Postepy Hig Med Dosw. (online), 2012; 66: 41-44
Original Article
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Etiology of thrombosed external hemorrhoids
Etiologia zakrzepicy żył okołoodbytowych
Konrad Wronski
Department of General and Vascular Surgery, Mikolaj Pirogow Regional Specialist Hospital, Lodz, Poland (the European Community)
Corresponding author
Konrad Wroński MD, PhD, MBA, Department of General and Vascular Surgery, Wojewódzki Specjalistyczny Szpital im. dr M. Pirogowa w Łodzi, ul. Wólczańska 195, 90-531 Łódź; e-mail: konradwronski@wp.pl

Received:  2011.10.27
Accepted:  2012.01.09
Published:  2012.01.30

Streszczenie
Wstęp: Żylaki zewnętrzne odbytu umiejscowione są poniżej linii grzebieniastej i pokryte anodermą. Zakrzepica żył okołoodbytowych jest jedną z częściej występujących ostrych chorób odbytu, któ­ra może być skutecznie leczona w warunkach ambulatoryjnych. Etiologia tej choroby jest nadal nieznana. Ustalenie etiologii zakrzepicy żył okołoodbytowych może przyczynić się do zmniej­szenia liczby nawrotów tej choroby i przygotować skuteczną profilaktykę.
Materiał/Metody: Grupa 50 chorych z rozpoznaną zakrzepicą żył okołoodbytowych, leczonych w Wojewódzkim Specjalistycznym Szpitalu im. Dra Mikołaja Pirogowa w Łodzi została przebadana i wybrana za pomocą kwestionariusza opracowanego przez autora artykułu, w którym zbadano opublikowane hipotezy dotyczące tej choroby i dane demograficzne pacjentów. Dane statystyczne opracowano za pomocą programów STATISTICA 7.1 i EXCEL 2008.
Wyniki: Analiza wyników badań wykazała zależność istotną statystycznie między występowaniem zakrze­picy żył okołoodbytowych a obecnością żylaków wewnętrznych odbytu, uprawianiem seksu anal­nego i nadużywaniem napojów alkoholowych. W przeprowadzonym badaniu nie zaobserwowa­no zależności istotnej statystycznie pomiędzy podnoszeniem ciężkich przedmiotów, jedzeniem pikantnych potraw, oddawaniem twardych stolców czy parciem na stolec podczas defekacji a za­krzepicą żył okołoodbytowych.
Wnioski: Przeprowadzone badanie potwierdziło trzy hipotezy na temat przyczyn powstawania zakrzepi­cy żył okołoodbytowych, które zostały przedstawione w innych czasopismach medycznych do­stępnych w bazie MEDLINE. Autor artykułu uważa, że konieczne jest przeprowadzenie wielo­ośrodkowych badań, które mogłyby wyjaśnić dokładnie etiologię tej choroby. Wiedza o etiologii zakrzepicy żył okoloodbytowych może się przyczynić do opracowania skutecznych metod zapo­biegania i leczenia tej choroby.
Słowa kluczowe: etiologia • żylaki odbytu • zakrzepica żył okołoodbytowych


Summary
Introduction: External hemorrhoids are located outside of the dentate line and covered by anoderm. Thrombosed external hemorrhoids are one of the frequent acute anorectal diseases which are treated success­fully in the proctology outpatient room. The etiology of this disease is still unknown. Knowledge of the etiology of thrombosed external hemorrhoids could prevent recurrence of this disease and help prepare good prophylaxis.
Material/Methods: A group of 50 patients with a diagnosis of thrombosed external hemorrhoids and treated in the Mikolaj Pirogow Regional Specialist Hospital in Lodz was interviewed by means of the author's own questionnaire concerning demography and published hypothesis. The necessary statistics were conducted by means of STATISTICA 7.1 and EXCEL 2008 programs.
Results: The analysis of the survey results shows a significant relationship of thrombosed external he­morrhoids and presence of internal hemorrhoids, practice of anoreceptive sex and consumption of more alcohol products than usual. There was no statistical relationship between lifting heavy objects, eating spicy food, having hard stools or straining at toilet during motions and thrombo­sed external hemorrhoids.
Conclusions: This study confirmed three hypotheses on the causes of thrombosed external hemorrhoids which were presented in medical journals available in the MEDLINE database. The author of this ar­ticle believes that it is necessary to conduct a multi-center study, which would explain the exact etiology of this disease. Knowledge about the etiology of thrombosed external disease would help develop effective prevention and treatment.
Key words: etiology • hemorrhoids • thrombosed external hemorrhoids




Introduction
External hemorrhoids are located outside of the dentate line and covered by anoderm [11,12,23]. Thrombosed external hemorrhoids are one of the frequent acute anorectal dise­ases which are treated successfully in the proctology out­patient room [8,11,12,16,17,23]. Patients go to a hospital be­cause of severe pain in the anorectal region which is caused by internal sphincter hypertonicity [3,4,5,12,16,23,]. Pain caused by thrombosed external hemorrhoids is presented during standing, sitting or defecating [3,4,7,8,9,22,23]. During physical examination of the anal area, a single ve­nous thrombosed external hemorrhoid is visible (Fig. 1) or a perforating clot of blood on top of the external hemorr­hoid (Fig. 2) [11,12,16,23]. Such symptoms are often ac­companied by bleeding [3,7,8,11,17,23].
Figure 1. Thrombosed external hemorrhoid, diameter 15-20 mm, in 27-year-old woman

