External Hemorrhoids Research Articles

Anal center detection and classification of perianal healthy condition

Objective: The very first step for an autonomous lower gastrointestinal (GI) tract robot to carry out a diagnostic or a therapeutic task is to enter the lower GI. The natural entry point of the lower GI tract is the anus. Thus, to find the anus center is the very first step before entering the lower GI tract. However, to the authors’ knowledge, there doesn’t exist any results of detection of anus center.Methods: An image processing pipeline is proposed by combing several classical image methods including Otsu’s method, the multiscale method and the threshold method and two deep neural networks, including Mask R-CNN and Inception-V3. Also, as a complementary result, the classification of healthy and diseased anus is determined by another Inception-V3, for healthy anus.Results: The positional error of the center detection by the proposed workflow is 2.15% averagely compared to the diagonal length, which is at the same level to that ten experienced proctologists. The proposed anal center detection method is applicable for both hairy anus and hairless anus. Also, the approach is valid for the anus in several common perianal diseases including perianal eczema, the mixed hemorrhoids, the anal fistula, the thrombotic external hemorrhoids, the internal hemorrhoids, and the external hemorrhoid.Conclusion: Anus center is detected by the proposed method with a similar accuracy to human doctors. Significance: This study provides the first solution for the anus center detection, enabling autonomous lower gastrointestinal tracts robot to enter anus without human guidance.

Comparison of Different Doses Botulinum Toxin Type a Efficacy in Chronic Anal Fissure Treatment

Abstract Objective: To compare the results of chronic anal fissure treatment with 10 IU and 40 IU botulinum toxin type A. Patients and methods: 56 patients were enrolled in case-control study divided into 2 groups consistent by the main clinical criteria. 28 patients in the study group had fissure excision in combination with 10 IU botulinum toxin type A (Xeomin) injection into internal anal sphincter, while 28 patients in control group received 40 IU product injections. Results: No statistically significant results in the pain assessment during the day and after bowel movement were obtained (p=0.41 and p=0.93, respectively). The groups were comparable by the frequency of complications such as transient anal incontinence, perianal skin hematoma, acute urinary retention (p>0.05). Complications such as thrombosis of external hemorrhoids and chronic non-healing wounds were most common in the study group (p=0.43 and p=0.0005, respectively). The product dose increase to 40 IU has a more significant effect on the functional treatment results (p=0.0053 and p=0.0002, respectively) and increases the odds for postoperative wound epithelialization 15-fold (p=0.01). Conclusion: 40 IU Botulinum toxin type A shows improvement in the treatment of chronic anal fissure without any increased risk of postoperative complications.

Una bambina con sanguinamento perineale ricorrente

A four-year old girl is evaluated for 8 recurrent episodes of perineal bleeding of undefined origin appeared six months before. Physical examination is normal except for a small anal fissure and a mild congestion of external haemorrhoids during Valsalva manoeuvre. Different diagnostic hypotheses and treatment options are discussed.

Adozioni e ADHD: quando si aprono le porte

A four-year old girl is evaluated for 8 recurrent episodes of perineal bleeding of undefined origin appeared six months before. Physical examination is normal except for a small anal fissure and a mild congestion of external haemorrhoids during Valsalva manoeuvre. Different diagnostic hypotheses and treatment options are discussed.

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.

Perianal thrombosis: no need for surgery.

There is little evidence for the best therapy for perianal thrombosis. No prospective trials exist. Even quality of retrospective data is low, due to low patient numbers or vague follow-up data. Six hundred nineteen patients with thrombosis of internal or external hemorrhoids who presented in our clinic between March 2017 and August 2018 were enrolled in the study. All patients were treated conservatively, with sitz baths and oral pain medication, if needed. No surgery was performed. Follow-up data was obtained by personal examination. Data was gathered prospectively, and data analysis was retrospective. Five hundred four patients had perianal thrombosis (81.4%), and 115 patients had thrombosed hemorrhoids. Mean pain on a numerical rating scale (0-10) was 3.8 for perianal thrombosis and 5.2 for thrombosed hemorrhoids. Five hundred forty-eight patients (88.5%) did not need a sick leave. On follow-up, patients stated that their pain had largely resolved after 5 days and completely disappeared after 10 days. Local recurrence rate after perianal thrombosis was 6.3%. Perianal thrombosis and thrombosed hemorrhoids heal well without surgery. There is no evidence for advantages surgical therapy could offer.

