Abstract
PURPOSE: The risk factors and mechanisms that contribute to the occurrence of hemorrhoids are not well understood. The study of the comorbid occurrences of hemorrhoids with other diagnoses in identical patients may point to a common underlying pathophysiology. The present study was undertaken to determine which diagnoses are associated with the occurrence of hemorrhoids. METHODS: A case-control study compared the occurrence of comorbid diseases in case subjects with hemorrhoids with that of control subjects without hemorrhoids. The case population comprised all patients with hemorrhoids (International Classification of Diseases codes 455.0–455.9), who were discharged from hospitals of the U.S. Department of Veterans Affairs between 1986 and 1996. In a multiple logistic regression analysis, the occurrence of hemorrhoids served as outcome variable, and age, gender, ethnicity, and the comorbid occurrence of other diagnoses served as predictor variables. RESULTS: A total of 96,314 individual patients with hemorrhoids and the same number of control subjects were identified. In a chart review of a random sample of 100 cases, the diagnosis of hemorrhoids could be confirmed in 97 percent of all instances checked. The variety of diagnoses associated with hemorrhoids could be broken down into five large categories: 1) diseases associated with diarrhea (odds ratio, 1.30; 95 percent confidence interval, 1.27–1.33); 2) spinal cord injuries (odds ratio, 1.17; 95 percent confidence interval, 1.09–1.26); 3) constipation and related diseases (odds ratio, 1.48; 95 percent confidence interval, 1.43–1.54); 4) various types of anorectal diseases (odds ratio, 4.71; 95 percent confidence interval, 4.44–5.0); and 5) conditions that could be considered manifestations or sequelae of the hemorrhoidal disease itself (odds ratio, 3.41; 95 percent confidence interval, 3.30–3.51). CONCLUSIONS: The types and spectrum of comorbid diagnoses associated with hemorrhoids suggest that an increased tone of the anal sphincter constitutes a common pathophysiologic mechanism for the development of hemorrhoids.
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References
Loder PB, Kamm MA, Nicholls RJ, Phillips KS. Hemorrhoids: pathology, pathophysiology and aetiology. Br J Surg 1994;81:946–54.
Burkitt DP, Graham-Steward CW. Hemorrhoids—postulated pathogenesis and proposed prevention. Postgrad Med J 1975;51:631–6.
Burkitt DP. Varicose veins, deep venous thrombosis, and hemorrhoids: epidemiology and suggested etiology. BMJ 1972;2:556–61.
Burkitt DP. Hemorrhoids, varicose veins and deep venous thrombosis: epidemiologic features and suggested causative factors. Can J Surg 1975;18:483–8.
Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. Gastroenterology 1990;98:380–6.
Johanson JF, Sonnenberg A. Constipation is not a risk factor for hemorrhoids: a case-control study of potential etiological agents. Am J Gastroenterol 1994;89:1981–6.
The international classification of diseases, 9th revision. Clinical modification. 3rd ed. DHHS Publ. No. 89–1260. 1989.
Kahn HA, Sempos CT. Statistical methods in epidemiology. New York: Oxford University Press, 1989:95–8.
SAS Institute Inc. SAS/STAT® user's guide, Version 6, Vol 2. 4th ed. Chapter 27. The logistic procedure. Cary, North Carolina: SAS Institute, 1989:1071–126.
Duret M. Researches sur la pathogénie des hémorrhoïdes. Arch Gen Med 1879;4:641–65.
Stieve H. Über die Bedeutung des venösen Wundernetzes für den Verschluss einzelner Öffnungen des menschlichen Körpers. Dtsch Med Wochenschr 1928;54:87–90:103–3.
Stieve H. Über den Verschluss des menschlichen Afters. Z Mikrosk-Anat Forsch (Leipz) 1930;21:642–53.
Gibbons CP, Trowbridge EA, Bannister JJ, Read NW. Role of anal cushions in maintaining continence. Lancet 1986;1:886–8.
Lestar B, Penninckx F, Rigauts H, Herremans R. The internal anal sphincter can not close the anal canal completely. Int J Colorectal Dis 1992;7:159–61.
Read MG, Read NW, Haynes WG, Donnelly TC, Johnson AG. A prospective study of the effect of hemorrhoidectomy on sphincter function and fecal continence. Br J Surg 1982;69:396–8.
Lin J-K. Anal manometric studies in hemorrhoids and anal fissures. Dis Colon Rectum 1989;32:839–42.
Gibbons CP, Bannister JJ, Read NW. Role of constipation and anal hypertonia in the pathogenesis of hemorrhoids. Br J Surg 1988;75:656–60.
