In the study, we comment on the article by Qu et al. Internal hemorrhoids are the most common anorectal disorders worldwide with bleeding, prolapse, and difficulty in defecation. Endoscopic rubber band ligation (ERBL) is a safe, convenient, quick, and economical outpatient procedure. The main goal of ERBL is to alleviate prolapse, but the high incidence of recurrence and post-procedural pain are of clinical concern. Polidocanol foam as a local hemostatic and anesthetic agent could reduce the rates of post-procedural pain and bleeding. Endoscopic polidocanol foam sclerobanding (EFSB) is a novel approach that could lift the mucosa for easy ligation and promote increased scarring in the submucosal tissue which translates into long-term relief from prolapse recurrence and reduced 24-h post-procedural pain. The study by Qu et al is a novel multi-center prospective randomized study to compare ERBL and EFSB in patients with grades II and III internal hemorrhoids with one-year follow-up. Results showed that EFSB is a novel therapy for internal hemorrhoids, but future studies with a larger sample, multiple treatment sessions, and long-term follow-up are required to confirm these findings.

Endoscopic rubber band ligation (ERBL) is a nonsurgical technique for the treatment of symptomatic internal hemorrhoids but is limited by recurrence and post-procedural pain.

To evaluate satisfaction, long-term recurrence, and post-procedural pain in managing internal hemorrhoids using a combination of polidocanol foam sclerotherapy and ERBL.

This was a prospective, multicenter, randomized study. A total of 195 consecutive patients diagnosed with grade II-III internal hemorrhoids were enrolled from four tertiary hospitals and randomly divided into a cap-assisted endoscopic polidocanol foam sclerobanding (EFSB) or an ERBL group. All patients were followed-up for 12 months. Symptom-based severity and post-procedural pain were assessed using a hemorrhoid severity score (HSS) and a visual analog scale (VAS). Continuous variables were reported as medians and interquartile range.

One hundred and ninety-five patients were enrolled, with 98 in the EFSB group. HSS was lower in the EFSB group than in the ERBL group at 8 weeks [4.0 (3.0-5.0) vs 5.0 (4.0-6.0), P = 0.003] and 12-month [2.0 (1.0-3.0) vs 3.0 (2.0-3.0), P < 0.001] of follow-up. The prolapse recurrence rate was lower in the EFSB group at 12 months (11.2% vs 21.6%, P = 0.038). Multiple linear regression analysis demonstrated that EFSB treatment [B = -0.915, 95% confidence interval (CI): -1.301 to -0.530, P = 0.001] and rubber band number (B = 0.843, 95%CI: 0.595-1.092, P < 0.001) were negatively and independently associated with the VAS score 24 hours post-procedure. The median VAS was lower in the EFSB group than in the ERBL [2.0 (1.0-3.0) vs 3.0 (2.0-4.0), P < 0.001].

Cap-assisted EFSB provided long-term satisfaction and effective relief from the recurrence of prolapse and pain 24 hours post-procedure.

Grade II and III hemorrhoids often require a multimodal approach that may ultimately culminate in surgical resection. Age and overall medical conditioning around the time of diagnosis can often impact the decision.

The objective of this study was to evaluate patients with a diagnosis of symptomatic grade II or grade III hemorrhoids and determine progression to hemorrhoidectomy based on age and the time interval between diagnosis and surgical intervention.

A retrospective cohort study.

Group practice at a single institution.

Patients aged 18 to 75 years with grade II or grade III internal hemorrhoids between 2015 and 2020 were included. Patients with thrombosed hemorrhoids or surgical contraindications to hemorrhoidectomy were excluded. A total of 961 patients met inclusion criteria for grade II (n = 442) and III (n = 519) hemorrhoids.

Treatments included hemorrhoidectomy, in-office procedures, and/or medical management.

Baseline demographics, treatment choices, and time to hemorrhoidectomy (if applicable) were stratified and analyzed on the basis of hemorrhoid grade (grade II and III) and age groupings that were predetermined by the authors (18-30, 31-50, and 51-75 years).

