Hemorrhoids Flashcards
2024
What are hemorrhoids?
A) Abnormal growths in the rectum
B) A common condition characterized by rectal bleeding, sometimes pain and itching due to inflammation of the blood vessels within the anal canal
C) Severe sharp pain which always occurs during defecation; small amounts of red blood can be seen on tissue or in stool
D) Varicose veins in the rectum
E) A type of cancerous lesion
B) A common condition characterized by rectal bleeding, sometimes pain and itching due to inflammation of the blood vessels within the anal canal
Hemorrhoids are when the veins or blood vessels in and around your anus and lower rectum become swollen and irritated.
Symptomatic hemorrhoids are experienced by approximately ______% of individuals at some point in their lives.
According to MedSask (2023), symptomatic hemorrhoids are experienced by 58–86% of individuals at some point in their lives.
- Approx 75% of population will have hemorrhoids at some point in their lifetime at least once.
Actual prevalence is assumed to be under-reported since many people self-treat.
When are hemorrhoids cautioned to be a medical problem? (4)
Not necessarily red flags btw
Only if they become
- enlarged — If hemorrhoids become enlarged, they can cause symptoms like bleeding, itching and burning around the anus,
- thrombosed (i.e., obstructed or affected by a clot of coagulated blood),
- prolapsed (abnormal downward displacement), or
- start bleeding
Hemorrhoids are sometimes INCORRECTLY referred to as ________ in the anal canal.
Varicose veins
Hemorrhoids become medical problems only if they become enlarged, __________, prolapsed, or start bleeding
Thrombosed
Symptoms of hemorrhoids are often self-limiting, usually resolving without treatment within ________ [time frame].
2 weeks.
_________ in the anal canal are a normal part of human anatomy, and these cushions or plexus normally help to seal the upper anal canal and contribute to continence.
Hemorrhoidal cushions
What are hemorrhoids [anatomical term]?
A) Abnormal growths in the anal canal
B) Vascular structures located in the anal canal
C) Varicose veins in the rectum
D) A type of cancerous lesion
B) Vascular structures located in the anal canal
Hemorrhoids [anatomical] are vascular structures located in the anal canal and consist of normal anatomic features, including connective tissue, an arteriovenous plexus, and smooth muscle.
T/F: Internal hemorrhoids are typically painful.
False!
INTERNAL Hemorrhoids originate ABOVE the Dentate line (also called pectinate or anorectal line) and should not cause pain UNLESS complications develop, since this area has NO NERVE FIBRES.
Internal hemorrhoids usually will involve painless bleeding with the bowel.
Hemorrhoids contribute to continence by aiding in the closure of the __________.
Anal opening.
What are the (3) Goals of Therapy for Hemorrhoids?
i) Relieve symptoms
ii) Prevent complications
iii) Prevent future episodes by promoting good bowel habits and hygiene
What is the location of internal hemorrhoids?
A) Above the dentate line
B) Below the dentate line
C) Outside the anal canal
D) In the skin around the anus
A) Above the dentate line.
Has no nerve fibres and is why internal hemorrhoids are usually painless bleeding.
T/F: External hemorrhoids can develop a blood clot, leading to thrombosis.
True! This is why external hemorrhoids can be painful.
External hemorrhoids can become painful, especially if they develop a blood clot, a condition known as thrombosis.
Symptoms of hemorrhoids may include _________, itching, discomfort, pain, and swelling around the anus.
Rectal bleeding
Symptoms of hemorrhoids reported by patients may include rectal bleeding, _______, discomfort, pain, and swelling around the anus.
(What are some common things patients might tell me about it)
Itching
Symptoms of hemorrhoids may include rectal bleeding, itching, _______/______, and swelling around the anus.
Discomfort / Pain
Symptoms of hemorrhoids may include rectal bleeding, itching, discomfort, pain, and ________ around the _______.
Swelling ; Anus
What factors can contribute to the development of hemorrhoids?
A) Prolonged sitting or standing
B) Regular exercise
C) Drinking plenty of water
D) Avoiding fiber-rich foods
E) All of the above
A) Prolonged sitting or standing
Hemorrhoids can be classified as internal, external or mixed.
