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Clinical 1 (Part B) > 17 - Hemorrhoids > Flashcards

17 - Hemorrhoids Flashcards

1
Q

List the two types of epithelium of the anal canal

A
  • squamous epithelium

- columnar epithelium

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2
Q

What is the division between the two tissues called?

A

Dentate line (or pectinate line)

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3
Q

_____ dentate line = may experience pain

A

below

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4
Q

_____ dentate line = rarely cases pain

A

above

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5
Q

List some causes of hemorrhoids

A
  • may be as a result of age or sustained passage of hard stools
  • straining increases the venous pressure and leads to distension
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6
Q

Hemorrhoids can be classified as 3 types:

Describe them

A

1) Internal - originate above dentate line
2) External - originate below dentate line
3) Mixed (internal & external)

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7
Q

Are internal hemorrhoids painful?

A

Not normally

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8
Q

Internal hemorrhoids:

Graded by severity, describe 1st degree

A

swell in the anal cushion due to straining (do not prolapse into the anal canal)

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9
Q

Internal hemorrhoids:

Graded by severity, describe 2nd degree

A

protrude into the anal canal with straining or defecating and reduce spontaneously when straining ceases

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10
Q

Internal hemorrhoids:

Graded by severity, describe 3rd degree

A

remain in the prolapsed position after defecation (manual replacement)

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11
Q

Internal hemorrhoids:

Graded by severity, describe 4th degree

A

prolapsed and can’t be reintroduced in the anus (very painful) - likely requires surgery

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12
Q

Risk factors for hemorrhoids

A
  • chronic constipation/diarrhea
  • increasing age
  • medications
  • pregnancy
  • occupation that requires prolonged sitting
  • work that requires lifting (physical exertion)
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13
Q

What are some signs & symptoms of hemorrhoids?

A
  • 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
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14
Q

What are some assessment questions to ask?

A
  • 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?
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15
Q

When do you refer hemorrhoids?

A
  • 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
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16
Q

Goals of therapy

A
  • Relieve symptoms
  • Prevent complications (such as prolapse, thrombosis, or anal fissures)
  • Promote good bowel habits and good anal hygiene
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17
Q

List 4 non-pharms for hemorrhoids

A

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

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18
Q

Are donut therapies recommended for hemorrhoids?

A

No - actually increases pressure and blocks the blood from returning

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19
Q

What are the 3 groups of pharmacological products for the treatment of hemorrhoids?

A

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

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20
Q

Astringent:

MOA

A

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

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21
Q

Astringent:

Give examples

A
  • zinc oxide
  • zinc sulfate
  • hammelis water (witch hazel)
  • calamine
  • bismuth salts
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22
Q

Local anesthetics:

MOA

A

Block nerve conduction in an effort to temporarily relieve itching, irritation and discomfort.
Evidence of efficacy lacking
**would not recommend these

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23
Q

Local anesthetics:

Examples

A
  • benzocaine
  • lidocaine
  • dibucaine
  • pramoxine
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24
Q

Antiseptics:

MOA

A

Inhibit microbial growth in the area where it is used

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25
Q

Antiseptics:

Examples

A

Domiphen

  • old agent
  • would not recommend
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26
Q

Protectants:

MOA

A

Provides a physical barrier to irritation by forming a protective layer o ver the mucous membranes lining the anorectal area

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27
Q

Protectants:

Examples

A
  • zinc oxide
  • shark liver oil
  • white petrolatum
  • glycerin
  • mineral oil
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28
Q

Vasoconstrictors:

MOA

A

Stimulates alpha adrenergic receptors in the blood vessels, causing constriction of the arterioles. Helps with discomfort, irritation, itching and swelling

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29
Q

Vasoconstrictors:

Examples

A
  • phenylephrine (preparation H-PE gel)

- naphazoline (old)

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30
Q

Wound healing agent:

MOA

A

Some products claim to promote healing or tissue repair in anorectal disease.
No scientific evidence to support these clains

31
Q

Wound healing agents:

Examples

A
  • Shark liver oil

- Live yeast cells (Prep H w Bio-Dyne)

32
Q

List some contraindications to phenylephrine (vasoconstrictor)

A
  • HTN
  • BPH
  • glaucoma
  • diabetes
33
Q

Potential side effects of all products?

A

burning, irritation

34
Q

Zinc sulfate:

MOA

A

astringent and protectant

35
Q

Dosing schedule of zinc sulfate?

A

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

36
Q

Zinc sulfate & Pramoxine HCl:

MOA

A

astringent and local anesthetic

37
Q

Dosing schedule of zinc sulphate & pramoxine HCl?

