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Carlo Ratto - Hemorrhoids

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Book:
Hemorrhoids
Author:
Carlo Ratto / Angelo Parello / Francesco Litta
Publisher:
Springer
Genre:
Books / Romance novel
Year:
2018
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This book offers a comprehensive guide to hemorrhoidal disease, the most frequent coloproctological affection. In addition to amply illustrated chapters covering the epidemiology and anatomic, physiologic, and pathophysiologic bases of hemorrhoids, readers will find helpful information on the classification of hemorrhoidal disease and modalities to assess it, as well as their significant impact on the choice of treatment. The work presents a complete panel of all therapies usually adopted to treat this condition and their outcomes, which are critically commented on by prominent specialists. Further, management of the disease in special conditions is also discussed. Lastly, a literature review and evaluation of the impact of different treatments on the patients quality of life round out the volume, which is part of the Reference Work series entitled Coloproctology.

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Part I
Basics on Hemorrhoids

Springer International Publishing AG, part of Springer Nature 2018

Carlo Ratto , Angelo Parello and Francesco Litta (eds.) Hemorrhoids Coloproctology

1. Epidemiology of Hemorrhoidal Disease

Gaetano Gallo 1

(1)

Department of Medical and Surgical Sciences, O.U. of General Surgery, University of Catanzaro, Catanzaro, Italy

(2)

Department of Medical and Surgical Sciences, O.U. of Digestive Surgery, University of Catanzaro, Catanzaro, Italy

Gaetano Gallo (Corresponding author)

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Rosario Sacco

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Giuseppe Sammarco

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Abstract

Hemorrhoids are vascular cushions that underlie the distal rectal mucosa and contribute approximately 1520% of the resting anal pressure, ensuring complete closure of the anal canal.

Hemorrhoids became symptomatic when enlarged, inflamed, thrombosed, or prolapsed, and the most common symptom is painless rectal bleeding, which is why hemorrhoids are one of the most frequent causes of severe acute lower gastrointestinal bleeding.

Defining the term hemorrhoids and their epidemiology has always been controversial.

Unfortunately, at present, even after years of articles, debates, and pathogenetic theories, we do not know the extent of this phenomenon.

In this chapter, we will discuss the epidemiology of hemorrhoidal disease and compare the most important studies in the literature.

Introduction

Hemorrhoidal disease is one of the oldest and most common proctologic diseases that has been described (Trompetto et al. ).

We can find traces of their description in both the Old Testament and Buddhist scriptures (Burkitt and Graham ). More recently, historical study shows signs of the presence of hemorrhoids even in battle. Everybody knows that 200 years ago (18 June 1815), Napoleon Bonaparte was defeated at Waterloo by the Duke of Wellington, who was joined by the Prussians and an invisible enemy, hemorrhoids.

Literature is poor in data on the current incidence and prevalence of hemorrhoidal disease in the general population, especially because most people have no symptoms and often hide this disease out of a sense of embarrassment.

Nevertheless, the number of terms used to define hemorrhoids when pathological has generated enormous confusion.

Epidemiology of Hemorrhoidal Disease

Over the years, several epidemiological investigations have demonstrated the influence of environmental factors in the development of hemorrhoidal disease.

Hyams and Philpot were among the first in the modern age to study the prevalence of hemorrhoids, just a few years before Burkitts theory (Hyams and Philpot ). They classified patients according to age, sex, socioeconomic status, race, religion, bowel habits, and pregnancy. The most important finding was that one in four individuals over 30 years had a certain degree of hemorrhoidal disease.

Following the theory of Burkitt in the early 1970s (Burkitt ) performed an epidemiological investigation comparing the epidemiology of hemorrhoids with the epidemiology of constipation and failed to demonstrate any correlation.

In fact, constipation, in contrast to hemorrhoids, was more common with increasing age, among blacks and among those with low socioeconomic status and less education.

The results, which were similar regardless of sex, showed a prevalence rate of hemorrhoidal disease of 4.4% with a peak between 45 and 65 years old and a decline after age 65. Moreover, hemorrhoids were uncommon in patients under 20 years old. Conversely, whites were affected 1.5 times more frequently than blacks, and in England and Wales (but not in the United States), higher social class was linked with an increasing prevalence of hemorrhoids (1.8 times more common). According to the authors, this trend was due to the difference in social classification. In fact, in England and Wales social class was closely related with occupation.

Interestingly, a theory about the role of occupation on the etiopathogenesis of hemorrhoids was developed by Prasad et al. (). They noted that most of their patients (66%) with hemorrhoids had occupations involving prolonged sitting.

An earlier article by Johanson and Sonnenberg () claimed that physician visits, hospital discharges, and surgical procedures for hemorrhoids in the USA had considerably decreased over the past 2530 years. The authors used only statistics based on the International Classification of Disease (ICD) and consequently not based on patient self-diagnosis.

There may be many reasons for this decrease: increased use of conservative treatment, self-medications with over-the-counter preparations, and the increased use of stool softeners and fiber supplements.

The fact that the epidemiology of hemorrhoids has always been a topic of interest was demonstrated in a letter to the editor by Haas () in response to the latter debated articles of Johanson and Sonnenberg.

Haas criticized the definition of hemorrhoids used by the authors [a dilation of hemorrhoidal plexus that protrudes into the lumen of the anal canal (Johanson and Sonnenberg ): haemorrhoids are normal components of human anatomy, i.e., if hemorrhoids are a normal component of the human body, then their prevalence should be 100% without any provocation.

According to Haas, the criteria used by Johanson and Sonnenberg, which were based on the definition of hemorrhoids written in the ICD, in determining the prevalence and occurrence of hemorrhoids were wrong.

Therefore, how could the epidemiology of hemorrhoids be established without defining it properly?

The answer by Johanson and Sonnenberg () was quick to come, and even to this day the term hemorrhoids continues to be used to describe a pathological rather than a normal anatomic entity.

A few years previous, Haas et al. () reviewed the records of 835 patients seen in their clinic. They had performed routine rectal examinations consisting of inspection of the anal area, digital examination, anoscopy, and sigmoidoscopy. The examinations were performed by five surgeons who were not advised of the purpose of the study to prevent selection bias.

Hemorrhoidal disease was diagnosed in 720 patients (86%): 198 (198/241; 82%) among the asymptomatic group and 522 among the symptomatic group (522/594; 88%). There were no significant differences between men and women with respect to prevalence, and socioeconomic factors do not influence the incidence of hemorrhoids. Interestingly, women were more likely to be symptomatic than men.

In the twenty-first century, there was a reduction in epidemiological studies on the prevalence of hemorrhoidal disease. However, chronologically, four studies deserve to be mentioned.

In a mini-review published by Everhart and Ruhl (), hemorrhoidal disease was classified as the fourth leading outpatient digestive system diagnosis in the United States, with only gastroesophageal reflux disease, chronic constipation, and abdominal wall hernia being more common. There was an estimated 2 million ambulatory care visits with hemorrhoids as the first listed diagnosis and 3.3 million visits as a diagnosis listed at all. Visit rates were highest among patients older than 65 years and among whites. There were no differences between genders.

Riss et al. conducted an epidemiological cross-sectional study to determine the prevalence of hemorrhoids in adults that also tried to define associated risk factors (Riss et al. ).

The authors included in the study all patients between 2008 and 2009 consecutively who underwent colorectal cancer screening in four Austrian medical institutions.

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