Hemorrhoids are frequently encountered in daily practice as approximately 25 to 40% of the general population is affected by the disease. In the US alone, 10 million patients complained of symptoms attributable to hemorrhoids in 1990. There is some shame and fear surrounding this disease essentially because of its location.
Hemorrhoids
means blood flowing (Greek: haema= blood and rhoos= flowing) and can be traced
as far back as the time of Hippocrates (460 BC). It is an ancient disease that
was carried through civilization. Hemorrhoids are called by many names. John
Ardenne in his treatise in 1370 said: “the common people call them piles, the
aristocracy call them haemorrhoids; the French call them figs, the name does
not matter, so long as you can cure them.”
The
pathophysiology of hemorrhoids also evolved through the times. Galen believed
that bleeding from hemorrhoids was a way of discharging unsound juices. Internal
hemorrhoids are currently believed to be vascular cushions present as distinct
masses at three primary sites in the anal canal. They serve to plug the anal
lumen and help maintain continence. When straining during defecation, these
vascular cushions are subjected to downward pressure. When the fibro-muscular
fibers become weakened, the hemorrhoids slide, become congested, bleed and then
prolapse in due time.
The common manifestations of hemorrhoids based on our experience are: bleeding (92%), protrusion (81%), anal pain (72%) and anal itch (23%).
“Not all that protrudes or bleeds is hemorrhoids.” Many patients are initially
misdiagnosed as having either amoebiasis
(amoebic dysentery) or hemorrhoids when in fact they have a more dreadful
condition-- colo-rectal cancer. Such that it is best to have an expert examine the
patient first and the diagnosis established before anything else. A rigid proctosigmoidoscopy or flexible sigmoidoscopy is needed in this regard.
Routine stool examinations are not helpful and even oftentimes misleading.
The
staging based on symptoms and signs is not an accurate pathological
classification and is usually helpful only in deciding treatment options.
Nevertheless, hemorrhoids are either first degree (without protrusion), second
degree (protrusion with spontaneous reduction), third degree
(protrusion but manually reducible) and fourth degree (irreducible
protrusion).
The treatment of hemorrhoids has also metamorphosed through the ages. During the early times, insertion of suppositories and application of leeches were tried. Galen in controlling the bleeding advocated wearing the “stone of India” around the neck, placing an emerald on the navel or the black leg of a toad in the armpit.
Today,
there are three general methods of treating internal hemorrhoids—medical, endoscopic and surgical. Patients
with uncomplicated hemorrhoids can have periods of remissions and exacerbations
even without definitive treatment aside from the use of symptomatic use of
ointments, laxatives and suppositories. Eventually, however, these patients
will require some form of treatment that should result in cure.
The
medical treatment is aimed at reducing downward pressure and is achieved by
taking high residue diet, bulk forming laxatives and avoiding straining and
prolonged sitting.
Surgically,
it is aimed at either reducing sphincter pressure (internal sphincterotomy) or
removal of the hemorrhoids itself (hemorrhoidectomy). Surgery would have been
the perfect remedy because the procedure is definitive, recurrence rate is low
and the redundant skin which is most annoying to some patients are also
removed. However, there are disadvantages— anesthesia and hospitalization are
required. Recovery after surgery is long, complications such as pain is common,
stenosis and incontinence are possibilities, and most of all it is expensive.
Endoscopically,
fixation of the vascular cushions to the underlying sphincter is achieved
through several modalities—cryotherapy,
electro-coagulation, photocoagulation, heater probe, rubber band ligation and
sclerotherapy. The endoscopic treatment of simple
internal hemorrhoids may prevent the onset of complications potentially needing
surgical intervention.
Considering the pain and expense of surgery, simple internal hemorrhoids must be managed in a manner that is more effective than plain medical remedy and approaches the cure rate of surgery but without its possible complications and expenses. Current evidence shows that protruding and non-protruding hemorrhoids with or without bleeding except those with irreducible prolapse (Grade IV) may be treated endoscopically.
Of
the endoscopic modalities, sclerotherapy
(Sclerosing Injection Treatment or SIT) based on our experience is the simplest, effective, safe, fast and cost effective
option not to mention its being painless.
Injection treatment of internal hemorrhoids was first advocated in the US by
Blackwood in 1866. Several sclerosing solutions were then used, such as
quinine, urea hydrochloride and phenol. The method initially gained wide
acceptance but died down rapidly due to complications mainly attributable to
the sclerosing solution used and the procedure used by charlatans and ignorant
practitioners.
Recently, enthusiasm on the use of Aethoxysclerol (Polidocanol) as the sclerosing agent in the injection treatment of internal hemorrhoids was the result of the exceptionally good experience in its use in the control of variceal and non-variceal bleeding in the upper GI tract. From 1987 to 1990, Ricardo R. Santi, M.D.*, conducted a clinical research at the De La Salle University Medical Center to evaluate the efficacy and safety of Polidocanol, 0.5% solution as the sclerosing agent in the endoscopic treatment of internal hemorrhoids. The results of which were presented in the Asia- Pacific Congress of Gastroenterology in Bangkok in 1990. Subsequently, “A cost effectiveness analysis of Injection Sclerotherapy versus hemorrhoidectomy in the management of grade III internal hemorrhoids” was conducted by Versoza and Santi. The results were presented during the Joint Annual Convention of the Philippine Society of Gastroenterology and Philippine Society of Digestive Endoscopy in 1999. Both research studies showed the safety, efficacy and cost effectiveness of sclerotherapy in the treatment of internal hemorrhoids.
A
study conducted by Wroblesky showed that sclerotherapy for Grade I, II and III
internal hemorrhoids had a success rate of 89 percent, 87.5 percent, and 85
percent, respectively and a complication rate of only 1%. Another study
conducted by Walker, et al, compared the efficacy of rubber band ligation,
infra-red photocoagulation and injection sclerotherapy. Sclerotherapy was shown
to be safe, fast and an acceptable alternative to
surgery in the treatment of internal hemorrhoids. Rubber band
ligation was associated with higher incidence of post-treatment pain while
infrared photocoagulation had a higher recurrence rate.
Dr. Santi is Life Fellow
of the Philippine Society of Gastroenterology, former Chairman, Philippine
Specialty Board of Gastroenterology and also former President, Association of
Philippine Medical Colleges (APMC) among others. Currently, he is Associate Professor and Chief, Section of
Gastroenterology at DLSU Medical Center, Dasmariñas, Cavite. Tel. Nos. (046) 416- 5722, 416- 5723, 416- 0226 (local 198) E-mail: rrsantimd@yahoo.com