• Hemorrhoidal artery ligation and mucopexy
• Hemorrhoidopexy
• Hemorrhoids
• Laser hemorrhoidoplasty
• Stapled hemorrhoidopexy

• classification
• hemorrhoids
• review
• surgical operative
• surgical procedures

• Angiography
• Anorectal Varices
• Anorectal bleeding
• Anorectal foreign bodies 
• Anorectal sepsis
• Antibiotics
• Diagnosis
• Embolization
• Fournier’s gangrene
• Guidelines
• Hemorrhoids
• Non-operative management
• Surgery
• Technique
• Timing

• Emergencies
• Humans
• Rectal Diseases/diagnosis
• Rectal Diseases/therapy
• United States

• Conservative treatment
• Hemorrhoidal disease
• Hemorrhoids
• Office-based procedures
• Postoperative complications
• Special conditions
• Surgical treatment

• Aged
• Consensus
• Digestive System Surgical Procedures
• Female
• Hemorrhoids/surgery
• Humans
• Italy
• Pregnancy

Background  Hemorrhoids are vascular structures in the anal canal which are seldom used to evaluate vascular diseases. Cigarette smoking is well-known to cause both arterial and venous vascular injuries. However, the impact of smoking on hemorrhoid vasculature is unknown.

Objective  Considering that vasculature in the hemorrhoids has the same anatomy and pathophysiology of vascular damage as other systemic vasculatures, we conducted this study to evaluate the relation between smoking and incidence of hemorrhoidal vascular injury.

Design and Data Analysis  Retrospective review of all the screening colonoscopies performed at our Department of Gastroenterology (predominantly serving urban minority population) over 3 years was conducted and patients with recorded smoking history were included in the study ( n  = 242). Fisher's exact test with two-tailed p -value and odds ratio were used to evaluate for the association between smoking and incidence of hemorrhoids.

Results  We studied 242 subjects and found statistically significant association between smoking and hemorrhoids ( p  < 0.05) with the risk of developing hemorrhoids among smokers being 2.4 times that of a nonsmoker. We further noted no significant difference in the incidence of hemorrhoidal vascular injuries between the past versus current smokers and male versus female smokers.

Conclusion  This is one of the first studies to establish an association between smoking and hemorrhoids. Our study shows that the hemorrhoidal vasculature is impacted by smoking similar to other vascular systems. This study sheds light on the possibility of evaluating hemorrhoids for clues of other systemic and gastrointestinal vascular damage. This correlation can add clinical value especially given the flexibility of assessing hemorrhoids as an outpatient in a cost effective and comfortable manner.

• anal canal
• cigarette smoking
• gastrointestinal vasculature
• hemorrhoid vascular injuries
• hemorrhoids
• piles
• smoking associated vascular injuries
• symptomatic hemorrhoids
• varicose veins of the anus

• anal disorders
• guidelines
• hemorrhoidectomy
• hemorrhoids

This review discusses the pathophysiology, epidemiology, risk factors, classification, clinical evaluation, and current non-operative and operative treatment of hemorrhoids. Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions. The most common symptom of hemorrhoids is rectal bleeding associated with bowel movement. The abnormal dilatation and distortion of the vascular channel, together with destructive changes in the supporting connective tissue within the anal cushion, is a paramount finding of hemorrhoids. It appears that the dysregulation of the vascular tone and vascular hyperplasia might play an important role in hemorrhoidal development, and could be a potential target for medical treatment. In most instances, hemorrhoids are treated conservatively, using many methods such as lifestyle modification, fiber supplement, suppository-delivered anti-inflammatory drugs, and administration of venotonic drugs. Non-operative approaches include sclerotherapy and, preferably, rubber band ligation. An operation is indicated when non-operative approaches have failed or complications have occurred. Several surgical approaches for treating hemorrhoids have been introduced including hemorrhoidectomy and stapled hemorrhoidopexy, but postoperative pain is invariable. Some of the surgical treatments potentially cause appreciable morbidity such as anal stricture and incontinence. The applications and outcomes of each treatment are thoroughly discussed.

• Hemorrhoids
• Pathophysiology
• Treatment
• Management
• Outcome

AIM: To investigate the value of retroflexion in detecting neoplasia in the distal rectum.

METHODS: This was a prospective observational study performed in an academic endoscopy unit. Consecutive patients undergoing colonoscopy had careful forward viewing of the distal rectum by retroflexion. Of 1502 procedures, 1076 (72%) procedures were performed with a 140° angle of view colonoscope and 426 (28%) were performed with a 170° angle of view colonoscope. The outcome measurement was the yield of neoplasia in the distal rectum detected by forward viewing vs retroflexion.

RESULTS: A total of 1502 patients, including 767 (51%) females and 735 (49%) males, with mean age of 58.8 ± 12.5 years were enrolled. Retroflexion was successful in 1411 (93.9%) patients, unsuccessful or not performed because the rectum appeared narrow in 91 (6.1%). Forty patients had a polyp detected in the distal rectal mucosa. Thirty-three were visible in both the forward and retroflexed view (25 hyperplastic, 8 adenomatous). Seven polyps were visualized only by retroflexion (6 hyperplastic sessile polyps, one 4 mm sessile tubular adenoma). There was no significant difference in information added by retroflexion with 140° vs 170° angle of view instrument.

CONCLUSION: To our knowledge, this is the largest reported evaluation of retroflexion in the rectum. Routine rectal retroflexion did not detect clinically important neoplasia after a careful forward examination of the rectum to the dentate line. Since retroflexion has risks and may cause discomfort, the use of routine retroflexion should be at the discretion of the endoscopist.

• Colonoscopy
• Colorectal polyps
• Retroflexion
• Rectum