REVIEW ARTICLE


https://doi.org/10.5005/jp-journals-10085-9131
Annals of SBV
Volume 12 | Issue 2 | Year 2023

Review of Treatment Modalities in Hemorrhoidal Disease


Urvin Shah1 Saravana Kumar2 Tirou Aroul T3 Robinson Smile4

1–4Department of General Surgery, Mahatma Gandhi Medical College and Research Institute, Pillaiyarkuppam, Puducherry, India

Corresponding Author: Urvin Shah, Department of General Surgery, Mahatma Gandhi Medical College and Research Institute, Pillaiyarkuppam, Puducherry, India, Phone: +91 9833298973, e-mail: urvins93@gmail.com

How to cite this article: Shah U, Kumar S, Aroul TT, Smile R. Review of Treatment Modalities in Hemorrhoidal Disease. Ann SBV 2023;12(2):49–54.

Source of support: Nil

Conflict of interest: None

Received on: 05 June 2023; Accepted on: 09 December 2023; Published on: 02 February 2024

ABSTRACT

Introduction: Hemorrhoid disease is one of the most common diseases of the anal region and constitutes majority of colorectal investigations. Symptoms related to hemorrhoids include bleeding during or after defecation, pain or discomfort, and perianal itch or irritation.

Methodology: We have included various studies that evaluate the effectiveness of lifestyle modification, conservative pharmacological treatments, non-surgical procedures, and surgical procedure in the management of hemorrhoids from PubMed, Cochrane Library, and Google Scholar. We have included articles published from 1990 to 2020.

Conclusion: First-degree hemorrhoids can be managed with conservative and medical treatments. Second-degree and relatively small third-degree hemorrhoids can be treated with nonoperative modalities. Surgery is generally reserved for the minority of patients who have large third-degree or fourth-degree hemorrhoids, acutely incarcerated and thrombosed hemorrhoids, hemorrhoids with an extensive and symptomatic external component, or patients who have undergone less aggressive therapy with poor results.

Keywords: Hemorrhoids, Piles, Sclerotherapy.

INTRODUCTION

Hemorrhoid disease is one of the most common disease of the anal region and constitutes majority of colorectal investigations.1 Its incidence are often seen at any age and in both genders equally.1 It is estimated that 50–85% of individuals round the world had hemorrhoids.1 Hemorrhoids, generally have the peak prevalence at the age of 45–65 years and affects both the genders.2

Hemorrhoid disease has a high impact on quality of life and can be managed with a multitude of surgical and nonsurgical treatment.3 Symptoms include bleeding during or after defecation, pain, discomfort, mass descending per anal, and perianal itching.4 Based on the degree of prolapse, Goligher has graded the hemorrhoids for the accurate treatment as – first-degree hemorrhoids are only visible vessels, second-degree hemorrhoids that prolapse with defecation and restore instantly, third-degree hemorrhoids prolapse but require manual replacement and fourth-degree hemorrhoids prolapse out of the anal canal (Fig. 1).

Fig. 1: Anatomy of anal canal

Low grades hemorrhoids are usually treated with a conservative approach using methods such as lifestyle modification, fiber supplement, suppository delivered anti-inflammatory drugs and administration of venotonic drugs. Higher grades of hemorrhoids are treated with non-operative approaches like sclerotherapy, rubber band ligation, laser therapy, and surgical approaches like hemorrhoidectomy and stapled hemorrhoidopexy.5 Surgical approach is indicated when non-surgical approaches have failed or complications have occurred.6,7 Surgical modalities are associated with postoperative complications like postoperative pain and urinary retention. Hence in the modern era, there has been a paradigm shift from surgical to non-surgical techniques for the treatment of hemorrhoidal disease. This analysis focuses on the outcomes of the various modalities on the grades of hemorrhoids.

METHODOLOGY

We have included different examinations that assess the viability of way of life alteration, moderate pharmacological medicines, non-surgeries, and surgery in the administration of hemorrhoids. Moderate modalities will incorporate dietary and way of life adjustments, sitz shower, fiber supplements, venotonic medications, and purgative use. Non-surgeries incorporate elastic band ligation, sclerotherapy, infrared coagulation, bipolar diathermy, and ruler dilatation. Careful strategies incorporate traditional excisional hemorrhoidectomy (Milligan Morgan’s method, Stapled hemorrhoidopexy, Trans-butt-centric hemorrhoidal dearterialization).

