PNR-bleed classification and the prospects of future research for the management of hemorrhoids

Mudassir Ahmad Khan; Zubair Afzal Khan; Fazl Q Parray; Mir Fahiem ul Hassan; Asif Mehraj; Arshad Ahmed Baba; Rauf Ahmad Wani; Nisar A Chowdri

doi:10.4103/ijcs.ijcs_1_21

REVIEW ARTICLE

Year : 2021 | Volume : 4 | Issue : 3 | Page : 68-72

PNR-bleed classification and the prospects of future research for the management of hemorrhoids

Mudassir Ahmad Khan¹, Zubair Afzal Khan¹, Fazl Q Parray², Mir Fahiem ul Hassan³, Asif Mehraj², Arshad Ahmed Baba⁴, Rauf Ahmad Wani², Nisar A Chowdri²
¹ Department of General Surgery, GMC, Rajouri, Jammu and Kashmir, India
² Department of General Surgery, SKIMS, Srinagar, Jammu and Kashmir, India
³ Department of Paediatric Surgery, Maternal and Child Hospital, Bisha, Saudi Arabia
⁴ Directorate of Health Services, Jammu and Kashmir, India

Date of Submission	29-Jan-2021
Date of Decision	06-Jun-2021
Date of Acceptance	06-Jun-2021
Date of Web Publication	24-May-2022

Correspondence Address:
Mudassir Ahmad Khan
Department of General Surgery, GMC, Rajouri, Jammu and Kashmir
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijcs.ijcs_1_21

Abstract

The classification and diagnostic and therapeutic protocols are yet to reach to an unequivocal and shared vision level. There is a dire need of some decisive guidelines for the management of hemorrhoids, but these new guidelines could not have any significant clinical impact unless they are based on a sound classification system. To overcome the drawbacks of previous classifications and to set the stage for further research for devising some robust guidelines for the management of hemorrhoids, our recently published classification system for hemorrhoids, viz., “PNR-Bleed Classification for hemorrhoids,” describes the hemorrhoidal disease more vividly. In the present article, we have discussed the possible directions for future research for the management of hemorrhoids based on this classification. The future studies may redefine the treatment options for hemorrhoids more clearly based on this classification. Initial theoretical and intuitive assessment of the “PNR-Bleed Classification” suggests that future studies on this project may have profound clinical and research consequences. Moreover, these future studies may help in revising and rediscovering the protocols for the management of hemorrhoidal disease. For regular follow-up of the hemorrhoidal patients, the “PNR-Bleed Classification”-based hemorrhoid severity score may prove a useful outpatient department-based assessment tool to the general surgeons and coloproctologist.

Keywords: Goligher's classification, Hemorrhoid severity score, Hemorrhoidal grades, Hemorrhoids, PNR-Bleed Classification

How to cite this article:
Khan MA, Khan ZA, Parray FQ, ul Hassan MF, Mehraj A, Baba AA, Wani RA, Chowdri NA. PNR-bleed classification and the prospects of future research for the management of hemorrhoids. Indian J Colo-Rectal Surg 2021;4:68-72

How to cite this URL:
Khan MA, Khan ZA, Parray FQ, ul Hassan MF, Mehraj A, Baba AA, Wani RA, Chowdri NA. PNR-bleed classification and the prospects of future research for the management of hemorrhoids. Indian J Colo-Rectal Surg [serial online] 2021 [cited 2022 Jun 29];4:68-72. Available from: https://www.ijcrsonweb.org/text.asp?2021/4/3/68/345915

Introduction

Throughout the world, the hemorrhoids are the most prevalent anorectal disease conditions encountered in daily practice by general practitioners, general surgeons, and the coloproctologists. Known for centuries, the hemorrhoidal disease is classified as benign but nonetheless has a high socioeconomic impact. Approximately 5% of the general population has symptomatic piles at any given point of time, and it has been projected that by the time age 50 years, about 50% of the population would have hemorrhoids at some point in their life.^[1],[2],[3] The higher incidence and prevalence of hemorrhoids in any society result in increased patient sufferings, decreased quality of life, and increased overall economic burden in terms of treatment costs, healthcare utilization, and increased off-workdays. Taking this into account, it has become imperative upon us that we follow the evidence-based practice in the management of hemorrhoids. However, any evidence-based practice for the treatment of any disease is based upon the robust system of classifying and grading that particular disease. Further, a critical review of the management of hemorrhoids has become indispensible because of the introduction of day-care (ambulatory) surgery in the management of benign proctologic diseases.