Patients with grade III versus grade II hemorrhoids were more likely to choose hemorrhoidectomy as the initial treatment management (27.6% vs 4.1%). Patients in the age groups of 18 to 30 and 30 to 50 years were more likely to choose hemorrhoidectomy as the initial treatment management compared to those in the age group of 51 to 75 years (23.5% and 22% vs 12.8%). In patients who were initially treated with medical management or office-based procedures and then progressed to hemorrhoidectomy, no significant differences in the length of time to hemorrhoidectomy were noted on the basis of hemorrhoid grade or age.

Data only looked at age groups and their treatment selection. Personal biases of surgeon and patient may alter results.

Our study shows that the younger population tends to seek hemorrhoidectomy first over the older population. See Video Abstract .

ANTECEDENTES:Las hemorroides de grado II y III a menudo requieren un abordaje multimodal que en última instancia puede culminar en una resección quirúrgica. La edad y el estado médico general en el momento del diagnóstico a menudo pueden afectar la decisión.OBJETIVO:El objetivo de este estudio fue evaluar a pacientes con diagnóstico de hemorroides sintomáticas grado II o grado III y determinar la progresión a hemorroidectomía en función de la edad y el intervalo de tiempo entre el diagnóstico y la intervención quirúrgica.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:Práctica grupal en una sola institución.PACIENTES:Se incluyó a pacientes de 18 a 75 años con hemorroides internas de grado II o III entre 2015 y 2020. Se excluyeron los pacientes con hemorroides trombosadas o contraindicaciones quirúrgicas para hemorroidectomía. Un total de 961 pacientes cumplieron los criterios de inclusión para hemorroides de Grado II (n=442) y III (n=519).INTERVENCIÓN:Los tratamientos incluyeron hemorroidectomía, procedimientos en el consultorio y/o manejo médico.PRINCIPALES MEDIDAS DE RESULTADO:Los datos demográficos iniciales, las opciones de tratamiento y el tiempo hasta la hemorroidectomía (si corresponde) se estratificaron y analizaron según el grado de hemorroides (grado II y III) y los grupos de edad predeterminados por los autores (18-30, 31-50). y 51-75).RESULTADOS:Los pacientes con hemorroides de Grado III versus Grado II tuvieron más probabilidades de elegir la hemorroidectomía como tratamiento inicial (27,6% versus 4,1%). Los pacientes de los grupos de edad de 18 a 30 y de 30 a 50 años tenían más probabilidades de elegir la hemorroidectomía como tratamiento inicial en comparación con los de 51 a 75 años (23,5% y 22% frente a 12,8%). En los pacientes que inicialmente fueron tratados con manejo médico o procedimientos en el consultorio y luego progresaron a hemorroidectomía, no se observaron diferencias significativas en el tiempo hasta la hemorroidectomía según el grado o la edad de las hemorroides.LIMITACIONES:Los datos solo analizan los grupos de edad y su selección de tratamiento. Los sesgos personales del cirujano y del paciente pueden alterar los resultados.CONCLUSIÓN:Nuestro estudio muestra que la población más joven tiende a buscar primero la hemorroidectomía que la población de mayor edad. (Traducción-Dr. Felipe Bellolio ).

Benign conditions of the colon and rectum are a heterogeneous group of conditions that range from inflammatory to infectious to pelvic floor health conditions that affect large segments of the US population. These conditions include diverticular disease, hemorrhoids, and anorectal lesions. The initial presentation of these very common conditions often occurs in the outpatient primary care setting, and most can be managed by the primary care clinician. This article will provide an overview on the prevalence, diagnosis, and management of some of the most common benign colorectal disorders; these are broadly divided into diverticular disease, hemorrhoids, and anorectal conditions.