EPIDEMIOLOGY

It is undeniably challenging to figure out the specific predominance of hemorrhoids as parcel of individuals do not reveal this condition until they are exceptionally suggestive and many misconstrue hemorrhoidal illness for some other lower gastrointestinal pathology.8,9 It is assessed that roughly half of the total populace experience the ill effects of this sickness once in their life time.5

PATHOPHYSIOLOGY OF HEMORRHOIDS

The pathophysiology of interior hemorrhoids is exceptionally intricate and indistinct. The four famous speculations with respect to pathophysiology of hemorrhoids are—first and foremost the sliding system of butt-centric pads, second the disintegration of the connective tissue of the pad, third the decrease of venous return from sinusoids to the unrivaled hemorrhoidal vein and center hemorrhoidal vein during poo and fourth, the stagnation of blood inside the widened plexus.10

Expanded intra-stomach pressure and the missing valves in rectal veins prompts decline in venous waste of sinusoids during poo in this way bringing about unusual dilatation of the arteriolar-venular anastomoses of the inward hemorrhoidal plexus.11 Erect position, pregnancy, corpulence, ascites, stressing during crap, exhausting lifting and weighty activity may all cause an ascent in intra-stomach pressure.3

The sitting position (Western latrines) while pooping forestalls the fixing of the anorectal point, yet the point is fixed in crude crouching position (Indian latrine). In the previous it prompts more prominent exertion and expanded intra-abdominal strain to conquer this general point by the plunging stool.12

Blockage prompts expansion in intra-abdominal pressure and straightforwardly diminishes venous return from hemorrhoidal plexus. Solid intra-butt-centric tension is expected to conquer the strain made by hard stools on the butt-centric pads. Drawn-out crap endeavors in the obstructed patient might prompt rehashed and incapable clearing, which diminishes the venous return from the hemorrhoids even more13 (Fig. 2).

Fig. 2: Grading of hemorrhoids

Butt-centric submucosal muscle interfaces butt-centric pads to the inward sphincter. Park’s tendon interfaces butt-centric pads to conjoined longitudinal muscle. The interior sphincter and butt-centric pads move in inverse headings (the previous descends, the last option unwinds) and the two pieces of Treitz’s muscle are lengthened and extended during crap. These rehashed patterns of lengthening and shortening of Treitz’s muscle following nonstop stressed poos bring about its unwinding which prompts its breaking down. Debilitating of Treitz muscle filaments happens because of pelvic floor issues and with expanding age. This prompts industriousness of the prolapsed butt-centric pads outside the rear-end after poop. In the underlying phases of hemorrhoidal illness (first and second degree), butt-centric pads are maneuvered once more into the rear-end with next to no work from the patient. In cutting edge grades, there is debilitating of conjoined longitudinal muscle with disappointment of unconstrained decrease into the butt-centric channel driving for manual decrease (third degree) or unchangeable (fourth degree).10

Chronic diarrhea leads to increase in the stretching of anal tissue and exerts pressure on the draining venous system of sinusoids. Thus, diarrhea is currently believed to have greater risk factor for hemorrhoids when compared with constipation.14

Hemorrhoids occur due to the congestion of sinusoids. This is primarily due to increased abdominal pressure and decreased venous return during defecation.10 The arterial hyperperfusion of sinusoids causes impaired arteriolar sphincteric mechanism and the decreased vascular tone thus leading to the congestion of sinusoids.15,16 The relaxed and hypertrophied connective tissue loses its capacity to support the vascular network in the long-term leading to passive congestion of sinusoids. This along with increased internal anal sphincter activity impedes venous return and worsens the congestion.17

Increased congestion, enlargement, and engorgement of anal cushions lead to formation of hemorrhoids. As they lose their muscular and fibrous fixation, they prolapse through the anal canal. The sliding down process of anal cushions is the most crucial pathophysiologic feature of the disease.10 The mucosa of the prolapsing nodule is rectal and mucus-producing. This becomes inflamed and the mucosa of the prolapsing nodule produces more mucus.18 This leads to perineal irritation, itching, and soiling. These prolapsed nodules in the narrow anal canal are gradually strangulated and incarcerated.19 This leads to painful hemorrhoids.

Bleeding is the commonest symptom of internal hemorrhoids.9 In the majority of cases, bleeding is painless with an exception of thrombosed hemorrhoids because of the absence of pain fibers above the dentate line.3 Hemorrhage is due to congestion of the sinusoids, transferred backwards to the presinusoidal arterioles. The bright red bleeding from hemorrhoids is arterial in origin.18 This dilated arterioles located in the lamina propria have very high chances to be inflamed, injured, and eroded during defecation by hard or diarrheal stool. Oozing is the commonest type of bleeding. Erosion of small arterioles leads to spurting of the bright red blood causing “blood in pan” appearance.18

TREATMENT

The management approach of hemorrhoids should be mainly focused on symptomatic resolution along with minimal morbidity or complications.