How does one classify Internal hemorrhoids vs. External hemorrhoids?
a) Based on if patient experiences pain and the severity of the discomfort
b) Based on the location where the hemorrhoid originates from
c) Based on age and demographic
d) Based on after other serious differential diagnoses, such as colorectal cancer or IBD has been ruled out.
e) All of the above.
b) Based on the location where the hemorrhoid originates from
Internal and External hemorrhoids are classified based on its location above or below the dentate line, respectively.
- Internal hemorrhoids originate above the dentate line.
- External hemorrhoids originate and are located below the dentate line and can be painful (especially if thrombosed). Note: they are not necessarily outside the anal canal, just below the dentate line.
What are the symptoms of symptomatic hemorrhoids?
A) Rectal bleeding (bright red) and itching
B) Pruritus or burning, pain and swelling around the anus
C) Discomfort during bowel movements (straining)
D) All of the above
D) All of the above
- pruritus or burning, swelling, rectal bleeding (often during or immediately following a bowel movement), and possibly pain.
Hemorrhoids are the most common cause of rectal bleeding.
Bright red blood is characteristic of hemorrhoids. The bleeding may vary from light spotting on the toilet paper to drops in the toilet bowl, and most often occurs during or immediately following defecation.
_______ hemorrhoids are located beneath the skin around the anus.
External hemorrhoids
T/F: Hemorrhoids are only symptomatic when they become thrombosed.
False.
Hemorrhoids can become symptomatic when they are enlarged, inflamed, prolapsed, or thrombosed.
What is the junction between the rectum and the anal canal called?
A) Perianal region
B) Dentate line
C) Anorectal ring
D) Anal sphincter
B) Dentate line
(also called pectinate or anorectal line)
Hemorrhoids can become symptomatic when they are __________, inflamed, prolapsed, or thrombosed.
Enlarged.
T/F: Straining during bowel movements is not a factor contributing to the development of hemorrhoids.
False!
Straining during bowel movements is indeed a factor contributing to the development of hemorrhoids, as well as it is another symptom of hemorrhoids.
What is the term for hemorrhoids that have both internal and external components?
A) Symptomatic hemorrhoids
B) Mixed hemorrhoids
C) Thrombosed hemorrhoids
D) Prolapsed hemorrhoids
B) Mixed hemorrhoids
Hemorrhoids can become symptomatic when they are enlarged, inflamed, ______, or thrombosed.
prolapsed
Bleeding is one of the characteristics of hemorrhoids; however, not all kinds of bleeding indicates hemorrhoids and/or requires MD referral.
Which of the following statements warrants an MD referral (and no longer pharmacist territory)?
a) Bright red blood
b) Drops of blood in the toilet bowl during or after a bowel movement
c) Dark blood or blood mixed with fecal matter
d) Any blood that is found on toilet paper upon wiping
e) All of the above
c) Dark blood or blood mixed with fecal matter should be suspicious of an alternate diagnosis and is to be referred to MD as can be indicative of something like Upper GI Bleed.
Black, tarry stool is also a red flag and should be referred.
Any form of rectal bleeding is something pharmacists know we can’t do much about, but we still dive in a bit and try to lay the ground work and see how serious it is and let patient decide when to see MD with our help.
T/F: Constipation refers to the condition where there is difficulty in passing stool, while hemorrhoids refer to the swelling of blood vessels in the anal canal.
True!
T/F: Hemorrhoids can cause rectal bleeding, while constipation cannot
False!
Both hemorrhoids and constipation can cause rectal bleeding.
Which of the following may contribute to the development of both hemorrhoids and constipation?
A) Drinking plenty of water
B) Regular exercise
C) Prolonged sitting or standing
D) Eating a high-fiber diet
C) Prolonged sitting or standing
T/F: Hemorrhoids and constipation are mutually exclusive conditions and cannot occur simultaneously.
False.
Hemorrhoids and constipation can occur simultaneously, and one condition does not exclude the other.
BUT not necessarily something that is generally common to occur.
A patient presents with painless rectal bleeding during bowel movements. Upon examination, the healthcare provider observes swollen blood vessels located above the dentate line.