Unusual Skin Ulcerations in a Patient With Hematochezia

Question: A 31-year-old Hispanic woman with a past medical history of systemic lupus erythematosus, perianal condyloma acuminatum, and chronic iron deficiency anemia who presented with 2 days of palpitations in the setting of 2 months of intermittent hematochezia and multiple painful anogenital and left inframammary skin ulcers. She reports associated chronic foul-smelling perianal discharge, but denies any fever, nausea, vomiting, abdominal or perianal pain, melena, or changes in bowel habits. She had undergone an upper endoscopy and colonoscopy as part of her iron deficiency anemia workup 3 years before presentation, which revealed a normal esophagus, stomach, and duodenum, but had multiple small rectal and sigmoid colon polyps as well as internal and external hemorrhoids.

Homeopathic therapy for patients with acute hemorrhoids

Introduction . The prevalence of hemorrhoids in the adult population, according to various authors, ranges from 15 to 90%. In case of exacerbation of external hemorrhoids, conservative or surgical treatment can be applied. Of particular and important interest is homeopathic ointment, has an analgesic, antimicrobial, anti-inflammatory effect, and also affects the tone of the venous vessel. The purpose of our study was to study the effectiveness of Fleming’s ointment for the treatment and prevention of patients with acute hemorrhoids. Materials and methods . A prospective comparative study was conducted with the participation of 154 patients with acute hemorrhoids. In the main group (n = 76) of patients, treatment was carried out using diosmin and homeopathic ointment, which was applied 2 times a day for 7 days. In the control group (n = 78) patients, treatment was carried out using enteral administration of diosmin at a dosage of 1000 mg 1 time per day for 30 days and direct-acting anticoagulants in the form of an ointment 2 times a day for 7 days. Results . Within 3 months after the end of treatment, 4 (5.3%) patients of the main group and 12 (15.4%) patients of the control group had exacerbations of hemorrhoids. After 3 months, a statistically significant difference was revealed in the indicator of the subjective impact of hemorrhoidal disease on everyday life, which is associated with the development of exacerbations of hemorrhoids. Conclusions . Homeopathic ointment is an effective and pathogenetically justified remedy for the conservative treatment of patients with acute hemorrhoids. Its use leads to a significant decrease in the severity of clinical symptoms of the disease and an improvement in the indicators of objective research methods with good tolerability, the absence of undesirable effects and better long-term results compared to the standard treatment regimen.

Pressure dressings versus nonpressure dressings after hemorrhoidectomy: study protocol for a randomized controlled trial

BackgroundPressure dressings have been used after open hemorrhoidectomy to protect surgical wounds and manage postoperative bleeding for many years. However, pressure dressings may increase the incidence of postoperative complications, such as urinary retention, medical adhesive-related skin injury, and pain. A previous controlled trial included 67 patients who underwent Milligan-Morgan hemorrhoidectomy. The data indicated that the use of a nonpressure dressing after hemorrhoidectomy reduces the incidence of urinary retention and catheterization. However, the incidence of severe postoperative bleeding and other postoperative complications was not assessed. There is no consensus on whether it is necessary and beneficial to use a nonpressure dressing after hemorrhoidectomy. The results of this randomized clinical study will help answer this question.MethodsIn this study, we plan to include 186 patients who have undergone modified Milligan-Morgan hemorrhoidectomy, which only sutured external hemorrhoids to reduce the risk of bleeding. The purpose is to determine whether the use of nonpressure dressings after open hemorrhoidectomy is inferior to the use of pressure dressings in terms of severe postoperative bleeding and postoperative complications. The primary endpoints of the trial are the incidence of urinary retention within 24 h after surgery and the incidence of severe postoperative bleeding 1 h after dressing removal, which requires revision surgery within 24 h after the surgery. The secondary endpoints of the study are the pain score, anal distension score, postoperative use of analgesics, and incidence of medical adhesive-related skin injury, all of which will be assessed before removing the dressings. The length of hospitalization in days and hospitalization expenses will be recorded. Safety will be assessed with consideration of all adverse and severe adverse events related to the study treatment.DiscussionThe study received full ethics committee approval. The first patient was enrolled on 27 November 2020. The results of this trial will finally answer the question of whether a nonpressure dressing after open hemorrhoidectomy is necessary and beneficial.Trial registrationChinese Clinical Trial Registry ChiCTR2000040283. Registered on 28 November 2020.

