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- Clin Colon Rectal Surg
- v.29(1); 2016 Mar
Review of Hemorrhoid Disease: Presentation and Management
1 Department of Surgery, Duke University, Durham, North Carolina
Symptomatic hemorrhoid disease is one of the most prevalent ailments associated with significant impact on quality of life. Management options for hemorrhoid disease are diverse, ranging from conservative measures to a variety of office and operating-room procedures. In this review, the authors will discuss the anatomy, pathophysiology, clinical presentation, and management of hemorrhoid disease.
Hemorrhoid disease is the fourth leading outpatient gastrointestinal diagnosis, accounting for ∼3.3 million ambulatory care visits in the United States. 1 Self-reported incidence of hemorrhoids in the United States is 10 million per year, corresponding to 4.4% of the population. Both genders report peak incidence from age 45 to 65 years. Notably, Caucasians are affected more frequently than African Americans, and higher socioeconomic status is associated with increased prevalence. 2 Contributing factors for increased incidence of symptomatic hemorrhoids include conditions that elevate intra-abdominal pressure such as pregnancy and straining, or those that weaken supporting tissue.
Despite its prevalence and low morbidity, hemorrhoid disease has a high impact on quality of life, and can be managed with a multitude of surgical and nonsurgical treatments. In this review, we will discuss the anatomy, presentation, and management of symptomatic hemorrhoid disease.
Anatomy and Pathophysiology
Hemorrhoids are clusters of vascular tissues, smooth muscles, and connective tissues that lie along the anal canal in three columns—left lateral, right anterior, and right posterior positions. Because some do not contain muscular walls, these clusters may be considered sinusoids instead of arteries or veins ( Fig. 1 ). 3 Hemorrhoids are present universally in healthy individuals as cushions surrounding the anastomoses between the superior rectal artery and the superior, middle, and inferior rectal veins. Nonetheless, the term “hemorrhoid” is commonly invoked to characterize the pathologic process of symptomatic hemorrhoid disease instead of the normal anatomic structure.
Anatomy of the anal canal and vasculature of hemorrhoids. (Reprinted with permission from Cintron J, Abcarian H. Benign anorectal: hemorrhoids. In: The ASCRS Textbook of Colon and Rectal Surgery. New York, NY: Springer-Verlag, Inc; 2007:156–77; with kind reprint permission of Springer Science + Business Media.)
Classification of a hemorrhoid corresponds to its position relative to the dentate line. External hemorrhoids are located below the dentate line and develop from ectoderm embryonically. They are covered with anoderm, composed of squamous epithelium, and are innervated by somatic nerves supplying the perianal skin and thus producing pain. Vascular outflows of external hemorrhoids are via the inferior rectal veins into the pudendal vessels and then into the internal iliac veins. In contrast, internal hemorrhoids lie above the dentate line and are derived from endoderm. They are covered by columnar epithelium, innervated by visceral nerve fibers and thus cannot cause pain. Vascular outflows of internal hemorrhoids include the middle and superior rectal veins, which subsequently drain into the internal iliac vessels.
While no taxonomy of external hemorrhoids is used clinically, internal hemorrhoids are further stratified by the severity of prolapse. First-degree internal hemorrhoids do not prolapse out of the canal but are characterized by prominent vascularity. Second-degree hemorrhoids prolapse outside of the canal during bowel movements or straining, but reduce spontaneously. Third-degree hemorrhoids prolapse out of the canal and require manual reduction. Fourth-degree hemorrhoids are irreducible even with manipulation. 4
The exact pathophysiology of symptomatic hemorrhoid disease is poorly understood. Previous theories of hemorrhoids as anorectal varices are now obsolete—as shown by Goenka et al, patients with portal hypertension and varices do not have an increased incidence of hemorrhoids. 5 Currently, the theory of sliding anal canal lining, which proposes that hemorrhoids occur when the supporting tissues of the anal cushions deteriorate, is more widely accepted. Advancing age and activities such as strenuous lifting, straining with defecation, and prolonged sitting are thought to contribute to this process. Hemorrhoids are therefore the pathological term to describe the abnormal downward displacement of the anal cushions causing venous dilatation. 6 On histopathological examination, changes seen in the anal cushions include abnormal venous dilatation, vascular thrombosis, degenerative process in the collagen fibers and fibroelastic tissues, and distortion and rupture of the anal subepithelial muscle. In severe cases, a prominent inflammatory reaction involving the vascular wall and surrounding connective tissue has been associated with mucosal ulceration, ischemia, and thrombosis. 7
Symptoms and Presentation
A total of 40% of individuals with hemorrhoids are asymptomatic. 8 For symptomatic hemorrhoids, there is great variance in the constellation of symptoms. In addition, many other anorectal pathologies such as anal fissure, fistula, pruritus, condyloma, and even anal cancer are often labeled as “hemorrhoids” by the layperson.
For internal hemorrhoids, bleeding is the most commonly reported symptom. The occurrence of bleeding is usually associated with defecation and almost always painless. The blood is bright red and coats the stool at the end of defection. Blood can be found on the toilet paper, dripping into the bowl, or even dramatically spraying across the toilet bowl. Another frequent symptom is the sensation of tissue prolapse. Prolapsed internal hemorrhoids may accompany mild fecal incontinence, mucus discharge, sensation of perianal fullness, and irritation of perianal skin. Pain is significantly less common with internal hemorrhoids than with external hemorrhoids, but can occur in the setting of prolapsed, strangulated internal hemorrhoids that develop gangrenous changes due to the associated ischemia.
In contrast, external hemorrhoids are more likely to be associated with pain, due to activation of perianal innervations associated with thrombosis. Patients typically describe a painful perianal mass that is tender to palpation. This painful mass may be initially increasing in size and severity over time. Bleeding can also occur if ulceration develops from necrosis of the thrombosed hemorrhoid, and this blood tends to be darker and more clotted than the bleeding from internal disease. Painless external skin tags often result from previous edematous or thrombosed external hemorrhoids.
Rectal pain and bleeding should never be blindly attributed to hemorrhoids. A thorough history and physical examination is required to help identify any possible alternative diagnosis, and the possibility of a more insidious cause of rectal bleeding should always be considered. In the colorectal surgeon's office, a detailed anorectal examination is crucial to diagnosis. Patients may be examined in a prone-jackknife or left lateral position. External inspection will reveal any thrombosed external hemorrhoid, which often appears as a firm, purplish nodule that is tender to palpation. Thrombosed hemorrhoids may also have ulcerations with bloody drainage. Skin tags maybe signs not only of prior hemorrhoids but also of fissure disease. Digital examination will exclude distal rectal mass and anorectal abscess or fistula. Evaluation of sphincter integrity during the digital examination is important to establish baseline function, and is especially important in patients who report incontinence as any future surgical intervention may further worsen function. Lastly, anoscopy and rigid or flexible proctosigmoidoscopy should be performed routinely to identify internal hemorrhoids or fissures, and to rule out distal rectal masses. Internal hemorrhoids can be reliably identified in the three above-mentioned columns, and described based on grade and degree of inflammation.
If uncertainty remains after office examination, a total colonoscopy is often appropriate to rule out a proximal source of bleeding. Certainly, any patient over the age of 50 years without an up-to-date colonoscopy requires this to be performed. For younger patients, the decision for colonoscopy must be based on risk factors, clinical suspicion, and response to initial therapy.
Management of Hemorrhoid Disease
The natural history of most cases of hemorrhoid disease is self-limited. For symptomatic hemorrhoid disease that presents to the clinic or emergency room, treatments range from nonoperative medical interventions and office-based procedures to surgery. One general guiding principle is that the least-invasive approaches should be considered first, except in cases of acute thrombosis. Specific choices of treatments depend on patients' age, severity of symptoms, and comorbidities. A summary of management strategies is shown in Table 1 .
Source: Adapted and modified with permission from Cintron J, Abcarian H. Benign anorectal: hemorrhoids. In: The ASCRS Textbook of Colon and Rectal Surgery. New York, NY: Springer-Verlag, Inc; 2007:156–77; with kind reprint permission of Springer Science + Business Media.
Conservative Medical Treatments
Lifestyle and dietary modification are the mainstays of conservative medical treatment of hemorrhoid disease. Specifically, lifestyle modifications should include increasing oral fluid intake, reducing fat consumptions, avoiding straining, and regular exercise. Diet recommendations should include increasing fiber intake, which decreases the shearing action of passing hard stool. In a meta-analysis of seven randomized trials comparing fiber to nonfiber controls, fiber supplementation (7–20 g/d) reduced risk of persisting symptoms and bleeding by 50%. However, fiber intake did not improve symptoms of prolapse, pain, and itching. 9
For symptomatic control, topical treatments containing various local anesthetics, corticosteroids, or anti-inflammatory drugs are available. Notable topical drugs include 0.2% glyceryl trinitrate, which has been studied to relieve grade I or II hemorrhoids with high resting anal canal pressures, but is associated with headaches in 43% of patients. 10 Patients also commonly self-medicate with Preparation-H (Pfizer Incorporated, Kings Mountain, NC), a formulation of phenylephrine, petroleum, mineral oil, and shark liver oil (vasoconstrictor and protectants), which provides temporary relief in acute symptoms of hemorrhoids such as bleeding and pain on defecation. 11 Topic corticosteroids in cream or ointment formulations are commonly prescribed, but their efficacy remains unproven.
Except in the case of thrombosis, both internal and external hemorrhoids respond readily to conservative medical therapy. However, when medical interventions fail to resolve symptoms or if the extent of hemorrhoid disease is severe, there are various options for invasive procedures available to the colorectal surgeon.
Nonsurgical Office-based Procedures
For internal hemorrhoids, rubber band ligation, sclerotherapy, and infrared coagulation are the most common procedures but there is no consensus on optimal treatment. Overall, the goals of each procedure are to decrease vascularity, reduce redundant tissue, and increase hemorrhoidal rectal wall fixation to minimize prolapse.
Rubber Band Ligation
Rubber band ligation is the most commonly performed procedure in the office and is indicated for grade II and III internal hemorrhoids. 12 Contraindications include symptomatic external disease and patients with coagulopathies or on chronic anticoagulation (due to risk of delayed hemorrhage). There is also an increased risk of sepsis in immunocompromised patients. 13 Performing rubber band ligation does not require any local anesthetic. Patients are placed in jackknife or left lateral position and the procedure is performed through an anoscope. Several platforms are available, but the two most prevalent ligating devices are the McGivney forceps ligator and the suction ligator. Small rubber band rings are deployed tightly around the base of the internal hemorrhoids. They should be placed at least half a centimeter above dentate line to avoid placement into somatically innervated tissue ( Fig. 2 ). Patients should be asked about presence of pain prior to release of rubber bands. While it is safe to ligate more than one column during a single visit, some experts recommend starting with a single column during the first visit to accurately assess the patient's tolerance of the technique. 11
Banding of an internal hemorrhoid through an anoscope using a McGown suction-ligator. (Adapted with permission from Cintron J, Abcarian H. Benign anorectal: hemorrhoids. In: The ASCRS Textbook of Colon and Rectal Surgery. New York, NY: Springer-Verlag, Inc; 2007:156–77; with kind reprint permission of Springer Science + Business Media.)
Rubber band ligation works by causing hemorrhoid tissue necrosis and its fixation to the rectal mucosa. As the tissues become ischemic, necrosis develops in the following 3 to 5 days, and an ulcerated tissue bed is formed. Complete healing occurs several weeks later. Complications are very uncommon, but those may occur include pain, urinary retention, delayed bleeding, and very rarely perineal sepsis.
In a large review of 805 patients from a single practice that performed 2,114 rubber band ligations, hemorrhoid disease requiring the placement of four or more bands was associated with a trend in higher failure rates and greater need for subsequent hemorrhoidectomy. Complications observed in this patient cohort included bleeding (2.8%), thrombosed external hemorrhoids (1.5%), and bacteremia (0.09%). Higher bleeding rates were encountered with the use of aspirin, nonsteroidal anti-inflammatory drugs, and warfarin. 14 Time to recurrence was less with subsequent treatment courses and treatment of recurrent symptoms with rubber band ligation resulted in success rates of 73, 61, and 65% for the first, second, and third recurrences, respectively. Cumulatively, a success rate of 80% is observed with rubber band ligation. 12 Overall, banding is a safe, quick, and effective procedure for internal hemorrhoids.
