Phlebotonics for haemorrhoids

Clinical evidence and rationale of mesoglycan to treat chronic venous disease and hemorrhoidal disease: a narrative review

Chronic venous disease (CVD) and hemorrhoidal disease (HD) are among the most common vascular diseases in the world, with CVD affecting 22-41% of the population in Europe and HD having a point prevalence of 11-39%. The burden is substantial in terms of the effect of symptoms on patients' health-related quality of life (HRQoL) and direct/indirect medical costs. Treatment begins with lifestyle changes, compression in CVD and topical therapies in HD, and escalates as needed through oral therapies first and eventually to surgery for severe disease. CVD and HD share etiological features and pathological changes affecting the structure and function of the tissue extracellular matrix. Mesoglycan, a natural glycosaminoglycan (GAG) preparation composed primarily of heparan sulfate and dermatan sulfate, has been demonstrated to positively impact the underlying causes of CVD and HD, regenerating the glycocalyx and restoring endothelial function, in addition to having antithrombotic, profibrinolytic, anti-inflammatory, antiedema and wound-healing effects. In clinical trials, oral mesoglycan reduced the severity of CVD signs and symptoms, improved HRQoL, and accelerated ulcer healing. In patients with HD, mesoglycan significantly reduced the severity of signs and symptoms and the risk of rectal bleeding. In patients undergoing excisional hemorrhoidectomy, adding mesoglycan to standard postoperative care reduced pain, improved HRQoL, reduced incidence of thrombosis, and facilitated an earlier return to normal activities/work, compared with standard postoperative care alone. The clinical effects of mesoglycan in patients with CVD or HD are consistent with the agent's known mechanisms of action.

Recurrence Rates and Pharmacological Treatment for Hemorrhoidal Disease: A Systematic Review

INTRODUCTION

Hemorrhoidal disease (HD) is characterized by prolapse of the inflamed and bleeding vascular tissues of the anal canal. Although HD is associated with a high recurrence rate, there is a lack of understanding around interventions that can reduce recurrence and improve outcomes for patients. As such, a systematic literature review (SLR) was conducted to summarize evidence on epidemiology, recurrence, and efficacy of interventions in HD.

METHODS

Real-world evidence (RWE) studies evaluating the incidence, prevalence, or recurrence of HD, as well as SLRs including a meta-analytic component reporting on the efficacy of systemic or topical pharmacological treatments for adults with HD, were included. Systematic searches were conducted in MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Database of Systematic Reviews.

RESULTS

The SLR identified 44 eligible publications. Consistent data were limited on the epidemiology of HD or HD recurrence. Specifically, incidence and prevalence reported across geographies were impacted by differences in data collection. Reported risk factors for HD were sedentary behavior, constipation, male gender, and age. Twenty-three RWE studies and one meta-analysis reported HD recurrence rates ranging from 0 to 56.5% following surgery or phlebotonics, with most (n = 19) reporting rates of 20% or less. In addition to time since treatment, risk factors for recurring disease were similar to those for HD in general. With respect to treatment, micronized purified flavonoid fractions significantly improved the main symptoms of HD compared to other pharmacological treatments.

CONCLUSION

The SLRs did not identify any RWE studies reporting recurrence in patients receiving systemic or topical treatments, highlighting the need for future research in this area. Further, more studies are needed to understand the optimum duration of medical treatment to prevent recurrence.

Flavonoids and saponins: What have we got or missed?

BACKGROUND

Flavonoids and saponins are important bioactive compounds that have attracted wide research interests. This review aims to summarise the state of the art of the pharmacology, toxicology and clinical efficacy of these compounds.

METHODS

Data were retrieved from PubMed, Cochrane Library, Web of Science, Proquest, CNKI, Chongqing VIP, Wanfang, NPASS and HIT 2.0 databases. Meta-analysis and systematic reviews were evaluated following the PRISMA guideline. Statistical analyses were conducted using SPSS23.0.

RESULTS

Rising research trends on flavonoids and saponins were observed since the 1990s and the 2000s, respectively. Studies on pharmacological targets and activities of flavonoids and saponins represent an important area of research advances over the past decade, and these important resources have been documented in open-access specialised databases and can be retrieved with ease. The rising research on flavonoids and saponins can be attributed, at least in part, to their links with some highly investigated fields of research, e.g., oxidative stress, inflammation and cancer; i.e., 6.88% and 3.03% of publications on oxidative stress cited by PubMed in 1990 - 2021 involved flavonoids and saponins, respectively, significantly higher than the percentage involving alkaloids (1.88%). The effects of flavonoids concern chronic venous insufficiency, cervical lesions, diabetes, rhinitis, dermatopathy, prostatitis, menopausal symptoms, angina pectoris, male pattern hair loss, lymphocytic leukaemia, gastrointestinal diseases and traumatic cerebral infarction, etc, while those of saponins may have impact on venous oedema in chronic deep vein incompetence, erectile dysfunction, acute impact injuries and systemic lupus erythematosus, etc. The volume of in vitro research appears way higher than in vivo and clinical studies, with only 10 meta-analyses and systematic reviews (involving 290 interventional and observational studies), and 36 clinical studies on flavonoids and saponins. Data are sorely needed on pharmacokinetics, in vitro pan-assay interferences, purity of tested compounds, interactions in complex herbal extracts, real impact of anti-oxidative strategies, and mid- and long-term toxicities. To fill these important gaps, further investigations are warranted. On the other hand, drug interactions may cause adverse effects but might also be useful for synergism, with the goals of enhancing effects or of detoxifying. Furthermore, the interactions between phytochemicals and the intestinal microbiota are worth investigating as the field may present a promising potential for novel drug development.

