Hemorrhoids: Epidemiology, Risk Factors, and Treatment Trends...pharmacyteach

Hemorrhoids: Epidemiology, Risk Factors, and Treatment Trends

 Background

Hemorrhoids are a common anorectal disorder that affects millions of people, particularly those between the ages of 45 and 65[1].The distal prolapse of the muscle fibers, surrounding connective tissue, and arteriovenous bundle as an envelope below are known as hemorrhoids. The anal canal's dentate line. Usually, they exhibit painless rectal bleeding at first.[2]

Rather than depending on imaging investigations or laboratory testing, the diagnosis of hemorrhoids is made based on the patient's history and physical examination.[1] Usually, bright red blood on the toilet paper or coating the stool indicates painless rectal bleeding related to bowel movements as the initial presenting symptom. Anal discomfort and severe itching are also frequent, particularly in those with persistent hemorrhoids. [2], [3]

Epidemiology of Hemorrhoids 

The prevalence of symptomatic hemorrhoids worldwide is estimated to be 4.4% within the general population. Within the United States, medical treatment is sought by up to one third of the 10 million individuals with hemorrhoids, resulting in 1.5 million related prescriptions annually.[4]

There has been a decline in the number of hemorrhoidectomies performed in hospitals across the United States. A peak of 117 hemorrhoidectomies per 100,000 individuals was observed in 1974, with this rate decreasing to 37 hemorrhoidectomies per 100,000 people by 1987. Some of this reduction can be attributed to outpatient and office-based treatment of hemorrhoids.[5]

Patients who present with hemorrhoidal disease tend to be predominantly white, from higher socioeconomic backgrounds, and residing in rural regions. While there is no known sex bias, men are more inclined to seek treatment. However, physiological changes during pregnancy make women more susceptible to developing symptomatic hemorrhoids. The expansion of the gravid uterus exerts pressure on the inferior vena cava, leading to reduced venous return and distal congestion.

External hemorrhoids are more prevalent among young and middle-aged adults compared to older individuals. The incidence of hemorrhoids rises with age, peaking in individuals aged 45-65 years.[4], [5]

Types of hemorrhoids

There are two categories of hemorrhoids: internal hemorrhoids, which manifest in the lower rectum, and external hemorrhoids, which emerge beneath the skin surrounding the anus. [6]

External hemorrhoids are deemed the most distressing due to the irritation and erosion of the overlying skin. The occurrence of a blood clot within external hemorrhoid can result in abrupt and intense pain, often accompanied by the sensation or observation of a lump near the anus. Typically, the clot dissolves eventually, leading to the presence of excess skin known as a skin tag, which might induce itching or irritation.

Internal hemorrhoids, in contrast, are generally painless even in instances where they induce bleeding. Observable manifestations may include the sight of bright red blood on toilet paper or trickling into the toilet bowl. Moreover, internal hemorrhoids have the potential to prolapse, extending beyond the anus and giving rise to various complications. Protrusion of a hemorrhoid can lead to the accumulation of minute amounts of mucus and fecal matter, triggering an irritation termed pruritus ani. Excessive wiping as a means to alleviate itching can exacerbate the issue.

Diagnosing Methods of hemorrhoids

Certainly! The diagnosis of hemorrhoids commonly entails a blend of medical history scrutiny, physical evaluation, and sometimes, additional diagnostic measures. Presented here are the diagnostic techniques frequently employed in the assessment of hemorrhoids:[7]

 

1. *Medical History*: - 

A thorough patient medical history is crucial. It should cover daily food patterns, frequency of bowel movements, associated symptoms (such as constipation or fecal incontinence), duration, severity, and extent of symptoms; data about the bowel movements (such as time spent during each bowel movement and concurrent cell phone use). Initial inquiries made by the healthcare provider typically revolve around the patient's symptoms, encompassing rectal bleeding, pain, itching, or protrusion of tissue from the anus. - Questioning may extend to the frequency and duration of symptoms, potential triggers (such as straining during defecation), and relevant medical background (including past occurrences of hemorrhoids or other gastrointestinal disorders).

 

2. *Physical Examination*: - 

Visual Observation: The healthcare provider conducts a visual assessment of the anal region to detect indications of external hemorrhoids (dilated veins around the anus) or internal hemorrhoids (potentially not visible internally). - Digital Rectal Examination (DRE): This procedure involves the insertion of a lubricated, gloved finger into the rectum to palpate internal hemorrhoids or any other abnormalities, facilitating the evaluation of the size, location, and sensitivity of internal hemorrhoids.