Overview of Kshar-sutra in treatment of Ano-rectal diseases- review of cases treated at ACTH in 2011-2012: Retrospective study

Background
 Anorectal disorders including Fissure in Ano, Fistula in Ano and hemorrhoids are among the most common digestive complications. To our knowledge there is no any retrospective study of previous medical record data of Ayurveda Campus and Teaching Hospital (ACTH), Institute of Medicine, Tribhuvan University, Kirtipur, Kathmandu, Nepal available on the prevalence of major anorectal problems. Therefore, this retrospective was carried out to analyze the medical record of Shalya department OPD in fiscal year 2011-12 A.D. to estimate the prevalence of anorectal problems among the patients of anorectal complaints.
 Materials and Methods: This was a retrospective study conducted from January 2020 to December 2020 A.D. All the patients visiting the Department with anorectal complaints were screened. Name, sex, age, address and diagnosis was entered into Microsoft excel 2016 from registers of medical record; and analyzed in SPSS Version 2021 after coding the variables in excel. The findings were presented with percentage and frequency in pie and bar diagram.
 Results: Overall, anorectal cases (n=1067) were enrolled and analyzed in the study. The findings of major anorectal diseases like Fissure in Ano, Fistula in Ano and Hemorrhoids were commonly found in age group of 21-30 year; and followed by 31-40 year and 41-50 year. Fistula in Ano was also significantly found in the old age group of 61-70 year. Furthermore, the prevalence of Fissure in Ano, Fistula in Ano, Internal and External Hemorrhoids were 20%, 32%, 31.2% and 12% among ano-rectal problems in this hospital during this fiscal year respectively.
 Conclusion: Anorectal diseases are one of the common diseases observed in adolescent and adult patients which is more common in male than female. The prevalence of hemorrhoids is higher among Fissure in Ano and Fistula in Ano. Ksharasutra is the most effective procedure for treatment of these anorectal diseases.

Less postoperative pain and more frequent recurrence: Can this dilemma caused by the stapled haemorrhoidopexy procedure be avoided?

Although early studies highlighted the advantages of stapled haemorrhoidopexy (SH) (minimal pain and a rapid return to work), long-term follow-up revealed that residual skin tags, external prolapsed haemorrhoids and recurrence were frequent. The aim of our study was to investigate whether the above-mentioned problems could be prevented by performing additional interventions (AIs) during SH. We compared SH with and without AIs in terms of pain, wound-healing time, patient satisfaction and recurrence. A total of 106 patients with Grade III-IV haemorrhoids diagnosed between 2016 and 2018 were included. There were four subgroups: Grade III-IV patients undergoing SH alone or SH+AI. Subgroup 1 (Grade III; SH alone) showed significant decreases in the visual analogue scale pain scores on days 1 and 15 (P=.004), but no significant decreases were found in subgroups 2-4 (P=.839, P=.092, and P=.781, respectively). Satisfaction was highest in subgroup 1 (4.22±1.01), but there was no significant difference in satisfaction among the subgroups (P=.323). The overall recurrence rate was 13.2% and the difference among subgroups was significant (P=.023). Depending on the haemorrhoid characteristics, the use of more than one repair method provides the best results. Although AIs increase pain and wound-healing time, patient counselling enhances long-term satisfaction and success.

Gastrointestinal Bleeds.

Gastrointestinal Bleeds.