Rationale and effectiveness of combination therapy of chronic anal fissures and hemorrhoids

Hemorrhoids and anal fissures are a serious medical problem at the intersection of specialties. The disease has a progressive course, there are several stages. In the 3rd and 4th stages, surgical intervention is required, but in the 1st and 2nd stages, i.e. in more than 90% of all cases of the disease, it is enough to correct the lifestyle, physical activity, diet and nature of the diet, as well as conservative drug treatment. The complexity and multifactorial nature of the pathogenesis of hemorrhoidal disease dictate the need for the impact of therapy on the key mechanisms of the development of the disease. This can be achieved by combining agents with different effects and routes of administration to provide potentiation. Treatment of acute and chronic hemorrhoids includes general and local use of painkillers, antiinflammatory, phlebotonic, hemostatic and complex preparations. Among systemic drugs, the leading place belongs to phlebotonic agents of the flavonoid series of plant origin. Their effectiveness is associated with the effect both on the state of the vascular wall with a decrease in venous stasis and improvement of lymphatic outflow, and with an effect on the rheological properties of the blood. There is also a local anti-inflammatory effect of the combination “diosmin + hesperidin”, and in general, a palette of positive properties predetermines the use of these drugs for hemorrhoids. The combination of systemic flavonoids with local agents that provide repair of damaged tissues and have hemostatic effects contributes to an increase in the effectiveness of treatment. The combined use of systemic phlebotonic preparations and local reparative agents, which together provide a complex effect on various pathogenetic mechanisms and symptoms of hemorrhoids and anal fissures, accelerates the achievement of a positive result of treatment and the prevention of recurrence of the disease.

Prevalent Technique and Results of Hemorrhoidal Embolization

Hemorrhoids are blood cushions located in the anus and lower rectum, acknowledged as a common cause of bleeding, which can reduce quality of life. The development of minimally invasive techniques such as endovascular embolization of superior rectal artery, "Emborrhoid technique", is an effective treatment, with no pain or ischemic complications, and allows quick patient recovery. Our purpose is to describe the general technique and discuss the results of the current literature.

The Emborrhoid Technique for Treatment of Bleeding Hemorrhoids in Patients with High Surgical Risk

The Emborrhoid is an innovative non-surgical technique for the treatment of severe hemorrhoidal bleeding. Patient selection and the impact on quality of life have not been fully investigated. This prospective observational study aims to evaluate the clinical outcomes after Emborrhoid in patients with high surgical risk. All patients with high surgical risk and anemia due to hemorrhoids were enrolled. Clinical data and previous blood transfusions were collected. The Hemorrhoidal Disease Symptom Score and Short Health Scala were completed before the procedure and during the follow-up visits at 1, 6 and 12 months. Transfusions and serum hemoglobin level variations were registered. Perioperative complications and the recurrence of bleeding were assessed. Trans-radial/femoral embolization of superior rectal artery, and/or middle rectal artery was performed with Interlock and Detachable Embolization Coils. From September 2020 to February 2022, 21 patients underwent a superselective embolization of all branches of the superior rectal artery. The transradial approach was most frequently performed compared to transfemoral access. After the procedure, no signs of ischemia were identified; three minor complications were observed. The mean follow-up was 18.5 ± 6.0 months. At the last follow-up, the mean increase of hemoglobin for patients was 1.2 ± 1.6 g/dL. Three patients needed transfusions during follow-up for recurrent hemorrhoidal bleeding. The Hemorrhoidal Disease Symptom Score and Short Health Scala decreased from 11.1 ± 4.2 to 4.7 ± 4.6 (p < 0.0001) and from 18.8 ± 4.8 to 10.2 ± 4.9 (p < 0.0001), respectively. Patients who had given up on their daily activities due to anemia have returned to their previous lifestyle. Emborrhoid seems to be a safe and effective option for the treatment of bleeding hemorrhoids in frail patients. The low complication rate and the significant reduction of post-defecation bleeding episodes are related to the improvement of the hemorrhoidal symptoms and patients’ quality of life.

Strategies to Reduce Post-Hemorrhoidectomy Pain: A Systematic Review

Background and Objectives: Excisional hemorrhoidectomy is considered as a mainstay operation for high-grade hemorrhoids and complicated hemorrhoids. However, postoperative pain remains a challenging problem after hemorrhoidectomy. This systematic review aims to identify pharmacological and non-pharmacological interventions for reducing post-hemorrhoidectomy pain. Materials and Methods: The databases of Ovid MEDLINE, PubMed and EMBASE were systematically searched for randomized controlled trails (published in English language with full-text from 1981 to 30 September 2021) to include comparative studies examining post-hemorrhoidectomy pain as their primary outcomes between an intervention and another intervention (or a sham or placebo). Results: Some 157 studies were included in this review with additional information from 15 meta-analyses. Fundamentally, strategies to reduce post-hemorrhoidectomy pain were categorized into four groups: anesthetic methods, surgical techniques, intraoperative adjuncts, and postoperative interventions. In brief, local anesthesia-alone or combined with intravenous sedation was the most effective anesthetic method for excisional hemorrhoidectomy. Regarding surgical techniques, closed (Ferguson) hemorrhoidectomy performed with a vascular sealing device or an ultrasonic scalpel was recommended. Lateral internal anal sphincterotomy may be performed as a surgical adjunct to reduce post-hemorrhoidectomy pain, although it increased risks of anal incontinence. Chemical sphincterotomy (botulinum toxin, topical calcium channel blockers, and topical glyceryl trinitrate) was also efficacious in reducing postoperative pain. So were other topical agents such as anesthetic cream, 10% metronidazole ointment, and 10% sucralfate ointment. Postoperative administration of oral metronidazole, flavonoids, and laxatives was associated with a significant reduction in post-hemorrhoidectomy pain. Conclusions: This systematic review comprehensively covers evidence-based strategies to reduce pain after excisional hemorrhoidectomy. Areas for future research on this topic are also addressed at the end of this article.

