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I. ДИАГНОСТИКА И ЛЕЧЕНИЕ
EPIDEMIOLOGY OF HEMORRHOIDS IN KAZAKHSTAN
МРНТИ 79.29.29
Medeubekov U.Sh., Tyan L.V., Sagatov I.Y., Zholdangarova D.A., Bekbolatkyzy N.
JSC «National Scientific Center of Surgery named after A.N. Syzganov», Almaty, Kazakhstan
Abstract
Introduction: Hemorrhoids is the most common disease among diseases of the anorectal zone. This disease can be attributed to diseases of civilization and its lifestyle. Objective: review the most important studies of the incidence of hemorrhoids in foreign literature, determine the apparent prevalence of hemorrhoids in Kazakhstan based on an analysis of the available statistical data. Materials and methods. We conducted an analysis of official statistics on the activities of medical organizations of the Republic of Kazakhstan for2014-2019. The analysis does not include information about patients who received medical care in private medical organizationsbecause they did not record patients with hemorrhoids in official and accessible information resources during the indicated period of our research. Results. North-Kazakhstan region, East-Kazakhstan region, Nur-Sultan city - are the leaders in terms of the proportion of OD treatment for hemorrhoids. This trend is observed from year to year without significant changes in indicators (based on the results of 2015, 2016, 2017) and reaches 16.2% in the South-Kazakhstan region, 11.1% in the East-Kazakhstan region and 10.4% in the Nur-Sultan city respectively according to the results of 2017. At the same time, it should be noted that in such a large metropolis of the country as Almaty, the number of patients referred to polyclinics for hemorrhoids takes only 2.3% in 2017, which does not fit into the overall picture explaining the higher proportionof appeals with the number of people living in the area. Conclusion. In the Republic of Kazakhstan, a large-scale epidemiological study is necessary to determine the true incidence of Hemorrhoids. In the OD: to develop methods of prevention, to increase detection in the early stages of hemorrhoids, to introduce the position of coloproctologist (general surgeons who have specialized in coloproctology) at the level of urban clinics.
ABOUT THEАUTHORS
Medeubekov U.Sh. - Vice Chairman of the Board on scientific clinical activities at JSC "NSCS named after A.N. Syzganov", dr. med., professor. E-mail: medeubek@mail.ru
Tyan L.V. - Head of ambulance coloproctology department of #1 Multidisciplinary city Hospital of NurSultan city, PhD
Sagatov I.Y. - Head of the managment department of SR, JSC "NSCS n. a. A.N. Syzganov"
Zholdangarova D.A. - Master's degree student of Kazakhstan's medical university«KSPH»
Bekbolatkyzy N. - employee of the org.-methodical department, JSC "NSCS n. a. A.N. Syzganov"
Keywords
epidemiology, hemorrhoids
Казакстандагы геморройдьщ эпидемиологиясы
Медеубеков ¥.Ш., Тян Л.В., Саратов I.E., Жолдангарова Д.Э., Бекболаткызы Н.
«А.Н. Сыз?анов атында?ы Улттык, ?ылыми хирургия орталь™» АК,, Алматы, Казахстан
Андатпа
Юрюпе. Геморрой - бул ен квп таралтан аноректалды ауру. Бул ауруды вркениет жэне вм'р салты ауруларына жаткызуга болады. Мацсаты: шетелдк эдебиеттерге сэйкес геморрой ауруынын манызды зерттеулерне шолужасау, колда бар статистикалыкдеректердi талдау непзще Казакстанда геморройдьщ таралуын аныктау. Материалдар мен эдстер. Бз Казахстан Республикасыныц медициналык уйымдарыныц 2014-2019 жылдардалы кызмет туралы ресми статистикага талдау жYрriздiк. Талдау жеке медициналык уйымдарда медициналык квмек алган пациенттер туралы акпаратты камтымайды, вйткеш олар бiздiц зергтеуiмiздiц кврсетлген кезещнде ресми жэне кол жетiмдi акпараттык ресурстарда геморрой-мен ауыратын наукастарды лркемеген. Нэтижелер. Солтуст'ш Казакстан облысы, Шылыс Казакстан облы-сы, Нур-Султан каласы - геморройдан OD емдеуде квшбасшылар. Бул тенденцияжылданжылга байкалады (2015, 2016, 2017 жылдыц нэтижелерi бойынша) жэне Оцтустк Казакстан облысында 16,2%, Шылыс Казакстан облысында - 11,1%жэне 10,4% - Нур-Султан каласында сэйкеснше, 2017жылдыц корытындысы бойынша. Сонымен б'рге, елiмiздiц Алматы сиякты улкен мегаполиснде 2017 жылы геморройга арналган емханапарла баратын пациенттердщ саны бар-жолы 2,3% -ды кураланын атап вту керек, бул келушлердщ квп болуын ту^н^рет жалпы кврЫске сэйкес келмейдi. ауданда туратын адамдардыц саны. Цорытынды. Казакстан Республикасында геморройдыц накты ауруын аныктау ушт кец квлемд эпидемиологиялык зерттеулер кажет. НК-да: алдын-алу эдстерн жасау, геморройдыц алташку сатысында аныктау децгешн жоларылату, калалык клиникалар децгейнде колопроктолопыц (колопроктологияла мамандандырылган жалпы хирургтардын) жалдайын енпзу.
