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World J Gastroenterol. Oct 21, 2026; 32(39): 121904
Published online Oct 21, 2026. doi: 10.3748/wjg.121904
Endoscopic score predicting recurrence after foam sclerotherapy in grade I internal hemorrhoids: Development and external validation
Fei-Yu Zhang, Lei-Ming Xu, Feng-Yu Gao, Wen Wang, Wu-Lian Lin, Hao Zhang, Ke-Zhou Wang, Qing-Jing Wang, Ao-Jia Jin, Ru-Ping Yang, Chun-Ying Qu, Yi Zhang, Zheng-Hong Li, Dou Wang, Cui-Cui Shi, Tian-Ben Shen, Fei Shen, Ye Hu, Feng Shen
Fei-Yu Zhang, Lei-Ming Xu, Qing-Jing Wang, Ao-Jia Jin, Ru-Ping Yang, Chun-Ying Qu, Yi Zhang, Zheng-Hong Li, Cui-Cui Shi, Tian-Ben Shen, Fei Shen, Ye Hu, Feng Shen, Department of Gastroenterology and Endoscopy, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
Feng-Yu Gao, Department of Endoscopy, Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan 250014, Shandong Province, China
Wen Wang, Wu-Lian Lin, Department of Gastroenterology, The 900th Hospital of the People’s Liberation Army Joint Service Support Force, Fuzhou 350025, Fujian Province, China
Hao Zhang, Department of Endoscopy, Baoshan People’s Hospital of Yunnan Province, Baoshan 678000, Yunnan Province, China
Ke-Zhou Wang, Department of Pathology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
Qing-Jing Wang, Department of Gastroenterology, Jinshan Hospital of Fudan University, Shanghai 201508, China
Dou Wang, Department of Gastroenterology, Shigatse People’s Hospital, Shigatse 857000, Tibet Autonomous Region, China
Co-first authors: Fei-Yu Zhang and Lei-Ming Xu.
Co-corresponding authors: Ye Hu and Feng Shen.
Author contributions: Zhang FY and Xu LM share first authorship and contributed equally to this work; Zhang FY, Xu LM, Hu Y and Shen F conceived and designed the study; Gao FY, Wang W, Lin WL, Zhang H, Wang QJ, Jin AJ, Yang RP, Qu CY, Zhang Y, Li ZH, Wang D, Shi CC, Shen TB and Shen F collected clinical, endoscopic and follow-up data; Wang KZ performed the pathological assessment; Zhang FY and Xu LM analyzed the data and drafted the manuscript; Hu Y and Shen F share corresponding authorship and jointly supervised the study, critically revised the manuscript; all authors interpreted the data, approved the final manuscript, and agree to be accountable for all aspects of the work.
AI contribution statement: ChatGPT (OpenAI; accessed June 2026) was used solely for linguistic refinement and formatting assistance. No artificial intelligence tool was used to generate research data, perform statistical analyses, interpret results, or formulate conclusions. All AI-assisted text was critically reviewed and revised by the authors.
Supported by the Discipline Peak-Climbing Plan of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. XKPF2024B400; the Shanghai Science and Technology Commission Innovation Ecosystem Construction Plan ‘Domestic Science and Technology Cooperation’ Project, No. 25010702300; and the National Natural Science Foundation of China, No. 82472899.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (approval No. XHEC-C-2020-003-1) and by the ethics committees of the participating centers.
Informed consent statement: All study participants or their legal guardians provided informed written consent prior to study enrollment. Due to the large sample size, only a representative de-identified informed consent form is provided. All original signed informed consent forms are securely archived at our institution and are available upon request.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
STROBE statement: The authors have read the STROBE Statement—a checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-a checklist of items.
Data sharing statement: The deidentified data that support the findings of this study are available from the corresponding authors upon reasonable request, subject to institutional and ethical approval.
Corresponding author: Feng Shen, MD, Chief Physician, Department of Gastroenterology and Endoscopy, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665 Kongjiang Road, Shanghai 200092, China.
shenfeng01@xinhuamed.com.cn
Received: April 7, 2026
Revised: June 29, 2026
Accepted: July 20, 2026
Published online: October 21, 2026
Processing time: 155 Days and 15.3 Hours
BACKGROUND
Foam sclerotherapy is an effective minimally invasive treatment for grade I internal hemorrhoids, but recurrence limits long-term benefit and no validated endoscopic tool is available for individualized risk prediction.
AIM
To develop and validate an endoscopy-based score for predicting recurrence after foam sclerotherapy in patients with grade I internal hemorrhoids.
METHODS
In this prospective, multicenter observational cohort, consecutive adults with grade I internal hemorrhoids treated with 1% polidocanol foam were enrolled. A Cox model was developed from clinical and standardized endoscopic predictors. Discrimination, calibration, bootstrap internal validation, and 36-month decision curve analysis were assessed. The unchanged model was evaluated in an independent external cohort, and a separate cohort provided exploratory endoscopic and histopathological biological verification.
RESULTS
A total of 483 patients were included in model development; 115 developed recurrences during follow-up, with cumulative recurrence rates of 10.1% at 24 months and 20.0% at 36 months. The weighted continuous Endoscopic Hemorrhoid Recurrence Score (Endo-HRS) was: Endo-HRS = 1 × male sex + 4 × number of hemorrhoids + 11 × maximum hemorrhoid diameter (cm) + 2 × red color sign grade (0-3). A nomogram estimated individual 36-month recurrence probability. Discrimination was good in development (C-index = 0.82; continuous-model 36-month area under the curve = 0.88) and external validation (n = 279; bootstrap-corrected C-index = 0.90, 95% confidence interval: 0.862-0.933). Exploratory endoscopic and histopathological findings were directionally consistent with higher-risk groups.
CONCLUSION
Endo-HRS is a weighted endoscopy-based recurrence score with encouraging internal and external performance. It may support risk stratification and inform future evaluation of risk-adapted follow-up, but its clinical impact requires prospective assessment.
Core Tip: In this prospective multicenter study, we developed and externally evaluated Endoscopic Hemorrhoid Recurrence Score (Endo-HRS), a weighted continuous score based on sex, number of hemorrhoids, maximum hemorrhoid diameter, and red color sign grade. The model showed good discrimination in the development and external cohorts, and a nomogram estimates individual 36-month recurrence probability. Exploratory endoscopic and histopathological findings supported biological plausibility. Endo-HRS may aid risk stratification, although prospective impact studies are required before it is used to direct surveillance or retreatment.
