Children who require enteral nutrition often report gastrointestinal symptoms. There is a growing interest in nutrition formulas that meet nutritional requirements and also maintain gut ecology and function. Fiber-containing enteral formulas can improve bowel function, promote the growth of healthy gut microbiota, and improve immune homeostasis. Nonetheless, guidance in clinical practice is lacking.

This expert opinion article summarizes the available literature and collects the opinion of eight experts on the importance and use of fiber-containing enteral formulas in pediatrics. The present review was supported by a bibliographical literature search on Medline via PubMed to collect the most relevant articles.

The current evidence supports using fibers in enteral formulas as first-line nutrition therapy. Dietary fibers should be considered for all patients receiving enteral nutrition and can be slowly introduced from six months of age. Fiber properties that define the functional/physiological properties of the fiber must be considered. Clinicians should balance the dose of fiber with tolerability and feasibility. Introducing fiber-containing enteral formulas should be considered when initiating tube feeding. Dietary fiber should be introduced gradually, especially in fiber-naïve children, with an individualized symptom-based approach. Patients should continue with the fiber-containing enteral formulas they tolerate best.

Bread presents one of the easiest opportunities as a food vehicle for delivery of nutritional and health-promoting benefits to large segments of the world population. However, its low nutritional status due to lack of balance of essential amino acids and inadequate macro- and micronutrients has necessitated recent interest in the development of high-protein hybrid breads (HPHB). Sorrel seed, an underutilized, neglected protein-rich seed holds promising nutritional and antioxidant potentials as source of good quality protein, dietary fibre and bioactive compounds. Furthermore, germination of plant seeds increases the bioavailability of these nutritional and bioactive compounds. Hence, this study has investigated the influence of germination time on nutritional, and functional properties of sorrel seed flour. Further, the amino acid profile, dietary fibre and rheological functionality of wheat-germinated defatted sorrel seed bread were assessed. The sorrel seed was germinated for 24-48 h and defatted. Thereafter, the germinated defatted sorrel seed flours were used to partially replace wheat flour using a linear replacement (w/w) of 95-80% wheat (W) and 5-20% germinated defatted sorrel seed (GS) flours to obtain W95:GS5; W90:GS10, W85:GS15 and W80:GS20. These composite flours and 100% wheat flour (control) were used to produce breads using standard recipe and methods. Results showed significant increase (P < 0.05) in crude protein, dietary fibre and mineral contents after 24 and 48 h germination of sorrel seed. While 24 h germination significantly (P < 0.05) increased WAC from 93.75% to 103.13%, further germination (48 h) caused a reduction of 26.67% (from 93.75 to 68.75%). In vitro protein digestibility of wheat flour decreased significantly (P < 0.05) as supplementation of germinated defatted sorrel seed flour increased. Supplementation of wheat flour with germinated defatted sorrel seed flour in bread production resulted in 51.84-121.42% significant (p < 0.05) increase in the protein content of wheat bread. Similarly, total essential amino acids, dietary fibre, mineral, and ash contents followed the same increasing trend. The in-vivo biological value which ranged from 82.10 to 89.40% was significantly higher (p < 0.05) than 58.30% obtained for the control (100% wheat bread) Thus, inclusion of germinated defatted sorrel seed flour in bread production may serve as a low-cost nutritional supplement for enhancing the nutritional profile and functional benefits of wheat bread.

Hemorrhoidal disease (HD) is common in adults. Treatment is largely conservative, although more invasive procedures may be required. Venoactive drugs such as micronized purified flavonoid fraction (MPFF) are widely used, but a recent and comprehensive review of supporting evidence is lacking. In acute HD, MPFF can reduce HD symptoms such as bleeding, pain, anal discomfort, anal discharge and pruritus. In patients undergoing surgery, postoperative adjunct MPFF consistently reduces pain, bleeding duration and use of analgesia. MPFF treatment is appropriate and effective both as a first-line conservative treatment and as a postoperative adjunct treatment. MPFF reduces the duration of hospital stay following surgery, facilitating a return to normal activity and improving quality of life. MPFF may also prevent HD recurrence.