АВТОРЛАР ТУРАЛЫ
МедеубековY.Ш. — А.Н. Сызранов атындары Улттык шлыми хирургия орталыгынын, баскарма Терагасынын, гылыми-клиникалык кызметтер жвнiндeп орынбасары, мяд., профессор. medeubek@mail.ru
ТянЛ.В. - Нур-Султан к., №1 Кепсалалы клиникалык ауруханасынын, амбулаторлы колопроктологиясынын, xeTernid,
M.F.K.
Сагатов I.E. - А.Н. СызFанов атындагы YFXO-н, F3X менеджментi бвлiмiнiц басшысыб м^.д.
Жолдангарова Д.Э. -«ВШОЗ» Казакстанды; медицина унивeрситeтiнiн, магистранты
Бекболаткызы Н. - уйымдастыру-нускаулык белiмнiц кызметкерi
Туйш сездер
эпидемиология, геморрой
Эпидемиология геморроя в Казахстане
ОБ АВТОРАХ
Медеубеков У.Ш. - заместитель Председателя правления по научно-клинической деятельности АО ННЦХим. А.Н. Сызганова, д.м.н., профессор, e-mail: medeubek@mail.ru
Тян Л.В. - Руководитель амбулаторной колопроктологии №1 Многопрофильной городской больницы г. Нур-Султан, к.м.н.
Сагатов И.Е. - руководитель отдела менеджмента НИР ННЦХ им. А.Н. Сызганова, д.м.н.
Жолдангарова Д.А. — магистрант Казахстанского медицинского университета«ВШОЗ»
Бекболаткызы Н. - сотрудник орг. -методического отдела ННЦХ им. А.Н. Сызганова
Ключевые слова
эпидемиология, геморрой
Медеубеков У.Ш., Тян Л.В., Сагатов И.Е., Жолдангарова Д.А., Бекболаткызы Н.
АО «Национальный научный центр хирургии им. А.Н. Сызганова», Алматы, Казахстан
Аннотация
Введение. Геморрой является наиболее распространенным заболеванием аноректальной зоны. Это заболевание можно отнести к болезням цивилизации и образа жизни. Цель: сделать обзор наиболее важных исследований заболеваемости геморроем по данным зарубежной литературы, определение распространенности геморроя в Казахстане на основании анализа имеющихся статистических данных. Материалы и методы. Мы провели анализ официальной статистики о деятельности медицинских организаций Республики Казахстан за 2014-2019 годы. Анализ не включает информацию о пациентах, которые получали медицинскую помощь в частных медицинских организациях, потому что они не регистрировали пациентов с геморроем на официальных и доступных информационных ресурсах в течение указанного периода нашего исследования. Результаты. Северо-Казахстанская область, Восточно-Казахстанская область, город Нур-Султан - лидеры по доле лечения ОД от геморроя. Эта тенденция наблюдается из года в год без существенных изменений показателей (по итогам 2015, 2016, 2017 гг.) и достигает 16,2% в Южно-Казахстанской области, 11,1% в Восточно-Казахстанской области и 10,4% в г. Нур -Султан соответственно по итогам 2017 года. В то же время следует отметить, что в таком крупном мегаполисе страны, как Алматы, количество пациентов, обращающихся в поликлиники по поводу геморроя, в 2017 году составляет всего 2,3%, что не вписывается в общую картину, объясняющую более высокую пропорцию обращений с количеством людей, проживающих в этом районе. Вывод. В Республике Казахстан необходимы широкомасштабные эпидемиологические исследования для определения истинной заболеваемости геморроем. В ОД: разработать методы профилактики, повысить уровень выявления на ранних стадиях геморроя, ввести позицию колопроктолога (общих хирургов, специализирующихся в колопроктологии) на уровне городских поликлиник.
