Hemorrhoids Flashcards
What are the 2 kinds of epithelium in the anal canal and the perianal area?
- squamous epithelium and columnar epithelium
What is the division between the 2 tissue types called?
- the dentate line
Is there pain associated with tissue above the dentate line?
rarely experience pain
Is there pain associated with tissue below the dentate line?
yes it may experience pain
What is the other name for hemorrhoids?
- anal cushions
These structures are rich in what?
arterial blood supply leading directly to the distensible venous spaces
- consist of connective tissue and smooth muscle
Are hemorrhoids normal in all people?
yes
What happens in a diseased hemorrhoid state?
- weakened connective tissue supporting the anal cushion
these can be a result of age or sustained passage of hard stools
How does straining lead tot he development of diseased hemorrhoids?
- increased the venous pressure and leads to distension
What is the definition of a diseased hemorrhoid?
- patients are experiencing symptoms as a result of swelling and/or prolapse of the anal cushions
- abnormally large or symptomatic conglomerates of blood vessels, supporting tissues and overlying mucous membrane or skin in the anorectal area
What are diseased hemorrhoids also known as?
piles
What is an internal hemorrhoid?
- lack of sensory nerve fibres, therefore they are not painful
- they develop above the dentate line from the superior hemorrhoidal vein
What is a first degree internal hemorrhoid?
- swell in the anal cushion due to straining (do not prolapse into the anal canal)
What is a second degree internal hemorrhoid?
- protrude into the anal canal with straining or defecting and reduce spontaneously when straining ceases
What is a third degree internal hemorrhoid?
- remain in the prolapsed position after defecation (manual replacement)
What is a fourth degree internal hemorrhoid?
- prolapsed and cannot be reintroduced in the anus (very painful)- likely requires surgery
What is the definition of an external hemorrhoid?
- develops below the dentate line, from the interior hemorrhoidal vein
- this anus is well inverted and therefore often more painful - may cause minimal discomfort to severe pain
- may be visible as bumps at the internal or distal boundary of the anal canal, if bluish it is due to thrombosed blood vessels
What is the prevalence of hemorrhoids?
- rare in children
- both genders are affected
- prevalence will increase with age until the 7th decade and then it will diminish
What are the risk factors of hemorrhoids?
- chronic constipation and diarrhea
- increasing age
- medications
- pregnancy
- occupation that required prolonged sitting
- work that requires lifting (physical exertion)
Why can sitting on a toilet seat for a long period of time increase the risk of hemorrhoids?
- the pressure of the toilet seat is blocking the return of the blood supply and blocking it from going back into circulation - increases the risk of hemorrhoids
What are the most common signs and symptoms of hemorrhoids?
- swelling and bump around the anus
- itching (pruritis ani) and irritation/ burning in the perianal area
- small amount of bright red blood after a BM
- mucous discharge
- associated pain (may take the form of a dull ache, severe, sharp pain upon defecation)
- seepage
- internal hemorrhoids may prolapse
When should hemorrhoids be referred?
- patient is under 12 y/o
- anorectal symptoms that do not resolve within 7 days
- manual replacement needed to a prolapsed hemorrhoid
- severe pain
- rectal bleeding and painful defecation, a lot of blood, or dark blood
- rectal bleeding is recurrent
- rectal bleeding and a high risk of colon cancer
What things cause an increase in colon cancer risk?
- over 50 years of age
- history of colorectal cancer and adenomatous polyposis
- family history of familial adenomatous polyposis or hereditary nonpolyposis colon cancer
- IBD
- strong family history
What are the treatment goals for hemorrhoids?
- relieve symptoms
- prevent complications (such as prolapse, thrombosis or anal fissure)
- promote good bowel habits and good anal hygiene
Is there any curative treatment for hemorrhoids?
- no- you can only treat symptoms
What are some of the non-pharms that can be used to treat hemorrhoids?
- prevention of constipation
- modification or lifestyle factors - increase exercise and fluid intake
- adapt good bowel habits- avoid straining and practice goof anal hygiene (gently wipe anorectal area with mild soap and water after a BM)
- replace prolapsed hemorrhoid with a moistened tissue
- sitz bath (helps to receive symptoms - sit in a tub of warm water for 15 minutes TID to QID)
- cryotherapy (cool off in the fridge and then add to the anal area- keep it inserted for 5 minutes)
What are the three classes of agents that are typically used in those that have hemorrhoids?
- oral analgesics (acetaminophen)
- stool softeners
- hemorrhoidal products (relieve pain, itch, irritation and burning - do NOT decrease bleeding or risk of prolapse)
Why are NSAIDs not used hemorrhoids?
- because of the GI issues and the increased risk of bleeding
What are the ingredients that can alleviate the symptom of pain?
- local anesthetics, astringents, antipruritics, oral analgesics
What are the ingredients that can alleviate the symptom of itching?