Flavonoids: Antiplatelet Effect as Inhibitors of COX-1

Flavonoids are compounds with a benzopyranic structure that exhibits multiple pharmacological activities. They are known for their venotonic activity, but their mechanism of action remains unclear. It is thought that, as this mechanism is mediated by prostaglandins, these compounds may interfere with the arachidonic acid (AA) cascade. These assays are designed to measure the antiplatelet aggregation capacity of quercetin, rutin, diosmetin, diosmin, and hidrosmin, as well as to evaluate a potential structure−activity ratio. In this paper, several studies on platelet aggregation at different concentrations (from 0.33 mM to 1.5 mM) of different flavone compounds are conducted, measuring platelet aggregation by impedance aggregometry, and the cyclooxygenase (COX) activity by metabolites generated, including the activity of the pure recombinant enzyme in the presence of these polyphenols. The results obtained showed that quercetin and diosmetin aglycones have a greater antiplatelet effect and inhibit the COX enzyme activity to a greater extent than their heterosides; however, the fact that greater inhibition of the pure recombinant enzyme was achieved by heterosides suggests that these compounds may have difficulty in crossing biological membranes. In any case, in view of the results obtained, it can be concluded that flavonoids could be useful as coadjuvants in the treatment of cardiovascular pathologies.

Perianal thrombosis: no need for surgery

AIM

There is little evidence for the best therapy for perianal thrombosis. No prospective trials exist. Even quality of retrospective data is low, due to low patient numbers or vague follow-up data.

PATIENTS AND METHODS

Six hundred nineteen patients with thrombosis of internal or external hemorrhoids who presented in our clinic between March 2017 and August 2018 were enrolled in the study. All patients were treated conservatively, with sitz baths and oral pain medication, if needed. No surgery was performed. Follow-up data was obtained by personal examination. Data was gathered prospectively, and data analysis was retrospective.

RESULTS

Five hundred four patients had perianal thrombosis (81.4%), and 115 patients had thrombosed hemorrhoids. Mean pain on a numerical rating scale (0-10) was 3.8 for perianal thrombosis and 5.2 for thrombosed hemorrhoids. Five hundred forty-eight patients (88.5%) did not need a sick leave. On follow-up, patients stated that their pain had largely resolved after 5 days and completely disappeared after 10 days. Local recurrence rate after perianal thrombosis was 6.3%.

CONCLUSION

Perianal thrombosis and thrombosed hemorrhoids heal well without surgery. There is no evidence for advantages surgical therapy could offer.

[Modern trends in combined treatment of hemorrhoids: topical form Tribenoside + Lidocaine and phlebotonic Ginkgo biloba + Troxerutin + Heptaminol]

Acute hemorrhoids are the most common reason for referring to coloproctologist in people of working age. In the modern world, food culture and lifestyle are the most prominent factors leading to the risk of hemorrhoids. In the 21st century, it is hard to overestimate an importance of potential employability and active social role regarding socio-economic well-being. This thesis applies to patients suffering from proctological diseases, and those with hemorrhoids prevail among these ones. Minimally invasive treatment and pharmacotherapy defined primary needs of patients, i.e. treatment should be quick, safe and effective. Favorable treatment outcomes are possible only in pathogenetic therapy. In this review, we will define the priorities in effective combined treatment of hemorrhoids.

Evaluation of the Efficacy and Safety of a Compound of Micronized Flavonoids in Combination With Vitamin C and Extracts of Centella asiatica, Vaccinium myrtillus, and Vitis vinifera for the Reduction of Hemorrhoidal Symptoms in Patients With Grade II and III Hemorrhoidal Disease: A Retrospective Real-Life Study

Background and Aim: Several evidences have shown how, in hemorrhoidal disease, phlebotonic flavonoid agents such as quercetin reduce capillary permeability by increasing vascular walls resistance, how rutin and vitamin C have antioxidant properties, and that Centella asiatica has reparative properties towards the connective tissue. A retrospective study was designed in order to evaluate the efficacy and safety of a compound consisting of micronized flavonoids in combination with vitamin C and extracts of C. asiatica, Vaccinium myrtillus, and Vitis vinifera for grade II and III hemorrhoidal disease.

Patients and Methods: Data of 49 patients, over 18, who were following a free diet regimen, not on therapy with other anti-hemorrhoid agents, treated with a compound consisting of 450 mg of micronized diosmin, 300 mg of C. asiatica, 270 mg of micronized hesperidin, 200 mg of V. vinifera, 160 mg of vitamin C, 160 mg of V. myrtillus, 140 mg of micronized quercetin, and 130 mg of micronized rutin (1 sachet or 2 tablets a day) for 7 days were collected. Hemorrhoid grade according to Goligher’s scale together with anorectal symptoms (edema, prolapse, itching, thrombosis, burning, pain, tenesmus, and bleeding) both before treatment (T0) and after 7 days of therapy (T7) were collected. Primary outcomes were the reduction of at least one degree of hemorrhoids according to Goligher’s scale assessed by proctological examination and compound safety. The secondary outcome was the reduction of anorectal symptoms assessed by questionnaires administered to patients.

Results: Forty-four patients (89.8%) presented a reduction in hemorrhoidal grade of at least one grade (p < 0.001). No adverse events with the use of the compound were noted. A significant reduction was observed in all anorectal symptoms evaluated (p < 0.05). No predictors of response to the compound were identified among the clinical and demographic variables collected.

Conclusion: The compound analyzed was effective and safe for patients with grade II and III hemorrhoidal disease according to Goligher’s scale.

