Review: Why Do We Know So Little About Hemorrhoids?

The time has come for targeted research to understand the causes, symptoms, and best treatment for patients with symptomatic hemorrhoids, write Robert S. Sandler and Anne F. Peery in a review article in the January issue of Clinical Gastroenterology and Hepatology.

Anorectum with internal and external hemorrhoids.

Although hemorrhoids are responsible for considerable economic cost and personal suffering, they have received surprisingly little research attention. In the United States, hemorrhoids are one of the most common outpatient gastrointestinal diagnoses, with nearly 4 million office and emergency department visits annually. It is not clear what causes the hemorrhoids—a low-fiber diet and constipation are thought to increase risk, but this has not been proven.

Symptoms include bleeding, pain, pruritus, fecal seepage, prolapse, and mucus discharge. However, these symptoms are equally reported by patients with and without hemorrhoids. Medical therapies for hemorrhoids have not been formally studied except for fiber, which produced inconsistent results. 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.

Sandler and Peery review the etiology of hemorrhoids and conclude that commonly believed risk factors for hemorrhoids have not been studied adequately. Additional research is necessary to make evidence-based recommendations to patients. The authors also discuss symptoms, which could be due to other causes, and treatments, which include medical therapies, nonsurgical office-based treatments, and surgery. Guidelines have concluded that rubber-band ligation is the most effective office-based therapy. However, the authors list the shortcomings of different approaches and the reasons we have not been able to determine the best treatment.

Sandler and Peery conclude that there is insufficient evidence about hemorrhoid risk factors, effects, and therapy. The authors state that enormous amounts of time and money are spent by patients with hemorrhoid symptoms. Patients and physicians value the application of evidence in making decisions about health care. Given the numerous gaps in our understanding of hemorrhoids, the time has come for research designed to expand the evidence base.

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