What are hemorrhoids and what is their relationship to the portal venous system?

Minimally Invasive Treatment for Advanced Hemorrhoids

Hemorrhoids, the most common anorectal disease, give rise to symptoms such as bleeding, prolapse, and pruritus. The treatment for advanced hemorrhoids (Grade III or IV) is gradually shifting toward minimally invasive procedures. These procedures focus on reduction of blood flow in hemorrhoids. Conventional hemorrhoidectomy (CH), also known as Milligan-Morgan or Ferguson hemorrhoidectomy, is considered as the standard treatment for Grade III and IV hemorrhoids because it achieves the lowest recurrence rate. Over the years, alternative minimally invasive techniques such as stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization (THD) have been developed. A new, effective sclerosant, aluminum potassium sulfate and tannic acid (ALTA), has been developed in Japan and has been used for all grades of hemorrhoids; however, its effectiveness declines over time. Other minimally invasive, nonsurgical procedures, including rubber band ligation, endoscopic injection sclerotherapy, and infrared coagulation, have also been performed for Grade III hemorrhoids. Those minimally invasive treatments improve bleeding and prolapse and are highly recommended for patients who are unfit for CH. THD with mucopexy or ALTA sclerotherapy has also been performed for Grade IV hemorrhoids. However, the recurrence rate after ALTA sclerotherapy for Grade IV hemorrhoids was higher than that for Grade III lesions in our case study. In conclusion, minimally invasive treatments are a valid alternative for patients with advanced hemorrhoids after clear explanation of recurrence rates and possible complications.

Evaluation of Multiple Embolic Agents for Embolization of the Superior Rectal Artery in an Animal Model

OBJECTIVE

To prospectively compare the safety of transcatheter embolization of superior rectal arteries in healthy pigs with multiple agents such as coils, spheres and liquids.

MATERIALS AND METHODS

Nine adult domestic pigs (three males, mean weight: 60 kg [50-70]) were randomly assigned to the embolization group: copolymer of ethylene vinyl alcohol (EVOH)-Onyx® (group 1, n = 3), microspheres 500 µ (group 2, n = 3), 2-mm micro-coils (group 3, n = 3). After a selective angiogram has been acquired, the embolic agent was infused at the distal part of rectal arteries. An angio-CT was performed before and after each embolization. After one week, angiography was repeated prior to euthanasia. At necropsy, the anorectal juncture was removed for histopathologic examination.

RESULTS

At necropsy, 100% of animals embolized with Onyx developed a significant necrosis zone of the distal part of the rectum. Histological examination revealed a mural infarction. For the micro-coil and microsphere groups, gross examination of the intestines did not reveal any evidence of ischaemia. The coils were found in the distal arterial vasculature of the meso-rectum, allowing a downstream revascularization by collaterals. The microspheres and onyx in the rectal wall, more distally.

CONCLUSION

Microspheres appear to induce fewer histologic complications than the liquid embolic agent and provide a more distal occlusion than micro-coils. These results suggest that, for superior rectal artery embolization, a super-selective embolization using spheres in human clinical conditions should be more effective and as safe as coil embolization. EVOH might be an unsafe embolization agent for haemorrhoids.

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.

Pathophysiology of internal hemorrhoids

Hemorrhoidal disease is a fairly common and debilitating clinical entity. Despite centuries’ of attempts to shed light on its pathophysiology, to cure those affected and to improve sufferers’ quality of life, many aspects of the disease remain elusive. Individual beliefs and historical legends, accompanied by undocumented theories, have established and perpetuated the confusion regarding the mechanisms leading to the development of the disease and the rules governing its treatment. Hemorrhoids are classified as internal or external and are viewed as a disease when they become symptomatic. Returning to basic medical sciences, this mini-review focuses on internal hemorrhoids and aims to define the histology and anatomy of the normal and abnormal internal hemorrhoidal plexus and to encourage clinicians to comprehend the pathophysiology of the disease. If doctors can understand the pathophysiology of hemorrhoidal disease, they will be able to clarify the nature of the associated symptoms and complications and to make the correct therapeutic decision.