The consumption of whole grain products is often related to beneficial effects on consumer health. Dietary fibre is an important component present in whole grains and is believed to be (at least partially) responsible for these health benefits. The dietary fibre composition of whole grains is very distinct over different grains. Whole grains of cereals and pseudo-cereals are rich in both soluble and insoluble functional dietary fibre that can be largely classified as e.g., cellulose, arabinoxylan, β-glucan, xyloglucan and fructan. However, even though the health benefits associated with the consumption of dietary fibre are well known to scientists, producers and consumers, the consumption of dietary fibre and whole grains around the world is substantially lower than the recommended levels. This review will discuss the types of dietary fibre commonly found in cereals and pseudo-cereals, their nutritional significance and health benefits observed in animal and human studies.

We evaluated the efficacy of new flavonoids mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) to reduce bleeding from I-III degrees hemorrhoidal disease in the short and medium time.

One hundred fifty-four consecutive patients with hemorrhoidal disease recruited in four colorectal units were enrolled to the study. Exclusion criteria were allergy to the flavonoids, inflammatory bowel disease, obstructed defecation syndrome, pregnancy and puerperium, associated anal disease or hemorrhoidal thrombosis, proctologic surgical procedures within 1 year before recruitment, contemporary cancer or HIV, previous pelvic radiotherapy, patients receiving oral anticoagulant therapy, or contemporary administration of other therapy for hemorrhoids. Patients with inability to understand the study or mental disorders were also excluded.

Seventy-eight were randomized to receive the mixture of diosmin, troxerutin, rutin, hesperidin, and quercetin (study group, SG), and 76 a mixture of diosmin in combination with hesperidin, diosmetin, isoroifolin, and linarin in purified micronized fraction (control group, CG). Bleeding, number of pathological piles, and Golligher's grade were assessed at each scheduled visit and compared using the Chi-square test. During the study period, bleeding improved after 1 and 6 months both in the SG (79.5 and 70.5%) and in the CG (80.2 and 75%) without significant differences between two groups. Satisfaction degree after 6 months was greater in the patients of the SG (4.05) towards the CG (3.25): this result was statistical significant (p 0.003).

Use of flavonoids mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) is a safe and effective mean of managing bleeding from hemorrhoidal disease and minimal adverse events are reported.

This study was conducted to determine the frequency of complaints in a cohort of patients with symptomatic hemorrhoidal disease (HD) treated with micronized purified flavonoid fraction (MPFF, Detralex). MPFF was selected for conservative treatment in this population owing to its proven effects on hemorrhoidal symptoms in a large number of patients.

This multicenter, non-interventional study was part of the international CHORUS survey (Chronic venous and HemORrhoidal diseases evalUation for improvement of Scientific knowledge), conducted in nine centers in different regions of Russia with the participation of 80 coloproctologists. The study enrolled consecutive patients with complaints of hemorrhoids. All were prescribed MPFF-based conservative treatment. The effect of treatment on HD clinical signs and symptoms was assessed at two follow-up visits performed 5-7 days and 25-30 days after enrollment. Surgical and minimally invasive treatment could be performed from day 7 onwards if required.

A total of 1952 patients were enrolled. Over the entire period of observation, MPFF-based conservative treatment was effective in 1489 (76.3%) patients in eliminating the main clinical manifestations of disease, i.e., bleeding and prolapse of internal nodes. Invasive treatment was performed in 68 (3.5%) patients with grade IV hemorrhoids and was combined with MPFF conservative treatment in 395 (20.2%) patients with grades I-III hemorrhoids.

Conservative therapy with MPFF was beneficial for relieving hemorrhoidal symptoms in the majority of patients. MPFF-based treatment was most effective in patients with grade I and II hemorrhoids before irreversible degenerative changes in ligaments of the hemorrhoidal plexuses have occurred. It was also beneficial in preventing disease relapse in patients with more advanced HD and for promoting optimal conditions in the postoperative period.

Servier.

To present a systematic review of randomised controlled trials (RCTs) examining the effects of MPFF in the management of haemorrhoid symptoms.

Electronic databases including CENTRAL, CINAHL, EMBASE, MEDLINE were searched up to April 2018 for relevant RCTs. Journal and conference proceedings were also searched. Two review authors independently selected trials, extracted data, assessed the risks of bias in included trials and graded the quality of evidence. Meta-analyses were conducted for studies presenting similar outcomes.

