"PNR-Bleed" classification and Hemorrhoid Severity Score-a novel attempt at classifying the hemorrhoids / Classificação "PNR-Bleed" e escore de gravidade das hemorróidas - uma nova tentativa de classificação de hemorróidas

ABSTRACT Hemorrhoids are the most common anorectal disorders with a prevalence of 39% in general population. Hemorrhoids are generally classified on the basis of their location and degree of prolapse. Goligher's classification does not describe the number of hemorrhoidal columns involved and does not give much consideration to the amount of blood loss. To describe the hemorrhoidal disease more vividly, we devised the "PNR-Bleed" (or PNR-Booking) classification system. We tried to classify the hemorrhoids based on the four main characteristics of the hemorrhoidal disease i.e. the degree of hemorrhoidal Prolapse (P), Number (N) of the primary hemorrhoidal columns involved, Relation (R) of the hemorrhoidal tissue to dentate line and the amount of Bleeding (B) from it. All the four components in this classification system are graded into five grades ranging from 1 to 5. The peculiarity of this new classification system is that it allows more detailed documentation of the hemorrhoids in a particular patient and conveys more explicit meaning and information about the hemorrhoids for future references. Based on this 'PNR-Bleed' classification, we are introducing another concept of scoring the severity of hemorrhoids and referred it as the Hemorrhoid Severity Score (HSS). Hemorrhoid Severity Score (HSS) is the total score obtained by the sum of the numerical grades of all four characteristics of hemorrhoids in "PNR-Bleed" classification. This new "PNR-Bleed" system of classifying the hemorrhoids and calculation of HSS seems to be more comprehensive, detailed, more objective and easily reproducible.

RESUMO As hemorróidas são os distúrbios anorretais mais comuns, com uma prevalência de 39% na população em geral. As hemorróidas são geralmente classificadas com base em sua localização e grau de prolapso. A classificação de Goligher não descreve o número de colunas hemorroidais envolvidas e não dá muita importância à quantidade da perda de sangue. Para descrever a doença hemorroidária de maneira mais precisa, criamos o sistema de classificação "PNR-Bleed" (ou PNR-Booking). Tentamos classificar as hemorróidas com base nas quatro principais características da doença hemorroidária, isto é, o grau de prolapso da hemorroida (P), número (N) das colunas hemorroidais primárias envolvidas, a relação (R) do tecido hemorroidário para a linha denteada e a quantidade de sangramento (B) originando-se dele. Todos os quatro componentes deste sistema de classificação são classificados em cinco graus, variando de 1 a 5. A peculiaridade desse novo sistema de classificação é que ele permite uma documentação mais detalhada das hemorróidas em um paciente em particular e transmite o significado e informações mais explícitos sobre as hemorróidas. para referências futuras. Com base nessa classificação "PNR-Bleed", estamos introduzindo outro conceito para o escore da gravidade das hemorróidas e denominado HSS, de "Hemorrhoid Severity Score". O escore de gravidade da hemorroida (HSS) é o escore total obtido pela soma dos graus numéricos de todas as quatro características das hemorróidas na classificação "PNR-Bleed". Esse novo sistema "PNR-Bleed" de classificação de hemorróidas e cálculo do HSS parece ser mais abrangente, detalhado, mais objetivo e facilmente reproduzível.

Transanal haemorrhoidal dearterialization with mucopexy (thd-m) for treatment of hemorrhoids: is it applicable in all grades? brazilian multicenter study / A técnica de desarterialização hemorroidária transanal associada à mucopexia (thd-m) é aplicável em todos os graus? estudo multicêntrico brasileiro

ABSTRACT Background: Transanal haemorrhoidal dearterialization with mucopexy (THD-M) is a valuable option for treating patients with haemorrhoidal disease. However, there is still controversy with regard to its efficacy for more advanced grades. Aim: To evaluate the effectiveness of THD-M technique for treating hemorrhoidal disease and to compare the immediate and late results in different grades. Method: Seven hundred and five consecutive patients with Goligher's grade II, III or IV symptomatic haemorrhoids underwent surgical treatment using the THD-M method in five participating centres. Six well-trained and experienced surgeons operated on the patients. Average follow-up was 21 months (12-48). Results: Intraoperative complications were observed in 1.1% of cases, including four cases of haematoma, two of laceration of the mucosa, and two of bleeding. All of these were controlled by means of haemostatic suturing. In relation to postoperative complications, the most common of these were as follows: transitory tenesmus (21.4%); pain (7.2%); mucosal or haemorrhoidal prolapse (6.4%); residual skin tag (5.6%); faecal impaction (3.2%); haemorrhoidal thrombosis (2.8%); bleeding (2.1%); anal fissure (0.7%); and anal abscess (0.3%). Most of the complications were treated conservatively, and only 7.5% (53/705) required some type of surgical approach. There was no mortality or any severe complications. The recurrence of prolapse and bleeding was greater in patients with grade IV haemorrhoidal disease than in those with grade III and II (26.54% and 7.96% vs. 2.31% and 0.92% vs. 2.5% and 1.25%), respectively. Conclusion: The THD-M method is safe and effective for haemorrhoidal disease grades II and III with low rates of surgical complications. However, for grade IV hemorrhoids, it is associated with higher recurrence of prolapse and bleeding. So, THD-M method should not be considered as an effective option for the treatment of grade IV hemorrhoids.

