A Conservative Approach to the Management of Hemorrhoidal Disease

Hemorrhoids is a common, multifactorial anorectal disease affecting millions worldwide and one of the oldest proctological illnesses. It is defined as the symptomatic enlargement and distal displacement of the normal anal cushions leading to abnormal dilatation and inflammatory changes in the supportive connective tissue (1). Hemorrhoids have a major negative influence on the quality of life and also bring with them hampered productivity and economic burden (2).

Clinical Classification of Hemorrhoids

Understanding Hemorrhoids and their grading is quite necessary for their management. Hemorrhoids are graded based on their location and degree of prolapse:

Based on the location-

• Internal- Arise above the dentate line.
• External- Arise below the dentate line.
• Mixed- Arise above and below the dentate line.

Based on the degree of prolapse-

• Grade 1- Anal cushion bleed but no prolapse
• Grade 2- Anal cushion prolapse on straining but reduced spontaneously
• Grade 3- Anal cushion prolapse on straining and need to be replaced manually
• Grade 4- Prolapse stays out all the time and is irreplaceable

Evaluation and Management of Hemorrhoids: Overview

American Society of Colon and Rectal Surgeons has put forth guideline recommendations for the management of hemorrhoids as follows (3)

• A disease-specific history and physical examination should be performed, emphasizing the degree and duration of symptoms and risk factors.
• Complete endoscopic evaluation of the colon is indicated in select patients with symptomatic hemorrhoids and rectal bleeding.
• Dietary modification consisting of adequate fluid and fiber intake and counseling regarding defecation habits typically form the primary first-line therapy for patients with symptomatic hemorrhoid disease.
• Medical therapy for hemorrhoids represents a heterogeneous group of treatment options that can be offered with minimal harm and a decent potential for relief.
• Most patients with grade I and II and select patients with grade III internal hemorrhoidal disease who fail medical treatment can be effectively treated with office-based procedures, such as banding, sclerotherapy, and infrared coagulation (IRC). Hemorrhoid banding is typically the most effective treatment option.
• Certain patients with thrombosed external hemorrhoids may benefit from early surgical excision. Hemorrhoidectomy should typically be offered to patients whose symptoms result from external hemorrhoids or combined internal and external hemorrhoids with prolapse (grades III-IV)
• Patients undergoing surgical hemorrhoidectomy should use a multimodality pain regimen to reduce narcotic usage and promote a faster recovery.

Conservative Treatment Approach of Hemorrhoids

Conservative management of hemorrhoids includes simple management techniques ranging from dietary and lifestyle modification (4) to maintaining hygiene and using medical therapy. Grade I and II hemorrhoids can be well managed conservatively. Altomare et al have put forward a few conservative techniques for the management of hemorrhoids which are:

• Dietary changes: These are the first, safe, cheap, and essential interventions that require high patient compliance. A fluid intake of 1.5-2L/day and a fiber intake of 30-40g/day is necessary to maintain regular bowel movements and the habit of producing soft stools. Fiber intake works well for patients having non-prolapsing hemorrhoids and takes nearly 6 weeks for their effect. Both soluble and insoluble fibers can be used (5). These fiber supplements reduce the risk of bleeding and symptoms by nearly 50% as they add bulk to the stools (1).
• Lifestyle modifications: Lifestyle changes like increasing physical activity, reducing the intake of constipating drugs, alcohol, and fat, following correct posture during defaecation with knees above the level of the anus (5), abstaining from straining while passing stools may help to reduce stress and facilitates easy movement of stools. Lifestyle changes should be advised to patients as a part of treatment and preventive measures (1).
• Sitz Bath: It is an instinctive topical management option used in the acute phase of hemorrhoids. The theory behind their mechanism of action is the thermosphincteric reflex, a neural pathway, that relaxes sphincter muscles, controls inflammation, and reduces edema thus providing immense relief to the patient. Despite the controversy on the temperature needed for sitz baths, they have provided relief to the patients. They also give relief to patients after rubber band ligation (1).
• Topical Agents: Other topical ointments containing anesthetics, steroids, emollients, and/or antiseptics have been used by patients for symptom relief but they can lead to sensitization and allergy.
• Venoactive Drugs: The rationale for using these agents is due to their effect on the vascular component of hemorrhoids with engorged and inflamed microcirculation. In the early grades of hemorrhoids, they help in remission, and in the most advanced grades, they improve vascular congestion. Plant extracts like oxerutin, diosmin, hesperidin, coumarin, rutosides, and quercetin and other synthetic products like calcium dobesilate are used to improve venous tone, microcirculation, and lymphatic drainage and protect the microcirculation from inflammatory mediators.

Among venoactive drugs, micronized purified flavonoid fraction, diosmin, troxerutin-carbazochrome, calcium dobesilate, hydroxyethylrutoside, and a flavonoid medication derived from a French maritime pine bark were reviewed in a Cochrane review and are found to show overall improvements in symptoms of hemorrhoids. The most common flavonoid used in clinical treatment is Micronized purified flavonoid fraction (MPFF) and is found to be more potent than pure diosmin in hemorrhoids.

Micronized purified flavonoid fraction: Pharmacological Overview

Micronized purified flavonoid fraction (MPFF) consists of 90% diosmin and 10% hesperidin. It is micronized to less than 2 µm to improve its solubility and absorption and lead to faster onset of action. It can reduce rectal discomfort, pain, and secondary hemorrhage following hemorrhoidectomy (6). MPFF possesses clinical effects at the following levels:

• At the microcirculatory level – MPFF exerts an effect on venous inflammatory processes that leads to endothelial protection and an attenuated inflammatory cascade from the early stages of venous inflammation to later stages involving skin changes.
• On microcirculatory permeability - MPFF reinforces capillary resistance, decreases capillary permeability, and improves micro lymphatic drainage.
• On venous tone - MPFF decreases venous distensibility and causes an increase in elastic modulus and venous emptying with an optimal dose/effect ratio achieved at a 1000 mg daily dose.