Ten RCTs involving 1164 participants were included. These RCTs varied in terms of patients' grade of haemorrhoids, length of trials, and outcome assessed. Most of the studies did not describe adequately the process of randomisation and allocation concealment. The pooled analysis of data from three studies indicated that there was significant difference between groups for the bleeding outcome, favoring the MPFF group (RR 1.46; 95% CI 1.10-1.93; p = 0.008). Except for bleeding, the current evidence did not show MPFF has significant effects on all the other outcomes examined when compared with placebo. Even then, the quality of evidence for bleeding was judged as low due to the small number and inconsistent results among the included studies.

This review highlights the need for further rigorous research if MPFF was to be routinely used for the treatment of haemorrhoid symptoms.

Optimal surgical intervention for low-grade haemorrhoids is unknown. Rubber band ligation (RBL) is probably the most common intervention. Haemorrhoidal artery ligation (HAL) is a novel alternative that may be more efficacious.

The comparison of HAL with RBL for the treatment of grade II/III haemorrhoids.

A multicentre, parallel-group randomised controlled trial.

UK NHS and Personal Social Services.

17 NHS Trusts.

Patients aged ≥ 18 years presenting with grade II/III (second- and third-degree) haemorrhoids, including those who have undergone previous RBL.

HAL with Doppler probe compared with RBL.

Primary outcome - recurrence at 1 year post procedure; secondary outcomes - recurrence at 6 weeks; haemorrhoid severity score; European Quality of Life-5 Dimensions, 5-level version (EQ-5D-5L); Vaizey incontinence score; pain assessment; complications; and cost-effectiveness.

A total of 370 participants entered the trial. At 1 year post procedure, 30% of the HAL group had evidence of recurrence compared with 49% after RBL [adjusted odds ratio (OR) = 2.23, 95% confidence interval (CI) 1.42 to 3.51; p = 0.0005]. The main reason for the difference was the number of extra procedures required to achieve improvement/cure. If a single HAL is compared with multiple RBLs then only 37.5% recurred in the RBL arm (adjusted OR 1.35, 95% CI 0.85 to 2.15; p = 0.20). Persistence of significant symptoms at 6 weeks was lower in both arms than at 1 year (9% HAL and 29% RBL), suggesting significant deterioration in both groups over the year. Symptom score, EQ-5D-5L and Vaizey score improved in both groups compared with baseline, but there was no difference between interventions. Pain was less severe and of shorter duration in the RBL group; most of the HAL group who had pain had mild to moderate pain, resolving by 3 weeks. Complications were low frequency and not significantly different between groups. It appeared that HAL was not cost-effective compared with RBL. In the base-case analysis, the difference in mean total costs was £1027 higher for HAL. Quality-adjusted life-years (QALYs) were higher for HAL; however, the difference was very small (0.01) resulting in an incremental cost-effectiveness ratio of £104,427 per additional QALY.

At 1 year, although HAL resulted in fewer recurrences, recurrence was similar to repeat RBL. Symptom scores, complications, EQ-5D-5L and continence score were no different, and patients had more pain in the early postoperative period after HAL. HAL is more expensive and unlikely to be cost-effective in terms of incremental cost per QALY.

Blinding of participants and site staff was not possible.

The incidence of recurrence may continue to increase with time. Further follow-up would add to the evidence regarding long-term clinical effectiveness and cost-effectiveness. The polysymptomatic nature of haemorrhoidal disease requires a validated scoring system, and the data from this trial will allow further assessment of validity of such a system. These data add to the literature regarding treatment of grade II/III haemorrhoids. The results dovetail with results from the eTHoS study [Watson AJM, Hudson J, Wood J, Kilonzo M, Brown SR, McDonald A, et al. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial. Lancet 2016, in press.] comparing stapled haemorrhoidectomy with excisional haemorrhoidectomy. Combined results will allow expansion of analysis, allowing surgeons to tailor their treatment options to individual patients.

Current Controlled Trials ISRCTN41394716.

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 88. See the NIHR Journals Library website for further project information.

The role of a mixture of phlebotonics in the treatment of acute hemorrhoid crisis is investigated to test their efficacy.