Arabi Y, Alexander-Williams J, Keighley MR. Anal pressures in hemorrhoids and anal fissure. Am J Surg 1977;134:608–10.
Hiltunen K-M, Matikainen M. Anal manometric findings in symptomatic hemorrhoids. Dis Colon Rectum 1985;28:807–9.
El-Gendi MA, Abdel-Bakey N. Anorectal pressure in patients with symptomatic hemorrhoids. Dis Colon Rectum 1986;29:388–91.
Deutsch AA, Moshkovitz M, Nudelman I, Dinari G, Reiss R. Anal pressure measurements in the study of hemorrhoid etiology and their relation to treatment. Dis Colon Rectum 1987;30:855–7.
Hancock BD. Internal sphincter and the nature of hemorrhoids. Gut 1976;18:651–6.
Lane RH. Measurement of anal pressure in patients with hemorrhoids. Schweiz Rundsch Med Prax 1982;71:112–5.
Hancock BD, Smith K. The internal sphincter and Lord's procedure for hemorrhoids. Br J Surg 1975;62:833–6.
Creve U, Hubens A. The effect of Lord's procedure on anal pressure. Dis Colon Rectum 1979;22:483–5.
Schouten WR, van Vroonhoven TJ. Lateral internal sphincterotomy in the treatment of hemorrhoids: a clinical and manometric study. Dis Colon Rectum 1986;29:869–72.
Farouk R, Duthie GS, Bartolo DC, MacGregor AB, Miller R. Failure of internal sphincter relaxation: the cause of fissure? Gut 1991;32:A1203.
Farouk R, Duthie GS, MacGregor AB, Bartolo DC. Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum 1994;37:424–9.
Gibbons GP, Read NW. Anal hypertonia in fissures: cause or effects? Br J Surg 1986;73:443–5.
Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow: the vascular pathogenesis of anal fissures. Dis Colon Rectum 1994;37:664–9.
Lund JN, Scholefield JH. Aetiology and treatment of anal fissure. Br J Surg 1996;83:1335–44.
Schouten WR, Briel JW, Auwerda JJ, Boerma MO. Anal fissure: new concepts in pathogenesis and treatment. Scand J Gastroenterol 1996;218:78–81.
Schouten WR, Briel JW, Auwerda JJ, de Graaf EJ. Ischemic nature of anal fissure? Br J Surg 1996;83:63–5.
Schouten WR, Briel JW, Auwerda JJ, de Graaf EJ. Why do anal fissures heal after lateral internal sphincterotomy? [meeting abstract] Dis Colon Rectum 1994;37:P9.
Jost WH, Schimrigk K. Use of botulinum toxin in anal fissure [letter]. Dis Colon Rectum 1993;36:974.
Jost WH, Schimrigk K. Therapy of anal fissure using botulin toxin. Dis Colon Rectum 1994;37:1321–4.
Gui D, Cassetta E, Anastasio G, Bentivoglio AR, Maria G, Albanese A. Botulinum toxin for chronic anal fissure. Lancet 1994;344:1127–8.
Gorfine SR. Topical nitroglycerin therapy for anal fissures and ulcers [letter]. N Engl J Med 1995;333:1156–7.
Watson SJ, Kamm MA, Nicholls RJ, Phillips RK. Topical glyceryl trinitrate in the treatment of chronic anal fissure. Br J Surg 1996;83:771–5.
Schouten WR, Briel JW, Boerma MO, Auwerda JJ, Wilms EB, Graatsma BH. Pathophysiological aspects and clinical outcome of intra-anal application of isosorbide-dinitrate in patients with chronic anal fissure. Gut 1996;39:465–9.
Lund JN, Scholenfield JH. A randomized, prospective, double-blind, placebo-controlled trial of glyceryltrinitrate ointment in the treatment of anal fissure. Lancet 1997;349:11–4.
Hyams L, Philpot J. An epidemiological investigation of hemorrhoids. Am J Proctol 1970;21:177–93.
Thomson WH. The nature of hemorrhoids. Br J Surg 1975;62:542–52.
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Dr. Delcò was supported by the Swiss National Research Foundation.
Read in part at the annual meeting of the American College of Gastroenterology, Chicago, Illinois, October 19 to 23, 1997. Published in abstract form in Am J Gastroenterol;92:1674.
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Delcò, F., Sonnenberg, A. Associations between hemorrhoids and other diagnoses. Dis Colon Rectum 41, 1534–1541 (1998). https://doi.org/10.1007/BF02237302
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DOI: https://doi.org/10.1007/BF02237302