Meta-analysis of flavonoids for the treatment of haemorrhoids

Efficacy of Micronized Purified Flavonoid Fraction in the Posthemorrhoidectomy Period Trial: Open-Label Randomized Controlled Trial

BACKGROUND

Frequent early postoperative complications of hemorrhoidectomy are thrombosis and edema of mucocutaneous "bridges."

OBJECTIVE

This study aimed to investigate the efficacy of micronized purified flavonoid fraction in preventing complications after elective hemorrhoidectomy.

DESIGN

Prospective unicentral open-label randomized controlled trial.

SETTINGS

2021-2022 at the Clinic of Colorectal and Minimally Invasive Surgery at Sechenov University (Moscow, Russia).

PATIENTS

Patients who underwent hemorrhoidectomy for grade III and IV hemorrhoids.

INTERVENTIONS

After hemorrhoidectomy, patients were randomly assigned either to standard treatment (peroral nonsteroid anti-inflammatory drugs and local anesthetics, topical steroids, psyllium, warm sitz baths, and nifedipine gel), referred to as the control group, or to standard treatment with micronized purified flavonoid fraction, referred to as the study group, and followed up for 60 days.

MAIN OUTCOME MEASURES

Thrombosis or edema of mucocutaneous bridges and pain intensity on a visual analog scale оn postoperative days 1-7, 14, 21, and 30; quality of life and patient-assessed treatment effect оn postoperative days 1, 3, 7, 21, and 30; and perianal skin tags оn postoperative day 60.

RESULTS

The data from 50 patients were analyzed (25 in each group). The visual analog scale demonstrated no differences between groups in each follow-up point. Compared to the control group, the patients in the study group had a significantly higher patient-assessed treatment effect оn postoperative days 1, 3, 7, 21, and 30 and a significantly lower rate of thrombosis or edema of mucocutaneous bridges оn postoperative days 1-7 and 14. Patients in the study group had significantly lower rates of perianal skin tags.

LIMITATIONS

Unicenter open-label design.

CONCLUSIONS

Micronized purified flavonoid fraction in the posthemorrhoidectomy period is an effective adjunct to standard treatment that helps reduce the rate of thrombosis and edema of mucocutaneous bridges, improves patient-assessed treatment effect, and prevents postoperative perianal skin tags formation. Micronized purified flavonoid fraction in the posthemorrhoidectomy period is not associated with additional pain relief in comparison with nonmicronized purified flavonoid fraction standard treatment. See Video Abstract .

EFICACIA DE LA FRACCIN DE FLAVONOIDES PURIFICADA MICRONIZADA EN EL PERODO POSTERIOR A LA HEMORROIDECTOMA ENSAYO MOST ENSAYO CONTROLADO, ALEATORIZADO, ABIERTO

ANTECEDENTES:Una complicación postoperatoria temprana frecuente de la hemorroidectomía es la trombosis y el edema de los "puentes" mucocutáneos.OBJETIVO:Investigamos la eficacia de la fracción de flavonoides purificada micronizada en la prevención de complicaciones después de una hemorroidectomía electiva.DISEÑO:Ensayo controlado aleatorio, prospectivo, unicentral, abierto.AJUSTES:2021-2022 Clínica de Cirugía Colorrectal y Mínimamente Invasiva Universidad Sechenov (Moscú, Rusia).PACIENTES:Pacientes después de hemorroidectomía, que se realizó para hemorroides de grado III-IV.INTERVENCIONES:Después de la hemorroidectomía, los pacientes fueron asignados aleatoriamente al tratamiento estándar (antiinflamatorios no esteroides perorales y anestésicos locales, esteroides tópicos, psyllium, baños de asiento tibios, gel de nifedipina) - grupo de control, o al tratamiento estándar con flavonoide purificado micronizado. fracción (grupo de estudio) y seguido durante 60 días.RESULTADOS DE MEDIDAS PRINCIPALES:Trombosis o edema de puentes mucocutáneos e intensidad del dolor en una escala analógica visual entre el 1.º, 7.º, 14.º, 21.º y 30.º día postoperatorio; calidad de vida y efecto del tratamiento evaluado por el paciente el día 1, 3, 7, 21 y 30 del postoperatorio; Marcas cutáneas perianales en el día 60 del postoperatorio.RESULTADOS:Se analizaron los datos de 50 pacientes (25 en cada grupo). La escala analógica visual no demostró diferencias entre grupos en cada punto de seguimiento. En comparación con el grupo de control, los pacientes en el grupo de estudio tuvieron un efecto del tratamiento evaluado por el paciente significativamente mayor en los días 1, 3, 7, 21 y 30 después de la operación, una tasa significativamente menor de trombosis o edema de los puentes mucocutáneos en los días 1, 7 y 14.. Los pacientes del grupo de estudio tuvieron tasas significativamente más bajas de marcas en la piel perianal.LIMITACIONES:Diseño Unicenter de etiqueta abierta.CONCLUSIONES:La fracción de flavonoides purificada micronizada en el período posterior a la hemorroidectomía es un complemento eficaz del tratamiento estándar que ayuda a reducir la tasa de trombosis y edema de los puentes mucocutáneos, mejora el efecto del tratamiento evaluado por el paciente y previene la formación de marcas cutáneas perianales posoperatorias. La fracción de flavonoides purificados micronizados en el período posterior a la hemorroidectomía no se asocia con un alivio adicional del dolor en comparación con el tratamiento estándar con la fracción de flavonoides purificados no micronizados. (Traducción-Yesenia Rojas-Khalil ).

