Review: laxatives in the form of fibre reduce symptoms in patients with symptomatic haemorrhoids
Q Do laxatives in the form of fibre induce symptom resolution in patients with symptomatic haemorrhoids?
Cochrane Central Register of Controlled Trials (Cochrane Library, Issue 2, 2005), Medline (1966 to April 2005), EMBASE/Excerpta Medica (1980–2005), CINAHL (1982–2005), BIOSIS, AMED, bibliographies of relevant articles, pharmaceutical companies, content experts, and registries of ongoing trials (eg, Meta Register of Controlled Trials and US National Institute of Health register).
Study selection and assessment:
randomised controlled trials (RCTs), crossover trials, and quasi-randomised trials that compared any type of laxative with placebo or no therapy in patients with symptomatic haemorrhoids. Study quality was assessed using criteria that included existence and method of randomisation, blinding of caregivers and outcome assessors, accounting for losses to follow up, and use of validated outcome measures. 7 RCTs (n = 378) that compared fibre with placebo met the selection criteria. Types of fibre studied included Ispaghula hust (3 trials), plantago ovata (1 trial), psyllium seed (1 trial), sterculia (1 trial), and unprocessed bran (1 trial).
individual or global symptom improvement, number of recurrences in a time period, change in degree of prolapse, need for surgical treatment, and adverse effects.
Meta-analyses were done using a random effects model. A pooled analysis for overall improvement showed that risk of not improving was lower in the fibre group than the placebo group (table). Among individual symptoms, risk of bleeding was lower in the fibre group than in the placebo group (table). Also, 1 RCT showed that the rate of recurrence was lower in the fibre group than the placebo group (relative risk reduction 66%, 95% CI 23 to 85). The groups did not differ for any other individual symptoms or adverse effects.
Fibre induces symptom resolution in patients with symptomatic haemorrhoids.
- Carolyn Auerhahn, EdD, APRN, BC, NP-C
Haemorrhoids are a common problem affecting both men and women. Although haemorrhoids are not usually dangerous and symptoms generally resolve in a few days, recurrences are common and symptoms can cause substantial discomfort. Treatment is initially focused on symptom relief and includes warm baths and topical creams or suppositories. Recommendations for prevention of recurrence include increased fluid and fibre intake.1
The review by Alonso-Coello et al provides evidence to support one of the most common recommendations for preventing recurrence of hemorrhoids—increased fibre intake. It also provides evidence for its usefulness in terms of overall improvement, symptom relief, and risk of bleeding. Despite the minor author-acknowledged limitations of this review, the benefits of increasing fibre intake clearly outweigh any possible harms. Increasing fibre intake has already been found to be associated with substantial reductions in the risk of many chronic diseases, including certain types of cancer.2 The only possible harms are those related to side effects such as gas and abdominal bloating.
The clinical implications of this review may extend beyond the treatment of haemorrhoids. Despite the known benefits of increased fibre intake, average daily consumption of fibre is still well below recommended levels.2 Given the high prevalence of haemorrhoids, providing an evidence base for a recommendation already in common practice may lead to greater uptake of this recommendation.
For correspondence: Dr P Alonso-Coello, Iberoamerican Cochrane Centre, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
Sources of funding: Instituto de Salud Carlos III, Subdirección General de Investigación Sanitaria; Spanish Society of Family Practice (semFYC); and Red Temática de Medicina Basada en la Evidencia.