In your clinical practice, when, in which type of ...€¦ · Madbouly , Egypt 5. C. Tohme, Lebanon 6. D. ... morrhoidal disease have not self-medicated, and a few will have taken

1. J. Bocobo, Philippines

2. M. L. Esquivel Herrera, Mexico

3. A. Karimuddin, A. Farooq, Canada

4. K. Madbouly, Egypt

5. C. Tohme, Lebanon

6. D. Voiculescu, Romania

Which clinical practice and medical treatments for hemorrhoidal patients? MEDICOGRAPHIA, Vol 41, No. 2, 2019 85

C O N T R O V E R S I A L Q U E S T I O N

In your clinical practice,when, in which type

of hemorrhoidal patients,and how do you usemedical treatments?

THE QUESTION

Hemorrhoidal disease is acommon and benign ano-rectal condition. Treatment

of hemorrhoids depends on thenature of the clinical presentation,and the type of treatment shouldbe tailored to each patient. In thisarticle, experts discuss the typesof patients they see, as well aswhen and how these patients aretreated.


MEDICOGRAPHIA, Vol 41, No. 2, 2019 Which clinical practice and medical treatments for hemorrhoidal patients?86

Joseph BOCOBO, MD

Institute of Digestive and Liver Diseases

St. Luke's Medical Center

Quezon City, 1100

PHILIPPINES

(email: [email protected])

H emorrhoidal disease is a common disorder that I usu-ally encounter in my daily clinical practice. I see pa-tients complaining of fresh blood during defecation,

either dripping or staining the toilet paper, especially if thestool is hard and they strain. Many of them would undergo acolonoscopy, which, most of the time, confirms the diagnosisof internal hemorrhoids, upon exclusion of other possible caus-es of bleeding, or the colon is identified to be unremarkableor normal. Several patients who would go through the aboveprocedure for other indications (eg, screening for colon can-cer and suspected inflammatory bowel disease), would havean incidental finding of engorged internal hemorrhoids. Onthe other hand, very few patients will come complaining ofpainful lump(s) or swelling in the distal anal canal aggravat-ed by a bowel movement, and, on perianal examination, theidentification of thrombosed external hemorrhoids would beestablished. Most of these individuals of either type of he-morrhoidal disease have not self-medicated, and a few willhave taken an underdosed oral drug, applied a topical oint-ment or cream, or used a suppository.

In my experience, more than 95% of the patients with symp-tomatic internal hemorrhoids are grade 1, the others aregrade 2. These patients are the best candidates to receivemedical management. My treatment protocol consists of a

high-fiber diet, such as fruits, vegetables, wheat, and oats, andmicronized purified flavonoid fraction (MPFF) diosmin and hes-peridin 500 mg tablets, 2 tablets three times a day for 4 days,then 2 tablets twice a day for 3 days, then 2 tablets once a dayfor 1 to 3 months. The recurrent bleeding rate is approximate-ly less than 10%, which is normally among patients noncom-pliant with the prescribed treatment regimen. However, forthose who thoroughly follow the instituted medical care, theoutcome is a lot better. Relief of hemorrhoidal symptoms, suchas pain and bleeding, is experienced promptly, improving moresignificantly day after day, as they proceed with their courseof therapy, leading to total control of the hemorrhage.

I have yet to come across patients with the more severe gradesof hemorrhoidal disease though. In the Philippines, these pa-tients go directly to our surgeon colleagues for operative pro-cedures. However, for those patients I encounter with throm-bosed external hemorrhoids, I give my usual treatment regimenwith the addition of a hot sitz bath for 5 minutes twice a dayuntil the discomfort is gone. Moist heat is convincingly an-other factor that alleviates pain due to its ability to decreaseanal canal pressure. I do find this management effective sinceat least 5 of those patients that I can recall have successfullyresponded, with adequate follow-up postmedication, and sofar no recurrence, saving them from an excisional procedure.To date, none of my patients to whom I have prescribed MPFFhas ever reported any adverse reaction or untoward side ef-fect with the medication.