Non-surgical therapies have the advantage of lower postoperative pain and complication rates compared with surgical therapies. Rubber band ligation and coagulation are two kinds of non-surgical therapies. The aim of this study is to compare the clinical outcomes of rubber band ligation and coagulation. A systematic review was conducted to identify randomised clinical trials that compare rubber band ligation and coagulation treatments for haemorrhoids. PubMed and Web of Science were searched, from inception to April 30th,2022. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Fifty-nine studies were identified. Nine trials met the inclusion criteria. All trials were of moderate methodological quality. No significant difference was found between rubber band ligation and coagulation in terms of efficacy rate, postoperative prolapse rate, recurrence rate and postoperative urine retention rate after treatment. Patients undergoing rubber band ligation had higher postoperative pain rate and lower postoperative bleeding rate than patients undergoing coagulation. The subgroup analysis showed that there was no significant difference between rubber band ligation and infrared coagulation or non-infrared coagulation in terms of efficacy rate, postoperative bleeding and postoperative urine retention rate after treatment. Patients undergoing rubber band ligation had a higher postoperative pain rate than patients undergoing infrared coagulation or non-infrared coagulation. We believe that coagulation for haemorrhoids still has a good future. PROSPERO registration number CRD42022311281.

Hemorrhoids, the most common anorectal disease, give rise to symptoms such as bleeding, prolapse, and pruritus. The treatment for advanced hemorrhoids (Grade III or IV) is gradually shifting toward minimally invasive procedures. These procedures focus on reduction of blood flow in hemorrhoids. Conventional hemorrhoidectomy (CH), also known as Milligan-Morgan or Ferguson hemorrhoidectomy, is considered as the standard treatment for Grade III and IV hemorrhoids because it achieves the lowest recurrence rate. Over the years, alternative minimally invasive techniques such as stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization (THD) have been developed. A new, effective sclerosant, aluminum potassium sulfate and tannic acid (ALTA), has been developed in Japan and has been used for all grades of hemorrhoids; however, its effectiveness declines over time. Other minimally invasive, nonsurgical procedures, including rubber band ligation, endoscopic injection sclerotherapy, and infrared coagulation, have also been performed for Grade III hemorrhoids. Those minimally invasive treatments improve bleeding and prolapse and are highly recommended for patients who are unfit for CH. THD with mucopexy or ALTA sclerotherapy has also been performed for Grade IV hemorrhoids. However, the recurrence rate after ALTA sclerotherapy for Grade IV hemorrhoids was higher than that for Grade III lesions in our case study. In conclusion, minimally invasive treatments are a valid alternative for patients with advanced hemorrhoids after clear explanation of recurrence rates and possible complications.

Rubber band ligation (RBL) using rigid anoscope is a commonly recommended therapy for grade I-III symptomatic internal hemorrhoids. Severe complications of RBL include pain, hemorrhage and sepsis. Flexible endoscopic RBL (ERBL) is now more commonly used in RBL therapy but few severe complications have been reported. Here we report on a case of massive bleeding after ERBL.

A 31-year-old female was admitted to the department of gastroenterology with a chief complaint of discontinuous hematochezia for 2 years. No previous history, accompanying diseases or drug use was reported. Physical examination and colonoscopy showed grade II internal hemorrhoids. The patient received ERBL therapy. Five days after ligation, the patient presented with mild hematochezia. On days 7 and 9 after ligation, she presented with a large amount of rectal bleeding, dizziness and weakness. Emergency colonoscopy revealed active bleeding and an ulcer in the anal wound. The patient received two sessions of hemoclipping on days 7 and 9 to treat the bleeding. No further bleeding was reported up to day 15 and she was discharged home. Although the hemorrhoid prolapse disappeared after ERBL, she was dissatisfied with the subsequent complications.

ERBL therapy is an effective treatment for symptomatic internal hemorrhoids with satisfactory short and long-term recovery. Pain and anal bleeding are the most frequently reported postoperative complications. Coagulation disorders complicate the increased risk of bleeding. Although rarely reported, our case reminds us that those patients without coagulation disorders are also at risk of massive life-threatening bleeding and need strict follow-up after ligation.