Japanese Practice Guidelines for Anal Disorders I. Hemorrhoids

The pathogenesis of hemorrhoids is a weakening of the anal cushion and spasm of the internal sphincter. Bowel habits and lifestyles can be risk factors for hemorrhoids. The prevalence of hemorrhoids can encompass 4 to 55% of the population. Symptoms include bleeding, pain, prolapsing, swelling, itching, and mucus soiling. The diagnosis of hemorrhoids requires taking a thorough history and conducting an anorectal examination. Goligher's classification, which indicates the degree of prolapsing with internal hemorrhoids, is useful for choosing treatment. Drug therapy for hemorrhoids is typically utilized for bleeding, pain, and swelling. Ligation and excision (LE) is considered for Grade III and IV internal and external hemorrhoids. Rubber band ligation is used to treat up to Grade III internal hemorrhoids. Phenol almond oil is effective for internal hemorrhoids up to Grade III, while aluminum potassium sulfate and tannic acid have shown efficacy in treating prolapsing in internal hemorrhoids at Grades II, III, and IV. Procedure for prolapse and hemorrhoids (PPH) is surgically effective for Grade III internal hemorrhoids; however, the long-term prognosis is not favorable, with high recurrence rates. Separating ligation is effective surgical treatment for internal/external hemorrhoids Grade III and Grade IV. The basic approach to thrombosed external hemorrhoids and incarcerated hemorrhoids is conservative treatment; however, in some acute or severe cases, surgical resection is considered. Comparing the different instruments used for hemorrhoid surgery, all reduce operating time, blood loss, post-operative pain, and length of time until the return to normal activity. They do, of course, increase the cost of the procedure.

Carcinoembryonic antigen levels in the peripheral and mesenteric venous blood of patients with rectal carcinoma

CONTEXT

The serum carcinoembryonic antigen (CEA) is an important prognostic factor in colorectal cancer, however the rectum presents different routes of venous drainage, stating that the level of CEA in peripheral and mesenteric rectal tumors may be different, depending on the location of the tumor in the rectal segment.

OBJECTIVE

The goal of this study was to evaluate the relationship between the peripheral and mesenteric venous levels of CEA and the association between these levels and the tumour location in the rectums of patients successfully operated on for rectal carcinoma.

METHODS

Thirty-two patients who were surgically treated for rectal carcinoma were divided into patients with tumours located in the upper rectum (n = 11) or lower rectum (n = 21). The CEA values were assessed by electrochemiluminescence immunoassay. Serum and mesenteric CEA levels were associated with the tumour anatomopathological characteristics: location, histological type, cellular differentiation grade, depth of invasion into the rectal wall, angiolymphatic invasion, tumour, node, and metastasis staging; and the CEA index (≤1.0 or ≥1.0 ng /mL).

RESULTS

Analysis of the serum CEA values using clinical and anatomopathological parameters revealed no significant association with tumour location, histological type, cellular differentiation grade, depth of invasion into the intestinal wall, and tumour, node, and metastasis staging. The mesenteric CEA levels were significantly associated with the tumour location (P = 0.01). The CEA values in the mesenteric venous blood and the presence of angiolymphatic invasion (P = 0.047) were significantly different. A significant relationship was found between the CEA index value and the rectal tumour location (P = 0.0001).

CONCLUSIONS

The CEA levels were higher in the mesenteric vein in tumours located in the upper rectum and in the presence of angiolymphatic invasion. CEA drainage from lower rectum adenocarcinomas preferentially occurs through the systemic pathway.

Systematic review of anorectal varices

AIM

Anorectal varices are an uncommon, but significant, source of bleeding in patients with portal hypertension. The aim of this article was to review systematically the available literature on the aetiology, clinical presentation and management of anorectal varices, and to suggest a simple treatment algorithm based on available evidence and local expertise.