Sclerotherapy is indicated for patients with grade I and II internal hemorrhoids and may be a good option for patients on anticoagulants. Like rubber band ligation, sclerotherapy does not require local anesthesia. Performed through an anoscope, internal hemorrhoids are located and injected with a sclerosant material—typically a solution including phenol in vegetable oil—into the submucosa. The sclerosant subsequently causes fibrosis, fixation to the anal canal, and eventual obliteration of the redundant hemorrhoidal tissue. Complications of sclerotherapy include minor discomfort or bleeding. However, rectal fistulas or perforation can very rarely occur due to misplaced injections. 15
Infrared coagulation refers to direct application of infrared light waves to the hemorrhoidal tissues and can be used for grade I and II internal hemorrhoids. To perform this procedure, the tip of the infrared coagulation applicator is usually applied to the base of the internal hemorrhoid for 2 seconds, with three to five treatments per hemorrhoid. By converting infrared light waves to heat, the applicator causes necrosis of the hemorrhoid, visualized as a white, blanched mucosa. Over time, the affected mucosa scars, leading to retraction of the prolapsed hemorrhoid mucosa. This procedure is very safe with only minor pain and bleeding reported.
As a comparison of the various office-based procedures, MacRae and McLeod conducted a meta-analysis of 18 trials and concluded that rubber band ligation was better than sclerotherapy in response to treatment for grade I and III hemorrhoids, with no differences in the complication rate. 16 The authors also noted that patients treated with sclerotherapy or infrared coagulation were more likely to require additional subsequent procedure or therapies in comparison to those treated with rubber band ligation. Finally, although pain was greater after rubber band ligation, recurrent symptoms were less common.
Continued symptoms despite conservative or minimally invasive measures usually require surgical intervention. In addition, surgery is the initial treatment of choice in patients with symptomatic grade IV hemorrhoids or those who have strangulated internal hemorrhoids. It may also be required for symptomatic grade III hemorrhoids and in patients who present with thrombosed hemorrhoids.
For patients who present with thrombosed external hemorrhoids, surgical evaluation and intervention within 72 hours of thrombosis may result in significant relief, as pain and edema peak at 48 hours. 17 However, after 48 to 72 hours, organization of the thrombus and amelioration of symptoms generally obviates the need for surgical evacuation, which is consistent with the natural history of hemorrhoidal thrombosis. After the initial 72-hour window, the pain typically plateaus and slowly improves, at which point the pain from hemorrhoid excision would exceed the pain from the thrombosis itself.
For those patients requiring intervention, excision of the thrombosed hemorrhoid can be performed in the office or emergency-room setting and rarely requires the operating room. The thrombosed hemorrhoid should be injected with a local anesthetic, followed by an elliptical incision and excision of the entire thrombosed hemorrhoid. Simple incision and drainage is insufficient, and leads to increased rates of symptom recurrence due to inadequate clot evacuation. Postprocedure management includes analgesics and sitz baths. A retrospective review of 231 patients who received excision versus conservative management of thrombosed hemorrhoid showed that time to symptom resolution averaged 24 days in the conservative group versus 3.9 days in the surgical group. 18
In the nonemergent setting, popular procedures performed in the operating room include hemorrhoidectomy, stapled hemorrhoidopexy, and Doppler-guided hemorrhoidal artery ligation.
There are two major types of hemorrhoidectomy: Ferguson, or closed hemorrhoidectomy and the Milligan–Morgan, or open hemorrhoidectomy. The open hemorrhoidectomy is often the preferred approach to surgically treat severe acute gangrenous hemorrhoids where tissue edema and necrosis preclude closure of the mucosa ( Fig. 3 ). 19 Preoperatively, full mechanical bowel prep is not indicated. Additionally, there is no benefit to perioperative antibiotic administration. 20
Open (Milligan–Morgan) hemorrhoidectomy. Panel A: external hemorrhoid is grasped. Panel B: internal hemorrhoid is grasped. Panel C: external skin and hemorrhoids excised. Panel D: tie placed around the hemorrhoid vascular bundle. Panel E: ligation of the vascular bundle. Panel F: excision of the hemorrhoid tissue distal to the tie. (Reprinted with permission from Cintron J, Abcarian H. Benign anorectal: hemorrhoids. In: The ASCRS Textbook of Colon and Rectal Surgery. New York, NY: Springer-Verlag, Inc; 2007:156–77; with kind reprint permission of Springer Science + Business Media.).
An excisional hemorrhoidectomy typically begins with the injection of a local anesthetic, often containing epinephrine to help with bleeding and swelling. After a Hill–Ferguson retractor is placed into the anal canal for exposure, the junction of the internal and external component of the hemorrhoid is grasped and serves as a handle to retract the hemorrhoid away from the sphincter muscles. An elliptical incision is made, and the hemorrhoid tissue is carefully dissected away from the superficial internal and external sphincter muscles to the main vascular pedicle in the anal canal, carefully avoiding any injury to the anal sphincters. The base of the pedicle is ligated and the hemorrhoid is excised. Devices using advanced energy, such as ultrasonic shears or a bipolar vessel sealant, can be used to perform this procedure with similar efficacy. 21
Operative hemorrhoidectomy is a relatively morbid procedure compared with other less-invasive options. Due to the extent of dissection and the presence of incisions below the dentate line, postoperative pain can be severe, and may delay return to normal activities for several weeks. Pain can usually be managed with oral analgesics, avoidance of constipation, and sitz baths. Bleeding may occur in 1 to 2% of patients after 1 week from surgery as a result of eschar separation and is usually self-limited. 22 Infection is uncommon after hemorrhoid surgery with submucosal abscesses occurring in less than 1% of cases and severe fasciitis or necrotizing infections are rare. 22 Urinary retention has been reported to be as high as 34% after hemorrhoidectomy, which is attributed to pelvic floor spasm, narcotic use, and excess intravenous fluids. 23 Treatment for urinary retention after hemorrhoidectomy is temporary Foley catheter insertion with self-resolution in majority of cases. Injury to the sphincter resulting in fecal incontinence occurs in 2 to 10% of cases and can have significant impact on quality of life. 24 Lastly, anal stenosis is a late complication that can result from excessive tissue resection or aggressive suturing. Stenosis is more common with multiple excised quadrants; it is often difficult to treat and should be diligently avoided by assuring adequate mucosal bridges between the excised hemorrhoids.
Despite its relative higher morbidity, surgical hemorrhoidectomy is more effective than band ligation for preventing recurrent symptoms. 16 In a randomized trial among elective cases, there were no differences in open versus closed hemorrhoidectomy. 25 Patients with grade III and IV hemorrhoids benefit the most from surgical hemorrhoidectomy.
An alternative to operative hemorrhoidectomy is stapled hemorrhoidopexy, in which a stapling device is used to resect and fixate the internal hemorrhoid tissues to the rectal wall. Since the staple line is above the dentate line, patients typically experience less pain than those who undergo hemorrhoidectomy. To perform this procedure, a circular stapler is introduced into the anus and prolapsing tissue is brought into the stapler. The most critical component of stapled hemorrhoidopexy is the placement of a circumferential, purse-string, nonabsorbable suture in the submucosa far enough away to avoid any sphincter muscle involvement—usually at ∼4 cm from the dentate line. Additionally, before engaging the stapler, an examination of the posterior vaginal wall should be conducted. Finally, the staple line should be evaluated for any bleeding that would require additional suture ligation.
Complications from stapled hemorrhoidopexy include bleeding from the staple line, incontinence for injury of the sphincter muscles, and stenosis from incorporation of excess rectal tissue. Moreover, there is a risk of recto-vaginal fistula in women due to incorporation of vaginal tissue into the purse-string.
Three systematic reviews concluded that stapled hemorrhoidopexy was less effective than conventional hemorrhoidectomy. 26 27 28 Stapled hemorrhoidopexy was associated with a higher long-term risk of hemorrhoid recurrence. Due to need for additional operations, the incidence of prolapse and tenesmus was also higher after stapled hemorrhoidopexy as compared with hemorrhoidectomy. Conversely, the stapled approach was associated with significantly less pain, shorter operative time, and shorter time to resumption of normal activity. In a 2010 European multicenter randomized trial of stapled hemorrhoidopexy versus hemorrhoidectomy, both options were shown to be equally effective in preventing recurrence after 1 year. Patients undergoing hemorrhoidectomy were more likely to have symptomatic relief from the hemorrhoids (69 vs. 44%), but had significantly greater postoperative pain. 29
Overall, stapled hemorrhoidopexy remains a viable alternative to hemorrhoidectomy, and is especially attractive for patients without much external disease. However, while the published complication rates are low, they can be quite severe, and the surgeon must have appropriate training and proceed with great caution, when performing this procedure.
Doppler-guided Hemorrhoidal Artery Ligation
First described by Morinaga et al in 1995, this technique involves use of Doppler ultrasound to identify and ligate the hemorrhoidal arteries. 30 This is also referred to as transanal hemorrhoidal dearterialization (THD). Different platforms with different associated nomenclatures exist for this technique, but the principles include the use of a Doppler probe to identify the six main feeding arteries within the anal canal, ligation of these arteries with absorbable suture and a specialized anoscope, and then plication of redundant hemorrhoidal mucosa. The plication is often referred to as recto-anal-repair, mucopexy, or hemorrhoidopexy. Proposed benefits of this procedure are similar to stapled hemorrhoidopexy, with less associated pain due to the suturing being above the dentate line.
Early results of Doppler-guided hemorrhoidal artery ligation (DGHAL)/THD were promising, with lower pain scores than hemorrhoidectomy, and relief of bleeding and tissue prolapse in over 90% of patients. 31 Since then, several randomized clinical trials have been performed with mixed results. 32 33 34 Currently, DGHAL/THD remains a viable approach to multicolumn internal hemorrhoids. However, the short-term benefits regarding postoperative pain have recently not been as remarkable as in the earlier studies.
Hemorrhoids should be distinguished from hypertrophic skin tags that are associated with Crohn disease. Skin tags in Crohn disease are often tender and associated with ulceration of the anal canal. For patients with Crohn disease and active anorectal inflammation, treatment of hemorrhoids should be kept as conservative as possible, with every attempt made to avoid surgery, as these patients can have significant issues with wound healing after hemorrhoidectomy, and surgery may actually exacerbate their disease and worsen symptoms. Hemorrhoidectomy can be performed in a highly selective basis when disease is quiescent, but it is generally discouraged. 35
Immunosuppressed patients such as those with acquired immunodeficiency syndrome (AIDS) or those on chronic immunosuppressive medications are at greater risk of sepsis and poor wound healing. 36 37 38 Conservative treatments should be exhausted before performing any invasive procedures; however, less-invasive approaches can be undertaken. In a small series of 22 AIDS patients that underwent sclerotherapy injection of their hemorrhoids, all demonstrated improvement after 6 weeks. Four patients with 4-year follow-up showed improvement lasting 18 months but subsequently required repeat injections for recurrence symptoms. 37
Cirrhosis and Portal Hypertension
Contrary to previous teachings, the incidence of hemorrhoid disease in patients with portal hypertension is not different from the general population. 39 Rectal varices, the result of porto-systemic communication via the hemorrhoid veins, occur commonly in patients with portal hypertension. However, bleeding from rectal varices is rare, accounting for < 1% of massive bleeding in portal hypertension. When it does occur, it should typically be treated with portal decompression. 40
Hemorrhoid disease is a common but complex disease. Patients who present with signs and symptoms of hemorrhoids should be carefully evaluated to exclude other masquerading entities. There are a multitude of options for the management of hemorrhoid disease and specific treatment choice should be based on individual patient and clinical factors.
Source of Funding
Conflict of Interest None.
TIMOTHY MOTT, MD, KELLY LATIMER, MD, MPH, AND CHAD EDWARDS, MD
Am Fam Physician. 2018;97(3):172-179
Patient information : A handout on hemorrhoids is available.
Author disclosure: No relevant financial affiliations.