Multiple treatments for early-moderate grade symptomatic haemorrhoids currently exist, each associated with their respective efficacy, complications, and risks. The aim of this study was to compare the relative clinical outcomes and effectiveness of interventional treatments for grade II-III haemorrhoids.

A systematic review was conducted according to PRISMA criteria for all the RCTs published between 1980 and 2020; manuscripts were identified using the MEDLINE, Embase, and CENTRAL databases. Inclusion criteria were RCTs comparing procedural interventions for grade II-III haemorrhoids. Primary outcomes of interest were: symptom recurrence at a minimum follow-up of 6 weeks, postprocedural pain measured on a visual analogue scale (VAS) on day 1, and postprocedural complications (bleeding, urinary retention, and bowel incontinence). After bias assessment and heterogeneity analysis, a Bayesian network meta-analysis was performed.

Seventy-nine RCTs were identified, including 9232 patients. Fourteen different treatments were analysed in the network meta-analysis. Overall, there were 59 RCTs (73 per cent) judged as being at high risk of bias, and the greatest risk was in the domain measurement of outcome. Variable amounts of heterogeneity were detected in direct treatment comparisons, in particular for symptom recurrence and postprocedural pain. Recurrence of haemorrhoidal symptoms was reported by 54 studies, involving 7026 patients and 14 treatments. Closed haemorrhoidectomy had the lowest recurrence risk, followed by open haemorrhoidectomy, suture ligation with mucopexy, stapled haemorrhoidopexy, and Doppler-guided haemorrhoid artery ligation (DG-HAL) with mucopexy. Pain was reported in 34 studies involving 3812 patients and 11 treatments. Direct current electrotherapy, DG-HAL with mucopexy, and infrared coagulation yielded the lowest pain scores. Postprocedural bleeding was recorded in 46 studies involving 5696 patients and 14 treatments. Open haemorrhoidectomy had the greatest risk of postprocedural bleeding, followed by stapled haemorrhoidopexy and closed haemorrhoidectomy. Urinary retention was reported in 30 studies comparing 10 treatments involving 3116 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had significantly higher odds of urinary retention than rubber band ligation and DG-HAL with mucopexy. Nine studies reported bowel incontinence comparing five treatments involving 1269 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had the highest probability of bowel incontinence.

Open and closed haemorrhoidectomy, and stapled haemorrhoidopexy were associated with worse pain, and more postprocedural bleeding, urinary retention, and bowel incontinence, but had the lowest rates of symptom recurrence. The risks and benefits of each treatment should be discussed with patients before a decision is made.

Hemorrhoids are common and affect mainly the young and middle-aged populations. Current guidelines recommend treating grade I and II hemorrhoids with office-based procedures. These therapies usually require multiple applications. Hemorrhoid energy therapy treats the hemorrhoids at 1 treatment session.

The purpose of this study was to evaluate the safety and efficacy of hemorrhoid energy therapy.

This was a prospective pilot study evaluating patients with symptomatic grade I and II internal hemorrhoids.

The study was conducted at a tertiary academic center.

Patients over the age of 18 years with chronic, symptomatic grade I and II internal hemorrhoids who failed 2 weeks of conservative therapy were enrolled between July 2015 and January 2019. Exclusion criteria included patients with grade III or IV internal hemorrhoids, external hemorrhoids, nonhemorrhoidal GI bleeding, active proctitis, and IBD.

Hemorrhoid energy therapy was administered in clinic, and 2 postprocedure visits were completed. A pretreatment hemorrhoid symptom score was obtained from each patient. A visual analog score was assessed posttreatment.

The primary end point was to evaluate the effect of hemorrhoid energy therapy on hemorrhoid symptoms and its safety. The secondary end point was evaluation of postprocedural pain.

