus with regard to hemorrhoidal disease., Materials and Methods: The anorectal vascular plexus was investigated in 17 anorectal and five hemorrhoidectomy specimens by means of conventional histology and immunohistochemistry. Vascular corrosion casts from two fresh rectal specimens were used for scanning electron microscopy. Transperineal color Doppler ultrasound (CDUS) with spectral wave analysis (SWA) was performed in 38 patients with hemorrhoidal disease and 20 healthy volunteers., Results: The anorectal vascular plexus was characterized by a network of submucosal vessels exhibiting multiple thickened venous vessels separated by distinct sphincter-like constrictions. CDUS and SWA showed significant flow differences in peak velocities (6.8 +/- 1.3 cm/s vs. 10.7 +/- 1.5 cm/s; P = 0.026) and acceleration velocities (51 +/- 4 ms vs. 94 +/- 11 ms; P = 0.001) of afferent vessels between the control group and patients with hemorrhoidal disease., Conclusions: Coordinated filling and drainage of the anorectal vascular plexus is regulated by intrinsic vascular sphincter mechanisms. Both morphological and functional failure of this vascular system may contribute to the development of hemorrhoidal disease.

Introduction: Haemorrhoids are an abnormal, tortuous dilatation of the arteriovenous plexus of the anus. Although increased resting anorectal pressure is deemed to be a major initiating factor, a thorough understanding of the pathogenesis is still lacking. Mast cells, through release of granules, can affect local vessels with respect to changes in calibre, changes in permeability and thrombosis. Thus, mast cells could play a role in haemorrhoid pathophysiology, although this has not been previously investigated., Methods: 48 cases of haemorrhoids were retrospectively collected at King Chulalongkorn Memorial Hospital, with normal anorectal tissue from surgically-removed colorectal cancer serving as controls. Mast cells were identified by toluidine blue staining and quantitated around venous vessels., Results: Mast cells around haemorrhoidal vessels were significantly more numerous than in normal specimens (p-value is less than 0.001). Similar values were found for haemorrhoids showing chronic changes and those in a more acute stage., Conclusion: These findings support the hypothesis that mast cells may play a role in the pathophysiology of haemorrhoids. Mast cells appear to participate equally in the early and later stages of these lesions. Mast cells are known to affect local vascular conditions through release of their chemical mediators and cytokines, and may influence haemorrhoid symptomatology and progression at this level.

Aim: To study the results for the treatment of symptomatic hemorrhoids using rubber band ligation (RBL) method., Methods: A retrospective study for 750 patients who came to the colorectal unit from June, 1998 to September, 2006, data was retrieved from archived files. RBL was performed using the Mc Gown applicator on an outpatient basis. The patients were asked to return to out-patient clinic for follow up at 2 wk, 1 mo, 6 mo and through telephone call every 6 mo for 2 years)., Results: After RBL, 696 patients (92.8%) were cured with no difference in outcome for second or third degree hemorrhoids (P = 0.31). Symptomatic recurrence was detected in 11.04% after 2 years. A total of 52 patients (6.93%) had 77 complications from RBL which required no hospitalization. Complications were pain, rectal bleeding and vaso-vagal symptoms (4.13%, 4.13% and 1.33% of patients, respectively). At 1 mo there were a significant improvement in mean SF-36 scores over baseline in five items, while after 2 years there were improvement in all items over baseline, but not significant. No significant manometeric changes after band ligation., Conclusion: RBL is a simple, safe and effective method for treating symptomatic second and third degree hemorrhoids as an out patient procedure with significant improvement in quality of life. RBL doesn't alter ano-rectal functions.