One hundred and thirty-four consecutive patients with an acute hemorrhoidal crisis recruited in five colorectal units entered the study. Sixty-six of them were randomized to receive a mixture of diosmin, troxerutin and hesperidin (group A), and 68 a placebo (group B). The main symptoms, the use of oral painkillers and the Bristol scale score were recorded at each scheduled visit and compared using both Student's t test for independent samples and the ANOVA models for repeated measures. The presence of edema, prolapse and thrombosis were also recorded and compared using the Chi-square test. Furthermore, the trend of proportions during the time of the evaluations was assessed by the Chi-square test for linear trend.

Pain, bleeding and the proportion of patients who reported persistence of edema and thrombosis decreased significantly after 12 days of treatment in group A. After 6 days, the number of paracetamol tablets taken by patients in group A was significantly lower than the amount of flavonoid mixture.

The use of a mixture of diosmin, troxerutin and hesperidin is a safe and effective mean of managing symptoms of acute hemorrhoidal disease. Furthermore, in patients receiving treatment, there was faster control and lower persistence of edema and thrombosis.

While debate continues as to which is the best surgical method for the treatment of hemorrhoids, none of the currently available surgical methods approach the ideal surgical option, which is one that is effective while being safe and painless. In reality, the less painful the procedure, the more likely it is to be associated with recurrence post-op. Where hemorrhoids surgery is concerned, there isn't a "one size fits all" option. Most of the randomized controlled trials performed to date include hemorrhoids of various grades and with a focus on only comparing surgical methods while failing to stratify the outcomes according to the grade of hemorrhoid. We believe that surgery needs to be tailored not only to the grade of the hemorrhoids, but also to the size, circumferential nature of the disease, and prevailing symptomatology.

Haemorrhoids are variceal dilatations of the anal and perianal venous plexus and often develop secondary to the persistently elevated venous pressure within the haemorrhoidal plexus (Kumar 2005). Phlebotonics are a heterogenous class of drugs consisting of plant extracts (i.e. flavonoids) and synthetic compounds (i.e. calcium dobesilate). Although their precise mechanism of action has not been fully established, they are known to improve venous tone, stabilize capillary permeability and increase lymphatic drainage. They have been used to treat a variety of conditions including chronic venous insufficiency, lymphoedema and haemorrhoids.Numerous trials assessing the effect of phlebotonics in treating the symptoms and signs of haemorrhoidal disease suggest that there is a potential benefit.

The aim of this review was to investigate the efficacy of phlebotonics in alleviating the signs, symptoms and severity of haemorrhoidal disease and verify their effect post-haemorrhoidectomy.

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library 2011 issue 9 , MEDLINE (1950 to September 2011) and EMBASE (1974 to September 2011).

Only randomised controlled trials evaluating the use of phlebotonics in treating haemorrhoidal disease were used. No cross-over or cluster-randomized trials were included for analysis and any trial which had a quasi-random method of allocation was excluded.

Two authors independently extracted the data and analysed the eligibility of the data for inclusion. Disagreements were resolved by meaningful discussion.

We considered twenty-four studies for inclusion in the final analysis. Twenty of these studies (enrolling a total of 2344 participants) evaluated the use of phlebotonics versus a control intervention. One of these twenty studies evaluated the use of phlebotonics with a medical intervention and another study with rubber band ligation.The remaining four studies included two which compared different forms of phlebotonics with each other, one study which evaluated phlebotonics with a medical intervention and one study which compared the use of phlebotonics with infrared photocoagulation. Eight studies were excluded for various reasons including poor methodological quality.Phlebotonics demonstrated a statistically significant beneficial effect for the outcomes of  pruritus (OR 0.23; 95% CI 0.07 to 0.79) (P=0.02), bleeding (OR 0.12; 95% CI 0.04 to 0.37) (P=0.0002), bleeding post-haemorrhoidectomy (OR 0.18; 95% 0.06 to 0.58)(P=0.004), discharge and leakage (OR 0.12; 95% CI 0.04 to 0.42) (P=0.0008) and overall symptom improvement (OR 15.99 95% CI 5.97 to 42.84) (P< 0.00001), in comparison with a control intervention. Although beneficial they did not show a statistically significant effect compared with a control intervention for pain (OR 0.11; 95% CI 0.01 to 1.11) (P=0.06), pain scores post-haemorrhoidectomy (SMD -1.04; 95% CI -3.21 to 1.12 ) (P= 0.35) or post-operative analgesic consumption (OR 0.54; 95% CI 0.30 to 0.99)(P=0.05).