Identification of bioactive components on antihemorrhoidal activity of Cistus laurifolius L. using RP-HPLC and LC-QTOF-MS

ETHNOPHARMACOLOGICAL RELEVANCE

Cistus laurifolius is widely used in folk medicine in Anatolia for the treatment of many ailments. The leaves of the plant are used in the form of tea in the treatment of hemorrhoids in the Western Black Sea Region and Central Anatolia.

AIMS OF THE STUDY

It was aimed at evaluating the anti-hemorrhoidal effects of C. laurifolus leaves in croton oil-induced hemorrhoid model in rats.

MATERIALS AND METHODS

The methanolic and aqueous extracts of C. laurifolius were tested for in vivo anti-hemorrhoidal efficacy using an experimental hemorrhoid model, followed by histological and biochemical analysis. Hemorrhoid was created by using croton oil on the anal region of the rats. TNF-α and VEGF mRNA expression levels were assessed using real-time PCR detections. The extract was also tested for anti-inflammatory properties, which are based on the suppression of an increase in capillary permeability caused by acetic acid. LC-QTOF-MS and RP-HPLC were used for the phytochemical analysis.

RESULTS

In comparison to the control, histological and biochemical assessment showed that the methanolic extract of C. laurifolius is particularly effective against hemorrhoids. The same extract group's TNF-α mRNA expression was found to be the lowest. Additionally, the methanolic extract showed a strong inhibitory effect on the increase in capillary permeability resulted on by acetic acid. Three phenolic compounds were discovered in the extracts by phytochemical analyses, while more than eighteen compounds were found by LC-QTOF-MS analysis. Five of these compounds are phenolic acid derivatives, and flavonoids constitute the majority of the group.

CONCLUSION

This is the first evidence from the research that C. laurifolius possesses strong anti-inflammatory and anti-hemorrhoidal properties.

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.

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.

Top 100 most-cited articles on hemorrhoids: A bibliometric analysis and visualized study

Background

Hemorrhoids have a significant incidence in people and are becoming a common public health problem. This study provides a bibliometric and visualized analysis of the most influential literature in the field. The aim is to reveal trends in the field of hemorrhoids and to provide a reference for researchers.

Methods

The 100 most frequently cited studies in the field of hemorrhoids were collected from the Web of Science(WOS), and were analyzed in terms of the annual publication, types of literature, countries, institutions, authors, journals, and keywords. During the study, we used a combination of VosViewer, Carrot2, Microsoft Excel, and Tableau tools to better present the visual information.