Introduction
Hemorrhoids is the most common disease among diseases of the anorectal zone. This disease can be attributed to diseases of civilization and its lifestyle [1, 2, 3].
Currently the world recognizes two main theories of the development of hemorrhoids - vascular and mechanical. According to the first of them, the cause is the occurrence and disclosure of arterio-venous shunts and reflux of arterial blood into the venous system with an increase in intra-abdominal pressure [4, 5, 6]. According to the mechanical theory, hemorrhoids are the result of degenerative changes in the connective tissue and micro-tears of the connective tissue supporting structures [7, 8, 9].
Clinically Hemorrhoids occur when the nodes increase, become inflamed, thrombose and fall out of the anal canal. ^mmon manifestation of this processis painless rectal bleeding. Hemorrhoids can be one of the causes of severe acute rectal bleeding.
According to the anatomical principle hemorrhoids are classified into internal and external. The main manifestations of external hemorrhoids include irritation of the perianal zone, painful swelling
in the anal area. The main manifestation of internal hemorrhoids is bleeding, prolapse of nodes and their strangulation [10,11].
Despite the ongoing urbanization of society over the past few decades and the associated changes in lifestyle, modern literature does not have enough information about the epidemiology of hemorrhoids in which reports prevalence of this disease.
Objective: review the most important studies of the incidence of hemorrhoids in foreign literature, determine the apparent prevalence of hemorrhoids in Kazakhstan based on an analysis of the available statistical data.
A review of foreign literature on the frequency and prevalence of the disease. After many years of heated discussion and debates, publication of various articles and put forward pathogenic theories, we do not know the true prevalence of hemorrhoids in the world, because most people have no symptoms and often hide this disease due to the intimate nature of this pathology. Nevertheless, according to most estimates of foreign authors, the total prevalence of hemorrhoids is 4-5% of the total population, but many authors believe these figures greatly underestimate its prevalence [12, 13].
Several foreign epidemiological studies have demonstrated the influence of environmental factors on the development of hemorrhoids.
Hyams and Philpot et al. (1970) were among the first in the modern era to study the prevalence of hemorrhoids, several years before the Burkitt theory. They classified patients by age, gender, socioeconomic background, race, religion, habitsand in case of women - pregnancy. But the most important result of their study was that one in four people over 30 years had a certain extent of hemorrhoids.
According to the theory proposed by Burkitt in the early 1970s (Burkitt, 1972, 1975; Burkitt and Graham, 1975), hemorrhoids were causally associated with chronic constipation.
The relationship between chronic constipation or portal hypertension as an etiological factor in the development of hemorrhoids was also not revealed in studies conducted by Jacobs D.M. et al. [14].
Haas et al. (1983) studied the records of 835 patients who visited their clinic. They performed rectal examinations consisting of examination of the anal area, anoscopy, and sigmoidoscopy. Examinations were conducted by five surgeons who were not informed of the purpose of the study in order to maintain the purity of the research. Hemorrhoids were diagnosticated in 720 (86%) patients: in 198 (82%) of 241 patients who did not make any complaints and in 522 (88%) among 594 patients with symptoms of hemorrhoids. However, they did not reveal any significant differences between men and women in terms of prevalence and socio-economic factors did not influence on the incidence of hemorrhoids.
Further Haas studies in 1984 showed that the process of hemorrhoids development is directly related to the destruction of the structure of the connective tissue of the periproctousarea [15].
According to other authors hemorrhoids is the most common proctologic disease and it is about 50% of colorectal study finds. According to estimates of Indian scientists, 75% of the population of India has experienced this disease [16].
