Hemorrhoids Flashcards
Define External hemorrhoids
Originate and are located below the dentate line and can be painful especially if thrombosed
Note: not necessarily outside the anal canal but in most cases patients present with lumps around the anus caused by increased or repeated straining such as with severe cases of diarrhea or constipation or increased intra-abdominal pressure
Define hemorrhoids
common condition characterized by pruritus or burning, swelling, rectal bleeding and possibly pain
Define internal hemorrhoids and differentiate between the different grades of severity/degree of prolapse
Originate above the dentate line, most commonly causing painless bleeding with bowel movements
Grade 1: swelling of anal cushion often with straining and are usually painless, do not prolapse below dentate line
Grade 2: prolapse through the anus on straining but spontaneously return to normal position
Grade 3: remain in prolapsed position after straining and require manual replacement
Grade 4: chronically prolapsed, creating a permanent bulge and cannot be replaced after a bowel movement –> painful and bleeding is common, greater risk of thombosis and gangrene
What is the dentate line?
The point at which the squamous anoderm of the anus meets the columnar mucosa of the rectum and typically lies about 3 cm above the anal verge
Major anatomic reference point when classifying hemorrhoids
What is a hemorrhoid anatomically?
Cushions in the sub-epithelial space of the anal canal
What are the characteristics of internal hemorrhoids?
- covered by mucous membranes
- leads to deposition of mucous on perianal skin
- can prolapse through the anal canal
- impede the ability to seal the anus (soiling is common)
Why is the hemorrhoid grading system widely criticized?
Does not involve the patient or their perception of the ailment
What are the characteristics of external hemorrhoids?
- appearance of small soft skin folds or thicker, fleshier appendages
- somatic innervation that causes pain
- can be asymptomatic, itch/moisture/irritation/thrombus
What is the clinical presentation of hemorrhoids?
- rectal bleeding identified on toilet paper or bowl, NOT mixed with stool
- bleeding exacerbated with straining
- usually bright red in colour
- mucous deposition causing itching and burning
- fecal soiling
- pain with thromboses external hemorrhoid
Why is the colour of the blood important when someone presents with hemorrhoids?
Bright red is better as a distal source, dark red indicates proximal cause
What are risk factors for hemorrhoids?
- peaks at 45-65 years
- constipation; hard stool shears the anal cushons
- diarrhea
- prolonged sitting on toilet
- type of work
- physical exertion and weight lifting
- pregnancy due to constipation, venous stasis and hormonal factors
What are some things that are NOT risk factors for hemorrhoids?
- spicy food
- coffee
- alcohol
- participation in sports
- ethnic or socioeconomic groups
What causes pain from external hemorrhoids?
Thrombosis –> firm nodule that has blue or purple tinge and is visible and palpable at the anal orifice (may be non-tender or incredibly painful)
What are the points on assessing dietary history of someone presenting with hemorrhoids?
- inadequate intake of fiber containing foods or fluids is often found
- recent changes in diet or medications should be recorded
What are the red flag s/s that warrant referral?
- prolapse is manually replaced
- rectal bleeding associated with painful defacation
- blood is present in large amounts
- blood is dark in colour
- bleeding is recurrent
- patient is at high risk of colorectal cancer
- patient <12 years
- problems persist for more than 7 days
What are the therapies that are recommended according to the grade of hemorrhoids presented?
1 –> conservative therapy with fiber supplements, dietary and lifestyle changes
2 –> office based treatments
3 –> rubber band ligation, consider surgical management
4 –> surgical management
What are some of the diet modifications that can be done to help in the management of hemorrhoids?
- hard/dry stools are commonly caused by inadequate intake of dietary fiber and fluid
- fibre laxatives = start low and increase slowly, ensure ~1500-200mL/day fluids and ingest 25-30g of fiber per day
What is a Sitz bath and how does it help in the management of hemorrhoids?
- sit in tub of warm water for 15 minutes as a time
- 3-4x daily
benefit: moist heat is thought to lower internal sphincter and anal canal pressure to relieve irritation and pruritus
What are toilet behaviours to recommend to patients for the management of hemorrhoids?
- repeated straining and too much time on the toilet can worsen symptoms
- avoid delaying when feeling the urge to defecate; if bowel movement is not produced in a few minutes (max 5), go on about your day until the call to defecate returns
- wipe with a moistened tissue to minimize abrasion trauma
- blot area dry after using moistened wipes
What are some counselling points if a patient requests a topical medical therapy for the management of hemorrhoids?