Graptophyllum pictum Extract in the Treatment of Experimental Hemorrhoids: Effects on Vascular Leakage and Matrix Metalloproteinase-9 Levels

BACKGROUND: The micronized purified flavonoid fraction, which has been shown to be effective for the treatment of hemorrhoids, is too expensive for Indonesian patients and is not included in the National Formulary. AIM: The aim of this study was to investigate the effects of Graptophyllum pictum extract (GPE), a phlebotropic drug, as it is a cheaper and safer alternative medication for the treatment of hemorrhoids. MATERIALS AND METHODS: Twenty-eight male Wistar rats were randomly divided into four groups. Hemorrhoids were induced in groups 2, 3, and 4 using 6% croton oil. After induction, group 1 (negative control) and group 2 (positive control) were administered normal saline, whereas groups 3 and 4 were administered 100 mg/kg BW and 300 mg/kg BW GPE, respectively. On the 9th day, blood samples were collected to measure serum matrix metalloproteinase (MMP)-9 levels. The anus, containing the internal and external sphincters, was resected. Vascular leakage was measured based on edema and extravascular leukocyte count. The edema was measured using the rectoanal coefficient. RESULTS: The highest rectoanal coefficient was observed in groups 2 (3.13 ± 0.85) and 3 (2.46 ± 0.41); that in group 4 (2.60 ± 0.34) was significantly lower than that in group 2 (p < 0.05). The highest leukocyte count was observed in groups 2 (1003.28 ± 99.30) and 3 (900.14 ± 48.09); that in group 4 (835.85 ± 42.65) was significantly lower than that in group 2 (p < 0.05). The highest mean serum MMP-9 level was observed in groups 2 (1840.25 ±437.84) and 3 (525.78 ± 577.33); that in group 4 (1122.03±675.76) was significantly lower than that in group 2 (p < 0.05). CONCLUSIONS: GPE effectively reduced vascular leakage (edema and extravascular leukocyte count) and MMP-9 level in this experimental model of hemorrhoids.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Hemorrhoid embolization: A review of current evidences

Hemorrhoids are local vascular structure dilations in the lower rectum, associated with morbidity and reduced quality of life. Endovascular coil or particle embolization of the superior rectal arteries, known as Emborrhoid technique, is a minimally invasive, image-guided therapy that targets the hemorrhoidal plexus and reduces hemorrhage. The purpose of this review was to analyze the results of published studies to determine the efficacy, clinical outcomes, and morbidities associated with the endovascular occlusion of hemorrhoidal arteries for the treatment of internal hemorrhoids. Current evidences suggest that hemorrhoids treated by Emborrhoid technique using microcoils, embolic particles or a combination is safe with no reported serious complications. Hemorrhoid embolization can preserve the anal tone without direct anorectal trauma and maintain the hemorrhoidal tissue in place requiring minimal local wound care on an outpatient basis. However, due to the paucity of high-quality trials, further research is warranted to evaluate its long-term outcomes, compare its efficacy with other treatment modalities, and fully assess its role in the treatment of hemorrhoid.

Benefits of flavonoid and metronidazole use after excisional hemorrhoidectomy: a randomized double-blind clinical trial

BACKGROUND

Excisional hemorrhoidectomy remains the most effective treatment for a significant group of patients with hemorrhoids, despite the potential for postoperative pain. The purpose of this study was to evaluate the effects of flavonoid and metronidazole use in the postoperative period on patients undergoing excisional hemorrhoidectomy.

METHODS

A double-blind randomized clinical study was performed. Sixty-eight patients underwent excisional hemorrhoidectomy and were randomized into 4 groups of 17 patients each to receive double-placebo (G1), metronidazole plus placebo (G2), flavonoids plus placebo (G3) or metronidazole plus flavonoids (G4) in the postoperative period. A standard analgesic protocol was offered equally for all groups. Postoperative pain, bleeding, edema, pruritus and tenesmus were evaluated during the following three periods: from immediately after the operation until postoperative day (POD)7, from POD 8 to POD 14, and from POD 15 to POD 30. The patients were required to complete symptom questionnaires and to attend postoperative follow-up on PODs 7, 14 and 30. The effect of each drug was assessed for each symptom, and the groups were compared with each other and over time.

RESULTS

There was less severe pain in all postoperative periods in the groups using flavonoids (G3 and G4, both p < 0.0001), with an observed synergistic effect of flavonoids combined with metronidazole during the first 14 days after surgery (p < 0.0001). Flavonoid use was also associated with decreased bleeding (G3, p = 0.031 and G4, p = 0.016) between the first and second postoperative weeks CONCLUSIONS: The use of flavonoids alone and in combination with metronidazole resulted in a reduction of most symptoms, particularly pain, after excisional hemorrhoidectomy.

TRIAL REGISTRATION

The present study was registered in the SISNEP (document CAAE-0035.0.240.000-11), after approval by the research ethics committee (CEP) of the Hospital Felício Rocho (protocol nº393 / 11).

A Prospective Study on the Efficacy of Two Different Phlebotonic Therapies as a Bridge to Surgery in Patients with Advanced Hemorrhoidal Disease

The aims of this study were to evaluate the efficacy of two different phlebotonic therapies, preoperatively administered in advanced hemorrhoidal disease (HD) patients with recommendation for surgery, and to assess patient satisfaction after treatment. In this prospective observational study, 100 patients were preoperatively treated either with micronized purified flavonoid fraction (group A) or sublingual nano-emulsion flavonoid (group B). HD symptoms, local inflammation signs and patients' satisfaction were evaluated at baseline visit (T0), after 4 weeks of therapy (T1) and 8 weeks after its discontinuation (T2). In group A, a significant improvement for all HD symptoms and inflammation signs was observed after therapy (T1), followed by a reduction of efficacy in T2, except for itching and edema. In group B, therapy had a significant benefit on symptoms and local inflammation at T1, which persisted after its discontinuation for all symptoms, and edematous hemorrhoids. In both groups, the satisfaction rate was "good" in 60% of patients and patients were statistically significant more satisfied at T1 compared with T2 (p = 0.0001). No adverse events were recorded. Preoperative treatment was safe and useful to optimize patients' clinical condition prior to surgery.

