Mikelangelo: переводы

→Overall, hemorrhoidal disease is a quite common and annoying disease, by definition symptomatic. It is imperative for clinicians who manage patients with internal hemorrhoids (gastroenterologists, surgeons, general practitioners) to be familiar with the normal and abnormal anatomy of hemorrhoids and to be capable of correlating their clinical findings with the subsequent pathophysiology. The pathophysiological explanation of clinical and/or endoscopic signs is an indispensable component of the roadmap to successful treatment of the hemorrhoidal patient.

→Concluding remarks

→Doppler-guided hemorrhoidal artery ligation offers a tailored, individualized therapy, since it locates the feeding terminal branch of the SRA that supplies each hemorrhoidal nodule [21], ultimately performing targeted suture ligation [13,66]. Consequently, the increased blood supply to the anal cushion is diminished, its engorgement is prevented, its size is decreased and it is ultimately firmly fixed to the floor of the upper surgical anal canal [67]. This alternative operational technique has been proven to relieve patients’ symptoms, with only minor complications and rare relapses [68].

→The rationale of stapled hemorrhoidopexy is the fact that both the loose mucosa and the enlarged hemorrhoidal nodules above the dentate line contribute to the prolapse of internal hemorrhoids [9,64]. This operation is not a hemorrhoidectomy. Instead, a circular device excises a ring of redundant mucosa and fixes the hemorrhoidal plexus above the dentate line. During this operation, 3 critical nodes in the pathogenesis of hemorrhoids are targeted: first, prolapse is restored; second, the volume of the hemorrhoidal nodules is significantly reduced; and third, the vessels supplying the internal hemorrhoidal plexus are ligated, limiting the blood supply to the nodules [65].

→The modified (Ferguson) excision hemorrhoidectomy is currently the commonest type of hemorrhoidectomy. In this operation, both the prolapsed sinusoidal tissue and the hypertrophied connective tissue are removed, whereas the anoderm is preserved, the internal sphincter is protected and the sliding process, the fundamental pathophysiologic feature of hemorrhoids, is totally inverted [58-63].

→The principle of the “rubber-band ligation” technique is to band the mucosa and the submucosa of the anal cushion. Banding generates inflammation, with ultimate ischemia and necrosis of the banded part. Apart from removing the nodule, the final sequela of the procedure is the fibrosis generated: it fixes the remaining tissue in the underlying tissue of the surgical anal canal and corrects the prolapse [16,21,41,55]. It is considered the mainstay of therapy for hemorrhoids grade I and II [10,22] and of selected patients with grade III [10,56]. Several trials have proven that this minimally invasive therapeutic procedure is efficient, reliable and safe for hemorrhoidal patients [56,57].

→Surgically valuable correlations

→Preparation-H, which contains 0.25% phenylephrine, petrolatum, light mineral oil and shark liver oil, relieves acute pain and bleeding on defecation by restoring the imbalance between vasoconstrictive and vasodilating agents inside sinusoids. Its vasopressor effect is attributed principally to phenylephrine, which acts mainly on the arterial branch of the hemorrhoidal plexus [53]. The clinical efficacy of this formulation in relieving hemorrhoidal symptoms has been proven in a recent prospective randomized open-label study [54].

→Anti-inflammatory suppositories are used to improve the symptoms of hemorrhoids; the rationale of using them is that inflammation is the triggering factor of bleeding and contributes to pain and irritation of perianal skin [10,11,40]. Nonetheless, solid evidence to justify their efficacy in hemorrhoids is lacking [8-11].

→The principle mode of action of flavonoids (especially the micronized ones, which are easily absorbed and act very shortly) is by increasing the impaired vascular tone [47]. Moreover, they are supposed to relieve congestion inside sinusoids (they reduce venous capacity and decrease capillary permeability [48]) to facilitate lymphatic drainage [49] and to exert anti-inflammatory effects [50]. Recent clinical trials have proven the effectiveness of treatment with flavonoids, both in chronic and in acute hemorrhoidal disease. In chronic disease, conservative therapy with micronized purified flavonoid fraction was found to be beneficial both in relieving hemorrhoidal symptoms and in preventing disease relapse in the majority of patients [51]. In acute hemorrhoidal disease, a mixture of flavonoids (diosmin, troxerutin and hesperidin) was shown to control symptoms efficiently and to manage both congestion and thrombosis of anal cushions [52].