In conclusion, my personal experience confirms the efficacyof medical management, particularly with MPFF diosmin andhesperidin 500 mg, among patients with grades 1 and 2 in-ternal hemorrhoids, as well as those with thrombosed exter-nal hemorrhoidal disease. ■

1. J. Bocobo, Philippines



A lthough the actual prevalence of hemorrhoidal diseaseis difficult to identify by different factors, it fluctuatesaround 40% in the US population and it is very similar

in Western countries. Of the three hundred and thirty-onemillion Americans, about one hundred and forty million aresuffering from some degree of the disease and only about10% to 20% will require surgical treatment. The universe ofpatients who will require conservative treatment is very vast.The treatment is then divided into conservative and surgical;the latter in turn into noninvasive and invasive.1-7 Based onGoligher’s classification, grade 1 patients will require the mostbasic measures, including a high fiber diet and/or bolus for-mers (eg, psyllium plantago), adequate fluid intake, a reduc-tion in the intake of possible irritants, an increase in physicalactivity, and a modification in their evacuation habits. Thesemeasures also apply to all grades of the disease in stages ofexacerbation. Additional measures could include a sitz bath(at a temperature of 40°C) in order to decrease edema and torelax sphincter contractions (2018 American Society of Colonand Rectal Surgeons guideline recommendation grade 1B).In some cases, conservative medical treatment, ie, topicaltreatments, such as oils, creams, and suppositories with anes-thetics and/or anti-inflammatories, for short periods of time.The time duration is short due to the risk of skin sensitization,the discomfort of its application, and the usefulness only asa symptomatic treatment. For many patients, Preparation H ®

is the most used treatment. It is available as a cream, a re-freshing gel, suppositories, and even wipes, with most con-taining anti-inflammatory ingredients and/or hydrocortisone.Preparation H is elaborated with petrolatum, mineral oil,phenylephrine chloride, and shark liver oil; phenylephrine chlo-ride has a vasoconstrictive effect, while the other components

are skin protectors. This treatment will not cure the disease,but it is commonly used for relieving the most frequent man-ifestations.

In addition, stool softeners and flavonoids are frequently usedin cases of exacerbation. Among flavonoids, micronized pu-rified flavonoid fraction (MPFF) has been the best studied.The active components of MPFF include diosmin, diosmetin,hesperidin, linarin, isorhoifolin. The synergy between the com-ponents plus the micronization of its particles (<2 mm) im-proves drug absorption two fold vs other available flavonoids.MPFF improves vascular tone, and, at the microcirculatory lev-el, reinforces capillary resistance, decreases capillary perme-ability, and improves microlymphatic flow. Another action in-cludes an effect on venous inflammatory processes througha reduction in the inflammatory cascade. These effects makeMPFF an initial step in treating all patients with pruritus, analbleeding, pain during and after defecation, prolapse, and whenhemorrhoids are detected during a proctological screening.The dosage is 1000 mg per day in one or two doses untilthe symptomatology disappears and for a period of up to 3months. The American Society of Colorectal Surgeons ap-proves its use with a IIB grade of recommendation, mainlyfor improving anal bleeding, pruritus, and recurrence. ■

References1. Hnátek L. Therapeutic potential of micronized purified flavonoid fraction (MPFF)

of diosmin and hesperidin in treatment chronic venous disorder [in Czech]. VnitrLek. 2015;61(9):807-814.

2. Giannini I, Amato A, Basso L, et al. Flavonoids mixture (diosmin, troxerutin, hes-

peridin) in the treatment of acute hemorrhoidal disease: a prospective, random-

ized, triple-blind, controlled trial. Tech Coloproctol. 2015;19(6):339-345.

3. Perera N, Liolitsa D, Iype S, et al. Phlebotonics for haemorrhoids. CochraneDatabase Syst Rev. 2012;8:CD004322.

4. Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society

of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management

of Hemorrhoids. Dis Colon Rectum. 2018;61(3):284-292.

5. Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, et al. Meta-analysis of flavonoids

for the treatment of haemorrhoids. Br J Surg. 2006;93(8):909-920.