 

3. *Proctoscopy or Anoscopy*: - 

Proctoscopy and anoscope are techniques enabling direct visualization of the rectum and anal canal using specialized instruments like a Proctoscopy or anoscope. - Proctoscopy targets the lower rectum, whereas Anoscopy focuses on the anal canal. - These procedures aid in the identification of internal hemorrhoids, assessment of their severity, and exclusion of other conditions like rectal polyps or tumors.

 

4. *Colonoscopy or Sigmoidoscopy*:-

(if applicable): - In specific instances, a colonoscopy or sigmoidoscopy may be recommended, especially if there are concerns regarding additional gastrointestinal conditions or if the patient presents risk factors for colorectal malignancies. - These procedures involve the introduction of a flexible, illuminated tube with a camera (colonoscope or sigmoidoscope) into the rectum and colon for a comprehensive examination of the colon's entire length. - While not typically employed exclusively for hemorrhoid diagnosis, colonoscopy or sigmoidoscopy can aid in ruling out alternative causes of rectal bleeding or discomfort.

 

5. *Imaging Studies*(rarely utilized for hemorrhoid diagnosis): - 

Imaging modalities like MRI (Magnetic Resonance Imaging) or CT (Computed Tomography) scans are infrequently employed for diagnosing hemorrhoids, but may be warranted if complications or underlying conditions are suspected.

 

In overall, the diagnosis of hemorrhoids heavily relies on medical history and physical examination outcomes, complemented by procedures like proctoscopy or anoscopy for a detailed evaluation of internal hemorrhoids. Should concerns arise regarding complications or other gastrointestinal issues, further investigations such as colonoscopy or imaging studies might be advised.

Grading of Hemorrhoidal disease

Grade 1 Hemorrhoid – protrudes into the anal canal but does not prolapse outside the anus.[8]

Grade 1 hemorrhoids are categorized as internal hemorrhoids that do not prolapse or extend beyond the anus. Physicians typically recommend a treatment plan for Grade 1 hemorrhoids that involves incorporating fiber into the diet and considering various over-the-counter options for hemorrhoid management. Within the United States, Preparation H stands out as a widely used over-the-counter treatment for hemorrhoids. Other products like Proctofoam, Tucks hydrocortisone ointment, and Analpram are also available as over-the-counter hydrocortisone creams for addressing hemorrhoids. These specific creams for hemorrhoid treatment are designed to alleviate inflammation, reduce swelling, and relieve itching associated with hemorrhoidal irritation.

Grade 2 hemorrhoids – are internal hemorrhoids that protrude through the anus during straining or evacuation but return spontaneously. [8]

For Grade 2 hemorrhoids, medical professionals typically opt for conservative treatment approaches, initially addressing them similarly to Grade 1 hemorrhoids and progressing to painless in-office procedures if necessary. These painless treatment methods may involve rubber band ligation, injection sclerotherapy, or infrared coagulation. It is crucial to emphasize that these interventions are exclusively intended for internal prolapsed hemorrhoids, not external ones.

 

Grade 3 hemorrhoids – are internal hemorrhoids that protrude through the anus during straining or evacuation but require manual repositioning.[8]

Grade 4 hemorrhoids – are internal hemorrhoids that remain prolapsed outside of the anus.[8]

 Management of Grade 3 and Grade 4 hemorrhoids often involves referrals to surgeons for more advanced treatment modalities. Among the most common surgical interventions for hemorrhoids are surgical excision and hemorrhoid stapling procedures.

 

Grading system of hemorrhoids 

 

Treatment options for Hemorrhoids 

When selecting the treatment for hemorrhoids, it is essential to consider the grade and severity of the disease, its impact on the individual's quality of life, the level of pain experienced, the likelihood of the patient complying with the treatment, and the personal preference of the patient. Irrespective of the severity, the initial step in treatment typically involves adopting a high-fiber diet and making lifestyle adjustments, including changes in bowel movement patterns. This necessitates healthcare providers to dedicate significant time to educate patients, regardless of the nature or severity of the condition.[1]

 Treatment options can be categorized into three groups: conservative, office-based, and surgical. Healthcare providers should engage in detailed discussions with the patient regarding these options, highlighting the advantages and disadvantages of each.[1], [7]

1. Conservative treatments for hemorrhoids:

Therapeutic approaches for hemorrhoids encompass phlebotonics, local topical preparations, anti-infective and anti-inflammatory agents, myorelaxants, and transit regulators.

Phlebotonics, exemplified by oral diosmin and topical troxerutin, are utilized to ameliorate venous tone and mitigate inflammation. [9]

Common topical remedies, such as hydrocortisone or lidocaine-based creams or ointments, aid in easing itching and pain. [10]

Anti-infective medications, such as antibiotics, may be administered in cases where hemorrhoidal infections are present.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in reducing inflammation and alleviating pain. [7]

Muscle relaxants, such as calcium channel blockers, are employed to ease the contractility of the anal sphincter's smooth muscles and alleviate pressure on the hemorrhoids.

