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Therapeutic aspects of hemorrhoid treatment

For many decades, hemorrhoids have been and remain a pressing medical problem. This is due to the widespread prevalence of the disease - hemorrhoids and its complications are the cause of 40% of visits to a surgeon or proctologist, a significant decrease in the quality of life of such patients, and an increase in the total number of days of disability.

The first scientific definition of hemorrhoids was given in the 18th century, when cavernous plexuses were discovered, formed during normal embryogenesis in the submucosal layer of the distal part of the rectum. However, only in the middle of the last century did foreign and domestic scientists establish that hemorrhoids are the result of impaired hemodynamics and an inflammatory process in the vessels of the hemorrhoidal plexuses, which is accompanied by thrombosis, varicose veins, as well as sclerosis of the veins and is often complicated by bleeding.

Etiology and classification of hemorrhoids

Despite the fact that a significant number of studies have been devoted to the problem of hemorrhoids, the etiology of this disease is still not fully understood. Currently, great importance is attached to hereditary factors, in particular genetically mediated incompetence of vascular connective tissue and mesenchyme in general [5, 6].

Factors contributing to the appearance and development of hemorrhoids are:

constipation, which occurs in more than 75% of patients;
venous circulation disorders in the lower half of the body, developing with prolonged standing, sedentary lifestyle, obesity, bronchial asthma;
dysfunction of the rectum, causing spasm of the internal sphincter (psycho-emotional disorders, adhesive disease);
disruption of portosystemic blood flow due to alcohol abuse, fatty foods, and the use of certain medications;
chronic inflammatory diseases of the anorectal zone and pelvic organs (bacterial salpingoophoritis, prostatitis, cystitis), leading to inflammation of vascular formations, hemodynamic disturbances and lymphogenous spread of infection into the hemorrhoidal plexuses;
pregnancy.

Depending on the location of hemorrhoids, internal hemorrhoids are distinguished, in which the nodes are located inward from the dentate line of the anal canal, and external, with the nodes located distal to it. A combined form of the disease is often encountered.

The course of hemorrhoids can be acute or chronic. There are four degrees of severity of hemorrhoids:

I degree - swollen, sometimes bleeding, captive hemorrhoids; II degree - prolapsed nodes are reduced independently; III degree - prolapsed hemorrhoids can be reset only by manual manipulation or instrumentally; IV degree - prolapsed hemorrhoids cannot be reduced.

Typical locations for hemorrhoids are the left lateral, right anterior and right posterior walls of the anal canal.

Clinical picture and diagnosis

Hemorrhoids affect people of any age, and men and city residents who lead a sedentary lifestyle are more likely to suffer from hemorrhoids.

The clinical picture of hemorrhoids is characterized by a triad of symptoms, including pain, bulging of hemorrhoids due to thrombosis and inflammation in the node itself and surrounding tissues, as well as bleeding.

Pain during bowel movements and emptying the rectum is most often associated with thrombosis of the internal hemorrhoid or anal fissure. Discharge from the anal canal in acute hemorrhoids is a consequence of the inflammatory process and is a mucous or inflammatory substance. They can cause a feeling of wetness, which leads to anal itching and scratching of the skin of the perianal area.

Bleeding from hemorrhoids usually occurs after or during a bowel movement and rarely leads to significant blood loss and anemia. It should be remembered that the symptoms of colon diseases are quite monotonous and bleeding can be a sign not only of hemorrhoids, but also of malignant neoplasms, polyps, ulcerative colitis and Crohn's disease [4]. In case of bleeding associated with damage to the perianal area, the released blood (in the form of traces on toilet paper or drops falling on the walls of the toilet) is usually not mixed with feces, which in such cases retains its inherent brown color. If the source of bleeding is located proximal to the rectosigmoid colon, then the blood is more or less evenly mixed with the stool, so that it is usually not possible to identify its normal color.

To make a correct diagnosis, it is imperative to carry out not only an examination of the perianal area, but also a digital examination of the rectum and anoscopy or sigmoidoscopy to a level of 15-60 cm above the anus. At the slightest suspicion of a neoplasm and detection of multiple polyps in the colon, a colonoscopy or irrigoscopy is performed.

Thus, the diagnostic criteria for hemorrhoid decompensation are [1, 8]:

anorectal bleeding;
characteristic pain syndrome;
bulging hemorrhoids;
unusual rectal discharge;
swelling and pathological sensations in the perianal area;
dissatisfaction with the act of defecation.

Treatment

The main methods of treating hemorrhoids today are [1, 2, 3]:

radical hemorrhoidectomy (open, closed, closed circular stapler, submucosal);
minimally invasive treatment methods (ligation of nodes with rubber strips, sclerotherapy, direct current electrocoagulation, coagulation with infrared rays, cryotherapy);
conservative treatment.