- no well designed study for these products; limited evidence for efficacy
- manage symptoms for short term use <7 days
- creams and ointments are preferred over suppositories
***not curative, only control symptoms
What are the different classes of topical products for the management of hemorrhoids?
- local anesthetics
- protectants
- astringents
- corticosteroids
- vasoconstrictors
Local anesthetic topical products - list their MOA, how long you can use them, evidence to support use, possible AEs and some examples.
- used to help relieve pain
- safe for use <7 days, longer increases risk of CD
- no data to support use, evidence in hemorrhoids is lacking
- AEs: CD, prolonged use can lead to absorption, hypersensitivity and potential CNS AEs
Examples: dibucaine, pramoxine
Protectant topical products - list their MOA, evidence to support use and examples.
- Prevents skin irritation by forming physical barrier on the skin; reduce irritation, itching, pain and burning by preventing contact of anal discharge with perianal tissue
- no data to support use
Examples: petrolatum, glycerin, shark liver oil
Astringent topical products - list their MOA, evidence to support use and some examples.
- cause clumping of proteins in the cells of perianal skin or lining of anal canal; promotes dry skin which may relieve burning, itching and pain
- no data to support use
Examples: witch hazel and zinc sulfate
Corticosteroid topical products - list their MOA, safety, evidence to support use and an example.
- temporary relief of itching and reduction of inflammation
- not recommended for >7 days due to increased risk of muscle atrophy
- no data to support use
Example: hydrocortisone (hemorrhoid products are prescription only)
Vasoconstrictor topical products - list their MOA, onset/duration, evidence to support use and possible AEs.
- topical decongestants reduce vascular tone
- rapid onset (~1 min), duration of action only 2-3 hours
- no data to support use
- possible systemic absorption (caution in patients with HTN, CV disease and diabetes)
How do Phlebotonics help in the management of hemorrhoids? List the evidence for efficacy and an example with its dosage regimen.
Oral product that may increase venous tone and strengthen blood pressure wall
Cochrane review showed potential benefit and few safety concerns
Example: Diosmin (OTC) - 1 600mg tablet TID for 4 days, then BID for 3 days
Rubber band ligation - list what they are effective for, how effective they are and risk of complications.
Commonly used for recurrent grade 1 & 2 hemorrhoids
Highly effective and most commonly performed non-surgical procedure for hemorrhoids
Very effective - short term success 99%, long term 80%
Risk of complications is low (1-3%): post-banding pain, bleeding and vasovaginal symptoms
How does rubber band ligation work?
Band is placed close to the dentate line and it causes the banded tissue to necrose and slough in 5-7 days
Inflammatory reaction due to necrosis leads to inflammation that re-fixates the mucosa to the underlying tissue and helps to eliminate the hemorrhoidal prolapse
Can be done every 4-6 weeks if required
What is sclerotherapy?
Injection of sclerosant into the apex of the hemorrhoid; soft tissue reaction following causes thrombosis of involved vessels
What agents are typically used in sclerotherapy and what are the potential complications of the procedure?
5% phenol in oil, 5% quinine and urea, hypertonic saline, 5% sodium morrhuate and sodium tetradecyl sulfate
Complications: pain (12-70%), urinary retention, abscess, and impotence
Which is a superior treatment, rubber band ligation or sclerotherapy?
Rubber band ligation, also superior to infrared coagulation in the treatment of grade 1, 2, and 3 hemorrhoids
What is infrared coagulation?
- involves direct application of infrared waves resulting in protein necrosis
- 3-4 pulses of infrared energy are applied to the normal mucosa proximal to the hemorrhoid tissue, not the hemorrhoid itself
- 1-2 hemorrhoids are treated per session with sessions repeated as needed every 2-4 weeks
- procedure is well tolerated and pain occurs in a small # of patients
**success rates are inferior to rubber band ligation
Who is hemorrhoidal surgery reserved for?
- patients who are refractory to office procedures
- unable to tolerate office procedures
- with large external hemorrhoids
- combined internal and external hemorrhoids with significant prolapse
What are the first line options for management of hemorrhoids in pregnancy?
Dietary and lifestyle modifications: increase in fiber and fluid, sitz baths and proper toilet techniques
***Topical products have NOT been assessed for safety in pregnancy
What pharmacological agents are recommended for symptom relief in pregnancy?
Short term use of diosmin is safe and effective in pregnancy
topical anesthetics and mild corticosteroids can be used for short term relief; excessive use of TCS can be systemically absorbed and can affect fetal growth
