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Haemorrhoids-Postulated Pathogenesis and Proposed Prevention D Postgrad Med J: first published as 10.1136/pgmj.51.599.631 on 1 September 1975. Downloaded from Postgraduate Medical Journal (September 1975) 51, 631-636. Haemorrhoids-postulated pathogenesis and proposed prevention D. P. BURKITT C. W. GRAHAM-STEWART C.M.G., M.D., F.R.C.S., F.R.S. M.S., F.R.C.S. Medical Research Council, Harrogate General Hospital Summary occur in animals. Morgagni attributed their develop- The very high prevalence of haemorrhoids in the most ment in man to his upright posture but others had economically developed countries is contrasted with insight (Graham-Stewart, 1962) to suggest that the their low prevalence in rural communities in developing absence of haemorrhoids in animals was because countries. Traditional concepts of causation are shown 'they seldom attempt to defaecate until they have a to be no longer tenable. It is argued from epidemio- strong desire to go to stool', thus obviating excessive logical, clinical and experimental evidence that the straining. Nevertheless, being unaware of the fact, fundamental cause of piles is straining at viscid stools no attention was drawn to the rarity ofhaemorrhoids which are the result of fibre-depleted diets. in people living traditionally. The size of the problem Geographical distribution Haemorrhoids have been referred to in literature One of us (D.B.) during 20 years' surgical practiceProtected by copyright. dating back to the pre-Christian era, but the term in Africa, was frequently confronted with haemor- seems often to have included other peri-anal con- rhoids in the relatively small expatriate community ditions. Not a few great men in previous centuries but seldom in a much larger African practice. were allegedly afflicted, but there is no information Cleave, Campbell and Painter (1969) and Dodd as to whether the poorer people suffered from the (1964) have drawn attention to the relative rarity of disease, nor about its overall prevalence. Haemor- haemorrhoids in developing countries and Trowell rhoids have for centuries been treated by ligature and (1960) recounted that in nearly 30 years' practice in cautery, but their cause has remained obscure. Africa one of the only two African patients he had Today, haemorrhoids are considered to be one of seen with severe anaemia due to bleeding piles was the most common ills of man, a judgment made by a prince taking a semi-European diet. those with vision limited to the western world. The An attempt has been made to substantiate exten- prevalence of haemorrhoids is still unknown and sive anecdotal evidence of the relative rarity of the lack of clear definition makes an assessment haemorrhoids in rural communities in developing impossible. It has been suggested that at least one countries by a prospective study in which eighty-five person in two in the western world over the age of rural hospitals in Africa and India have been report- 50 years has some degree of haemorrhoid formation ing on a monthly questionnaire form the number of http://pmj.bmj.com/ (Goligher, 1967). Hyams and Philpot (1970) speci- patients seen with bleeding or prolapsed piles. In fically questioned 1584 adults and concluded that rural Africa less than one case is seen, whether ad- about one in four of those over 30 years had some mitted or not, per 1500 hospital admissions, which degree of haemorrhoids. represents approximately 15,000 outpatients. Hae- The cost to the community, both financial and in morrhoids appear to be commoner in Nigeria and lost working days, is great and by any standards Ghana, both longer exposed to western influences, this condition must be considered a major health than in East Africa. They seem to be about three on October 1, 2021 by guest. hazard. times more common in rural Indians than in Africans. In this communication only so-called idiopathic Even accounting for gross under-recording there haemorrhoids will be considered. can be little doubt that haemorrhoids are much less common in developing countries than they are in Epidemiological evidence North America and western Europe. Almost all those who have sought to account for the occurrence of haemorrhoids have incorrectly Changing patterns assumed western experience to be representative of The biggest demonstration of the influence of a all mankind, but this is far from the truth. Morgagni changed environment on the prevalence of haemor- in the 18th century, and, more recently, other rhoids is the current comparable prevalence of the observers recognized that haemorrhoids did not condition in black and white Americans in contrast 632 D. P. Burkitt and C. W. Graham-Stewart Postgrad Med J: first published as 10.1136/pgmj.51.599.631 on 1 September 1975. Downloaded from to its relative rarity in Africa, including the areas not be considered to be idiopathic. More bizarre from which American slaves had originally been explanations have been attempted, varying from taken. sitting on hot radiators to riding horses. Many of There is considerable evidence that haemorrhoids these postulated aetiological factors can be elimin- become commoner with progressive adoption of a ated as primary causes by measuring them against more western way of life. Osman (1973) has drawn the yardstick of epidemiological evidence. This does attention to their increasing prevalence in Khartoum, not exclude their playing a contributory role. and Bremner (1971) to the increasing number of Africans requiring treatment in Johannesburg. 