Many Americans between 45 and 65 years of age experience hemorrhoids. Hemorrhoidal size, thrombosis, and location (i.e., proximal or distal to the dentate line) determine the extent of pain or discomfort. The history and physical examination must assess for risk factors and clinical signs indicating more concerning disease processes. Internal hemorrhoids are traditionally graded from I to IV based on the extent of prolapse. Other factors such as degree of discomfort, bleeding, comorbidities, and patient preference should help determine the order in which treatments are pursued. Medical management (e.g., stool softeners, topical over-the-counter preparations, topical nitroglycerine), dietary modifications (e.g., increased fiber and water intake), and behavioral therapies (sitz baths) are the mainstays of initial therapy. If these are unsuccessful, office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step because it has a lower failure rate than infrared photocoagulation. Open or closed (conventional) excisional hemorrhoidectomy leads to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures; therefore, hemorrhoidectomy should be reserved for recurrent or higher-grade disease. Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain. Stapled hemorrhoidopexy elevates grade III or IV hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue; however, this procedure has several potential postoperative complications. Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids because patients may experience less pain and recover more quickly. Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms.
Hemorrhoids develop when the venous drainage of the anus is altered, causing the venous plexus and connecting tissue to dilate, creating an outgrowth of anal mucosa from the rectal wall. However, the exact pathophysiology is unknown. Hemorrhoids occur above or below the dentate line where the proximal columnar transitions to the distal squamous epithelium ( Figure 1 1 ) . The anus is approximately 4 cm long in adults, with the dentate line located roughly at the midpoint. 2 Hemorrhoids developing above the dentate line are internal. They are painless because they are viscerally innervated. External hemorrhoids develop below the dentate line and can become painful when swollen. The extent of prolapse of internal hemorrhoids can be graded on a scale from I to IV, which guides effective treatment ( Figure 2 ) . This grading system is incomplete, however, because it focuses exclusively on the extent of prolapse and does not consider other clinical factors, such as size and number of hemorrhoids, amount of pain and bleeding, and patient comorbidities and preferences. 3
Hemorrhoids are common. The exact prevalence is unknown because most patients are asymptomatic and do not seek care from a physician. 4 A study of patients undergoing routine colorectal cancer screening found a 39% prevalence of hemorrhoids, with 55% of those patients reporting no symptoms. 5 Hemorrhoids are more prevalent in persons 45 to 65 years of age. 5 , 6 Although the precise cause is not well understood, hemorrhoids are associated with conditions that increase pressure in the hemorrhoidal venous plexus, such as straining during bowel movements secondary to constipation. Other associations include obesity, pregnancy, chronic diarrhea, anal intercourse, cirrhosis with ascites, pelvic floor dysfunction, and a low-fiber diet. 6 , 7
The history and physical examination are important because patients often attribute any anorectal symptom to hemorrhoids when there may be another reason ( Table 1 ) . 5 – 11
Symptomatic internal hemorrhoids often present with painless bright red bleeding, prolapse, soiling, bothersome grape-like tissue prolapse, itching, or a combination of symptoms. The bleeding typically occurs with streaks of blood on stool and rarely causes anemia. 8 External hemorrhoids may present similarly to internal hemorrhoids, with the exception that they can become painful, especially when thrombosed. Patients younger than 40 years with suspected hemorrhoidal bleeding do not require endoscopic evaluation if they do not have red flags (e.g., weight loss, abdominal pain, fever, signs of anemia), do not have a personal or family history of colorectal cancer or inflammatory bowel disease, and respond to medical management. 6
Risk factors for colorectal cancer include a family history of colorectal cancer, adenomatous polyps, or inherited cancer syndromes such as familial adenomatous polyposis (including Gardner syndrome) or hereditary nonpolyposis colorectal cancer (Lynch syndrome). Close follow-up is important in patients with rectal bleeding who do not undergo endoscopy because the incidence of colorectal cancer in younger adults is rising, with patients born in 1990 having twice the lifetime risk of a patient born in 1950. 9 Patients older than 40 years with rectal bleeding and younger patients with risk factors should undergo full colon evaluation by colonoscopy, computed tomographic colonography, or barium enema, unless they have had a normal colon evaluation within the previous 10 years. 6 , 10
In addition to an abdominal examination, the perineal and rectal areas should be inspected with the patient at rest and while bearing down. 7 , 11 The patient can be in the lateral decubitus, lithotomy, or prone jackknife position (i.e., patient prone with table adjusted so that hips are flexed, with head and feet at a lower level). The presence of external hemorrhoids or prolapse of internal hemorrhoids may be obvious. A digital rectal examination can detect masses, tenderness, and fluctuance, but internal hemorrhoids are less likely to be palpable unless they are large or prolapsed.
Anoscopy is an effective way to visualize internal hemorrhoids that look like purplish bulges through the anoscope. Physicians should avoid use of clock face terms to describe lesions, because the position of the patient can vary. Instead, the physician should use terms relative to the patient, such as anterior, posterior, left, or right. 7 Typically, hemorrhoids develop on anatomic planes, or hemorrhoidal columns, in the left lateral, right anterior, or right posterior aspect of the anus.
First-line conservative treatment of hemorrhoids consists of a high-fiber diet (25 to 35 g per day), fiber supplementation, increased water intake, warm water (sitz) baths, and stool softeners. 7 , 11 – 13 Giving patients a chart with the fiber content of common foods may help them increase their fiber intake. One list is available at https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/high-fiber-foods/art-20050948 . Fiber supplementation decreases bleeding of hemorrhoids by 50% and improves overall symptoms. 12 Warm water baths decrease pain temporarily. 13
There are multiple topical over-the-counter hemorrhoid remedies. 11 These may provide temporary relief, but most have not been studied for effectiveness or safety for long-term use. Among these include astringents (witch hazel), protectants (zinc oxide), decongestants (phenylephrine), corticosteroids, and topical anesthetics. Over-the-counter hemorrhoid preparations often combine two or more of these ingredients. Supplements containing bioflavonoids (e.g., hidrosmin, diosmin, hesperidin, rutosides) are commonly used in other parts of the world for symptomatic relief of hemorrhoids. 14 Although bioflavonoids may decrease bleeding, pruritus, and fecal leakage, as well as lead to overall symptom improvement, most studies are small and heterogeneous, and bioflavonoids are not approved by the U.S. Food and Drug Administration for hemorrhoid treatment. 14 , 15
Prescription therapies may also be part of first-line treatment. Topical nitroglycerin as a 0.4% ointment decreases rectal pain caused by thrombosed hemorrhoids, although it is more commonly used for anal fissures. 16 Topical nifedipine also has been demonstrated to be effective for pain relief, but it must be compounded by a pharmacy because there is no commercially available preparation. 17 A single injection of botulinum toxin into the anal sphincter effectively decreases the pain of thrombosed external hemorrhoids. 18
Office-based and surgical procedures can effectively treat hemorrhoids refractory to medical therapies. In general, the lower the grade, the more likely an office-based procedure will be successful, whereas recurring and grade III or IV hemorrhoids are more amenable to excisional hemorrhoidectomy.
Thrombosed external hemorrhoids can be extremely painful. Although conservative management with topical therapies is reasonable, surgical removal of the thrombus within the first two to three days leads to quicker symptom resolution, lower risk of recurrence, and a prolonged recurrence interval. 11 , 19 – 22 This procedure has been previously described in American Family Physician . 22
The primary office-based procedures to treat grade I to III internal hemorrhoids include banding and infrared photocoagulation. In rubber band ligation, a ligation instrument is inserted through a speculum to grasp or suction the targeted hemorrhoid to facilitate placement of a rubber band over the hemorrhoid down to its pedicle. The hemorrhoid ischemically necroses, and a virtual mucopexy occurs as the anal mucosa is pulled upward and the necrotic base puckers mucosa together, effectively elevating the more inferior anal mucosa 7 , 10 , 21 ( Figure 3 ) . Infrared photocoagulation similarly stimulates necrosis to the proximal base of a hemorrhoid. 7 , 10 , 11
When the two methods are compared, long-term success favors rubber band ligation, whereas pain improvement is greater with infrared photocoagulation. 23 Photocoagulation is likely associated with less pain because there is no mucopexy during the procedure (i.e., pulling of the mucosal tissue and its somatic innervation upward from below the dentate line into the banding). Although rubber band ligation may be more painful historically, the differences in reported pain are smaller in more recent studies, and the failure rate is four times less than with photocoagulation. 10 , 23 Recognizing specific characteristics of hemorrhoids (e.g., pedunculated clearly above the dentate line vs. broad-based and near the dentate line) facilitates decision making when considering which procedure to perform.
The three goals of surgical hemorrhoidectomy are to remove the symptomatic hemorrhoidal columns, reduce the redundant tissue that accounts for the prolapsing hemorrhoidal tissues (mucopexy), and minimize pain and complications. Generally, the more definitive the excision, the greater the pain and the longer the recovery period without a significant reduction in possible complications. 7 , 10 , 24 , 25 As noted with rubber band ligation, the reduction in postoperative pain is usually achieved by limiting the extent of the mucopexy portion of the procedure ( Table 2 ) . 7 , 21 , 23 – 28
Surgical excision is primarily accomplished through closed hemorrhoidectomy (mucosal defect typically closed; the most common technique in the United States) or open hemorrhoidectomy (removal of hemorrhoidal tissue with mucosal defect left open). 29 – 31 These conventional techniques are the most effective for recurrent, highly symptomatic grade III or IV hemorrhoids. Compared with office-based procedures, conventional hemorrhoidectomy is more painful and associated with more blood loss and longer recovery time, but it has significantly lower rates of recurrence. 7 , 23 , 26
Conventional hemorrhoidectomy has been modified to include two alternative energy devices, Ligasure and Harmonic Scalpel, which use diathermy and ultrasonic energy, respectively, to limit blood loss and postoperative pain as the instruments cut through tissue. 32 , 33 A Cochrane review of 10 studies demonstrated significantly lower pain scores (using a validated visual analog scale) on postoperative day 1 in patients receiving Ligasure vs. conventional hemorrhoidectomy (weighted mean difference = −2.07; 95% confidence interval, −2.77 to −1.38). 34 Additionally, the Ligasure procedure took less time to complete (11 trials; 9.15 minutes; 95% confidence interval, 3.21 to 15.09). 34
An additional surgical procedure is the stapled hemorrhoidopexy. 25 This is often referred to as stapled hemorrhoidectomy, which is a misnomer because the excised tissue is not the actual hemorrhoid, but rather loose proximal mucosa that has contributed to the prolapsed hemorrhoid. In this procedure, mucosal tissue 4 cm proximal to the dentate line is circumferentially removed and stapled so that the distal hemorrhoidal columns are effectively lifted back above the anal verge and attached to each other (mucopexy). A Cochrane review of 12 trials demonstrated that recurrent hemorrhoids were significantly more common after stapled hemorrhoidopexy vs. conventional excisional hemorrhoidectomy (odds ratio = 3.22; 95% confidence interval, 1.59 to 6.51). 35 A 2007 meta-analysis showed no significant differences in complication rates between the two procedures, with the exception of increased rates of persistence or recurrence of hemorrhoids and prolapse at one year of follow-up in patients who had stapled hemorrhoidopexy. 36 Additionally, patients undergoing stapled hemorrhoidopexy were noted to have small but significant benefits with less time to first bowel movement, shorter hospital stays, and fewer unhealed wounds at four weeks. 36
Hemorrhoidal artery ligation, also known as transanal hemorrhoidal dearterialization, is a promising emerging therapy for grade II or III hemorrhoids. 28 In this procedure, the superficial artery directly proximal to the associated hemorrhoid is isolated and ligated. Specialized lighted anal speculums with or without Doppler probes and/or suture ports have been developed to assist with this technique. This can be performed with or without mucopexy. Early evidence suggests that hemorrhoidal artery ligation has similar outcomes to stapled hemorrhoidopexy with less postoperative pain. 28 , 37 Hemorrhoidal artery ligation appears to have overall outcomes approaching those of conventional hemorrhoidectomy with similar postoperative pain. 28 , 37
Postoperative pain has historically been universal with surgical hemorrhoidectomy. Pudendal and anal blocks with local anesthetics have greatly reduced the amount of post-hemorrhoidectomy pain. 24 The use of a lateral internal sphincterotomy in conjunction with conventional hemorrhoidectomy has also demonstrated a reduction in postoperative pain. 38
Discerning postoperative complications (e.g., abscess, proctitis) from anticipated symptoms can be challenging. Pain and anal fullness are expected within the first week following hemorrhoidectomy or hemorrhoidopexy. Local medications are used to manage postoperative pain, with topical nitroglycerine ointment having the strongest evidence of effectiveness. 39 Postoperative injection of botulinum toxin as well as oral or topical metronidazole (Flagyl; Metrogel) are also options, although their effectiveness is disputed. 40 – 43
In addition to pain, common complications in the early postoperative period include bleeding, urinary retention, and thrombosed external hemorrhoids. 37 , 44 Rare but potentially life-threatening complications that must be identified early include abscess, sepsis, massive bleeding, and peritonitis. 37 , 45 – 47 Complications in the later postoperative period include recurrent hemorrhoids, anal stenosis, skin tags, late hemorrhage, constipation (often due to narcotic use), and fecal incontinence, all of which are often lesser than in the early postoperative period. 37 , 47
This article updates a previous article on this topic by Mounsey, et al. 11
Data Sources: The following evidence-based medicine resources were searched using the key words stapled hemorrhoidopexy, hemorrhoidectomy, hemorrhoids, hemorrhoid treatment, rubber band ligation hemorrhoids, hemorrhoid surgery, hemorrhoids pregnancy, and thrombosed external hemorrhoids: Essential Evidence Plus, the Cochrane Database of Systematic Reviews, PubMed, UpToDate, the National Guideline Clearinghouse, the Institute for Clinical Systems Improvement, and the Database of Abstracts of Reviews of Effects. Search dates: June 2, 2016, and June 25, 2017.
