THE EVALUATION AND TREATMENT OF HEMORRHOIDS: AN UPDATED SYSTEMATIC REVIEW

Background: Hemorrhoids are naturally occurring veins in the lower rectum and anus that aid in continence. The severity of pain or discomfort associated with hemorrhoids is influenced by factors such as their size, thrombosis, and location relative to the dentate line. During the history-taking and physical examination, it's crucial to identify risk factors and clinical signs that may suggest more serious underlying conditions.The objective of this study is to conduct an extensive systematic review involving the evaluation and treatment of hemorrhoids based on literature published within the past decade. Methods: The systematic review followed PRISMA 2020 standards and examined full-text English literature published between 2014 and 2024. This review excluded editorials, review papers from the same journal, and submissions without a DOI. Literature was sourced from online platforms such as PubMed, SagePub, and SpringerLink. Result: A total of 1,097 articles s were retrieved from online databases (PubMed, SagePub, and SpringerLink). After three rounds of screening, five articles directly relevant to the systematic review were selected for full-text reading and analysis. Conclusion: Hemorrhoids require proper diagnosis and management. Pregnancy and inflammation increases the risk of hemorrhoids. Conservative treatments work for mild cases, while surgery may be needed for severe ones. Theres an association between hemorrhoids and colorectal cancer, prompting screening recommendations for patients.


INTRODUCTION
Hemorrhoids are naturally occurring veins in the lower rectum and anus that aid in continence.Hemorrhoids develop due to the enlargement and congestion of the anal cushions, which can progress to prolapse as the condition worsens.Hemorrhoids are prevalent among adults aged 45 to 65, with around 39% of those undergoing colorectal cancer screening having enlarged hemorrhoids, often asymptomatic.Hemorrhoidal disease affects millions worldwide and poses significant medical and socioeconomic challenges.Its etiology includes factors like constipation and prolonged straining. 1classification of hemorrhoids is crucial for selecting appropriate treatments and establishing standardized parameters for scientific research.Hemorrhoids are typically categorized based on location and the extent of prolapse.Internal hemorrhoids occur above the dentate line and are covered with mucosa, while external hemorrhoids occur below the dentate line and are covered by squamous epithelium.The Goligher classification is widely accepted and includes four grades: Grade I involves bleeding without prolapse, Grade II involves piles prolapsing during straining but reducing spontaneously, Grade III involves piles prolapsing during straining and requiring manual reduction, and Grade IV involves irreducible prolapse. 2mptomatic hemorrhoids can present various issues, but it's essential to consider other conditions that may mimic hemorrhoidal symptoms.Symptoms of hemorrhoidal prolapse include itching, bleeding, swelling, prolapse, and leakage due to mucus deposition.Internal hemorrhoids, covered by insensitive mucosa, typically don't cause pain.Thus, if pain is present, further investigation for additional clinical issues is needed.Moreover, around 20% of individuals with hemorrhoids also have anal fissures, necessitating additional treatment alongside hemorrhoids for complete symptom relief. 3oper physical examination for patients with hemorrhoids or anorectal complaints involves several steps: visual examination, digital anorectal exam, and possibly endoscopic options.This examination should include abdominal examination, inspection of perianal tissues, anorectal digital examination, and anoscopy. 2etary counseling emphasizing fiber and fluid intake is the initial approach for mild symptomatic hemorrhoidal disease.Non-operative treatments aim to re-fixate prolapsed hemorrhoidal tissue and reduce vascularity.However, severe prolapse often requires surgical intervention.Milligan-Morgan hemorrhoidectomy (MMH) was previously a standard surgical technique, but newer methods like closed/open hemorrhoidectomy, bipolar diathermy, stapling, and LigaSure are now available. 3,4The objective of this study is to conduct an extensive systematic review involving the evaluation and treatment of hemorrhoids based on literature published within the past decade.

METHODS Protocol
The author carefully followed the rules laid out in the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020.This was done to make sure the study met all its standards.The selection of this methodological approach was specifically aimed at ensuring the precision and reliability of the conclusions drawn from the investigation.

Criteria for Eligibility
This systematic review examined the evaluation and treatment of hemorrhoids based on literature published within the past decade.This study meticulously analyzed data on literatures to provide insights and enhance patient treatment strategies.The primary objective of this paper is to highlight the collective significance of the identified key points.
Inclusion criteria for this study entail: 1) Papers must be in English, and 2) Papers must have been published between 2014 and 2024.Exclusion criteria comprise: 1) Editorials; 2) Submissions without a DOI; 3) Previously published review articles; and 4) Duplicate entries in journals.

