Medical Therapy of Hemorrhoidal Disease
Hemorrhoids can occur normally as part of the vasculature of the anal canal, however; in some patients they can also be the source of a number of bothersome perianal problems. These problems encompass a condition referred to as hemorrhoidal disease. The cardinal features of this condition include anal pruritus, prolapse, bleeding, and pain in the case of thrombosis. Symptomatic hemorrhoids have a prevalence ranging from 4.4% in the general population, to 36.4% in the population attending general practitioners (Johanson and Sonnenberg, Gastroenterology 98:380–386, 1990), and are known to have an increased prevalence during pregnancy and postpartum (Johanson and Sonnenberg, Gastroenterology 98:380–386, 1990).
Medical treatment of hemorrhoidal disease include the treatment of the associated disorders like constipation and the active treatment of hemorrhoidal disease.
The therapy for hemorrhoidal associated constipation is discussed in Sect. 2. Briefly, constipation is a common and sometimes disabling condition worldwide, above all among patients presenting hemorrhoids. A variety of traditional and novel treatment options are nowadays available. Fiber has been indiscriminately recommended for the treatment of constipation. As a matter of fact, an increase in the amount of dietary fiber is an almost universal recommendation in the primary care management of constipation and more in general in the management of hemorrhoids. Insoluble fibers appear to have the greatest impact on stool frequency and output. Traditional laxatives are effective at inducing bowel movements, but data for their role in long-term management and on efficacy on constipation-associated abdominal symptoms are limited. Long-term studies are available for polyethylene glycol (Macrogol), confirming sustained efficacy. The critical importance of the enteric microbiota to intestinal and, especially, colonic function, together with some limited clinical evidence to suggest some changes in the flora in the constipated subject provide a rationale for the use of probiotics and prebiotics in constipation. However, with the exception of the constipated IBS subject, clinical trial data on these agents in constipation, per se, is very scanty. Large-scale, high-quality, trials are indicated and are clearly feasible given the prevalence of the complaint. When patients fail to respond to standard therapy, the colonic secretagogue lubiprostone, or the 5-HT4 agonist prucalopride, or linaclotide, a GC-C receptor agonist, are available as the next step in management. In controlled trials in chronic constipation, these drugs were shown to significantly improve constipation and its associated symptoms, and both seem to have a favorable safety record, although a high incidence of nausea was reported with lubiprostone. Among the new therapeutic agents Plecanatide, another GC-C agonist, has been proven to be effective in the treatment of constipation, although its long-term risks and benefits remain to be determined. The accessibility of multiple drugs with different mechanisms of action will continue to benefit patients suffering from chronic constipation as well as the hemorrhoids-associated one. The treatment of constipation has become easier with the exciting development of new medications and effective biofeedback therapy over the past decade. Other therapies on the horizon should further improve health care providers’ ability to effectively treat symptoms of hemorrhoids and its complications.
The active therapy for hemorrhoidal disease is discussed in Sect. 3. Briefly, conservative approaches are recommended in particular for low-grade internal hemorrhoids and nonthrombosed external hemorrhoids (grade I hemorrhoids), which can generally be effectively treated with dietary and lifestyle modifications. The main goal of medical treatment is to control hemorrhoidal symptoms. Several drugs are available in various forms including tablet, suppository, cream, and wipes. Oral therapy is based on flavonoids, mesoglycan, calcium dobesilate, and herbal extracts. Local therapy is based on corticosteroids, analgesics, vasoconstrictors, and barrier cream including several active ingredients such as sodium hyaluronate, aloe vera, and other herbal extracts. Flavonoids are a heterogeneous class of drugs with venotonic properties, capable of increasing vascular tone, reducing venous capacity, decreasing capillary permeability, and facilitating lymphatic drainage in addition to having anti-inflammatory effects. Mesoglycan is a set of glycosaminoglycans of venous vascular diseases due to its fibrinolytic effect. Calcium dobesilate is a venotonic drug, which is capable of controlling symptoms of a hemorrhoidal attack, reducing microvascular permeability, decreasing platelet aggregation, and having antioxidant properties. Oral supplementation with herbal extracts as Aesculus hippocastanum, Ruscus aculeatus, Centella asiatica, and Hamamelis virginiana may help control hemorrhoidal symptoms. Pharmacological mechanisms of action are very similar to those of the flavonoid drug class, by improving circulation and reducing inflammation. Several dietary factors including a low-fiber diet, spicy or fatty foods, coffee, alcohol, and others may be implicated in the pathogenesis of hemorrhoidal disease, but reported data in most cases is inconsistent or conflicting. Increasing dietary fiber intake and oral fluids are both recommended to manage hemorrhoidal disease and reduce the likelihood of recurrence. Spicy food is one of the most important dietary risk factors for hemorrhoidal crisis. Alcohol is another possible risk factor for hemorrhoidal disease, and although reliable data in the literature is sparse, patients should still avoid alcohol consumption during a hemorrhoidal crisis. Smoking is not associated with an increased risk of hemorrhoid. Local anesthetics reduce hemorrhoidal symptoms by exerting a local anesthetic effect, which eliminates the burning and itching associated with hemorrhoidal prolapse. They have less of an effect on bleeding, although they are frequently used for this indication. Antispasmodic agents, glyceryl trinitrate (GTN), and nifedipine are used to relieve symptoms associated with anal sphincter spasm and high resting anal canal pressures. Topical GTN treatment has also resulted in a decrease rectal bleeding, an improvement of anal pain, throbbing, itching, and irritation. Nifedipine ointment has good efficacy particularly in the treatment of acute thrombosed external hemorrhoids and chronic anal fissures. Phenylephrine is a vasoconstrictor which provides temporary relief of acute symptoms of hemorrhoids, such as bleeding and pain on defecation. Anti-inflammatory topical therapy is based on hydrocortisone acetate or 5-aminosalicylic acid (5-ASA), both with similar anti-inflammatory effects, and suppository forms are more useful than cream to treat internal hemorrhoids. Several botanical extracts have been shown to improve hemorrhoidal symptoms. Aloe vera is one of the most commonly used extracts for treating acute and chronic wounds. The gel of aloe vera reduces the pain, swelling and itching of burns, and skin irritation. Topical therapy with herbal extracts, such as Aesculus hippocastanum, Ruscus aculeatus, Centella asiatica, and Hamamelis virginiana, may also help control hemorrhoidal symptoms, these are often prescribed in clinical practice due to their effectiveness and the very few reported side effects.
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