New Research Sheds Light
On a Dark and Painful Place

Old joke: Last year's annual meeting of the Procrastinators Society will be held next year - maybe. Who among us hasn't at least occasionally thought, "Why do today what I can put off until tomorrow?" Certainly that thought takes center stage when we are faced with the need for surgery, one of life's major bummers. And on any list of operations we would most like to avoid (or have to tell our friends about), hemorrhoidectomy - the surgical removal of hemorrhoids - must rank high.

Small wonder, then, that those who need hemorrhoid surgery - even those who need it badly to relieve pain and bleeding - are prone to postpone it to a "more convenient time." There's nothing wrong with that, except that the pain and bleeding need to be controlled as much as possible in the interim. Pain can be suppressed, to varying degrees, with analgesics, lubricants, and anti-inflammatory or anesthetic ointments, but that is not what this article is about. Here the question is: how can we stop the bleeding?


Varicose Vein. Blood back-flows since valves do not close.

DIOSMIN AND HESPERIDIN FOUND TO BE BENEFICIAL, AGAIN
New research has shown that a pair of natural phytonutrients (plant-based nutrients) called diosmin and hesperidin are remarkably effective in stopping hemorrhoidal bleeding. They belong to a class of compounds called flavonoids, and both may help maintain healthy vein function. Readers of this magazine may recall the article about flavonoids in the June 2000 issue called "Get Relief from Varicose Veins and Hemorrhoids." There we discussed research demonstrating the benefits of flavonoids - the same two mentioned above - for the treatment of chronic venous insufficiency, a general weakening of the walls of our veins. One of the symptoms of this serious disorder is hemorrhoids.1 (Technically, hemorrhoids are varicose veins of the anus.)

The subject of hemorrhoidal bleeding was not featured in that article. The new research on this distasteful but important aspect of the problem demands our attention, however, so let's put on our lab coats, pretend we're doctors, and have a close look at what's going on in there.

THIS PART IS NOT FOR THE SQUEAMISH
First of all, most hemorrhoids don't bleed, and most don't even hurt - although when they do, the pain can be excruciating. It all depends on where they're located and how bad they get. External hemorrhoids occur at or near the anal opening and are easily felt and seen. Internal hemorrhoids are located well inside the anus, a roughly 4-inch-long canal that leads to the rectum (few, if any, hemorrhoids occur in the rectum itself). If an internal hemorrhoid becomes sufficiently large and distended, it may protrude through the anal opening, a condition called prolapse. Prolapsed hemorrhoids can often be gently pushed back inside. Most hemorrhoids shrink spontaneously in about a week, but if they don't, they can become a serious problem, often requiring surgical intervention.

Whether external or internal, prolapsed or not, hemorrhoids are, by definition, full of blood (the word comes from a Greek term meaning "flowing with blood"), because they are, after all, veins - albeit diseased ones. The serious trouble comes, however, when the blood in the hemorrhoid clots and becomes stagnant, a condition called stasis. This causes inflammation that leads to increased permeability, fragility, and necrosis (cell death) of the vessel wall, and those factors are a perfect setup for injury and pain.

When the bulging outer wall of the hemorrhoid is thus weakened, it can tear and bleed, sometimes profusely. The bleeding is initiated or exacerbated by the passage of stools, especially if they are large, dry, and hard, as is common in people with a low-fiber diet. Such stools often lead to constipation and straining during bowel movements. Straining can cause hemorrhoids by spiking the blood pressure in that region, and it aggravates existing hemorrhoids in the same way. A high-fiber diet, by contrast, promotes the more frequent elimination of smaller, moister, softer stools, and it greatly reduces - but does not eliminate - the likelihood of hemorrhoid formation in the first place. Incidentally, people who supplement at high levels often find that their stools become softer - a desirable outcome (so to speak) in general, not just for relief from hemorrhoids.

FLAVONOIDS: A NATURAL "CHEMICAL TOURNIQUET"
In a recently published article in the British Journal of Surgery, the authors report on a 90-day, randomized, double-blind, placebo-controlled study conducted in India to assess the effect of a flavonoid formulation in stopping acute bleeding of internal hemorrhoids and preventing relapse of the bleeding.2 The formulation, a mixture of diosmin and hesperidin in a 9:1 ratio by weight, is known generically as MPFF (micronized purified flavonoid fraction) and is used in many countries for the treatment of chronic venous insufficiency.

