Human beings have suffered from hemorrhoids since they have started to walk, and hemorrhoids are described in both Old Testament and Buddhist scriptures. Some known mentioning of this affliction are the existence of doctors treating hemorrhoids in Egyptian palaces in 2500 BC, treatment records of both Edwin Smith Papyrus (1700 BC) and Ebers Papyrus (1500 BC), and treatment records in India, China, Greece, and Rome.

Haemorrhoidal disease (HD) is one of the most commonly encountered disorders affecting mostly adults of 50 years or above. Risk factors like straining to attain complete evacuation, inadequate fiber intake, or prolonged lavatory sitting, can lead to hemorrhoids becoming inflamed and swollen with venous blood, and ultimately aggravate hemorrhoidal disease.

External Haemorrhoidal disease is one of the most commonly encountered disorders affecting mostly adults of 50 years or above. Risk factors like straining to attain complete evacuation, inadequate fiber intake, or prolonged lavatory sitting, can lead to hemorrhoids becoming inflamed and swollen with venous blood, and ultimately aggravate hemorrhoidal disease.

External haemorrhoids occurs due to swelling of the external perianal vasculature and is therefore mostly associated with symptoms of pain and pruritus, and occasionally bleeding or thrombosis.

Internal Haemorrhoids occurs when the internal hemorrhoids swell and slide toward the anus, and is usually manifested as anal bleeding during defecation, which is painless and stops naturally at the end of straining to defecate.

Hemorrhoids are classified as internal or external based on the location from the dentate line. External hemorrhoids are located below, develop from ectoderm embryonically and are supplied by somatic nerves thus producing pain. In contrast, internal hemorrhoids lie above the dentate line, develop from endoderm and innervated by visceral nerve fibers so do not cause pain.

Haemorrhids is the consequence of an increased inflow into the superior rectal artery, which causes dilatation of the hemorrhoidal plexus.

Anatomy

Anatomically, hemorrhoidal cushions are clusters of vascular tissues, smooth muscles, and connective tissues that lie along the anal canal in three columns, namely left lateral, right anterior, and right posterior positions. These correspond to 3, 7, and 11 o’clock positions with the patient in lithotomy position. These are the area of anastomoses between the superior rectal artery and the superior, middle, and inferior rectal veins¹.

Hemorrhoidal cushions play a significant physiologic role in augmenting closure of the anal canal in response to increased abdominal pressure by engorging with increased inferior vena cava pressure contributing 15%–20% of resting anal canal pressure. The 7 o’ clock position was the most frequent site of hemorrhoid occurence. The anus forms an acute posteriorly directed angle with the axis of the rectum, approximately 90°at rest; with voluntary squeeze, it becomes more acute, around 70°, and during defecation, it becomes more obtuse, at 110°–130°. The predilection for the 7 o’ clock position (right lower quadrant) is possibly due to more shearing action during defecation¹.

Grading Haemorrhoidal Disease

Hemorrhoids are classified as

Grade I when they are seen during anoscopy as congested veins,

Grade II when they prolapse but spontaneously reduce,

Grade III when they prolapse and need manual reduction, 

Grade IV when they are irreducible 

Hemorrhoids, can present with pain, itching, bleeding, discharge, or prolapse.

The Goligher system classifies hemorrhoids into four grades or degrees of prolapse;

Grade 1 hemorrhoids do not prolapse outside the anal canal.

Grade 2, there is prolapse upon bearing down at defecation, but this retracts spontaneously;

Grade 3 hemorrhoids prolapse on bearing down at defecation but require manual reduction.

Grade 4 there is a persistent non-reducible prolapsed hemorrhoid.

Lifestyle and Risk Factors in Hemorrhoidal Disease

Constipation, a low fiber diet, a high Body Mass Index, pregnancy, and a sedentary lifestyle  increase the risk of hemorrhoidal disease (HD).

Presentation

Haemorrhoids can present with a variety of symptoms, including anal bleeding, prolapse, itching, and/or perianal skin irritation.

Diagnosis

is done by detailed history and examination. On proctoscopy dilated congested anal cushions are seen either produting into the lumen or with active bleeding. Diagnosis including inspection of the anal margin at rest and with straining patients helps in the grading of haemorrhoidal disease.

Micronized Purified Flavonoid Fraction (MPFF) for conservative management of Piles / Hemorrhoids - MPFF consists of micronized diosmin (90%) and other active flavoids (hesperidin, diosmetin, linarin and isorhoifolin - 10%)

MECHANISM OF ACTION OF VENOACTIVE DRUGS (MPFF)

Venoactive drugs or phlebotonics, which are used for the treatment of chronic venous disease (CVD; e.g., varicose veins), have also been used to treat Haemorrhoidal disease. Acting via enhancing the venous tone and reducing the capillary permeability, vascular endothelial activation, and inflammation; these drugs have exhibited a superior efficacy by reducing the risk of recurrent symptoms in Haemorrhoidal Disease, with apparent reductions in the risks of bleeding, pain, itching, and recurrences.

