How Can Molecules Induce Hemorrhoids? The Role of Genetics and Epigenetics in Hemorrhoidal Disease

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Unfortunately, this is a very imprecise literature review that fails to address the main topic. There are few articles that actually address hemorrhoidal disease, as can be seen from the citations.

Nothing new. No clinical implications. Many of the claims are questionable.

 

Comments on the Quality of English Language

Moderate english-editing needed

Author Response

Unfortunately, this is a very imprecise literature review that fails to address the main topic. There are few articles that actually address hemorrhoidal disease, as can be seen from the citations.

Nothing new. No clinical implications. Many of the claims are questionable.

 

Dear Reviewer,

Unfortunately, we cannot address a comment that does not provide any critical feedback that can be incorporated into the manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

The manuscript shows tremendous work, and the number of screened articles is impressive. The article has clear sections, and the schemes and tables are informative and help the reader understand the topic. However, I have some major points requiring, in my opinion, your attention:

 

The paragraphs on gut microbiota, obesity, and constipation are partly redundant and not directly connected to the main topic. I recommend significant reduction of this part, to include only the information on molecular mechanisms and their impact on the hemorrhoids or including the relevant parts in other paragraphs to avoid repetition. The paragraph on constipation is irrelevant to the topic, except for the observation that constipation is sometimes associated with IBS, and IBS is associated with genetic/epigenetic mechanisms. Moreover, in line 503 the meaning of the expression „hemorrhoids can likely occur because of constipation during genetic and epigenetic modifications in IBS” is not clear.

 

The first paragraph of the Discussion repeats unnecessary (and unrelated to the main topic) information on constipation and IBS. The observation that obesity, IBS, constipation are possible targets in hemorrhoids prevention and therapy is not novel. In this manuscript I would expect suggestions and information on possible novel drug targets (working through the molecular mechanisms). Based on the literaturę search, the Authors cannot provide any new clinical recommendations; however, they should be able to suggest emerging possibilities and not just provide the reader with encouragement for further research. Furthermore, the necessity of confining the number of reviewed articles is not a weakness of the study; it is the essence of the narrative review. The authors’ scientific contribution is choosing the articles that are relevant to the subject and up-to-date, and not providing the readers with an abbreviated version of as many articles as possible, or assessing the cited works. The cited references are largely from >5 years ago, I suggest including more current publications. I don’t think the remarks on the „weaknesses” of the study are necessary in this type of article. At the same time, a short Conclusions section is lacking and it most required, to summarize the knowledge presented in the article and provide the reader with clear recommendations on future possiilities and on the areas of much-needed research.

 

Other minor remarks:

 

Lines 40-41: „those placed below the dentate line of the anus – internal hemorrhoids, and those placed above that line – external”  - the expressions below/ above are not clear in this context, I suggest replacing with „proximally to/ distally to”.

 

 

Lines 51-62 and 76-82 are redundant, I suggest removing one of the paragraphs.

Line 91 – part of the sentence seems to be missing („PGE2 expression to After research and some possibly needed (…)”

 

I suggest including the search methods as a „Materials and Methods” paragraph directly after the Introduction and I recommend reducing the information on the search methods, such extensive description is not essential for narrative reviews and is tiring to the reader. Also, in a Review, the journal’s Instructions for Authors do not require a „Results” section, „Relevant Sections” are recommended instead – I suggest resignation from the „Results” section and instead, including just the titles of the subsequent paragraphs.

 

The general pathogenesis of the hemorrhoidal disease is described in the introduction, which seems sufficient and not needed in the first paragraph of the „Results”. In this section I recommend focusing strictly on the topic of the paper, which are molecular mechanisms in the disease.

 

Please include the explanation to all abbreviations when first mentioned in the text (e.g. VEGF, TNF-alpha, IFN, IL).

 

Line 147 and 158: it would be more informative to include the exact substances names.

 

Line 189: please remove one „were” („while downregulated were miRNAs in hemorrhoids were (…)”)

Author Response

Dear Reviewer,

We are sincerely grateful for your insightful and constructive feedback. We have incorporated suggested by you changes into our text and we believe that they have substantially improved the quality of our manuscript.

Below, we provide a point-by-point response to each comment, marking the corresponding modifications by line numbers.

