Haemorrhoids are abnormal engorgement of arteriovenous plexus in anal cushions lining the anal canal. Theory of sliding anal canal lining shows that weakening of supporting tissues of anal cushions causes descent of blood vessel. (1) It is a condition characterized by the prolapse of an anal cushion that may result in bleeding and pain. (2)

 Pectinate line is the demarcation which divides upper 2/3 and lower 1/3 of the anus. Haemorrhoids are classified as ‘internal’ or ‘external’. Internal haemorrhoids are located above the pectinate line and are covered with cells that are same as those that line the rest of the intestines. External haemorrhoids develop below the line and have cells that resemble skin. (3)

As per clinical BPRST classification, staging of haemorrhoids is based on bleeding and prolapse of blood vessels. According to this, patients with bleeding per rectum, without prolapse or external components like fibrotic skin tags or thrombosed piles detectable on physical examination is classified as stage I. (4) In stage II, patients have prolapsed haemorrhoid (regardless of circumference or number of haemorrhoids) which reduce spontaneously or by digital maneuver. (5) Patients with irreducible prolapse, symptomatic fibrotic skin tags, or acute hemorrhoidal thrombosis is diagnosed as stage III. (4)

As per data, Hemorrhoidal disease affects 40% of people all over the world and it is one of the most common diseases in the anorectal region (6). About half of the people over the age of 50 years develop symptoms referring to this disease at some point in life. (7) However, one of the hospital-based study conducted in Karnataka, India, showed prevalence of nearly 75%. (8) Still there is embarrassment involved in seeking treatment among the affected people. (8) So, most of the patients thought to self-treat with over-the-counter therapy (9) and as a result, out of all affected people, only 4% opted for the treatment of this disease. (10) Due to this, the actual burden of the disease in the society remains undisclosed.

Patients with haemorrhoids are usually asymptomatic (11), but some researchers suggested that about 75 % of people will have symptomatic haemorrhoids at some point of time in their lives. (12) Patients with internal haemorrhoids commonly present with bleeding with or without defecation, a swelling, mild discomfort or irritation, pruritus ani, mucus discharge and sometime prolapse accompanied with pain. (11) Patients with external haemorrhoids may have painful swelling or a hard lump around the anus that results when a blood clot is formed. (13) Some researchers showed, 1/3rd patients had soiled their clothes also. (14)

These symptoms of haemorrhoids produce physical and psychological discomfort and may significantly influence the quality of life of the diseased which hampers patient’s ability to live normally and work efficiently. (15)

Weakening of the supporting connective tissue framework in the Ano-rectal apparatus leads to hemorrhoidal disease. (16) So, the determinants which cause weakening of the supporting tissue, like, age and factors which cause increased intra-abdominal pressure are likely to be associated with hemorrhoidal disease. Amongst these, some are modifiable like constipation, prolonged straining at stool, inadequate dietary fibre, high body mass index (BMI). (2,8,14-15,17) Other determinants like inadequate water intake, smoking, alcohol consumption and sedentary behaviour are also modifiable. (2,8,14-15,17) Age, gender and family predisposition are some non-modifiable determinants of this diseases. (2,8,14-15,17) Furthermore, socio - demographic factors like education, occupation and socio-economic status are also associated with this disease. (5, 20, 21, 23, 24)

Even though, haemorrhoids are well studied in different parts of the world, however, in Gujarat, India, hemorrhoidal disease and its determinants are not well documented. Hence, present study was planned with the objective to know the prevalence and determinants of haemorrhoids among the patients attending OPD of the general surgery department of a tertiary care hospital of the Mehsana district, Gujarat, India.

This Hospital based cross sectional study was conducted in the outpatient department (OPD) of general surgery department of a tertiary care hospital of Mehsana district, Gujarat, India from July 2022 to December 2022. Total 5261 new patients attended OPD of general surgery department during above time period. Out of all these patients, 441 patients were found to have haemorrhoids with various stages of severity. Haemorrhoids was diagnosed by inspection that included visual examination of anus and surrounding area, per rectal digital examination and proctoscopy. The examination was done by trained consultant. Out of 441, 429 patients were included in this study whose age was more than 18 years and gave consent for present study. Those who had chronic liver disease and bleeding disorders and who did not give consent were excluded. Participants were enrolled by nonprobability convenient sampling technique.

