Hemorrhoids Flashcards
What is the difference between an internal and external hemorrhoid?
Internal: above the dentate line
External: below the dentate line
What are internal hemorrhoids?
Cushions in the anal canal, crucial for maintaining continence (gas vs. liquid/solids)
Cause of development is not fully understood
What is a grade I hemorrhoid?
Prominent hemorrhoidal vessels that may bleed but with no prolapse
What is a grade II hemorrhoid?
A small part of the anal mucosa or cushion may protrude at the anus during defecation
What is a grade III hemorrhoid?
Hemorrhoids remain in the prolapsed position after defecation, but may be replaced manually within the anus
What is a grade IV hemorrhoid?
Hemorrhoids cannot be replaced after a bowel movement, and thus create a permanent bulge at the anus
What are external hemorrhoids?
Small, soft skin folds or thicker fleshier appendages.
Can be asymptomatic
How many people complain of hemorrhoids?
5% of population, but likely that more people experience them.
How do external hemorrhoids present clinically?
Many times completely asymptomatic
Itching and moisture due to difficulty cleansing the region
May appear red and swollen due to scratching and vigorous cleansing
Do not cause pain unless a thrombosis is present
What are risk factors for hemorrhoids?
Constipation/diarrhea Prolonged sitting on the toilet Type of work (exertional) Physical exertion and weight lifting Pregnancy
How do internal hemorrhoids present clinically?
Itching and perianal irritation
Fecal soiling
Feeling of pressure
What are red flag symptoms of hemorrhoids?
Prolapse that must be manually replaced
- rectal bleeding and: bleeding is associated with painful poops, blood is present in large amounts, blood is dark in colour, bleeding is recurrent, patient is at high risk of colorectal cancer.
- patient is under 12 y/o
- problem persists for more than 7 days
What counselling points should you go over when talking about fibre?
Can take up to 6 weeks for it to work
- start low and slow, increase slowly to reduce the risk of bloating
- ensure adequate fluid intake
- ingest an average of 25-30g of fibre daily
How is a sitz bath thought to help hemorrhoids?
Moist heat is thought to lower internal canal and anal pressure
What toileting behaviour changes should be implemented to avoid hemorrhoids?
Repeated straining and spending too much time on the toilet
Avoid delaying the urge to poop
Reading or cellphone use on the toilet
If you feel the need to poop, but are unsuccessful, leave and try again later
What evidence do we have for topical products for hemorrhoids?
No well designed RCTs, but can use to control symptoms
What dosage form is preferred for treating hemorrhoids?
Creams and ointments– suppositories will go into the rectum and will not work
What local anesthetic options exist to treat hemorrhoids? Any important counselling points?
Dibucaine, pramoxine
Safe if used for <7 days, but longer duration increases the risk of contact dermatitis
What do protectants do? What are examples?
Prevent irritation of the perianal area by forming a physical barrier on the skin
Petrolatum, glycerin, shark liver oil
What do astringents do? What are examples?
Cause clumping of proteins in the cells of the perianal skin
Ex. zinc sulfate, witch hazel
Not much data to support
How do vasoconstrictors work to help treat hemorrhoids?
Topical decongestants used to increase vascular tone, but no data to support use
Possible systemic absorption, should be used with caution in people with htn, cv disease and diabetes
What are phelbotonics?
Oral product– most common class is flavonoids
MOA is unknown, but may increase venous tone
Diosmin
What is rubber band ligation?
Office therapy used for grade I and II hemorrhoids, and some grade III hemorrhoids
most commonly performed nonsurgical treatment
Treatment– not just managing symptoms
What is sclerotherapy?
Office procedure reserved for grade I and II hemorrhoids, involves and injection into the hemorrhoid to kill off the tissue there. Used for patients where rubber band therapy is ineffective
What is infrared coagulation?
Office procedure that involves application of infrared waves to the tissue around the hemorrhoidal tissue
When would we consider hemorrhoidal surgery?
Patients:
- refractory to office procedures
- unable to tolerate office procedures
- with large external hemorrhoids
- with combined internal and external hemorrhoids with prolapse
How would we treat hemorrhoids in pregnancy?
Non-pharmacological options, such as sitz baths, fibre and proper toileting