When choosing a tactic and method of treating hemorrhoids, it is necessary to take into account the location and severity of the disease, the presence of complications, the severity of pain, the severity of the patient’s general condition and the degree of his disability, as well as the patient’s plans for treatment.

Currently, according to most literature sources, conservative therapy, which is justified in 20-45% of cases, is an effective and appropriate method of treating hemorrhoids [5]. A clear confirmation of this is the fact that the number of surgical hemorrhoidectomies in the United States decreased from 165,000 in 1982 to 30,000 in 1994 [6, 7].

Indications for conservative treatment are mild and moderate hemorrhoids, severe hemorrhoids of any location that occur during pregnancy, as well as the impossibility of surgical treatment for other reasons.

The most important conditions for successful treatment and prevention of subsequent exacerbations of the disease are normalization of the digestive tract, regulation of the consistency of intestinal contents and its transit through the colon. For this purpose, a diet rich in plant fiber is prescribed along with regular and sufficient consumption of water and osmotically active nutrients, such as fruit and vegetable juices. As a source of dietary fiber, or, as they are also called, hydrophilic colloids, in our country wheat bran, seaweed and flaxseed are traditionally used in their natural form or in the form of pharmacological preparations. Abroad, psyllium seeds and husks and flaxseed are more often used, which form the basis of such drugs as agiolax, fiberlax, nutriclinz, which have a high water-holding capacity. In the system of treatment and preventive measures, a significant role is given to the correction of emotional disorders, cessation of smoking and consumption of alcohol, drugs, coffee, and increasing the physical activity of patients.

Pharmacotherapy as the main component of conservative treatment of hemorrhoids has several goals:

pain relief;
elimination of the inflammatory process;
elimination of hemorrhoidal thrombosis;
relaxation of the internal sphincter of the rectum;
normalization of microcirculation in the affected area.

Just a few years ago, the arsenal of drugs available to help achieve these goals was minimal, limiting choice. Nowadays, the abundance of remedies used for hemorrhoids, on the contrary, has given rise to the opposite problem: which one to choose in each specific case. To do this, it is necessary to know the mechanisms of action of drugs and those aspects of pathogenesis that they should influence.

Planned conservative therapy includes:

painkillers;
thrombolytic agents;
antibacterial therapy;
laxatives;
physiotherapy;
drugs that help stop straining during bowel movements.

Drug therapy for hemorrhoids can be local (ointments, creams, gels, rectal suppositories) or general (systemic).

To eliminate pain, combined painkillers in the form of gels, ointments and suppositories are used. The most widely used drugs are aurobin, ultraproct, and procto-glivenol. It should be noted the effectiveness of new painkillers - nefluan and emla, which are characterized by high concentrations of lidocaine and neomycin. The use of a short course of systemic non-narcotic analgesics is justified only for severe and complicated hemorrhoids. Prescribing narcotic analgesics is not advisable, since these drugs significantly increase the tone of the internal sphincter of the rectum and make defecation difficult.

Anti-inflammatory therapy is based on the use of fast-acting glucocorticoids, in particular prednisolone. For hemorrhoids, preference should be given to local treatment, since it does not interfere with tissue repair, is accompanied by minimal resorption and a low risk of systemic action of glucocorticoids. However, local treatment is contraindicated for viral, fungal and other specific lesions of the rectum and anorectal area. In these cases, nonsteroidal anti-inflammatory drugs with a combined effect (ketoprofen, diclofenac, indomethacin) are used.

Thrombosis of hemorrhoidal vessels, especially complicated by their inflammation, is an indication for the use of combination drugs containing analgesic, thrombolytic and anti-inflammatory components. This group of drugs includes proctosedyl, procto-glivenol, hepatrombin G, produced in the form of ointments, gels and suppositories. The preference for prescribing the latter drug is explained by the fact that it contains the three most active components of the pathogenetic treatment of hemorrhoids: heparin, polidocanol and prednisolone. Heparin, by binding plasma coagulation factors and having an inhibitory effect on hemostasis, has a thrombolytic effect; polidocanol provides an analgesic effect; prednisolone is anti-inflammatory. In addition, the drug contains panthenol, which stimulates metabolic processes, granulation and epithelization of tissues. Rectal suppositories Gepatrombin G are administered into the rectum after bowel movements 1-3 times a day. Gepatrombin G ointment is advisable to use for external hemorrhoids. The course of treatment with hepatrombin G is 1-2 weeks. The advantages of the drug are the extremely rare development of side effects and the possibility of use during pregnancy due to the minimal systemic effect. According to G.I. Vorobyov, rapid subsidence of pain was noted in 87% of patients who underwent treatment; reduction of thrombosis and inflammatory processes - in 91% of patients [2].