Later Johanson J.F. and Sonnenberg A. (1990) conducted an epidemiological study comparing the epidemiology of hemorrhoids with the epidemiology of chronic constipation and were unable to identify any connection between them. The results of their study, which were the same regardless of gender, showed the prevalence of hemorrhoids in the United States in 4.4% of the population with a peak between the ages of 45 and 65 and a decline after 65 years. The authors found that constipation in contrast to hemorrhoids was more likely to occur with increasing age, among representatives of the Afro-Americans and among people with a low socio-economic status and a lower level of educa-
tion. At the same time, hemorrhoids were rare in patients under the age of 20 years.
Conversely, representatives of the Caucasian race suffered hemorrhoids 1.5 times more often than African Americans.In England and Wales, the increase in the prevalence of hemorrhoids was directly related to belonging to the higher social status (1.8 times more often). At the same time, the authors note that only a small number of patients seek medical help, about 500.000 people undergo treatment for hemorrhoidal bleeding annually in the USA alone, and from 10 to 20% of patients require surgical treatment [13].
Johanson and Sonnenberg (1991) argued in their study that outpatient physician visits and surgical treatment for hemorrhoids in US hospitals have declined significantly over the past 25-30 years. The authors used only statistics based on the International Classification System of Diseases (ICD). The reasons for the decline may bethe widespread use of conservative treatment, self-medication with over-the-counter drugs, and the wider use of stool and fiber softeners.
Haas in 1992 did not agree with the definition of hemorrhoids that Johanson and Sonnenberg proposed: "the expansion of the hemorrhoid plexus that protrudes into the lumen of the anal canal." He considered incorrect the criteria for determining the frequency and prevalence of hemorrhoids that were used by these authors. According to Haas hemor-rhoid are "a normal component of human anatomy" and its prevalence should be 100% without any conditions and causes. Therefore, Johanson and Sonnenberg (1992) believed that the epidemiology of hemorrhoid cannot be established without correct definition. So far, as a result, the term "hemorrhoids" continues to be used to describe a pathological rather than a normal anatomical object.
According to Russian scientists, the incidence of hemorrhoids is 118-120 cases per 1000 population and is historically due to the upright posture of a human. The authors predict that in the future there is no reason to expect a decrease in the incidence rate [17, 18].
According to the report of the Ministry of Health of England for 2002-2003, 75252 (0.59%) inpatient consultations were reported for anorectal disorders and 92% of these consultations in the hospital required hospitalization for treatment. The average length of stay of these patients was 5.4 days [19].
According to a report from the Center for Disease Control and Prevention, together with the UK National Statistics Center in 2010, 20 deaths due to hemorrhoids were recorded in the United Kingdom [20]. It has also been stated that 50% of the population will experience hemorrhoid symptomsin some rate throughout their lives. [21].
In a review published by Everhart and Ruhl (2009) hemorrhoid was named the fourth most common outpatient diagnosis for digestive system diseases in the United States after GERD, chronic constipation, and hernias of the anterior abdominal wall.
Approximately 2 million outpatient visits per year were associated with hemorrhoids as the primary diagnosis. The total number of visits to clinics with a diagnosis of hemorrhoids is 3.3 million. The frequency of visits was highest among the Caucasian race and among patients over 65 years of age. Differences between the sexes were not revealed.
In Europe researchers are also deal with the question of true incidence of hemorrhoids.
In 2008-2009 Stefan Risset al. conducted an epidemiological cross-sectional study in adults to determine the prevalence and associated risk factors for hemorrhoid. They conducted a prospective study of those who attended a nationwide colorec-tal cancer screening program at four Austrian medical facilities. The authors determined hemorrhoids in accordance with a standardized grading system using flexible colonoscopy and detailed examina-tionwhich were performed in all patients. Out of 976 participants, 380 patients (38.93%) suffered from hemorrhoids. In 277 patients (72.89%) hemorrhoids were classified as stage I, in 70 (18.42%) as stage II, in 31 patients (8.16%) as stage III, and in 2 patients (0.53 %) as stage IV. 170 patients (44.74%) complained of symptoms characteristic of hemorrhoids, while 210 patients (55.26%) did not have symptoms. In a one-dimensional and multidimensional analysis, the body mass index (BMI) had a significant effect on the occurrence of hemorrhoids with p = 0.0391 and p = 0.0282 respectively. It turned out that even with correction for other potential risk factors, an increase in BMI per unit increases the risk of hemorrhoids by 3.5%. In addition, the authors report that there is very little data on the relationship between the incidence of hemorrhoids and the racial affiliation of patients, although some sources report that the likelihood of seeking treatment for residents of the Caucasian region is higher than representatives of other races. Moreover, the causes of this phenomenon have not been investigated [22].
