Diverticulosis and Hemorrhoids: Fact or Artefact?

We read with great interest the article by Sninsky et al1Sninsky J.A. et al.Clin Gastroenterol Hepatol. 2023; 21: 1097-1099Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar in Clinical Gastroenterology and Hepatology. This case-control study suggests that internal hemorrhoids are associated with colonic diverticulosis. Sninsky et al1Sninsky J.A. et al.Clin Gastroenterol Hepatol. 2023; 21: 1097-1099Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar also suggested that it might be explained by neuromuscular or connective tissue dysfunction. Such a supposition is of interest because the pathophysiology of hemorrhoidal pathology still is unknown,2Margetis N. Ann Gastroenterol. 2019; 32: 264-272PubMed Google Scholar and, therefore, any contribution is important. However, we believe that the results of this study should be interpreted with caution. First, Sninsky et al1Sninsky J.A. et al.Clin Gastroenterol Hepatol. 2023; 21: 1097-1099Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar speak of hemorrhoids being "present" or "not present," but hemorrhoids are always "present." Indeed, these anal fibrovascular cushions are normal structures of the human body and an integral component of the mechanism for anal sensation and the preservation of continence.3Wald A. et al.Am J Gastroenterol. 2021; 116: 1987-2008Crossref PubMed Scopus (32) Google Scholar Second, we believe that endoscopic retroflexion is not the best way to visualize and assess internal hemorrhoids. Visual inspection of the anal margin and the anal canal over its entire length using an anoscope is recommended and probably more efficient.4Davis B.R. et al.Dis Colon Rectum. 2018; 61: 284-292Crossref PubMed Scopus (138) Google Scholar Third, Sninsky et al1Sninsky J.A. et al.Clin Gastroenterol Hepatol. 2023; 21: 1097-1099Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar graded the hemorrhoids as "small, medium, or large." However, apart from the very subjective nature of such an assessment, this vascular tissue may vary in size over time. The size depends on the degree of distention of the hemorrhoidal arteriovenous anastomoses, blood stagnation, and inflammation, among other factors.5De Marco S. et al.Front Surg. 2021; 8729166Crossref PubMed Scopus (4) Google Scholar In this instance, the diarrhea induced by the preparation for colonoscopy may have induced local inflammation and had an impact on the size of the internal hemorrhoids. The indication for colonoscopy also can be a confounding factor because hemorrhoids can appear different depending on whether the examination was performed because of bleeding, often resulting from hemorrhoidal disease4Davis B.R. et al.Dis Colon Rectum. 2018; 61: 284-292Crossref PubMed Scopus (138) Google Scholar; constipation, associated with an increased risk of hemorrhoidal disease6Kalkdijk J. et al.Eur J Gastroenterol Hepatol. 2022; 34: 813-822Crossref PubMed Scopus (2) Google Scholar; or another reason. Moreover, daily practice has shown us that there is not necessarily a correlation between the size of hemorrhoids and possible hemorrhoidal disease. Fourth, we believe it would have been preferable to try to correlate hemorrhoidal symptoms (using a score that includes bleeding, prolapse, and pain)7Jin J. et al.Colorectal Dis. 2020; 22: 1518-1527Crossref PubMed Scopus (6) Google Scholar and patient-reported outcome measures8Kuiper S.Z. et al.Front Surg. 2021; 8728532Crossref PubMed Scopus (1) Google Scholar with the presence or absence of diverticulosis. Finally, it would have been informative to know the age of the patients because it is known that the prevalence of diverticulosis increases with age, whereas this is probably not true for hemorrhoidal disease. In conclusion, we applaud Sninsky et al1Sninsky J.A. et al.Clin Gastroenterol Hepatol. 2023; 21: 1097-1099Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar for conducting this study. However, we believe that it is not possible to establish a formal association between internal hemorrhoids and diverticulosis based on the results of this study.