METHOD

A systematic literature search was carried out to identify articles on anorectal varices, and the search strategy identified 57 relevant references. The inclusion criteria included a consecutive cohort of patients having treatment for anorectal varices with details of success rates and the number of different techniques used. Exclusion criteria included papers published in languages other than English with no English version and results not reported separately for anorectal varices.

RESULTS

Anorectal varices can occur in up to 89% of patients with portal hypertension, although the overall incidence in the general population is low. Diagnosis is best achieved with anoscopy or flexible sigmoidoscopy. The current evidence supports the use of local procedures, such as endoscopic band ligation, to arrest bleeding where feasible, with radiological or surgical procedures used in the event of failure.

CONCLUSION

As there are no large series on this pathology, we present a systematic approach for the patient with anorectal varices.

Hemorrhoids and fistulas: new solutions to old problems

Symptoms thought related to hemorrhoids must be carefully considered before intervention. The first line of therapy for any hemorrhoidal complaint remains conservative management with increased fluid and fiber intake and appropriate modification of toileting behavior. Bleeding in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely managed with office-based therapies; some grade 3 hemorrhoids would also respond to this, though more treatment sessions would likely be required. Operative therapy is the best choice for management of persistently symptomatic grade 2 disease and for grades 3 and 4 symptomatic hemorrhoids as well. With proper patient selection and preparation, along with a familiarity with instrumentation and techniques, good results can be obtained with newer operative interventions for internal hemorrhoids. Outcomes must always be compared with those obtained with classic excisional hemorrhoidectomy.

Matrix Metalloproteinases in Pathogenesis of Hemorrhoidal Disease

The aim of this study is to investigate the accuracy of serum matrix metalloproteinase (MMP) levels in an effort to find a reliable factor that may play an important role in pathogenesis of hemorrhoidal disease. Twenty control subjects and 21 Grade I, 19 Grade II, 20 Grade III, and 21 Grade IV patients with internal hemorrhoid were included in this prospective study. The mean ages of control subjects were 47.65 ± 6.71 standard deviation (SD) years (range, 37 to 60 years). The mean age of internal Grade I, Grade II, Grade III, and Grade IV patients with internal hemorrhoid were 48.85 ± 6.44, 47.20 ± 6.75, 44.90 ± 6.13, and 42.95 ± 3.49 SD years (ranges, 38 to 58, 38 to 60, 34 to 55, and 38 to 50 years), respectively. Ten milliliters of blood was taken from all subjects. Enzymelinked immunosorbent assay (ELISA) for MMP-1, -2, -7, and -9 levels were performed using an ELISA kit (R&D Systems) following the manufacturer's instructions. There was an important difference between Grade I and Grade II groups in the serum levels of MMP-9 ( P < 0.01). Patients with Grade III hemorrhoidal disease had significantly higher serum levels of all MMP than patients with Grade I and Grade II hemorrhoidal disease ( P < 0.001). Also, patients with Grade 4 hemorrhoidal disease had higher serum levels of MMP-7 and -9 according to Grade I, II, and III groups ( P < 0.01, 0.001). High serum levels of MMP are present in patients with hemorrhoids, suggesting the possible mechanism in the pathogenesis of hemorrhoids.

Common anorectal disorders for the intensive care physician

Although anorectal disorders such as abscess, fissure, and hemorrhoids are typically outpatient problems, they also occur in the critically ill patient population, where their presentation and management are more difficult. This article will provide a brief review of anorectal anatomy, explain the proper anorectal examination, and discuss the current understanding and treatment concepts with regard to the most common anorectal disorders that the intensive care unit clinician is likely to face.