CONSERVATIVE THERAPY

Dietary and lifestyle modifications are the first-line recommendations made to patients with hemorrhoids. These include increasing dietary fiber, avoidance of straining or minimizing the time on the toilet during defecation, and doing sitz baths. Studies have proved that the use of dietary fiber in the medical treatment of symptomatic hemorrhoid disease as well as high fiber diet may decrease the likelihood of recurrence.17,18,20,21 One twofold visually impaired fake treatment controlled preliminary showed that the utilization of psyllium decreased hemorrhoidal draining and difficult defecation,22 yet other investigation of fiber has shown less noteworthy or unimportant results.23 On the grounds that loose bowels fuels hemorrhoidal side effects, controlling it with fiber, antimotility specialists, and explicit treatment of any fundamental reason will probably be of advantage.

NON-SURGICAL TECHNIQUES

Elastic band ligation-elastic band ligation causes tight encompassing causing ischemia of excess mucosa, connective tissue, and veins in the hemorrhoidal complex. The banding should be over the dentate line. Interior hemorrhoid ligation can be performed on OPD premise with one of a few financially accessible instruments, including gadgets that utilization pull to bring the repetitive tissue into the utensil to put forth the method a one-individual attempt. Endoscopic variceal ligators are compelling for hemorrhoid ligation.

It is an extremely compelling treatment for most of hemorrhoid patients, with momentary achievement paces of up to almost 100% and long-haul achievement paces of up to 80%. The detailed chance of entanglement is 1–3% of patients which incorporates post banding agony, dying, and vasovagal symptoms.18,24

Sclerotherapy includes the infusion of sclerosants into the submucosal space at the foundation of hemorrhoids. This leads to delicate tissue response followed by fibrosis of the tissue alongside apoplexy of the elaborate vessels and a refixation of the prolapsing mucosa to the hidden rectal solid tissue. Khoury et al. showed that 89.9% of patients with grades I and II hemorrhoids were side-effect free after sclerotherapy.25 Approximately, 3% polidocanol is viewed as a sclerosing specialist with sedative properties, all around endured, with low necrotic potential and an extremely encouraging specialist for the treatment of grade I hemorrhoidal sickness. Froth sclerotherapy with 3% Polidocanol prompts more noteworthy adequacy making expanded sclerosing activity due expansion in the space of contact with vascular endothelium.26 Ambrose et al. reasoned that patients treated by photocoagulation required rehashed treatment contrasted and just a single after infusion sclerotherapy.27

Tomiki et al. concluded that the therapeutic effects of Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy were similar to those of surgery and has shown promising results in treating internal hemorrhoids without resection. Therefore, endoscopic ALTA has the potential to become a minimally invasive and useful approach for ALTA sclerotherapy.28

M Takano, J Iwadare H Ohba showed that sclerosant treatment with OC-108 was viable for prolapse in patients with third- and fourth-degree inside hemorrhoids to a comparable degree as medical procedure. The OC-108 treatment was less intrusive and will be a valuable option for the treatment of hemorrhoids.29 They closed hemorrhoidectomy for hemorrhoids, needs hospitalization, being joined by torment. Sclerotherapy could be performed on short-term premise with next to no serious aggravation or complication.29

Rathore reasoned that infusion sclerotherapy utilizing polidocanol evokes great outcomes with less inconveniences and minimal expense. The outcomes showed that this strategy is compelling in second degree hemorrhoids as that of an exhaustive round of questioning hemorrhoids.2

Philip Coleridge Smith reasoned that froth sclerotherapy is definitely more successful than fluid sclerotherapy in treating varicose vein. Froth sclerotherapy is a protected and successful technique for treating varicose veins and 3% polidocanol froth is not any more viable than 1% polidocanol foam.30

Ronconi et al. displayed in 83% of the cases hemorrhoids vanished as soon as after the primary meeting. The examination of a legitimacy score concerning dying, torment level and feeling of distress detailed by patients showed a genuinely huge contrast (p < 0.0015) among when technique. They reasoned that hemorrhoidal endosclerosis with froth is by all accounts a viable and safe technique to fix hemorrhoidal pathologies and appears to offer great outcomes in the short-center term with OK outcomes as far as understanding solace and generally cost to society.31

Fernandes and Fonseca presumed that polidocanol froth treatment of indicative hemorrhoid infections is exceptionally protected. It needn’t bother with any exceptional inside arrangement, sedation, or agony control, and it very well may be performed on a short-term premise. Polidocanol froth ought to be utilized as first-line treatment of most hemorrhoid patient, including those under anticoagulation and hostile to platelet therapy.30

Moser et al. showed that in the froth bunch fundamentally more patients (88%) were dealt with effectively after one sclerotherapy meeting contrasted with the fluid gathering (69%). Results were preferable in the froth bunch over in the fluid gathering (almost 100 vs 84%). Additionally, in the froth bunch, essentially less treatment meetings were required, and the aggregate sum of infused polidocanol was decreased. They presumed that in the treatment of 1st grade hemorrhoidal sickness, 3% polidocanol froth is more successful and similarly safe contrasted with fluid polidocanol and froth sclerotherapy is a new, imaginative, powerful, and safe non-careful therapy choice for hemorrhoidal disease.32