Figure 2. Thrombosed external hemorrhoid, diameter 15-20 mm, with a black clot, perforating on the top, in a 40-year-old man

Material and methods
The study group consisted of 50 patients with diagnosed thrombosed external hemorrhoids who were treated in the outpatient room in Mikolaj Pirogow High Specialized Hospital in Lodz, with consent and a correctly filled qu­estionnaire. The survey was conducted from January 2008 to May 2011. Patients had been directed to the proctology outpatient room by general practitioners, urologists and gynecologists. The diagnosis was made after proctologic assessment in the knee-chest position.
The study included 50 patients, of whom 28 (56%) were female and 22 (44%) male (Tab. 1). The predominant age of respondents ranged from 26 to 44 years old - there were 37 (74%) surveyed patients. In the group of patients who were surveyed, 21 (42%) had secondary education. Among the 50 respondents, 45 (90%) lived in a city with over 500 000 citizens (Tab. 1).
Table 1. The features of the group under examination

The necessary calculations were performed using the package STATISTICA 7.1 and EXCEL 2008. The survey results were compared with hypotheses about the etiology of thrombosed external hemorrhoids which were published in medical journals available in the MEDLINE database.
Consent
This research was carried out in compliance with the Helsinki Declaration. In order to conduct this study an anonymous questionnaire was prepared. Completion of the survey by the patient was voluntary and anonymous. Each patient gave oral consent to participate in this research.
Results
Among the 50 examined patients there were no patients suf­fering from liver cirrhosis, fissure in ano, rectal prolapse or proctitis. Patients have never taken anticoagulants. Examined women were not pregnant or after childbirth in the last 6 mon­ths. In this study no patient had diarrhea, cough or sneeze, or operation in the anorectal region within 4 weeks before the occurrence of thrombosed external hemorrhoids. In this su­rvey there was a strong statistical correlation between pre­sence of internal hemorrhoids, practice of anoreceptive sex and consumption of more alcohol products than usual within 4 weeks before the occurrence of thrombosed external he­morrhoids (p<0.05) (Tab. 2). The performed statistical ana­lysis using STATISTICA 7.1 shows that there was no statisti­cally significant dependence between gender, age, education, place of residence and the presence of internal hemorrhoids, anal sex or higher than usual alcohol consumption (p>0.05).
Table 2. Patients' response to the questions in the questionnaire

There was no significant relationship between thrombo­sed external hemorrhoids and lifting heavy objects, eating spicy food, having hard stools or straining at toilet during motions (p<0.05).
Discussion
There are many hypotheses regarding the etiology of throm­bosed external hemorrhoids which have been published in medical journals available in the MEDLINE database [1,2,5,6,9,13,14,15,19,20,21].
In many studies, including in this research, most people suffering from thrombosed external hemorrhoids are re­latively young people [1,2,11,15].
Delanini et al. [7], Roschke et al. [19] and Stein [21] fo­und a statistically significant correlation between the pre­sence of internal hemorrhoids and the risk of occurrence of thrombosed external hemorrhoids. A similar conclusion follows from the results of this study.
Another study revealed no statistically significant relation­ship between pregnancy and the risk of thrombosed exter­nal hemorrhoids [6,13,21]. But in the prospective study conducted by Abramovitz et al. [1], thrombosed external hemorrhoids were observed in 13 (7.8%) women during pregnancy and in 33 (20%) women during the postpar­tum period.
Several studies have shown a strong correlation betwe­en hard stool, constipation and severe physical exertion and the occurrence of thrombosed external hemorrhoids [13,14,15,19,21]. Oh [15] suggested that the stagnation of blood and trauma to the anal vessels due to strain is the common denominator in the development of thrombosis and postulated eliminating stasis, trauma, and excess stra­in. Oh [15] recommended softening the stool, which is according to him the key to preventing excessive strain.
It is certain that during anal sex damage of the anal ves­sels and sphincter spasm are observed, which might lead to temporarily high intravenous pressure in the anal veins which causes rupture of the endothelial lining and initia­tion of thrombosis [5,15,20].
It seems that constant anal hygiene through the use of bath­tubs, showers and washing after defecation may reduce the risk of occurrence of thrombosed external hemorrhoids [10].
Factors which may influence the occurrence of thrombosed external hemorrhoids may be local inflammation of anal skin triggered by different agents and substances, anal fi­stulas and detergents within soaps or shower gels [2,20].
This study confirmed three hypotheses on the causes of thrombosed external hemorrhoids which were presented in medical journals available in the MEDLINE databa­se. The author of this article believes that it is necessary to conduct a multi-center study which would explain the exact etiology of this disease. Knowledge about the etio­logy of thrombosed external disease would help develop effective prevention and treatment.
Competing interests
There were no competing interests. The study was sponso­red by the author of this article. There were no financial or non-financial competing interests (personal, political, reli­gious, academic, intellectual or any other).
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The author has no potential conflicts of interest to declare.