Local anticoagulants are widely used in the treatment of hemorrhoids. In addition to the above-mentioned hepatrombin G, this group of drugs includes heparin and troxevasin ointment, nigepan. Medicines containing heparin are the drugs of choice for acute thrombosis of hemorrhoids, but they are quite effective for any form of hemorrhoids. When prescribing locally acting heparin-containing drugs, complete resorption of thrombotic masses occurs no earlier than 4-8 weeks from the start of therapy, which must be taken into account when developing treatment tactics. A relative contraindication to local treatment with heparin is disorders of the blood coagulation system.

In 70-80% of cases, the inflammatory process spreads to the subcutaneous tissue and perianal area. In these cases, drugs containing heparin are used in combination with water-soluble ointments that have a powerful anti-inflammatory effect, such as levosin, levomekol, mafenide.

The basis of hemorrhoid therapy is the use of phlebotropic drugs that increase the tone of the veins, improve microcirculation in the cavernous bodies and normalize blood flow in them. This problem can be solved with the help of drugs such as escin, tribenoside, troxerutin, as well as new generation drugs: detralex, cyclo-tri-forte, ginkor-forte, endothelon.

According to most experts, the most effective drug in this group is Detralex. Its use leads to relief of pain in 83% of cases, reduction of prolapse of nodes in 81% of cases, and reduction of bleeding in 91% of cases. In the group of patients taking Detralex, there was a 2-fold reduction in the frequency of use and a 2-fold reduction in the dosage of non-narcotic analgesics, a 2.2-fold reduction in the incidence of annual exacerbations, a 2-fold reduction in the duration of exacerbations, and a 1.5-fold reduction in the overall average severity of exacerbations [2 ].

For intestinal bleeding, a laxative diet, taking a 10% solution of calcium chloride orally, and introducing suppositories with novocaine, belladonna extract and epinephrine into the rectum are indicated. You can use suppositories containing adrenaline. In addition, local hemostatic materials such as adroxon, beriplast, tachycomb, spongostan, consisting of fibrinogen and thrombin, are used. When introduced into the anal canal, they dissolve, forming a fibrin film that blocks the bleeding areas of the hemorrhoids.

An important role in the conservative treatment of hemorrhoids is given to drugs that reduce straining and cause easier bowel movements. For this purpose, laxatives with emollient and osmotic effects are prescribed: psyllium, lactulose and macrogol. To relax the internal sphincter of the rectum, ointments and creams containing nitroglycerin, isosorbide dinitrate, nifedipine, as well as suppositories containing belladonna extract are used [1, 4, 6].

Local anti-inflammatory and fibrinolytic treatment, as well as regulation of the tone of the internal sphincter of the rectum, as well as measures aimed at facilitating defecation, do not lose their relevance even after surgical treatment, since they not only contribute to the rapid rehabilitation of the patient, but also prevent the development of scars and dystrophic diseases skin of the anorectal area, strictures, fissures and rectal incompetence.

Literature

Vovk E.I. Rational pharmacotherapy is a factor in the successful treatment of hemorrhoids // Breast Cancer. 2002. T.10. No. 2. pp. 73-77.
Vorobyov G.I., Shelygin Yu.A., Blagodarny L.A. Conservative therapy of acute hemorrhoids // Consilium medicum. Application. 2001. pp. 32-34.
Datsenko B. M., Druzhinin E. B., Protsenko A. G. Hemorrhoids: principles of treatment and diagnosis // Kharkov Med. magazine. 1995. No. 3-4. pp. 43-46.
Rivkin V.L., Kapuller L.L., Dultsev Yu.V. Hemorrhoids and other diseases of the anal canal // M.: Medicine, 1994. 143 p.
Brisinda G. // BMJ 2000. Sep. 9; 321 (7261). R. 582-583.
Bruch HP, Roblick UJ // Chirurg. 2001. Jun; 72(6). R. 656-659.
Metcalf A. Anorectal disorders. Five common causes of pain, pain and bleeding // Postgraduate Medicine Univ. Jova Hospital and Clinic. 1995. R. 221-228.
Otto P., Otto J., Kisbi K. Haemorrhoids: a clinical update // Med. J. Austria, 1997. 167. R. 85-88.

Note!

Hemorrhoids and their complications are the cause of 40% of visits to a surgeon or proctologist, as well as a significant decrease in the quality of life of patients.
Hemorrhoids affect people of any age, and men and city residents who lead a sedentary lifestyle are more likely to suffer from hemorrhoids. The clinical picture of hemorrhoids is characterized by a triad of symptoms, including pain, bulging of hemorrhoids due to thrombosis and inflammation in the node itself and surrounding tissues, as well as bleeding.
Indications for conservative treatment are mild and moderate forms of hemorrhoids, as well as severe hemorrhoids of any location that occur during pregnancy, or the impossibility of surgical treatment of hemorrhoids for other reasons.
When choosing a tactic and method of treating hemorrhoids, it is necessary to take into account the location and severity of the disease, the presence of complications, the severity of pain, the severity of the patient’s general condition and the degree of his disability, as well as the patient’s plans for treatment.