Diagnosis and Management of Internal Hemorrhoids: A Brief Review

Hemorrhoidal disease is a pathological condition due to the abnormal engorgement of the arteriovenous plexus beneath the anal mucosa. Anatomically, it can be located under the skin on the outer part of the dentate line, known as external hemorrhoid; or inside the anus on the proximal part of the dentate line, called internal hemorrhoid. Internal hemorrhoid may further develop from a painless anal mass into protruded and painful mass throughout the anal canal, often accompanied by inflammation and more severe symptoms. Various management strategies need to be considered carefully to ensure the success of therapy and improve the quality of life of patients with internal hemorrhoids. Conservative management is the initial stage that can be performed, including the provision of high-fiber nutrition, education related to bathroom habits, and the use of flavonoid regimens. Surgical therapy can be divided into outpatient intervention and conventional surgeries. This review will encompass the comprehensive diagnostic approach and management of internal hemorrhoids to help clinicians understand the appropriate management and provide better clinical benefits for the patients.

Doppler-guided hemorrhoidal dearterialization. Technical evolution and results of treatment (review)

Hemorrhoidectomy is considered as the “gold standard” for hemorrhoidal disease, but is associated with a long rehabilitation period. For this reason, 20 years ago, an innovative method for hemorrhoids was developed – Doppler-guided hemorrhoidal dearterialization. The aim of the work is to analyze the literary data of the use of Doppler-guided dearterialization for hemorrhoidal disease, the technical evolution of the method and the analysis of the results. An analysis of the literature shows that Dopplerguided dearterialization is a safe and effective method for hemorrhoidal disease. The combination of dearterialization with transanal mucopexy improves outcomes in patients with hemorrhoids III and IV stages. However, good results can be obtained not in all forms of hemorrhoidal disease. The efficacy depends on the peculiar features of the anorectal zone vascularization, the degree of destruction of the suspensory ligaments of the internal hemorrhoidal plexus and the degree of enlargement of the external hemorrhoid plexus. The adequacy of the dearterialization and mucopexy requires an objective control for assessment of the procedure.

CLINICAL-MORPHOLOGICAL CLASSIFICATION OF ACUTE THROMBOSIS OF THE EXTERNAL HEMORRHOID NODE IN RELATION TO A DIFFERENTIATED APPROACH IN ITS TREATMENT

Acute thrombosis of the external hemorrhoid node is one of the common manifestations of hemorrhoids and a frequent reason for seeking specialized medical care. Despite existing prospective studies proving the effectiveness of operative treatment, there is no clear position in determining the indications, timing and methods of surgery, nor the combination of the latter with conservative therapy.The article formulated and described the original clinical-morphological classification of acute thrombosis of the external hemorrhoid node based on the data of its ultrasound examination (ultrasound). Effectiveness of various methods of treating acute thrombobosis of external hemorrhoid node, carried out on the basis of proposed classification, is evaluated.Purpose of the study. Improving treatment outcomes for patients with acute thrombosis of the external hemorrhoid node.Results. Ultrasound types of thrombosis of external hemorrhoidal node are revealed:– mononuclear (in ultrasound, it is a single thrombus or a dense, intimately soldered group of thrombotic masses of an an- or isoechogenic structure with untested swelling of the skin and subcutaneous fat (PWD), from 10 mm or more in size);– polynuclear (clusters of thrombotic masses of an- or isoechogenic structure up to 10 mm in size, located at a short distance from each other, with moderate swelling of the skin and subcutaneous fat);– edema (during sonography, multiple small, up to 2–3 mm, anechogenic thrombotic masses are visualized against the background of pronounced edema of subcutaneous fat fiber and skin).Effectiveness of various methods of treating patients with acute thrombosis of external hemorrhoid node in groups formed on the basis of proposed classification is evaluated. It has been found that in patients with edematous sonographic type of thrombosis, it is more advisable to apply only conservative therapy or carry out surgical treatment after completion of taking diosmin-containing preparations. Such tactics reduced the duration of treatment and reduced pain syndrome. In patients with a mononuclear type of thrombosis of the external hemorrhoidal node, a similar result was noted during surgery and the beginning of conservative therapy on the day of circulation.Conclusion. Application of ultrasound diagnostics allows establishing the type of hemorrhoid node thrombosis and using the obtained data when choosing treatment tactics. A differentiated approach to treating this category of patients, based on the proposed classification, allows improving the treatment results of patients with acute thrombosis of the external hemorrhoid node.

Clinical current features and treatment tactics of acute external hemorrhoids in outpatient and polyclinic conditions