S2261 An Unexpected Cause of Gastrointestinal Bleeding: A Birthday Surprise

Introduction: Infrequently, basic procedures can turn into complex cases due to unforeseen circumstances. It is important for providers to recognize when standard techniques may be inadequate and more creative techniques should be implemented. Case Description/Methods: A 67-year-old male with a past medical history of poliomyelitis, developmental delay, mechanical aortic valve replacement on warfarin, and seizure disorder was transported from his group living facility to the emergency room due to melena. The patient was nonverbal at baseline, so his history was obtained via telephone from his case manager who reported he had developed weakness and fecal incontinence the morning prior to his admission. Stools were reportedly “bloody and black” in color. There was no reported epistaxis. He had been admitted to a nearby hospital two weeks prior for melena with an INR of 21. EGD reportedly showed duodenitis and colonoscopy was not performed. His discharge Hb was 11.5 g/dL. On examination, the patient was resting in the hospital bed comfortably, indicating that he was hungry. Vital signs were notable for relative hypotension compared to his baseline pressure. There was a large scab in his left nare, no oropharyngeal lesions, and his abdomen was soft and nontender to palpation. Rectal exam revealed nonbleeding external hemorrhoids and melena in the rectal vault. Hemoglobin was 9.4 g/dL, BUN 47, and INR 3.1. EGD was notable for a 4cm hard plastic “cupcake topper” in the stomach, no active bleeding, and multiple clots. Attempts to remove the object were unsuccessful due to its large diameter and unmalleable quality which prevented removal via the esophagus or overtube. The foreign body was successfully removed a few days later via fragmentation with a biliary lithotripsy device. Discussion: This case highlights how standard procedures such as GI bleed management can be impacted by unforeseen circumstances, the importance of recognizing when standard endoscopic techniques may not be feasible, and how endoscopic instruments can be utilized for alternative purposes. Although the patient was able to somehow swallow the foreign body, the object was unable to be safely removed en bloc without causing significant esophageal tearing. Because the object’s diameter was >2.5cm, there was low likelihood it would pass into the duodenum, allowing time to plan the optimal extraction technique.Figure 1.: A: Gross photo of macroglossic tongue. B: MRI with contrast of demonstrating macroglossia in the sagittal view.

Diagnosis and Management of Internal Hemorrhoids: A Brief Review

Hemorrhoidal disease is a pathological condition due to the abnormal engorgement of the arteriovenous plexus beneath the anal mucosa. Anatomically, it can be located under the skin on the outer part of the dentate line, known as external hemorrhoid; or inside the anus on the proximal part of the dentate line, called internal hemorrhoid. Internal hemorrhoid may further develop from a painless anal mass into protruded and painful mass throughout the anal canal, often accompanied by inflammation and more severe symptoms. Various management strategies need to be considered carefully to ensure the success of therapy and improve the quality of life of patients with internal hemorrhoids. Conservative management is the initial stage that can be performed, including the provision of high-fiber nutrition, education related to bathroom habits, and the use of flavonoid regimens. Surgical therapy can be divided into outpatient intervention and conventional surgeries. This review will encompass the comprehensive diagnostic approach and management of internal hemorrhoids to help clinicians understand the appropriate management and provide better clinical benefits for the patients.

Small cell neuroendocrine carcinoma disguised as an external hemorrhoid.

This article describes a patient who presented to the ED with persistent nausea and vomiting, constipation, weight loss, and a new complaint of an external hemorrhoid and hematochezia with stooling. Comprehensive diagnostic evaluation included imaging studies that showed extensive metastatic disease but did not identify a primary neoplasm. Biopsy of the external hemorrhoid revealed small cell neuroendocrine carcinoma of the anal canal.