Results

A total of 4,481 articles were retrieved, of which 3,592 were of the Article and Review types, among which we selected the 100 most frequently cited. A large amount of highly cited literature on hemorrhoid surgery emerged from 1990 to 2010, and the interest of researchers in hemorrhoid surgery seems to have waned after 2010. The sources of highly cited literature in the field of hemorrhoids are predominantly Western, with the United States. and the United Kingdom accounting for almost half of the publications worldwide. However, countries with higher prevalence populations do not have significant research on hemorrhoids. St. Mark's Hospital has published the largest number of influential articles in the field of hemorrhoid disease. Kamm MA and Phillips RKS are the most authoritative authors in the field. Diseases of the Colon & Rectum and the British Journal of Surgery are the most influential journals in this field. The highly cited literature covers a wide range of disciplines, with Thomson's classic “The nature of hemorrhoids” receiving the most attention among the studies focusing on hemorrhoids. Keyword and clustering analysis revealed that The most famous focus in the field of hemorrhoid research is the evolution of stapled hemorrhoidectomy (SH) and Milligan-morgan hemorrhoidectomy (MMH).

Conclusions

This study is the first to explore developments in the field of hemorrhoids, and it helps surgeons quickly understand global trends in the field of hemorrhoids. In recent years, the development of hemorrhoids seems to have hit a bottleneck, with scholarly interest in the field of waning, especially in surgery Procedures. The theory of inferior anal cushion migration has proven to be the most influential theory in the field, but after studies based on SH and MMH, more high-quality evidence is needed to continue advancing the field of hemorrhoids. The results of this study are intended to add to the attention and interest of scholars in this area and provide a reference for further research.

Efficacy and safety of micronized purified flavonoid fractions for the treatment of postoperative hemorrhoid complications: A systematic review and meta-analysis

BACKGROUND

Hemorrhoids, a common anorectal disease, seriously affects patients' quality of life. Micronized purified flavonoid fractions (MPFF) have been shown to improve hemorrhoid symptoms.

PURPOSE

To evaluate the efficacy and safety of MPFF in treating postoperative hemorrhoid complications.

STUDY DESIGN

A systematic review and meta-analysis of existing literature on natural compounds for treating postoperative complications of hemorrhoids.

METHODS

A literature search was conducted using five databases, namely PubMed, WanFang, CNKI, Embase, and the Cochrane Library, to identify randomized controlled trials (RCTs) on the effects of MPFF treatment on hemorrhoids. Stata 15.1 and Revman 15.4 were used to assess the data, while subgroup and sensitivity analyses were performed to evaluate potential heterogeneity, and trial sequential analysis (TSA) and Egger test were used to evaluate the reliability of each trial.

RESULTS

A total of 22 RCTs, including 2,335 participants were included in the analysis. MPFF improved the clinical efficacy of post-hemorrhoidectomy and reduced the bleeding rate, pain score, and edema score, although no substantial effect on adverse reactions was reported. Subgroup analyses showed a significant reduction in pain score and bleeding rate in trials with duration of 4-10 days and an improvement in clinical efficacy. Treatment for ≥ 10 days significantly improved the edema score; a dosage range of 1,800-2,700 mg/day of MPFF significantly reduced edema and pain scores, whereas < 1,800 mg/day significantly improved clinical efficacy.

CONCLUSIONS

Based on searching the relevant literatures, this is the first meta-analysis on MPFF treatment of postoperative hemorrhoid complications. Our findings, validated by TSA, suggest that MPFF is safe and effective in reducing postoperative hemorrhoid complications, and that dose and duration are key factors in its efficacy, as illustrated by subgroup analysis. However, due to the small sample size, the standardized treatment regimen of MPFF could not be obtained; therefore, further research is warranted.

Perianal Diseases in Pregnancy and After Childbirth: Frequency, Risk Factors, Impact on Women's Quality of Life and Treatment Methods

Hemorrhoids and anal fissures occur in about 40% of pregnant women and women during postpartum period. Usually they occur during the third trimester of pregnancy and 1–2 days after giving birth. Constipation during pregnancy, perianal diseases during previous pregnancy and childbirth, instrumental delivery, straining duration of more than 20 min, and weight of the newborn more than 3,800 g are associated with hemorrhoids. Perianal diseases reduce the quality of life of both pregnant and postpartum women. In the absence of acute conditions, surgical treatment of hemorrhoids is delayed after pregnancy, childbirth, and lactation. Thrombosed internal hemorrhoids and perianal thrombosis are to be treated conservatively in most instances by prescribing adequate pain relief, oral, and topical flavonoid preparations.

[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.

