17 - Hemorrhoids Flashcards
List the two types of epithelium of the anal canal
- squamous epithelium
- columnar epithelium
What is the division between the two tissues called?
Dentate line (or pectinate line)
_____ dentate line = may experience pain
below
_____ dentate line = rarely cases pain
above
List some causes of hemorrhoids
- may be as a result of age or sustained passage of hard stools
- straining increases the venous pressure and leads to distension
Hemorrhoids can be classified as 3 types:
Describe them
1) Internal - originate above dentate line
2) External - originate below dentate line
3) Mixed (internal & external)
Are internal hemorrhoids painful?
Not normally
Internal hemorrhoids:
Graded by severity, describe 1st degree
swell in the anal cushion due to straining (do not prolapse into the anal canal)
Internal hemorrhoids:
Graded by severity, describe 2nd degree
protrude into the anal canal with straining or defecating and reduce spontaneously when straining ceases
Internal hemorrhoids:
Graded by severity, describe 3rd degree
remain in the prolapsed position after defecation (manual replacement)
Internal hemorrhoids:
Graded by severity, describe 4th degree
prolapsed and can’t be reintroduced in the anus (very painful) - likely requires surgery
Risk factors for hemorrhoids
- chronic constipation/diarrhea
- increasing age
- medications
- pregnancy
- occupation that requires prolonged sitting
- work that requires lifting (physical exertion)
What are some signs & symptoms of hemorrhoids?
- swelling and bump around the anus
- itching, irritation, burning
- small amounts of bright red blood after BM
- mucous discharge
- associated pain
- seepage
- internal hemorrhoids may prolapse
What are some assessment questions to ask?
- Pain?
- Bleeding?
- How long have you had this?
- Anything makes it worse or better?
- Fecal soiling or seepage?
- Have you been straining when going to the bathroom?
- Diet, exercise, water intake?
- Pregnant?
When do you refer hemorrhoids?
- Patient < 12
- Anorectal symptoms that do not resolve within 7 days
- Manual replacement needed for a prolapsed hemorrhoid
- Severe pain
- Rectal bleeding and painful defecation
- Rectal bleeding with a lot of blood
- Rectal bleeding with dark blood
- Rectal bleeding is recurrent
- Rectal bleeding with a high risk of colon cancer:
- > 50
- history of colorectal cancer
- IBD
Goals of therapy
- Relieve symptoms
- Prevent complications (such as prolapse, thrombosis, or anal fissures)
- Promote good bowel habits and good anal hygiene
List 4 non-pharms for hemorrhoids
1) Prevent constipation: ensure adequate fibre and water intake, increase exercise
2) Don’t sit on toilet for more than 1-2 minutes
3) Adapt good bowel habits - don’t strain, ensure proper anal hygiene
4) Sitz bath
Are donut therapies recommended for hemorrhoids?
No - actually increases pressure and blocks the blood from returning
What are the 3 groups of pharmacological products for the treatment of hemorrhoids?
1) Oral analgesics may provide relief of mild discomfort or pain
2) Stool softeners - help alleviate pain associated with constipation and straining
3) Hemorrhoidal products
- relieve pain, itch, irritation and burning
- don’t decrease bleeding or risk of prolapse
- creams, ointments, suppositories, cleansing pads
Astringent:
MOA
Relieve the irritation and burning sensation by protecting underlying tissue. The effect on the mucous membrane includes contracting, wrinkling, blanching and decreasing secretions resulting in drying the tissue.
Effective for mild tissues
Astringent:
Give examples
- zinc oxide
- zinc sulfate
- hammelis water (witch hazel)
- calamine
- bismuth salts
Local anesthetics:
MOA
Block nerve conduction in an effort to temporarily relieve itching, irritation and discomfort.
Evidence of efficacy lacking
**would not recommend these
Local anesthetics:
Examples
- benzocaine
- lidocaine
- dibucaine
- pramoxine
Antiseptics:
MOA
Inhibit microbial growth in the area where it is used
Antiseptics:
Examples
Domiphen
- old agent
- would not recommend
Protectants:
MOA
Provides a physical barrier to irritation by forming a protective layer o ver the mucous membranes lining the anorectal area
Protectants:
Examples
- zinc oxide
- shark liver oil
- white petrolatum
- glycerin
- mineral oil
Vasoconstrictors:
MOA
Stimulates alpha adrenergic receptors in the blood vessels, causing constriction of the arterioles. Helps with discomfort, irritation, itching and swelling
Vasoconstrictors:
Examples
- phenylephrine (preparation H-PE gel)
- naphazoline (old)
Wound healing agent:
MOA
Some products claim to promote healing or tissue repair in anorectal disease.
No scientific evidence to support these clains
Wound healing agents:
Examples
- Shark liver oil
- Live yeast cells (Prep H w Bio-Dyne)
List some contraindications to phenylephrine (vasoconstrictor)
- HTN
- BPH
- glaucoma
- diabetes
Potential side effects of all products?
burning, irritation
Zinc sulfate:
MOA
astringent and protectant
Dosing schedule of zinc sulfate?