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the U.S. Navy, the U.S. Department of Defense, or the U.S. government.
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Prevalence and associated factors of hemorrhoids among adult patients visiting the surgical outpatient department in the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia
Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing
* E-mail: [email protected]
Affiliation Department of Human Anatomy, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
Roles Data curation, Investigation, Software, Writing – original draft, Writing – review & editing
Roles Conceptualization, Investigation, Methodology, Software, Validation, Visualization, Writing – original draft, Writing – review & editing
- Anteneh Ayelign Kibret,
- Mohammed Oumer,
- Abebe Muche Moges
- Published: April 20, 2021
- Reader Comments
Hemorrhoidal disease is a very common benign anorectal disease. It affects millions of people around the world, and represent a major medical and socioeconomic problem. However, studies that determine the magnitude and risk factors are limited. Therefore, the aim this study is to assess the prevalence and associated factors of hemorrhoid among adult patients visiting the surgical outpatient department at the University of Gondar Comprehensive Specialized Hospital (UoGCSH) Northwest Ethiopia.
An institution-based cross-sectional study was conducted from February to May 2020. A systematic random sampling technique was used to select a total of 403 participants. The data were collected then entered using EPI DATA version 3.1 and exported to the STATA 14 for analysis. Bivariable and multivariable logistic regression analysis were performed. Adjusted odds ratio (AOR) with 95% confidence interval was used as a measure of association. Variables having P-value < 0.05 from the multivariable analysis were considered to have a significant association with the outcome.
Out of the 403 study participants, 13.1% (95%CI; 10.1, 16.8) had hemorrhoids. Constipation (AOR = 4.32, 95% CI; 2.20, 8.48) and BMI ≥25kg/m 2 (AOR = 2.6, 95% CI; 1.08, 6.23) had a statistically significant association with hemorrhoid.
The overall prevalence of hemorrhoid was high and its prevalence was higher in male subjects. Constipation and being overweight were found to increase the odds of having hemorrhoids. Screening for early identification and intervention of hemorrhoids, especially for risk groups is better to be practiced by health professionals.
Citation: Kibret AA, Oumer M, Moges AM (2021) Prevalence and associated factors of hemorrhoids among adult patients visiting the surgical outpatient department in the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. PLoS ONE 16(4): e0249736. https://doi.org/10.1371/journal.pone.0249736
Editor: Y. Zhan, German Centre for Neurodegenerative Diseases Site Munich: Deutsches Zentrum fur Neurodegenerative Erkrankungen Standort Munchen, GERMANY
Received: November 5, 2020; Accepted: March 23, 2021; Published: April 20, 2021
Copyright: © 2021 Kibret et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: According to the ethical review committee, the data contains potentially identifying characteristics as well as sensitive patient information and cannot be shared publicly. All data requests can be sent to the Director of the School of Medicine (Dr Mezgebu Silamsew at [email protected] ), or the Director of the Postgraduate Committee (Mr. Getasew Amare at [email protected] ).
Funding: The authors received no specific funding for this work.
Competing interests: There is no any competing of interests related with this work.
Abbreviations: BMI, Body mass index; IAP, Intra-abdominal pressure; BP, blood pressure; OPD, Outpatient department; UOGCSH, University of Gondar Comprehensive Specialized Hospital; USA, United State of America
Hemorrhoid is the anastomoses between the superior rectal artery and the superior, middle, and inferior rectal vein that surround the distal rectum and anal canal. It is a distal displacement and venous distention of the hemorrhoidal cushions [ 1 , 2 ]. Based on location, hemorrhoids are usually classified as internal and external hemorrhoids. Internal hemorrhoids arise above the dentate line and are covered by columnar epithelium, while external hemorrhoids arise below the dentate line and are covered by squamous epithelium [ 3 – 5 ]. Patients with hemorrhoids are usually asymptomatic but the common symptoms are bleeding with or without defecation, a swelling, mild discomfort or irritation and pruritus ani [ 6 , 7 ]. Though, some patients need to undergo surgery, many hemorrhoid patients can successfully be treated with conservative medication and ointments [ 8 ]. The pathogenesis of hemorrhoids is a weakening of the anal cushion leads to descent or prolapse of the hemorrhoids and spasm of the internal sphincter [ 9 , 10 ]. In the United States, hemorrhoid disease is the fourth leading outpatient gastrointestinal diagnosis, accounting for 3.3 million ambulatory care visits [ 5 ]. The estimated worldwide prevalence of hemorrhoids in the general population is to be 4.4% [ 11 ]. Globally, various studies were conducted to assess the prevalence and associated factors of hemorrhoids. The prevalence of hemorrhoid is higher in Australia (38.93%) which is followed by Israel (16%) and Korea (14.4%) [ 12 – 14 ].Very few attempts have been made to assess the prevalence of hemorrhoids in Africa. The prevalence of hemorrhoid among Egypt patients subjected to colonoscopy was 18% [ 15 ].
Studies conducted elsewhere indicated that inadequate dietary fiber, constipation, diarrhea, hypertension, high body mass index (BMI), pregnancy and old age are the commonly identified risk factors for the development of hemorrhoids [ 1 , 13 , 14 ].
Hemorrhoids are now considered a major cause of morbidity and impose both economical and social impact on society [ 12 ]. It has social impact, as it is inter-linked to lifestyles, such as interpersonal, and impacted by food and hygienic and sexual habits, and also has economic burden on health systems in direct costs and working days lost [ 16 ]. The hemorrhoidal disease creates physical and psychological discomfort and significantly affects the quality of life of the patients due to its sensitive symptoms such as anal bleeding, pain and itching sensation [ 12 , 17 ]. Besides, hemorrhoids hinder patient’s ability to live normally and work efficiently even after management due to its frequent recurrence, incomplete elimination of discomfort and postoperative pain [ 14 ]. The most common and serious complications of hemorrhoids include perianal thrombosis and incarcerated prolapsed internal haemorrhoids with subsequent thrombosis [ 18 ].
Reports on the magnitude and risk factors of hemorrhoids have paramount importance to the policymakers, clinical practitioners, and the society at large. In spite of sever clinical and social impacts, there is no documented evidence in Ethiopia so far. The present study is aimed to determine the prevalence and associated factors of hemorrhoids among patients visiting the surgical outpatient department (OPD) at the UoGCSH, Northwest Ethiopia.
Study design and setting
An institution based cross-sectional study design was conducted from February to May 2020 G.C among adult surgical patients who visited the surgical outpatient department (OPD) at the UoGCSH. The hospital was found in1954 and it is located in the Central Gondar administrative zone, Amhara National Regional State, which is about 750 km Northwest of Addis Ababa (the capital city of Ethiopia). According to the 2015 population projection of major cities in Ethiopia, the total population size of Gondar town was estimated to be 323,900. Currently, Gondar town has one Referral Hospital and eight government Health Centers. University of Gondar Comprehensive Specialized Hospital is a teaching hospital, which serves more than five million people of the North Gondar zone and peoples of the neighboring zones. It is estimated that around 21,000 patients visit the surgical OPD per year.
Population and sample size determination
The source population of the study was all adult patients above 18 years’ old who visited the surgical OPD at the UOG Comprehensive Specialized Hospital. The study population was all adult patients above 18 years’ old who visited the surgical OPD during the time of data collection in the UOG Comprehensive Specialized Hospital. Patients who were unable to communicate, mentally ill, and severely ill were excluded from the study. The sample size was determined using a single population proportion formula, by using a 95% confidence interval, 0.05 margin of error, 5% non-response rate. As far as our search is concerned, there was no previous study conducted in the area and the expected proportion of hemorrhoids was considered to be 50%. Therefore, the final sample size was 403 and participants were selected using a systematic random sampling technique with skipping intervals of three.
Variables and data collection procedures
The outcome variable of this study was hemorrhoids. Patients were diagnosed based on history and anorectal examination which includes inspection, digital examination and anoscopy. Grading of hemorrhoids was documented and classified according to the international classification recommended by Banov et al: Hemorrhoids that do not prolapse and appear as a bulge into the lumen of the anal canal with or without bleeding (grade I). Hemorrhoids that prolapse and reduce spontaneously (grade II). Hemorrhoids that require digital reduction of prolapsed tissue (grade III).Hemorrhoidal piles prolapse is irreducible(grade IV) [ 12 ]. The first group of factors assessed was socio-demographic characteristics including age, sex, residence, educational status, occupation, marital status, and average monthly income. The second was clinical factors which includes a Family history of hemorrhoids, constipation, body mass index (BMI), hypertension, fiber diet intake, and chronic diarrhea. The third group of characteristics assessed was Behavioral and obstetric factors mainly focused on Smoking, alcohol intake and parity. Blood pressure(BP) was measured three times in a sitting position using a standard mercury sphygmomanometer BP cuff with the appropriate cuff size that covers two-thirds of the upper arm after the participant rested for at least five minutes and no smoking or caffeine 30 minutes before measurement. The second and the third measurements were taken five-to-ten minutes after the first and the second measurement, respectively. Finally, the average of the three BP measurements was calculated to determine the BP status of the participant. An individual was diagnosed as hypertensive if systolic blood pressure (SBP) is ≥130mmHg or diastolic blood pressure(DBP) is ≥80 mmHg or previous diagnosis of hypertension or current use of the anti-hypertensive drug [ 19 ]. Constipation means unsatisfactory defecation characterized by infrequent stool, difficulty in defecation or both at least for previous 3 months [ 20 ]. Fiber diet intake was measured, if participants took fiber diet once in a week considered as they had a history of adequate fiber diet intake. Weight and height to calculate BMI and was taken using calibrated equipment and BMI was calculated by dividing weight in kg by height in meters square. BMI <18.5 kg/m 2 was considered as underweight 18.5–24.9 kg/m 2 as normal, 25–29.9 kg/m 2 overweight and ≥30 kg/m 2 as obese [ 21 ].
The interviewer-administered questionnaire was adopted from different works of literature. The questionnaire was first developed in English and then translated into Amharic language and back to English and consistency was checked. The data was completed by trained five B. Sc nurses who were working at the surgical OPD using the Amharic version questionnaire. Data quality was controlled through the provision of one-day training to the data collectors. To evaluate the general approachability and feasibility of the questionnaire, a pretest was carried out using 10% of a sample size at Debretabor Primary Hospital. Hence, correction and modification were made to the questionnaire accordingly.
Data processing and analysis
After data collection, each questionnaire was checked visually for completeness. Data were coded and entered using EPI DATA 3.1 version and exported to the STATA 14 for analysis. Data cleaning was done by identifying and correcting missed values and inconsistencies. Descriptive statistics like frequency, percentage, median, and Interquartile range (IQR) was done to describe the study population in relation to different variables. A Chi-square test was done for all variables to check the assumptions. The binary logistic regression model was fitted as a primary method of analysis. Variables having p-value ≤ 0.2 from the bivariable analysis were chosen as a candidate for the final multivariable logistic regression model and variables having p-value <0.05 were considered to have a significant association with the outcome variable. An adjusted odds ratio with 95% CI was used as a measure of association. The model goodness of fit was assessed by the Hosmer-Lemeshow test.