ROLE OF MICRONIZED PURIFIED FLAVONOID FRACTION (MPFF) IN HEMORRHOIDAL DISEASE

Micronised purified flavonoid fraction (MPFF)is a flavonoid-based venoactive preparation. It is composed of 90% micronized diosmin and 10% other active flavonoids like hesperidin, diosmetin, linarin and isorhoifolin. MPFF has significantly diverse anti-inflammatory, antioxidant, and venoprotective actions, which form the basis of its beneficial clinical effects.

MECHANISM OF ACTION OF Micronized Purified Flavonoid Fraction (MPFF)

MPFF acts by modulating noradrenergic signaling and reducing norepinephrine metabolism. This action improves venous tone and lymphatic drainage and significantly reduces capillary hyper-permeability and improves capillary resistance in patients with abnormal capillary fragility, leading to additional improvement of microcirculation.

MPFF increases venous tone, has free-radical scavenging properties, reduces capillary permeability (edema), improves lymphatic drainage, reduces blood viscosity, and/or erythrocyte aggregation, and acts on the inflammatory processes in veins by decreasing the expression of adhesion molecules by neutrophils and monocytes. 

Oral MPFF treatment is appropriate and effective for all grades of Haemorrhoids, as there is significantly reduced bleeding and improved pain, pruritis, anal discomfort, tenesmus, anal discharge or leakage, and edema in patients after treatment with oral micronized purified flavonoid fraction. Examples of MPFF - Daflon (an oral phlebotropic drug consisting of 90% micronised diosmin and 10% flavonoids).

External skin tags are discrete folds of skin arising from the anal verge. Such tags may be the end result of thrombosed external hemorrhoids or may be a complication of inflammatory bowel disease independent of any hemorrhoidal problem. External hemorrhoids comprise the dilated vascular plexus that is located below the dentate line and covered by squamous epithelium.

THROMBOSED EXTERNAL HEMORRHOIDS

Thrombosed external hemorrhoids are a fairly common complication of hemorrhoidal disease. The condition usually occurs without a known cause. Most patients give no history of straining or physical exertion and do not have a history of hemorrhoidal disease. The typical patient’s history is that of a painful mass in the perianal area. The pain usually is described as burning rather than throbbing, and its degree depends on the size of the thrombus. Histopathologic studies reveal an intravascular thrombus of the capillaries that can be stretched to 1 cm in diameter or larger. The thrombus is confined to the anoderm and does not cross proximally beyond the dentate line. The natural history of thrombosed external hemorrhoids is an abrupt onset of an anal mass and pain that peaks within 48 hours. The pain becomes minimal after the fourth day. If left alone, the thrombus will shrink and dissolve in a few weeks. Occasionally, the skin overlying the thrombus becomes necrotic, causing bleeding and discharge or infection, which may cause further necrosis and more pain. A large thrombus can result in a skin tag. Since thrombosed external hemorrhoids are self limited, the treatment is aimed at relief of severe pain, prevention of recurrent thromboses, and residual skin tags. In case of intense pain, excision is done. On the other hand, if the pain already is subsiding and the thrombosed hemorrhoid has started to shrink, it is best to manage it conservatively. Management includes use of a non-constipating analgesic drug, warm sitz baths for comfort, proper anal hygiene, and bulk-producing agents such as bran or psyllium seed. Proctoscopy or flexible sigmoidoscopy is performed to rule out associated anorectal disease. Since the thromboses are intravascular and frequently multiple, the entire thrombus must be excised.

The procedure for removal of thrombus is done with use of local anesthetic (0.25% bupivacaine containing 1:200,000 epinephrine). It is best to anesthetize the entire anal canal so that a large Hill–Ferguson anal speculum can be used for the exposure. Excising the skin along with the mass is not necessary nor is it desirable. Instead, an incision is made over the mass, and the thrombus can be easily dissected out with a scissors. Excessive skin is trimmed, and the wound is closed with running or interrupted 3–0 chromic catgut or a rapidly absorbable synthetic suture or can be left open if infected. The relief of pain usually is immediate provided the wound is closed without tension. Warm sitz baths of 10–15 minutes three to four times daily are used for reduction of pain. Excision of thrombosed external hemorrhoids under local anesthesia has been found to have good results.

A conservative treatment of thrombosed external hemorrhoids has been successful using nifedipine gel. External hemorrhoids may shrink or decrease in size with time; it is wise to wait and see. However, fibrotic anal skin tags should be excised at the same sitting.