Haemorrhoidal disease presentation notes

Summarized hemmorrhoid notes

1. Optimal Management of Haemorrhoidal disease Dr. Miriam Gatehi GASTROENTEROLOGIST KUTRRH

2. Case Study AH 57 year old male with longstanding anal pain*3 years Is a diplomat who travels often Anal pain worse on defecation. Denies constipation Wishes to have a colonoscopy before travelling back to his home country Any thoughts? 2

3. Case Study AH 57 year old male with longstanding anal pain*3 years Is a diplomat who travels often Anal pain worse on defecation. Denies constipation Wishes to have a colonoscopy before travelling back to his home country O/E-Large external haemorrhoids 3 and 7 o’clock, tender+++. Unable to complete DRE due to pain Approach to Management? 3

4. Anatomy of hemorrhoids Hemorrhoids -symptomatic enlargement and distal displacement of the normal anal cushions Internal hemorrhoids arise from the internal hemorrhoidal plexus, while external hemorrhoids arise from the external plexus Boundary is the dentate line (pectinate line)

5. Epidemiology 4% of US population estimated to have symptomatic haemorrhoidal disease; one third seek medical attention In the USA, >32,000 annual surgeries are carried out, and 1.5 million HD-related prescriptions Men and women equally affected, peak 45-65 years 50% recurrence after medical Rx 5-20% recurrence after surgery Tucker H. et al. Ann R Coll Surg Engl. 2008 NIH Publication (November 2010, USA). Johanson J. et Sonnenberg A. Gastroenterology. 1990

6. Vascular component of anal cushions

7. Pathophysiology of hemorrhoid disease Incompletely understood Overall 4 core pathophysiological events 1. the sliding process of anal cushions 2. deterioration of the connective tissue of the cushion 3. reduction of venous return from sinusoids to the SRV and MRV during defecation 4. stagnation of blood inside the dilated plexus

8. 9 Straining/Increased abdominal pressure Aging (degenerative change) Increased anorectal blood flow Mechanical injury (hard stool) Tissue inflammation Venous stasis & Venous inflammation Loss of fixation Disruption of supporting tissue in anal cushions Inflamed v enodilation Engorged and tortuous veins in hemorrhoidal plexus HEMORRHOIDS ANAL CUSHIONS Collective pathophysiology for hemorrhoidal disease Lohsiriwat V . World J Gastroenterol 2012 May 7;18 (17):2009-2017 . 9 Hemorrhoidal disease might appear local acting but is ACTUALLY SYSTEMIC in origin and requires a systemic approach

9. Hemorrhoid classification: The four-grade system

10. Symptoms of hemorrhoids Approximately 4 of 10 patients with hemorrhoids are symptomatic Bleeding–painless bright red oozing, sometimes spurts, rarely spraying, with defecation often precedes prolapse Prolapse

11. PROLAPSE

12. SYMPTOMS…… Perineal irritation, itching and soiling Mild fecal incontinence Rectal fullness and feeling of incomplete evacuation Pain-not the typical symptom except coexisting external hemorrhoids Thrombosis, ischemia, incarceration, strangulation Exclude perirectal abscess or anal fissure

13. Clinical Evaluation Abdominal examination Inspect the perineal and rectal areas with the patient at rest and while bearing down Inspect for presence of external hemorrhoids or prolapse of internal hemorrhoids Skin tags-prior hemorrhoids, or anal fissure Digital rectal examination to detect masses, tenderness, assess sphincter intregrity Anoscopy to visualize internal hemorrhoids

14. Indications for colonoscopy To rule out a proximal source of bleeding if uncertain history Any patient over the age of 45 years Presence of risk factors and clinical suspicion for other causes of GI bleeding Lack of response to initial therapy.

15. Lifestyle modifications First line treatment Dietary modification consisting of adequate water and fiber intake counselling on defecation habits (grade 1B recommendation-strong recommendation based on moderate quality of evidence) Prevent formation of new hemorrhoids even after invasive treatment Increase fluid to 2liters per day

16. Fiber supplementation Integral part for initial management and after other modalities of treatment Eliminates the straining during defecation which causes shearing forces on anal cushions leading to symptomatic hemorrhoids Reduces the risk of bleeding by approximately 50%, No improvement of prolapse, pain, and itching Effective treatment in non-prolapsing hemorrhoids Takes up to 6 weeks for a significant improvement to be manifest Psyllium, iphaghula husk, unprocessed bran, 25g/day

17. Defecation habits Limit time for evacuation to 1 minute No reading Sitz baths for thrombosed hemorrhoids Most patient respond well

18. Topical ointments Contain astringents, protectants (zinc oxide), decongestants (phenylephrine), corticosteroids, and topical anesthetics Effective for control of pruritus and irritation Use for short periods due to allergic reactions Topical nitroglycerine 0.4% ointment if pain is associated, reduces anal muscle spasms