Doppler-guided hemorrhoid artery ligation with Recto-Anal-Repair modification: functional evaluation and safety assessment of a new minimally invasive method of treatment of advanced hemorrhoidal disease

Purpose: We present 12-month followup results of functional evaluation and safety assessment of a modification of hemorrhoidal artery ligation (DGHAL) called Recto-Anal-Repair (RAR) in treatment of advanced hemorrhoidal disease (HD). Methods: Patients with grade III and IV HD underwent the RAR procedure (DGHAL combined with restoration of prolapsed hemorrhoids to their anatomical position with longitudinal sutures). Each patient had rectal examination, anorectal manometry, and QoL questionnaire performed before 3 months, and 12 months after RAR procedure. Results: 20 patients completed 12-month followup. There were no major complications. 3 months after RAR, 5 cases of residual mucosal prolapse were detected (25%), while only 3 patients (15%) reported persistence of symptoms. 12 months after RAR, another 3 HD recurrences were detected, to a total of 8 patients (40%) with HD recurrence. Anal pressures after RAR were significantly lower than before (P < 0.05), and the effect was persistent 12 months after RAR. One patient (5%) reported occasional soiling 3 months after RAR. Conclusions: RAR seems to be a safe method of treatment of advanced HD with no major complications. The procedure has a significant influence on anal pressures, with no evidence of risk of fecal incontinence after the operation.

Intra-anal Iferanserin 10 mg BID for hemorrhoid disease: a prospective, randomized, double-blind, placebo-controlled trial

BACKGROUND

Despite the prevalence of internal hemorrhoid disease (HD), there are few pharmacologic options. Iferanserin, a selective serotonin receptor antagonist, is being studied for use in the treatment of HD.

OBJECTIVE

This Phase IIb study evaluated the efficacy and tolerability of 10-mg twice-daily iferanserin intra-anal ointment for the cessation of bleeding and other symptoms associated with internal HD.

METHODS

This randomized, double-blind, placebo-controlled study was conducted at 5 sites in Germany. Outpatients with Goligher grade I, II, and/or III hemorrhoids and bleeding were randomly assigned to receive iferanserin ointment 10 mg or inactive vehicle (placebo) BID for 14 days. During treatment, patients rated the severity of HD symptoms daily on a 10-point scale using a diary form. At enrollment and study end, physicians recorded the frequency and intensity of HD symptoms, adverse events, and results from blood and urine analyses on clinical-report forms.

RESULTS

Of the 121 patients enrolled in the study, 118 were evaluable for tolerability and 111 for efficacy. The mean age of the tolerability population was 52.7 years, 78.9% were male, and all were white. The 2 groups had similar HD symptoms at baseline, but overall, patients in the placebo group had numerically higher grades of HD than did patients in the iferanserin group. Compared with placebo, iferanserin was associated with significantly lower patient-reported severity ratings of daily bleeding and itching, beginning at day 1 for bleeding and at day 2 for itching (P < 0.05), but not with reduced ratings for severity of other HD symptoms, including pain, tenderness, difficulty with defecation, fullness, throbbing, and gas. In the physician assessments, iferanserin was associated with significantly reduced bleeding frequency by day 14 compared with placebo (P < 0.05). Adverse events were mild and infrequent, with no significant differences in prevalences between the 2 treatment groups and no clinically significant changes in laboratory values in any patient.

CONCLUSION

Compared with placebo, intra-anal iferanserin was associated with significantly reduced patient-reported severity of bleeding and itching and physician-assessed bleeding frequency in these patients presenting with grade I, II, and/or III internal hemorrhoids and bleeding at 5 sites in Germany. ClinicalTrials.gov identifier: 01483833.

Hemorrhoids

Hemorrhoid disease is the most common reason patients seek evaluation by a colon and rectal surgeon. The majority of hemorrhoids can be managed nonoperatively with medical management or office-based procedures. The authors review the anatomy, pathophysiology, presentation, and management of hemorrhoids.

Doppler guided haemorrhoidal arterial ligation with recto-anal-repair (RAR) for the treatment of advanced haemorrhoidal disease

OBJECTIVE

A modification of Doppler guided haemorrhoidal artery ligation (DGHAL) to include the addition of recto-anal repair is reported. Preliminary results of function and safety of third and fourth degree haemorrhoidals are given.

