Hemoroidal Hastalığın Konservatif Tedavisi
Özet
Hemoroidal hastalığın konservatif tedavisi, akut ciddi kanama veya strangülasyon dışındaki durumlarda birinci basamak olarak uygulanan güvenli, ucuz ve etkin bir yöntemdir. Genellikle 6-8 hafta süren bu tedavi, Evre I-II hastalarda çoğunlukla yeterli olurken, ileri evrelerde ve cerrahi öncesi/sonrası süreçlerde de mutlaka önerilmektedir. Konservatif yaklaşımın temelini diyet değişiklikleri oluşturur; gaita kıvamını normalleştirmek amacıyla günlük 25-50 gram çözünülebilir lif ve en az 2 litre su alımı ile orta düzey fiziksel aktivite tavsiye edilir. Ayrıca tuvalette uzun süre oturulmaması, sabah ilk öğün sonrası gastrokolik refleksin ötelenmemesi gibi dışkılama alışkanlıklarının düzenlenmesi kritik öneme sahiptir. Semptomatik rahatlama sağlamak amacıyla 15 dakikalık ılık su oturma banyoları ve akut dönemde 7 günü geçmeyecek şekilde topikal anestezik veya steroid içeren kremler kullanılabilir. Oral tedavilerde ise vasküler tonusu artırıp enflamasyonu azaltan flebotonikler (flavonoidler, kalsiyum dobesilat), hem akut/kronik semptomların giderilmesinde hem de cerrahi öncesi ve sonrası dönemde nüks ile kanamaları azaltmada etkinliği kanıtlanmış vazoaktif ajanlar olarak öne çıkmaktadır.
Conservative treatment of hemorrhoidal disease is a safe, cost-effective, and efficient first-line approach recommended for all patients, except those presenting with acute severe bleeding or strangulation. Typically lasting 6-8 weeks, this management is usually sufficient for Grade I-II diseases and is strongly advised before and after surgical or office procedures. Dietary modifications represent the cornerstone of conservative therapy, aiming to achieve a soft, formed stool consistency through a daily intake of 25-50 grams of soluble fiber, at least 2 liters of water, and moderate physical activity. Regulating bowel habits, such as avoiding prolonged straining on the toilet and aligning defecation with the morning gastrocolic reflex, is also crucial. For symptomatic relief, 15-minute warm sitz baths can be utilized, and topical agents containing anesthetics or steroids may be prescribed for acute phases, capped at 7 days to prevent side effects. Regarding oral medications, phlebotonics like flavonoids and calcium dobesilate serve as effective vasoactive agents that enhance vascular tone and reduce inflammation, proving beneficial in managing both acute and chronic symptoms, as well as minimizing postoperative bleeding and recurrence.
Referanslar
Jakubauskas M, Poskus T. Evaluation and Management of Hemorrhoids. Dis Colon Rectum. 2020;63:420-426
Altomare DF, Giannini I. Pharmacological treatment of hemorrhoids: a narrative review. Expert Opinion on Pharmacotherapy. 2013;14(17):2343-2349
Steele, S. R. Hull, T. L. Hyman, N. Maykel, J. A. Read, T. E. Whitlow, C. B. (2022). The ASCRS Textbook of Colon and Rectal Surgery. (Fourt edition). Cham: Springer
Andersson H, et al. Colonic transit after fibre supplementation in patients with haemorrhoids. Hum Nutr Appl Nutr. 1985;39(2):101-107(21)
Alonso-Coello P, Mills E, Heels-Ansdell D, et al. Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am J Gastroenterol 2006;101:181-8.
Zhang c, et al. Meta-analysis of randomized controlled trials of the effects of probiotics on functional constipation in adults. Clin Nutr. 2020;39:2960-2969
Higuero T, Abramowitz L, Castinel A, et al. Guidelines for the treatment of hemorrhoids (short report). Journal of Visceral Surgery. 2016;153:213-218
Hari Krishnan R. A rewiew on squat-assist devices to aid elderly with lower limb difficulties in toileting to tackle constipation. Proc Inst Mech Eng H. 2019;233(4):464-475
Maestre Y, Pare´s D, Salvans S, et al. Cold or hot sitz baths in the emergency treatment of acute anal pain due to anorectal disease? Results of a randomised clinical trial. Cir Esp 2010;88:97-102
Tejirian T, Abbas MA. Sitz bath: where is the evidence? Scientific basis of a common practice. Dis Colon Rectum 2005;48:2336-40
Jiang Z, Tang W, Cao J. Double-blind randomized clinical trial in evaluating the efficacy and safety of rectum mucosa protector in the treatment of acute hemorrhoids. Chin J Surg 2001;39:53-55.
Cusano F, Luciano S. Contact dermatitis from pramoxine. Contact Dermatitis. 1993;28(1):39.
Kawada A, et al. Fixed drug eruption induced by lidocaine.Contact Dermatitis. 1996;35(6):375.
Van Den Berg M, Stroeken HJ, Hoofwijk AG. Favorable results of conservative treatment with isosorbide dinitrate in 25 patients with fourth-degree hemorrhoids: a pilot study. Ned TijdschrGeneeskd 2003;147:971-3
Chen L, et al. Intracellular signaling pathways of inflammation modulated by dietary flavonoids: the most recent evidence. Crit Rev Food Sci Nutr. 2018;58(17):2908–2924.
Perera N, et al. Phlebotonics for haemorrhoids. Cochrane Database Syst Rev. 2012;(8):CD004322.
Godeberge P, Sheikh P, Lohsiriwat V, et al. Micronized purified flavonoid fraction in the treatment of hemorrhoidal disease. J Comp Eff Res.2021;10(10):801–813
Sheikh P, Lohsiriwat V, Shelygin Y. Micronized Purified Flavonoid Fraction in Hemorrhoid Disease: A Systematic Review and Meta-Analysis. Adv Ther. 2020;37:2792-2812
Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, et al. Meta-analysis of flavonoids for the treatment of haemorrhoids. Br J Surg. 2006;93:909-920
La Torre F, Nicolai AP. Clinical use of micronized purified flavonoid fraction for treatment of symptoms after hemorrhoidectomy: results of a randomized, controlled, clinical trial. Dis Colon Rectum. 2004;47(5):704-710
Ho, Y.H.; Foo, C.L.; Seow-Choen, F.; Goh, H.S. Prospective randomized controlled trial of a micronized flavonoid fraction to reduce bleeding after haemorrhoidectomy. Br. J. Surg. 1995, 82, 1034–1035
Babaikere, M.M.; Huang, H.G.; Re, W.N.; Fan, K.; Chu, H.; Ai, E.H.; Li-Mu, M.M.; Wang, Y.R.; Wen, H. How we can improve patients’ comfort after Milligan-Morgan open haemorrhoidectomy. World J. Gastroenterol. 2011, 17, 1448–1456
Orefice R, Litta F, Parello F, et al. A Prospective Study on the Efficacy of Two Different Phlebotonic Therapies as a Bridge to Surgery in Patients with Advanced Hemorrhoidal Disease. J Clin Med. 2021;10:1549
Menteş BB, Görgül A, Tatlıcioglu E, et al. Efficacy of Calcium Dobesilate in Treating Acute Attacks of Hemorrhoidal Disease. Dis Colon Rectum. 2001;44(10):1489-1495
Changazi SH, Bhatti S, Choudary A, et al. Calcium Dobesilate Versus Flavonoids for the Treatment of Early Hemorrhoidal Disease: A Randomized Controlled Trial. Cureus. 2020;12(8:e9845