RESUMO Racional: A desarterialização hemorroidária transanal associada à mucopexia (THD-M) tem sido indicada como alternativa à hemorroidectomia convencional para o tratamento da doença hemorroidária nos seus variados graus. No entanto, ainda hoje existe controvérsia com relação a sua eficácia para os graus mais avançados. Objetivo: Avaliar a eficácia da técnica THD-M para tratamento doença hemorroidária e comparar os resultados imediatos e tardios nos diferentes graus. Método: Entre julho de 2010 e setembro de 2015, 705 pacientes consecutivos com hemorroidas sintomáticas de graus II, III e IV foram submetidos ao tratamento cirúrgico pelo método THD-M e acompanhados por um período médio de 21 meses (12-48). As operações foram realizadas por seis cirurgiões com experiência em cirurgia colorretal, em três estados brasileiros. Resultados: Complicações intraoperatórias foram observadas em 1,1% dos casos, incluindo quatro casos de hematoma, dois de laceração da mucosa e dois de sangramento. Todos foram controlados com sutura hemostática. As complicações pós-operatórias mais comuns foram: tenesmo transitório (21,4%); dor (7,2%); prolapso mucoso ou hemorroidário (6,4%); plicoma residual (5,6%); impactação fecal (3,2%); trombose hemorroidária (2,8%); sangramento (2,1%); fissura anal (0,7%) e abscesso anal (0,3%). Não houve casos de complicações severas ou mortalidade perioperatória. A recorrência do prolapso e sangramento foi maior na doença hemorroidária grau IV do que nos graus III e II (26.54% e 7.96% vs. 2.31% e 0.92% vs. 2.5% e 1.25%; p<0,001), respectivamente. Conclusão: O método THD-M é seguro e efetivo no tratamento da doença hemorroidária nos graus II e III com baixo índice de complicações. No entanto, para a doença hemorroidária de grau IV essa técnica está relacionada com maior índice de recorrência e complicações tardias, não devendo ser considerada opção eficiente neste estágio de doença.

Comparison of rubber B and ligation versus injection sclerotherapy in second degree haemorrhoids

The objective of this study was to compare the efficacy of rubber band ligation versus injection scierotherapy in second degree haemorrhoids. This randomized control study has been conducted at Surgical O.P.D Nishtar Hospital Multan from 3rd April 2008 to 3[rd] October 2008. The study included 70 patients divided randomly in two equal groups. Patients in group A were subjected to injection sclerotherapy while patients in group B were treated with rubber band ligation. The patients were followed up at two weeks after the treatment and history regarding bleeding and pain was taken and proctoscopy was done to see pile core sclerosis. No patient was below 20 years of age in each category. Males were affected more than females. Only 31.43% of patients complained of mild pain after RBL while 60% of the patients had no pain at all. 91.43% and 88.57% of patients were free from the cardinal symptoms of bleeding and prolapse respectively, after RBL, at the end of 2 weeks of follow up 62.86% and 65.71% of patients were free from the cardinal symptoms of bleeding and prolapse while 34.29% of patients complained of mild pain after injection scierotherapy at 2 weeks. Rubber band ligation showed better results and good efficacy as compared to injection scierotherapy and should be considered as a procedure of choice for outpatient treatment of second degree haemorrhoids

Management of third degree hemorrhoids: comparison between open versus closed haemorrhoidectomy regarding hospital stay and postoperative complications