The study protocol was approved by the ethical review committee of the College of Medicine and Health Sciences, University of Gondar (Reference SOM 950/12 dated February 15, 2020). Verbal informed consent was taken from all respondents enrolled in the study. Since most of our participants were an able to read and write so that we were not able to take written consent. The verbal consent was taken after introducing the topic of the research to the study participants, initially the data collectors give a brief description about the main aim of the research and telling them there honest and genuine participation by responding to the questions prepared is very important and highly appreciated to attain this purpose. Finally enable the study participants to know about their response to personal question are confidential and also can have a right to not answer any question if they do not want to and stop the interview at any time. The Institutional Review Board (IRB) approved use of consent. To keep confidentiality, respondent’s names and other personal identifiers were not included. The collected data were password protected and properly discarded.
In the present study, a total of 403 study participants were involved with a response rate of 100%. The median age of the participants was 38 years old (IQR: 28, 52). Both sexes had nearly equal frequency, 207 (51.3%) female subjects and more than half of the study participants 210 (52.15%) had no formal education. Of the participants, 135 (33.5%) were farmers and 290 (72%) were married. Almost half of the study participants 200 (49.6%) had an average monthly income less than 1210 ETB ( Table 1 ).
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Clinical, behavioral, and obstetric characteristics
Of the total participants, 30 (7.4%) had a family history of hemorrhoids and one fourth 102 (25.3%) had a history of alcohol intake. Among female study participants, the majority of them 153 (74%) gave at least one birth. Out of the total study participants, 96 (24%) had constipation and 151 (37.4) had a history of taking a high fiber diet ( Table 2 ).
Prevalence of hemorrhoids
The result of this study revealed that among 403 study participants 53 had hemorrhoids with an overall prevalence of 13.1% (95%CI; 10.1, 16.8). Participants having hemorrhoid were classified as grade I to IV and the prevalence of grade I, II, III, and IV were 34 (64.1%), 12 (22.7%), 6 (11.3%), and 1 (1.9%), respectively. The prevalence of hemorrhoids among male and female participants was 18.8% (95% CI: 13.6, 25.0) and 7.7% (95%CI: 4.48, 12.4), respectively. Out of the total of hemorrhoid cases that occurred among females, 11 (68.7%) of them were diagnosed from those who gave one and above birth ( Fig 1 ).
Factors associated with hemorrhoids
From the multivariable logistic regression analysis constipation and BMI had a significant association with the occurrence of hemorrhoid. The odds of having hemorrhoid was 4.32 times higher among participants who had constipation as compared to their counterparts (AOR = 4.32, 95%CI; 2.20, 8.48). The patients who had BMI ≥25 kg/m 2 were 2.6 times higher odds of having hemorrhoid as compared to BMI < 25 kg/m 2 (AOR = 2.6, 95%CI; 1.08, 6.23) ( Table 3 ).
The present study was conducted to determine the prevalence of hemorrhoids in adult patients visiting surgical OPD at the UOG Comprehensive Hospital, Ethiopia, and to define associated risk factors. Constipation and being overweight found to be significantly associated with hemorrhoids.
In this study, the prevalence of hemorrhoids was found to be 13.1%. The result is consistent with a study conducted in Israel 16% (13) and Korea 14.4% (14). However, it is lower than the study from Australia and Egypt which reported the prevalence to be 38.9% and 18% respectively [ 12 , 15 ]. In Australia, participants were from colorectal cancer screening and the investigation was conducted in multi-centered area. In a way, hemorrhoids and colorectal cancer have similar symptom which may increase the prevalence in Austria study. Similarly, study conducted in Egypt included those patients who came for colonoscopic examinations and patients with anorectal disease which may contribute to the rise of the prevalence of hemorrhoid. However, in our study we considered merely patients who visited surgical OPD.
In our study, study subjects with constipation were more likely to have hemorrhoids as compared to their counterparts. Similarly, studies conducted elsewhere supported the notion of significant contribution of constipation to the induction of hemorrhoid [ 1 , 22 – 24 ]. This could be due to degeneration of the supportive tissue in the anal canal and tear of elastic supportive tissue due to prolonged straining during defecation and hard stool Subsequently, causing a distal displacement of anal cushions and development of hemorrhoid [ 25 , 26 ]. Passage of hard stool and increased intra-abdominal pressure could also obstruct venous return, resulting in engorgement of the hemorrhoidal plexus and arteriovenous anastomoses of the anorectal junction this leads to the development of hemorrhoid [ 27 ].
The current study found that being overweight increased the odds of having hemorrhoids. The notion of our study is supported by other studies done elsewhere [ 12 , 14 , 28 ]. This could be attributed to an increase in the intra-abdominal pressure due to the high body weight and visceral fats which are thought to give rise to the venous congestion of the distal rectum [ 14 ]. Obesity will induce the release of inflammatory cytokines and acute phase proteins which will eventually activate the innate immune system and affect metabolic homeostasis, which contributes to the formation of hemorrhoids [ 14 ].
This study helps us to know the burden and possible risk factor of the disease and may allow us to easily identify individuals at risk of hemorrhoids and to provide early diagnosis, prevention measures, and appropriate interventions. However, there are some limitations of this study such as it could not establish a cause-effect relationship because of the cross sectional nature of the study design. In addition, this study was an institution based and the findings may not fully reflect the entire population and also possible that recall bias may have been introduced. The study did not assess the frequency of fiber diet intake based on the recommendations of WHO.
Hemorrhoid is found to be the common health problem among surgical patients and its prevalence was higher in male subjects. Constipation and being overweight were found to increase the odds of having hemorrhoids. Screening for early identification and intervention of hemorrhoids, especially for risk groups is better to be practiced by health professionals. We recommend every individual to maintain their normal body weight and avoid any risk that can cause constipation. Further, community based study should be conducted on the burden of hemorrhoid in Ethiopia.
We are grateful to thank the study participant for their valuable contribution and provide appropriate information Dr. Solomon Yirdaw and Dr. Miklol Mengistu for their close, friendly, comments, assistance, intellectual and guidance to our work. The authors like to express their gratitude to the Surgery Department of the University of Gondar Comprehensive Specialized Hospital as their contributions were vital in the completion of this research work.
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- 21. Organization WH. Obesity: preventing and managing the global epidemic: World Health Organization; 2000.
Case-based learning: haemorrhoids
After reading this article, you should be able to:
- Recognise the symptoms of haemorrhoids and when referral is needed;
- Understand the pharmacological and non-pharmacological treatment options available, including any advice relating to self-care and prevention ;
- Know how to advise patients on the rectal application of creams/ointments and suppositories;
- Understand that there are different presentations of haemorrhoids.
Haemorrhoids are clusters of vascular tissue, smooth muscle and connective tissue arranged in three columns along the anal canal  . In healthy individuals, they act as cushions that help maintain continence  . Although haemorrhoids — or ‘piles’ as they are otherwise commonly known — are normal structures, the term has become synonymous with them in an abnormally swollen and symptomatic state  . This happens when the venous drainage of the anus is altered, causing the venous plexus (a congregation of multiple veins) and connecting tissue to dilate, creating an outgrowth from the rectal wall  .
The exact prevalence of haemorrhoids is unknown because many patients are asymptomatic and do not seek medical attention  . A US colorectal cancer screening study found a 39% prevalence of haemorrhoids, with 55% of those patients reporting no symptoms  . Community-based UK studies have reported that haemorrhoids affect 13–36% of the general population, although this estimate may be higher than the actual prevalence owing to self-reporting and the incorrect attribution of anorectal symptoms to haemorrhoids, such as pain and bleeding [1,2] .
NHS signposting for common clinical conditions and minor ailments encourages patients to seek prompt clinical advice and treatment from their local pharmacy. Therefore, acute or chronic presentations of haemorrhoids may frequently be seen in community pharmacies  and it is important that pharmacists can provide patients with the appropriate guidance and information for management.
The aetiology of haemorrhoids is currently speculative; however, this may change as large-scale studies are in progress to investigate the genetic causes  . Although unproven, a low-fibre diet and constipation have historically been thought to be risk factors  . Other proposed risk factors include:
- Age — there is higher prevalence in persons aged 45–65 years;
- Socioeconomic status — there is higher prevalence with higher socioeconomic status, although this may reflect differences in health-seeking behaviour rather than true prevalence;
- Pregnancy ;
- Heavy lifting;
- Chronic cough ;
- Certain toilet behaviours, such as straining or spending more time on a seated toilet than on a squat toilet; squatting provides a better angle for defecation [1–7] .
Haemorrhoids are classified as external or internal depending on their position in relation to the dentate line (dividing the upper two-thirds from the lower third of the anal canal). External haemorrhoids originate below the dentate line and are covered by modified squamous epithelium, which is richly innervated with pain fibres ( see Figure 1 ). Internal haemorrhoids arise above the dentate line and are covered by columnar epithelium, which have no pain fibres. Internal haemorrhoids are graded by degree of prolapse using Goligher staging, although classification does not always reflect the severity of the symptoms ( see Figure 2 )  . Internal and external haemorrhoids can be present at the same time [1,2] .
Signs and symptoms
External haemorrhoids are often described as lumps and bumps around the anus with itching. The latter is a result of irritation from faecal matter not being fully removed upon wiping  . Pain is uncommon unless very severely swollen owing to thrombosis  .
Symptoms of internal haemorrhoids will commonly include a feeling of discomfort and a sensation of fullness in the rectum or incomplete evacuation, especially after passing stools. Further straining should be avoided to prevent haemorrhoids from prolapsing  . Prolapsed haemorrhoids may become itchy and irritated owing to the presence of moisture, mucus and faecal matter. Pain is not usually reported with internal haemorrhoids unless the haemorrhoid is prolapsed and strangulated; the latter occurring when the blood supply has been cut off by pressure applied from the anal muscles [2,10] .
Where bleeding is present, this will typically occur after bowel motions because of the microtrauma of passing hard stools. As this is arterial blood, it will usually be bright red in colour and may appear as streaks on toilet paper when wiping, on the surface of stools, or in the toilet water [2,10] . GP referral to exclude other diagnoses should be made if the blood has a different appearance, such as darker red, brown or black, or is mixed with the stool. These signs suggest a more proximal blood source and may be a ‘red flag’ cancer symptom [11,12] . Please see Box 1 for example questions that pharmacists can ask to assess symptoms.
Box 1: Example questions that pharmacists may ask as part of symptom assessment
- “Can you describe to me your current symptoms and when you first noticed them?”
- “Do you feel the symptoms are getting worse, better or staying about the same?”
- “Have you had these sorts of symptoms before, or is this the first time you’ve felt like this?”
- “Aside from the discomfort around your back passage, how do you feel in general? Are you eating OK? Have you had any digestive problems recently, lost any weight or noticed any bleeding?”
- “Have you already tried any medicines to help relieve these symptoms?” or “If you’ve felt like this before were there any treatments you tried previously that helped?”
Pharmacists have a duty of care to refer patients who present with ‘red flag’ symptoms, but where the bleeding is mild and localised, and in the absence of other red flags ( see Figure 3 [2,12–14] ), treatment initiation with appropriate safety-netting advice and follow up guidance may be appropriate  .
Thorough history taking will help the pharmacist to exclude other potential causes or alternative diagnoses. See Box 2 for a list of differential diagnoses.
Box 2: Differential diagnoses
Differential diagnoses of haemorrhoids include:
- Adenomatous polyps;
- Anal fissure;
- Anal or colorectal cancer ;
- Anorectal fistula;
- Condylomata acuminata (warts);
- Diverticular disease ;
- Inflammatory bowel disease ;
- Perianal abscess;
- Portal hypertension;
- Pruritus ani and associated causes;
- Rectal prolapse;
- Sexually transmitted infections (e.g. gonorrhoea , syphilis or chancroid)  .
Pharmacists should advise surveillance of the affected area in case dermatological complications develop. The skin may become macerated owing to mucus discharge, ulcerated owing to thrombosed external haemorrhoids, or irritated, secondary to skin tags  . Changes that suggest signs of infection or of skin breakdown should be referred for review.
