The Effect of Benzyladenine and Indolebutyric Acid on Shooting and Rooting of Miniature Rose

Hemorrhoids is recognized as one of the most common surgical conditions in general population. It is clinically characterized by painless rectal bleeding during defecation with or without prolapsing anal tissue. The etiology of hemorrhoids is venous congestion/stasis. The most common cause of hemorrhoids in adolescents is chronic liver failure or chronic constipation, that results in straining to pass stool or simply habitually sitting on a toilet for a long time [1]. Bleeding per rectum, prolapse, perianal swelling, and itching are the common symptoms. Pain occurs in cases with complicated hemorrhoids [2] (Figure 1).

Generally, hemorrhoids can be divided into two types:

a. Internal hemorrhoid

b. External hemorrhoid

Figure 1:Differentiation of hemorrhoids based on dentate line.

External hemorrhoids originate below the dentate line, while internal hemorrhoids are above the line [3]. Hemorrhoids are the third most common outpatient gastrointestinal diagnosis with nearly 4 million office and emergency department visit annually [3].

In India approximately 41 million (40,723,288) people are reported to have hemorrhoids and 1 million new cases are added annually. The prevalence works out to be 47 per 1000 and increases with age being maximum in the age group of 45-65yrs. It has been projected that about 50% of the population would have hemorrhoids at some point in their life probably by the time they reach the age 50, and approximately 5% population suffer from hemorrhoids at any given point of time [4]. In elderly patients’ symptoms like feeling of incomplete evacuation, change in bowel habits, and weight loss if any need to be evaluated to rule out other pathologies such as anal and rectal carcinomas, anal condylomas, and inflammatory bowel disease. Patient history and physical examination are the essential components in the diagnosis of hemorrhoidal disease.

There are a few myths related to Hemorrhoids (H) especially in rural India like Only old people get H, spicy food cause hemorrhoids, what you eat does not matter, sitting on cold surfaces cause H, exercises increase H and therefore should be avoided, only surgery is the treatment, and they increase the risk of Cancer [4].

Hemorrhoids management protocol

External hemorrhoid usually requires no specific treatment unless it becomes acutely thrombosed or causes patient’s discomfort (Figure 2).

Figure 2: Hemorrhoid management algorithm.

Low-graded internal hemorrhoids can be effectively treated with medication and non-operative measures such as Rubber band ligation, injection sclerotherapy, and infrared coagulation are used in the treatment of grade I–II and selective grade III hemorrhoids with highest success rates with rubber band ligation but a higher complication rate as compared to injection sclerotherapy). Surgery is indicated for high-graded internal hemorrhoids, or when nonoperative approaches have failed, or complications have occurred. Although excisional hemorrhoidectomy remains the mainstay operation for advanced hemorrhoid.

A 19-year-old boy presented with bleeding per rectum during defecation for 2 years and protruding of some mass from anus with bleeding during passage of stool for 6 months. The patient reported of pushing up the mass by hand after defecation and ablution for last 6 months. Initial 6 months there was no pain, but he did not take any treatment during painless bleeding. The patient was brought to the OPD of a private surgical multispecialty hospital in the district headquarter, with a surgeon popular for anal fissure and hemorrhoids management in the area.

Physical examination

A well-built youth with visible pallor and signs of discomfort (Figure 3).

Figure 3:Hemorrhoids was found to be 3,7,11o clock position.

Rectal examination

Direct visualization-Thrombosed prolapsed external hemorrhoids and skin tags were visualized. Prolapse on defecation require manual reduction.

Proctoscopy

Hemorrhoids was found to be 3,7,11o clock position.

Management

First prescription- phosphorus 200/2 doses-OD *2 days Placebo 30/BD*15 DAYS. Advised-Sitz bath, restrict spicy and oily food.

Prognosis

The treatment with phosphorus in various potencies, did neither help stopping bleeding from hemorrhoid, nor protrusion reduced. Therefore, they returned for the surgery.

Investigation

On arrival Routine blood and Urine examination along with HIV, HbsAg (as mandated for any surgery) were got done.