Treatment of hemorrhoids in a comorbid patient: selection of a preparation of plant origin

Real clinical practice is currently characterized by a significant increase in clinical situations, when it is already difficult to talk about the presence of only one disease in a patient, and in most clinical cases the patient has a combined or concomitant pathology.Hemorrhoidal disease has been known since ancient times and remains one of the most common human diseases. In the acute and initial stages of chronic hemorrhoids, conservative treatment is carried out. Its main goal is to relieve pain and inflammation, normalize blood circulation in the rectum. Given the high prevalence of hemorrhoids and the main risk factors for its development, which are simultaneously important in the development of other diseases and pathological conditions, a patient with hemorrhoids should be considered as a comorbid patient. Drug therapy for a comorbid patient always carries the risk of harm to the patient’s health by the drug itself, designed to resist the disease.Homeopathic medicines should be considered as a drug of choice for topical therapy in the management of uncomplicated forms of external haemorrhoids. In the presented review, the effects of the main components (Calendula officinalis, hamamelis virginiana, Aesculus hippocastanum, Mentholum, Zinci oxydum) of the ointment are considered and it is noted that the main medicinal properties of the combined preparation are anti-inflammatory, regenerating, disinfecting, drying effects. In conclusion, 2 clinical examples are given, indicating the effectiveness of the ointment in comorbid patients in acute and early stages of chronic hemorrhoids.

Efficacy of Ruiyun procedure for hemorrhoids combined simplified Milligan\u2013Morgan hemorrhoidectomy with dentate line-sparing in treating grade III/IV hemorrhoids: a retrospective study

BackgroundHemorrhoids are common. Hemorrhoidectomy should typically be offered to patients whose symptoms result from external hemorrhoids or combined internal and external hemorrhoids with prolapse (grades III/IV). However, none of the currently used surgical methods could be considered an ideal surgical option that is effective, safe, and painless. We hypothesized that a combination of Ruiyun procedure for hemorrhoids (RPH) and simplified Milligan–Morgan hemorrhoidectomy (sMMH) will increase the safety and effectiveness of surgical treatment hemorrhoids. This study aimed to evaluate the efficacy of Ruiyun procedure for hemorrhoids combined simplified Milligan–Morgan hemorrhoidectomy with dentate line-sparing (RPH + sMMH) to treat grade III/IV hemorrhoid.MethodsTotal 452 patients with hemorrhoids of grade III/IV were retrospectively reviewed in China-Japan Friendship Hospital, 244 cases were assigned to RPH + sMMH group, and 208 cases in MMH group. The primary efficacy outcome was rate of curative at 3 month after operation, and the recurrence rate within 12 months post operation. Secondary efficacy outcomes included wound healing time, time required to resume normal work, constipation symptom, quality of life, and pain post operation was also evaluated. The safety outcome included postoperative complications.ResultsThere were no differences between the two groups in demographic characteristics. There was no statistically significant difference between the two groups in the curative rate. The recurrence rate after 12 months post operation in the RPH + sMMH (3.0%) was significantly lower than the sMMH group (7.8%) (P = 0.032). The wound healing time was significantly shorter in RPH + sMMH group than that in MMH group (P < 0.001). The time required to resume normal work in the RPH + sMMH group was significantly shorter than MMH group (P < 0.001). Compared with the MMH group, the RPH + sMMH therapy preserve better life quality and lower constipation symptom (all P < 0.05). Patients who underwent RPH + sMMH had significantly less postoperative pain than MMH therapy. The total rate of patients with postoperative complications in the RPH + sMMH group (8.6%) was significant lower than the MMH group (16.3%) (P = 0.012).ConclusionRPH + sMMH may more effective in treating patients with III/IV hemorrhoids, which indicated lower recurrence rate, lower postoperative complications and pain, shorter recovery and return to normal life.

