Association of Hemorrhoid Vascular Injuries with Cigarette Smoking—An Evaluation with Interesting Prospects

Abstract

Background Hemorrhoids are vascular structures in the anal canal which are seldom used to evaluate vascular diseases. Cigarette smoking is well-known to cause both arterial and venous vascular injuries. However, the impact of smoking on hemorrhoid vasculature is unknown.

Objective Considering that vasculature in the hemorrhoids has the same anatomy and pathophysiology of vascular damage as other systemic vasculatures, we conducted this study to evaluate the relation between smoking and incidence of hemorrhoidal vascular injury.

Design and Data Analysis Retrospective review of all the screening colonoscopies performed at our Department of Gastroenterology (predominantly serving urban minority population) over 3 years was conducted and patients with recorded smoking history were included in the study (n = 242). Fisher's exact test with two-tailed p-value and odds ratio were used to evaluate for the association between smoking and incidence of hemorrhoids.

Results We studied 242 subjects and found statistically significant association between smoking and hemorrhoids (p < 0.05) with the risk of developing hemorrhoids among smokers being 2.4 times that of a nonsmoker. We further noted no significant difference in the incidence of hemorrhoidal vascular injuries between the past versus current smokers and male versus female smokers.

Conclusion This is one of the first studies to establish an association between smoking and hemorrhoids. Our study shows that the hemorrhoidal vasculature is impacted by smoking similar to other vascular systems. This study sheds light on the possibility of evaluating hemorrhoids for clues of other systemic and gastrointestinal vascular damage. This correlation can add clinical value especially given the flexibility of assessing hemorrhoids as an outpatient in a cost effective and comfortable manner.

Keywords

hemorrhoids - piles - hemorrhoid vascular injuries - gastrointestinal vasculature - symptomatic hemorrhoids - anal canal - varicose veins of the anus - cigarette smoking - smoking associated vascular injuries

Financial Disclosure

No grants or financial compensation was received for this study. None of the authors have any financial relationships associated with this study.

Previous Publications

This study has never been published as a manuscript before. However, the abstract of this study was presented as an oral presentation at American Medical Association Annual Research Symposium on November 11th, 2016 in Orlando, Florida and won the “Best Podium Presentation” award and was also presented as a digital poster at Mount Sinai GME Consortium Research Day on June 1st, 2018 at New York City.

Ethical Statement

The original observational study protocol was approved by our institutional review board (IRB) and this study was conducted using the information acquired from the original data pool as a secondary study. Being a retrospective study, all patient identifiers were available only to the main research personnel approved by IRB and all identifiers were safely destroyed after completion of data collection. Consent could not be obtained as this was a retrospective study where no direct patient contact was involved during the time of the data collection and no patient identifiers were used after data collection.

• References

• 1 Goligher JC. Surgery of the Anus, Rectum, and Colon. 4th ed. London: Ballierè Tindal; 1980
• 2 Harish K, Harikumar R, Sunilkumar K, Thomas V. Videoanoscopy: useful technique in the evaluation of hemorrhoids. J Gastroenterol Hepatol 2008; 23 (8 Pt 2): e312-e317
• 3 Sadahiro S, Mukai M, Tokunaga N, Tajima T, Makuuchi H. A new method of evaluating hemorrhoids with the retroflexed fiberoptic colonoscope. Gastrointest Endosc 1998; 48 (03) 272-275
• 4 Thomson WH. The nature of haemorrhoids. Br J Surg 1975; 62 (07) 542-552
• 5 Morgado PJ, Suárez JA, Gómez LG, Morgado Jr PJ. Histoclinical basis for a new classification of hemorrhoidal disease. Dis Colon Rectum 1988; 31 (06) 474-480
• 6 Michael Pittilo R. Cigarette smoking, endothelial injury and cardiovascular disease. Int J Exp Pathol 2000; 81 (04) 219-230
• 7 Stankevicius E, Kevelaitis E, Vainorius E, Simonsen U. [Role of nitric oxide and other endothelium-derived factors] [Article in Lithuanian]. Medicina (Kaunas) 2003; 39 (04) 333-341
• 8 Han W, Wang ZJ, Zhao B. , et al. [Pathologic change of elastic fibers with difference of microvessel density and expression of angiogenesis-related proteins in internal hemorrhoid tissues] [Article in Chinese]. Zhonghua Wei Chang Wai Ke Za Zhi 2005; 8 (01) 56-59
• 9 Brand FN, Dannenberg AL, Abbott RD, Kannel WB. The epidemiology of varicose veins: the Framingham study. Am J Prev Med 1988; 4 (02) 96-101
• 10 Michiels C, Arnould T, Remacle J. Hypoxia-induced activation of endothelial cells as a possible cause of venous diseases: hypothesis. Angiology 1993; 44 (08) 639-646
• 11 Piérard GE. [Heavy legs, venular microangiopathy and stasis acrodermatitis] [Article in French]. Rev Med Liege 1996; 51 (08) 510-513
• 12 Ducimetiere P, Richard JL, Pequignot G, Warnet JM. Varicose veins: a risk factor for atherosclerotic disease in middle-aged men?. Int J Epidemiol 1981; 10 (04) 329-335
• 13 Leary T. Arteriosclerosis and varicose veins. JAMA 1942; 119 (13) 1041
• 14 Androulakis AE, Katsaros AA, Kartalis AN. , et al. Varicose veins are common in patients with coronary artery ectasia. Just a coincidence or a systemic deficit of the vascular wall?. Eur J Vasc Endovasc Surg 2004; 27 (05) 519-524
• 15 Chang S-S, Sung F-C, Lin C-L, Hu W-S. Association between hemorrhoid and risk of coronary heart disease: a nationwide population-based cohort study. Medicine (Baltimore) 2017; 96 (31) e7662