Purpose of the study. The study of the current problems for acute external hemorrhoids (AEH) diagnosis and treatment from the point of view of a practicing ambulatory coloproctologist in the Tver region (based on an analysis of the clinical features of the disease, its course and the applied tactics of the coloproctologist) was made.Patients and methods. A retrospective study with continuous series of 124 patients (2016–2017), using clinical and statistical research methods.Results. Acute external hemorrhoids (AEH) is a painful formation that suddenly arises due to acute thrombosis of the external hemorrhoid plexus, located near the anus, mainly at 3, 5, 7 hours on the proctological dial, with a free space between the hemorrhoid and the mucous membrane of the anal canal. Patients with AEH turned to the ambulatory coloproctologist at a later date (on average 11.7 days after the onset of the disease), most often without pain or with slight pain in the anus, with mild and moderate severity of the disease. The main complications of AEH were necrosis and hemorrhoidal wall rupture with bleeding from it. Conservative treatment of patients with AEH was due to clinical guidelines of the Russian Coloproctologists Association (RCA); it was ineffective in 11.3% of patients, who underwent outpatient surgery. All patients with severe pain, high grades of AEH, were offered for hospitalization to the surgical department (including coloproctologcal), but they refused. Low operative activity and late surgery in patients with AEH, who applied to the polyclinic, were due to the fact that only 12 (9.7%) patients sought help within the first 72 hours of the onset of the disease, low severity of pain, as well as the patients refused the proposed operations.Conclusions. The studied features of the outpatient coloproctologic service in AEH reveal the inadequate availability of system resources for patients, inappropriate informing the population with «mass-media» technologies; it makes difficulties to implement the recommendations of the RCA.

Anorectal Disorders

Anorectal disorders can generate considerable patient discomfort and disability. Although mortality due to such complaints is very low, it is important for the clinician to maintain a high index of suspicion for systemic illness caused by an anorectal source. A detailed history and physical examination should be performed, and the need for imaging or procedures should be assessed. This review examines the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with anorectal disorders. Figures show the important structures of the anal canal; differences in the anatomy of the origin of internal and external hemorrhoid venous supplies; depictions of a typical anodermal linear tear; Foley catheter–assisted rectal foreign body removal technique; and pertinent anatomy related to a prolapsed rectum through the anus; and types and locations of anorectal abscesses and fistulas. Tables list common painful and painless anorectal disorders; key differences in anal canal structures above and below the pectinate line; anal symptoms mistakenly attributed to hemorrhoids; internal hemorrhoidal grading, description, and recommended treatment; Rome III criteria for the diagnosis of constipation; and a summary of anorectal conditions. This review contains 6 highly rendered figures, 6 tables, and 80 references. Keywords: functional constipation; PEG; abdominal radiographs; pediatric constipation

Anorectal Disorders

Anorectal disorders can generate considerable patient discomfort and disability. Although mortality due to such complaints is very low, it is important for the clinician to maintain a high index of suspicion for systemic illness caused by an anorectal source. A detailed history and physical examination should be performed, and the need for imaging or procedures should be assessed. This review examines the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes for patients with anorectal disorders. Figures show the important structures of the anal canal; differences in the anatomy of the origin of internal and external hemorrhoid venous supplies; depictions of a typical anodermal linear tear; Foley catheter–assisted rectal foreign body removal technique; and pertinent anatomy related to a prolapsed rectum through the anus; and types and locations of anorectal abscesses and fistulas. Tables list common painful and painless anorectal disorders; key differences in anal canal structures above and below the pectinate line; anal symptoms mistakenly attributed to hemorrhoids; internal hemorrhoidal grading, description, and recommended treatment; Rome III criteria for the diagnosis of constipation; and a summary of anorectal conditions. This review contains 6 highly rendered figures, 6 tables, and 80 references. Keywords: functional constipation; PEG; abdominal radiographs; pediatric constipation

LONG TERM RESULTS AFTER STAPLED HEMORRHOIDOPEXY ALONE AND COMPLEMENTED BY EXCISIONAL HEMORRHOIDECTOMY: A RETROSPECTIVE COHORT STUDY

ABSTRACT Background: Stapled hemorrhoidopexy is associated with less postoperative pain and faster recovery. However, it may be associated with a greater risk of symptomatic recurrence. We hypothesized that undertaking a limited surgical excision of hemorrhoid disease after stapling may be a valid approach for selected patients. Aim: To compare long-term results after stapled hemorrhoidopexy with and without complementation with closed excisional technique. Method: In a retrospective uni-institutional cohort study, sixty-five (29 men) patients underwent stapled hemorrhoidopexy and 21 (13 men) underwent stapled hemorrhoidopexy with excision. The same surgeons operated on all cases. Patients underwent stapled hemorrhoidectomy associated with excisional surgery if symptoms attributable to external hemorrhoid piles were observed preoperatively, or if residual prolapse or bulky external disease was observed after the firing of the stapler. A closed excisional diathermy hemorrhoidectomy without vascular ligation was utilized in all complemented cases. All clinical variables were obtained from a questionnaire evaluation obtained through e-mail, telephone interview, or office follow-up. Results: The median duration of postoperative follow-up was 48.5 (6-40) months. Patients with grades 3 and 4 hemorrhoid disease were operated on more frequently using stapled hemorrhoidopexy complemented with excisional technique (95.2% vs. 55.4%, p=0.001). Regarding respectively stapled hemorrhoidopexy and stapled hemorrhoidopexy complemented with excision, there was no difference between the techniques in relation to symptom recurrence (43% and 33%, p=0.45) and median interval between surgery and symptom recurrence (30 (8-84) and 38.8 (8-65) months, p=0.80). Eight (12.3%) patients were re-operated after stapled hemorrhoidopexy and 2 (9.6%), after hemorrhoidopexy with excision (p=0.78). Patient distribution in both groups according to the degree of postoperative satisfaction was similar (p=0.97). Conclusion: Stapled hemorrhoidopexy combined with an excisional technique was effective for more advanced hemorrhoid disease. The combination may have prevented symptomatic recurrence associated to stapled hemorrhoidopexy alone.