Hemorrhoidal Disease-History and Pathophysiology
Hemorrhoids, which are characterized by symptomatic expansion and distal displacement of the usual anal cushions, are commonly encountered forms of anorectal disease. They are a significant medical and socio-economic issue affecting millions worldwide.[1]
Delving into the history of Hemorrhoidal Disease
Hemorrhoids have plagued human beings since time immemorial. While there is no clear-cut date to which this disorder can be traced back, there are several pieces of evidence in the ancient literature indicating that this disease existed and how physicians and apothecaries attempted to treat it. The Arsho Roga [the disease which troubles a person like enemies] explained by Sushruta includes several diseases of the anorectal region and has mentioned treatment for hemorrhoids and other anorectal diseases.[2]
Evolution of Theories Regarding the Bleeding Golden Veins
The earliest reliable descriptions of hemorrhoids and other conditions affecting the anus and anal canal date back to Mesopotamia circa 1500 BC. However, there are much older records in Chinese and Indian literature [3]. According to Hippocrates, hemorrhoids are the result of blood, phlegm, and black bile becoming stagnant in the anal blood vessels known as the golden vein. He felt that this mechanism eliminated impurities and cleansed our bodies, therefore bleeding from hemorrhoids was considered positive and was not entirely halted. [4]
As years went on, many theories were hypothesized, and most of them were disregarded. One such theory is the varicose vein theory, which bifurcated hemorrhoids and anorectal varices to be separate conditions. The varicose veins theory, which for years held that hemorrhoids were caused by varicose veins in the anal canal, is no longer valid. Thompson came up with 'The sliding anal theory,' which is widely recognized, proposes that the primary pathologic event is the aberrant slipping of cushions through the anal canal [1]. After 2006, researchers reached a common ground that the theory of hypervascularization causes hemorrhoids. [5]
Risk factors of Hemorrhoidal Disease
The potential risk factors for developing hemorrhoids in an individual include [6]
1. Constipation
2. Straining
3. Sitting on the Commode for a long time
4. Obesity
5. Pregnancy
6. Standing for a long time
7. Low fiber diet
Pathophysiology of Hemorrhoidal Disease
Anal cushions have 2 components:
- Vascular component- It is composed of corpus cavernosum recti [CCR] which gave rise to the hypothesis of hypervascularization theory [5]. Recent research has demonstrated that increasing amount of microvascular density in hemorrhoidal tissue which in turn suggests neovascularization as an important contributor in hemorrhoids. Endoglin, one of the TGF- binding sites and a proliferative marker for neovascularization, was found to be expressed in more than half of hemorrhoidal tissue specimens compared to none from the normal anorectal mucosa, according to a study published by Chung et al. [1]
- Non-vascular component- It is composed of elastic tissue, connective tissue, and fibers from the ligament of Treitz [7]. Once they start prolapsing it is called Sliding anal cushion theory. Hemorrhoid patients exhibit severe pathological abnormalities in their anal cushions. These alterations include fibroelastic tissue degeneration, anal subepithelial muscle distortion, and rupture.[1]
Internal hemorrhoids v/s External hemorrhoids
Based on the location, hemorrhoids can be classified into internal and external hemorrhoids. The clinical manifestation of internal hemorrhoids includes bleeding, prolapse, thrombosis, itching, burning, and mucosal drainage, while the symptoms of external hemorrhoids are external thrombosis leading to excruciating pain.[6]
Portal Hypertension and Rectal varices
One should differentiate between hemorrhoids and rectal varices in a clinical setting because hemorrhoids may appear independently of anorectal varices and are unrelated to the severity of portal hypertension [8]. Rectal varices are present in patients with portal hypertension but they rarely bleed [9] while in patients having hemorrhoids, the anal canal resting tone is increased.
Historical Evolution of Treatment Options for Hemorrhoidal Disease
Contemporary Indian Evidence: Going back to the times of Sushruta: From the Indian perspective, Sushruta has inscribed treatments for hemorrhoidal illness in his Sushruta Samhita and much focusing on kshara karma which is a non-surgical procedure and includes the application of herbal mixture to the affected site with the help of special slit proctoscope. This process is a type of chemical cauterization [10]. All of these treatments have their specific indications, and they are only effective when taken for those particular indications; otherwise, they can cause difficulties or recurrences. In cases with recent onset and mild symptoms, Sushruta suggests medicinal therapy. Sushruta recommended Kshara Karma, a para-surgical technique when a person has internal hemorrhoids with a tendency to bleed.[2]
Western Evidence: For anal symptoms that are suggestive of symptomatic hemorrhoids, Edwin Smith Papyrus (1700 BC) and Ebers Papyrus (1500 BC) prescribed astringent treatments containing honey, myrrh, flour, ibex fat, and sweet beer [11]. However, no surgical treatment has been documented. The father of medicine, Hippocrates (460–375 BC), was the first to advocate surgical treatment for hemorrhoids that are symptomatic, the concepts of ligation, excision, or cauterization are still relevant today. [12]
Over the years, medical science has evolved, and newer medicines and techniques have been developed so that patients can have a better quality of life. Surgical options also evolved over the ages, from the most primitive options like Open hemorrhoidectomy to the Hemorrhoids Laser Procedure (HeLP) combined with mucopexy procedure [HeLPexx] [12]. Newer medications are also introduced which can alleviate the symptoms of hemorrhoids. Venoactive drugs like micronized purified flavonoid fraction [MPFF] are the preferred drug of choice among physicians [13].
