| Abstract|| |
Two hundred and twenty-four consecutive patients seen for the first time with symptomatic hemorrhoids were given a high fiber diet supplemented by ispaghula husk. Patients were seen at 1, 3, 6 and 12 months and showed improvement. The results suggest that conservative treatment using only a high fiber diet supplemented by Metamucil is highly effective in the symptomatic treatment of patients with piles.
|How to cite this article:|
Murshid KR. Hemorrhoids ! Don't call the surgeon yet. Saudi J Gastroenterol 1997;3:94-5
The aim of treatment of piles should be the relief of symptoms rather than improving the appearance of the anal canal ,, . Working on this principle it has been found that most patients with symptomatic hemorrhoids may be successfully treated by minor procedures that avoid the need for hemorrhoidectomy  . But, can the most minor of these methods, i.e. dietary fiber and bulking agents alone give satisfactory results? A medline search was conducted from 1966 to 1996 but revealed no study where all patients were first tried on dietary fiber and bulking agents alone, before any other procedure was undertaken. In fact, the most recent study of relevance was published 15 years ago.
This is a prospective study where the aim was not to compare the different conservative modalities, but to assess the effectiveness and remind practitioners of the most conservative of these methods of treatment of symptomatic hemorrhoids (excluding those who required urgent surgical intervention, e.g. 4th degree piles and thrombosed piles, and those whose main complaint was of skin tags).
| Patients and methods|| |
The author studied 224 patients with symptomatic hemorrhoids (180 men and 44 women) for which no prior procedure was undertaken. The ages ranged from 16 to 84 with an average age of 44.6 years. [Table - 1] gives the main presenting symptom of the patients. Patients were given a list of high roughage food and a three months course of one tablespoonful of Metamucil to be taken thrice daily for the first month, twice a day for the second month and once a day thereafter. The patients' follow-up included a symptomatic review at 1, 3, 6 and 12 months. The period of the study extended for four years between January 1993 and January 1997.
| Results|| |
[Table - 1] shows the main presenting symptoms, the commonest being bleeding, 57%. Constipation was present in 27%.
[Table - 2] shows the symptomatic results at 1, 3, 6 and 12 months after treatment. Patients who showed no improvement or worsening of their symptoms after three months of treatment were treated by rubber-banding or surgical hemorrhoidectomy (i.e. the 15 + 2 patients in [Table - 2]). No side effects were reported.
Almost 65% of the patients treated conservatively were completely asymptomatic after only one month of treatment. This improved to about 80% after three months, over 84% after six moths and 86% after one year of treatment.
The total percentage of patients improved after one month of treatment was over 90% and 92% after three months of treatment. Only two patients (0.9%) reported worsening of their symptoms and only 15 (6.7%) did not improve after three months of treatment.
| Discussion|| |
The relationship between constipation and piles has been recognized for centuries, and dietary manipulation to prevent constipation and straining is widely recommended  . In one study high fiber diet has been found to be better than placebo in reducing symptoms  . In another study, using ispaghula husk, there has been a significant improvement in the fiber treated group with first and second degree piles .
It appears from our results that apart from those patients who were referred to the surgeon with complications of piles requiring urgent surgical intervention and those obsessed with skin tags being some kind of malignancy, a large percentage of patients with piles will benefit from the most conservative form of treatment. In most patients the benefits will be evident after one month, and about 80% will be competely asymptomatic after three months of treatment.
Although high roughage diet and bulking agents cannot cure all hemorrhoids, they certainly cure a large percentage of them and single out those that indeed require further treatment options. In addition to the costs and complications of anesthesia, they minimize costs and complications associated with these options in the form of hospitalization, days off work, pain and bleeding.
The treatment of many diseases is shared by physicians and surgeons. Examples include peptic ulcer disease, inflammatory bowel disease and portal hypertension. In these examples it has become common practice to call the surgeon only when conservative treatment fails. Should uncompleted hemorrhoids be included in this list ?
| References|| |
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|2.||Jones CB: A comparative study of the methods of treatment for hemorrhoids. Proc R See Med 1974; 67:51-3. |
|3.||Maclntyre IM, Balfour TW: Results of the Lord nonoperative treatment for hemorrhoids. Lancet, 1972; 20:1094-5. |
|4.||Lord PH: A day case procedure for the cure of third degree hemorrhoids. Br J Surg 1969; 56:747-9. |
|5.||Alexander-Williams J: The management of piles (editorial). Br Med J Clin Res Ed 1982; 23;285:1137-9. |
|6.||Moesgaard F, Nielsen ML, Hansen JB, Knudsen JT: Highfiber diet reduces bleeding and pain in patients with hemorrhoids: A double blind trial of Vi-Siblin Dis Colon Rectum. 1982; 25:454-6. |
|7.||Webster DJ, Gough DC, Craven JL: The use of bulk evacuant in patients with hemorrhoids. Br J Surg 1978; 65:291-2. |
Khalid Rida Murshid
Department of Surgery, King Khalid University Hospital, P. 0. Box 7805, Riyadh 11472
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2]