Advertisement

Rethinking What We Know About Hemorrhoids

  • Robert S. Sandler
    Correspondence
    Reprint requests Address requests for reprints to: Robert S. Sandler, MD, MPH, Division of Gastroenterology and Hepatology, Department of Medicine, CB#7555, 4157 Bioinformatics Building, University of North Carolina, Chapel Hill, North Carolina 27599-7555. fax: (919) 966-9185.
    Affiliations
    Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
    Search for articles by this author
  • Anne F. Peery
    Affiliations
    Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
    Search for articles by this author
Published:March 27, 2018DOI:https://doi.org/10.1016/j.cgh.2018.03.020
      Although hemorrhoids are responsible for considerable economic cost and personal suffering, they have received surprisingly little research attention. In the United States, hemorrhoids are the third most common outpatient gastrointestinal diagnosis with nearly 4 million office and emergency department visits annually. The etiology of hemorrhoids is speculative. A low-fiber diet and constipation have historically been thought to increase the risk for hemorrhoids, but not proven. Symptoms commonly attributed to hemorrhoids include bleeding, pain, pruritus, fecal seepage, prolapse, and mucus discharge. Research has found that these symptoms were equally reported by patients with and without hemorrhoids. Medical therapies for hemorrhoids have not been formally studied except for fiber where the results have been inconsistent. A number of office-based interventions such as rubber band ligation and infrared coagulation are widely used and economically favorable for practitioners. Surgical procedures are effective at eliminating hemorrhoids but may be painful. Given the burden of disease and numerous gaps in our understanding, the time has come for targeted research to understand the cause, symptoms, and best treatment for patients with symptomatic hemorrhoids.

      Keywords

      Abbreviations used in this paper:

      HCUP (Healthcare Cost and Utilization Project), IRC (infrared coagulation), OR (odds ratio), PRO (patient-reported outcome)
      To read this article in full you will need to make a payment
      AGA Member Login
      Login with your AGA username and password.

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Everhart J.E.
        • Ruhl C.E.
        Burden of digestive diseases in the United States part II: lower gastrointestinal diseases.
        Gastroenterology. 2009; 136: 741-754
        • Sun Z.
        • Migaly J.
        Review of hemorrhoid disease: presentation and management.
        Clin Colon Rectal Surg. 2016; 29: 22-29
        • Ganz R.A.
        The evaluation and treatment of hemorrhoids: a guide for the gastroenterologist.
        Clin Gastroenterol Hepatol. 2013; 11: 593-603
        • Haas P.A.
        • Fox Jr., T.A.
        • Haas G.P.
        The pathogenesis of hemorrhoids.
        Dis Colon Rectum. 1984; 27: 442-450
        • Madoff R.D.
        • Fleshman J.W.
        Clinical Practice Committee AGA. American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids.
        Gastroenterology. 2004; 126: 1463-1473
        • LeClere F.B.
        • Moss A.J.
        • Everhart J.E.
        • et al.
        Prevalence of major digestive disorders and bowel symptoms, 1989.
        Adv Data. 1992; 212: 1-15
        • Etzioni D.A.
        • Beart Jr., R.W.
        • Madoff R.D.
        • et al.
        Impact of the aging population on the demand for colorectal procedures.
        Dis Colon Rectum. 2009; 52 (discussion 590–591): 583-590
        • Peery A.F.
        • Crockett S.D.
        • Barritt A.S.
        • et al.
        Burden of gastrointestinal, liver, and pancreatic diseases in the United States.
        Gastroenterology. 2015; 149: 1731-1741 e3
      1. Preparation H - Product - Overview | Evaluate. Available at: http://www.evaluategroup.com/View/11546--1002-modData/product/preparation_h. Accessed April 26, 2018.