Pre-operative preparation

No food to eat for 6 hours before and nothing to drink for 2-3 hours before the operation. Pre-operative enema was given. Pulse, BP and Temperatures measured.

Surgery

Under general anesthesia the surgeon did conventional open Hemorrhoidectomy a suitable option for the treatment of grade III– IV hemorrhoids. The closed procedure has advantages in terms of postoperative pain and bleeding than an open procedure.

Post-operative care

After a brief observation in a recovery room, he was shifted to ward. Very next day dressing was done, and some blood staining was noted in the first 24 hours. With daily dressings, the wound was oozing some dark blood during and later yellow discharge for a week. There was some pain for a few days that was treated with simple painkillers. By the end of about a week the wound was painless. Topical analgesics used included calcium channel blockers, Glyceryl Trinitrate (GTN), local anesthetics, metronidazole sucralfate for alleviation of post-hemorrhoidectomy pain. Shortterm incontinence, difficult urination or urinary retention were there in the first week but managed well.

Outcome

The outcome was excellent as he recovered fully 15-20 days after surgery. Overall hospital stay was for 4weeks.

Follow up

Patient was asked to come for follow up every 15 days for a period of 6 month. During each visit he was questioned regarding all clinical features in the assessment criteria and clinically examined and progress documented. He is asymptomatic with no recurrence of symptoms. 6th months follow up that reveal did not recurrence or any sort of discomfort while passing stool.

Hemorrhoids popularly known as Piles is affecting more and more people in India because of bad food choice like fast food and lack of exercise. Every year, almost 1 million cases are added annually in India. The main reasons appear to be constipation, stress, insomnia, and a growing inclination for fast food and the sedentary lifestyle.

While Hemorrhoidal Disease (HD) is common in adults, it is rare in children and not uncommon among teenagers. Advanced techniques like ligature, harmonic scalpel, and mono- or bipolar modes of electrosurgery could be helpful in initial stages but in advanced stages conventional open hemorrhoidectomy is the choice of surgeons in India.

The need for treatment for hemorrhoids is primarily based on the subjective perception of severity of symptoms and the assignment of treatment is decided on the traditional classification of hemorrhoids as shown in Figure 1, which is not connected to the severity of symptoms [5]. The question of the optimal treatment technique remains unanswered despite most of the techniques in use being subjected to randomized evaluation. Though LHP is significantly better considering operation time, post-operative pain and recovery time, its accessibility and cost has limited takers in India. An uncomplicated hemorrhoidectomy is satisfactory for both, patient, and surgeon [5].

A study was done by Yildiz et al. [6] of 56 patients (48 boys and 8 girls) with a mean age of 140.8±45.2 months at Sakarya university medical school pediatric surgery department. Constipation (33 or 59%) and a positive family history (29or 52%) were the most common risk factors. conservative treatment was performed in 53 (94.6%) patients. Recurrence was observed in 5 (8.9%) and skin tag was detected in 6(10.7%) patients [6].

A cross sectional study was done by Najar et al. [7]. Of the 1800 patient with anorectal ailment were screened and 911 (50%) were diagnosed with hemorrhoids becoming a common anorectal condition. Risk factors responsible were constipation and the present era lifestyle particularly low roughage diet [7]. Faulty food habits of high intake of junk food, spices, aerated drinks, and low intake of a fiber-rich diet, among teenagers and youth are blamed. Hence a high- fiber diet with plenty of salads, seasonal vegetables, and fresh fruits should come on the top in one’s meal on daily basis [8].

In a comparison trial between hemorrhoid laser procedure or open surgical hemorrhoidectomy made, at Aloka hospital in Kosovo where in patients with symptomatic grade III or grade IV hemorrhoids with minimal or complete mucosal prolapse were observed for operative time and early postoperative pain. Twenty patients treated with the Laser Hemorrhoidoplasty (LHP), and 20 patients–with open surgery hemorrhoidectomy. The procedure time for LHP was 15.94 min vs. 26.76 min for open surgery (p<0.01). The laser hemorrhoidoplasty procedure was more effective than open surgical hemorrhoidectomy. There was a statistically significant difference between the two groups in postoperative period: 1 week, 2 weeks, 3 weeks and 1 month after respective procedure (p<0.01) [5].