The evidence suggests that there is a potential benefit in using phlebotonics in treating haemorrhoidal disease as well as a benefit in alleviating post-haemorrhoidectomy symptoms. Outcomes such as bleeding and overall symptom improvement show a statistically significant beneficial effect and there were few concerns regarding their overall safety from the evidence presented in the clinical trials.However methodological limitations were encountered. In order to enhance our conclusion further, more robust clinical trials which take into account these limitations will need to be performed in the future.

Haemorrhoidal disease belongs to the most common benign disorders in the lower gastrointestinal tract. Treatment options comprise conservative as well as surgical therapy still being applied arbitrarily in accordance with the surgeon's expertise. The aim of this consensus statement was therefore to assess a stage-dependent approach for treatment of haemorrhoidal disease to derive evidence-based recommendations for clinical routine. The most common methods are discussed with respect of haemorrhoidal disease in extraordinary conditions like pregnancy or inflammatory bowel disease and recurrent haemorrhoids. Tailored haemorrhoidectomy is preferable for individualized treatment with regard to the shortcomings of the traditional Goligher classification in solitary or circular haemorrhoidal prolapses.

Only three non-surgical treatments of haemorrhoids are clearly validated: infrared coagulation, injection sclerotherapy and rubber band ligation. Those procedures are only indicated for painless symptoms related to internal haemorrhoids, i.e. bleeding at defecation or spontaneously reducible prolapse. Their main interest is to be possible on the outpatient clinic, with a simple anuscope, without enema or anaesthesia, since they are applied to non-sensitive area on the top of internal haemorrhoids. The aim of all these treatments is to create local fibrosis, which reduces vascular tissue and hold rectal mucosa to underlying muscle. Short-dated efficiency of all techniques is similar on bleeding. After one and three years, rubber band ligation is clearly more efficient than other techniques, especially on prolapse. Secondary effects are non-constant and usually minor, as transient pain or tenesmus, and mild bleeding for few days. Infrequent complications may occur, only after haemorrhoidal banding and sclerotherapy, as thrombosis, massive delayed bleeding or local abscess. Exceptional life-threatening pelvic cellulitis cases have been reported.

Dietary fiber intake provides many health benefits. However, average fiber intakes for US children and adults are less than half of the recommended levels. Individuals with high intakes of dietary fiber appear to be at significantly lower risk for developing coronary heart disease, stroke, hypertension, diabetes, obesity, and certain gastrointestinal diseases. Increasing fiber intake lowers blood pressure and serum cholesterol levels. Increased intake of soluble fiber improves glycemia and insulin sensitivity in non-diabetic and diabetic individuals. Fiber supplementation in obese individuals significantly enhances weight loss. Increased fiber intake benefits a number of gastrointestinal disorders including the following: gastroesophageal reflux disease, duodenal ulcer, diverticulitis, constipation, and hemorrhoids. Prebiotic fibers appear to enhance immune function. Dietary fiber intake provides similar benefits for children as for adults. The recommended dietary fiber intakes for children and adults are 14 g/1000 kcal. More effective communication and consumer education is required to enhance fiber consumption from foods or supplements.

We present a new technique for the surgical treatment of haemorrhoids, consisting of the repositioning of haemorrhoid cluster, using a rotating Proctoscope called Hemor Pex System((R)) (HPS). This procedure is performed as an outpatient procedure, with minimal postoperative pain and rapid integration into working life.

To present the experience with this technique during 3 years of follow up in two institutions in Genoa, Italy.

from January 2003 to June 2006, 1112 patients with grade II, III and IV haemorrhoids were operated on using the HPS technique, in two different hospitals. Prospectively analyzed the following parameters: postoperative pain, incidence of complications and recurrence of symptoms.

A total of 1112 patients were operated, of whom 719 have completed the follow-up. The mean age was 47 years. In 92% of cases the intervention was performed under local anaesthesia. The average time of surgery time was 20+/-5min. A total of 97% of patients were discharged at 6h after surgery. The immediate postoperative pain, according to the Visual Analogue Scale (VAS): absent (0) in 38 cases, slight (1-3) in 431 cases, 218 medium and intense in 32 cases.

We believe HPS is a safe procedure, with a short learning curve for surgeons, and in particular leads to a great reduction in post-operative pain for the patient.