        • Johanson J.F.
        • Sonnenberg A.
        The prevalence of hemorrhoids and chronic constipation. An epidemiologic study.
        Gastroenterology. 1990; 98: 380-386
        • Peery A.F.
        • Sandler R.S.
        • Galanko J.A.
        • et al.
        Risk factors for hemorrhoids on screening colonoscopy.
        PLoS One. 2015; 10: e0139100
        • Burkitt D.
        Varicose veins, deep vein thrombosis and haemorrhoids. Refined carbohydrate foods and disease.
        Elsevier BV, London1975: 143-160
        • Burkitt D.P.
        • Graham-Stewart C.W.
        Haemorrhoids–postulated pathogenesis and proposed prevention.
        Postgrad Med J. 1975; 51: 631-636
        • Burkitt D.P.
        Varicose veins, deep vein thrombosis, and haemorrhoids: epidemiology and suggested aetiology.
        BMJ. 1972; 2: 556-561
        • Talley N.J.
        • Lasch K.L.
        • Baum C.L.
        A gap in our understanding: chronic constipation and its comorbid conditions.
        Clin Gastroenterol Hepatol. 2009; 7: 9-19
        • Johanson J.F.
        • Sonnenberg A.
        Constipation is not a risk factor for hemorrhoids: a case-control study of potential etiological agents.
        Am J Gastroenterol. 1994; 89: 1981-1986
        • Delco F.
        • Sonnenberg A.
        Associations between hemorrhoids and other diagnoses.
        Dis Colon Rectum. 1998; 41 (discussion 1541–1542): 1534-1541
        • Loder P.B.
        • Kamm M.A.
        • Nicholls R.J.
        • et al.
        Haemorrhoids: pathology, pathophysiology and aetiology.
        Br J Surg. 1994; 81: 946-954
        • Plackett T.P.
        • Kwon E.
        • Gagliano Jr., R.A.
        • et al.
        Ehlers-Danlos syndrome-hypermobility type and hemorrhoids.
        Case Rep Surg. 2014; 2014: 171803
        • Nasseri Y.Y.
        • Krott E.
        • Van Groningen K.M.
        • et al.
        Abnormalities in collagen composition may contribute to the pathogenesis of hemorrhoids: morphometric analysis.
        Tech Coloproctol. 2015; 19: 83-87
        • Willis S.
        • Junge K.
        • Ebrahimi R.
        • et al.
        Haemorrhoids - a collagen disease?.
        Colorectal Dis. 2010; 12: 1249-1253
        • Serra R.
        • Gallelli L.
        • Grande R.
        • et al.
        Hemorrhoids and matrix metalloproteinases: a multicenter study on the predictive role of biomarkers.
        Surgery. 2016; 159: 487-494
      2. Hemorrhoid prevention and relief. Available at: http://www.squattypotty.co.za/page.php?10.

        • Sakakibara R.
        • Tsunoyama K.
        • Hosoi H.
        • et al.
        Influence of body position on defecation in humans.
        Low Urin Tract Symptoms. 2010; 2: 16-21
        • Tagart R.E.
        The anal canal and rectum: their varying relationship and its effect on anal continence.
        Dis Colon Rectum. 1966; 9: 449-452
        • Dehn T.C.B.
        • Kettlewell M.G.W.
        Haemorrhoids and defaecatory habits.
        Lancet. 1989; 333: 54-55
        • Jacobs D.O.
        Hemorrhoids: what are the options in 2018?.
        Curr Opin Gastroenterol. 2018; 34: 46-49
        • Sugerman D.T.
        Hemorrhoids.
        JAMA. 2014; 312: 2698
        • Riss S.
        • Weiser F.A.
        • Schwameis K.
        • et al.
        The prevalence of hemorrhoids in adults.
        Int J Colorectal Dis. 2011; 27: 215-220
        • Mazier W.P.
        Hemorrhoids, fissures, and pruritus ani.
        Surg Clin North Am. 1994; 74: 1277-1292
        • Rohde H.
        • Christ H.
        [Haemorrhoids are too often assumed and treated. Survey of 548 patients with anal discomfort].
        Dtsch Med Wochenschr. 2004; 129: 1965-1969
        • Johannsson H.O.
        • Graf W.
        • Pahlman L.
        Bowel habits in hemorrhoid patients and normal subjects.
        Am J Gastroenterol. 2005; 100: 401-406
        • Wald A.
        • Bharucha A.E.
        • Cosman B.C.
        • et al.
        ACG clinical guideline: management of benign anorectal disorders.
        Am J Gastroenterol. 2014; 109 (quiz 1058): 1141-1157
        • Rivadeneira D.E.
        • Steele S.R.
        • Ternent C.
        • et al.
        Practice parameters for the management of hemorrhoids (revised 2010).
        Dis Colon Rectum. 2011; 54: 1059-1064
        • Alonso-Coello P.
        • Mills E.
        • Heels-Ansdell D.
        • et al.
        Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis.
        Am J Gastroenterol. 2006; 101: 181-188
        • Broader J.H.
        • Gunn I.F.
        • Alexander-Williams J.
        Evaluation of a bulk-forming evacuant in the management of haemorrhoids.
        Br J Surg. 1974; 61: 142-144
        • Gibbons C.P.
        • Bannister J.J.
        • Read N.W.
        Role of constipation and anal hypertonia in the pathogenesis of haemorrhoids.
        Br J Surg. 1988; 75: 656-660
        • Chong P.S.
        • Bartolo D.C.
        Hemorrhoids and fissure in ano.
        Gastroenterol Clin North Am. 2008; 37 (ix): 627-644
        • Perera N.
        • Liolitsa D.
        • Iype S.
        • et al.
        Phlebotonics for haemorrhoids.
        Cochrane Database Syst Rev. 2012; 8CD004322
        • Technology Committee A.S.G.E.
        • Siddiqui U.D.
        • Barth B.A.
        • et al.
        Devices for the endoscopic treatment of hemorrhoids.
        Gastrointest Endosc. 2014; 79: 8-14
        • Ohning G.V.
        • Machicado G.A.
        • Jensen D.M.
        Definitive therapy for internal hemorrhoids–new opportunities and options.
        Rev Gastroenterol Disord. 2009; 9: 16-26
        • MacRae H.M.
        • McLeod R.S.
        Comparison of hemorrhoidal treatment modalities. A meta-analysis.
        Dis Colon Rectum. 1995; 38: 687-694
        • MacRae H.M.
        • McLeod R.S.
        Comparison of hemorrhoidal treatments: a meta-analysis.
        Can J Surg. 1997; 40: 14-17
        • Johnson D.A.
        Evolving perspectives for survival of gastroenterology practice: a business plan assessment for improved economic success.
        Endoeconomics. 2011; (August:5–7)
      3. Best Hemorrhoid Procedure: Physician Testimonials | CRH O'Regan System. http://physicians.crhsystem.com/start-offering-crh/physician-testimonials/. Accessed: December 20, 2017.