Clearing about the myths among people is a deserving public health intervention and need to be done as apart of health promotion. The main promotional messages can include:

a. While hemorrhoids are most common between ages 45 and 65, it is not unusual to see them in younger adults as well.

b. Hemorrhoids are caused by strain on the veins near the anus, not by anything happening in the body’s metabolism.

c. Eating a high-fiber diet and staying well hydrated helps keep bowel movements soft and prevent constipation (as constipation is one of the biggest risk factors) and avoid straining.

d. There is no evidence that cold surfaces can cause hemorrhoids, in fact, a cold compress may be helpful to relieve to reduce swelling and relieve discomfort on the anus for small periods of time. Just sitting on the toilet for a long time can cause hemorrhoids,

e. Exercise (except lifting heavy weights with holding your breath while you lift) is an important part of avoiding hemorrhoids.

f. The cornerstones of hemorrhoid treatment are lifestyle and dietary modifications, hardly 10 % of people may require surgery if the conservative approaches do not work.

Hemorrhoidal Disease (HD) is common in adults 40-60 yrs., not uncommon among teenagers it is but rare in children. Hemorrhoids is a common condition that a surgeon in India encounters in day-today practice, External hemorrhoids in children and teenagers are uncommon and occurs in boys in their second decade of life. Youth’s education to adopt dietary habits with increase in vegetables, fruits and roughage through green leafy vegetables and increasing daily physical activity will prevent the constipation and development of hemorrhoids. Accurate diagnosis and age specific considerations in management will lead to the best outcomes. Though LHP is better, but cost is an important consideration in making surgical choices in India, the preferred method is open Hemorrhoidectomy, as it is affordable and accessible even at sub-district level and gives excellent long-lasting cure rates in the hands of experienced surgeons.

Lesson learnt for public health

a) Hemorrhoids in uncommon among teenagers but occurs mostly due to constipation.

b) The risk of hemorrhoids can be minimized by making the teen eat fiber rich food, drinking adequate water and physical exercises.

c) Training teenagers to never to hold the urge to defecate as it flares up the hemorrhoids.

d) Avoid laxatives or use enemas unless recommended by your healthcare provider.

e) Hemorrhoids could be a painful condition in teenagers, and most of them might feel embarrassed to talk about it.

f) There are many myths about Hemorrhoids and therefore Parents must clarify and make them understand that this condition is treatable, and they need not suffer in silence.

1. Maloku H, Gashi Z, Lazovic R, Islami H, Shkololli AJ (2014) Laser Hemorrhoidoplasty procedure vs open surgical hemorrhoidectomy: A trial comparing 2 treatments for hemorrhoids of third and fourth degree. Acta Inform Med 22(6): 365-367.
2. Lohsiriwat V (2015) Treatment of hemorrhoids: A coloproctologist’s view. World J Gastroenterol 21(31): 9245-9252.
3. Reese GE, von Roon AC, Tekkis PP (2009) Haemorrhoids. BMJ Clin Evid.
4. https://www.everydayhealth.com/
5. Kibret AA, Oumer M, Moges AM (2021) Prevalence and associated factors of hemorrhoids among adult patients visiting the surgical outpatient department in the university of Gondar comprehensive specialized hospital, northwest Ethiopia. PLoS One 16: 1-11.
6. Yildiz T, Aydin DB, Ilce Z, Yucak A, Karaaslan E (2019) External hemorrhoidal in children and teenage: Clinical presentations and risk factors. Pakistan J Med Sci 35(3): 696-700.
7. Agarwal N, Singh K, Sheikh P, Mittal K, Mathai V, et al. (2017) Executive summary - The association of colon & rectal surgeons of India (ACRSI) practice guidelines for the management of haemorrhoids-2016. Indian J Surg 79(1): 58-61.
8. Jamshidi R (2018) Anorectal complaints: Hemorrhoids, fissures, abscesses, fistulae. Clin Colon Rectal Surg 31(2): 117-120.