A total of 35 patients were enrolled. The mean duration of hemorrhoid symptoms was 3.3 ± 6.4 years, and rectal bleeding and hemorrhoidal prolapse were the most common symptoms. After the procedure, patient hemorrhoid symptom scores decreased from mean 5.5 to 1.4. The mean immediate postprocedural visual analog score was 2.4 ± 2.1 and decreased to <1.0 after 14 days.

The limitations include lack of comparative groups, single-center design, and small cohort of patients.

The application of hemorrhoid energy therapy in the treatment of grade I and II internal hemorrhoids is safe and results in reduction of symptoms, low rate of short-term complications, and minimal pain. See Video Abstract at http://links.lww.com/DCR/B491. EVALUACIÓN DE UN SISTEMA DE COAGULACIÓN BIPOLAR MÍNI-INVASIVA PARA EL TRATAMIENTO DE HEMORROIDES INTERNAS GRADOS I Y II: La enfermedad hemorroidal es muy común y afecta principalmente poblaciones jóvenes y de mediana edad. Las guías actuales recomiendan tratar las hemorroides de grado I y II con procedimientos en el consultorio. Estos tratamientos suelen requerir múltiples aplicaciones. La aplicación de energía para tratar las hemorroides requiere de una sola sesión.Evaluar la seguridad y eficacia del tratamiento hemorroidal con una fuente de energía.Estudio piloto prospectivo que evalúa los pacientes con hemorroides internas de grado I y II sintomáticas.El estudio se realizó en un centro académico terciario.Entre julio de 2015 y enero de 2019 se inscribieron pacientes mayores de 18 años con hemorroides intomáticas internas crónicas grado I y II que fracasaron luego de 2 semanas de tratameinto conservador. Los criterios de exclusión incluyeron pacientes con hemorroides internas de grado III o IV, hemorroides externas, sangrado de orígen gastrointestinal no hemorroidal, proctitis activa y enfermedad inflamatoria intestinal.Se realizó la aplicación de energía sobre las hemorroides en el consultorio y se completó el procedimiento con dos visitas posteriores. Se obtuvo una puntuación analógica de síntomas hemorroidarios en cada paciente antes del tratamiento. Se evaluó la puntuación analógica visual luego del procedimiento.El principal criterio final fué evaluar el efecto de la terapia energética hemorroidaria con relación a los síntomas y la seguridad del dispositivo. El segundo criterio final fué el evaluar el dolor posoperatorio.Se registraron un total de 35 pacientes. La duración media de los síntomas hemorroidarios fué de 3,3 ± 6,4 años, el sangrado rectal y el prolapso hemorroidal fueron los síntomas más frecuentes. Después del procedimiento, las puntuaciones de los síntomas hemorroidarios disminuyeron en una media de 5,5 a 1,4. La puntuación analógica visual media inmediatamente posterior al procedimiento fue de 2,4 ± 2,1 y disminuyó a <1 después de 14 días.Las limitaciones incluyen la falta de grupos comparativos, el diseño de un solo centro y una pequeña cohorte de pacientes.La aplicación de energía como tratamiento de la enfermedad hemorroidal interna grado I y II es segura y da como resultados la reducción de los síntomas, una baja tasa de complicaciones a corto plazo y mínimo dolor. Consulte Video Resumen en http://links.lww.com/DCR/B491. (Traducción-Dr Xavier Delgadillo).

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Although hemorrhoids are responsible for considerable economic cost and personal suffering, they have received surprisingly little research attention. In the United States, hemorrhoids are the third most common outpatient gastrointestinal diagnosis with nearly 4 million office and emergency department visits annually. The etiology of hemorrhoids is speculative. A low-fiber diet and constipation have historically been thought to increase the risk for hemorrhoids, but not proven. Symptoms commonly attributed to hemorrhoids include bleeding, pain, pruritus, fecal seepage, prolapse, and mucus discharge. Research has found that these symptoms were equally reported by patients with and without hemorrhoids. Medical therapies for hemorrhoids have not been formally studied except for fiber where the results have been inconsistent. A number of office-based interventions such as rubber band ligation and infrared coagulation are widely used and economically favorable for practitioners. Surgical procedures are effective at eliminating hemorrhoids but may be painful. Given the burden of disease and numerous gaps in our understanding, the time has come for targeted research to understand the cause, symptoms, and best treatment for patients with symptomatic hemorrhoids.