Search Strategy
The keywords used for this research are "hemorrhoids", "prevention", and "treatment".The Boolean MeSH keywords inputted on databases for this research are:

Data retrieval
The authors assessed the studies by reviewing their abstracts and titles to determine their eligibility, selecting relevant ones based on their adherence to the inclusion criteria, which aligned with the article's objectives.A consistent trend observed across multiple studies led to a conclusive result.The chosen submissions had to meet the eligibility criteria of being in English and a full-text.This systematic review exclusively incorporated literature that met all predefined inclusion criteria and directly pertained to the investigated topic.Studies failing to meet these criteria were systematically excluded, and their findings were not considered.Subsequent analysis examined various details uncovered during the research process, including titles, authors, publication dates, locations, study methodologies, and parameters.

Quality Assessment and Data Synthesis
Each author independently evaluated the research presented in the title and abstract of the publication to determine which ones merited further exploration.The subsequent stage involved assessing all articles that met the predefined criteria for inclusion in the review.Decisions on including articles in the review were based on the findings uncovered during this evaluation process.This criterion aimed to streamline the paper selection process for further assessment, facilitating a comprehensive discussion of previous investigations and the factors that made them suitable for inclusion in the review.

RESULT
The initial number of articles retrieved from online databases (PubMed, SagePub, and SpringerLink) is 1,097 articles.
After conducting three levels of screening, five articles that directly relate to the current systematic review have been chosen for further assessment through full-text reading and analysis.Table 1 presents the selected literature included in this analysis.Poskus, et al. 5 (2022) suggested that modifying dietary and behavioral habits can effectively reduce hemorrhoid rates postpregnancy, offering a safe recommendation for pregnant women.Furthermore, a history of hemorrhoids before pregnancy and an increase in newborn height were associated with a higher risk of hemorrhoids.
Serra, et al. 6 (2016) demonstrated that analysis showed elevated levels of immunoreactive Matrix Metalloproteinases (MMP) and Neutrophil Gelatinase-Associated Lipocalin (NGAL) in all patients with hemorrhoids.MMPs and NGAL may serve as molecular markers for complications such as hemorrhoidal thrombosis.
Wu, et al. 7 (2021) showed that the incidence of colorectal cancer (CRC) is higher in the rectum and sigmoid among those with hemorrhoids.Colonoscopy is recommended for identifying CRC in patients with hemorrhoids, particularly if they have a positive fecal occult blood test result.
Zagriadskiıˇ, et al. 8 (2018) concluded that micronized purified flavonoid fraction (MPFF) conservative therapy was effective in relieving hemorrhoidal symptoms, especially in patients with grade I and II hemorrhoids.It was also beneficial in preventing disease relapse and promoting optimal conditions in the postoperative period for patients with more advanced hemorrhoidal disease.Aziz Ali, et al. 9 (2022) showed that stapled hemorrhoidopexy (SH) outperforms the Milligan-Morgan technique in treating third-degree and fourth-degree circumferential piles.SH demonstrates a significant reduction in intraoperative blood loss and recurrence rate without compromising fecal continence.Although there is no significant difference in the complication rates between the two techniques, including postoperative bleeding, urinary retention, and anal stenosis, SH shows promising advantages in terms of efficacy and outcomes.

DISCUSSION
Hemorrhoids are prevalent worldwide and are among the most troublesome anal conditions, causing symptoms like prolapse and bleeding.The condition poses significant medical and socioeconomic challenges, with constipation and straining being key contributing factors.Hemorrhoids are swollen fibrovascular cushions in the anal canal.Factors like constipation and straining increase the risk.Common symptoms include rectal bleeding, anal pain, masses, hygiene issues, and cosmetic concerns.Anatomically, hemorrhoids consist of mucosa or anoderm lining, stroma containing blood vessels and muscle, and an anchoring system connected to the internal sphincter.Elastic and collagen fibers provide tissue elasticity and strength.Hemorrhoids aid in anal closure and contribute to anal resting pressure. 6oper physical examination for hemorrhoids includes visual inspection, digital rectal exam, and possible endoscopic evaluation.This involves assessing the abdomen, perianal area, and performing anoscopy.Colonoscopy is recommended for all patients with colorectal symptoms, especially older individuals or those with specific risk factors.Flexible sigmoidoscopy may be sufficient for low-risk patients under 50.Anorectal manometry and endosonography are not routine but can aid in surgical planning and assessing tissue changes and sphincter function, respectively. 2evious study showed that pregnancy increases hemorrhoid risk due to factors like increased uterus pressure on veins, hormonal changes relaxing blood vessels, and constipation.Straining during bowel movements exacerbates symptoms.Labor can further strain the pelvic area, worsening hemorrhoids.Pregnant women should manage constipation, maintain a fiber-rich diet, and practice proper hygiene to reduce the risk and alleviate symptoms.A history of hemorrhoids before pregnancy and an increase in newborn height were associated with a higher risk of hemorrhoids. 5