Cissus quadrangularis L: A comprehensive multidisciplinary review

ETHNOPHARMACOLOGICAL RELEVANCE

Cissus quadrangularis L. is a perennial herb of the Vitaceae family and is utilized comprehensively as a medicinal herb in most tropical regions by various names. This herb is documented to possess a wide-ranging ethnomedicinal uses in malaria, fever, epilepsy, gout, piles, skin diseases, colic, etc. AIM OF THE REVIEW: A organized summary of the botany, traditional uses, phytochemistry, pharmacology, toxicology, available marketed formulations and filed patents were presented to explore the future therapeutic potential and scientific potential of this herb.

MATERIALS AND METHODS

For a review of the literature, various databases were searched, including PubMed, EMBASE, and Scopus etc. From, total 408 records of this herb, we have screened 155 articles consist of desired information and available as full text. Present manuscript is structured from comprehensive information on this herb from screened 155 records. Plant taxonomy was confirmed to the database "The Plant List".

RESULTS

Phytochemical assessment as a whole indicated the presence of flavonoids, triterpenoids, alkaloids, saponins, iridoids, stilbenes, vitamins, steroids, and glycosides. A toxicity study revealed that its LD₅₀ value is above 3000 mg/kg in animals indicating its safety. A variety of pharmacological studies of aerial parts of this herb by different extracts have demonstrated analgesic, anti-inflammatory, anticonvulsant, antimicrobial, anticancer, anti-osteoporotic activity and other bone-related disorders to justify its name as Hadjod. Still, the herb has been utilized in clinical practice and several patents were filed in India and US for its antiosteoporotic property.

CONCLUSION

The studies on Cissus quadrangularis Linn. are extensive, but gaps still remain. The molecular mechanism, structure-activity relationship, potential synergistic and antagonistic effects of these components needs to be further elucidated. These findings suggest the need for further research on this herb for the management of several other chronic ailments.

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.

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).

Micronized purified flavonoid fraction in the treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is common in adults. Treatment is largely conservative, although more invasive procedures may be required. Venoactive drugs such as micronized purified flavonoid fraction (MPFF) are widely used, but a recent and comprehensive review of supporting evidence is lacking. In acute HD, MPFF can reduce HD symptoms such as bleeding, pain, anal discomfort, anal discharge and pruritus. In patients undergoing surgery, postoperative adjunct MPFF consistently reduces pain, bleeding duration and use of analgesia. MPFF treatment is appropriate and effective both as a first-line conservative treatment and as a postoperative adjunct treatment. MPFF reduces the duration of hospital stay following surgery, facilitating a return to normal activity and improving quality of life. MPFF may also prevent HD recurrence.

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.

Experiences of patients with haemorrhoidal disease – a qualitative study

Purpose To obtain a better understanding of the patients’ experiences with haemorrhoidal disease’ impact on their daily life and results of treatment by performing a qualitative study.

Method Individually interviews were conducted among patients with haemorrhoidal disease between 2016 and 2017. Each interview was recorded using an audio recorder and transcribed verbatim. A semi-structured interview guide was used with pre-specified topics, based on a previous conducted literature review. Transcripts were coded and the analysis consisted highlighting passages in the text and assigning each passage a code representing the predefined themes from the interview guide. This resulted in a three-level theme hierarchy: overarching theme, mid-level sub-theme and issues.

Results Fifteen participants underwent individual interviews of whom thirteen were conducted by telephone. The mean age was 60.7 years (35–78); five of them were female (33.3%). Pain and blood loss were the most frequently reported symptoms. Participants indicated that these symptoms were directly associated with emotional burden, daily adjustments and social impact. Before diagnosis with haemorrhoidal disease blood loss resulted in feelings of fear and next in embarrassment during social activities. In daily life participants needed to get up early, used sanitary pads for blood loss and anal ice sticks to reduce pain. Participants were often not completely satisfied with the process and outcome of treatment.

Conclusion This first qualitative study provides detailed insight into the patients’ experiences with haemorrhoidal disease, impact on daily life and results of treatment. This information may be used in daily practice to create awareness among clinicians.

Role of micronize purified flavonoid fraction and ethanol Graptophyllum pictum extract on experimental anal ulcer healing. Study on Wistar rat

Aim of the study To evaluate the role of micronized purified flavanoid fraction and ethanol Graptophyllum pictum extract in the treatment of anal ulcer.