What is the most likely diagnosis?
A) Internal hemorrhoids
B) External hemorrhoids
C) Anal fissures
D) Colorectal cancer
A) Internal hemorrhoids
T/F: External hemorrhoids are located above the dentate line in the anal canal.
False.
External hemorrhoids are located below the dentate line.
A 45-year-old woman complains of itching around her anus, especially at night. She also notices small, white, thread-like worms in her stool. What is the most likely diagnosis?
a) Internal hemorrhoids
b) Constipation
c) Anal fissures
d) Cholera
e) Pinworms
e) Pinworms
Pinworms (Enterobius vermicularis) should be consider if predominant symptom is anal pruritus and there is a school-aged child in the household.
Often an entire family is infected due to transmission from the affected individual.
A 60-year-old man presents with unintentional weight loss, changes in bowel habits (including constipation alternating with diarrhea), and rectal bleeding. He also complains of abdominal pain and fatigue.
What condition should be suspected, and what diagnostic tests are indicated?
Colorectal cancer should be suspected.
Diagnostic tests may include colonoscopy, fecal occult blood test (FOBT), and imaging studies such as CT scans to evaluate the extent of the disease.
______ involves difficulty passing stool, often resulting in infrequent bowel movements or hard, dry stools.
Constipation
Which condition may present with melena (black, tarry stools) and symptoms of anemia such as fatigue and weakness?
A) Upper GI tract bleeding
B) Internal hemorrhoids
C) Anal fissures
D) Pinworms
A) Upper GI tract bleeding
If patient reports black, tarry stools, it is not typical of hemorrhoids and should be referred as could be possible upper GI tract bleeding, or other serious problems.
T/F: Hemorrhoids are typically associated with changes in bowel habits such as constipation alternating with diarrhea.
False…
Hemorrhoids themselves are not typically associated with changes in bowel habits such as constipation alternating with diarrhea. Hemorrhoids primarily present with symptoms such as rectal bleeding, itching, discomfort, pain, and swelling around the anus.
Constipation and diarrhea can both contribute to the development or exacerbation of hemorrhoids due to the strain and pressure exerted during bowel movements. However, hemorrhoids are not the primary cause of changes in bowel habits. Conditions such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and certain dietary factors are more commonly associated with alterations in bowel habits.
A 30-year-old woman complains of pain and swelling around her anus, especially after prolonged sitting. On examination, the healthcare provider observes bluish, tender lumps around the anal opening.
What is the likely diagnosis?
External hemorrhoids
How are hemorrhoids graded based on severity/degree of prolapse?
A) Grade A, Grade B, Grade C, Grade D
B) Grade I, Grade II, Grade III, Grade IV
C) Grade Mild, Grade Moderate, Grade Severe
D) Grade Primary, Grade Secondary, Grade Tertiary, Grade Quaternary
B) Grade I, Grade II, Grade III, Grade IV
Grade I is the least painful (or no pain), and Grade IV is the most discomforting and indicates likely chronic prolapsing.
T/F: Grade II hemorrhoids prolapse through the anus on straining but spontaneously return to the normal position. This is usually a painless form of internal hemorrhoids.
True!
Grade II usually painless as it is likely that the internal hemorrhoid has prolapsed through the anus on straining, but spontaneously return to normal position.
A small part of the anal mucosa or cushion that may protrude at the anus during defecation. After the bowel movement, the tissue spontaneously returns to its normal position. Usually painless
Grade ___ : Swelling of the anal cushion, often with straining, and are usually painless. They do not prolapse below the dentate line
Grade I of Internal Hemorrhoids classification.
Grade ____: Prolapse through the anus on straining, but spontaneously return to normal position.
Grade II of Internal Hemorrhoids classification.
Grade _____: Remain in the prolapsed position after straining and require manual replacement. Might be painful and rectal bleeding is common in this stage.
Grade III of Internal Hemorrhoids classification.
Grade _____: Chronically prolapsed, creating a permanent bulge and cannot be replaced after a bowel movement. This stage is quite painful and bleeding is common. In this stage of [internal] hemorrhoids, person at risk of thrombosis and gangrene
Grade IV of Internal Hemorrhoids classification.