Hemorrhoid disease is extremely common, and seldom requires surgical intervention. The vast majority of patients can be cared for in the office setting and by the gastroenterologist. This piece aims to summarize the epidemiology and pathophysiology of hemorrhoid disease, along with the proper evaluation and office-based treatment of these patients.

Most GI fellowship training programs spend little time on these topics, and the recommendation has been made to include anorectal care in the GI's "core curriculum." The use of the anoscope and a proper anorectal examination are keys to evaluating these patients, and the techniques available to treat these patients are described. Often overlooked in these patients are other anorectal issues that occur alongside hemorrhoidal issues very commonly-the most common being anal fissure. Comprehensive management of all of these issues will allow all but the most severely affected patients to avoid the expense and morbidity of surgical intervention. The anatomy, etiology, pathophysiology, diagnosis, and non-surgical treatment of hemorrhoid disease are presented with the gastroenterologist in mind.

The non-surgical treatments for hemorrhoids are cost and time-saving techniques usually performed in patients suffering early hemorrhoidal disease. The most used are rubber band ligation (RBL), injection sclerotherapy (IS), and infrared coagulation (IRC). We performed a systematic review in order to evaluate: do these procedures really help to avoid further more aggressive treatments? What are the common harms? What are the rare harms? How many recurrences there are? A total of 21 RCTs were included in this review: 12 on RBL, 4 on IRC and 5 on IS. In RBL bleeding stops in up to 90% and III degree hemorrhoids improves in 78%-83.8%. IV degree prolapse should have a more invasive treatment. The commonest complications are bleeding and pain (8-80%). IRC related improvement is 78%, 51% and 22% for I, II and III degree. Post-operative pain occurs in 15-100% and post-operative bleeding ranges from 15% to 44%. Recurrence rate is 13% at a three months follow-up. IS brings to the resolution of prolapse in 90%-100% of II degree and allows good results for III degree even if reported only by case series. The post-procedural pain is 36%-49%. Bleeding is a very rare harm. Even if not definitive, these treatments could be an alternative for mild symptomatic patients after a clear explanation of recurrence rates and possible complications.

Multiple endoscopic methods are available to treat symptomatic internal hemorrhoids. Because of its low cost, ease of use, low rate of adverse events, and relative effectiveness, RBL is currently the most widely used technique.

Gastrointestinal (GI) bleeding from the colon is a common reason for hospitalization and is becoming more common in the elderly. While most cases will cease spontaneously, patients with ongoing bleeding or major stigmata of hemorrhage require urgent diagnosis and intervention to achieve definitive hemostasis. Colonoscopy is the primary modality for establishing a diagnosis, risk stratification, and treating some of the most common causes of colonic bleeding, including diverticular hemorrhage which is the etiology in 30% of cases. Other interventions, including angiography and surgery, are usually reserved for instances of bleeding that cannot be stabilized or allow for adequate bowel preparation for colonoscopy. We discuss the colonoscopic diagnosis, risk stratification, and definitive treatment of colonic hemorrhage in patients presenting with severe hematochezia.

Symptoms thought related to hemorrhoids must be carefully considered before intervention. The first line of therapy for any hemorrhoidal complaint remains conservative management with increased fluid and fiber intake and appropriate modification of toileting behavior. Bleeding in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely managed with office-based therapies; some grade 3 hemorrhoids would also respond to this, though more treatment sessions would likely be required. Operative therapy is the best choice for management of persistently symptomatic grade 2 disease and for grades 3 and 4 symptomatic hemorrhoids as well. With proper patient selection and preparation, along with a familiarity with instrumentation and techniques, good results can be obtained with newer operative interventions for internal hemorrhoids. Outcomes must always be compared with those obtained with classic excisional hemorrhoidectomy.