The frequency of haemorrhoid disease and the deterioration in the quality of life in the immediate post-operative period has led to the appearance of new techniques in an attempt to obtain improve patient satisfaction.

A prospective study was carried out in which 50 consecutive patients with a diagnosis of Goligher grade III haemorrhoids were intervened. To perform the haemorrhoid dearterialisation, a device called THD R was used (designed by TKC SRL and distributed by Palex Medical). The technique consisted of, a reduction in arterial flow using ligation of the terminal branches above the anorectal ring, starting in the anterior position, it was carried out in a clockwise direction: 1, 3, 5, 7, 9, 11. Follow up was carried out at one week, 1 month, 3 months, 6 months and 1 year.

We intervened 50 consecutive patients with a diagnosis of grade III haemorrhoids. The mean age was 45 years (range, 25-78). The surgical indication was, pain-discomfort, 40 (80%); bleeding, 35 (70%), prolapse 6 (12%). The procedure was always performed under local/regional anaesthesia. The mean duration of the procedure was 25 minutes (range, 20-35). Analgesia was required by 90% of the patients during the first 24 hours, decreasing to 15% for those who continued to require it until the third day and only 2 (4%) patients continued for one week. Pain was resolved 48 hours after surgery, in all patients who consulted for this reason, except for one patient (2.5%) who had a recurrence in the pain as well as in his prolapse. This meant that patients could re-start their daily living within 48-72 hours.

Pending for randomised studies, we can say that in our experience, Doppler guided transanal haemorrhoidal dearterialisation is a technique that should be offered to the patient with haemor-rhoidal disease.

Some haemorrhoids are associated with high resting anal canal pressures. The aim of this study was to assess if Rectogesic, a topical glyceryl trinitrate 0.2% ointment was effective in relieving symptoms of early grade haemorrhoids associated with high resting anal canal pressures.

This was a prospective, two-centre, open label study of 58 patients with persistent haemorrhoidal symptoms. Patients with first or second degree haemorrhoids and a maximum resting anal canal pressure > 70 mmHg were included. Rectogesic was applied three times a day for 14 days. Anorectal manometry was performed 30 min after the first application of Rectogesic. A 28-day diary was completed during 14 days of therapy and for 14 days after cessation of treatment. This recorded the incidence of rectal bleeding, and visual analogue scales for anal pain, throbbing, pruritus, irritation and difficulty in bowel movement.

Maximum resting anal canal pressures were reduced after application of Rectogesic (115.0 +/- 40.4 mmHg vs 94.7 +/- 34.1 mmHg, P < 0.001). In the study period and at 14 days after cessation of Rectogesic, there was significant reduction in rectal bleeding (P = 0.0002), and significant improvement of anal pain (P = 0.0024), throbbing (P = 0.0355), pruritus (P = 0.0043), irritation (P = 0.0000) and difficulty in bowel movement (P = 0.001). The main adverse event was headache in 43.1% of patients.

Rectogesic is a safe and feasible treatment for patients with early grade haemorrhoids associated with high resting anal canal pressures.

Drug treatment for various anorectal conditions has been known since ancient times. Today, modern as well as traditional drugs are being increasingly used in all grades of symptomatic haemorrhoids. These drugs (oral and local) are used as a part of conservative management or as an adjuvant to invasive outpatient procedures. Flavonoids, in the new formulation of micronised purified flavonoid fraction (MPFF) or as part of the ancient traditional medicine derivative of the Ginkgo tree, are used for relief of acute symptoms (for control of bleeding and re-bleeding in all grades of haemorrhoids). MPFF has been recommended for control of acute bleeding in patients waiting for a definitive outpatient treatment. Similarly, better known drugs such as calcium dobisilate (used in diabetic retinopathy and chronic venous insufficiency), nitrates and nifedipine have also been effective and well tolerated in the medical treatment of haemorrhoids. However, drug treatment is not aimed at curing haemorrhoids. The prime objective of drug therapy is to control the acute phase (bleeding) so that definitive therapy (banding, injection sclerotherapy, infrared photocoagulation, cryotherapy or surgery) can be scheduled at a convenient time.

