Hemorrhoids Revisited- Understanding the diagnosis, risk factors, and medical management

Haemorrhoidal disease (HD) is one of the most commonly encountered disorders affecting mostly adults of 50 years or above [1]. Risk factors like straining to attain complete evacuation, inadequate fiber intake, or prolonged lavatory sitting, can lead to hemorrhoids becoming inflamed and swollen with venous blood, and ultimately aggravate hemorrhoidal disease [2].

External HD occurs due to swelling of the external perianal vasculature and is therefore mostly associated with symptoms of pain and pruritus, and occasionally bleeding or thrombosis. Internal HD occurs when the internal hemorrhoids swell and slide toward the anus, and is usually manifested as anal bleeding during defecation, which is painless and stops naturally at the end of straining to defecate.

HD is the consequence of an increased inflow into the superior rectal artery, which causes dilatation of the hemorrhoidal plexus [3].

Grading Haemorrhoidal Disease

Hemorrhoids are classified as grade I when they are seen during anoscopy as congested veins, grade II when they prolapse but spontaneously reduce, grade III when they prolapse and need manual reduction, and grade IV when they are irreducible [4]. HD, defined as symptomatic hemorrhoids, can present with pain, itching, bleeding, discharge, or prolapse [5].

In most patients, the prolapse is not sufficient to require surgery or an outpatient procedure (e.g. rubber band ligation [RBL] or sclerotherapy), and conservative medical treatment is, therefore, an important first option in managing HD. This includes diet and lifestyle modification to increase fiber and fluid intake, increased physical activity, and avoidance of constipation and straining during defecation [6]. Topical treatments, including creams containing anesthetics, corticosteroids, and anti-inflammatory drugs, may be used to provide some relief for HD [6].

Lifestyle and Risk Factors in Hemorrhoidal Disease

Constipation, a low fiber diet, a high Body Mass Index, pregnancy, and a sedentary lifestyle are often assumed to increase the risk of hemorrhoidal disease (HD) [7].

Analyzing the Risk Factors

HD can present with a variety of symptoms, including anal bleeding, prolapse, itching, and/or perianal skin irritation. All of these physical discomforts can significantly influence the quality of life (QoL) in patients with HD [7]. In addition, frequent recurrence and persisting pain and not negligible complication rate even after surgery raises the need to prevent HD through effective management of risk factors [8].

Role of Diagnosis in HD

A confirmed diagnosis of hemorrhoids is made after a complete history and clinical examination. Hemorrhoids are often misdiagnosed when presented with pain or pruritis alone as compared to when presented with a protruding lesion [7].

Colonoscopy is an essential diagnosis in cases where the symptoms are similar to proximal pathology that includes stools mixed with dark blood, anemia, positive fecal occult blood test, abdominal mass, or tenderness [7]. Diagnosis including inspection of the anal margin at rest and with straining patients helps in the grading of haemorrhoidal disease [7].

Retroflexed colonoscopy, along with being safe, can even diagnose asymptomatic hemorrhoids and thus play a vital role in the study of the prevalence of internal hemorrhoids [30].

Managing HD-The role of venoactive drugs

With studies reporting that only 5–10% of patients require surgical intervention (hemorrhoidectomy), that too only when conservative treatment and medical therapy have failed; targeted pharmacological therapy holds a position of paramount importance in controlling HD [22]. Also, most patients do not have prolapse to such an extent that necessitates surgery, medical treatment remains the mainstay in the management of HD.

MPFF treatment in HD

How does this drug act?

The recent focus on MPFF has revealed that each flavonoid present in MPFF contributes synergistically to its pharmacological effect [8,9]. Consistent with this synergy, MPFF increases venous tone, has free-radical scavenging properties, reduces capillary permeability (edema), improves lymphatic drainage, reduces blood viscosity, and/or erythrocyte aggregation, and acts on the inflammatory processes in veins by decreasing the expression of adhesion molecules by neutrophils and monocytes. Because venous pathologies and diminished venous return play prominent roles in HD, these actions of MPFF provide the rationale for its use in treating HD.

Notable studies supporting the irrevocable efficacy of micronized purified flavonoid fraction, MPFF, have been summarized as follows:

Several systematic reviews and meta-analyses have found evidence for the efficacy of flavonoids, MPFF, and other venoactive drugs in the treatment of HD [23,24,25]. Alonso-Coello et al. study reported that MPFF treatments reduced the risk of persistent symptoms by 58% (relative risk: 0.42; 95% CI: 0.28; 0.61), and showed an apparent reduction in the risk of bleeding, persistent pain, itching, and recurrence [24]. A Cochrane meta-analysis found that venoactive treatments were associated with statistically significant improvements in bleeding and overall symptoms in acute HD, and improvements in bleeding after hemorrhoidectomy [25]. Aziz et al. study concluded MPFF to significantly reduce bleeding over placebo [5].

Quantitative analysis of pooled results of a recent study indicated that 7 days of MPFF treatment was associated with a 90% reduction in the risk of bleeding, significant reductions in discharge and leakage, and a trend toward a reduction in pain. Consistent and statistically significant quantitative evidence was also found for overall improvement in symptoms, as assessed by patients and investigators [6].

Investigating its growing role in controlling postoperative bleeding, pain, and related symptoms (after hemorrhoidectomy), studies by Lee et al., Colak et al., La Torre et al., and Mlakar et al. have noted significantly lower scores in the MPFF group as compared to placebo [26-29].

Studies have also highlighted that MPFF treatment resulted in statistically significant relief of pain by day 3 and of discomfort by day 7 after sclerotherapy [26-29].

MPFF may play a significant role as an adjunct in combination with surgical or nonsurgical techniques in treating HD along with treatment of constipation and lifestyle changes.

Conclusion

Despite the prevalence and social significance of HD, it is unlikely that there will be any fundamental changes in treatment strategies in the coming years or even decades. Innovations of significance in the treatment of HD are now mainly procedural. Moreover, despite an impressive list of medicinal agents currently available for treating HD, only flavonoids have a systemic effect and influence, at least indirectly, on the pathogenesis of HD. At the same time, the real evidence base for the efficacy of conservative therapy in HD is, in general, currently relevant only for MPFF. Further, studies have mostly focused on surgical techniques to treat HD, without significantly advancing our knowledge of the pathophysiology of HD. Therefore, scientific research in this area, from clinical presentation to postoperative management, is extremely relevant.

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https://medicaldialogues.in/world-piles-day

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