Method Twenty-eight Wistar rats were randomly allocated into four groups. Groups 2, 3 and 4 the anus were induced with croton oil, but was not induced on group 1. Groups 1 and 2 were treated with normal saline, while groups 3 and 4 were treated with micronized purified flavanoid fraction, and ethanol G. pictum extract, respectively. On 9th days blood sample were taken from the retro-orbital region, and Wistar was killed by cervical dislocation under ether anesthesia. The anal canal was resected up 2 cm from anal opening, weighted, photographically taken to measure the percentage of residual ulcer, and then prepared for microscopic examination. Elisa methods were done for superoxide dismutase and malondialdedhyde. The total leukocyte in the anal specimen was counted under 400 magnification power. superoxide dismutase, anal coefficient, and total leukocyte for statistical analysis were using ANOVA and LSD, while malondialdedhyde and percentage of ulcers were using Kruskal–Wallis and Mann–Whitney.

Result Treatment with ethanol G. pictum extract dose of 100 mg/kg BW significantly reduces the percentage of anal ulcer, the edema, leukocyte infiltration, and malondialdedhyde, and increase the superoxide dismutase in comparison without treatment. Treatment with micronized purified flavanoid fraction did not reduce the leukocyte, anal coefficient, and percentage of anal ulcer, only increase malondialdedhyde and decrease superoxide dismutase significantly.

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.

Anti-hemorrhoidal activity of Lian-Zhi-San, a traditional Chinese medicine, in an experimental hemorrhoidal model in rats

OBJECTIVE

Hemorrhoidal disease (HD) is the most common proctological disease, with an estimated prevalence rate of 4.4%, and a peak in individuals between 45 and 65 years of age. This study was done to evaluate whether Lian-Zhi-San (LZS), a clinically used anti-hemorrhoidal ointment could alleviate the inflammatory injury, with its associated changes of inflammatory cytokines and morphology of anorectal tissues, in an experimental model of HD in rats.

METHODS

HD was induced by croton oil preparation (COP) applied to the anorectal region. Rats were then treated with cotton swabs soaked in LZS ointment, water or white vaseline, twice a day for 7 d. At the end of the experiment, HD was evaluated by measuring hemorrhoidal and biochemical parameters along with histopathological observations.

RESULTS

In this study, COP induced a significant increase in the macroscopic severity score, anorectal coefficient and Evans blue extravasation, compared to normal rats. Additionally, it greatly enhanced the expression and secretion levels of some important inflammation-related cytokines along with marked histological damage, compared to normal rats. Rats treated with LZS ointment experienced significantly ameliorated Evans blue extravasation (P < 0.05), decreased macroscopic severity score (0.86 ± 0.14 vs. 1.65 ± 0.16) and the anorectal coefficient (P < 0.01); its use also attenuated tissue damage and inhibited the expression and secretion levels of inflammation-related cytokines (interleukin-1β, interleukin-6 and tumor necrosis factor-α).

CONCLUSION

This study validates a preliminary understanding of the use of LZS ointment to treat inflammatory factors and tissue damage in an experimental model of HD in rats.

Calcium Dobesilate Versus Flavonoids for the Treatment of Early Hemorrhoidal Disease: A Randomized Controlled Trial

Background and Aim

Early hemorrhoidal disease is usually treated conservatively with fiber diet and medical therapy with flavonoids or calcium dobesilate. The purpose of this study was to compare the efficacy of these two agents in the treatment of early hemorrhoidal disease.

Materials and Methods

Patients having grade I and grade II hemorrhoidal disease were recruited in the study. One group received flavonoid therapy and the other group took calcium dobesilate treatment for three weeks. The symptoms and size of hemorrhoids were then assessed at the fourth week.

Results

 In this study, 70.2% of patients were male and 29.8% of patients were female. Of the total patients, 58.65% of patients were below 45 years of age and 41.34% of patients were above 45 years of age. Moreover, 83.65% of patients had grade II hemorrhoids, whereas 16.34% of patients had grade I hemorrhoids; 80.8% of patients showed a decrease in frequency and amount of bleeding after being treated by flavonoids, whereas 67.3% showed a decrease in frequency and amount of bleeding after administration of calcium dobesilate. A decrease in the size of hemorrhoids was seen in 67.3% of patients after treatment with flavonoids and 38.46% after giving calcium dobesilate.