Some epidemiological studies have been devoted to the effect of pregnancy and childbirth on the development of hemorrhoids. It is interesting that the theory about the role of childbirth in the etiopathogenesis of hemorrhoids in women was developed by Prasad et al. back in 1976. They also noted that most of their hemorrhoid patients (66%) had occupations associated with prolonged sitting.
Laurent Abramowitz (2002) identified constipation and late birth (39.7 weeks of pregnancy) as independent from each other risk factors for hemor-
rhoids in the third trimester of pregnancy and in the postpartum period with a frequency of thrombosed hemorrhoids of 7.9% in the last 3 months of pregnancy.
According to Gojnic et al. (2005) hemorrhoids are present in 85% of women in the second and third trimesters of pregnancy.
According to Altomare and Giannini (2013) studies, the prevalence of hemorrhoids during pregnancy is completely changing. Pregnant women are at high risk category for the development of hemorrhoids.
Poskus et al. (2014), in a prospective observational cohort study,attempted to determine the incidence of hemorrhoids, fissures, and other perianal diseases during pregnancy and the postpartum period by a physical examination of 280 pregnant women and anoscopy 1 month after parturition. As a result, perianal symptoms were revealed in 123 (43.9%), of which 114 (92.7%) were diagnosed with hemorrhoids and in 7 (5.7%) hemorrhoids were accompanied by the presence of an anal fissure. In addition, thrombosed hemorrhoids were diagnosed in 64 women (52.9%).
In examination of factors leading to the development of hemorrhoids in adults in South Korea, as part of the National Health and Nutrition Program, hemorrhoids prevalence was found to be 14.4%, among 17,228 participants in the program. Hemorrhoids occurred among women in 15.7%, among men in 13.0%. According to the authors, the presence of obesity, depression, lack of exercise, pregnancy, a low level of quality of life are associated with a high risk of developing the disease.
The level of education, alcohol consumption, diabetes mellitus, arterial hypertension, and dietary disorders, according to the results of this study, did not significantly affect the risk of hemorrhoids [23].
In a prospective observational study conducted in France, Tournus et al. (2017) examined patients for symptoms of hemorrhoids at an appointment with 57 general practitioners. Among 1061 patientssymptoms of hemorrhoids were identified in 166 (25.8%) cases.
In order to study the relationship between the use of a bidet and the incidence of hemorrhoids or urogenital infections, Kiuchi et al. (2017) a prospective one-dimensional 1-year study was conducted. The authors did not find potential risk factors, with the exception of an increase in body mass index which showed a significant correlation with the risk of hemorrhoids (p = 0.0391).
Robertson S. (2019), referring to statistics of the Hemorrhoids Treatment Center (North Carolina, USA), reports about half of Americans get hemorrhoids by the age of 50 and only a small part of these people go to a doctor. The number of people
in the United States suffering from hemorrhoids is estimated at approximately 10.4 million and 1 million new cases occur each year. Between 10% and 20% of these new cases require surgical intervention [12].
This short review of international literature shows that in the modern world, scientists have a common opinion thatbeing one of the most common diseases in the worldthe true epidemiology of hemorrhoids is still unknown. The reason is associated with the intimate nature of the disease, which leads to self-diagnosis and self-medication.
People with hemorrhoids and those who mistakenly thought that they had hemorrhoids tended to self-medicate without seeking medical help [24]. According to Google's 2012 annual survey (Google Zeitgeist), hemorrhoids were the most common health problem in the United States, ahead of GERD and sexually transmitted diseases. The quality of information on the Internet for the treatment of hemorrhoids was different and 50% of websites, according to the analysis, were of poor quality [26].
Foreign authors have no doubt that hemorrhoids are more common in industrialized countries. At the same time, scientists come to the paradoxical conclusions that changes and improvements in hygiene and nutritionwhich led to a decrease in mortality from infectious diseases and at the same time caused an increase in diseases such as hemorrhoids, cholelithiasis, coronary heart disease (Barker 1989).