19. Oral Flavonoids Oral flavonoids are Venotonic agents & are the main active phytoconstituents in plant extracts Have significant anti-inflammatory , antioxidant and venoprotective actions Reduce venous inflammation by inhibiting leukocyte rolling, adhesion, and migration Inhibit the synthesis of inflammatory mediators Improve venous tone and lymphatic drainage by modulating noradrenergic signaling & reducing norepinephrine metabolism Reduce capillary hyperpermeability and improves the capillary resistance, improve microcirculation

20. Micronized purified flavonoid fraction (MPFF) Is part of the oral flavonoids Consists of 90% diosmin and 10% hesperidin (an additional flavonoid fraction) The most common flavonoid used in clinical treatment The micronization (less than 2μm) improves absorption and rapidity of action and thus 30% better clinical efficacy compared to non-micronized formulations Venous pathologies and diminished venous return play prominent roles in HD, these actions of MPFF provide the rationale for its use in treating HD

21. Acting at the core of the disease : venous anti-inflammatory and venoprotective actions : Micronized Purified Flavonoid Fraction Ruscus : (+) mentioned in the 2018 CVD guidelines but there is no reference available Adapted from: Nicolaides A et al. Int Angiol . 2014;33(2):87-208 and Nicolaides A et al. Int Angiol . 2018;37(3):181-254. MAIN VADs Evidence based mode of action Venous tone Venous wall & valve Capillary leakage Lymphatic drainage Free radicals MPFF 1000 + + + + + Calcium dobesilate + + + + Diosmin * *No data available for Diosmin

22. Efficacy in acute hemorrhoidal symptoms 1 Zagriadskiĭ EA et al. Adv Ther. 2018;35(11):1979-1992. At 5 to 7 days (V0–V1) MPFF 1000 was effective in 84% of patients providing significant reduction in symptoms pain, bleeding, swelling and prolapse At 25 to 30 days (V2): the significant reduction in all symptoms continued ( P <0.001). MPFF 1000 is effective for all grades of HD Clinical outcomes with MPFF: anal bleeding, perianal edema, prolapse, anal pain at V1 and at V2. Statistically significant reduction in all HD symptoms ( P <0.001) Multicenter, observational, phase 4 study, 1952 patients with symptomatic hemorrhoids, MPFF based conservative treatment (fiber, topical ointments, NSAIDs if needed) for 4 weeks. Assessment: Visit at 5 to 7 days (V1) and at 25 to 30 days (V2) with VAS, questionnaire and anoscopy. Surgical and minimally invasive treatment could be performed from day 7 onward if required. (P<0.001).

23. Efficacy in prevention of relapses 2 Long-term, double-blind, randomized, placebo-controlled study on 120 patients who suffered from acute hemorrhoidalattacks in the previous 2 months Patients received MPFF 500mgx2/day or placebo for 2 months Patients were examined at day 0 and day 60. The frequency, duration, and severity of acute episodes were reported. Godeberge P. Phlebology . 1992;7(suppl 2):61-63. The number of patients who had at least one acute episode was significantly lower in MPFF group compared with the placebo group (40% vs 76%, P <0.05). Acute episodes were significantly fewer, shorter, and milder in the MPFF group: 0.6 episodes, 2.6 days, 1.1 severity vs 2.1 episodes, 4.6 days, 1.6 severity ( P <0.01). Fewer, shorter and milder acute epizodes with MPFF MPFF provides protection from relapses in Chronic HD patients

24. Efficacy of MPFF in reducing relapse Unlike topicals which offers superficial relief, MPFF addresses the root cause (venous inflammation) and restores the integrity of the damaged vessels (veins, capillaries and lymphatics) hence reducing the risk of recurrence. It makes sense to treat the root cause rather than to treat the symptoms alone. 27

25. Grade 1 Grade 2 Grade 3 Grade 4 Dietary and lifestyle modification Medication – MPFF, venoactive drugs Sclerotherapy Rubber-band ligation Non-exicisional operation Stapled hemorrhoidopexy Hemorrhoidectomy Recommended for all grades and in conjunction with procedures MPFF is the first-line treatment Modification from Lohsiriwat V. Approach to hemorrhoids. Curr Gastroenterol Rep. 2013;15:332-336 . 28

26. Recommendations from the Association of Colon & Rectal Surgeons of India: MPFF is recommended as a first-line treatment for grade I/II (a-c) and selected / minor grade III (a-c) hemorrhoids; also it is listed as an effective adjuvant to surgery and other procedures. 3 Recommendations from the American Gastroenterological Association: MPFF is recognized as the pharmacological treatment with efficacy in reducing all symptoms & signs of HD. 2 1. Higuero T et al. J Vasc Surg. 2016;153(3):213-218. 2. Abramowitz L et al. Gastroenterol Clin Biol. 2001;25(6-7):674-702. 3. Agarwal N et al. Indian J Surgery. 2017;79(1):58-61. 4. Shelygin YA et al. T he Russian Association of Coloproctology Clinical Guidelines for the Diagnosis and Treatment of Hemorrhoids . 2019;18. DOI: 10.33878/2073-7556-2019-18-1-7-38 6 MPFF as a “reference treatment” in Recommendations from the French Society of Coloproctology: MPFF : grade B recommendation ; as a short-term treatment for the symptoms of internal hemorrhoids (pain, prolapse, bleeding); for the treatment of internal hemorrhoids during pregnancy; for patients undergoing a pedicular hemorrhoidectomy for the management of their hemorrhoids for lessening the risk of hemorrhage. 1 Recommendations from the Russian Association of Coloproctology : MPFF is recommended for the treatment of HD (grade B- evidence level 1a), also for thrombosed hemorrhoids. 4