The aim of this study is to describe a role of diosmine in the management of bleeding nonprolapsed hemorrhoids. From November 2003 to January 2004, 60 patients were treated with Phlebodia (diosmine). Total colonoscopy was performed at the discretion of the authors according to the age, symptoms and genetic factors of the patient. Patients were treated with Phlebodia (diosmine, 3x1, 5 days) and in addition a bulk agent (3,26 g plantago ovata sachet, twice daily, for the period of next three months). Hemorrhoidal bleeding stopped after 3,2 days. Diosmine, used with fiber supplements, rapidly and safely stops bleeding from nonprolapsed hemorrhoids.

Herbal weight-loss supplements are marketed with claims of effectiveness. Our earlier systematic review identified data from double-blind, randomized controlled trials for a number of herbal supplements. The aim of this systematic review was to assess all clinical evidence of adverse events of herbal food supplements for body weight reduction for which effectiveness data from rigorous clinical trials exist. We assessed Ephedra sinica, Garcinia cambogia, Paullinia cupana, guar gum, Plantago psyllium, Ilex paraguariensis and Pausinystalia yohimbe. Literature searches were conducted on Medline, Embase, Amed and The Cochrane Library. Data were also requested from the spontaneous reporting scheme of the World Health Organization. We hand-searched relevant medical journals and our own files. There were no restrictions regarding the language of publication. The results show that adverse events including hepatic injury and death have been reported with the use of some herbal food supplements. For herbal ephedra and ephedrine-containing food supplements an increased risk of psychiatric, autonomic or gastrointestinal adverse events and heart palpitations has been reported. In conclusion, adverse events are reported for a number of herbal food supplements, which are used for reducing body weight. Although the quality of the data does not justify definitive attribution of causality in most cases, the reported risks are sufficient to shift the risk-benefit balance against the use of most of the reviewed herbal weight-loss supplements. Exceptions are Garcinia cambogia and yerba mate, which merit further investigation.

Micronised purified flavonoid fraction (MPFF) [Daflon 500 mg], an oral phlebotropic drug consisting of 90% micronised diosmin and 10% flavonoids expressed as hesperidin, improves venous tone and lymphatic drainage, and reduces capillary hyperpermeability by protecting the microcirculation from inflammatory processes. The absorption of diosmin is improved by its micronisation to particles with a diameter <2 microm. Compared with placebo, MPFF 500 mg twice daily significantly decreased ankle or calf circumference, and improved many symptoms of chronic venous insufficiency (CVI) and plethysmographic parameters in two randomised, double-blind, 2-month studies. Improvement in symptoms was parallelled by an improvement in health-related quality of life in a nonblind, 6-month trial. Significantly more venous leg ulcers </=10 cm in diameter completely healed with MPFF 500 mg twice daily plus standard management (compression and local treatment) for 2-6 months than with standard management alone or with placebo in a nonblind and a double-blind trial. The addition of MPFF to standard management was cost effective in a retrospective pharmacoeconomic analysis of the 6-month trial. Compared with placebo, the duration and/or intensity of individual symptoms of grade 1 or 2 acute internal haemorrhoids improved significantly with 3 tablets of MPFF 500 mg twice daily for 4 days then 2 tablets of MPFF 500 mg twice daily for 3 days. Two tablets of MPFF 500 mg daily for 60 or 83 days reduced the frequency, duration and/or severity of acute haemorrhoidal symptoms and improved the overall signs and symptoms of chronic (recurrent) haemorrhoids compared with placebo. Compared with a control group, MPFF significantly reduced the risk of secondary bleeding after elective haemorrhoidectomy. In clinical trials, MPFF had a tolerability profile similar to that of placebo; the most frequently reported adverse events were gastrointestinal and autonomic in nature. In conclusion, MPFF is a well established and well tolerated treatment option in patients with CVI, venous ulcers, or acute or chronic internal haemorrhoids. MPFF is indicated as a first-line treatment of oedema and the symptoms of CVI in patients in any stage of the disease. In more advanced disease stages, MPFF may be used in conjunction with sclerotherapy, surgery and/or compression therapy, or as an alternative treatment when surgery is not indicated or is unfeasible. The healing of venous ulcers </=10 cm in diameter is accelerated by the addition of MPFF to standard venous ulcer management. MPFF may reduce the frequency, duration and/or intensity of symptoms of grade 1 or 2 acute internal haemorrhoids, and also the severity of the signs and symptoms of chronic haemorrhoids.