METHOD

Thirty patients underwent DGHAL combined with recto-anal-repair (RAR). Each had rectal examination, anorectal manometry and Quality of Life assessment before and 3 months after the procedure.

RESULTS

Twenty-nine patients were included in the final analysis. There were three (10.34%) patients of intra-operative and one (3.45%) of postoperative bleeding. Three months after RAR (17.24%) patients with minor residual mucosal prolapse were detected, three (10.34%) patients reported residual symptoms. There was no case of recurrent bleeding. Anal manometry at 3 months after RAR was significantly lower than before the procedure (P < 0.05). One (3.45%) patient reported occasional soiling 3 months after RAR.

CONCLUSION

Recto-anal-repair is safe in treating third and fourth degree haemorrhoids with no major complications and low rate of residual disease.

Local anesthesia of upper anal canal for multiple rubber band ligation: description of technique and preliminary results

PURPOSE

Symptoms caused by hemorrhoids are worse during defecation because of relaxation of the anal canal causing prolapse. We reviewed our experience of multiple rubber band ligations in a relaxed state of the anal canal using local anesthesia.

METHODS

Forty-five patients, the majority of whom had Grade 2 or 3 symptomatic hemorrhoids, who required treatment underwent four quadrant local anesthetic infiltration in the submucosa of the upper anal canal. We used 1.5 ml of 0.25 percent bupivacaine in 1:200,000 epinephrine, 5 mm above the dentate line.

RESULTS

The exposure of the relaxed anal canal was excellent, allowing multiple introductions of the anoscope and application of multiple bands without discomfort. The average number of bands applied in a single session was 3.84 (range, 1-7). Forty-two percent of the patients had banding performed at four sites. Complications following the procedure were minimal. Forty-seven percent of patients reported pain, with an average pain score of 5.29 (range, 1-10). Forty-seven percent of patients did not experience any pain after the procedure. Seventy-three percent had relief of symptoms; 16 percent had symptomatic recurrences, one-half of them were successfully treated by repeat banding after local anesthetic; only one patient required surgical hemorrhoidectomy.

CONCLUSIONS

Local anesthesia of the upper anal canal results in full relaxation and maximal mucosal redundancy of the anal canal simulating the anus in a natural condition during defecation. This gives an excellent exposure of the anal canal, enabling an accurate and multiple applications of rubber bands without pain during and shortly after the procedure.

Successful treatment of giant rectal varices by modified percutaneous transhepatic obliteration with sclerosant: Report of a case

We present a female patient with continuous melena, diagnosed with rectal variceal bleeding. She had a history of esophageal varices, which were treated with endoscopic therapy. Five years after the treatment of esophageal varices, continuous melena occurred. Since colonoscopy showed that the melena was caused by giant rectal varices, we thought that they were not suitable to receive endoscopic treatment. We chose the modified percutaneous transhepatic obliteration with sclerosant, which is one of the interventional radiology techniques but a new clinical procedure for rectal varices. After the patient received this therapy, her condition of rectal varices was markedly improved.

Rubber band ligation of hemorrhoids. Convenient and economic treatment

We have reviewed and summarized 12 years of experience in treating hemorrhoids, a condition that affects 4.4% of the Western population, of whom a third are symptomatic and need treatment. During this time, in a proctological outpatient clinic of an urban hospital, 2,934 patients with second- and third-degree hemorrhoids were treated by rubber band ligation (RBL), usually one ligation per session. Of these patients, 79% were completely cured, 18% needed one or more additional sessions of treatment, and 2.1% failed to be cured by RBL and were referred for conventional hemorrhoidectomy. We found that by using this safe and convenient treatment we can save hundreds of hospitalization days and thousands of sick-leave days per year.