6. Ba-bai-ke-re MM, Huang HG, Re WN, et al. How we can improve patients’ com-

fort after Milligan-Morgan open haemorrhoidectomy. World J Gastroenterol.2011;17(11):1448-1456.

7. Zagriadskiĭ EA, Bogomazov AM, Golovko EB. Conservative treatment of hem-

orrhoids: results of an observational multicenter study. Adv Ther. 2018;35(11):

1979-1992.

Miguel Luis ESQUIVEL HERRERA, MD

Past President of the Mexican Society of

Surgeons of Recto, Colon and Anus A.C.

Professor of Coloproctology and

General Surgery

La Salle University

Queretaro, MEXICO


2. M. L. Esquivel Herrera, Mexico



H emorrhoidal disease is a common anorectal condi-tion presenting to general practitioners, gastroen-terologists, and general and colorectal surgeons. In

fact, sufferers of hemorrhoidal disease have their own patronsaint: St Fiacre, patron saint of gardeners and hemorrhoidsufferers.1 It is important for physicians to have an algorith-mic approach to dealing with hemorrhoidal disease, whichincludes nonsurgical options. The American Society of Colonand Rectal Surgeons (ASCRS) recently published clinical prac-tice guidelines on the management of hemorrhoids.2 Themainstays of therapy for the majority of patients includes in-creased fiber and water intake.2 A 2005 Cochrane review foundthat fiber supplementation was associated with a 53% im-provement in symptoms.3 Fiber intake reduces symptoms bybulking up stool and reducing straining. When recommend-ing fiber intake, patients should be aware that the goal of dailyfiber intake is 25 g to 30 g. Generally, this will require fiber sup-plementation, usually in the form of psyllium. A sometimesoverlooked detail of prescribing fiber supplementation is en-suring adequate fluid intake, usually recommended as twoglasses of water with the fiber.4,5 Fiber taken before bed orwithout enough water can paradoxically lead to colonic sta-sis and worsen constipation.5

Flavonoids, such as diosmin, are phenolic dietary supplementsthat are derived from plants.2 Also known as venotonics, flavo-noids are thought to be vasoactive, reduce inflammation, andincrease venous return.6 Flavonoids are much more popularin Europe than in the UK or North America, with France rep-resenting 70% of the world’s market.5 A Cochrane reviewby Alonso-Coello et al found that flavonoids were associatedwith a 50% relative risk reduction in symptoms, with little tono harm from the treatment,5 which has led to a recommen-dation by both ASCRS and Italian hemorrhoid guidelines forthe routine use of oral flavonoids to help manage hemorrhoidsymptoms related to bleeding and discomfort.

There are other commonly available over-the-counter creamsand topical ointments; most include a combination of agents,usually a barrier cream and steroids.4 The evidence for mostof these agents is very limited. In particular, the use of cortico-steroid creams, such as proctosol, should be discouraged,as they will thin the perianal skin and potentially aggravate

symptoms related to bleeding and itching.4 Patients general-ly present with one of two main symptoms: bleeding or pro-lapse. All patients should have a complete history and phys-ical exam. The physical exam typically involves anoscopicevaluation and rigid proctoscopy, with colonoscopy as indi-cated. Once it is clear that the bleeding is indeed outlet typebleeding from hemorrhoids, then we base our therapy on thegrade of hemorrhoids. Our first-line approach is fiber supple-mentation and flavonoids for at least 6 to 8 weeks, with re-evaluation if symptoms persist.

Grade 1 and 2 hemorrhoids usually respond to conservativetherapy,6 ie, a combination of fiber, fluids, and oral flavonoids.Grade 3 hemorrhoids will often respond, although they willoften require rubber band ligation. Grade 4 hemorrhoids willsometimes respond to conservative therapy, but many of thesepatients will require an excisional hemorrhoidectomy. Whilesymptoms may not be completely obviated, the symptomburden may be reduced enough with medical managementthat the patient can cope and have an improved quality of life,despite the presence of grade 3 or 4 hemorrhoids. In the caseof prolapse, our approach is similar. Grade 1 and 2 hemorrhoidstypically respond to conservative measures. Grade 3 hemor-rhoids will often require rubber band ligation. Grade 4 hem-orrhoids generally require an excisional hemorrhoidectomy.Therapy is driven by patient symptoms and their impact on thepatient’s quality of life rather than the grade of hemorrhoids.

