title: Anal endosonography in haemorrhoidal disease: do anatomical changes have clinical implications?
abstract: OBJECTIVE
  This study was designed to evaluate anal endosonographic findings in patients with internal haemorrhoids and to test whether endosonographic parameters can serve as prognostic factors for treatment outcome and recurrence.
  
  
  METHODS
  One hundred and twenty-nine patients (72 males, 57 females, mean age 48 years (range 19-82 years)) were treated for grade 1 to grade 3 internal haemorrhoids with either rubber band ligation (n = 62) or infrared photocoagulation (n = 67). Evaluation before and 1 month after the last treatment consisted of a symptom questionnaire, digital examination, proctoscopy and anal endosonography. The thickness of the submucosa (SMT) and internal (IST) and external anal sphincters (EST) was measured in four quadrants and averaged. Comparisons were made with 40 age- and sex-matched healthy controls. Follow up was 19.2 ± 7.8 months (mean ± s.d.). Multivariate analysis was performed to identify endosonographic factors for treatment outcome and recurrence.
  
  
  RESULTS
  Eighty-six patients had grade 1, 34 grade 2 and nine grade 3 haemorrhoids. At endosonography, most but not all haemorrhoids were recognized as anterior thickening of the submucosal layer with a partial hypoechoic appearance. Compared with healthy controls SMT (2.6 ± 0.8 mm vs 2.3 ± 0.5 mm, P < 0.03), IST (1.7 ± 0.5 mm vs 1.5 ± 0.5 mm, P < 0.03) and EST (8.7 ± 1.6 mm vs 7.7 ± 1.4 mm, P < 0.001) were increased. Submucosal thickness correlated with the degree of haemorrhoids (r = 0.19, P = 0.04). No difference in endosonographic appearance of anal morphology was found after treatment. With multivariate analysis no endosonographic factors could be identified which could predict treatment outcome or symptom recurrence.
  
  
  CONCLUSIONS
  Haemorrhoids are associated with endosono- graphic thickening of submucosal tissue, internal and external anal sphincter. Therefore, both sphincters as well as changes in the submucosa might be of pathophysiological importance. Endosonographic changes cannot predict treatment outcome or symptom recurrence.
authors.affiliation: Department of Surgery, University Hospital `Vrije Universiteit', Amsterdam, The Netherlands, Department of Gastroenterology, University Hospital `Vrije Universiteit', Amsterdam, The Netherlands.
authors.lastname: Poen
authors.lastname: Felt-Bersma
authors.lastname: Cuesta
authors.lastname: Meuwissen