15 - Hemorrhoids

Question 1

What is the Dentate line?

Answer 1

• The division between squamous epithelium and columnar epithelium
• Below dentate line may experience pain, while above dentate line rarely causes pain

Question 2

What are hemorrhoids?

Answer 2

• 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

Question 3

What causes “diseased” hemorrhoids?

Answer 3

• 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

Question 4

What are “diseased hemorrhoids”?

Answer 4

When a px experiences symptoms b/c of swelling and/or prolapse of anal cushions

Question 5

What are the classifications of hemorrhoids?

Answer 5

Internal, external, or mixed (internal and external)

Question 6

What are internal hemorrhoids?

Answer 6

• Develop above the dentate line from superior hemorrhoidal vein
• Lack sensory nerve fibres, so not normally painful

Question 7

What are the grades of internal hemorrhoids?

Answer 7

• 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)

Question 8

What are external hemorrhoids?

Answer 8

• Develop below dentate line, from inferior hemorrhoidal vein
• Often more painful
• May be visible as bumps at external boundary of the anal canal

Question 9

What are risk factors for hemorrhoids?

Answer 9

• Chronic constipation/diarrhea
• Increasing age
• Medications
• Pregnancy
• Occupation that requires prolonged sitting
• Work that requires lifting

Question 10

What are some signs and symptoms of hemorrhoids?

Answer 10

• 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

Question 11

What are red flags for hemorrhoids?

Answer 11

• 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

Question 12

Which patients are at high risk of colon cancer?

Answer 12

• 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)

Question 13

What are the treatment goals for hemorrhoids?

Answer 13

• Relieve symptoms
• Prevent complications
• Promote good bowel habits and good anal hygiene

Question 14

What are some non-pharms for hemorrhoids?

Answer 14

• 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)

Question 15

Medical therapy is most appropriate for ____ degree hemorrhoids

Answer 15

First

Question 16

What is the purpose of stool softeners?

Answer 16

Help alleviate pain associated w/ constipation and straining w/ defecation

Question 17

What is the MOA, dose, max/day, and potential SE of zinc sulfate?

Answer 17

• 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

Question 18

What is pramoxine hydrochloride?

Answer 18

Local anesthetic

Question 19

What is the MOA, dose, and possible side effects and a precaution of shark liver oil and yeast (preparation H)?

Answer 19

• 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

Question 20

What is the MOA, onset, dose, max/day, possible SE, and precaution of hamamelis and phenylephrine (Preparation H cooling gel)?

Answer 20

• 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

Question 21

What drugs does Preparation H cooling gel interact w/?

Answer 21

MAOIs

Question 22

What is the MOA, dose, max/day, and possible side effects for hamaelis and glycerin (Tucks wipes)?

Answer 22

• MOA = protectant and astringent
• Dose = as needed or after each BM
• Max/day = up to 6 times/day
• Possible SE = mild itching or burning

Question 23

What is diosmin (hemovel)?

Answer 23

• 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

Question 24

What products can pharmacists prescribe for hemorrhoids?

Answer 24

• Any products w/ hydrocortisone (aka all of them)
• Only products made specifically for hemorrhoids
• Must be for unspecified hemorrhoids w/o complication

Question 25

What is the dosing of hydrocortisone for hemorrhoids?

Answer 25

• 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)

Question 26

Is hydrocortisone used alone for hemorrhoids?

Answer 26

Never; always used in a combination w/ at least 1 other product

Question 27

What is pramoxine? What are some possible adverse effects?

Answer 27

• Local anesthetic

- SE = allergic reactions, local irritation (burning, itching)

Question 28

What is framycetin sulfate? What is it used for? What are some possible adverse effects?

Answer 28

• Antibiotic
• Meant to relieve superimposed bacterial infection leading to a decrease in edema, inflammation, and itching
• SE = irritation, itching, sensitivity

Question 29

What is cinchocaine HCl (aka dibucaine)? How long can it be used?

Answer 29

• Local anesthetic
• One of the most potent and toxic long-acting local anesthetic
• Can only be used for a few days

Question 30

Which preparation is preferred for pharmacists to prescribe for hemorrhoids?

Answer 30

Hydrocortisone/zinc sulfate (Anusol-HC)

Question 31

What are monitoring parameters for hemorrhoids?

Answer 31

• Anorectal symptoms should improve or minimize w/in first few doses
• Monitor SE (product dependent)
• Duration of therapy = 1 week

Question 32

When should a px be referred after trying hemorrhoid treatment?

Answer 32

• If symptoms worsen or do not improve in 7 days

- Bleeding, protrusion, or seepage occurs

Question 33

What are some counselling points regarding hemorrhoid products?

Answer 33

• 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

Question 34

What is the tx of hemorrhoids during pregnancy?

Answer 34

• 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