Which grade of internal hemorrhoids requires manual replacement after prolapsing?
A) Grade I
B) Grade II
C) Grade III
D) Grade IV
C) Grade III
Grade IV cannot have replaced after bowel movement.
T/F: Grade IV hemorrhoids are characterized by chronic prolapse, creating a permanent bulge that cannot be replaced after a bowel movement.
True!
Which grade of hemorrhoids is at risk of thrombosis and gangrene?
A) Grade I
B) Grade II
C) Grade III
D) Grade IV
D) Grade IV
T/F: Grade I of internal hemorrhoids often cause pain and discomfort, especially during bowel movements.
False.
Grade I and II are usually painless.
According to Orkin (1999), out of all hemorrhoid complaints reported, when seen at an MD’s office, _____% of cases were not hemorrhoids but something else instead.
50% approximately
In SK, what age group are pharmacists required to Refer individuals who suspect themselves to have hemorrhoids?
< 12 years-old
Individuals who are under the age of 12 are to be referred.
List the (4) Risk Factors of Colorectal Cancer that would require SK Pharmacists to Refer people to see the MD when they suspect hemorrhoids:
1) Over 50 years of age with new onset of symptoms not diagnosed by their primary care provider (note: age alone is NOT a reason to refer btw)
2) History of inflammatory bowel disease
3) Personal history of colorectal cancer or adenomatous polyposis
4) Strong family history of EITHER cancer or polyps in a first-degree relative <60 years old OR two first-degree relatives of any age)
Which of the following conditions are not usually associated with the anus and/or the anal canal?
a) Constipation
b) Internal hemorrhoids
c) External hemorrhoids
d) Anal fissures
a) Constipation does NOT affect the anal and/or the anal canal…
Constipation usually affects either the colon or rectum.
Hemorrhoids affects which region of the body?
a) Anus
b) Anal canal
c) Rectum
d) Both a and b
e) All of the above
e) All of the above!
Hemorrhoids generally affects the anal canal. The anal canal is what is connecting the rectum to the end of the gastrointestinal system, the anus.
For example, internal hemorrhoids occurs Inside the rectum, above the dentate line… External hemorrhoids occurs beneath the skin around the anus.
______ May present with sharp pain during bowel movements, visible tear or crack in the skin around the anus.
a) Anal fissures
b) Internal hemorrhoids
c) External hemorrhoids
d) Consequences of straining during constipation and/or hemorrhoids.
a) Anal fissures
By coincidence, anal fissures can be concurrently seen in approx. ____% of hemorrhoid sufferers according to Clin Gas Hep 2013?
Approx. 20% will see concurrent incidences.
______ May present with abdominal bloating, cramping, discomfort, or pain, feeling of incomplete evacuation of stool
Constipation
_______ May present with both painless rectal bleeding and pain/discomfort around the anus
Mixed hemorrhoids
What are the two symptoms for hemorrhoids that can also be an indication of possible Colorectal Cancer signs?
Bleeding and Pain
Bleeding for colorectal cancer is recurrent, often darker in colour (but could still be bright or mixed with fecal matter)
Along with that, Change in bowel habits (stool consistency, frequency, narrower stools), and Unexplained weight loss are also indications that can flag possible colorectal cancer.
_______ can be described to be associated with Pain, itching, discomfort, swelling, palpable lump around the anus
External hemorrhoids
If symptoms of suspected hemorrhoids does not improve after _______ (unless worsening of symptoms, or develops red flag symptoms) of starting pharmacological treatment, patient should be referred to MD.
7 days.
Patients with suspected with hemorrhoids should be referred to MD if rectal bleeding persisting after local treatment for ____ to ____ week(s), with or without a change in stool consistency and/or frequency.
6-8 weeks
(regardless of changes in stool consistency and/or frequency)
___ are abnormal tissue growths that can occur in various parts of the body, including the colon, rectum, stomach, uterus, and nasal passages, among others. Usually found via scope.