The effect of sucralfate-containing ointment on quality of life in people with symptoms associated with haemorrhoidal disease and its complications: the results of the EMOCARE survey

Background and aim:

A rectal ointment containing 3% of sucralfate and herbal extracts (calendula, witch hazel leaf (hamamelis), chamomile), became available in Italy in 2019 for the treatment of symptoms associated with haemorrhoidal disease. This survey evaluated the effect of the mentioned sucralfate ointment, on quality of life (QoL) and symptom frequency in participants seeking treatment for haemorrhoidal disease from community pharmacies in Italy.

Methods:

EMOCARE was a multicentre prospective survey conducted at community pharmacies in Italy. Eligible participants (≥18 years) were those with haemorrhoidal symptoms in the last 7 days and were willing to initiate a treatment with the sucralfate ointment and herbal extracts (calendula, witch hazel leaf (hamamelis), chamomile). A survey was administered by the investigating pharmacists at the beginning and end (~14 days) of treatment. The primary endpoint was the change in HEMO-FISS-QoL scores.

Results:

Of the 290 (mean age 53.1 years old; 58.3% female) enrolled, 287 attended the follow-up visit. After a mean duration of 13 days, the sucralfate ointment significantly improved total HEMO-FISS-QoL scores (mean change from baseline: –10.41; 95%CI –11.95, –8.86; P<0.001) and mean scores for all domains of the HEMO-FISS-QoL scale (–11.13 [95%CI –12.95, –9.30] for physical disorders, –6.14 [95%CI –7.42, –4.85] for psychology, –18.79 [95% CI –21.67, –15.90] for defaecation, and –6.46 [95%CI –8.40, –4.51] for sexuality; all P<0.001 versus baseline). At the end of treatment, 39.4% of participants reported that they no longer had haemorrhoidal symptoms and the frequency of all assessed symptoms were reduced significantly from baseline (all P<0.05).

Conclusions:

After a mean 13 days of treatment the sucralfate ointment with herbal extracts improved HEMO-FISS-QoL scores and reduced symptoms in people with haemorrhoidal disease. (www.actabiomedica.it)

Belgian consensus guideline on the management of hemorrhoidal disease

Introduction

Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking.

Methods

A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020.

Results

Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids.

Conclusions

The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.

Micronized Purified Flavonoid Fraction in Hemorrhoid Disease: A Systematic Review and Meta-Analysis

Introduction

Hemorrhoidal disease (HD) is a common and recurrent problem for many adults worldwide. Venoactive drugs, such as micronized purified flavonoid fraction (MPFF; Daflon^®), have been used to treat HD and their clinical benefits have been demonstrated in previous meta-analyses of clinical trials. The aim of this study was to evaluate the efficacy of MPFF across the broader spectrum of signs and symptoms following treatment of patients with HD.

Methods

We performed a systematic review of the literature to identify randomized clinical trials in which MPFF treatment was compared to placebo or no treatment for acute HD or for relief of symptoms after patients had undergone medical management or a surgical procedure to remove hemorrhoids. The main endpoints investigated were bleeding, pain, pruritus, discharge or leakage, and overall improvement. There was no limit on treatment duration.

Results

From 351 unique records retrieved, 11 studies reported in 13 articles were included. On the basis of findings from qualitative analysis, MPFF was reported in most studies to be beneficial in treating bleeding, pain, pruritus, anal discharge/leakage, and tenesmus, and in overall improvement. Quantitative meta-analysis of four studies indicated that MPFF treatment provided significant benefits for bleeding (odds ratio [OR] 0.082, 95% confidence interval [CI] 0.027–0.250; P < 0.001), discharge/leakage (OR 0.12, 95% CI 0.04–0.42; P < 0.001), and overall improvement according to patients (OR 5.25, 95% CI 2.58–10.68; P < 0.001) and investigators (OR 5.51, 95% CI 2.76–11.0; P < 0.001). MPFF also tended to decrease pain (OR 0.11, 95% CI 0.01–1.11; P = 0.06).

Conclusion

Taken together, these results suggest that MPFF treatment can improve the most important signs and symptoms of HD.

Comparison of Centella with Flavonoids for Treatment of Symptoms in Hemorrhoidal Disease and After Surgical Intervention: A Randomized Clinical Trial

Phlebotonics’ effects were evaluated to reduce time-to-stop bleeding and anal irritation in 130 patients who complained of hemorrhoidal disease (HD); bleeding and pain after hemorrhoidectomy (31 patients) and hemorrhoidal thrombosis (34 patients) in the short time. Sixty patients were randomized to receive the routine treatment (both conservative and surgical) (control Group C). The treated group (both conservative and surgical) was divided into two subgroups: one treated with flavonoids (Group A, n = 73), the other with Centella (Group B, n = 66). Time-to-stop bleeding was checked at baseline and checkups (0 up to day 42). Healing was estimated with Kaplan-Meier method, the Kruskal-Wallis test estimated changes in the VAS scores. The HD median time-to-stop bleeding was 2 weeks for Groups A and B; 3 weeks for Group C. VAS scores comparison among Groups (irritation): A vs C, p = 0.007; B vs C, p = 0.041; and A vs B, p = 0.782 resulted respectively. As for operated hemorrhoids, the time-to-stop bleeding was 3 and 4 weeks in Groups A and B and 5 in Group C. Histopathology showed an association between flavonoids and piles’ fibrosis (p = 0.008). Phlebotonics in HD, as well as after surgery, showed significant beneficial effects. Flavonoids are the most effective phlebotonics against bleeding and anal irritation.

Treatment of haemorrhoidal disease with micronized purified flavonoid fraction and sucralfate ointment

Hemorrhoidal disease is a very common disease characterized by the presence of a mucous prolapse of the rectum and by varicosis of the hemorrhoidal plexus. Medical therapy is mainly indicated for the treatment of symptoms such as bleeding, pain and itching. The use of the micronized purified flavonoid fraction (MPFF) has proven to be effective in treating symptoms of hemorrhoidal disease. Topical use of sucralfate has shown good results in the reduction of hemorrhoidal pain and itching. Our experience with three cases treated with combined use of MPFF and a topical medical device in the form of rectal ointment, composed by sucralfate and herbal (calendula, witch hazel leaf (hamamelis), chamomile) extracts, has shown good results in terms of pain and itching control and in edema reduction.