Approval for the study was obtained from institutional ethics committee. Before introducing questionnaire, objectives and methodology were described in detail to the participants followed by written informed consent. Confidentiality about the information of participants was maintained throughout the research. For data collection pre-tested and pre-structured validated questionnaire was used that included various determinants which are known or likely to be associated with haemorrhoids. The questionnaire included basic socio demographic details of participants like age, gender, education, occupation, socioeconomic status based on monthly per capita family income. Other determinants, like, family history of haemorrhoids, constipation, stay in the toilet for evacuation based on time in minutes, chronic cough, fibre diet intake, daily intake of spicy food, daily water intake, smoking, alcohol intake, sedentary behaviour and obesity based on BMI. Sign and symptoms of the registered patients were also documented and grading of severity done based on clinical BPRST classification. (4)

Constipation was evaluated in patients by asking about bowel movement frequency in a day or per week. Along with that, patients were also enquired for feeling of incomplete bowel evacuation, passage of hard or lumpy stool, feeling of obstruction or blockage during passing stool, straining or manual removal. (18) Duration of stay in the toilet for evacuation considered in minutes. Shorter duration of stay in toilet means stay less than 10 minutes and longer stay means more than 10 minutes. (17) Fibre diet intake was considered adequate if the participant took fibre diet once in a week. (19)

Consumption of water more than 8 glasses per day was considered adequate and less than that was considered inadequate intake. (17) History of smoking and alcohol intake was also documented by asking number of drinks or number of cigarettes/bidis per day.

Sedentary behaviour of the participants was considered as per the criteria defined by the WHO for adult population. (20)) Weight was measured using standard digital weighing machine. Height was measured with calibrated fixed scales while the patients stood bare feet. BMI was calculated by dividing one's weight in kilograms by the square of height in meters. Weight disorders were evaluated based on BMI. (21)

Data analysis was done by entering data in Epi info version 7.2.1. Descriptive statistics were applied. Percentages and frequencies of the categorical variables were measured.

Out of 441 patients with haemorrhoids, 429 were interviewed depending on inclusion and       exclusion criteria.

Table I showed prevalence of haemorrhoids to be 8.38%.

Table II showed haemorrhoids was present more commonly in people with age less than 40 years. It was more prevalent in the male participants (68.63%). Total 53.25% participants were illiterate or educated up to primary level. Haemorrhoids were more commonly observed in participants who were labourer (43.14%) and belonged to low socio-economic class (Class IV and V) (58.64%).

Table III showed prevalence of various risk factors amongst participants. Most common risk factor was constipation which was present among nearly 80% of the participants. Almost 75% participants had straining while passing stool and had more than 10 minutes duration of stay in the toilet for evacuation. Nearly 1/3^rd participants had family history of haemorrhoids. Almost 65% and 40% participants were not consuming fibre and water in adequate amount respectively. Nearly 50% consumed spicy food daily. Almost 22% had sedentary behaviour and 18% were obese. About 15% had habit of alcohol intake and smoking.

Table IV showed grading of severity of haemorrhoids as per clinical BPRST classification in which almost half of the presented patients had Grade I haemorrhoids followed by Grade II (33.33%). Almost 18% participants had Grade III haemorrhoids.

Table I: Distribution of Patients according to the Presence of Haemorrhoids attending OPD of General Surgery Department

Table II: Socio-demographic characteristics of the study population (n=429)

Table III: Distribution of the risk factors in study population (n=429)

Table IV: Grading of severity of Haemorrhoids as per clinical BPRST classification in study population (n=429)

Current study was conducted in patients attending surgical OPD to know the prevalence and determinants of haemorrhoidal disease.