Hemorrhoidal disease is a common and benign anorectal con-dition that is presented to many general practitioners and sur-geons. We have outlined the commonly accepted medicaltherapies, as well as our approach. All patients should have atrial of conservative therapy, which may sometimes requiremultiple office visits. This trial period is important to build rap-port with the patient and to gain a greater understanding of theirexpectations and main symptoms. In our experience, many pa-tients are looking for reassurance, amelioration of their difficultsymptoms, with only a small proportion of patients with he-morrhoidal disease ultimately going on to require surgery. ■

References1. Senagore AJ. Surgical management of hemorrhoids. J Gastrointest Surg Off J

Soc Surg Aliment Tract. 2002;6(3):295-298.

2. Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American So-

ciety of Colon and Rectal Surgeons Clinical Practice Guidelines for the Man-

agement of Hemorrhoids. Dis Colon Rectum. 2018;61(3):284-292.

3. Alonso-Coello P, Mills E, Heels-Ansdell D, et al. Fiber for the treatment of hem-

orrhoids complications: a systematic review and meta-analysis. Am J Gastro-enterol. 2006;101(1):181-188.

4. Garg P. Conservative treatment of hemorrhoids deserves more attention in guide-

lines and clinical practice. Dis Colon Rectum. 2018;61(7):e348.

5. Steele SR, Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow CB, eds. TheASCRS Textbook of Colon and Rectal Surgery. 3rd ed. New York, NY: Springer;

2016.


for the treatment of haemorrhoids. Br J Surg. 2006;93(8):909-920.

3. A. Karimuddin, A. Farooq, Canada

Ahmer KARIMUDDIN, MD

Ameer FAROOQ, MD

St. Paul’s Hospital, Department of Surgery

University of British Columbia

Vancouver, BC, Canada


▲



H emorrhoidal disease is common in both Eastern andWestern communities. More than 50% of individu-als over the age of 50 years have, at some point, ex-

perienced symptoms related to hemorrhoids. Medical treat-ment of hemorrhoids depends on the nature of the clinicalpresentation. The most common presenting complaint is brightred bleeding. With worsening disease, internal hemorrhoidsstart to prolapse through the anal canal, and they might re-duce spontaneously (grade 2), require manual reduction(grade 3), or remain chronically prolapsed (grade 4) with mu-coid discharge and/or perianal irritation. If bleeding is relatedto straining or diarrhea, treatment should be directed to thecause of the bleeding. Changes in lifestyle behaviors, as wellas using oral and topical medications to decrease symptomsare usually applied. The goal of behavioral, oral, and topicalapproaches is to relieve symptoms, not to cure hemorrhoids.

Alonso-Coello et al1 performed a meta-analysis of 378 pa-tients from 7 randomized trials to analyze the effect of usingfiber supplements on symptomatic hemorrhoids. In the fibergroup, there was a 47% decrease in overall symptoms, a50% decrease in bleeding, and no significant improvement inprolapse, pain, or itching.

Flavonoids have been used for decades in the treatment ofbleeding hemorrhoids. Corsale et al 2 used flavonoids in aprospective, double-blind trial on 154 patients with hemor-rhoidal bleeding. Bleeding improved after 1 and 6 months inboth the study and control groups, with no significant be-tween-group differences. Yet, the degree of satisfaction af-ter 6 months was statistically greater in the patients who re-ceived flavonoids (P=0.003). In addition, Alonso-Coello et al 3

conducted a meta-analysis on 1514 patients from 14 trials. They suggested that flavonoids decrease the risk of symp-toms that persist or do not improve by 58% and showed anapparent reduction in the risk of bleeding (relative risk, 0.33).

