15 - Hemorrhoids Flashcards
What is the Dentate line?
- The division between squamous epithelium and columnar epithelium
- Below dentate line may experience pain, while above dentate line rarely causes pain
What are hemorrhoids?
- Normal structures in all patients (also called anal cushions)
- Consist of connective and smooth muscle; rich in arterial blood supply
- Help seal upper anal canal and promote continence
What causes “diseased” hemorrhoids?
- Weakened connective tissue supporting the anal cushion
- May be a result of age or sustained passage of hard stools
- Straining also causes them b/c increases venous pressure
What are “diseased hemorrhoids”?
When a px experiences symptoms b/c of swelling and/or prolapse of anal cushions
What are the classifications of hemorrhoids?
Internal, external, or mixed (internal and external)
What are internal hemorrhoids?
- Develop above the dentate line from superior hemorrhoidal vein
- Lack sensory nerve fibres, so not normally painful
What are the grades of internal hemorrhoids?
- 1st degree – swell in anal cushion due to straining
- 2nd degree – protrude into anal canal w/ straining or defecating and reduce when straining ceases
- 3rd degree - remain in prolapsed position after defecation
- 4th degree - prolapsed and can’t be reintroduced into anus (likely requires surgery)
What are external hemorrhoids?
- Develop below dentate line, from inferior hemorrhoidal vein
- Often more painful
- May be visible as bumps at external boundary of the anal canal
What are risk factors for hemorrhoids?
- Chronic constipation/diarrhea
- Increasing age
- Medications
- Pregnancy
- Occupation that requires prolonged sitting
- Work that requires lifting
What are some signs and symptoms of hemorrhoids?
- Swelling and bump around anus
- Itching and irritation in perianal area
- Small amounts of bright red blood after BM
- Mucous discharge
- Seepage (fecal matter on underwear)
- Internal hemorrhoids may prolapse
What are red flags for hemorrhoids?
- Patient under 12 y/o
- Anorectal sx that don’t resolve w/in 7 days
- Manual replacement needed for a prolapsed hemorrhoid
- Severe pain
- Rectal bleeding and painful defecation
- Rectal bleeding w/ lot of blood
- Rectal bleeding w/ dark blood
- Rectal bleeding and high risk of colon cancer
Which patients are at high risk of colon cancer?
- Over 50 y/o
- History of colorectal cancer or adenomatous polyposis
- Family history of familial adenomatous polyposis or hereditary nonpolyposis colon cancer
- Inflammatory bowel disease
- Strong family history (either cancer or polyps in 1st degree relative over 60 y/o or 2nd degree relative of any age)
What are the treatment goals for hemorrhoids?
- Relieve symptoms
- Prevent complications
- Promote good bowel habits and good anal hygiene
What are some non-pharms for hemorrhoids?
- Prevent constipation (fibre supplementation)
- Modify lifestyle factors (increase exercise and fluid intake)
- Adapt good bowel habits (avoid straining and practice good anal hygiene)
- Replace prolapsed hemorrhoid w/ moistened tissue
- Sitz bath
- Cryotherapy (cooling the area)
Medical therapy is most appropriate for ____ degree hemorrhoids
First
What is the purpose of stool softeners?
Help alleviate pain associated w/ constipation and straining w/ defecation
What is the MOA, dose, max/day, and potential SE of zinc sulfate?
- MOA - astringent
- Dose - ointment = every 4 hours or as needed and after each BM; suppository = 1 in the morning, at bedtime, and after each BM
- Max/day = 6x/day
- Potential SE = burning and irritation
What is pramoxine hydrochloride?
Local anesthetic
What is the MOA, dose, and possible side effects and a precaution of shark liver oil and yeast (preparation H)?
- MOA = protectant and wound healing?
- Dose = ointment/cream and suppositories - morning, night, after each BM, and whenever sx occur
- Possible SE = may stain clothing
- Precaution - insufficient evidence for efficacy of yeast as a wound healing agent
What is the MOA, onset, dose, max/day, possible SE, and precaution of hamamelis and phenylephrine (Preparation H cooling gel)?
- MOA = astringent and vasoconstrictor
- Onset w/in 1 minute
- Dose = morning, night, and after each BM
- Max/day = up to 4x/day
- Possible SE = increased BP, CNS disturbances, cardiac arrhythmia, aggravation of sx of hyperthyroidism
- Precautions - heart disease, hypertension, thyroid disease, diabetes, prostatic hypertrophy, intraocular pressure
What drugs does Preparation H cooling gel interact w/?
MAOIs
What is the MOA, dose, max/day, and possible side effects for hamaelis and glycerin (Tucks wipes)?
- MOA = protectant and astringent
- Dose = as needed or after each BM
- Max/day = up to 6 times/day
- Possible SE = mild itching or burning
What is diosmin (hemovel)?
- Natural health product thought to decrease inflammation of hemorrhoids
- Thought to be beneficial during acute hemorrhoidal symptoms or to treat bleeding
- Quality of trials is lacking
What products can pharmacists prescribe for hemorrhoids?
- Any products w/ hydrocortisone (aka all of them)
- Only products made specifically for hemorrhoids
- Must be for unspecified hemorrhoids w/o complication
What is the dosing of hydrocortisone for hemorrhoids?
- BID (morning and bedtime) and after each BM
- Not used for longer than 7 days (can be used up to 14 days if significant improvement occurring)
Is hydrocortisone used alone for hemorrhoids?
Never; always used in a combination w/ at least 1 other product
What is pramoxine? What are some possible adverse effects?
- Local anesthetic
- SE = allergic reactions, local irritation (burning, itching)
What is framycetin sulfate? What is it used for? What are some possible adverse effects?
- Antibiotic
- Meant to relieve superimposed bacterial infection leading to a decrease in edema, inflammation, and itching
- SE = irritation, itching, sensitivity
What is cinchocaine HCl (aka dibucaine)? How long can it be used?
- Local anesthetic
- One of the most potent and toxic long-acting local anesthetic
- Can only be used for a few days
Which preparation is preferred for pharmacists to prescribe for hemorrhoids?
Hydrocortisone/zinc sulfate (Anusol-HC)
What are monitoring parameters for hemorrhoids?
- Anorectal symptoms should improve or minimize w/in first few doses
- Monitor SE (product dependent)
- Duration of therapy = 1 week
When should a px be referred after trying hemorrhoid treatment?
- If symptoms worsen or do not improve in 7 days
- Bleeding, protrusion, or seepage occurs
What are some counselling points regarding hemorrhoid products?
- Apply after each BM
- Clean anorectal area w/ mild soap and water and pat dry before applying product
- Use external products sparingly
- Local anesthetics should only be used in perianal area or lower anal canal
- Creams and ointments preferred over suppositories
What is the tx of hemorrhoids during pregnancy?
- First line = non-pharms (increase fibre, increase liquids, improve toilet habits)
- If medication is required, external products preferred (zinc based products)
- Refer if px very uncomfortable