Endoscopic findings in the older patients with iron-deficiency anemia

Aim: The presence of iron-deficiency anemia, which is an important indication for endoscopic&#x0D; procedures, in the geriatric population necessitates the exclusion of a possible malignancy in the&#x0D; gastrointestinal system. This study aims to examine endoscopic findings in geriatric patients that&#x0D; underwent esophagogastroduodenoscopy and colonoscopy because of iron-deficiency anemia.&#x0D; Materials and Methods: Sixty patients aged 65 and over who underwent&#x0D; esophagogastroduodenoscopy and colonoscopy because of iron-deficiency anemia between August&#x0D; 2019 and August 2020 were retrospectively evaluated. Age, sex, geriatric age groups of patients,&#x0D; presence of Helicobacter pylori in gastric biopsy, esophagogastroduodenoscopy findings, colonoscopy&#x0D; findings, presence of internal and / or external hemorrhoids, and duodenal biopsy results were&#x0D; examined.&#x0D; Results: Thirty (50%) of 60 patients included in the study were male and the mean age was 72.47 ±&#x0D; 6.07 years. Of these patients, 41 (68.4%) were young-old, 17 (28.3%) were middle-old and 2 (3.3%)&#x0D; were old-old. The most common causes that might explain iron-deficiency anemia in&#x0D; esophagogastroduodenoscopy were atrophic gastritis (21.2%), Helicobacter pylori-positive gastritis&#x0D; (20%), gastric polyp (11.7%), and gastric cancer (3.3%), whereas colonoscopy results were found&#x0D; colon polyps in 23.3% of patients, diverticulum in 15% and angiodysplasia in 15%, and colon cancer in&#x0D; 8.3%. Internal hemorrhoids were also observed in 44 (73.3%) patients.&#x0D; Conclusion: In the older population, blood loss from the gastrointestinal system is the most important&#x0D; cause of iron-deficiency anemia and just hemorrhoids cannot explain IDA. While examining the&#x0D; etiology of patients diagnosed with iron-deficiency anemia, performing both&#x0D; esophagogastroduodenoscopy and colonoscopy is an accurate approach to reach the underlying&#x0D; cause and not to miss a possible malignancy

THE FIRST EXPERIENCE OF SURGICAL TREATMENT OF HEMORRHOIDS USING THE WIRELESS DOPPLER OPERATING COMPLEX TRILOGY HAL-RAR UNIT

Summary. Objective: To improve the results of treatment of patients with stage II-III hemorrhoids using the wireless Doppler surgical complex Trilogy HAL-RAR Unit.&#x0D; Materials and methods. In the clinic of coloproctology of the Military Medical Clinical Center of the Southern region of Odessa according to the method of disarterization of hemorrhoidal arteries and recto-anal recovery using wireless Doppler surgical complex Wi-3 Trilogy HAL-RAR for the period from January 2019. to June 2020 19 patients were operated on.&#x0D; Results and discussion. In the postoperative period, moderate pain was observed for three days in 13 patients (68.4 %), only one of them had pain for the first 6 days after surgery. In 6 (31.6 %) patients no complaints of pain in the postoperative area were noted. In all patients, the pain was acquired by taking nonspecific anti-inflammatory drugs without the use of narcotic analgesics. In the postoperative period, patients were examined for 2, 7 and 90 days after surgery. No complications were noted in the postoperative period. In 4 (20 %) patients, due to the presence of enlarged hemorrhoids, the operation was extended by removing the external hemorrhoids and suturing the mucosal defect. All patients noted no reduction in quality of life in the postoperative period.&#x0D; Conclusions. Surgical treatment of hemorrhoids using Trilogy HAL-RAR technology is a minimally invasive method that reduces the patient’s stay in the hospital in the postoperative period, does not require the use of narcotic analgesics, promotes rapid recovery and may be the surgery of choice for surgical treatment of hemorrhoids II-III.

Results of the use of intranodal laser coagulation in patients with chronic internal hemorrhoids stage III

Aim: to assess the efficacy of intranodal laser coagulation for hemorrhoids stage III.Patients and methods: the study included 62 patients with chronic internal hemorrhoids stage III without external hemorrhoids, who were informed of the INLC technology, its advantages and disadvantages. The selection for this procedure was done due to the high-resolution anoscopy, in the presence of type 1 and type 2 severity of inflammatory changes in the nodes.Results: on the 3rd day, no pain occurred in 52 (83.9%) patients. After 12 months, a complete disappearance of hemorrhoid symptoms was observed in 51 (82.3%) patients, while 7 (11.3%) patients had a recurrence. In 8 (12.9%) patients, symptoms of discomfort and itching were noted.Conclusions: intranodal laser coagulation allowed in 61 (98.4%) cases to perform this procedure on an outpatient basis, and did not affect the anal sphincter function. Good long-term results were obtained in 82.3% of cases. Intranodal laser coagulation is an effective method for chronic hemorrhoids.