Thus, given the absence in Kazakhstan of authoritative scientific work on the epidemiology of hemorrhoids, the relevance of the chosen topic is very high.
Materials and methods
We conducted an analysis of official statistics on the activities of medical organizations of the Republic of Kazakhstan for 2014-2019. The analysis does not include information about patients who received medical care in private medical organizationsbe-cause they did not record patients with hemorrhoids in official and accessible information resources during the indicated period of our research.
Results
According to official statistics, the average annual population in the Republic of Kazakhstan in 2015 amounted to 17 544 thousand (0.2%), in 2016 - 17 794 thousand (0.3%), in 2017 - 18 037 thousand (0.3%) people.
The number of officially registered patients' complaints about hemorrhoids (ICD code - I84) to medical organizations of Kazakhstan at outpatient-polyclinic level (hereinafter - OD) in 2015-2017 presented in the diagram (Fig. 1).
The presented diagram demonstrates an increase in the number of registered cases of patients with hemorrhoids in medical organizations at the level of OD. The total incidence of hemorrhoids in the country per 100 000 of population was respectively: in 2015 - 198.7; in 2016 - 266.2; in 2017 - 270.4. At the same time, the primary incidence per 100,000 of population in the same period was: in 2015 - 123.1; in 2016 - 139.2; in 2017 - 128.6.
Even though the primary incidence in 2017 has a slight tendency to decrease, the number of patients registered in the dispensary has growth indicators. Given the growth of demographic indicators in the country, in our opinion, the situation does not fully reflect the true numbers of the first-time sick (or first-contacting to the physician) patients in clinics in 2017.
The share of patients' negotiability to medical organizations at the level of OD in the context of regions and cities of republican significance for the same period is presented in the following diagram (Fig. 2).
According to the diagram in Figure 2, North-Kazakhstan region, East-Kazakhstan region, Nur-Sul-tan city - are the leaders in terms of the proportion of OD treatment for hemorrhoids. This trend is observed from year to year without significant changes in indicators (based on the results of 2015, 2016, 2017) and reaches 16.2% in the South-Kazakhstan region, 11.1% in the East-Kazakhstan region and 10.4% in the Nur-Sultan city respectively according to the results of 2017. At the same time, it should be
47380
-48778
34864
21597
24769
.23206
Fig. 1.
The diagram. The number of visits of patients with hemorrhoids (ICD code -I84)to outpatient organizations of Kazakhstan in 2015-2017. (abs. n.)
1519
2546
2741
2015 2016
-Total number of registered patients First registered
2017
Registered on OD
Fig. 2.
The diagram. The share of patients with hemorrhoids (ICD code - I84)in the OD in 2015-2017 (%) by regions of the Republic of Kazakhstan
12015 2016 2017
xO* ** a4o* ^ ,oO ^ ,o<> ^ ** 4
.¿p ^
# # ^
noted that in such a large metropolis of the country as Almaty, the number of patients referred to polyclinics for hemorrhoids takes only 2.3% in 2017, which does not fit into the overall picture explaining the higher proportionof appeals with the number of people living in the area.
Based on the analysis of appeals to the OD, all regions of the Republic of Kazakhstan were divided into 3 groups: with a low (up to 5%), medium (from 5 to 10%) and high (more than 10%) rate of appeal (Fig. 3).
In the presented Fig. 3, the highest appeal rates in OD were noted in the South-Kazakhstan (15.3%), East-Kazakhstan (11.1%), Akmola (14.9%) and Almaty (12.3%) regions.
Data on the incidence of hemorrhoids by gender in the total number of patients who sought medical care in 2015-2017, at the level of OD, are presented in Fig. 4.
It should be noted that the circulation in the OD in the above regions is quite low and at the end of 2017 amounted to 0.3%, 8.2%, 6.8%.
According to the analysis, hemorrhoids were more common in female patients than in men (by
3.6-5%), which is due to the increased risk of developing of this disease in pregnant women. The results are consistent with research data from foreign authors: Hass et al. (1983), Altomare and Giannini (2013).
Dynamics of changes in the number of patients treated in stationary beds of medical organizations of the Republic of Kazakhstan for hemorrhoids (ICD code - I84) in 2014-2019 presented in figure 5.