Applicability of MPFF in Various Grades of Hemorrhoids:

Evidence shows that MPFF can be used as an effective and appropriate treatment option in all grades of hemorrhoids (7).

MPFF and its Use in Global Management Guidelines:

Various associations across the globe have added MPFF to their management guidelines (7).

• The American Gastroenterological Association: Recognizing its efficacy in reducing signs and symptoms, MPFF is cited as a pharmacological treatment option.
• The French National Society of Coloproctology: Recommends MPFF (1000–2000 mg/day) as a short-term treatment for the symptoms of Internal Hemorrhoids.
• The Association of Colon & Rectal Surgeons of India (ACRSI) recommends MPFF as a first-line treatment for grade I–II and selected/minor grade III hemorrhoids. The recommended dosage is

Treatment of acute bleeding

Micronized purified flavonoid fraction: Review of Clinical Evidence Literature:

• Philippe Godeberge et al reviewed MPFF in the treatment of hemorrhoidal disease (HD). They mentioned that in acute HD, MPFF can reduce symptoms such as bleeding, pain, anal discomfort, anal discharge, and pruritus. In patients who are undergoing surgery, postoperative adjunct MPFF consistently reduces pain, bleeding duration, and use of analgesia, reduces hospital stay, facilitates return to normal activity, and also improves the quality of life (7).
• In a systematic review and meta-analysis by Parvez Sheik et al on the efficacy of MPFF across the broader spectrum of signs and symptoms in hemorrhoidal patients, they found that MPFF treatment can improve signs and symptoms of HD. From 11 studies reported across 13 articles, it was found that MPFF was beneficial in treating bleeding, pain, pruritus, anal discharge/leakage, and tenesmus, and resulted in an overall improvement (8).
• Evgeny et al in their multicenter observational study determined the frequency of complaints treated with micronized purified flavonoid fraction (MPFF, Detralex). In a total of 1952 patients who enrolled in the study, MPFF-based conservative treatment was effective in 1489 (76.3%) patients in eliminating the main symptoms like bleeding and prolapse of internal nodes. They concluded that conservative therapy with MPFF was beneficial and effective in patients with grade I and II hemorrhoids for reducing hemorrhoidal symptoms (6).
• Haiqi Fu et al in their meta-analysis evaluated the efficacy and safety of MPFF in treating postoperative hemorrhoid complications. They included 22 RCTs, with 2,335 participants in the analysis. They found that MPFF is safe and effective in reducing postoperative hemorrhoid complications. (9)

Take-Home Pointers

• Nearly 40% of adults have hemorrhoidal disease (HD).
• Constipation, inadequate dietary fiber, diarrhoea, obesity, increasing age, pregnancy, and a sedentary lifestyle are some of the risk factors for HD.
• Conservative management includes dietary measures to avoid constipation and venoactive drugs.
• MPFF was found to be effective, safe, and well tolerated in all grades of HD, either as a first-line treatment or as an adjunct in patients recovering from Hemorrhoidectomy.

This World Piles Day, Let's Vouch To Strike the Core of Hemorrhoidal Disease. To get more information about Piles/ Hemorrhoids, from Diagnosis to Management, click on the link below.

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

References:

1. Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012;18(17):2009-2017. doi:10.3748/wjg.v18.i17.2009.

2. Sandler RS, Peery AF. Rethinking What We Know About Hemorrhoids. Clin Gastroenterol Hepatol. 2019;17(1):8-15. doi:10.1016/j.cgh.2018.03.020

3. Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2018;61(3):284-292. doi:10.1097/DCR.0000000000001030

4. Lorenzo-Rivero S. Hemorrhoids: diagnosis and current management. Am Surg. 2009;75(8):635-642.

5. Altomare DF, Giannini I. Pharmacological treatment of hemorrhoids: a narrative review. Expert Opin Pharmacother. 2013;14(17):2343-2349. doi:10.1517/14656566.2013.836181

6. Zagriadskiĭ EA, Bogomazov AM, Golovko EB. Conservative Treatment of Hemorrhoids: Results of an Observational Multicenter Study [published correction appears in Adv Ther. 2018 Nov 1;:]. Adv Ther. 2018;35(11):1979-1992. doi:10.1007/s12325-018-0794-x.

7. Godeberge P, Sheikh P, Lohsiriwat V, Jalife A, Shelygin Y. Micronized purified flavonoid fraction in the treatment of hemorrhoidal disease. J Comp Eff Res. 2021;10(10):801-813. doi:10.2217/cer-2021-0038.

8. Sheikh P, Lohsiriwat V, Shelygin Y. Micronized Purified Flavonoid Fraction in Hemorrhoid Disease: A Systematic Review and Meta-Analysis. Adv Ther. 2020;37(6):2792-2812. doi:10.1007/s12325-020-01353-7.

9. Fu H, Guo W, Zhou B, Liu Y, Gao Y, Li M. Efficacy and safety of micronized purified flavonoid fractions for the treatment of postoperative hemorrhoid complications: A systematic review and meta-analysis. Phytomedicine. 2022;104:154244. doi:10.1016/j.phymed.2022.154244.