Many creams and suppositories are used to stop the bleed-ing. The active ingredients usually include a vasoconstrictorand soothing agents that may lead to temporary relief ofburning and itching. Symptoms of pruritus ani may be ame-liorated, yet the hemorrhoids do not shrink. Sitz baths leadto a symptomatic improvement in hemorrhoids. Dodi et al4

performed anorectal manometry on volunteers and on pa-tients with anorectal problems. A statistically significant de-crease in resting pressure was observed after immersion inthe warm water, which is why patients with hemorrhoids andelevated anal pressures could benefit from Sitz baths.

Patients with thrombosed external hemorrhoids usually pres-ent with a painful, tender mass at the anal verge. If the patientis seen after more than 2 days, medical management in theform of sitz baths, stool softeners, and a mild analgesic shouldbe offered. Topical nifedipine and lidocaine ointment havebeen demonstrated to cause excellent pain relief comparedwith local anesthetic alone in a randomized clinical trial.5

Hemorrhoidal complaints are not uncommon in patients withinflammatory bowel disease. In patients with ulcerative colitis,the general guidelines for treatment are followed and surgerycan be offered, as there are few complications. However, inCrohn’s disease, conservative measures are better and surgeryshould be avoided because of the high rate of complications.

Medical treatment of hemorrhoids ranges from dietary andlifestyle changes to topical and oral medications, with initialmanagement usually being medical and preventative. Timingand type of medical treatment should be tailored case bycase. ■

References1. Alonso-Coello P, Mills E, Heels-Ansdell D, et al. Fiber for the treatment of hem-

orrhoids complications: a systematic review and meta-analysis. Am J Gastroen-terol. 2006;101:181-188.

2. Corsale I, Carrieri P, Martellucci J, et al. Flavonoid mixture (diosmin, troxerutin,

rutin, hesperidin, quercetin) in the treatment of I-III degree hemorroidal disease:

a double-blind multicenter prospective comparative study. Int J Colorectal Dis.2018;33(11):1595-1600.


for the treatment of haemorrhoids. Br J Surg. 2006;93:909-920.

4. Dodi G, Bogoni F, Infantino A, et al. Hot or cold in anal pain? A study of the changes

in internal anal sphincter pressure profiles. Dis Colon Rectum. 1986;29:248-251.

5. Perrotti P, Antropoli C, Molino D, et al. Conservative treatment of acute throm-

bosed external hemorrhoids with topical nifedipine. Dis Colon Rectum. 2001;

44:405-409.

Khaled MADBOULY, MD, MS, PhD, FRCS

(Glasg), FACS, FASCRS, FISUCRS, MBA

Professor of Colorectal Surgery, Department

of Surgery, University of Alexandria, Egypt

Associate Secretary General of the International

Society of University of Colon & Rectal Surgeons

Vice President of the Egyptian Board of Colon

& Rectal Surgery

President-elect of the Egyptian Society of

Colon & Rectal Surgeons, EGYPT


4. K. Madbouly, Egypt



N o matter how bad the hemorrhoids look, they shouldnot be treated unless they are symptomatic. Varioustreatments are available; they depend mainly on the

type and severity of hemorrhoids, patient preferences, andthe expertise of the physician. Not all people will require anoffice procedure or surgery. First-line treatment of all first- andsecond-degree and many third-degree internal hemorrhoidsshould be conservative. Initial treatment of symptomatic hem-orrhoids consists of warm sitz baths (twice or three times dai-ly), dietary modifications (high fiber diet, adequate fluid in-take), stool softeners, topical analgesic or steroid cream, andphlebotonics.1

Constipation and abnormal bowel habits (straining, prolongedsitting) play a significant role in patients with symptomatichemorrhoids. Increased fiber and fluid intake with or withouta stool softener or a laxative should be recommended andhave been shown to improve symptoms of mild and moder-ate prolapse and to minimize the risk of bleeding by approx-imately 50% when applied for up to 6 weeks. A Cochranereview that included 7 randomized trials (378 patients) com-pared fiber with a no fiber control and showed that fiber had abeneficial effect in the treatment of symptomatic hemorrhoids.Fiber supplementation had a significant effect on bleeding withno effect on prolapse, pain, or itching.2 Patients should also beadvised to exercise regularly and to maintain proper bowelhabits, such as avoidance of straining and sitting on the toi-let for a long period of time. Decreasing straining (and con-stipation) shrinks internal hemorrhoids and decreases theirsymptoms.