According to official statistics in the Republic of Kazakhstan, annually about 6000 patients with hemorrhoids receive inpatient medical care, this indicator has a tendency to increase, and in 20182019 exceeded 6 thousand cases of hospitalization.
Each year, about 25 thousand people in Kazakhstan for the first time apply for hemorrhoids in the OD, of which more than 6 thousand patients are hospitalized for surgical beds in medical hospitals.
An analysis of the hospitalization rate of patients with hemorrhoids per 100 thousand people by region (for 2018) showed an ambiguous picture of the consumption of inpatient care. This indicator
Fig. 3.
The share of patients' negotiability (ICD code -I84) in the OD in 20152017 (%) by regions of the Republic of Kazakhstan
I Female I Male
2015 2016 2017
RRQ9 RR31 6113
6695
12014
12015
12016
12017
2018
2019
varies in different regions with a difference of up to 2.5 times (Figure 6).
Fig. 6. shows the difference in the number of hospitalizations per hospital bed, from 14.7 in the Atyrau region to 70.4 in the Karaganda region per 100 thousand of population. On the leading positions are: Karaganda, Aktobe, Mangistau and Pav-lodar regions. The level of appeal and the volume of medical care are higher at the stationary level in relation to the OD (Fig. 7).
It should be noted that the circulation in the OD in the above regions is quite low and at the end of 2017 amounted to 0.3%, 8.2%, 6.8%.
And conversely, the indicator of consumption of inpatient care in regions where the highest number of visits to polyclinics is lower than in the above regions by almost 2 times (South-Kazakhstan region, Almaty and the region).
Thus, presented data lead to the conclusion that in regions with the least provision of medical
X ,«/ ¿f / /
Fig. 4.
The diagram. Hemorrhoids incidence rate (ICD code - I84) at the level of OD 2015-2017 depending on gender
Fig. 5.
Diagram. The number of treated patients with hemorrhoids (ICD code -I84) in an inpatient bed in 2015-2019. (abs. n.)
services at the outpatient department level, they are compensated by an increase in the provision of inpatient medical care.
Comparative indicators of age groups in the total number of patients treated in inpatient beds in 2014-2019 presented in Fig. 8.
An analysis of the proportion of different age groups among treated patients in hospitals of the Republic of Kazakhstan showed that the incidence of hemorrhoids prevails in people in the age group of 40-60 years, which is about 46% of the total incidence, tends to decrease in people over 60 years of age, and much less observed in individuals younger than 20 years old.
Our results confirm the research data of J.F. Jo-hanson and A.Sonnenberg. Data for a decrease or increase in incidence within individual groups have not been analyzed.
For the analyzed period were hospitalized according to the ICD codes:
Fig. 6.
The diagram. Hospitaliza-tion rate for patients with hemorrhoids (ICD code -I84) on an inpatient bed in 2019 in the context of the regions of the Republic of Kazakhstan (per 100 thousand of population)
Fig. 7.
The indicator of hospitalization of patients with hemorrhoids (ICD code - I84) to hospitals in 2018 (per 100 thousand of population) in the context of the regions of the Republic of Kazakhstan
Fig. 8.
The diagram. The dynamics of the proportion of different age groups in the total volume of hemorrhoids treated in hospitals of the Republic of Kazakhstan in 2014-2019. (%)
2015 2016 2017 120-30 y.o. ■ 30-40 y.o.
2018 2019 40-60 y.o. ■ > 60 y.o.
- I84.0 / Internal thrombosed hemorrhoids;
- I84.3 / External thrombosed hemorrhoids;
- I84.7 / Thrombosed hemorrhoids, unspecified
- I84.1 / Internal hemorrhoids with other complications;
- I84.4 / External hemorrhoids with other complications;
- I84.8 / Hemorrhoids with other complications, unspecified.
Comparative analysis of the proportion of hospitalization of patients with uncomplicated and complicated course hemorrhoids in dynamics over the period 2014-2019 in the hospitals of the Republic of Kazakhstan is presented in Fig. 9.
In Fig. 9, the number of patients with complicated hemorrhoids is several times higher than the number of patients with uncomplicated course, which is a consequence of late appeal to medical care. For the analyzed period since 2014 to 2019, the ratio of cases of hemorrhoids with complications to uncomplicated was 6.6:1, with a peak in the total number of patients registered at the hospital level with this pa-
thology in 2019 equal to 6695, of which 6034(90,1%) cases were hemorrhoids with complicated course.