Infrared coagulation-infrared energy by means of a tungsten-incandescent light is given to the hemorrhoidal tissue via a polymer tip. This method has shown achievement paces of 67–96% for grade I and II out of two randomized controlled trials.9

Bipolar Diathermy, Direct Current Electrotherapy, and Warmer Test Coagulation

These methods are utilized in treating grades I, II, and III. The radiator test and bipolar diathermy gadgets produce heat which influences coagulation of the treated tissue, prompting a fibrotic response at the site of therapy with obsession of the treated tissue. Bigger hemorrhoids might require various sittings. Bipolar burning has achievement paces of 88–100% in randomized preliminaries yet the confusion rate is somewhat high.3335

Ruler’s Dilatation

This is a methodology of the past and is not any more done as a result of drawn-out recuperation and inconveniences. Rear-end was extended physically to diminish sphincteric pressure. There are different examinations which showed high post-employable incontinence and thus this technique was abandoned.3738

Every technique for nonoperative treatment portrayed has its defenders. Randomized controlled preliminaries have contrasted every strategy and at least one of the others, yet no single review has analyzed each of the five (sclerotherapy, elastic band ligation, bipolar diathermy, direct-current electrotherapy, and infrared photocoagulation). A meta-examination by Johanson and Rimm inspected five preliminaries including 862 patients with first- or second-degree hemorrhoids who went through infrared photocoagulation, sclerotherapy, or elastic band ligation. Elastic band ligation was more compelling than sclerotherapy, and patients treated with elastic band ligation required fewer extra medicines than those treated with sclerotherapy or infrared photocoagulation.39

SURGICAL TECHNIQUES

Traditional Excisional Hemorrhoidectomy (Milligan Morgan’s Method)

This method is profoundly viable and have low repeat rates yet has critical torment and a delayed recuperation period.40

Stapled Hemorrhoidopexy

A roundabout stapling gadget is utilized to separate, resect, and fix the mucosa and submucosa. This makes an interference of blood vessel inflow the hemorrhoids which staples the beforehand prolapsing mucosa to the fundamental rectal wall. Benefits of the methodology incorporate less postoperative agony and handicap than customary hemorrhoidectomy; however, it brings about confusions like anovaginal fistula, fistula in ano, drain, sepsis, and perforation.24

Trans-butt-centric Hemorrhoidal Dearterialization

In this method, the distal rectal blood vessel branches are recognized utilizing Doppler and ligated. This diminishes the blood vessel stream to the hemorrhoidal pads alongside post-provocative mucosal obsession.41

This prompted progression of non-careful therapies in the new years like elastic band ligation (RBL), sclerotherapy, infrared coagulation, cryosurgery, bipolar diathermy, and laser coagulation.42 It has been accounted for that grade I and II hemorrhoids answer moderate administration, with clean dietary measures and clinical treatment, yet now and again side effects endure and painless careful medicines are required. A high level of grade III hemorrhoids answer non-careful methods, with just the most serious instances of grade III hemorrhoids and grade IV requires careful treatment.18 Nonsurgical methodologies are fruitful in 80%, the vast majority of patients with hemorrhoidal issues yet in nonresponders medical procedure can be contemplated.43

As displayed in Figure 3,21 Grade I and asymptomatic instances of grade II can be made do with moderate administration like way of life and diet changes; Suggestive grade II, bombed moderate administration of grade I and II hemorrhoids and grade III patients can be overseen by non-careful office strategies like elastic band ligation, sclerotherapy, infrared coagulation; bombed non-surgeries in grades II and III, grade IV hemorrhoids are overseen precisely by regular hemorrhoidectomy, stapled hemorrhoidopexy, and Doppler-directed hemorrhoidal corridor ligation.21

Fig. 3: Outline of management of hemorrhoids

CONCLUSION

Essential side effects of hemorrhoids incorporate dying, distension, and tingling. The executives relies upon the degree of hemorrhoidal sickness. First-degree hemorrhoids can be dealt with moderate and clinical medicines. Second-degree and generally little third-degree hemorrhoids can be treated with nonoperative modalities. Medical procedure is for the most part held for the minority of patients who have huge third-degree or fourth-degree hemorrhoids, intensely imprisoned and thrombosed hemorrhoids, hemorrhoids with a broad and suggestive outside part, or patients who have gone through less forceful treatment with unfortunate outcomes.

ORCID

Urvin Shah https://orcid.org/0000-0002-3619-536X

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