Topical applications of ointments containing local anesthetic,antibiotics, steroids, or emollients are commonly used. Thereis no strong scientific evidence regarding their efficacy. Littlehigh-quality data exist regarding their use in patients with symp-tomatic hemorrhoids. Topical steroids can be used to decrease

symptoms of pruritus, inflammation, and sometimes bleed-ing, but they are not to be used longer than 10 to 14 days.Their prolonged use may be detrimental and should be avoid-ed because of the associated side effects, such as mucos-al atrophy, local allergic reaction, or sensitization of the skin.

Phlebotonics are a group of treatment options that can beoffered with expectations of minimal harm and a decent po-tential for relief. These drugs are used in early grades whereprolapse is not significant, as a primary control of acute bleed-ing until definitive office procedures or surgery is done if nec-essary or in stage III and IV as a bridge-to-surgery. They areassociated with strengthening of blood vessel walls, increas-ing venous tone and lymphatic drainage, and normalizing cap-illary permeability.3 In a Cochrane review of 24 randomizedcontrolled trials with 2234 patients that compared phleboton-ics with a control, phlebotonics demonstrated a statisticallysignificant effect on pruritus, bleeding, discharge, and leak-age, as well as overall symptom improvement. Although ben-eficial, they did not show a beneficial effect on pain.4 Flavonoids(diosmin, micronized purified flavonoid fraction, troxerutin, andrutosides) are the most commonly used agents and werenoted to decrease bleeding by 67%, pruritus by 35%, per-sistent pain by 65%, and recurrence by 47% in a meta-analy-sis reviewing 14 randomized controlled trials (1514 patients)comparing flavonoids with placebo or no therapy, but themethodological quality of the studies was moderate with a riskof bias.5 They are usually used for a period of 4 to 6 weeks.

In conclusion, many patients see improvement or completeresolution of their symptoms with this treatment. Hemorrhoidscan recur in 25% of the patients after medical treatment. Ag-gressive therapy is reserved for patients who have persist-ent symptoms after 1 month of conservative treatment. ■

References1. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clinical guideline: man-

agement of benign anorectal disorders. Am J Gastroenterol. 2014;109:1141-

1157.

2. Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of

hemorrhoids. Cochrane Database Syst Rev. 2005;4:CD004649.

3. Davis BR, Lee-Kong SA, Migaly J, Steele SR. The American Society of Colon

and Rectal Surgeons Clinical Practice Guidelines for the Management of Hem-

orrhoids. Dis Colon Rectum. 2018;61:284-292.

4. Perera N, Liolitsa D, Iype S, et al. Phlebotonics for haemorrhoids. CochraneDatabase Syst Rev. 2012;8:CD004322.


for the treatment of haemorrhoids. Br J Surg. 2006;93:909-920.

5. C. Tohme, Lebanon

Cyril TOHME, MD, MHHM

Lebanese Hospital Geitaoui

University Hospital, Beirut, LEBANON




H emorrhoidal disease is the most common cause ofanorectal complaints and this condition has an in-creased incidence. Trying to find a perfect solution for

treatment has been a concern for the medical world over time,without getting a true consensus so far. What is clearly es-tablished is that curative treatment is the interventionist one(classic or minimally invasive surgery). From this point of view,can we consider that medical treatment still finds a place,and if so, what would it be?

The answer to this question is clearly affirmative because med-ical treatment remains an effective adjuvant for all stages ofevolution of symptomatic hemorrhoidal disease. I highlightsymptomatic because it is currently considered almost unan-imous that a diagnosed hemorrhoidal disease, in the absenceof symptomatology, does not require treatment, even if theanoscopically assessed lesion is obviously significant.1 Thismedical treatment primarily consists of the systemic use ofmicronized purified flavonoid fraction (diosmin/hesperidin) byoral administration. This combination is the largest used veno-tonic; there are numerous studies offering data on the way itworks and the safety profile of this medication.2 The mech-anisms by which such medication is useful are complex andinclude: increasing vascular tone, reducing venous capaci-ty, the anti-inflammatory effect on the venous wall, reducingcapillary permeability, and increasing lymphatic drainage.3,4