Present study showed that the prevalence of hemorrhoidal disease was nearly 8% amongst the 429 interviewed patients, which is low as compared to study done in general population by international web-based survey which showed prevalence to be 11%. (22) This might be because the present study was hospital-based study and many researchers have documented that many patients suffering from this disease feel awkward to give history and get examined (13), and so they go for self-treatment with over-the-counter therapy. (14) So, a smaller number of patients attend the hospital than actually affected. However, other studies have documented the prevalence of haemorrhoidal disease as ranging from 4.4 to 88%. (16)

In this study we observed that the most common age group affected with haemorrhoids was below 40 years of age, as nearly half of the patients belonged to that age group. This finding is consistent with that of Ravindranath GG et.al., who documented similar results in their study. (14) In contradiction to this, study of Khan et al. and Sadiqa et al., observed that patients above 40 years of age were more at risk. (8,17)

 Present study documented that males were affected more frequently (68.63%) than females (31.37%). One of the studies conducted in Pakistan also showed the male preponderance for the disease. (17) Ravindranath GG et.al. also documented the similar finding in their study in which 66.67% males and 33.33% females had haemorrhoidal disease.(14) This could be explained with an argument that women are more hesitant, as compared to men, to discuss anorectal problems and they usually avoid anal examination for the diagnosis of haemorrhoids.(1)  Parvez Sheikh et.al. did online web-based survey in general population and it showed that this disease was more prevalent in females compared to males (22) supporting above findings.

 Similar to other studies, the development of haemorrhoids among patients with low educational status was observed more in this study. (12)  However, study conducted in semi urban area of India, did not find any relation with education. (9)

 Khan et.al. (8) detected that haemorrhoids is associated with those occupations which require prolonged standing, sitting or weight lifting as they increase the intra-abdominal pressure, which is also a risk factor for haemorrhoids. In our study also, nearly 43% of participants with haemorrhoids were labourers.

 In current study, haemorrhoids disease was observed more in the people with lower socio-economic class. This finding was consistent with study conducted by Sadiqa et.al. (17), but Ponkiya et.al. documented higher prevalence of haemorrhoids in upper class compared to the lower class. (1)

Present study noted positive family history as a predisposing factor for haemorrhoids. Similar to this, Sadiqa et al. had also documented the role of family history in haemorrhoids. (17)  While finding of the study conducted in Ethiopia only 7.4% participants had positive family history. (19)

 Constipation was found to be highly prevalent in patients with haemorrhoids in our study. Findings of other studies are consistent with this. (14,17,19,23) This could be explained as patients with constipation, do strain to pass hard stool leading to supportive tissue tear and degeneration in the anal canal which further causes displacement of anal cushions and development of haemorrhoids. (24) Also, passage of hard stool raises intra-abdominal pressure which could obstruct venous return, ending in engorgement of the hemorrhoidal plexus and arteriovenous anastomoses of the anorectal junction which leads to the development of haemorrhoids. (16)

In concordance with other study, this study showed a longer stay in toilet for evacuation predisposes to haemorrhoids (74.51%) as it causes more straining and consequently leads to the development of haemorrhoids. (17)

This study showed that low intake of fibre and inadequate water intake are also contributing factors for haemorrhoids. As both lead to development of constipation. Many studies backed these finding. (3,17) A study showed that high intake of spicy food had direct relation with development of haemorrhoids. (17) Present study findings were in consistence with it.

In concordance with the other study, sedentary behaviour as well as high BMI are also found to be risk factors for haemorrhoids in this study. Khan et.al. corroborated this finding in his study. (8) Another study conducted in Ethiopia also recorded that overweight increased the odds of having haemorrhoids. (6, 15, 17, 19) Study by Parvez Sheikh also documented that 52% patients with haemorrhoids were either overweight or obese. In this study, nearly 17% of the patients with haemorrhoids had obesity and 21% had sedentary life style. (22)

 In present study, nearly 50% presented with complain of bleeding per rectum without any prolapse. Which was similar to the results observed by Ali et.al. in his study. He also documented most common symptom was bleeding per rectum. (23) This finding also consistent with other studies also. (1, 14) In this study, nearly 1/3rd had patients had prolapse with bleeding per rectum. Whereas Ponikya et.al. reported 84% and Ravindra Gandhe reported 59% participant had prolapse. (1, 14) which was higher compared to this study.

In present study, 8.38% patients had hemorrhoidal disease. Various modifiable factors like constipation, low fibrous and more spicy diet, smoking, consumption of alcohol, inadequate water intake, high BMI and sedentary lifestyle were present among the patients with haemorrhoids. Education regarding fibrous diet, water intake and management of the constipation should be done. Education regarding healthy life style to change sedentary life pattern and obesity is required. Screening for risk factors in patients with haemorrhoids should be practiced for better management.

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