The objective of the study was to compare open versus closed haemorrhoidectomy regarding relief of the symptoms [bleeding, prolapse, mucus discharge, Pruritis ani, constipation, and diarrhea], hospital stay and postoperative complications [bleeding, pain, recurrence, wound sepsis, urinary retention, fecal incontinence and anal stenosis]. This study was carried out at the Surgical Department, Bahawal Victoria Hospital [BVH] Bahawalpur from March 2009 to November 2009. A total of 50 patients were studied. The patients were divided into two equal groups [25 each]. Group-A was subjected to open haemorrhoidectomy and in Group-B for closed haemorrhoidectomy was done. In both groups, sixty percent of the patient were between 20-50 years of age and 64% of the patients were male. Relief of symptoms after performing haemorrhoidectomy in both groups was equally good. Constipation and Diarrhea were completely relieved in both groups. Bleeding was relieved in 20[80%] of patients of Group-A and 19[76%] of Group-B; prolapse was relieved in 18[72%] of the patients in Group-A and 22[88%] of Group-B. Mucus discharge and Pruritis were also successfully treated in more than 20[more than 80%] patients of each group. Duration of hospital stay after haemorrhoidectomy was significantly shorter in Group-B. Regarding postoperative complications, bleeding, wound sepsis, fecal incontinence, anal stenosis and recurrence of the disease were almost same but postoperative pain in Group-A was slightly higher than Group-B. In our study we concluded that both methods are fairly efficient treatment of choice for hemorrhoids, without serious complications. None of the methods has any significant advantage in terms of post operative pain reduction over the other. The wound heals faster in closed technique and consequently hospital stay is shorter but the risk of wound dehiscence seems exaggerated along with the increased incidence of sepsis

Evaluación de la mucosectomía cincunferencial (PPH) en el tratamiento de la patología hemorroidal: experiencia U. C / Evaluation of circunferential mucosectomy (PPH) in the treatment of hemorrhoidal pathology: U. C. experience

En el tratamiento quirúrgico de la patología hemorroidal se ha reportado el uso de engrapadora circular asociada con menor dolor en el postoperatorio y una temprana incorporación a la actividad normal. El objetivo de este trabajo fue evaluar los resultados de la mucosectomía circunferencial con engrapadora en pacientes con prolapso hemorroidal y/o mucoso en nuestro centro. Material y Métodos. Se realizó un estudio prospectivo de pacientes con patología hemorroidal sintomática, entre agosto del 2001 y julio del 2004. Los pacientes fueron sometidos a mucosectomía circunferencial con engrapadora. Todos los pacientes recibieron cuidados pre-operatorios estándares y regímenes de analgesia con anti-inflamatorios no esteroidales (AINES) en el post-operatorio. En la primera semana del postoperatorio los pacientes completaron encuestas de escalas análogas de dolor (1-10). Durante el seguimiento los pacientes fueron evaluados con un cuestionario por teléfono y contacto con el médico tratante. Resultados. En total 34 pacientes fueron evaluados. El promedio de dolor en el primer día postoperatorio fue escaso (promedio 2,8) y hacia el cuarto día referían mínimo dolor (promedio 1,3). La mediana de seguimiento fue de 12 meses. Las complicaciones en el postoperatorio inmediato fueron: Tres pacientes presentaron hemorragia aguda y uno presentó retención urinaria. Durante el seguimiento 5 pacientes presentaron recidiva de síntomas hemorroidales (2 debieron ser reoperados). Además, 2 presentaron dolor anal limitado y 2 dolor anal crónico por corchete de la engrapadora circular. Conclusión. En esta serie la mucosectomía circunferencial con engrapadora demostró ser la técnica asociada con escaso dolor en el post-operatorio. Sin embargo, no está exenta de complicaciones y recidiva que deben considerarse al ofrecer este procedimiento a nuestros pacientes.

Hemorroidectomía con técnica de Mitchell modificada: experiencia del Hospital Clínico Regional de Valdivia entre los años 1991-2000 / Hemorrhoidectomy with Mitchell's modified technique: experience of Hospital Clinico Regional of Valdivia between years 1991-2000

Introducción. El objetivo del trabajo es describir la técnica y analizar los resultados obtenidos con el tratamiento quirúrgico de la patología hemorroidal mediante el método Mitchell modificado, durante el decenio 1991-2000. Pacientes y Métodos. Entre 1991 al 2000 se intervinieron 71 pacientes utilizando esta técnica. Se analiza la técnica, dolor postoperatorio, la morbilidad y la recurrencia. Resultados. El dolor postoperatorio fue nulo o leve en el 77 por ciento de los pacientes, siendo manejado en la gran mayoría sólo con analgésicos no esteroidales. Las complicaciones más frecuentes atribuibles a la cirugía fueron fístula perianal en un 2,8 por ciento y hemorragia precoz en un 2,8 por ciento. Otras complicaciones fueron cefalea post-raquídea y retención urinaria. No hubo recurrencia en la serie. Conclusión. La hemorroidectomia con la técnica de Mitchell modificada es una alternativa fácil, rápida y segura para el manejo de la patología hemorroidal. El dolor postoperatorio es manejable con antiinflamatorios no esteroidales en la mayoría de los pacientes. Esta técnica se asocia a un bajo número de complicaciones y de recurrencia.

