Hemorrhoids Flashcards
What is the line separating the Internal from the external hemorrhoids?
Dentate Lane
What is a significant difference between Internal and External hemorrhoids?
Internal: less pain and pressure receptors
patients with external hemorrhoids are more likely to suffer from pain
Pathophysiology of Hemorrhoids
-Vascular cushions slide -> Congested -> Bleed and Protrude
-Originate from superior hemorrhoidal vein
What are the risk factors of Hemorrhoids?
-Diet/lifestyle
-Prolonged sitting or standing
-Erect posture
-Bowel habits
-Constipation
-Diarrhea
-Pregnancy (may be alleviated after delivery)
-Heavy lifting with straining
Difference between Internal and External Hemorrhoids?
-Pain in external hemorrhoids (due to lack/presence of sensory nerve)
Internal: Covered by anal canal
mucous membrane
External: Covered by squamous
epithelium
Thrombosis common in extern Hemorrhoids
Non-Hemorrhoidal Anorectal Disorders
-REFER
-Abscesses
-Fistulas
-Fissures
-Neoplasms
-Polyps
-Pruritus ani
-Inflammatory bowel disease (IBD)
What are symptoms indicate Hemorrhoids or Non-hemorrhoids?
-Hemorrhoids: Itching, Irritation, Inflammation, Burning Discomfort, Swelling; could be some bleeding and pain too
-Non-hemorrhoidal: Pain, Bleeding, Seepage, Change in bowel patterns, Prolapse (rectal)
-> REFER
Symptoms of GI Bleeding
-shortness of breath (SOB)
-Dizziness
-Fatigue
-Orthostasis
-Hypotension
-Lab change -> anemia
-> REFER to ER
Non-pharmacologic Therapy
-Diet: add 25-30 g of fiber to a low-fiber diet
-Bowel habits: less than 10 min, reduce straining, do not hold BM
-Hygiene: Mild unscented soap, Sitz bath
-Surgery: internal hemorrhoids
What are the types of Hemorrhoidal drugs?
-Local anesthetics
– Vasoconstrictors
– Protectants
– Astringents
– Keratolytics
– Corticosteroids
– Analgesics/anesthetics/antipruritics
MOA for local Anesthetics
-blockade of nerve impulse transmission
-Use in only perianal areas or areas below the dentate line
-Reliefs pain QUICKLY!
Types of Local Anesthetics
-Amide group (-caines)
-Pramoxine
EXTERNAL hemorrhoids USE ONLY! -> rectal absorption -> systemic effects (CV and CNS)
Example of a local Anesthetic
-TUCKS Hemorrhoidal Ointment
-> Pramoxine 1%; zinc oxide 12.5%; mineral oil 46.6%; cocoa
butter; kaolin
How do vasoconstrictors help with Hemorrhoids?
-Stimulates alpha-adrenergic = constriction of
arterioles = transient reduction of swelling
-Relieve Itching, discomfort, irritation
-Caution: May increase cardiac contractility, HR, and
bronchodilation
-Phenylephrine with less systemic effects
API of Vasoconstrictors
-Phenylephrine (related to Epinephrine and norepinephrine)
-Example: Preparation H Cooling Gel
Witch hazel 50%; phenylephrine 0.25%
Which Patient population should not use Vasocontrictors?
-patients on Anti-hypertensive bc vasoconstrictors increase BP
-patients on MOAIs (depression, psychiatric illness)
-patients on TCAs
-> due to some systemic absorption -> DDI
Adverse effects of Vasoconstrictors
Nervousness, tremor (shaking), sleeplessness, nausea, and loss of appetite
Protectants
-OILY
-Protective barrier and softens the dry anal area
-prevents irritation caused by fecal matter
-itching, irritation, and burning associated with
external and internal hemorrhoids
-Minimal systemic absorption
Protectant with EXTERNAL USE only
Glycerin
could affect bowel movement (seen in constipation meds), so better for external hemorrhoids
MOA Astringents
-Contracting, wrinkling, blanching of the affected area, and decreasing secretions = become drier
-targets: itching, irritation, and burning
Which API is appropriate for external and internal Hemorrhoids?
External: Witch hazel
Internal and external: Calamine and zinc oxide
Example: Preparation H Cooling Gel
-> Witch hazel 50%; phenylephrine 0.25% (vasoconstrictor)
Keratolytics
Desquamation and debridement/sloughing (removal of damaged tissue) of epidermal cells
-AVOID: Adverse effects outweigh potential benefits
especially in children
Examples of Keratolytics
– Alcloxa, Resorcinol
What are the effects of Hydrocortison-containing products?
-Local anti-inflammatory effects
-> Antipruritic (Anti-itching), Analgesia/vasoconstictor
- Long-term use should be avoided
->Permanent damage and thinning of perianal skin/mucosa
Onset and max concentration of Hydrocortisone?
Onset: may take 12 hours
Max conc: 1%
For itching and pain
Example of Hydrocortisone
Preparation H Anti-Itch Cream
-Hydrocortisone 1%; glycerin (also in protectant - external use only); lanolin;
methylparaben,; petrolatum
What is the API in Analgesics/Anesthetics/Antipruritics (Counterirritants)?
-contain Menthol (need a WARNING)
-never recommended by Dr. Gray
-Distracting local sensation (cool, warm, or tingling)
-> targets Pain, itching, burning
-Example ingredients:
– Menthol, Juniper tar, Camphor
Combination Product Example
TUCKS Medicated Pads
Witch Hazel 50% (Vasoconstrictor - external); glycerin (protectant -External use only)
Special populations to look out for
-Pregnant women, breast-feeding
-children under 12y
Which dosage form is not recommended as the initial form?
Suppositories
CAM Therapy
-Horse chestnut seed extract
targets: Itching, N/V; Caution poorly compounded preps -> poisonous
-have not been assessed for safety or efficacy
Chief complaint: Pain
Local Anesthetics - TUCKS Hemorrhoidal Ointment
-> API for pain relief: Pramoxine 1%
-contact dermatitis doesn’t happen often (there is a lot of mucosal acting as a barrier)
Chief complaint: Itching, Irritation
-Vasoconstrictor (API: Phenylephrine) - reduce swelling due to vasoconstriction
-Protectant (API: Glycerin)
-Astringent
-Hydrocortisone
Chief complaint: Itching and Pain
Hydrocortisone
Role of Phenylephrine
Vasoconstriction
-has some systemic absorption
The most common Astringent API
-Witch Hazel
-drying component
Protectant API
-Oily substances
-Glycerin
Corticosteroids
Hydrocortisone
-> Itching and PAIN
-Onset: 20-30 minutes, can take up to 12h
-best benefit: application over a period of time
Which drugs help immediately with Pain?
Phenylephrine (Vasoconstrictor) and Analgesics (Pramoxine -> External Use only, some systemic absorption)