 

Dear Authors,

The manuscript shows tremendous work, and the number of screened articles is impressive. The article has clear sections, and the schemes and tables are informative and help the reader understand the topic. However, I have some major points requiring, in my opinion, your attention:

The paragraphs on gut microbiota, obesity, and constipation are partly redundant and not directly connected to the main topic. I recommend significant reduction of this part, to include only the information on molecular mechanisms and their impact on the hemorrhoids or including the relevant parts in other paragraphs to avoid repetition.

The mentioned parts were reduced to include only information on molecular mechanisms (see lines 419-462).

 

The paragraph on constipation is irrelevant to the topic, except for the observation that constipation is sometimes associated with IBS, and IBS is associated with genetic/epigenetic mechanisms. Moreover, in line 503 the meaning of the expression „hemorrhoids can likely occur because of constipation during genetic and epigenetic modifications in IBS” is not clear.

In this paragraph, only information about IBS has been left (see lines 452-462). Line 503 has been modified and cleared out, matching the rest of the paragraph.

 

The first paragraph of the Discussion repeats unnecessary (and unrelated to the main topic) information on constipation and IBS. The observation that obesity, IBS, constipation are possible targets in hemorrhoids prevention and therapy is not novel. In this manuscript I would expect suggestions and information on possible novel drug targets (working through the molecular mechanisms). Based on the literature search, the Authors cannot provide any new clinical recommendations; however, they should be able to suggest emerging possibilities and not just provide the reader with encouragement for further research.

The discussion has been rewritten in a way that highlights the molecular pathways described in the text. Possible novel therapeutic targets have been highlighted (see lines 463-506).

 

Furthermore, the necessity of confining the number of reviewed articles is not a weakness of the study; it is the essence of the narrative review. The authors’ scientific contribution is choosing the articles that are relevant to the subject and up-to-date, and not providing the readers with an abbreviated version of as many articles as possible, or assessing the cited works. The cited references are largely from >5 years ago, I suggest including more current publications. I don’t think the remarks on the „weaknesses” of the study are necessary in this type of article.

As research related to molecular mechanisms occurring in hemorrhoids is scarce, we have decided to include all the relevant data. All of the novel and current publications related to this subject have been included as well.

 

At the same time, a short Conclusions section is lacking and is most required, to summarize the knowledge presented in the article and provide the reader with clear recommendations on future possibilities and on the areas of much-needed research.

The conclusions section has been added as chapter 11 (see lines 507-519).

 

Other minor remarks:

 

Lines 40-41: „those placed below the dentate line of the anus – internal hemorrhoids, and those placed above that line – external”  - the expressions below/ above are not clear in this context, I suggest replacing with „proximally to/ distally to”.

Those lines were removed according to a comment from another reviewer regarding too extensive background about hemorrhoid anatomy.

 

Lines 51-62 and 76-82 are redundant, I suggest removing one of the paragraphs.

I have removed lines 76-82.

 

Line 91 – part of the sentence seems to be missing („PGE2 expression to After research and some possibly needed (…)”

I have corrected the sentence (see line 69).

 

I suggest including the search methods as a „Materials and Methods” paragraph directly after the Introduction and I recommend reducing the information on the search methods, such extensive description is not essential for narrative reviews and is tiring to the reader. Also, in a Review, the journal’s Instructions for Authors do not require a „Results” section, „Relevant Sections” are recommended instead – I suggest resignation from the „Results” section and instead, including just the titles of the subsequent paragraphs.

I would gladly move this section right after the introduction, but it is suggested by the publisher to keep it at the end of the article. I have removed the Results section and changed every subsection into sections in their own right (see chapter 12 – materials and methods). I would like to keep the detailed description of the methods, as we have received a comment from another reviewer that this section should be even more developed.

 

The general pathogenesis of the hemorrhoidal disease is described in the introduction, which seems sufficient and not needed in the first paragraph of the „Results”. In this section I recommend focusing strictly on the topic of the paper, which are molecular mechanisms in the disease.

I think this short paragraph at the beginning of the Results falls into the narrative of this section, presenting a detailed list of factors that increase the risk of developing hemorrhoids and being a foundation for the results presented further.

 

Please include the explanation to all abbreviations when first mentioned in the text (e.g. VEGF, TNF-alpha, IFN, IL).

Abbreviations were explained.

 

Line 147 and 158: it would be more informative to include the exact substances names.

The names of the substances have been added (see line 125).

 

Line 189: please remove one „were” („while downregulated were miRNAs in hemorrhoids were (…)”)

The additional word has been removed.

