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ABSTRACT
Introduction & Objectives: Hemorrhoidal disease is one of the most common conditions affecting people in developed countries. Studies evaluating the epidemiology in the USA showed that the prevalence of hemorrhoids is between 4.4% and 86%, with a peak prevalence occurring between 45 and 65 years of age. However, only few prospective randomized clinical studies have investigated medical treatments and there are substantial differences in disease management between countries. The aim of this analysis was to arrive a consensus on the value of noninvasive treatment for hemorrhoidal disease. Materials & Methods: A group of international clinical experts in proctology examined the existing clinical practice between countries and compared various national guidelines for primary care physicians on the use of topical and oral therapy in hemorrhoidal disease. Results: With a high incidence of hemorrhoids in the general population, primary care healthcare providers are more likely to encounter the disorder in everyday practice. After physical examination to confirm disease etiology, conservative treatment measures are recommended initially, avoiding a specialist referral and more invasive treatments for the patient. Also most first-line treatments have little or no evidence basis for disease management after todays requirements. Topical therapies are used for symptomatic pain relief in the early stages of hemorrhoidal disease and supportive therapy in advanced stages. Long-term prevention should be addressed with defecation regulation management and advice about diet and lifestyle changes. Surgery is only used in 10% of patients and this practice is decreasing. Various non-invasive therapies (e.g. venotonics, analgesics, astringents, antiseptics) were observed and common recommendations deflected. On this basis, a treatment algorithm for the management of hemorrhoidal disease was derived. Conclusions: Topical therapies, especially controlled therapy with combinations of topical corticosteroids and anesthetics are the cornerstone of symptomatic relief of hemorrhoidal diseases. However, further clinical studies are required to cement the empirical findings. Consensus recommendations are the first step towards improving clinical practice by providing a universal guide to clinical management of hemorrhoidal disease.
INTRODUCTION
Haemorrhoids can have a substantially negative impact on patients quality of life and social wellbeing.1 Hemorrhoidal symptoms are the most common reason for consultation in proctology. Management is essentially medical for most patients, but there are several options for self-medication. Epidemiology: The incidence of hemorrhoidal disease in the general population is largely unknown, and studies have reported a wide range of prevalence: 4.4-86%.2 However, only one third of patients with symptomatic hemorrhoids seek medical help.3 Symptoms: Generalized pain, painful defecation, severe anal itching, moist or weeping wounds and bleeding. Treatment options: Only 10% of patients undergo surgery,4 but less invasive measures are recommended initially. Topical and systemic drug therapy is possible for all hemorrhoidal pathologies and first-choice treatment is topical (corticosteroid or anesthetic). Other studies: There have been few randomized clinical studies investigating treatments for hemorrhoidal disease and there is a lack of evidence for most first-line treatments. Most therapy practices are based on clinical experience, not evidence-based medicine. Current guidelines: Although symptoms of hemorrhoidal disease overlap between countries, management strategies often differ and there are no universal guidelines. AIM OF THE PRESENT STUDY To arrive at a consensus on the effects of topical and oral treatment of hemorrhoidal disease to be used in primary care and as a first step towards the creation of evidence-based guidelines.
METHOD
A group of international experts in proctology formed a consensus panel to examine the existing clinical evidence and individual national treatment approaches for the treatment of hemorrhoidal disease in primary care, with a view to resolving existing international variations. Various topics were discussed including topical, surgical and systemic therapy, treatment options for special populations (e.g. pregnancy) and options before or after surgery.
References: 1. Johannsson H, et al. Bowel habits in haemorrhoid patients and normal subjects. Am J Gastroenterol 2005;100:401-6. 2. Abramowitz L. The management of haemorrhoidal diseases. Aliment Pharmacol Ther 2010;31(Suppl 1):211. 3. Alonso P, et al. Phlebotonics for haemorrhoids. (Protocol) Cochrane Database of Systematic Reviews 2003;1:CD004322.
RESULTS
The use of both oral and topical therapies, particularly combined topical corticosteroid-anesthetic preparations are the cornerstone of symptomatic pain relief. Long-term prevention of hemorrhoidal disease recurrence should be addressed through defecation-disorder management with diet and lifestyle changes. CLASSIFICATION AND DIFFERENTIAL DIAGNOSIS Grade1 I Symptoms and physical examination
Enlarged hemorrhoids without anal prolapse but with internal hemorrhoid bleeding Enlarged hemorrhoids on anoscopy Bleeding with prolapse on defecation that resolves spontaneously after defecation Prolapse does not reposition without manual digital reduction Hemorrhoids remain permanently prolapsed and no reduction is possible
II III IV
References: 1. Goligher JC. Surgery of the anus, rectum and colon, 5th edn, London: Bailliere Tindall & Cassell, 1984. 2. American Gastroenterological Association. Technical review on the diagnosis and treatment of haemorrhoids. Gastroenterology 2004;126:146373.
Grade I
Grade II
Grade III
Grade IV
Basic Therapy:
Persistent bleeding
Infrared coagulation
Infrared coagulation
+ instrumental treatment
Sclerosis
Surgery (hemorrhoidectomy)
*If eczema is present, resolve with topical therapy prior to surgery
These consensus recommendations and algorithms provide practical diagnostic evaluation and treatment guidance for primary healthcare providers. Conservative treatments measures are recommended initially; thereafter, instrumental management in specialist care settings has a high success rate. Clinical data and further studies are needed to cement these findings in order to produce evidence-based recommendations.
CONCLUSION