Portuguese Society of Gastroenterology Consensus on the Diagnosis and Management of Hemorrhoidal Disease

Hemorrhoidal disease (HD) is a frequent health problem with considerable repercussions on patients' quality of life. However, much of the clinical practice related to HD is based on knowledge without scientific evidence and supported largely by empirical experience of the physician who deals with this pathology. As in other countries, the goal of this consensus is to establish statements supported by solid scientific evidence and whose purpose will be to standardize and guide the diagnosis and management of HD both in the general population and in some particular groups of patients.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Hemorrhoid management in women: the role of tribenoside + lidocaine

Hemorrhoids are commonly reported in women. However, despite the high prevalence of hemorrhoids in women and the major impact of this condition on quality of life, specific evidence and recommendations on the treatment of hemorrhoids in women are scant. This paper reviews various options in current therapy for hemorrhoids in women—namely, medical intervention (topical and systemic drug therapy)—and discusses the available clinical evidence for an appropriate use of over-the-counter topical formulations for the symptomatic treatment of hemorrhoids. Its focus is on a medical preparation containing tribenoside + lidocaine, available as a rectal cream (tribenoside 5%/lidocaine 2%) and a suppository (tribenoside 400 mg/lidocaine 40 mg) and marketed under the brand Procto-Glyvenol^® (Recordati, SpA, Italy). Given its rapid comprehensive efficacy on all the different symptoms of hemorrhoids, the tribenoside + lidocaine combination can find a place in the treatment of this hemorrhoidal disease. Importantly, its efficacy and tolerability have been formally evaluated in several well-conducted studies, some of which were specifically conducted in women. In particular, tribenoside + lidocaine can be safely administered in postpartum women and in pregnant women after the first trimester of pregnancy. In pregnant women, the tribenoside/lidocaine combination significantly improved both subjective and objective symptoms of hemorrhoids. Fast onset of symptom relief was reported from 10 minutes after administration, lasting up to 10–12 hours. On these bases, tribenoside + lidocaine can represent a fast, effective, and safe option to treat hemorrhoids when conservative therapy is indicated, and it deserves consideration as a first-line treatment of this disease in clinical practice.

THE RUSSIAN ASSOCIATION OF COLOPROCTOLOGY CLINICAL GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF HEMORRHOIDS

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Flavonoid mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) in the treatment of I-III degree hemorroidal disease: a double-blind multicenter prospective comparative study

PURPOSE

We evaluated the efficacy of new flavonoids mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) to reduce bleeding from I-III degrees hemorrhoidal disease in the short and medium time.

METHODS

One hundred fifty-four consecutive patients with hemorrhoidal disease recruited in four colorectal units were enrolled to the study. Exclusion criteria were allergy to the flavonoids, inflammatory bowel disease, obstructed defecation syndrome, pregnancy and puerperium, associated anal disease or hemorrhoidal thrombosis, proctologic surgical procedures within 1 year before recruitment, contemporary cancer or HIV, previous pelvic radiotherapy, patients receiving oral anticoagulant therapy, or contemporary administration of other therapy for hemorrhoids. Patients with inability to understand the study or mental disorders were also excluded.

RESULTS

Seventy-eight were randomized to receive the mixture of diosmin, troxerutin, rutin, hesperidin, and quercetin (study group, SG), and 76 a mixture of diosmin in combination with hesperidin, diosmetin, isoroifolin, and linarin in purified micronized fraction (control group, CG). Bleeding, number of pathological piles, and Golligher's grade were assessed at each scheduled visit and compared using the Chi-square test. During the study period, bleeding improved after 1 and 6 months both in the SG (79.5 and 70.5%) and in the CG (80.2 and 75%) without significant differences between two groups. Satisfaction degree after 6 months was greater in the patients of the SG (4.05) towards the CG (3.25): this result was statistical significant (p 0.003).

CONCLUSIONS

Use of flavonoids mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) is a safe and effective mean of managing bleeding from hemorrhoidal disease and minimal adverse events are reported.

Conservative Treatment of Hemorrhoids: Results of an Observational Multicenter Study

Introduction

This study was conducted to determine the frequency of complaints in a cohort of patients with symptomatic hemorrhoidal disease (HD) treated with micronized purified flavonoid fraction (MPFF, Detralex). MPFF was selected for conservative treatment in this population owing to its proven effects on hemorrhoidal symptoms in a large number of patients.

Methods

This multicenter, non-interventional study was part of the international CHORUS survey (Chronic venous and HemORrhoidal diseases evalUation for improvement of Scientific knowledge), conducted in nine centers in different regions of Russia with the participation of 80 coloproctologists. The study enrolled consecutive patients with complaints of hemorrhoids. All were prescribed MPFF-based conservative treatment. The effect of treatment on HD clinical signs and symptoms was assessed at two follow-up visits performed 5–7 days and 25–30 days after enrollment. Surgical and minimally invasive treatment could be performed from day 7 onwards if required.

Results

A total of 1952 patients were enrolled. Over the entire period of observation, MPFF-based conservative treatment was effective in 1489 (76.3%) patients in eliminating the main clinical manifestations of disease, i.e., bleeding and prolapse of internal nodes. Invasive treatment was performed in 68 (3.5%) patients with grade IV hemorrhoids and was combined with MPFF conservative treatment in 395 (20.2%) patients with grades I–III hemorrhoids.