Conclusion
Hemorrhoidal disease remains a frequently prevalent illness today and is a menace to patients by directly interrupting their quality of life. The treatment of hemorrhoids has continued to evolve over a period of time. The use of MPFF in reducing the symptoms of hemorrhoids has been proven [14], and it can be opted in selected clinical presentations as an appropriate treatment option.
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 May 7;18(17):2009-17. doi: 10.3748/wjg.v18.i17.2009. PMID: 22563187; PMCID: PMC3342598.
[2]Dr. Shivanand A. Kembhavi, Dr. Muralidhara Sharma, & Dr. Hemanth Toshikhane. (2020). Review of Arsha as per Sushruta Samhita - Classification and principles of management. Journal of Ayurveda and Integrated Medical Sciences, 5(03), 68-74
[4]] Laufman, H. (1941). The history of hemorrhoids. The American Journal of Surgery, 53(2), 381–387. doi:10.1016/s0002-9610(41)90323-9
[5] Aigner, F., Bodner, G., Gruber, H. et al. The vascular nature of hemorrhoids. J Gastrointest Surg 10, 1044–1050 (2006). https://doi.org/10.1016/j.gassur.2005.12.004
[6] https://www.mayoclinic.org/diseases-conditions/hemorrhoids/symptoms-causes/syc-20360268
[7] Margetis N. Pathophysiology of internal hemorrhoids. Ann Gastroenterol. 2019 May-Jun;32(3):264-272. doi: 10.20524/aog.2019.0355. Epub 2019 Jan 23. PMID: 31040623; PMCID: PMC6479658.
[8] Hosking SW, Smart HL, Johnson AG, Triger DR. Anorectal varices, hemorrhoids, and portal hypertension. Lancet. 1989 Feb 18;1(8634):349-52. doi: 10.1016/s0140-6736(89)91724-8. PMID: 2563507.
[9] Sanchez C, Chinn BT. Hemorrhoids. Clin Colon Rectal Surg. 2011 Mar;24(1):5-13. doi: 10.1055/s-0031-1272818. PMID: 22379400; PMCID: PMC3140328.
[10]Mahapatra A, Srinivasan A, Sujithra R, Bhat RP. Management of internal hemorrhoids by Kshara karma: An educational case report. J Ayurveda Integr Med. 2012 Jul;3(3):115-8. doi: 10.4103/0975-9476.100169. PMID: 23125506; PMCID: PMC3487235.
[11]Warusavitarne, Janindra & Phillips, Robin. (2007). Hemorrhoids Throughout History—A Historical Perspective. Seminars in Colon and Rectal Surgery. 18. 140-146. 10.1053/j.scrs.2007.07.002.
[12]Pata F, Gallo G, Pellino G, Vigorita V, Podda M, Di Saverio S, D'Ambrosio G, Sammarco G. Evolution of Surgical Management of Hemorrhoidal Disease: An Historical Overview. Front Surg. 2021 Aug 30;8:727059. doi: 10.3389/fsurg.2021.727059. PMID: 34527700; PMCID: PMC8435716.
[13]Godeberge P, Sheikh P, Zagriadskiĭ E, Lohsiriwat V, Montaño AJ, Košorok P, De Schepper H. Hemorrhoidal disease and chronic venous insufficiency: Concomitance or coincidence; results of the CHORUS study (Chronic venous and HemORrhoidal diseases evalUation and Scientific research). J Gastroenterol Hepatol. 2020 Apr;35(4):577-585. doi: 10.1111/jgh.14857. Epub 2019 Oct 30. PMID: 31512275; PMCID: PMC7187474.
[14]Lyseng-Williamson KA, Perry CM. Micronised purified flavonoid fraction: a review of its use in chronic venous insufficiency, venous ulcers, and hemorrhoids. Drugs. 2003;63(1):71-100. doi: 10.2165/00003495-200363010-00005. PMID: 12487623.