27. MPFF clinical proofs in Hemorrhoidal disease Conclusions MPFF provides major efficacy in the treatment of acute hemorrhoidal attacks MPFF rapidly stops bleeding in most of HD patients MPFF provides significant improvement in all symptoms and signs from the 2 nd day. MPFF has been demonstrated to protect patient against recurrent HD attacks. MPFF provides patients with additional benefits combined with surgery MPFF is the reference treatment for HD from a large number of clinical trials MPFF is the only veno -active treatment recommended from Grade I to Grade III in the guidelines

28. Minimally invasive therapies Rubber band ligation Infrared Coagulation Bipolar diathermy ( Bicap ) Sclerotherapy etc

29. Indications for surgery Symptomatic third-degree, fourth-degree, or mixed internal and external hemorrhoids Symptomatic hemorrhoids with a concomitant anorectal condition that requires surgery Strangulated internal hemorrhoids

30. Surgical options Closed hemorrhoidectomy Open hemorrhoidectomy with excision and ligation Stapled hemorrhoidectomy/ hemorrhoidopexy

31. Efficacy in post-hemorrhoidectomy patients 2 Prospective, randomized, controlled study 228 patients underwent an elective hemorrhoidectomy using the diathermy excision method. MPFF group: 114 patients who received postoperative MPFF 500 mg (2 tablets three times daily for 3 days, then 1 tablets three times daily for 4 days) Control group: 114 patients Postoperative analgesics and laxatives were prescribed for both groups Ho YH et al. Br J Surg. 1995;82(8):1034-1035. The risk of secondary bleeding from a hemorrhoidectomy is reduced significantly with postoperative MPFF. For internal use only MPFF reduces bleeding after hemorrhoidectomy Less bleeding after hemorrhoidectomy with MPFF 10 8 6 4 2 0.0 Control group Incidence of hemorrhage (%) MPPF group n=228 6,1% 0,9% P =0,03

32. Efficacy in post-hemorrhoidectomy patients 2 Prospective, randomized, controlled study 112 patients who underwent an hemorrhoidectomy were divided in 2 groups MPFF group:56 patients received MPFF 500 mg (3 tablets twice daily for 3 days, then 2 tablets twice daily for 4 days) Control group: 56 patients The severity of pain and the number of intramuscular analgesic injections required were recorded for the first 3 days, then 1 week after hemorrhoidectomy. Colak T et al. Surg Today . 2003;33(11):828-832. MPFF significantly reduced the severity of pain and the analgesic requirement starting from postoperative day 2. The hospital stay was shorter and patient satisfaction was superior with MPFF treatment after hemorrhoidectomy. MPFF reduces the severity of pain and the analgesic requirement after hemorrhoidectomy Pain scores after hemorrhoidectomy (VAS) 5.0 4.0 3.0 2.0 1.0 0.0 Postop DAY 1 Postop DAY2 Postop DAY3 Postop DAY7 cm MPFF control 7.0 6.0 * ** *** * P =0,033 ** P =0,011 *** P =0,001 n=112

33. Our Patient Colonoscopy done-Unremarkable except for large external haemorrhoids Management: Sitz baths BD, high fibre diet, Laxative(declined), MPPF( Daflon 1000mg tds for 3 days then BD for 4 days then OD for 3 months) Surgical Max given as an option. Patient decided on Surgery Surgical Management: Infrared Coagulation done ; post surgical follow-up difficult-pain, recurrence after 4 weeks Decision made to do open Haemorrhoidectomy; MPPF( Daflon ) continued…Patient doing well 36

34. Conclusion The pathogenesis of anal hemorrhoids involves destruction of connective tissues and venous inflammation caused by venous stasis Lifestyle recommendations are paramount in the treatment and secondary prevention for all grades of hemorrhoids Hemorrhoidal disease might appear local acting but may have a systemic origin and therefore requires a systemic approach Important to note that topicals act locally to provide temporary relief and the patient still needs a treatment that acts at the root cause of the disease Among different treatment modalities, Micronized purified flavonoid fractions ( Diosmin ) relieves the patient from acute HD symptoms & protects them from relapses Micronized purified flavonoid fractions ( Diosmin ) has been shown to be very useful before, during and after surgery as it helps in rapid patient healing

35. THANK YOU