Results of injection sclerotherapy in 1st and 2nd degree haemorrhoids

Equal numbers of Ist degree and second degree hemorrhoid patients were assessed clinically after receiving injection sclerotherapy. Efficacy was found 95% in Ist degree and 60% in 2nd degree haemorrhoids after Ist shot of injection 5% phenol in almond oil. The result of this procedure is quite encouraging and needs to be used more frequentlly

Clinical presentation of haemorrhoidal disease

Patients suffering with hemorrhoid disease were presented in surgical OPD with complaints of bleeding 85 percent, constipation [68 percent] pruritis ani [55 percent] and pain [45 percent]. The prevalence of different degrees of hemorrhoids were 3rd Degree 45 percent, 2nd and 3rd Degree 28 percent. The disease is mainly observed in middle age group with almost no change of its mode of presentation

Hemorroides: conceptos actuales / Hemorrhoids: present concepts

Las hemorroides representan la patología más habitual en el ámbito protológico. Existe una serie de conceptos tradicionales sobre esta condición que muchas veces conducen a un manejo inadecuado de ella. En este artículo se revisan y actualizan algunos conceptos relevantes sobre su definición, etiopatogenia y tratamiento. Además se describen algunos criterios prácticos con relación al enfrentamiento de las hemorroides destacando el rol que le compete al manejo conservador, a los procedimientos ambulatorios y a la hemorroidectomía

new design form of suppository with sterile gauze-inlay for treatment of hemorrhoids

Hemorrhoids are varicosities of the hemorrhoidal venous plexuses, which causes through the heredity, erect posture, chronic constipation, pregnancy, and during childbirth due to persistently increased pressure hemorrhoidal venous plexuses. They are basically classified as externally and internally hemorrhoids. The symptoms of anorectal disease can de relieved using local ointment or suppository. Most of applied suppositories cross the anorectal line of perianal area to the anal canal cavity due to the powerful sphincter muscles. Such local treatment might be have a weak therapeutic response. A new design suppository is developed containing bismuth subgallate, hamamelidis fluid extract, beuzocain, hard fat and sterile gauze, which is immersed in the suppository [3 cm] and 14 cm is remained above the suppository. Such gauze-inlay ensures that the suppository remains in the perianal area to localize and elongate the treatment in the affected area. The clinical study with this new suppository on 60 adult patients with external hemorrhoids and 120 adult patients with internal hemorrhoids [for grad 1,11 and 111] has been demonstrated that these new suppositories have high effective value without any observed side effects, in comparison with the same suppository without gauze- inlay

La fotocoagulación por rayos infrarrojos en el tratamiento de la enfermedad hemorroidaria / Infrared photocoagulation in hemorrhoidal disease treatment

Propósitos. Evaluar la eficacia de la fotocoagulación por rayos infrarrojos en el tratamiento de la enfermedad hemorroidaria grados I y II, en el Servicio de Coloproctología del Hospital General de México de la SSa. Material y métodos. Se incluyeron 60 pacientes con hemorragia transanal como síntoma único, sin patología anorrectal agregada. Fueron 30 pacientes del sexo femenino y 30 del sexo masculino, con una edad media de 39.9 años. Cada paciente recibió de 1 o 4 sesiones de fotocoagulación de acuerdo con los resultados que se obtuvieron en cada una. Se utilizó el fotocoagulador marca Redfield. Técnica. La aplicación de los disparos fue en forma de diamante o en arco iris, con una duración de 1.5 segundos cada uno. El tiempo de seguimiento fue de 24 meses. Resultados. Se obtuvo respuesta favorable en el 66.6 por ciento de los casos a partir de la segunda aplicación, y del 93.4 por ciento al término del estudio; en 4 pacientes (6.6 por ciento no hubo respuesta favorable y fueron tratados quirúrgicamente. Conclusiones. El tratamiento de la enfermedad hemorroidaria con fotocoagulación por rayos infrarrojos ofrece una buena alterantiva en los grados I y II, es indoloro, no requiere hospitalización y su costo es bajo