        • Jensen D.M.
        • Jutabha R.
        • Machicado G.A.
        • et al.
        Prospective randomized comparative study of bipolar electrocoagulation versus heater probe for treatment of chronically bleeding internal hemorrhoids.
        Gastrointest Endosc. 1997; 46: 435-443
        • Hollingshead J.R.
        • Phillips R.K.
        Haemorrhoids: modern diagnosis and treatment.
        Postgrad Med J. 2016; 92: 4-8
        • Traynor O.J.
        • Carter A.E.
        Cryotherapy for advanced haemorrhoids: a prospective evaluation with 2-year follow-up.
        Br J Surg. 1984; 71: 287-289
        • Guindic L.C.
        Treatment of uncomplicated hemorrhoids with a Hemor-Rite(R) cryotherapy device: a randomized, prospective, comparative study.
        J Pain Res. 2014; 7: 57-63
        • Simillis C.
        • Thoukididou S.N.
        • Slesser A.A.
        • et al.
        Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids.
        Br J Surg. 2015; 102: 1603-1618
        • Chen J.S.
        • You J.F.
        Current status of surgical treatment for hemorrhoids–systematic review and meta-analysis.
        Chang Gung Med J. 2010; 33: 488-500
        • van Tol R.R.
        • Melenhorst J.
        • Dirksen C.D.
        • et al.
        Protocol for the development of a Core Outcome Set (COS) for hemorrhoidal disease: an international Delphi study.
        Int J Colorectal Dis. 2017; 32: 1091-1094
        • Gupta P.J.
        Infrared coagulation versus rubber band ligation in early stage hemorrhoids.
        Braz J Med Biol Res. 2003; 36: 1433-1439
        • Jutabha R.
        • Jensen D.M.
        • Chavalitdhamrong D.
        Randomized prospective study of endoscopic rubber band ligation compared with bipolar coagulation for chronically bleeding internal hemorrhoids.
        Am J Gastroenterol. 2009; 104: 2057-2064
        • Ambrose N.S.
        • Hares M.M.
        • Alexander-Williams J.
        • et al.
        Prospective randomised comparison of photocoagulation and rubber band ligation in treatment of haemorrhoids.
        Br Med J (Clin Res Ed). 1983; 286: 1389-1391
        • Yeo D.
        • Tan K.-Y.
        Hemorrhoidectomy - making sense of the surgical options.
        World J Gastroenterol. 2014; 20: 16976-16983
        • Ramzisham A.R.
        • Sagap I.
        • Nadeson S.
        • et al.
        Prospective randomized clinical trial on suction elastic band ligator versus forceps ligator in the treatment of haemorrhoids.
        Asian J Surg. 2005; 28: 241-245
        • Shanmugam V.
        • Thaha M.A.
        • Rabindranath K.S.
        • et al.
        Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids.
        Cochrane Database Syst Rev. 2005; 3CD005034
        • Riss S.
        • Weiser F.A.
        • Schwameis K.
        • et al.
        Haemorrhoids, constipation and faecal incontinence: is there any relationship?.
        Colorectal Dis. 2011; 13: e227-e233
        • Weldring T.
        • Smith S.M.S.
        Patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs).
        Health Serv Insights. 2013; 6: 61-68