Introduction

Hemorrhoidal disease affects 2-7% of patients with inflammatory bowel disease (IBD) (1,2), but treatment recommendations are limited due to apparent higher morbidity in this subset of patients (3,4). Currently, there is limited data about hemorrhoidal disease treatment in IBD, there is even less information regarding non-surgical treatment.

Aims & Methods

The authors aim to evaluate the safety and efficacy of office-based procedures in hemorrhoidal disease in patients with IBD. This is a retrospective and Portuguese multicenter study (7 centers) that included patients with IBD who underwent office-based procedures for hemorrhoidal disease between July 2013 and July 2021. Data relating to IBD and hemorrhoidal disease were analyzed namely success, relapse, and complications. Success was defined as a significant improvement in symptoms after office-based procedures, without the need for additional treatment. Relapse was defined as a worsening of symptoms, requiring new office-based procedures/surgery.

Results

129 patients were included, 70% with ulcerative colitis; in Crohn's disease, 5.4% had a history of perianal disease. Only 62% of patients had endoscopic remission and 18% were on biologics. Regarding Goligher's classification, the majority had grade II (48%). 77 patients underwent rubber band ligation (RBL), 44 patients underwent polidocanol injection and 8 patients underwent both techniques, in a total of 304 procedures (median of 2(2) sessions/patient). The treatment was effective in 88% of patients, of which 14% relapsed, with an average follow-up time of 55.3±34.5 months. Of 304 procedures, 17 (5.6%) procedures were complicated, in a total of 16 patients (12.4%), 2 (0.65%) required invasive treatment, without cases of pelvic sepsis. Success, relapse, and complications were not associated with IBD (type, medication, or remission at the time of treatment) (p>0.05). Success was greater in patients with Goligher grades I and II (p=0.037). Complications were higher in patients undergoing RBL (p=0.030) and in patients with Goligher grade III (p=0.031).

Conclusion

This is the first study about office-based procedures for hemorrhoidal disease in IBD, showing similar efficacy to the general population, with a low rate of complications, and should therefore be recommended in these patients.

References

1. Eglinton TW, Barclay ML, Gearry RB, Frizelle FA. The spectrum of perianal Crohn's disease in a population-based cohort. Dis Colon Rectum. 2012 Jul;55(7):773-7.
2. Choi YS, Kim DS, Lee DH, Lee JB, Lee EJ, Lee SD, et al. Clinical Characteristics and Incidence of Perianal Diseases in Patients With Ulcerative Colitis. Ann Coloproctol. 2018 Jun;34(3):138-143.
3. Jeffery PJ, Parks AG, Ritchie JK. Treatment of haemorrhoids in patients with inflammatory bowel disease. Lancet. 1977 May 21;1(8021):1084-5.
4. D'Ugo S, Franceschilli L, Cadeddu F, Leccesi L, Blanco Gdel V, Calabrese E, et al. Medical and surgical treatment of haemorrhoids and anal fissure in Crohn's disease: a critical appraisal. BMC Gastroenterol. 2013 Mar 11;13:47

Clinical Case Summary

Introduction: Mastocytosis is an uncommon hematopoietic neoplasm characterized by clonal proliferation of atypical mast cells. The clinical manifestations of mastocytosis are heterogeneous,ranging from limited cutanous involvement to aggressive disease with various levels of extra cutanous multi-organ involvement. Most cases of mastocytosis are indolent, usually cutanous or indolent systemic mastocytosis (SM). Aggressive SM is a rare and often fatal disease. Gastrointestinal involvement in aggressive SM presents with non specific symptoms and the final diagnosis depends on the pathology. Herein, we present a special case of colonic mastocytosis
Clinical case: We report a case of 66 years old female patient who presented with chronic abdominal pain not responding to treatment. On physical examination showed abnormal abdominal pigmentation and reported that skin biopsy previously revealed urticaria pigmentosa. Laboratory investigations were unremarkable. Colonscopy was planned and showed diffuse reddish mottling of cecum and ascending colon. Multiple biopsies were taken and histopathological examination revealed focal crypt architectural distortion. The lamina showed moderate inflammatory cellular infiltrate. These are formed of lymphocytes and plasma cells with excess eosinophils > 100/HPF. Esinophilic cryptitis is seen. Subtle population of scattered ovoid cells with rounded ovoid nuclei are seen. Slide stained for CD117 revealed positive reaction highlighting frequent mast cells. Moderate diffuse colitis with frequent mast cells and excess eosinophils > 100/HPF. Picture is suggestive of mastocytosis involving colon. The patient started imatinib and prednisone and long term follow up showed complete relieve of abdominal pain.