In spite of the continuous research going on for the evidence-based management of hemorrhoids; its pathophysiological basis has not been fully elucidated, and its classification and diagnostic and therapeutic protocols are yet to reach to an unequivocal and shared vision level.^[4] The reasons for this heterogeneity in the management of various aspects of hemorrhoidal disease can be identified at various levels such as the heterogeneity in the morphological characteristics of the disease, position of the hemorrhoidal plexuses, the subjective nature of the symptoms reported by the patient, and the lack of any universally accepted and scientifically sound classification systems. This heterogeneity is evident and expressed even more vividly while addressing the therapeutic phase of the hemorrhoidal disease,^[5] as is evidenced by the most recent reports from multicenter randomized trials^[6],[7],[8] on this topic.

The review of the literature about various treatment options and surgical techniques for hemorrhoids demonstrates that multitude of studies tries to fix the superiority or inferiority of a specific treatment protocol or a specific surgical technique compared with others. However, all these assumptions of superiority or inferiority are mostly based upon treating the heterogeneous groups of patients classified according to the Goligher's classification. The clubbing of the different heterogeneous types of hemorrhoids in various grades of Goligher's classification makes these comparative studies pointless and flawed. Because these studies are usually comparing a heterogeneous group of one particular grade of hemorrhoidal disease patients with the other same grade but differently heterogeneous group. That is, they are comparing the groups of different patient compositions (in terms of quantitative and qualitative burden of hemorrhoidal disease). Even though Goligher's classification is the mostly widely used, besides clubbing of heterogeneous group of patients, it has some other relevant limitations also. It lacks hemorrhoidal prolapse quantification, gives limited significance to the bleeding symptom, and lacks evaluation of symptom type and frequency and the presence of any associated diseases. For these reasons, this classification does not appear to be useful for defining the treatment of choice for a particular grade of hemorrhoids. Trying to overcome the drawbacks of Goligher's classification, several new classifications systems have been proposed considering exclusively the symptoms, anatomical features,^[9],[10] or a specific severity score of hemorrhoidal disease,^[11],[12] but none of them correlates to a specific treatment.

Need for Formulation of Prescriptive Protocols and Definitive Guidelines

From time to time, various national and international gastrointestinal and coloproctological scientific societies^{[13],[14],[15],[16],[17],[18]} have put forth their guidelines for the management of hemorrhoids. However, because of controversies from both the nosological classification of hemorrhoids and the multitude of available therapeutic options, the final choice of treatment is often left to the surgeon's preference in almost all of these guidelines.^[19] Further, most of these guidelines are based upon the Goligher's grading of hemorrhoids, which considers only the prolapsing grade of the hemorrhoids without giving due consideration to the number of hemorrhoid columns involved, amount of bleeding, and presence or absence of various ischemic and thrombotic complications. These drawbacks leave these guidelines only for the purpose of providing information that aids decision-making rather than dictating to a specific form of treatment,^[13] hence making these guidelines the mere advisories rather than prescriptive rules.^[17]

Hence, there is a dire need of some decisive guidelines for the management of hemorrhoids, but these new guidelines could not have any significant clinical impact unless they are based on a sound classification system for hemorrhoids. A classification system for any disease is useful in choosing an appropriate treatment for a particular class, and it allows the comparison of various available treatment options.^[20] Hemorrhoids are usually classified on the basis of their location and degree of prolapse. However, none of the classification systems for hemorrhoids is complete to give the full clinicopathological description of hemorrhoids in a particular patient.^[20]