Transit regulators, like fiber supplements or laxatives, play a role in softening stool consistency and preventing constipation, a factor that can exacerbate hemorrhoidal conditions.[1]

 

2. Instrumental/office -based treatments for hemorrhoids:

Sclerosing injections entail the introduction of a chemical solution into the hemorrhoid, inducing reduction and eventual disappearance.

 Infra-red photocoagulation employs a specialized device to administer heat to the hemorrhoid, leading to coagulation and reduction in size.

Cryotherapy encompasses the freezing of the hemorrhoid, prompting shrinkage and subsequent detachment.

Elastic rubber band ligation represents a prevalent non-operative intervention in which a small rubber band is positioned at the hemorrhoid's base to obstruct blood supply, leading to necrosis and detachment of the hemorrhoid.[11]

3. SURGERY based treatment for hemorrhoid

The most popular surgical options are open or closed hemorrhoidectomy, stapled hemorrhoidopexy, and Doppler-guided hemorrhoidal artery ligation. Each method has different success rates and different complication profiles, which need to be discussed with the patient. Overall, surgery is associated with more adverse effects than office-based treatments or medical management.[1], [12]

 

 

References

[1]      V. Devi et al., “Hemorrhoid Disease: A Review on Treatment, Clinical Research and Patent Data,” Infect. Disord. - Drug Targets, vol. 23, no. 6, pp. 15–35, 2023, doi: 10.2174/1871526523666230427115436.

[2]      R. L. Pullen, “Hemorrhoidal disease: What nurses need to know,” Nursing (Lond)., vol. 52, no. 5, pp. 19–24, May 2022, doi: 10.1097/01.NURSE.0000827128.26047.32.

[3]      G. G. Ravindranath and B. G. Rahul, “Prevalence and risk factors of hemorrhoids: a study in a semi-urban centre,” Int. Surg. J., vol. 5, no. 2, p. 496, Jan. 2018, doi: 10.18203/2349-2902.ISJ20180339.

[4]      G. Gallo, R. Sacco, and G. Sammarco, “Epidemiology of Hemorrhoidal Disease,” pp. 1–5, 2018, doi: 10.1007/978-3-319-51989-0_1-1.

[5]      Y. S. Hong et al., “Risk factors for hemorrhoidal disease among healthy young and middle-aged Korean adults,” Sci. Rep., vol. 12, no. 1, Dec. 2022, doi: 10.1038/S41598-021-03838-Z.

[6]      M. A. Khan et al., “‘PNR-Bleed’ classification and Hemorrhoid Severity Score—a novel attempt at classifying the hemorrhoids,” J. Coloproctology, vol. 40, no. 4, pp. 398–403, Oct. 2020, doi: 10.1016/j.jcol.2020.05.012.

[7]      Baiq Wanda Annisa, “Diagnosis and Management of Hemorrhoids,” Unram Med. J., vol. 11, no. 3, pp. 1085–1093, Nov. 2022, doi: 10.29303/JKU.V11I3.765.

[8]      “The Hemorrhoid Grading System - Google Search.” https://www.google.com/search?q=The+Hemorrhoid+Grading+System&oq=The+Hemorrhoid+Grading+System&aqs=chrome..69i57j33i160.860j0j15&sourceid=chrome&ie=UTF-8 (accessed Mar. 23, 2024).

[9]      D. D. Shlyk, I. A. Tulina, and P. V. Tsarkov, “Phlebotonics for conservative treatment of haemorrhoids: when, to whom, how?,” Ambulatornaya Khirurgiya, vol. 20, no. 1, pp. 148–155, 2023, doi: 10.21518/AKH2023-011.

[10]    R. Mathew, L. Chen, and M. Wong, “Literature Data on the Hemorrhoidal Disease Management,” pp. 1–13, 2018, doi: 10.1007/978-3-319-51989-0_45-1.

[11]    S. N. Gole, N. Toppo, and M. Poptani, “Study of efficacy of band ligation and suture ligation in the treatment of second degree hemorrhoids,” Int. Surg. J., vol. 8, no. 7, p. 2000, Jun. 2021, doi: 10.18203/2349-2902.ISJ20212320.

[12]    V. Lohsiriwat et al., “Recurrence Rates and Pharmacological Treatment for Hemorrhoidal Disease: A Systematic Review,” Adv. Ther., vol. 40, no. 1, pp. 117–132, Jan. 2023, doi: 10.1007/S12325-022-02351-7.