Conclusions

Treatment of early hemorrhoidal with flavonoid therapy was more effective in improving the symptoms of disease as compared to calcium dobesilate treatment.

European Society of ColoProctology: guideline for haemorrhoidal disease

AIM

The goal of this European Society of ColoProctology project was to establish a multidisciplinary, international guideline for haemorrhoidal disease (HD) and to provide guidance on the most effective (surgical) treatment for patients with HD.

METHODS

The development process consisted of six phases. In phase one we defined the scope of the guideline. The patient population included patients with all stages of haemorrhoids. The target group for the guideline was all practitioners treating patients with haemorrhoids and, in addition, healthcare workers and patients who desired information regarding the treatment management of HD. The guideline needed to address both the diagnosis of and the therapeutic modalities for HD. Phase two consisted of the compilation of the guideline development group (GDG). All clinical members needed to have affinity with the diagnosis and treatment of haemorrhoids. Further, attention was paid to the geographical distribution of the clinicians. Each GDG member identified at least one patient in their country who could read English to comment on the draft guideline. In phase three review questions were formulated, using a reversed process, starting with possible recommendations based on the GDG's knowledge. In phase four a literature search was performed in MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews. The search was focused on existing systematic reviews addressing each review question, supplemented by other studies published after the time frame covered by the systematic reviews. In phase five data of the included papers were extracted by the surgical resident (RT) and checked by the methodologist (JK) and the GDG. If needed, meta-analysis of the systematic reviews was updated by the surgical resident and the methodologist using Review Manager. During phase six the GDG members decided what recommendations could be made based on the evidence found in the literature using GRADE.

RESULTS

There were six sections: (i) symptoms, diagnosis and classification; (ii) basic treatment; (iii) outpatient procedures; (iv) surgical interventions; (v) special situations; (vi) other surgical techniques. Thirty-four recommendations were formulated.

CONCLUSION

This international, multidisciplinary guideline provides an up to date and evidence based summary of the current knowledge of the management of HD and may serve as a useful guide for patients and clinicians.

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.

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.

Role of a Micronized Purified Flavonoid Fraction as an Adjuvant Treatment to Rubber Band Ligation for the Treatment of Patients With Hemorrhoidal Disease: A Longitudinal Cohort Study

Purpose

Nonsurgical treatment of hemorrhoidal disease (HD) includes medical and instrumental techniques. We aimed to compare the efficacy of the most frequently used nonsurgical strategies, either alone or in combination, applied in an ambulatory setting.

Methods

Patients who received nonsurgical treatment for HD by proctology appointment at the Gastroenterology Department of Braga Hospital were evaluated. Isolated rubber band ligation (RBL) and a combination of RBL with a micronized purified flavonoid fraction (MPFF) were the 2 most frequently used strategies. Symptoms of HD (bleeding, pruritus, pain at rest, pain at defecation and prolapse) were assessed at days 0, 7, and 28 by using a severity grading scale (0 to 4/5). A Global Symptom score was constructed to assess the overall severity and compare the overall improvements of the HD symptoms between the 2 most frequently used strategies.

Results

Nineteen patients underwent the combined treatment (RBL + MPFF group) and 25 the RBL treatment (RBL group). A comparison of the 2 treatment groups showed significant improvements in the combined treatment group in terms of bleeding at days 7 (P = 0.001) and 28 (P = 0.002) and in the pruritus intensity during the first week (P < 0.001). A trend toward clinical benefit was also verified in the combined treatment group for all other HD symptoms (pain at rest, pain at defecation and prolapse).

Conclusion

A combined treatment approach with MPFF and RBL significantly reduced the intensity of bleeding during the first month and the pruritus during the first week.

Symptoms in Dilating Venous Disease

Lower extremity venous diseases or insufficiency include clinically deteriorating conditions with morphological and functional alterations of the venous system, including venous hypertension, vascular wall structural abnormality, and venous valvar incompetency in association with an inflammatory process. In fact, the same pathophysiological processes are the main underlying mechanisms of other venous insufficiencies in different vascular territories such as Peripheral Varicose Vein (PVV), varicocele, Pelvic Varicosities or Congestion Syndrome (PCS) and Hemorrhoidal Disease (HD). Regarding the anatomical continuity of lower extremity venous system, urogenital system (pampiniform plexus in male and broad ligament and ovarian veins in female) and anorectal venous system, it is reasonable to expect common symptoms such as pain, burning sensation, pruritis, swelling, which arise directly from the involved tissue itself. High coexistence rate of PVV, varicocele/PCS and HD between each other underlines not only the same vascular wall abnormality as an underlying etiology but also the existence of common symptoms originating from the involved tissue in dilating venous disease. Accordingly, it might be reasonable to query the common symptoms of venous dilating disease in other venous vascular regions in patients with complaints of any particular venous territory.