→Increased anal pressure is very important in the pathophysiology of hemorrhoids and is a frequent clinical sign, manifested as anal spasm on rectal examination. Increased anal pressure is the rationale for using topical nitroglycerine 0.4% ointment in the treatment of pain due to internal hemorrhoids [45,46]. Intra-anal pressure returns to normal after hemorrhoidectomy [22].

→One major goal of the conservative treatment of hemorrhoids is to normalize stool consistency; both diarrhea and constipation are clinically potent causes and triggering factors of symptoms in hemorrhoidal disease and their management is as invaluable as the treatment of hemorrhoids per se. The remaining elements of conservative therapy (e.g., avoiding of straining on defecation) have been proved to limit the prolapse of hemorrhoids [43,44].

→Medically valuable correlations

→Internal hemorrhoids may be found, clinically or endoscopically, in 3 distinct anatomical locations: first, above the dentate line, since they emerge and protrude from the mucosa of the upper anal canal [7-9]; second, below the dentate line, but remaining inside the anatomical anal canal; and third, outside the anal verge, in advanced cases.

→Pain is not the typical symptom, as already noted. Pain may be due to complicated internal hemorrhoids (thrombosis, ischemia, incarceration, strangulation) [11,16]. Nevertheless, thrombosis is a rare complication [10]. Consequently, when pain is the patient’s prominent symptom and possible complications of internal hemorrhoids are not detected on clinical or endoscopic examination, the physician should search for an alternative diagnosis: for example, coexisting external hemorrhoids, perirectal abscess or anal fissure [9,11,16].

→Internal hemorrhoids are not typically palpated on digital rectal examination, unless they are large enough or prolapsed [9,13].

→The mucosa of the prolapsing nodule is rectal and mucus-producing [14]. The prolapsed mucosa, therefore, permits the passive transfer of a greater amount of mucus outside the anus. Moreover, the inflamed mucosa of the prolapsing nodule produces even more mucus [10]. The net result is the presence of increased mucus in the perianal skin, which causes perineal irritation, itching and soiling. Besides this, patients with prolapsed hemorrhoids lack the capability to sense the composition of rectal sample [22] and to seal the anus after defecation [10,15,17]. Consequently, they complain of mild fecal incontinence and of finding unknown material in their underclothes [10,16]. Prolapsed internal hemorrhoids are also manifested by rectal fullness and/or a feeling of incomplete evacuation, because of their space-occupying effect.

→Blood may rarely emerge from the newly-formed, hypertrophied arterioles, leading to serious bleeding, manifesting as blood spray around the toilet bowl [16]. In rare cases, blood from internal hemorrhoids may follow a cranial direction towards the rectum, and then return caudally to the anus, presenting as hematochezia. Bleeding is usually the first complaint to appear, before the hemorrhoids start to prolapse (first degree) [11,42]. In this initial stage, the dilatation of sinusoids is still in evolution, rendering them prone to bleeding, while the deterioration of the fibromuscular supporting tissue has just begun. Therefore, although hemorrhoidal cushions may be prominent on endoscopic evaluation, their prolapse is not obvious on strenuous clinical examination [11,25].

→As presinusoidal arterioles are usually tiny, oozing is the commonest type of bleeding; blood is present in the toilet paper exclusively and is typically associated with bowel movements [16,23]. When small arterioles are corroded, bright red blood will spurt [7]; in this case bright red blood drips into the toilet bowl during or immediately after evacuation [11,16].

→Bleeding is the commonest symptom of internal hemorrhoids [41]. In the vast majority of cases bleeding is painless, because of the absence of pain fibers [16]. Hemorrhage is due to congestion of the sinusoids, transferred backwards to the presinusoidal arterioles. Bleeding from hemorrhoids is therefore arterial in origin, hence bright red [7,10]. Since dilated arterioles are located in the lamina propria, just below the inflamed, injured and friable epithelium of the descending nodule, they are easily eroded during defecation by hard [25], dehydrated [22] or diarrheal [29,35] stool.