A drop in haemogloblin may be detected when there is significant or continuous rectal bleeding. Signs and symptoms of anaemia may include fatigue, breathlessness or pale skin. Pharmacists should refer this to be managed by the GP who will confirm the diagnosis using a blood test [2,15] .
For some complications, such as incarcerated or thrombosed haemorrhoids, surgical intervention may be indicated to resolve symptoms and promote quicker healing. Referral for surgical correction or dilation may also be indicated where a narrowing of the anal canal, also known as anal stenosis, has developed over time [2,8] .
In more serious cases where infection has developed in the area, there is the risk of pelvic sepsis . All cases of suspected sepsis need urgent hospital referral to ensure first doses of antibiotics are administered in-line with antimicrobial policies [2,16] .
Complications of haemorrhoids can negatively affect quality of life and so appropriate signposting and advice should be given when making recommendations to ensure timely and appropriate escalation of management.
Treatment and management
In the absence of complications, haemorrhoids are self-limiting and typically heal within a week  . Where they are associated with pain, itching or discomfort, pharmacists may offer pharmacological treatment to promote healing and to alleviate symptoms  . Pharmacists should be prepared to offer lifestyle advice to aid healing and prevent recurrence.
The treatment of haemorrhoids in the community and primary care setting is usually limited to topical preparations that contain combinations of astringents, local anaesthetics and corticosteroids  . There is currently no evidence to suggest any one topical preparation is more effective than another. Simple analgesia may also be recommended for pain relief, although non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in the presence of rectal bleeding [6,7,17] .
Pharmacists should recommend onward referral to a GP if self-treatment with a non-prescription product does not improve symptoms within the first seven days of use. This is the typical treatment duration guidance issued in the product licenses for over-the-counter preparations  . Advice to avoid prolonged use of topical preparations also reflects the potential for ingredients to cause problematic effects if used over extended periods. For example, prolonged use of topical corticosteroids may cause skin atrophy, sensitisation and contact dermatitis, while extended use of topical local anaesthetics is associated with skin sensitisation [6,17] . Side effects are rare and usually limited to minor irritations for short courses of treatment.
Creams and ointments are usually the products of choice for external haemorrhoids and are typically applied morning and evening. They can also be applied after passing stools when symptoms often flare, using a clean finger or gauze dressing.
Suppositories are usually the best choice for internal haemorrhoids, although some topical preparations come packaged with an applicator that will apply the product into the anal passage. Suppositories can be inserted morning and evening and after passing stools. Pharmacy staff should counsel on the best ways to insert suppositories  . Practical advice on the insertion of rectal formulations is available in Box 1 of this article .
For patients with external and internal haemorrhoids, a suppository and topical product can be used at the same time. Information regarding counselling on suppository use can be found here .
Self-care and prevention
Self-care recommendations should be made to support the relief of symptoms and the healing process. This may include the use of a cold compresses to shrink the haemorrhoids, warm baths to soothe the area and the promotion of certain behaviours [2,7,17,19] . Adoption of the following behaviours may promote healing and help to prevent repeated episodes:
- A balanced diet with enough fibre (25-30g daily via high fibre foods or commercial supplements);
- Adequate fluid intake;
- Regular physical activity;
- Maintain stools that are soft and easy to pass;
- Avoid constipation and straining;
- Toilet behaviours, such as going as soon as you need and avoiding sitting on the toilet for long periods;
- Anal hygiene, such as moist, gentle cleaning following a bowel movement;
- Keeping a healthy weight [2,7,17,19] .
If dispensing or recommending a medication that can cause constipation, pharmacists should be prepared to give appropriate counselling advice that encourages a normal bowel frequency to be maintained  . This should be a frequency that is ‘normal’ for the patient.
Minimally invasive and surgical management
Referral to secondary care for consideration of further management may be indicated depending on the severity of symptoms and degree of prolapse. This will usually be for haemorrhoids that have failed to respond to or have recurred despite conservative management, are graded II–IV, or where the haemorrhoid is incarcerated or thrombosed [20–22] .
Incarcerated haemorrhoids are short-term complications that present as severe pain and irreducible prolapsing haemorrhoidal tissue. A referral for surgical intervention is indicated to manage these [19,20] .
Surgical intervention may also be indicated for patients who present early with severe symptoms of thrombosis, as this may lead to a quicker resolution of symptoms  . However, most patients with thrombosed haemorrhoids can be managed conservatively at home using analgesia, ice packs and stool softeners, with a topical calcium antagonist if required as an adjunct for pain relief. These should be given in combination with advice to avoid straining and constipation  .
Most minimally invasive (i.e. non-surgical) or surgical procedures will be performed as day cases  .
Case 1: Pregnancy
A 30-year-old woman presents at her pharmacy seeking advice on managing suspected piles. She explains to the assistant that she is six months’ pregnant and is referred to the pharmacist in the consultation room.
The patient explains that she has noticed a small lump around her back passage and has seen some bright red streaks of blood on toilet paper when wiping after defecation. It is quite tender but not painful. She describes no change in bowel habit but may be straining slightly when passing stools.
Diagnosis and advice
The pharmacist highlights that the symptoms are typical of haemorrhoids and a non-prescription treatment can be recommended. A simple, soothing product containing astringents in ointment form would be a safe, suitable option  . The patient is given a leaflet from the UK Teratology Information Service’s ‘bumps’ website for additional reassurance regarding the safe treatment of haemorrhoids and its common occurrence in pregnancy  . She is advised to see her GP if her symptoms worsen or do not resolve in the next few days.
The patient is also given dietary and lifestyle advice to prevent constipation and straining, as these can worsen haemorrhoids or cause them to recur.
Case 2: Patient seeking medication advice
A 65-year-old man makes a request at the pharmacy to switch his prescription for cinchocaine hydrochloride 0.5% ww with hydrocortisone 0.5% ww suppositories to ointment.
To avoid the consultation being overheard, the pharmacist takes the patient into the consultation room. The patient explains that his GP has examined him and suggested suppositories would be more effective for him owing to their position. He reveals he is reluctant to leave the pharmacy with the suppositories as he does not know how to use them. The pharmacist explains that both formulations contain the same ingredients, which relieve pain, itching and reduce inflammation, and explains how to use the prescribed medication.
When the pharmacist checks the patient’s understanding using the teach-back method, the patient confides that he does not think that he will be able to do this at work  . The pharmacist reassures the patient and provides advice on application standing up. As the pharmacist is a community pharmacist independent prescriber, the patient is encouraged to return if he has difficulties, when they could discuss the supply of a prescription-only ointment for use at work. The patient is given patient information leaflets to help prevent a further recurrence [7,18] .
Case 3: Haemorrhoid complication
A 45-year-old woman presents to the pharmacy at the weekend asking for haemorrhoid treatment. She is distressed when describing a swelling around her back passage which is “extremely tender and painful”.
The pharmacist takes a patient history, which includes a recent knee injury managed with PRICE (protection, rest, ice, compression, elevation) therapy, a two-week sick note for her employer and prescriptions for co-codamol.
The patient has no prior issues with her bowels, but over the past week has been straining when going to the toilet and passing stools less frequently than normal. The painful swelling at her back passage started two days ago and, after looking up the symptoms online, she has been using cold compresses on the area. She is now avoiding going to the toilet.
Based on the patient consultation, the pharmacist suspects a thrombosed external haemorrhoid.
The pharmacist highlights the risk factors for haemorrhoids and the contributory roles of opioids and immobility in inducing constipation. The pharmacist explains that thrombosed haemorrhoids can be managed conservatively or with surgical intervention, the latter providing quicker resolution of symptoms. Owing to the patient’s acute presentation, the pharmacist advises the patient to go to a hospital emergency department for further assessment.
- 1 Sandler RS, Peery AF. Rethinking What We Know About Hemorrhoids. Clinical Gastroenterology and Hepatology. 2019; 17 :8–15. doi: 10.1016/j.cgh.2018.03.020
- 2 NICE Clinical Knowledge Summary. Haemorrhoids. National Institute for Health and Care Excellence. 2016. https://cks.nice.org.uk/topics/haemorrhoids (accessed Jan 2022).
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- 4 How your pharmacy can help. NHS. https://www.nhs.uk/nhs-services/prescriptions-and-pharmacies/pharmacies/how-your-pharmacy-can-help/ (accessed Jan 2022).
- 5 Zheng T, Ellinghaus D, Juzenas S, et al. Genome-wide analysis of 944 133 individuals provides insights into the etiology of haemorrhoidal disease. Gut. 2021; 70 :1538–49. doi: 10.1136/gutjnl-2020-323868
- 6 Haemorrhoids (piles). NHS Inform. 2021. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/haemorrhoids-piles (accessed Jan 2022).
- 7 NHS. Piles (haemorrhoids). 2019. https://www.nhs.uk/conditions/piles-haemorrhoids (accessed Jan 2022).
- 8 Acheson AG, Scholefield JH. Management of haemorrhoids. BMJ. 2008; 336 :380–3. doi: 10.1136/bmj.39465.674745.80
- 9 Lohsiriwat V. Hemorrhoids: From basic pathophysiology to clinical management. WJG. 2012; 18 :2009. doi: 10.3748/wjg.v18.i17.2009
- 10 Migaly J, Sun Z. Review of Hemorrhoid Disease: Presentation and Management. Clinics in Colon and Rectal Surgery. 2016; 29 :022–9. doi: 10.1055/s-0035-1568144
- 11 Ng K, Holzgang M, Young C. Still a Case of ‘No Pain, No Gain’? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020. Ann Coloproctol 2020; 36 :133–47. doi: 10.3393/ac.2020.05.04
- 12 Identifying patients with suspected cancer: red flags and referral. The Pharmaceutical Journal. 2018. doi: 10.1211/pj.2018.20205538
- 13 NICE Clinical Knowledge Summary: Anal Fissure. National Institute for Health and Care Excellence. 2017. https://cks.nice.org.uk/topics/anal-fissure/ (accessed Jan 2022).
- 14 NICE Clinical Knowledge Summary: Gastointestinal tract (lower) cancers — recognition and referral. National Institute for Health and Care Excellence. 2021. https://cks.nice.org.uk/topics/gastrointestinal-tract-lower-cancers-recognition-referral/ (accessed Jan 2022).
- 15 NICE Clinical Knowledge Summary. Anaemia – iron deficiency. National Institute for Health and Care Excellence. 2021. https://cks.nice.org.uk/topics/anaemia-iron-deficiency/ (accessed Jan 2022).
- 16 Schmidt G, Mandel J. Evaluation and management of suspected sepsis and septic shock in adults. UpToDate. 2021. https://www.uptodate.com/contents/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults (accessed Jan 2022).
- 17 Haemorrhoids. British National Formulary. https://bnf.nice.org.uk/treatment-summary/haemorrhoids.html (accessed Jan 2022).
- 18 Hydrocortisone for piles and itchy bum. Cream, ointment and suppositories. NHS. 2020. https://www.nhs.uk/medicines/hydrocortisone-for-piles-and-itchy-bottom (accessed Jan 2022).
- 19 Haemorrhoids. Treatment algorithm. BMJ Best Practice. 2021. https://bestpractice.bmj.com/topics/en-gb/181/pdf/181/Haemorrhoids.pdf (accessed Jan 2022).
- 20 Tol RR, Kleijnen J, Watson AJM, et al. European Society of ColoProctology: guideline for haemorrhoidal disease. Colorectal Dis. 2020; 22 :650–62. doi: 10.1111/codi.14975
- 21 Chen M, Tang T-C, He T-H, et al. Management of haemorrhoids: protocol of an umbrella review of systematic reviews and meta-analyses. BMJ Open. 2020; 10 :e035287. doi: 10.1136/bmjopen-2019-035287
- 22 Davis BR, Lee-Kong SA, Migaly J, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Diseases of the Colon & Rectum. 2018; 61 :284–92. doi: 10.1097/dcr.0000000000001030
- 23 Bumps. Best use of medicines in pregnancy. UK teratology information service. https://www.medicinesinpregnancy.org/#:~:text=Bump%20leaflets%20are%20produced%20by%20the%20UK%20Teratology,England%20on%20behalf%20of%20the%20UK%20Health%20Departments (accessed Jan 2022).
- 24 The Health Literacy Place. NHS Education for Scotland . https://www.healthliteracyplace.org.uk (accessed Jan 2022).
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Original research article, top 100 most-cited articles on hemorrhoids: a bibliometric analysis and visualized study.