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.

European Society of Coloproctology Core Outcome Set for haemorrhoidal disease: an international Delphi study among healthcare professionals

AIM

There is considerable heterogeneity in outcomes in studies reporting on the treatment of haemorrhoidal disease (HD). The aim of this study was to develop a Core Outcome Set (COS) for HD in cooperation with the European Society of Coloproctology.

METHOD

A Delphi study was performed according to the Outcome Measures in Rheumatology (OMERACT) methodology. In total 38 healthcare professionals and 30 patients were invited to the panel. Previously, 10 outcome domains and 59 outcomes were identified through a systematic literature review. In this study, these domains and outcomes were formed into one questionnaire for healthcare professionals and a separate questionnaire for patients. Sequential questionnaire rounds prioritizing the domains and outcomes were conducted. Panel members were asked to rate the appropriateness of each domain and outcome on a nine-point Likert scale. During a face-to-face meeting, healthcare professionals agreed on the primary and secondary end-points of the COS for HD. Finally, a short survey was sent to the healthcare professionals in order to reach consensus on how the chosen end-points should be assessed and at which time points.

RESULTS

The response rate in questionnaire round 1 for healthcare professionals was 44.7% (n = 17). Sixteen out of 17 healthcare professionals also completed the questionnaire in round 2. The response rate for the patient questionnaire was 60% (n = 18). Seventeen healthcare professionals participated in the face-to-face meeting. The questionnaire rounds did not result in a clear-cut selection of primary and secondary end-points. Most domains and outcomes were considered important, and only three outcomes were excluded. During the face-to-face meeting, agreement was reached to select the domain 'symptoms' as primary end-point, and 'complications', 'recurrence' and 'patient satisfaction' as secondary end-points in the COS for HD. Furthermore, consensus was reached that the domain 'symptoms' should be a patient reported outcome measure and should include the outcomes 'pain' and 'prolapse', 'itching', 'soiling' and 'blood loss'. The domain 'complications' should include the outcomes 'incontinence', 'abscess', 'urinary retention', 'anal stenosis' and 'fistula'. Consensus was reached to use 'reappearance of initial symptoms' as reported by the patient to define recurrence. During an additional short survey, consensus was reached that 'incontinence' should be assessed by the Wexner Fecal Incontinence Score, 'abscess' by physical examination, 'urinary retention' by ultrasonography, 'anal stenosis' by physical examination, and 'fistula' by physical examination and MR imaging if inconclusive. During follow-up, the outcome 'symptoms' should be assessed at baseline, 7 days, 6 weeks and 1 year post-procedure. The outcomes 'abscess' and 'urinary retention' should be assessed 7 days post-procedure and 'incontinence', 'anal stenosis' and 'fistula' 1 year post-procedure.

CONCLUSIONS

We developed the first European Society of Coloproctology COS for HD based on an international Delphi study among healthcare professionals. The next step is to incorporate the patients' perspective in the COS. Use of this COS may improve the quality and uniformity of future research and enhance the analysis of evidence.

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.

Efficacy and tolerability of micronized purified flavonoid fractions (MPFF) for haemorrhoids: A systematic review and meta-analysis

OBJECTIVE

To present a systematic review of randomised controlled trials (RCTs) examining the effects of MPFF in the management of haemorrhoid symptoms.

METHODS

Electronic databases including CENTRAL, CINAHL, EMBASE, MEDLINE were searched up to April 2018 for relevant RCTs. Journal and conference proceedings were also searched. Two review authors independently selected trials, extracted data, assessed the risks of bias in included trials and graded the quality of evidence. Meta-analyses were conducted for studies presenting similar outcomes.