Hemorroides: algunos conceptos fisiopatológicos clínicos y terapéuticos / Hemorrhoids: some physiopathological, clinical and therapeutical concepts

Se presenta una revisión de la aptología hemorroidaria destacando los eventos fisiopatológicos y las técnicas de manejo en las distintas modalidades actualmente empleadas. Se destaca el manejo quirúrgico usado por los autores y se exhiben los resultados obtenidos durante los últimos 3 años con una csuística de 110 pacientes. Estos resultados coinciden con lo expuesto en la literatura extranjera. Se concluye que el tema, pese a su alta incidencia, es de escaso conocimiento entre los médicos generales y los no especialistas y merece una mayor dedicación para comprender más a fondo los problemas planteados y poder ofrecer la mejor terapia a cada paciente en particular

Management of the fourth degree haemorrhoids by lateral internal sphincterotomy - A safe alternative to emergency haemorrhoidectomy

Fourty patients with fourth degree haemorrhoids were treated by lateral internal sphincterotomy from April 1991 to April 1996. There was immediate relief of pain in all patients. The mean hospital stay was 4 days. The median out patient follow up was up to 12 months. Thirty five patients needed no further treatment. Four patients needed formal haemorrhoidectomy. In one patient the treatment was completed by elastic band ligation. The lateral internal Sphincterotomy is a safe and simple alternative for fourth degree haemorrhoids

Hemorroides: Tratamiento ambulatorio por medio de ligadura con banda elástica / Ambulatory treatment of symptomatic hemorrhoids with rubber band ligation

Se presentan 108 pacientes portadores de hemorroides sintomáticas grado I, II y III que fueron tratados por medio de ligadura con banda elástica en forma ambulatoria entre 1982 y 1990. Los resultados alejados fueron evaluados a través de un cuestionario que respondieron 72 pacientes y del cual se deduce que el 79 por ciento de éstos experimentaron "curación clínica" o mejoría de los síntomas. En el 10 por ciento de los casos se observaron complicaciones como dolor, disuria, trombosis, hemorragia, etc. Se concluye que el método es ideal para tratar hemorroides de estos grados por no requerir anestesia, ser ambulatorio, bien tolerado por los pacientes y de bajo costo operativo

Enfermedad hemorroidal: estado actual / Hemorrhoidal disease: update

En la presente revisión abordamos un tema de especial importancia que ha sido pocas veces desarrollada en la bibliografía nacional de modo integral y por el cual el gastroenterólogo y el cirujano son frecuentemente consultados. Se hace una evaluación de los conceptos tradicionales y actuales de la Enfermedad Hemorroidal, con especial énfasis en las bases anatómicas y los mecanismos fisiopatológicos implicados, una revisión de las causas y la clasificación, se resaltan las manifestaciones clínicas y métodos de evaluación y diagnóstico y se toca con especial interés el enfoque terapéutico hasta hoy desarrollado a nivel mundial. Por último, pretendemos inculcar el término de Enfermedad Hemorroidal en reemplazo del mal usado Hemorroides

La fotocoagulación infrarroja para el tratamiento de las hemorroides / Infrared photocoagulation for the treatment of the hemorroids

Se analizaron 171 pacientes con hemorroides sintomáticas, 129 de 1er y 2do grado y 42 de 3er grado, tratadas con fotocoagulación infrarroja (F.I.). Un 94.5%de 129 enfermos seguidos 6 meses, sobre 149 con esa evolución, se hallaban sin síntomas o muy aliviados. Esta proporción de buenos resultados se mantuvo en los 91 casos seguidos 1 año, sobre 112 posibles. Entre estos últimos, hubo 98%de buenos resultados en las hemorroides de 1er y 2do grado y 86%en las de 3er grado. Un 12.8%de la serie presentó dolor, proctorragia o trombosis hemorroidaria luego de alguna sesión del tratamiento, destacándose en varios casos la relación del dolor con la reapertura de una fisura anal recientemente cicatrizada y 1 proctorragia severa al 10 día de una fotocoagulación. Estos efectos desfavorables pueden disminuirse si no se efectúan más de 6 disparos del rojo infrarrojo en una misma hemorroide, ni más de 8 en total en 2 ó más hemorroides. La fotocoagulación infarroja es un método sencillo y rápido, no interrumpe las actividades habituales del paciente, produce pocos efectos colaterales, resultados muy efectivos en hemorroides de 1er y 2do grado y satisfactorios en hemorroides de 3er grado. Estos se logran cuando el tratamiento se prolonga hasta la desaparición o disminución satisfactoria de los síntomas