A

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

38
Q

Dibucaine:

MOA

A

local anesthetic

39
Q

Dosing schedule of Dibucaine?

A

Comes only as an ointment

Apply in the morning and even ing and after each bowel movement

Max = 30 g of ointment/day

40
Q

Shark liver oil & yeast (preparation H):

MOA

A

protectant and wound healing

41
Q

Dosing schedule of Preparation H (shark liver oil and yeast)?

A

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

42
Q 
Preparation H (shark liver oil and yeast)
-contain \_\_\_\_\_
A

lanolin

*ask about wool allergy

43
Q

Hamamelis & Phneylephrine (prep H cooling gel):

MOA

A

astringent and vasoconstrictors

44
Q

Hamamelis & Phneylephrine (prep H cooling gel):

Dosing schedule?

A

morning, night and after each bowel movement

45
Q

Hamamelis & Phneylephrine (prep H cooling gel):

Possible side effects?

A

increased BP, CNS disturbances, cardiac arrhythmia, aggravation of symptoms of hyperthyroidism

*Prob wouldn’t recommend, lots of CI

46
Q

Hamaelis & Glycerin (Tucks):

MOA

A

protectant and astringent

47
Q

Dosing schedule of Hamaelis & Glycerin (Tucks) cleansing wipes?

A

Use as needed or after each bowel movement

Max up to 6 times daily

48
Q

Describe Diosmin (Removal)

A
  • NHP
  • bioflavanoid thought to affect the vascular part of hemorrhoids resulting in decreased inflammation
  • AE: GI effects and headache
49
Q

All Rx products contain _______ combinations

A

hydrocortisone

50
Q

Rx products:

Proctofoam contains?

A

hydrocortisone/pramoxine

51
Q

Rx products:

Anusol-HC contains?

A

hydrocortisone/zinc sulfate

52
Q

Rx products:

Anugesic-HC contains?

A

hydrocortisone/zinc sulfate/pramoxine

53
Q

Rx products:

Proctosedyl contains?

A

hydrocortisone/framycetic sulfate/cinchocaine HCl/esculin

54
Q

How does hydrocortisone help hemorrhoids?

A

-decrease itching and inflammation

55
Q

Hydrocortisone:

takes up to ___ hours to take effect

A

12

56
Q

Hydrocortisone:

Should not use longer than ___ days

A

7

57
Q

Hydrocortisone:

Is it ever used by itself for hemorrhoids?

A

NEVER

58
Q

Hydrocortisone:

Dosing schedule

A

should be used sparingly 2 times a day (morning and bedtime) and after each bowel movement

59
Q

Pramoxine (local anesthetic):

Should not be used above _____ line because there are no fibres present

A

dentate

60
Q

Framycetin sulfate:

MOA

A
  • amino glycoside antibiotic

- meant to relieve superimposed bacterial infection leading to a decrease in edema, inflammation and itching

61
Q

Chinchocaine HCl also known as ?

A

dibucaine

62
Q 
Cinchocaine HCl (dibucaine):
MOA
A
  • amide local anesthetic
  • very potent and toxic and long-acting
  • should only be used on a short term basis
63
Q

Esculin:

MOA

A
  • component of horse chestnut

- thought the activity of the component Aescin may decrease swelling and inflammation

64
Q

Who is Esculin CI in?

A

pregnancy
breastfeeding
patients w bleeding disorders (may interact with ASA and other antithrombotics)

65
Q

Esculin:

AE

A 
pruritis
nausea
stomach complaints
bleeding
nephropathy
allergic reactions
66
Q

What are the monitoring parameters for hemorrhoids?

A

Improvement: anorectal symptoms should be improved or minimized with the 1st few doses.

Watch for bleeding/pain

SE: product dependent (local burning, irritation)

67
Q

What is the duration of therapy for hemorrhoids?

A

1 week

68
Q

When do you refer hemorrhoids?

A

If symptoms worsen or do not improve in 7 days, or bleeding, protrusion or seepage occurs - See Dr.

69
Q

List 3 key counselling points

A
  • 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)
70
Q

Describe the treatment of hemorrhoids during pregnancy

A

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)

71
Q

When do you refer a pregnant patient with hemorrhoids to the physician

A

-if patient very uncomfortable

72
Q

Hemorrhoids in pregnancy:

Can we use local anesthetics and corticosteroids?

A

only under medical supervision of a physician

73
Q

Hemorrhoids in pregnancy:

Excessive topical _______ use has been linked to intrauterine growth delay

A

corticosteroid

74
Q

Who should vasoconstrictors be avoided in?

A

patients with uncontrolled HTN, CV disease, hyperthyroidism or enlarged prostate
*acts right on the blood vessels

Clinical 1 (Part B) (11 decks)

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