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.

Bleeding internal haemorrhoids are common and used to be treated surgically with too many complications. Endoscopic therapy is trying to take the lead. Sclerotherapy and rubber band ligation are the candidates to replace surgical therapy especially in patients with liver cirrhosis. The aim of this study was to compare endoscopic injection sclerotherapy (EIS) to endoscopic rubber band ligation (EBL) regarding effectiveness and complications in the treatment of bleeding internal haemorrhoids in Egyptian patients with liver cirrhosis.

One hundred and twenty adult patients with liver cirrhosis and bleeding internal haemorrhoids were randomised into two equal groups; the first treated with EBL using Saeed multiband ligator, and the second with EIS using either ethanolamine oleate 5% or N-butyl cyanoacrylate. All groups were matched as regards age, sex, Child score and pre-procedure Doppler values. Patients were followed up clinically and with abdominal ultrasound/Doppler for 6 months. Endoscopic and endosonography/Doppler was done before and one month after the procedure. Pre and post-procedure data were recorded and analysed.

Both techniques were highly effective in the control of bleeding from internal haemorrhoids with a low rebleeding [10% in the EBL group and 13.33% in the EIS group] and recurrence [20% in the EBL group 20% in the EIS group] rates. Child score had a positive correlation with rebleeding and recurrence in EIS group only. Pain score and need for analgesia were significantly higher while patient satisfaction was significantly lower in EIS compared to EBL [p<0.05]. No significant difference between ethanolamine and cyanoacrylate subgroups was found [p>0.05].

Both EBL and EIS were effective in the treatment of bleeding internal haemorrhoids in patients with liver cirrhosis. EBL had significantly less pain and higher patient satisfaction than EIS. EBL was also safer in patients with advanced cirrhosis.

Doppler-guided hemorrhoid artery ligation is a minimal-invasive surgical treatment option for hemorrhoidal disease. The aim of our study was to evaluate the early and long-term results of the procedure 1 year after the operation.

In a period of 4 years, 90 patients were included in this study. The Doppler-guided hemorrhoid artery ligation was performed under either spinal anesthesia or local perianal block. We recorded the length of postoperative inpatient care, on-demand analgesics administered apart from the standard analgesic protocol, short- and long-term complications, and, finally, recurrences.

The mean age of patients was 46 ± 12.6 years. The operation was performed under spinal anesthesia in 82 patients and under local perianal block in 8 patients. The mean operative time was 26 ± 4.1 min. On-demand analgesics administration was reported in sixteen patients (17.7%) the first postoperative day and in four patients (4.4%) the second postoperative day. A total of 58 patients (64.4%) were discharged from the hospital the day of the operation, 29 (32.2%) patients stayed overnight, and in three (3.3%) patients, a hospitalization period of 2 days was needed. Four patients (4.4%), two with grade III and two with grade IV hemorrhoids, developed early postoperative complications. Late complications were observed in three patients (3.3%). Recurrences, manifested either as bleeding or as prolapsing piles, were observed in six patients (6.6%), two patients with initial grade III and four with grade IV hemorrhoids.

Doppler-guided hemorrhoid artery ligation seems to be a safe and effective treatment option for all grades of hemorrhoidal disease. Further prospective randomized comparative studies are needed in order to fully evaluate the true role of DG-HAL in the surgical armamentarium.

Portal hypertension is common in Egypt as a sequela to the high prevalence of hepatitis C virus and bilharziasis. In portal hypertension internal haemorrhoids are frequently found. The aim of this work was to compare the outcome of endoscopic band ligation (EBL) of symptomatic internal haemorrhoids with that of stapled haemorrhoidopexy (SH) in Egyptian patients with portal hypertension.