MPFF had previously been shown to be effective in reducing the severity of bleeding from hemorrhoids3 and in preventing relapse,4 but its effectiveness and speed in stopping the bleeding altogether had not been evaluated. The practical value of achieving this goal, in patients who might otherwise need prompt hemorrhoid surgery, is to buy some time to schedule the operation when it's more convenient for both patient and surgeon.

The current study was done on 100 men and women over 18 years of age who came to a clinic in northern India as outpatients with acute internal bleeding hemorrhoids of less than 3 days' duration and with a past history of hemorrhoids of less than 18 months. Pregnant women were excluded from the study, as were patients with significant nonhemorrhoidal diseases or disorders of the lower gastrointestinal tract, as well as patients who had undergone previous laser treatment or the use of a flavonoid medication within 1 month before inclusion in the study. Furthermore, eligibility for inclusion required that the patients were not being treated with analgesics, topical antihemorrhoidal ointments, nonsteroidal anti-inflammatory drugs, steroids, anticoagulants, or antiplatelet agents.

The 100 patients were randomly divided into two groups (treatment and control) of 50 each. The treatment group was given 3000 mg of MPFF (90% diosmin, 10% hesperidin) daily for 4 days, followed by 2000 mg daily for 3 days. Both groups were reassessed on the 8th day. Those who were still bleeding were withdrawn from the study and treated by other means, whereas those in whom the bleeding had stopped were given 1000 mg of MPFF or placebo daily for an additional 83 days, with periodic examinations for evidence of relapse.

The results during the initial week were striking. After only 3 days, bleeding had stopped in 80% of the MPFF group, vs. 38% in the control group, and these figures rose to 94% and 60%, respectively, by the end of the week. The mean duration of acute bleeding, from onset to cessation, was 2.1 days less with MPFF than with placebo. Furthermore, continued treatment after the bleeding had stopped prevented a relapse in 64% of the MPFF group, vs. 40% in the control group. The only side effects noted were three cases of gastritis.

BENEFITS BEYOND THOSE OF DIETARY FIBER
An interesting aspect of this study has to do with diet. Although the effects of dietary fiber were not assessed directly, the culturally determined staple food in that region of India is unleavened bread made from unrefined whole-wheat grain. Furthermore, 49 of the patients were vegetarians, and the randomization process divided them almost equally between the two groups. Thus it can be presumed that most patients in both groups were on a diet rich in fiber. And that means that the observed benefits from taking MPFF versus placebo are probably over and above the benefits obtained from dietary fiber.

HOW FLAVONOIDS PROMOTE HEALTHY VEINS
The new study tends to confirm what scientists have already come to believe, based on much experimental and clinical evidence: that the flavonoids diosmin and hesperidin act to increase venous tone, i.e., they strengthen the walls of our veins. This makes the veins less susceptible to varicosity in the first place, and it makes veins that have become varicose less susceptible to stasis. In addition, these flavonoids (which, by the way, are strong antioxidants) exert a potent anti-inflammatory action that further suppresses the tendency of varicose veins, including hemorrhoids, to become excessively permeable and fragile. The most dramatic evidence of these benefits is found in the fact that the flavonoids stop the bleeding in hemorrhoids that have already deteriorated to that point.

We sincerely hope, Dear Reader, that you have never been troubled by hemorrhoids, and never will be. But just in case, it should be gratifying to know that Mother Nature has kindly provided the possibility of relief in the form of diosmin and hesperidin. Here's to your venous health!

References

  1. Jantet G. RELIEF study: first consolidated European data. Angiol 2000 Jan;51(1):31-7.
  2. Misra MC, Parshad R. Randomized clinical trial of micronized flavonoids in the early control of bleeding from acute internal hemorrhoids. Brit J Surg 2000;87:868-72.
  3. 3. Cospite M. Double-blind, placebo-controlled evaluation of clinical activity and safety of Daflon 500 mg in the treatment of acute hemorrhoids. Angiol 1994;45:566-73.
  4. 4. Godeberge PH. Daflon 500 mg is significantly more effective than placebo in the treatment of haemorrhoids. Phlebol 1992;7(Suppl 2):61-3.

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