I have emphasized the role of oral medication not in the pur-pose of undermining local medication (ointments, supposi-tories), but for the simple reason that this last group of reme-dies generates a strictly local effect that actually does notinterfere with the venous pathophysiological mechanismsresponsible for the occurrence of symptomatology. Oral med-ication can be used in all circumstances of hemorrhoidal dis-ease: symptomatic hemorrhoids, acute complications of hem-orrhoids, or in the recovery period after invasive hemorrhoidaldisease treatment (banding, photocoagulation, sclerotherapy,hemorrhoidal artery ligation, Milligan-Morgan resection, etc).

In the first and second stages of hemorrhoidal disease, drugtreatment can be used to relieve symptoms, such as bleed-ing, pain, pruritus. It can be used in chronic administrationuntil the patient decides to undergo a specific treatment. Inthe third and fourth stages, medical treatment retains the samerole of alleviating symptoms, but with slightly reduced effica-cy. The used doses are the usual ones for chronic mainte-nance treatment and are administered over long periods oftime.4-6

For acute complications of hemorrhoidal disease, primarily wespeak of hemorrhoidal thrombosis, oral drug therapy is ap-propriately adapted by increasing the dose, being associat-ed with heparin ointments. This type of therapy can replacesurgical treatment in the situations when the patient cannothave access to the therapy, has temporary or absolute con-traindications (for example, Crohn disease7), or refuses the ther-apy. The results are quite satisfactory, although in many cases,in the absence of a surgical excision, the healing process willleave skin tags. Medical treatment necessarily accompaniesall of the therapeutic procedures that remove hemorrhoidaldilations. Its role is to prevent, reduce, or ameliorate the post-intervention symptoms: bleeding, local pain, local edema, andlocal venous plexus thrombosis. The doses used in thesesituations for oral administration are similar to those used inthe treatment of acute complications of the disease.

In conclusion, the medical treatment of hemorrhoidal diseasealways remains of interest, having clear indications and beingthe most important adjuvant in controlling the symptoms ofhemorrhoids in situations of both symptomatic disease andconvalescence after specific therapeutic procedures. ■

References1. Thornton SC, Perry KR, Rosh AJ, Talavera F, Gossman WF. Hemorrhoids. https://

emedicine.medscape.com/article/775407-overview. Updated Jan 18, 2017.

Accessed May 24, 2019.

2. Shelygin Y, Krivokapic Z, Frolov S, et al. Clinical acceptability study of micronized

purified flavonoid fraction 1000 mg tablets versus 500 mg tablets in patients suf-

fering acute hemorrhoidal disease. Curr Med Res Opin. 2016;32(11):1821-1826.

3. Cerera N, Liolitsa D, Iype S, et al. Phlebotonics for haemorrhoids. CochraneDatabase Syst Rev. 2012;8:CD004322.

4. Lohsiriwat V. Treatment of hemorrhoids: a coloproctologist’s view. World J Gas-troenterol. 2015;21(31):9245-9252.

5. Brown SR. Haemorrhoids: an update on management. Ther Adv Chronic Dis.2017;8(10):141-147.

6. Altomare D, Giuratrabocchetta S. Conservative and surgical treatment of haem-

orrhoids. Nat Rev Gastroenterol Hepatol. 2013;10(9):513-521.

7. D’Ugo S, Franceschilli L, Cadeddu F, et al. Medical and surgical treatment of

haemorrhoids and anal fissure in Crohn’s disease: a critical appraisal. BMCGastroenterol. 2013;13:47.

Daniel VOICULESCU, MD, PhD

Assistant Professor 1st Surgery Clinic

Universitary Emergency Hospital

Bucharest University of Medicine and

Pharmacy “Carol Davila”

Bucharest, ROMANIA


6. D. Voiculescu, Romania

Documents

In your clinical practice, when, in which type of ...€¦ · Madbouly , Egypt 5. C. Tohme, Lebanon 6. D. ... morrhoidal disease have not self-medicated, and a few will have taken