Hemorrhoids, anal fissure, and carcinoma of the colon, rectum, and anus during pregnancy

The pregnant patient afflicted with a variety of colorectal conditions merits special consideration for reasons related to the safety and timeliness of operation while preserving fetal viability and fertility. The literature is scanty with respect to hemorrhoids, fissures, and colorectal and anal carcinoma. Therefore, the patient has to have a forthright discussion with her physician(s) about the pros and cons of operative and nonoperative approaches, which can result in either therapeutic abortion and timely surgery versus preserving the fetus and taking on the unknown factor of whether delay in treatment will cause an adverse outcome. This underscores the need for a frank discussion with the patient with regard to anticipated outcomes. In benign conditions, there is more latitude to adopt a conservative approach, as the patient's ability to tolerate the symptoms of her condition would dictate the need for definitive operative therapy. In the patient with malignancy, delaying surgical or radiation therapy carries an unknown risk to the patient. Here, the patient's personal views regarding abortion and future fertility dictate the timing of definitive treatment.

Histopathological changes in haemorrhoid associated mucosa and submucosa

The histological features of haemorrhoids are detailed in this study with special attention to the mucosal changes. These include significant crypt distortion, with stromal hyperplasia which bear a remarkable resemblance to the changes seen in mucosal prolapse syndrome. We propose that the mucosal prolapse syndrome should include haemorrhoids as part of the spectrum.

Haemorrhoids: pathology, pathophysiology and aetiology

Haemorrhoidal disease is the consequence of distal displacement of the anal cushions, which are normal structures with an important role in continence. The causes of haemorrhoidal disease are unknown; constipation and abnormal bowel habit are commonly blamed despite largely contrary evidence. The most consistently demonstrated physiological abnormality is an increased maximum resting anal pressure. Most evidence points to this being a secondary phenomenon rather than the cause of haemorrhoidal disease. Among the many unexplored areas are the function of the longitudinal muscle in relation to haemorrhoidal disease, the description and pharmacological responsiveness of the anal subepithelial muscle, and the clinical role of specific pharmacological agents that might reverse some of the observed physiological changes.

Case report: transrectal ultrasound in the diagnosis of ano-rectal varices

Extensive ano-rectal varices were diagnosed by transrectal ultrasound (TRUS) in a patient with portal hypertension who presented with an altered bowel habit. The diagnosis of ano-rectal varices is usually made by direct inspection during procto-sigmoidoscopy in patients who present with rectal bleeding. However, the sigmoidoscopic and barium enema appearances of varices may mimic that of a tumour. A firm diagnosis can readily be made using TRUS and the local extent of varices clearly mapped out.

Rectal varices in extrahepatic portal hypertension

Rectal varices, as distinct from haemorrhoids, occur due to high pressure in the inferior mesenteric venous system in patients with portal hypertension. The exact prevalence of rectal varices in extrahepatic portal hypertension is unknown. To determine this, 116 patients with extrahepatic portal hypertension were studied for the presence of rectal varices. These lesions were found in 103 (88.8%) patients. Bleeding from rectal varices occurred in 14.6% of patients. Massive bleeding requiring hospitalization and blood transfusion was not encountered. It is concluded that rectal varices are common in extrahepatic portal hypertension. Bleeding from them is uncommon, and often mild and self-limiting. The available literature is reviewed and the importance of recognizing the condition stressed.

Incidence of haemorrhoids and anorectal varices in children with portal hypertension

A prospective study of 60 children with portal hypertension showed a significant incidence of haemorrhoids (33 per cent), anorectal varices (35 per cent) and external anal varices (15 per cent). Four children (7 per cent) complained of anorectal symptoms. A comparison of extrahepatic with intrahepatic disease showed that the former was associated with a higher incidence of both haemorrhoids and anorectal varices (57 versus 26 per cent and 64 versus 26 per cent respectively). The occurrence and severity of haemorrhoids was related to the number of previous oesophageal sclerotherapy sessions (P = 0.001). Problems relating to anorectal pathology were unusual, but treatment with haemorrhoidal sclerotherapy or banding was satisfactory for the symptomatic patients.