PNR-Bleed Classification

To overcome the drawbacks of Goligher's classification and to set the stage for further research for devising some robust guidelines for the management of hemorrhoids, we have recently put forth and published^[20] our new classification system for hemorrhoids, viz., “PNR-Bleed Classification for hemorrhoids.” The purpose of this classification is to describe the hemorrhoidal disease in detail and more vividly. This “PNR-Bleed” classification is based on the four main characteristics [Table 1] of the hemorrhoidal disease, i.e., the degree of hemorrhoidal Prolapse (P), Number (N) of the primary hemorrhoidal columns involved, Relation (R) of the hemorrhoidal tissue to dentate line, and the amount of Bleeding (B) from it.^[20] For the sake of simplicity and making it user-friendly, all the four components in this classification system are graded into five grades ranging from 1 to 5. Based on this “PNR-Bleed” classification, we proposed another concept of scoring the severity of hemorrhoids and referred it as the hemorrhoid severity score (HSS). HSS is the total score obtained by the sum of the numerical grades of all four characteristics of hemorrhoids in “PNR-Bleed” Classification.^[20]

Table 1: “PNR-Bleed” Classification of hemorrhoids^[20]

Click here to view

PNR-Bleed Classification and Prospects of Future Research

The peculiarity of this new “PNR-Bleed Classification” system is that it allows more detailed documentation of the hemorrhoids in a particular patient and conveys more explicit information about the hemorrhoids for future (posttreatment) references. However, this classification system for hemorrhoids is still in infancy owing to the lack of supporting published data. However, there is a great scope of new research about hemorrhoidal disease with respect to this PNR-Bleed Classification. Moreover, this classification system may provide new dimensions of research for the management of hemorrhoidal disease. As compared to Goligher's classification, this new classification seems to be more comprehensive, detailed, more objective, and easily reproducible. It may also help us in better comparison of various treatment options for hemorrhoids with respect to therapeutic outcomes, recurrence, and complication rates. The decoding and reciprocal reproduction of information about the hemorrhoidal disease of a particular patient encrypted in the pneumonic of “PNR-Bleed” may probably be done in a broader and more astare way than from the Goligher's grading system.

The future studies based on this “PNR-Bleed” Classification and HSS may redefine the treatment options for hemorrhoids more clearly based on HSS. For example, the different HSS range group patients of hemorrhoids can be allocated (based on future studies) to either conservative management group (in the form of dietary and lifestyle modifications and medications) or to the office-based procedures group (sclerotherapy, cryotherapy, and RBL) or to the surgical procedures group. Further, the incidence and type of surgical complications may possibly be predicted based upon preoperative PNR-Bleed Classification status and HSS. Moreover, the various surgical options for hemorrhoids can be better compared (in future studies) based on more comprehensive HSS rather than simpler Goligher's grading.

The need of the hour is that there be enough research with respect to various aspects of PNR-Bleed classification and HSS, and we invite the researchers and proctological societies to invest on this. However, to make the job the researchers slightly easier, we herein suggest underlying topics about “PNR-Bleed Classification” for the future research studies:

To study the clinical/clinicopathological profile of hemorrhoids with respect to the “PNR-Bleed Classification” in patients presenting to a secondary/tertiary care hospital or a specialist proctology unit
To study the occurrence of heterogeneity of various types of hemorrhoids according to the “PNR-Bleed Classification” in Grade III and IV of Goligher's classification
To describe the Grade III and IV hemorrhoids with respect to the “PNR-Bleed Classification”
Recategorization with respect to the “PNR-Bleed Classification” of the “hemorrhoids requiring surgical intervention” at any specialist hospital and to study their treatment outcome and complications
To study the change of “PNR-Bleed Classification” status and “HSS” at 3 months of follow-up after MIPH
To study the role of “PNR-Bleed Classification” and HSS for monitoring a case of hemorrhoidal crisis during the conservative management period
To study the use of “PNR-Bleed Classification” and HSS for monitoring (charting the progress) in patients of hemorrhoidal crisis to establish that which group of patients may need urgent surgical intervention and which group may be managed by elective or semielective surgical intervention
To study the interobserver bias and variability among different surgeons examining the same of the patient in grading the hemorrhoids using 'PNR-Bleed' classification viz-a-viz Goligher's grading
To study the change in “PNR-Bleed Classification” status and HSS in earlier grade hemorrhoids after they are put on conservative treatment protocols such as bulk laxatives and the oral calcium dobesilate (500 mg bd × 15 days)
To study the change in “PNR-Bleed Classification” status in pregnant ladies with hemorrhoids being managed conservatively, at 6 weeks after their delivery
To study the change in “PNR-Bleed Classification” status and HSS in earlier grade hemorrhoids after RBL at 6 weeks and 6 months of follow-up.

