Hemorrhoids (Almoranas) on the Web

 

 

Incidence

Historical background

Causes and predisposing factors

Usual manifestations

Diagnostic pitfalls

Degrees of internal hemorrhoids

Earlier treatment modalities

New treatment options

·      Medical treatment

·      Surgical treatment

·      Endoscopic treatment

Which treatment option to choose?      

Sclerotherapy-- the endoscopic treatment of choice

Current experience with sclerotherapy at DLSU Medical Center

Current experience with sclerotherapy elsewhere

Some graphical illustrations

Frequently asked questions

 

 

 

 

Incidence

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.

 

 

Historical background

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.”

 

 

Causes and predisposing factors

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.

 

 

Usual manifestations

The common manifestations of hemorrhoids based on our experience are: bleeding (92%), protrusion (81%), anal pain (72%) and anal itch (23%).

 

 

Diagnostic pitfalls

“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.

 

 

Degrees of internal hemorrhoids

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).

 

 

Earlier treatment modalities

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.

 

 

New treatment options

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.

 

 

Medical treatment

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.

 

 

Surgical treatment

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.

 

 

Endoscopic treatment

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.

 

 

Which treatment option to choose? 

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.

 

      

Sclerotherapy-- the endoscopic treatment of choice

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.

 

 

Current experience with sclerotherapy at DLSU Medical Center

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.

 

 

Current experience with sclerotherapy elsewhere

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.

 

 

Some graphical illustrations

 

 

Frequently asked questions

 

 

 

Last updated on: 19 December 2004

 

 

 

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