In this study, 26 portal hypertensive patients (with oesophageal and/or fundal varices) with a grade 2-4 internal haemorrhoids who had no coagulation disorders were randomised to treatment by EBL (13 patients) or SH (13 patients) after doing colonoscopy. Symptom scores of bleeding and prolapse were assessed before and after the intervention. Complications were recorded. Patients were followed up for 12months.

Goligher's grades of internal haemorrhoids improved significantly (p=0.018) 12weeks after SH (from 2.9±0.8 to 0.4±0.5; p=0.001) and after EBL (from 2.8±0.8 to 1.1±0.8; p=0.001). Symptom (bleeding and prolapse) scores significantly improved 4weeks after both EBL (from 1.6±0.8 to 0.6±0.8; p<0.001 and from 1.6±0.9 to 0.5±0.5; p=0.002, respectively) and SH (from 1.8±0.8 to 0.2±0.4; p=0.002 and from 1.5±0.9 to 0.2±0.4; p=0.001, respectively). The differences after 4weeks between EBL and SH were not significant (p=0.168 and p=0.225). Pain requiring analgesics occurred in five patients (38.5%) after EBL, compared with six (46.2%) after SH (p=0.691). Minimal bleeding occurred in two patients (15.4%) after EBL but not with SH; urinary retention was observed in one patient after EBL compared with two after SH; and anal fissures were observed in one patient after EBL. During 1-year follow-up, increased frequency of stool occurred in one patient after EBL. Recurrence of symptoms was observed in three patients after EBL and in one after SH.

For portal hypertensive patients with internal haemorrhoids and without coagulation disorders SH seems to be superior to EBL. However further studies are needed to evaluate EBL in different grades of cirrhosis.

Haemorrhoids is a common perianal disease, which often causes haematochezia. Besides a surgical operation or minimally invasive treatment, a variety of traditional Chinese medicinal herbs (TCMHs) have been used to treat bleeding haemorrhoids.

To assess the effectiveness of traditional Chinese medicinal herbs for stopping bleeding from haemorrhoids and the adverse effects caused by these herbs.

We searched the Cochrane Colorectal Cancer Group Trials Register, Cochrane Central Register of Contolled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CMCD (Chinese Medicine Conference Disc) and CBMD (Chinese Bio-Medicine Disc).

All randomised clinical trials (RCTs) of Chinese herbs for bleeding haemorrhoids were included.

Two authors independently extracted the data, which were analysed using RevMan 5.0 software. We estimated the relative risk for dichotomous data and calculated the weighted mean difference for continuous data.

Nine trials involving 1822 patients with bleeding haemorrhoids were identified. The included trials were generally not of high quality and used one TCMH preparation compared with another TCMH preparation (Type I) (five trials) or western medicines (Type II) (four trials). We could not pool the data to perform a meta-analysis as only two of the included trials used the same intervention or comparison.In the nine trials, TCMHs showed a statistically significant difference for the improvement in the general curative effects or total grade of symptoms in six trials (P < 0.05; P < 0.01), of hematochezia in three trials (P < 0.05; P < 0.001), and of inflammation of perianal mucosa in one trial (P < 0.05). The adverse effects reported were not serious and were scarce.

This review did not provide strong evidence concerning the effectiveness of TCMHs for stopping bleeding from haemorrhoids. Most of the included studies were of low quality and there was a scarcity of eligible trials and numbers of participants. Limited, weak evidence showed that some herbal formulae, when including Radix Sanguisorbae, Radix Rehmanniae, Fructus Sophorae, Radix Angelicae Sinensis, Radix Scutellariae, etc., may alleviate some symptoms caused by haemorrhoids. These include hematochezia, congestive haemorrhoidal cushions and inflammation of perianal mucosa in the short term. Well-designed clinical trials are required urgently before any confident conclusions can be drawn about the value of TCMHs for stopping bleeding from haemorrhoids.At present, the evidence is not enough that clinical practice should be changed immediately on the basis of these results.