Conclusion

Initial theoretical and intuitive assessment of the “PNR-Bleed Classification” suggests that future studies on this project may have profound clinical and research consequences. Moreover, these future studies may help in revising and rediscovering the protocols for the management of hemorrhoidal disease. For regular follow-up of the hemorrhoidal patients, the “PNR-Bleed Classification”-based HSS may prove a useful outpatient department-based assessment tool to the general surgeons and coloproctologist.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Min EK, Chong JU, Hwang HK, Pae SJ, Kang CM, Lee WJ. Negative oncologic impact of poor postoperative pain control in left-sided pancreatic cancer. World J Gastroenterol 2017;23:676-86.
2.	Mounsey AL, Halladay J, Sadiq TS. Hemorrhoids. Am Fam Physician 2011;84:204-10.
3.	Gallo G, Sacco R, Sammarco G. Epidemiology of hemorrhoidal disease. In: Ratto C, Parello A, Litta F, editors. Hemorrhoids. Coloproctology. Vol. 2. Switzerland: Springer, Cham; 2018. p. 3-7.
4.	Sun Z, Migaly J. Review of hemorrhoid disease: Presentation and management. Clin Colon Rectal Surg 2016;29:22-9.
5.	Jacobs DO. Hemorrhoids: What are the options in 2018? Curr Opin Gastroenterol 2018;34:46-9.
6.	Chen HL, Woo XB, Cui J, Chen CQ, Peng JS. Ligasure versus stapled hemorrhoidectomy in the treatment of hemorrhoids: A meta-analysis of randomized control trials. Surg Laparosc Endosc Percutan Tech 2014;24:285-9.
7.	Watson AJ, Cook J, Hudson J, Kilonzo M, Wood J, Bruhn H, et al. A pragmatic multicentre randomised controlled trial comparing stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease: The eTHoS study. Health Technol Assess 2017;21:1-224.
8.	Simillis C, Thoukididou SN, Slesser AA, Rasheed S, Tan E, Tekkis PP. Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg 2015;102:1603-18.
9.	Lunniss PJ, Mann CV. Classification of internal haemorrhoids: A discussion paper. Colorectal Dis 2004;6:226-32.
10.	Elbetti C, Giani I, Novelli E, Fucini C, Martellucci J. The single pile classification: A new tool for the classification of haemorrhoidal disease and the comparison of treatment results. Updates Surg 2015;67:421-6.
11.	Gaj F, Trecca A. PATE 2000 Sorrento: A modern, effective instrument for defining haemorrhoids. A multicentre observational study conducted in 930 symptomatic patients. Chir Ital 2004;56:509-15.
12.	Gaj F, Trecca A. New “PATE 2006” system for classifying hemorrhoidal disease: Advantages resulting fromrevision of “PATE 2000 Sorrento”. Chir Ital 2007;59:521-6.
13.	Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum 2018;61:284-92.
14.	Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clinical guideline: Management of benign anorectal disorders. Am J Gastroenterol 2014;109:1141-57.
15.	Clinical Practice Committee, American Gastroenterological Association. American gastroenterological association medical position statement: Diagnosis and treatment of hemorrhoids. Gastroenterology 2004;126:1461-2.
16.	Yamana T. Japanese practice guidelines for anal disorders I. hemorrhoids. J Anus Rectum Colon 2017;1:89-99.
17.	Altomare DF, Roveran A, Pecorella G, Gaj F, Stortini E. The treatment of hemorrhoids: Guidelines of the Italian Society of Colorectal Surgery. Tech Coloproctol 2006;10:181-6.
18.	Higuero T, Abramowitz L, Castinel A, Fathallah N, Hemery P, Laclotte Duhoux C, et al. Guidelines for the treatment of hemorrhoids (short report). J Visc Surg 2016;153:213-8.
19.	Rubbini M, Ascanelli S. Classification and guidelines of hemorrhoidal disease: Present and future. World J Gastrointest Surg 2019;11:117-21.
20.	Khan MA, Chowdri NA, Parray FQ, Wani RA, Mehraj A, Baba A. et al. “PNR-Bleed” classification and Hemorrhoid Severity Score—a novel attempt at classifying the hemorrhoids. J Coloproctol (Rio J). 2020;40:398-403. https://doi.org/10.1016/j.jcol.2020.05.012.