Chorus study revisited- Understanding the common trends of hemorrhoidal disease and chronic venous disease
Hemorrhoidal disease (HD) is a common cause of anal pathology, but its exact prevalence is difficult to determine as patients are often reluctant to seek medical attention.1,2 Levels of spontaneous consultation for anal symptoms are only around 2%, increasing to around 14% when patients presenting for an unrelated condition are subject to targeted questioning.1,2Chronic venous disease (CVD) is...
Hemorrhoidal disease (HD) is a common cause of anal pathology, but its exact prevalence is difficult to determine as patients are often reluctant to seek medical attention.1,2 Levels of spontaneous consultation for anal symptoms are only around 2%, increasing to around 14% when patients presenting for an unrelated condition are subject to targeted questioning.1,2
Chronic venous disease (CVD) is a condition in which the venous wall and/or valves in the leg veins do not work efficiently, creating difficulty for the blood to return to the heart from the legs. CVD causes blood to "pool" or collect in these veins, a phenomenon known as stasis.
Data on the coexistence of hemorrhoids with other conditions is sparse. Some data are consistent with a common pathophysiological link between straining at stool, constipation, and obstetrical events such as pregnancy and delivery.3These same factors are also involved in the development of chronic venous disease (CVD). Interference with venous return in the internal hemorrhoidal plexuses and saphenous veins may be a common anatomical mechanism.
Given the insufficiency of information on the profiles of patients with HD, the aim of the CHORUS study (CHronic venous and HemORrhoidal diseases evalUation and Scientific research) was to provide current, global data on patients presenting with HD in clinical practice and to explore the frequency of its coexistence with CVD and their shared risk factors.
The CHORUS study was performed to provide data on patients presenting with hemorrhoidal disease (HD) in clinical practice and to explore the frequency with which it coexists with chronic venous disease (CVD).
This international, non-interventional study enrolled adult patients attending a consultation for hemorrhoidal complaints.
CHORUS study was an international, cross-sectional, observational study, consisting of a one-time survey conducted between January 2015 and December 2016. Data were collected and subjects were asked to describe their anal complaints including symptoms over the last 15 days, presence and duration of constipation, use of laxatives, the time required for stool evacuation, stool consistency based on the seven-category Bristol stool scale.4The questionnaire completed by physicians established the subjects' demographic and lifestyle characteristics and collected information on HD grade and symptoms and signs of CVD. Physicians were asked to record details of any hemorrhoidal treatment that had been prescribed including dietary fiber, surgery, venoactive drugs, pain killers, and topical treatment. Physicians were provided with simple classifications based on clinical criteria in the form of the Goligher's classification5 (hemorrhoidal disease) and CEAP classification6(CVD).
The CHORUS study assessed two pathologies managed by different specialties with a diagnosis based on patient interviews with or without a physical examination. Univariate and multivariate logistic regression analyses were used to identify potential risk factors for HD and its recurrence.
Multivariate analysis revealed the variables with the strongest association with HD severity were older age, higher CVD CEAP (Clinical manifestations, Etiologic factors, Anatomic distribution of disease, and underlying Pathophysiology) class, constipation, and male gender. Elevated BMI stood as a risk factor for HD recurrence.
Most subjects with HD had suffered anal symptoms in the last 15 days (97.4%). The frequency of symptoms increased with disease severity. Hemorrhoids were diagnosed in 98.5% of respondents and a previous history of hemorrhoids was noted in 56.5% of respondents.
For women, the number of births had a significant association with both HD grade and recurrence.
The presence of CVD was reported in approximately half the patients (51.2%), was strongly associated with the advanced grade of HD.
Role of venoactive drugs –analyzing treatment patterns
Treatments most commonly prescribed were venoactive drugs (94.3%), dietary fiber(71.4%), topical treatment (70.3%), analgesics (26.3%), and surgery (23.5%). Venoactive drugs were prescribed in over 94.0% of subjects with Grade I to III hemorrhoids and in 86.8% of subjects with Grade IV hemorrhoids.
Among them, the most commonly prescribed was micronized purified flavonoid fraction (MPFF) (93.5%), followed by diosmin (obtained from citrus fruits) (3.5%). For these agents, the mean prescription duration was ≥ 4 weeks in 61.0% of participants, 2–3 weeks in 27.6%, and ≤ 1 week in 10.0%.
Other venoactive drug classes such as calcium dobesilate, horse chestnut seed extract (escin), rutosides, ruscus extracts, proanthocyanidines, and ginkgo biloba accounted for < 3.0% of prescriptions.
CHORUS confirmed that HD affects both sexes with peak presentation in those aged 35–50 years. An unexpected finding was the male predominance (53.8% vs 46.2% women predominance). Most female participants presenting with hemorrhoids (80.7%) had had at least one full-term pregnancy, and pregnancy was a risk factor for all hemorrhoid grades. Hemorrhoids are common during pregnancy, particularly the last trimester,7,8, and although they generally resolve after delivery these women are at greater risk of hemorrhoids later in life. Hemorrhoids were also more common in those with a BMI in the overweight or obese category. Previous studies have hypothesized that this may be because of increased intra-abdominal pressure and increased stress on rectal muscles.9
Among pharmacological approaches, venoactive drugs have emerged as a game-changer as they concomitantly address the underlying causes of both symptomatic hemorrhoids and CVD. The significant beneficial effects provided by these drugs on venous tone, inflammatory processes, and microcirculatory permeability have proved to be of immense aid. 10With growing evidence highlighting that timely use of venoactive drugs may play a pivotal role in preventing or slowing the development and recurrence of both hemorrhoidal and CVD signs and symptoms, 11,12 it's high time that clinicians reconsider these agents as first choice therapeutics when managing cases with HD, associated with CVD.
MPFF: Micronized purified flavonoid fraction (MPFF) is a well-known and well-studied venoactive drug, frequently prescribed for CVD symptom relief 13. With accumulating evidence supporting the efficacy of MPFF not only in reducing pain, bleeding, anal discharge, and prolapse in acute HD, but also in preventing relapse and reducing the duration and severity of acute attacks in chronic HD14;venoactive drugs can go a long way in managing such cases successfully.
Physicians should be aware of these risk factors and be proactive in questioning patients about potential hemorrhoid symptoms and conducting the appropriate examinations. As symptoms affect patients from Grade I disease, conservative pharmacological treatments should be the cornerstone of care.
MPFF is to be prescribed in all grades of hemorrhoid and chronic venous disease, as it improves venous and lymphatic return; thereby decreasing statis
Conclusion: The coexistence of HD and CVD in more than half the study population highlights the importance of examining for CVD among patients with a hemorrhoid diagnosis, particularly when shared risk factors are present.
This Piles Day Let's Vouch to strike the Core of Hemorrhoidal Disease. To get more information about Piles / Hemorrhoids ranging from Diagnosis to Management click on the Link Below.
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Dr. Kushal Mital MS, FACRSI, FIAGES, CSEPI, CCEBDM, is the Medical Director of Medicare hospital. He is a Surgical Gastroenterologist, Proctologist, Diabetic Foot surgeon, Varicose Vein Surgeon, and Sexologist at Medicare Hospital, having experience of more than 25 years in Surgical Practice. His area of interest lies in Proctology, Diabetic Foot, Sexology. He is also a visiting surgeon at KEM Hospital, Bombay Hospital, and Saifee Hospital, Mumbai. He is the Indian Editorial Advisor for the Journal of Dis of Colon & Rectum and the Course Director of Minimal Invasive Proctology at ceMAST, Mumbai.