Reviewer 3 Report

Comments and Suggestions for Authors

This review aims to summarize the current evidence on genetic and epigenetic mechanisms in hemorrhoidal disease.
Weaknesses: Although the topic is clearly presented, the formulation of the "main question" remains unclear. The authors mix mechanistic hypotheses with epidemiological associations without clearly prioritizing the mechanisms with the strongest evidence base. This lack of focus weakens the cohesion of the narrative.
The review addresses a poorly explored area, potentially relevant to both basic science and therapeutic development. Weaknesses: The novelty is mitigated by the inclusion of extensive background on hemorrhoid anatomy and classical, well-established, and widely available pathogenetic theories. The value-added content, particularly the genetic/epigenetic focus, would benefit from greater emphasis and support for a more critical assessment of the literature rather than a descriptive enumeration.
The compilation of candidate genes, miRNAs, and pathways is complete.
Weaknesses: The summary is largely tabulative and descriptive, with limited integration into a general mechanistic framework. Comparison with previous reviews is minimal to establish how this work contributes to the understanding of the phenomenon beyond existing summaries. Furthermore, some cited molecular associations appear to derive from single, unreplicated studies, but this is not systematically communicated to the reader.
The search strategy is described, but the key elements for reproducibility are barely adequate. Limiting PubMed and Google Scholar results to the first 200 results per query may have introduced selection bias, but no sensitivity analysis or justification for this threshold is provided. The review lacks a PRISMA-style flowchart or risk-of-bias assessment of included studies, which would improve transparency even for a narrative review. The inclusion/exclusion criteria are quite broad and inconsistently applied (for example, combining in vitro mechanistic studies with observational clinical data without clear stratification).

Author Response

We would like to express our sincere gratitude to the Reviewer for the insightful and constructive feedback on our manuscript. We have incorporated the suggested changes into the text, and we believe that they significantly improved its quality. 

Below, we provide the Reviewer with a point-by-point response to the comments. The changes made in the revised version of the manuscipt are indicated by adding the line numbers in the response below.

 

This review aims to summarize the current evidence on genetic and epigenetic mechanisms in hemorrhoidal disease.

Weaknesses: Although the topic is clearly presented, the formulation of the "main question" remains unclear. The authors mix mechanistic hypotheses with epidemiological associations without clearly prioritizing the mechanisms with the strongest evidence base. This lack of focus weakens the cohesion of the narrative.

The aim of the review has been added (see lines 49-51). Moreover, the paragraphs about epidemiological associations have been shortened (see lines 419-462), and the discussion has been modified to focus on molecular aspects (see lines 463-506).

The review addresses a poorly explored area, potentially relevant to both basic science and therapeutic development. Weaknesses: The novelty is mitigated by the inclusion of extensive background on hemorrhoid anatomy and classical, well-established, and widely available pathogenetic theories.

We have reduced the incorporation of background on hemorrhoid anatomy and well-established pathogenetic theories (see lines 30-44).

 

The value-added content, particularly the genetic/epigenetic focus, would benefit from greater emphasis and support for a more critical assessment of the literature rather than a descriptive enumeration.

We decided on a more descriptive approach to data synthesis because there do not exist at least two separate studies on the same factor or mechanism that could be compared with each other.

The compilation of candidate genes, miRNAs, and pathways is complete.
Weaknesses: The summary is largely tabulative and descriptive, with limited integration into a general mechanistic framework. Comparison with previous reviews is minimal to establish how this work contributes to the understanding of the phenomenon beyond existing summaries. Furthermore, some cited molecular associations appear to derive from single, unreplicated studies, but this is not systematically communicated to the reader.

No previous reviews have been conducted to date. The research in this field is scarce, and the majority of the studies related to particular molecular associations are the only research regarding that association.

The search strategy is described, but the key elements for reproducibility are barely adequate. Limiting PubMed and Google Scholar results to the first 200 results per query may have introduced selection bias, but no sensitivity analysis or justification for this threshold is provided. The review lacks a PRISMA-style flowchart or risk-of-bias assessment of included studies, which would improve transparency even for a narrative review. The inclusion/exclusion criteria are quite broad and inconsistently applied (for example, combining in vitro mechanistic studies with observational clinical data without clear stratification).

We would like to note that this review is not a systematic review, nor has it been conducted as such; therefore, we have refrained from using the PRISMA flow diagram intentionally. Regardless, if the use of PRISMA flow diagram would be more suitable for our review, we will be happy to provide it. We have added the PRISMA flow diagram for systematic reviews instead of the previous Figure 5.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for reviewing your work and your detailed answers. I find the manuscript appropriate for publication.