- Department of Anorectal Surgery, The Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, China
Background: Hemorrhoids have a significant incidence in people and are becoming a common public health problem. This study provides a bibliometric and visualized analysis of the most influential literature in the field. The aim is to reveal trends in the field of hemorrhoids and to provide a reference for researchers.
Methods: The 100 most frequently cited studies in the field of hemorrhoids were collected from the Web of Science(WOS), and were analyzed in terms of the annual publication, types of literature, countries, institutions, authors, journals, and keywords. During the study, we used a combination of VosViewer, Carrot2, Microsoft Excel, and Tableau tools to better present the visual information.
Results: A total of 4,481 articles were retrieved, of which 3,592 were of the Article and Review types, among which we selected the 100 most frequently cited. A large amount of highly cited literature on hemorrhoid surgery emerged from 1990 to 2010, and the interest of researchers in hemorrhoid surgery seems to have waned after 2010. The sources of highly cited literature in the field of hemorrhoids are predominantly Western, with the United States. and the United Kingdom accounting for almost half of the publications worldwide. However, countries with higher prevalence populations do not have significant research on hemorrhoids. St. Mark's Hospital has published the largest number of influential articles in the field of hemorrhoid disease. Kamm MA and Phillips RKS are the most authoritative authors in the field. Diseases of the Colon & Rectum and the British Journal of Surgery are the most influential journals in this field. The highly cited literature covers a wide range of disciplines, with Thomson's classic “The nature of hemorrhoids” receiving the most attention among the studies focusing on hemorrhoids. Keyword and clustering analysis revealed that The most famous focus in the field of hemorrhoid research is the evolution of stapled hemorrhoidectomy (SH) and Milligan-morgan hemorrhoidectomy (MMH).
Conclusions: This study is the first to explore developments in the field of hemorrhoids, and it helps surgeons quickly understand global trends in the field of hemorrhoids. In recent years, the development of hemorrhoids seems to have hit a bottleneck, with scholarly interest in the field of waning, especially in surgery Procedures. The theory of inferior anal cushion migration has proven to be the most influential theory in the field, but after studies based on SH and MMH, more high-quality evidence is needed to continue advancing the field of hemorrhoids. The results of this study are intended to add to the attention and interest of scholars in this area and provide a reference for further research.
Research shows that more than one-third of people have hemorrhoids that are found during colonoscopy ( 1 – 3 ); however, flexible endoscopy cannot diagnose asymptomatic hemorrhoids ( 4 ). This means that hemorrhoids have more potential to develop in the population and are one of the most common diseases in the world.
While the main symptoms of internal hemorrhoids are painless bleeding and intermittent prolapse, thrombosed external hemorrhoids can cause severe pain to the patient ( 5 ). Thomson's research in 1975 established the basis for the theory of inferior displacement of the anal cushion, which suggests that hemorrhoids develop due to congestion, hypertrophy, and prolapse of the anal cushion ( 6 ). A 2018 guideline suggests that improving diet and lifestyle habits is the first-line therapy for hemorrhoids, while there are many medication options ( 7 ). Conservative treatment usually fails, and patients with stage III and IV hemorrhoids can consider surgery. Surgery, outpatient treatment, and medication are effective treatments for hemorrhoids, but clinically they have more classifications and options ( 7 , 8 ).
Despite the enormous economic burden and distress hemorrhoids cause society, they still receive little attention ( 9 ). The lack of understanding of hemorrhoids by many physicians, coupled with the fact that hemorrhoids often have overlapping signs and symptoms with other anorectal conditions, means that hemorrhoids are often incorrectly evaluated ( 10 ). In the United States., billions of dollars are spent on hemorrhoid treatment each year, but physician misdiagnosis raises this value ( 5 ). Due to a lack of awareness, many cases of overtreatment may occur, or people may severely underestimate the dangers of symptomatic hemorrhoids ( 9 ).
Therefore, we explored the field of hemorrhoids for the first time using a bibliometric approach to identify global trends and the knowledge architecture of hemorrhoids. We hope to provide a comprehensive basis for surgeons' research and clinical work and insights into explorations in the field.
Bibliometric analysis and visualized study
Bibliometric analysis provides a quantitative approach to exploring a specific field to discover the dynamics and progress of a discipline ( 11 – 13 ). A visualized study facilitates the interpretation of data and uncovers the internal connections between them ( 14 ). During this study, we used Excel (Version 2021), VOSviewer (Version 1.6.18), Carrot2 ( https://search.carrot2.org/#/workbench ), and Tableau (Version 2022.2) for the bibliometric analysis and visualization of the literature. In scientific research, the act of citation is meant to endorse or critique the cited literature's results; thus, highly cited literature represents the hot spots of a field of research and the trend carriers of the discipline ( 15 ). Therefore, we selected 100 articles of great importance, including the main annual publication trends, type of literature, country, author, institution, publication, co-occurrence of keywords, and cluster analysis.
Search strategy and literature screening
WOS is considered the most worthwhile database for bibliometric analysis because of its high quality ( 16 , 17 ). We collected literature from the WOS Core Collection from 1900 to 2022, and searched for the date 2022–07–01. In developing the search strategy, we referred to the MeSH subject headings list and some older literature and finally settled on TS = (Hemorrhoids) OR TS = (Hemorrhoid) OR TS = (Haemorrhoids). After the search, we sorted all entries by citation frequency, and only original research articles and reviews were taken into account. Meeting abstract, letter, proceeding paper, and other types of materials will not be considered. Finally, we found the 100 most frequently cited articles. It is important to note that this literature contains several different fields, such as gastroenterology, surgery, and even botany, as we used a subject search, and some of the literature only mentioned hemorrhoids in the abstract and were therefore included in the study. We believe that these articles equally advance the field of hemorrhoids. The collection process of the literature was carried out independently by the two authors, and after that, after which a final agreement was reached through communication. We document the study flow in detail in Figure 1 to provide the reader with a better understanding of our work and to ensure the reproducibility of the study.
Figure 1 . Research flowchart.
Annual publication trends
Through the search, we found 4,481 publications and saved the 100 most cited Article and Review literature. Figure 2 shows that, literature was published from 1956 to 2018, with a low point before 1990, after which the number of publications grew significantly faster, with peaks in 2002 and 2008, with seven publications. However, there were only 15 highly cited publications from 2010 to 2018, and only 1 of them was related to surgery for hemorrhoids. As shown in Figure 3 , the number of Articles in the top 100 papers far exceeds that of Reviews, and most of the two literature types are primarily concentrated in 2000–2009. Table 1 records the ten most influential publications, and we found that Anderson's 2009 article was cited much more often than the other 9.
Figure 2 . Annual publication of the top 100 most-cited articles.
Figure 3 . Study type histogram of the top 100 most-cited articles.
Table 1 . Top 10 most-cited articles.
We use the algorithm that comes with VOSviewer for country publication measurement to ensure the most accurate statistics are obtained. The country statistics using VOSviewer takes into account all authors, but if multiple authors in 1 article are from the same country, only one count is performed. We merged Scotland into the UK, so 30 countries were involved in publishing highly cited literature. Figure 4A shows the geographical visualization between countries, and we find that they are primarily coastal. Table 2 records the 15 countries with the highest number of publications, with the United States. ( n = 25) and the UK ( n = 21) having nearly the same number of highly cited articles as the other countries combined. The average number of citations for publications from Australia, New Zealand, and the United States is significant, at 275.4, 274.3, and 221.5, respectively, indicating that some of their articles are highly influential. Figure 4B shows a lack of cooperation between countries, mainly concentrated among developed Western countries.
Figure 4 . Countries of publication of the top 100 most-cited articles. ( A ) Geographical visualization of national publications, ( B ) Countries’ cooperation coexistence diagram.
Table 2 . The top 15 influential countries.
Institutions and authors
A total of 163 institutions were involved in publishing highly cited literature, and the top 10 most cited institutions are recorded in Table 3 . The institution with the most publications is St. Mark's Hospital ( n = 5) in the UK, followed by the University of Minnesota ( n = 3), the University of North Carolina ( n = 3), and the University of Southern California ( n = 3), all in the United States. The partnership between the institutions can be seen in Figure 5A , which shows that St. Mark's Hospital has an early start and a significant number of high-value publications. As shown in Table 4 , a total of 393 authors participated in the highly cited literature, with Kamm MA ( n = 4), and Phillips RKS ( n = 4) publishing the most articles, and the remaining authors all publishing only 1–2 influential papers each in the field of hemorrhoids. The collaborative relationship between the authors is shown in Figure 5B .
Figure 5 . Publication status of authors and institutions of the 100 most-cited articles. (A) Institutions’ cooperation coexistence diagram, (B) authors’ cooperation coexistence diagram.
Table 3 . The top 10 most-influential institutions.
Table 4 . The top 10 most-influential authors.
The 100 most cited studies on hemorrhoids were published in 42 journals, and Table 5 records the ten most published journals, along with their citation frequency, impact factor, and division. Among them, Diseases of the Colon & Rectum ( n = 19) ranked first, followed by the British Journal of Surgery ( n = 14) and the American Journal of Gastroenterology ( n = 5), among others. This information will help inform the dissemination of articles in this area. Although there are few publications in Lancet and Gastroenterology , their average article citations are 220.8 and 330.3, respectively, but this does not explain the correlation between the impact factor and the number of citations.
Table 5 . The top 10 journals containing the most cited literature.
We performed a co-occurrence network analysis of keywords extracted from 100 documents to identify the most important keywords and their relationships. We set the keyword threshold to “3”, cleaned the data of keywords with the same meaning, and ticked to hide the keywords of “hemorrhoids,” “disease,” and “expression” with little meaning. As shown in Figure 6A , the size of each node depends on the number of keyword occurrences, the color represents the average year of keyword occurrences, and the connecting line represents two keywords appearing together in the literature.
Figure 6 . Network chart of keywords of the 100 most-cited articles. ( A ) Keyword co-occurrence chart, ( B ) Keyword heat diagram.
We found that “pregnancy,” “pressure,” “surgery,” “diagnosis,” and “complications” were the early keywords, suggesting that the early focus of researchers was on the onset of hemorrhoids, diagnosis, anal pressure, and the impact of surgery on complications. “Ferguson hemorrhoidectomy,”(FH) “quality of life,” “risk factors,” and “multicenter trial” are newer keywords in the figure, suggesting that researchers may henceforth focus more on high-quality randomized controlled trials, surgical modalities, and their prognosis. Numerous keywords on hemorrhoid treatment were focused on in 2006–2008, including “conventional hemorrhoidectomy,” (CH) “diathermy hemorrhoidectomy,”(DH) “excision hemorrhoidectomy,”(EH) “SH,” “MMH,” “injection sclerotherapy,” “hemorrhoidal artery ligation,” and “medicinal plants,” thus indicating that this period was a peak in the development of hemorrhoid disease, with the addition of evidence for many treatments driving the research the boom.
Figure 6B shows the visualization of keyword hotness, from which we can see that “MMH,” “DH”, “clinical-trial, “management,” and “pain” are the most popular keywords. These represent the most popular topics in the field of hemorrhoids. “Circumferential mucosectomy,” “rubber band ligation,” and “injection sclerotherapy” followed in popularity as the more common surgical treatments for hemorrhoids. To obtain satisfactory clustering results, we used Carrot2 to cluster the keywords of the highly cited literature on hemorrhoid disease. From Figure 7 , the most important clusters are “Compared with Hemorrhoidectomy” and “Surgical Treatments,” followed by “Medicinal Uses.”
Figure 7 . 30 clustered area diagram formed by the 100 most-cited articles.
Shneider A defines the development of disciplines as taking place in four stages: introducing new problems, the birth of research tools, the generation of disciplinary knowledge based on tools, and the transfer of knowledge and methods ( 18 ). Even though hemorrhoids are one of the most common diseases in the world, no scholars have used bibliometric tools to uncover knowledge in the field of hemorrhoids until now. A well-established field needs extensive citation literature to support it. Although a discussion of only the highly cited literature is not representative of the field as a whole, it gives us an idea of the most influential historical contributions and the directions scholars are most concerned with ( 19 ), and reduces the redundancy generated by large samples of data.
The amount of highly cited literature was low until 1990, after which it began to increase irregularly until after 2010 when scholarly interest in the field seems to have decreased again. However, some new articles in recent years may be of significant value but have been published for a relatively short period of time and therefore have not been widely cited. This may also be one of the reasons.