Ointment: every 4 hours or as needed and after each bowel movement
Max 6g/day
Suppository: 1 suppository in the morning, at bedtime and after each bowel movement
Zinc sulfate & Pramoxine HCl:
MOA
astringent and local anesthetic
Dosing schedule of zinc sulphate & pramoxine HCl?
Ointment: every 4 hours or as needed and after each bowel movement
Max 6g/day
Suppository: 1 suppository in the morning, at bedtime and after each bowel movement
Dibucaine:
MOA
local anesthetic
Dosing schedule of Dibucaine?
Comes only as an ointment
Apply in the morning and even ing and after each bowel movement
Max = 30 g of ointment/day
Shark liver oil & yeast (preparation H):
MOA
protectant and wound healing
Dosing schedule of Preparation H (shark liver oil and yeast)?
Ointment: every 4 hours or as needed and after each bowel movement
Max 6g/day
Suppository: 1 suppository in the morning, at bedtime and after each bowel movement
Preparation H (shark liver oil and yeast) -contain \_\_\_\_\_
lanolin
*ask about wool allergy
Hamamelis & Phneylephrine (prep H cooling gel):
MOA
astringent and vasoconstrictors
Hamamelis & Phneylephrine (prep H cooling gel):
Dosing schedule?
morning, night and after each bowel movement
Hamamelis & Phneylephrine (prep H cooling gel):
Possible side effects?
increased BP, CNS disturbances, cardiac arrhythmia, aggravation of symptoms of hyperthyroidism
*Prob wouldn’t recommend, lots of CI
Hamaelis & Glycerin (Tucks):
MOA
protectant and astringent
Dosing schedule of Hamaelis & Glycerin (Tucks) cleansing wipes?
Use as needed or after each bowel movement
Max up to 6 times daily
Describe Diosmin (Removal)
- NHP
- bioflavanoid thought to affect the vascular part of hemorrhoids resulting in decreased inflammation
- AE: GI effects and headache
All Rx products contain _______ combinations
hydrocortisone
Rx products:
Proctofoam contains?
hydrocortisone/pramoxine
Rx products:
Anusol-HC contains?
hydrocortisone/zinc sulfate
Rx products:
Anugesic-HC contains?
hydrocortisone/zinc sulfate/pramoxine
Rx products:
Proctosedyl contains?
hydrocortisone/framycetic sulfate/cinchocaine HCl/esculin
How does hydrocortisone help hemorrhoids?
-decrease itching and inflammation
Hydrocortisone:
takes up to ___ hours to take effect
12
Hydrocortisone:
Should not use longer than ___ days
7
Hydrocortisone:
Is it ever used by itself for hemorrhoids?
NEVER
Hydrocortisone:
Dosing schedule
should be used sparingly 2 times a day (morning and bedtime) and after each bowel movement
Pramoxine (local anesthetic):
Should not be used above _____ line because there are no fibres present
dentate
Framycetin sulfate:
MOA
- amino glycoside antibiotic
- meant to relieve superimposed bacterial infection leading to a decrease in edema, inflammation and itching
Chinchocaine HCl also known as ?
dibucaine
Cinchocaine HCl (dibucaine): MOA
- amide local anesthetic
- very potent and toxic and long-acting
- should only be used on a short term basis
Esculin:
MOA
- component of horse chestnut
- thought the activity of the component Aescin may decrease swelling and inflammation
Who is Esculin CI in?
pregnancy
breastfeeding
patients w bleeding disorders (may interact with ASA and other antithrombotics)
Esculin:
AE
pruritis nausea stomach complaints bleeding nephropathy allergic reactions
What are the monitoring parameters for hemorrhoids?
Improvement: anorectal symptoms should be improved or minimized with the 1st few doses.
Watch for bleeding/pain
SE: product dependent (local burning, irritation)
What is the duration of therapy for hemorrhoids?
1 week
When do you refer hemorrhoids?
If symptoms worsen or do not improve in 7 days, or bleeding, protrusion or seepage occurs - See Dr.
List 3 key counselling points
- Products should be used after BM for max benefit
- Anorectal area should be cleaned with mild soap & water and pat dry before applying product
- Creams & ointments are considered preferable to suppositories (tend to enter rectum and dissolve, therefore not providing medication in desire area of the anal canal)
Describe the treatment of hemorrhoids during pregnancy
First line: increase fibre, stool softeners, increase liquid, and improve toilet habits. Relief of constipation and sits baths are helpful
If medications required: external products recommended (Zinc sulfate)
When do you refer a pregnant patient with hemorrhoids to the physician
-if patient very uncomfortable
Hemorrhoids in pregnancy:
Can we use local anesthetics and corticosteroids?
only under medical supervision of a physician
Hemorrhoids in pregnancy:
Excessive topical _______ use has been linked to intrauterine growth delay
corticosteroid
Who should vasoconstrictors be avoided in?
patients with uncontrolled HTN, CV disease, hyperthyroidism or enlarged prostate
*acts right on the blood vessels