Conclusion

Conservative therapy with MPFF was beneficial for relieving hemorrhoidal symptoms in the majority of patients. MPFF-based treatment was most effective in patients with grade I and II hemorrhoids before irreversible degenerative changes in ligaments of the hemorrhoidal plexuses have occurred. It was also beneficial in preventing disease relapse in patients with more advanced HD and for promoting optimal conditions in the postoperative period.

Funding

Servier.

[Common sense of diosmin administration in combined treatment of hemorrhoids]

Flavonoids are herbal medicines and widely used for chronic venous diseases and hemorrhoids. Flavonoid diosmin in both micronized and non-micronized form is a part of various drugs. According to literature data, flavonoids are able to reduce venous stasis, suppress local inflammation, improve venous tone and lymphatic outflow. It should be noted that biological models of in vivo trials have certain limitations while available data of different researches are contradictory. However, flavonoids were recommended for hemorrhoids in view of meta-analysis of 14 trials comparing flavonoids (diosmin, micronized purified flavonoid fraction and rutosides) with placebo in 1514 patients with hemorrhoids and Cochrane review of 24 randomized controlled trials (2,334 participants). These drugs should be administered as a part of complex therapy. At the same time, there is no conclusive evidence to prefer only one of these medicines. There are also no data confirming the benefits of daily dosage of 3000 mg per day of micronized fraction of flavonoids compared with 1800 mg of purified diosmin per day for treatment of acute hemorrhoids.

A national evaluation of the management practices of hemorrhoidal disease in the Netherlands

PURPOSE

In this study, we describe current practices in the management of hemorrhoidal disease in the Netherlands.

METHODS

A validated online survey was performed among Dutch surgeons and residents treating hemorrhoidal disease. Contact details were retrieved from the Dutch Association for Surgery resulting in 619 contacts. Only doctors who were treating hemorrhoidal disease regularly were asked to complete the questionnaire. The following items were assessed: initial treatment, recurrence, complications, and follow-up.

RESULTS

In total, 133 respondents completed the survey. Ninety percent of the respondents started with rubber band ligation (RBL) as the first treatment in low-grade hemorrhoidal disease. In case of recurrence, 64% of the respondents repeated RBL three times before switching to a more invasive treatment modality. In grade III hemorrhoidal disease, the respondents preferred more invasive techniques: a sutured hemorrhoidopexy was performed in 24%, Doppler-guided hemorrhoidal artery ligation (DG-HAL) in 9%, stapled hemorrhoidopexy in 19%, and the traditional hemorrhoidectomy in 31% of the patients, respectively. The majority of the respondents (39%) reported a mild complication in 5-10% of the patients. The most reported complication was pain. Nearly all the respondents (98%) reported a major complication in less than 5% of the patients. The majority of the patients (57%) were seen in outpatient clinics 6 weeks post-treatment.

CONCLUSION

This Dutch survey showed areas of common practice for primary treatment of hemorrhoidal disease. However, it also demonstrated varying practices regarding recurrent hemorrhoidal disease. Practical guidelines are required to support colorectal surgeons in the Netherlands.

Haemorrhoids: an update on management

Haemorrhoids are common, affecting up to one quarter of all adults according to some estimates. Numerous interventions exist for their management, ranging from topical and medical therapies to outpatient treatments and surgical interventions that aim to fix or excise. Given the polysymptomatic nature of the disease, it is difficult to effectively judge which treatment option is best. Recently introduced novel haemorrhoid management techniques, such as stapled haemorrhoidopexy, Ligasure™ excision and haemorrhoidal artery ligation, aim to reduce harm whilst maintaining or improving on outcome. These new techniques are universally more expensive, and available good quality data suggest the additional cost does not necessarily equate to universally better outcomes compared with traditional older interventions, such as rubber band ligation and excisional haemorrhoidectomy. Whatever the intervention selected for treatment, it is clear that this should be tailored to the individual based on patient choice, convenience and degree of haemorrhoids.

Executive Summary - The Association of Colon & Rectal Surgeons of India (ACRSI) Practice Guidelines for the Management of Haemorrhoids-2016

This paper outlines the recommendations from the Association of Colon & Rectal Surgeons of India (ACRSI) practice guidelines for the management of haemorrhoids-2016. It includes diagnosis and management of haemorrhoids including dietary, non-surgical, and surgical techniques. These guidelines are intended for the use of general practitioners, general surgeons, colorectal surgeons, and gastrointestinal surgeons in India.

Antiplatelet activity of flavonoid and coumarin drugs

Polyphenols are used as phlebotonic drugs, but their mechanism of action remains unknown. Since platelet activity and platelet-endothelial cell interactions are involved in the pathogenesis of cardiovascular disease, this work examines whether different flavonoid and coumarin drugs are able to inhibit platelet aggregation. This specific case of coumarins, the antiplatelet effect is not linked with a possible interaction over blood coagulation since this effect only dicoumarols have it. The antiplatelet capacity of polyphenols was assayed using peripheral blood platelets from healthy controls. The distribution of the different platelets subsets was quantified by flow cytometry, using the calcium ionophore as a pro-aggregant. The number of GPIIb/IIIa receptors occupied by the drugs was assayed by flow cytometry using two CD61 surface fluorescein antibodies. All the polyphenols tested inhibited platelet aggregation. A percentage antiplatelet activity of 88.91±7.98% was recorded for naringin, 48.43±8.84% for naringenin, 53.83±7.87% for esculetin, 54.65±6.91% for fraxetin, and 25.75±4.12% for coumarin. Naringin showed significantly greater percentage occupation of GPIIb/IIIa receptors than did naringenin (14.82±0.81% vs. 3.90±0.55%), and esculetin returned significantly higher values than fraxetin and coumarin (12.47±0.97 vs. 7.53±0.49 and 7.90±0.69 respectively). All drugs show important antiplatelet activity. Naringin was the best antiplatelet compound, showing the greatest antiplatelet activity and the highest percentage binding of GPIIb/IIIa receptors. However, any of the compounds used could be used in the prevention of cardiovascular disease.

Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement

Hemorrhoids are one of the most common medical and surgical diseases and the main reason for a visit to a coloproctologist. This consensus statement was drawn up by the Italian society of colorectal surgery in order to provide practice parameters for an accurate assessment of the disease and consequent appropriate treatment. The authors made a careful search in the main databases (MEDLINE, PubMed, Embase and Cochrane), and all results were classified on the basis of the grade of recommendation (A-C) of the American College of Chest Physicians.

Long-standing hemospermia in a patient with megacava associated to a circumaortic renal vein

Hemospermia may have a broad range of functional and organic causes. It is defined as the presence of blood in seminal fluid and usually tends to resolve spontaneously within a few weeks. We present the case of a patient with a 10-year history of hemospermia associated with megacava and circumaortic renal vein. The diagnosis, treatment, and evolution of the condition are reported. Vascular anomalies are rare causes of chronic hemospermia, and the one described in our patient may constitute the first case reported in the literature.

Flavonoids mixture (diosmin, troxerutin, hesperidin) in the treatment of acute hemorrhoidal disease: a prospective, randomized, triple-blind, controlled trial

BACKGROUND

The role of a mixture of phlebotonics in the treatment of acute hemorrhoid crisis is investigated to test their efficacy.

METHODS

One hundred and thirty-four consecutive patients with an acute hemorrhoidal crisis recruited in five colorectal units entered the study. Sixty-six of them were randomized to receive a mixture of diosmin, troxerutin and hesperidin (group A), and 68 a placebo (group B). The main symptoms, the use of oral painkillers and the Bristol scale score were recorded at each scheduled visit and compared using both Student's t test for independent samples and the ANOVA models for repeated measures. The presence of edema, prolapse and thrombosis were also recorded and compared using the Chi-square test. Furthermore, the trend of proportions during the time of the evaluations was assessed by the Chi-square test for linear trend.

RESULTS

Pain, bleeding and the proportion of patients who reported persistence of edema and thrombosis decreased significantly after 12 days of treatment in group A. After 6 days, the number of paracetamol tablets taken by patients in group A was significantly lower than the amount of flavonoid mixture.

CONCLUSIONS

The use of a mixture of diosmin, troxerutin and hesperidin is a safe and effective mean of managing symptoms of acute hemorrhoidal disease. Furthermore, in patients receiving treatment, there was faster control and lower persistence of edema and thrombosis.

Evidências sobre tratamentos clínicos conservadores para doença hemorroidária

Objetivo: o objetivo desta avaliação de tecnologia em saúde foi analisar as evidências sobre tratamentos clínicos conservadores para doença hemorroidária utilizáveis na Atenção Primária à Saúde. Métodos: buscou-se no Embase, LILACS e MEDLINE via Pubmed por meta-análises, revisões sistemáticas e ensaios clínicos controlados e aleatorizados, publicados até dezembro de 2012, sem limite de linguagem. Os estudos deveriam avaliar os efeitos dos tratamentos clínicos conservadores (fibras ou laxantes, flavonoides, analgésicos, corticosteroides, banhos de assento ou pomadas de nitroglicerina) comparados a placebo ou entre si. Os desfechos considerados foram: melhora global dos sintomas, sangramento, prurido, dor, prolapso e efeitos adversos. Resultados: uma meta-análise demonstrou que fibras promovem melhora global dos sintomas e do sangramento e diminuem a recorrência após procedimentos ambulatoriais. Três meta-análises mostraram a eficácia de flavonoides para sangramento agudo e pós-operatório, melhora global dos sintomas, exsudação perianal e recorrência após episódio agudo. Não houve diferença estatística para prurido, dor, prolapso ou efeitos adversos nos dois casos. Flavonoides do tipo rutosídeos reduziram sintomas em gestantes, apesar da insuficiência dos dados para comprovar sua segurança. Não foram encontrados estudos que preenchessem os critérios de seleção para os demais tipos de tratamento. Conclusões: fibras ou flavonoides orais podem ser utilizados na atenção primária para a melhora global dos sintomas e sangramento na doença hemorroidária graus I e II; para paciente grau III que não deseje se submeter a procedimento ambulatorial; e no pós-operatório. Ensaios clínicos controlados e aleatorizados com qualidade metodológica adequada são necessários para confirmar estes resultados.

Modern management of hemorrhoidal disease

Complaints secondary to hemorrhoidal disease have been treated by health care providers for centuries. Most symptoms referable to hemorrhoidal disease can be managed nonoperatively. When symptoms do not respond to medical therapy, procedural intervention is recommended. Surgical hemorrhoidectomy is usually reserved for patients who are refractory to or unable to tolerate office procedures. This article reviews the pathophysiology of hemorrhoidal disease and the most commonly used techniques for the nonoperative and operative palliation of hemorrhoidal complaints.

Approach to hemorrhoids

Hemorrhoids are a very common anorectal disorder defined as the symptomatic enlargement and abnormally downward displacement of anal cushions. The current pathophysiologies of hemorrhoids include the degenerative change of supportive tissue within the anal cushions, vascular hyperplasia, and hyperperfusion of hemorrhoidal plexus. Low-grade hemorrhoids are easily and effectively treated with dietary and lifestyle modification, medical intervention, and some office-based procedures. An operation is usually indicated in symptomatic high-grade and/or complicated hemorrhoids. Whilst hemorrhoidectomy has been the mainstay of surgical treatment, more recently other approaches have been employed including Ligasure hemorrhoidectomy, stapled hemorrhoidopexy, and doppler-guided hemorrhoidal artery ligation. Post-procedural pain and disease recurrence remain the most challenging problems in the treatment of hemorrhoids. This article deals with modern approaches to hemorrhoids based on the latest evidence and reviews of the literature. The management of hemorrhoids in complicated situations is also discussed.