The number of highly cited studies in the United States. and the United Kingdom is almost equal to that of the other countries combined, especially since most institutions with many publications are from the United States. Hemorrhoids are a disease of all humans, and the fact that most of the highly cited literature comes from Western countries may be related to economic and scientific strength, not that hemorrhoids are widespread only in Western countries. For example, Asian countries such as Israel and South Korea and African countries such as Ethiopia alomst have the highest hemorrhoid rates globally, which is unbalanced ( 20 – 22 ). Some cooperation exists between western countries, but academic exchanges are still lacking in most other countries. The public has become aware of the economic and work day burden that hemorrhoids place on health systems ( 9 , 23 ), so we are calling on researchers to increase their attention to hemorrhoids, especially in countries whose population is that are deeply affected by hemorrhoids.
The most frequently cited article is Anderson 2009, which found that high levels of dietary fiber reduce the prevalence of hemorrhoids ( 24 ). The first ten articles also included three epidemiological reports: MacLennan 2000 concluded that hemorrhoid symptoms were positively correlated with age and fecundity ( 25 ), Peery 2015 found 4 million cases of hemorrhoids annually, accounting for the third highest number of outpatient diagnoses of gastrointestinal, liver, and pancreatic diseases in the United States ( 26 ), and Johanson 1990 found that hemorrhoids and constipation did not have a significant causal relationship ( 27 ). Unfortunately, none of the five most cited articles had hemorrhoids as a significant research target, so the most influential article in the field of hemorrhoids was Tomshen 1975 ( 5 ), which suggests that the doctrine of inferior anal cushion migration, based on this article, has the greatest influence in the current field of hemorrhoids. Also, the most popular studies were Mehigan 2000 and Macrae 1995, who compared different treatments for hemorrhoids ( 28 , 29 ).
Kamm MA ( n = 4), and Phillips RKS ( n = 4), published the most highly cited papers in the field of hemorrhoid disease, with their studies published from 1991 to 2003. The main topics include a comparison of the efficacy of SH and DH ( 30 , 31 ), the pathogenesis of hemorrhoids ( 32 ), and the effect of anal dilation on the anal sphincter ( 33 ). It was followed by Johanson JF ( n = 3), whose studies were published from 1990 to 2006 and included: an epidemiological comparison of hemorrhoids and constipation ( 27 ), and nonsurgical treatment of hemorrhoids ( 34 , 35 ). “MMH,” “DH,” and “RCT” are the most frequent keywords. MMH and DH are regarded as the same traditional hemorrhoid surgery ( 36 ), a classic procedure derived from the “Milligan” and “Morgan” of St. Mark's Hospital in the UK in 1937 ( 37 ), which was considered the gold standard for hemorrhoid surgery in the past ( 38 ). We read Citations Citing Articles to identify those keywords, and most of them are related to SH ( 39 – 41 ), a surgical method proposed by Longo in 1998 ( 42 ), which is also called the Procedure for Prolapse and Hemorrhoids ( 43 ), and was sometimes considered an alternative to conventional MMH ( 40 ). This can explain the second increase in the emergence of highly cited literature after 1998, implying that the impact of new surgical modalities was yielding important scientific results. We found that the comparison between SH and MMH is almost the most significant focus in the field of hemorrhoids because they are controversial, with the anastomosis procedure reducing short-term pain in patients but with problems of stool urgency and high recurrence rates in long-term follow up ( 44 – 46 ), so some scholars consider that MMH remains the gold standard for hemorrhoid surgery ( 38 , 47 ). We found many articles on hemorrhoid surgery appearing between 1988 and 2010, but of the 15 highly cited literature after 2010, only one was related to the surgery of hemorrhoids ( 48 ). This study summarizes and updates the previous Meta-analysis for comparing 11 surgical procedures for grade III and IV hemorrhoids. The highly cited literature after 2010 includes epidemiology and guidelines for hemorrhoids and also relates to pharmacology and gastroenterology. This implies that although the comparison of SH with MMH remains the most important part of the field as a whole, the development of procedures related to hemorrhoids after 2010 may have reached a bottleneck, leading to a waning of scholarly interest in the disease. Therefore, we believe that an update of the procedures and further cross-collaboration between hemorrhoids and other fields may be the key to the revitalization of the field again. In addition, we noted some high-frequency secondary keywords: “rubber band ligation” and “injection sclerotherapy.” Bleday found that 44.8% of patients underwent rubber band ligation in 1985, and 0.7% underwent injection sclerotherapy in 1990 ( 49 ). The 2018 ASCRS guidelines strongly recommend that they are a treatment option for grades I, II, and III hemorrhoids if pharmacologic therapy fails ( 7 ), but infrared coagulation did not appear in our high-frequency keywords.
We clustered the snippet and title of the document using the Lingo algorithm based on singular value decomposition. The Lingo algorithm, proposed by Osiński S ( 50 ), differs from traditional STC clustering algorithms in that it produces many small clusters and places great emphasis on the descriptive quality of the clusters. We performed a cluster analysis of these keywords to help identify some standard labels in the literature with similar characteristics and reveal hotspots ( 51 , 52 ). The two most significant clusters reiterate the focus in the field of hemorrhoids. In addition to SH and MMH, surgical modalities such as FH and Transanal hemorrhoidal dearterialization(THD) are included ( 48 , 53 ). The third central cluster, Medicinal Uses, mentions many medicinal plants for hemorrhoids ( 54 , 55 ), and although this literature is rarely referenced in the field of hemorrhoids, it may provide fruitful directions.
We have carefully considered the study's limitations and, therefore, need to describe our results more objectively. First, we designed this study to ensure the quality and integrity of the literature and to reduce the production of duplicate data by only selecting data from WOS, which, despite being the most prestigious database in the world, may still miss some studies. Second, the analysis of only the highly cited literature is not representative of the entire field; some new research has an impact, but citation frequency is a cumulative process. Third, unlike classification, clustering algorithms are a form of unsupervised deep learning, and although the computer uses the Lingo algorithm, which produces more easily decipherable clustering labels, there are still some labels whose meaning is unclear, and we usually need to focus only on the most important clusters.
This study is the first bibliometric analysis of the field of hemorrhoids. Our findings suggest that despite the significant increase in highly cited literature on hemorrhoids after 1990, scholarly interest has waned significantly after 2010, especially as the highly cited literature on hemorrhoid surgery is very sparse. This does not mean that the field is no longer essential to explore, as there are some new social burdens. In addition, excellence is necessary for the development of surgery. The volume of highly cited literature in the United States. and the United Kingdom is almost equal to that of other countries combined, so more research efforts are needed to advance the field of hemorrhoid disease. Our study reveals global trends in hemorrhoid disease, with the doctrine of inferior anal cushion migration having the greatest impact on the development of hemorrhoids, and the comparison of SH and MMH is probably the most popular focus in the field, meaning that the emergence of new surgical modalities will cause dramatic changes. Researchers can quickly learn about the field through the evolution of related procedures, for example, by looking for hot spots in the latest surgical approaches, leading to more collaborations.
Data availability statement
The original contributions presented in the study are included in the article/ Supplementary Material , further inquiries can be directed to the corresponding author/s.
RS proposed and designed the study. YL and XW collected database information. ZW and JH ran the software processed the figures and tables. ZW wrote the first draft, and JW revised the language and article content. All authors contributed to the article and approved the submitted version.
The research was funded by the National Natural Science Foundation of China (Nos. 81973852) and the Natural Science Foundation of Fujian Province (Nos. 2020Y01010177).
We thank the editor and reviewers for their time and effort, and for their insightful comments and valuable improvements to the paper. We also thank Professors RS and JW for their guidance.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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Keywords: bibliometric, visualized study, hemorrhoids, Milligan-morgan hemorrhoidectomy, stapled hemorrhoidectomy
Citation: Wang Z, Wu X, Li Y, Huang J, Shi R and Wang J (2022) Top 100 most-cited articles on hemorrhoids: A bibliometric analysis and visualized study. Front. Surg. 9:1021534. doi: 10.3389/fsurg.2022.1021534
Received: 17 August 2022; Accepted: 24 October 2022; Published: 11 November 2022.
© 2022 Wang, Wu, Li, Huang, Shi and Wang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Rong Shi [email protected] Jing Wang [email protected]
Specialty Section: This article was submitted to Vascular Surgery, a section of the journal Frontiers in Surgery
Hemorrhoids case study one
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The term hemorrhoids refers to a condition in which the veins around the anus or lower rectum are swollen and inflamed. There are two types of hemorrhoids: External hemorrhoids Hemorrhoids located outside of the anus are called external hemorrhoids. Here, swollen veins cause a soft lump around the anal opening. These lumps can turn hard
Description: Case study Hemorrhoids Copyright: Attribution Non-Commercial (BY-NC) Available Formats Download as DOCX, PDF, TXT or read online from Scribd Flag for inappropriate content Download now of 4 PATHOPHYSIOLOGY OF HEMORRHOIDS Hemorrhoids are dilated portions of veins in the anal canal.
Hemorrhoids are categorized according to their origin relative to the dentate line, which is typically located about 3 to 4 cm proximal to the anal verge. The line represents the site where the ...
An epidemiologic study by Johanson et al in 1990 showed that 10 million people in the United States complained of hemorrhoids, corresponding to a prevalence rate of 4.4%. In both sexes, peak prevalence occurred between age 45-65 years and the development of hemorrhoids before the age of 20 years was unusual.
Hemorrhoid disease is the fourth leading outpatient gastrointestinal diagnosis, accounting for ∼3.3 million ambulatory care visits in the United States. 1 Self-reported incidence of hemorrhoids in the United States is 10 million per year, corresponding to 4.4% of the population. Both genders report peak incidence from age 45 to 65 years.
Hemorrhoids develop when the venous drainage of the anus is altered, causing the venous plexus and connecting tissue to dilate, creating an outgrowth of anal mucosa from the rectal wall. However,...
Introduction Hemorrhoidal disease is a very common benign anorectal disease. It affects millions of people around the world, and represent a major medical and socioeconomic problem. However, studies that determine the magnitude and risk factors are limited. Therefore, the aim this study is to assess the prevalence and associated factors of hemorrhoid among adult patients visiting the surgical ...
Complications. Pharmacists should advise surveillance of the affected area in case dermatological complications develop. The skin may become macerated owing to mucus discharge, ulcerated owing to thrombosed external haemorrhoids, or irritated, secondary to skin tags  .Changes that suggest signs of infection or of skin breakdown should be referred for review.
Hemorrhoids Case Study Scribd Worst case is a lethal brain aneurysm. Straining too hard can lead to hemorrhoids or a hernia but there's a rare condition called defecation syncope -. Apple may finish arguing its case by Monday, after which Samsung can mount. in a report filed by another Apple expert witness named Russell Winer (Scribd link).
Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology. 1990 Feb. 98(2):380-6. [QxMD MEDLINE Link]. Johanson JF, Sonnenberg A. Constipation is not a risk factor for hemorrhoids: a case-control study of potential etiological agents. Am J Gastroenterol. 1994 Nov. 89(11):1981-6.
Case 048: Hemorrhoids. Mr. RCR was a 43 year old accountant who presented to his family doctor complaining of rectal bleeding. His history went back about 7 weeks when he noticed there were streaks of bright red blood coating his stool and spots of blood on the toilet paper from time to time.
We found that "pregnancy," "pressure," "surgery," "diagnosis," and "complications" were the early keywords, suggesting that the early focus of researchers was on the onset of hemorrhoids, diagnosis, anal pressure, and the impact of surgery on complications.
Crohn Research Paper 283 Words | 2 Pages Crohn 's is an immune-mediated inflammatory disease that belongs to a larger group of illnesses called inflammatory bowel disease (IBD). It is associated with inflammation of the digestive tract, or gastrointestinal (GI) tract, which runs from the mouth to the anus, and includes the stomach and intestines.
Case Studies Case #1. Hemorrhoids case study one On the Web Most recent articles. Most cited articles. Review articles. CME Programs. Powerpoint slides. Images. American Roentgen Ray Society Images of Hemorrhoids case study one All Images X-rays Echo & Ultrasound CT Images MRI; Ongoing Trials at Clinical Trials.gov. US National Guidelines ...