These indicators may be due to several reasons:
- asymptomatic course of the disease;
- untimely appeal to the OD;
- self-diagnosis and self-medication based on information available on the Internet, as well as OTC drugs;
- insufficient work of the network of medical institutions at the PHC level for screening and timely detection of hemorrhoids in the early stages of the disease.
The dynamics of changes in the number of operated patients in hospitals of the Republic of Kazakhstan in 2014-2019.
As can be seen from Fig. 10, annually in hospitals of the Republic of Kazakhstan more than 4 thousand operations are performed for hemorrhoids and its complications. The annual increase in surgical interventions at the hospital level is correlated with previous data on the number of hospitalizations of patients with complicated forms of hemorrhoids.
6034
2014
2015
2016
2017
2018
2019
Uncomplicated hemorrhoids ■ Complicated hemorrhoids
Fig. 9.
Diagram. Dynamics of changes in treated patients with uncomplicated and complicated hemorrhoids (ICD code - I84) in the hospitals of the Republic of Kazakhstan in 2014-2019 (abs. n.)
4356
4415
4821
12014
12015
12016
12017
2018
12019
The dynamics of changes in the indicator of surgical activity in hemorrhoids in hospitals of the Republic of Kazakhstan is shown in Fig. 11.
The indicator of operational activity in the treatment of hemorrhoid patients in the republic is increasing annually and currently amounts are 72.0%. At the same time, an analysis of the dynamics shows that doctors are increasingly choosing active surgical tactics and less conservative.
This is caused not only by an increase in the admission of patients to hospitals with complicated forms of the disease, but also by the active introduction in the regions of new minimally invasive technologies for the surgical treatment of hemorrhoids.
The dynamics of the hospital mortality rate for hemorrhoids is shown in Figure 12.
Hospital mortality is represented by isolated cases, complicated cases of the disease, against the background of many associated pathologies.
Conclusion
In the Republic of Kazakhstan, a large-scale epidemiological study is necessary to determine the true incidence of Hemorrhoids. In the OD: to develop methods of prevention, to increase detection in the early stages of hemorrhoids, to introduce the position of coloproctologist (general surgeons who have specialized in coloproctology) at the level of urban clinics.
The research shows that the statistics on the incidence of hemorrhoids in Kazakhstan is unreliable, since the analysis does not take into account the assistance provided in private medical institutions, the actual incidence of hemorrhoids in the country is higher.
A study of the epidemiology of hemorrhoids over the past 5 years at the level of medical organizations, ODs and hospitals by region showed an increase in the provision of medical care at the inpatient level. The predominance of complicated cases
61,4
66,5
68,7
74,7
72,2
72,0
12014 H2015 «2016
12017
2018
12019
0,08%
°'04% 0,03% 0,03%
12014 B2015 a2016
12017
0% 2018
0,00% ■ 2019
Fig. 10.
Diagram. Dynamics of changes in the number of operated patients from the total number of treated patients with hemorrhoids (ICD code - I84) in the hospitals of the Republic of Kazakhstan in 20142019. (abs. n.)
Fig. 11.
The diagram. Dynamics of changes in the indicator of surgical activity among treated patients with hemorrhoids (ICD code -I84) in the hospitals of the Republic of Kazakhstan in 2014-2019. (%)
Fig. 12.
The diagram. Dynamics of changes in hospital mortality rate (ICD code -I84) in the hospitals of the Republic of Kazakhstan in 2014-2019 (%)
of hemorrhoids at an inpatient level by 6.6 times indicates that patients must be actively identified at the primary level of medical care for early diagnosis of asymptomatic and uncomplicated forms of this disease.
From the studies carried out, even to the extent provided, it can be seen that majority of patients with hemorrhoids are operated on radically in various hospitals of the Republic, most of them by Milligan-Morgan technic, which is clearly shown in Fig. 5, 6, 7.
Outpatient departments conduct examinations, consultations and prescribe conservative therapy to. In recent years, the Ministry of Health of the Republic of Kazakhstan has intensively taken a course towards the hospital-replacing technologies development. In accordance with Order of the Republic of Kazakhstan No. 11 of 2013 (updating annually) the treatment of hem-
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