RESULTS

Ten RCTs involving 1164 participants were included. These RCTs varied in terms of patients' grade of haemorrhoids, length of trials, and outcome assessed. Most of the studies did not describe adequately the process of randomisation and allocation concealment. The pooled analysis of data from three studies indicated that there was significant difference between groups for the bleeding outcome, favoring the MPFF group (RR 1.46; 95% CI 1.10-1.93; p = 0.008). Except for bleeding, the current evidence did not show MPFF has significant effects on all the other outcomes examined when compared with placebo. Even then, the quality of evidence for bleeding was judged as low due to the small number and inconsistent results among the included studies.

CONCLUSION

This review highlights the need for further rigorous research if MPFF was to be routinely used for the treatment of haemorrhoid symptoms.

Traditional and modern aspects of hemorrhoid treatment in Iran: a review

Hemorrhoidal disease is a prevalent anorectal condition which is generally not managed well with current pharmacologic interventions. However, in Iranian traditional medicine (ITM) there are numerous plants with hemorrhoid-healing properties. The present research assembled plants with hemorrhoid-healing properties in ITM; their related pharmacological effects, phytochemical constituents and mechanisms of action in the modern medicine were also gathered. For this purpose, leading ITM textbooks were searched for plants with hemorrhoid-healing effects. Further, in vitro, in vivo and clinical studies on the most cited species were considered using scientific databases. Studying ITM textbooks revealed 37 medicinal plants with hemorrhoid-healing effects. Among the mentioned herbal medicines, six species, including Allium ampeloprasum, Phyllanthus emblica, Aloe vera, Terminalia chebula, Vitis vinifera and Commiphora mukul, had the largest number of related pharmacological effects documented in scientific databases. These herbs from ITM should be considered as important resources for producing novel drugs for hemorrhoid treatment.

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.

An Evidence-Based Study on Medicinal Plants for Hemorrhoids in Medieval Persia

Hemorrhoids is one of the most common gastrointestinal diseases. There are several therapeutic options associated with some complications. Therefore, researchers look for traditional medicines as a potential resource for introduction of new natural drugs. The current study reports an evidence-based review of herbal remedies for hemorrhoids in traditional Persian medicine. A comprehensive survey about hemorrhoids on the most important manuscripts of traditional Persian medicine was done. Then, scientific data banks were searched for possible related properties of each herb in the conventional medicine. We reported some historical aspects of traditional Persian medicine view on classification, examination, and predisposing factors of hemorrhoids. In addition, we have reported 105 medicinal plants belonging to 51 families. More than half of the reported herbs exhibited anti-inflammatory and analgesic effects. Although lack of human studies regarding the mentioned herbs is noted, positive results from experimental findings can be considered for new drug discovery supported by traditional and medieval experiences.

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.

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.

The efficacy of Shugan Jianpi Zhixie therapy for diarrhea-predominant irritable bowel syndrome: a meta-analysis of randomized, double-blind, placebo-controlled trials

Background

Shugan Jianpi Zhixie therapy (SJZT) has been widely used to treat diarrhea-predominant irritable bowel syndrome (IBS-D), but the results are still controversial. A meta-analysis of randomized, double-blind, placebo-controlled trials was performed to assess the efficacy and tolerability of SJZT for IBS-D.

Methods

The MEDLINE, EMBASE, Cochrane Library, the China National Knowledge Infrastructure database, the Chinese Biomedical Literature database and the Wanfang database were searched up to June 2014 with no language restrictions. Summary estimates, including 95% confidence intervals (CI), were calculated for global symptom improvement, abdominal pain improvement, and Symptom Severity Scale (BSS) score.

Results

Seven trials (N=954) were included. The overall risk of bias assessment was low. SJZT showed significant improvement for global symptom compared to placebo (RR 1.61; 95% CI 1.24, 2.10; P =0.0004; therapeutic gain = 33.0%; number needed to treat (NNT) = 3.0). SJZT was significantly more likely to reduce overall BSS score (SMD –0.67; 95% CI –0.94, –0.40; P < 0.00001) and improve abdominal pain (RR 4.34; 95% CI 2.64, 7.14; P < 0.00001) than placebo. The adverse events of SJZT were no different from those of placebo.

Conclusions

This meta-analysis suggests that SJZT is an effective and safe therapy option for patients with IBS-D. However, due to the high clinical heterogeneity and small sample size of the included trials, further standardized preparation, large-scale and rigorously designed trials are needed.

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.