1. Heredity The similar situation in black and white Americans Relationship to varicose veins in contrast to that in Africa and the evidence of Not only haemorrhoids but also varicose veins increasing prevalence following a change in life have their highest prevalence in more economically patterns, indicate that heredity is not a primary developed western communities and their lowest in causative factor. communities least influenced by western culture. In almost every situation investigated, the prevalence of 2. Anatomical features haemorrhoids appears to have risen before that of The absence of valves in the portal venous system varicose veins. There are many instances where both and the anatomical arrangement of haemorrhoidal conditions are common or both rare, and several veins and their surrounding structures have fre- where haemorrhoids are not uncommon but varicose quently been incriminated as being responsible for veins are still rare. the occurrence ofhaemorrhoids. The similar anatomy in communities with a high or low prevalence Relationship to stool characteristics invalidates such suggestions. Protected by copyright. Communities in which intestinal transit times are short and stools normally large and soft, have a low 3. Nutrition prevalence of haemorrhoids and varicose veins, and There is no evidence to suggest a relationship also of certain other characteristically western between haemorrhoid prevalence and nutritional diseases, for instance appendicitis, diverticular status. disease of the colon, large bowel cancer and hiatus hernia. In contrast, these diseases have their highest 4. Occupation prevalence in communities who pass small firm stools This could be a contributory but not a primary and have prolonged transit times (Burkitt, Walker factor, since haemorrhoids are not common amongst and Painter, 1972; Burkitt, 1973). those in developing countries following occupations There are, however, apparent exceptions to this which are said in the west to be responsible for this rule. In certain parts of India, haemorrhoids appear condition. to be not uncommon where stools are customarily large. Bowel infections in these areas and their 5. Climate possible relationship to haemorrhoids will be dis- Extremes of climate are experienced in East Africa cussed below. but this does not appear to affect in any way the http://pmj.bmj.com/ prevalence of haemorrhoids. Postulated causes examined in the light of epidemiological evidence 6. Psychic factors Numerous explanations have been offered to Evidence seems lacking. account for the occurrence of haemorrhoids. Bacon's (1949) list of postulated aetiological factors, given 7. Senility below, embodies most of the suggestions of those Although the prevalence of haemorrhoids, vari- on October 1, 2021 by guest. who have considered this problem: (1) heredity; cose veins, diverticular disease and hiatus hernia (2) anatomical features; (3) nutrition; (4) occupation; increases with age in western countries, none of (5) climate; (6) psychic factors; (7) senility; (8) endo- these diseases is common amongst the elderly in crine changes; (9) irritation from drugs or food; developing countries. (10) infection; (11) pregnancy; (12) increased intra- abdominal pressure from: (a) violent exercise, 8. Endocrine changes (b) constrictive clothing, (c) straining when coughing, These seem unrelated to the geographical and sneezing or vomiting; (13) constipation. socio-economical distribution. He included in addition tumours, engorgement of the portal circulation and uterine procidentia, but 9. Irritation from drugs or food haemorrhoids resulting from such conditions would Evidence seems lacking. Haemorrhoids 633 Postgrad Med J: first published as 10.1136/pgmj.51.599.631 on 1 September 1975. Downloaded from 10. Infection The following conclusions, which were reached in Evidence seems lacking. this work on the cause of piles, were drawn from deductions based on observation and reasoning, and 11. Pregnancy on experimental work. To consider this a primary factor would imply Firstly internal haemorrhoids, which are to a that mankind
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