Hemorrhoidal disease and chronic venous insufficiency: Concomitance or coincidence; results of the CHORUS study (Chronic venous and HemORrhoidal diseases evalUation and Scientific research)

Abstract

Background and Aim The CHORUS study (Chronic venous and HemORrhoidal diseases evalUation and Scientific research) was conducted to provide data on patients presenting with hemorrhoidal disease (HD) in clinical practice and to explore the frequency with which it coexists with chronic venous disease (CVD) and shared risk factors. Methods This international, noninterventional study enrolled adult patients attending a consultation for hemorrhoidal complaints. The questionnaire completed by physicians established the subjects' demographic and lifestyle characteristics and collected information on HD grade and symptoms and signs of CVD. Results A total of 5617 patients were analyzed. Symptoms commonly reported were bleeding (71.8%), pain (67.4%), swelling (55.0%), itching (44.1%), and prolapse (36.2%). Multivariate analysis revealed the variables with the strongest association with HD severity were older age, higher CVD CEAP (Clinical manifestations, Etiologic factors, Anatomic distribution of disease, and underlying Pathophysiology) class, constipation, and male gender (all P < 0.0001). Elevated BMI was a risk factor for HD recurrence. Among women, number of births had a significant association with both HD grade and recurrence. The presence of CVD, reported in approximately half the patients (51.2%), was strongly associated with advanced grade of HD (P < 0.0001). Treatments most commonly prescribed were venoactive drugs (94.3%), dietary fiber (71.4%), topical treatment (70.3%), analgesics (26.3%), and surgery (23.5%). Conclusions CHORUS provides a snap shot of current profiles, risk factors, and treatments of patients with HD across the globe. The coexistence of HD and CVD in more than half the study population highlights the importance of examining for CVD among patients with a hemorrhoid diagnosis, particularly when shared risk factors are present.

The patient experience in venous disease

“…In the study published in this issue, although the duration of hemorrhoidal episodes was generally less than 1 week, 85% of respondents had been experiencing hemorrhoidal episodes for over a year [2]. Thus, although the symptoms can sometimes be self-limiting [7], hemorrhoidal disease often represents an ongoing source of suffering for patients.…”

“…However, this is a gross underestimation of the true financial burden, as the study excluded those aged ≥65 years, and also did not include the millions of over-the-counter hemorrhoid treatments that are sold annually in the US [12,13]. The CHORUS study showed a significant association between hemorrhoid recurrence and constipation, older age, obesity, male gender and concurrent CVD [7]. In women, hemorrhoidal disease was also more likely to recur in those who had given birth, and the likelihood of recurrence increased with the number of births.…”

“…Although the exact reasons are unclear, it is generally assumed that patients with hemorrhoidal disease may be reluctant to seek medical attention due to embarrassment, cultural constraints or assumptions that the doctor will not be able to help or the symptoms will 'just go away' [2,14]. This reluctance can also lead to patients doing their own research, resulting in a self-diagnosis of hemorrhoidal disease, yet available data suggest that the majority of people who self-diagnose hemorrhoidal disease are mistaken [7]. This is concerning on several levels, including the fact that common hemorrhoid symptoms, such as anal bleeding and pain, fecal seepage and mucus discharge, may be symptoms of other more serious conditions, including cancer or inflammatory bowel disease [2].…”

“…CVD is an umbrella term that describes conditions characterized by long-standing morphological and functional venous abnormalities [3], while hemorrhoidal disease is characterized by abnormally enlarged anal venous cushions [4]. Both conditions have complex pathophysiological mechanisms that are not yet fully understood, with neither condition having a single cause [5][6][7]; however, both involve venous abnormalities [7]. As highlighted by the articles published in this issue, patients with these two conditions have similar comorbidities: allergy, asthma, depression, diabetes, hypertension and psoriasis were commonly reported in both studies [1,2].…”

“…There is also an overlap in risk factors, with increasing age, obesity, pregnancy and sitting or standing for prolonged periods of time increasing the risk for both conditions [8,9]. It is therefore perhaps unsurprising that CVD was reported in over half of the patients with hemorrhoidal disease in the large CHORUS study [7]. In the survey published in this issue, hemorrhoidal disease was reported by 28% of those with CVD, compared with only 10% of the general population [1].…”