Inpatient management of piles: a surgical audit

A retrospective study was performed on 160 patients admitted to the University Surgical Unit between July 1975 and November 1989 with haemorrhoidal disease. Patients' records were analysed with respect to predisposing factors, inpatient management, postoperative analgesia, hospital stay and post-management complications. One hundred and nineteen patients had haemorrhoidectomy (low ligation combined with an anal stretch). Of these, 1.6% developed urinary retention and 4.2% bled postoperatively but did not require surgical intervention. Ten patients were found to have tight anal canals post surgery and required outpatient anal dilatation. In no case was dilatation necessary for more than 3 months. Three patients required a therapeutic course of antibiotics. Of the 119 patients, 60 required narcotic analgesia for less than 24 hours. Hospital stay was 1-4 nights.

Symptomatic hemorrhoids and anorectal varices in children with portal hypertension

There have been few reports of the anorectal problems encountered in children with portal hypertension. We report the incidence of anorectal symptoms in a retrospective study of 189 children treated by injection sclerotherapy for esophageal varices secondary to portal hypertension. Anorectal symptoms, proctoscopic findings and treatment have been recorded in this group. The incidence of symptomatic hemorrhoids and rectal varices was 4.2%. Hemorrhoids are rare in children and the increased incidence can be assumed to be secondary to portal hypertension. Treatment is advised only for symptomatic patients and injection sclerotherapy is satisfactory for the majority.

Anorectal varices--their frequency in cirrhotic and non-cirrhotic portal hypertension

Anorectal varices in portal hypertension have been little studied: Seventy eight per cent of 72 patients with portal hypertension had anorectal varices shown at flexible sigmoidoscopy. Significantly more patients with noncirrhotic portal hypertension had these varices than patients with cirrhosis (89% v 56%, p less than 0.01).

Histoclinical basis for a new classification of hemorrhoidal disease

The present classification of first, second, and third grade hemorrhoids only reflects variation in size of a normal human tissue and does not relate to "hemorrhoidal disease." Cross-sections and coronal sections of the anal canal in 32 fetuses, with ages ranging from 28 to 38 weeks of development, were studied and the following fundamental facts were found: in the lumen of the anal canals of fetuses, there are prominences of mucosa formed by conjunctive and muscular tissue, arterial and venous vessels and glands, arranged without following any particular pattern, which resemble similar formations found in the adult that protrude equally in the inside of the canal, known as hemorrhoids. The muscular tissue, smooth or striated, is grouped in bundles, and bunches of collagen fibers of homogeneous, nonfragmented, and regular aspect are found between them. Blood vessels have an ample lumen with a defined structure of collagen tissue as well as muscular tissue in its walls. Prominences of mucosa are connected to the remainder of the intestinal wall by defined conjunctive thick, nonfragmented fibers, that permit firm adherence. In healthy adults, the findings were similar but there was an evident degenerative process in the collagen fibers. In 100 surgical specimens of hemorrhoidectomies, the histologic investigation demonstrated a severe inflammatory reaction that especially affected the blood vessel wall and conjunctive tissue, which probably produced an ischemic lesion of the mucosa that could condition the onset of a vascular thrombosis, allowing displacement of the mucosa and its protrusion through the anus. The files of 815 patients suffering from hemorrhoidal disease were also studied. The main physical findings were bleeding, thrombosis of the internal hemorrhoidal plexus, prolapse of the anal cushions, or a combination of these. The authors propose to classify hemorrhoidal disease as bleeding, prolapsing, thrombotic, and mixed hemorrhoidal disease, aiming toward a rational treatment.

Hemorrhoids or rectal varices: defining the cause of massive rectal hemorrhage in patients with portal hypertension

Identifying the source of lower gastrointestinal hemorrhage in patients with chronic liver disease and portal hypertension can be challenging. We present 2 cases of hemorrhage from rectal varices and a discussion on the differences between simple hemorrhoids and rectal varices. Evaluation of rectal bleeding in patients with portal hypertension is discussed and possible therapeutic options are described.

Suture of massive hemorrhoidal bleeding in portal hypertension

Massive hemorrhoidal hemorrhage in portal hypertension can be treated by figure-of-eight stick-tie suture.