Polyps
Proctitis vs. Hemorrhoids are very important differentials to note**
Proctitis and hemorrhoids both affect the ____ area and may share some symptoms (such as rectal bleeding), they are distinct conditions with different ____, diagnostic approaches, and ____ strategies.
Both conditions affects the Rectal Area.
But differ based on Different CAUSES and have different TREATMENT considerations.
Which demographic is more likely to see more polyps as a differential diagnosis?
Elderly patients.
______ refers to a child’s intentional refusal or reluctance to have a bowel movement. This behavior is commonly associated with constipation and can exacerbate the problem by leading to the retention of stool in the colon and rectum.
Withholding Behaviours in children.
When making assessments for hemorrhoids, which kind of hemorrhoids is likely to be described as being up to the size of a pea?
External hemorrhoids
Which kind of hemorrhoid is likely to be located more towards the middle of the anal canal?
Internal hemorrhoids - because it’s usually inside the rectum
At a pharmacy angle, rank the suspected likelihood of causes of rectal bleeding from most likely reason/diagnosis to least likely when considering:
- Colorectal cancer
- Hemorrhoids
- Anal fissures
- Other reasons
1: Hemorrhoids
Most common (likely):
#2: Anal Fissures
#3: Colorectal Cancer
#4: Other
** This is just an interpretation from Jeff’s observations. #3 and #4 were pretty much tied.
Note that as people get older, we get more concerned about the worser outcomes.
______ consists of a tub of warm water in which the individual sits for 15 minutes at a time. It can help relieve irritation and pruritus.
- can technically use cool water if can handle the discomforting temperatures as it can be anti-inflammatory.
Sitz Bath
How does a Sitz Bath work?
- a shallow basin (“shallow bowl”) is placed on top of the toilet
- a hose connected to a bag of water will allow the water to shoot up (think of it as a bidet LOL)
Alternative to a Sitz Bath for example, what can a person do to take the pressure off the area PRN?
This requires absolutely no products or change in diet
Laying down in a PRONE POSITION (face down) help take the pressure off the area when needed.
What can a person do to provide themselves with short-term or temporary relief from a prolapsed tissue?
Can try to PUSH THE PROLAPSED TISSUE BACK IN using own finger.
Push it back in and keep it safe.
How might we apply Dry Skin Lotions (PRN use) to help treat some symptoms associated w/ hemorrhoids - which can be an alternative means instead of buying a commercial product marketed for hemorrhoid use?
How would you apply or use these products
Using dry toilet paper as an “applicator” of the dry skin lotion and apply to the affected area PRN.
Which product contains pramoxine as its local anesthetic agent in addition to zinc sulfate?
a) Anusol
b) Anusol Plus
c) Preparation H
d) Proctosedyl and Proctol
e) Anusol-HC
b) Anusol Plus
(both their ointment and suppositories contains zinc sulfate plus pramoxine)
Do pharmacists recommend citrus bioflavonoids OTC/BTC products like Hemovel and Venixxa for hemorrhoids?
No! Skepticism is super high!!!!
{how is it possible for us to take an oral pill to be helpful to treat one of the most distal areas of our GI tracts in relieving symptoms?!}
[most] Preparation H is classified as being a _________ [drug class]
Yeast Derivative [Bio-Dyne]
- Live yeast cell derivative which is extracted from brewer’s yeast.
Which Preparation-H Product is the “black sheep” of its family and considered to be different from the rest of their products in their line?
Preparation H-PE Gel
This is a DIFFERENT from the other Prep-H products as the H-PE Gel contains the following Active ingredients (w/w):
- Phenylephrine hydrochloride 0.25%,
- [Hamamelis Water or Witch Hazel]
Hamamelis Virginiana 50%
***has no shark liver oil/Bio-Dyne in it **
What makes Preparation H-PE Gel so different from the rest of the Preparation-H products?
Contains:
- Phenylephrine
- Hamamelis Water
(it does NOT contain Bio-Dyne, yeast derivative like the rest of Prep-H products do)
Which Preparation-H product is likely to help with dark circles or bags under the eyes?
NONE!! Preparation-H is likely not going to have any effects on under eye bags.
(Sorry, Victor from Miss Congeniality lied to us!)