- vasoconstrictors, local anesthetics, protectants, hydrocortisone
What can be used to treat burning?
- local anesthetics, astringents, protectants
What can be used to treat irritation?
- local anesthetics, protectants and astringents
What is the best ingredient to treat inflammation?
- hydrocortisone
What is the mechanism of action of an astringent?
- relieve 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 symptoms
What is the MOA of a local anesthetic?
- block nerve conduction in an effort to temporarily relieve itching, irritation and discomfort. Evidence of efficacy is lacking
What is the MOA of an antiseptic?
- inhibit microbial growth in the area where it is used
What is the MOA of a protectant?
- provides a physical barrier to irritation by forming a protective layer over the mucous membranes lining the anorectal area
What is the MOA of a vasoconstrictor?
- stimulates an alpha-adrengeric receptors in the blood vessels, causing constriction of the arterioles. Helps with discomfort, irritation, itching and swelling
What is the MOA of a wound healing agent?
- some products claim to promote healing or tissue repair in anorectal disease
- no scientific evidence to support these claims
What are examples of astringents?
- zinc oxide, zinc sulfate, hamlets water, calamine, bismuth salts
What are examples of local anesthetics?
- benzocaine, lidocaine, dibucaine, pramoxine
What are the examples of protectants?
- ZO, shark liver oil, white petrolatum, glycerin, mineral oil
What is an example of a vasoconstrictor?
phenylephrine
What is an example of a wound healing agent?
- shark liver oil, live yeast cells
What is the MOA of zinc sulfate? Onset? Dose? Max/day?
MOA: astringent Onset: within the first few doses Dose: ung- Q4H prn and after each BM suppository - 1 supp in the morning, at bedtime and after each BM Max/day: max 6x daily
What should be precautioned when using pramoxine in an ointment?
sensitization
What are the potential SE of using pramoxine with zinc oxide?
burning, irritation, itching, allergic reaction
Should local anesthetics be used in suppositories to treat internal hemorrhoids?
- no, they should not because there is generally no pain associated with this
What is the onset of action of dibucaine? Dose?
- 15 minutes
- dose: apply in the morning and evening and after each BM
What are the potential SE associated with using dibucaine?
- contact dermatitis, allergic reactions, burning and itching
Shark liver oil and yeast may ____ clothing
stain
What is the onset of action of hamamelis and phenylephrine (preparation H cooling gel)
- within 1 minute
What is the SE associated with preparation H cooling gel?
- increased blood pressure, CNS disturbances, arrhythmia, aggravation of symptoms of hyperthyroidism
What are the precautions of preparation H cooling gel?
- heart disease, hypertension, thyroid disease, diabetes, prostatic hypertension, intraocular pressure
What are the drug interactions associated with using preparation H cooling gel?
- MAOIs
What is the mechanism of action of hamaelis and glycerin? (Tucks)
works as an astringent and protectant
What is the dose needed for tucks wipes and the max/day for tucks?
dose: use prn or after each BM
max/day: up to 6x per day
Diosmin is a _____ thought to affect the vascular part of hemorrhoids resulting in the decreased inflammation- it is administered po
bioflavonoid
When is diosmin though to be beneficial? Is it actually beneficial?
- beneficial during acute hemorrhoidal symptoms or to treat bleeding
- thought to be possibly safe for short term use and possibly effective for hemorrhoids
What is the mechanism of hydrocortisone?
- decrease itching and inflammation
- avoid prolonged use due to atrophic effects
- can take up to 12 hours to take effect
- should not use longer than 7 days
- avoid broken skin
- should be used sparingly bid and after each BM
- NEVER use by itself for hemorrhoids
What is the action of pramoxine?
- local anesthetic
- should not be used above the dentate line because there are no nerve fibres present
- less cross-sensitivity than other local anesthetics
What are the adverse effects associated with pramoxine?
- allergic reactions, local irritation (burning and itching)
What is the action of zinc sulfate?
- acts as an astringent
- will also act as a barrier, helping to prevent further irritation
What is the action of framycetin sulphate?
- aminoglycoside antibiotic
- meant to relieve superimposed bacterial infection leading to a decrease in edema, inflammation and itching
What are the adverse effects associated with using framycetin sulphate?
- irritation, itching, sensitivity
What is the MOA associated with cinchocaine HCl?
- an amide local anesthetic
- one of the most potent and toxic of the long acting local anaesthetics
- should only be used on a short term basis, because if used longer than a few days may lead to sensitization of the anal skin
What are some of the adverse effects associated with cinchocaine HCl?
- allergic reactions, local irritation (burning and itching)
What is the action of esculin?
may decrease swelling and inflammation
Is scullion okay to use in pregnancy?
NO (also breastfeeding and bleeding disorders)
What might esculin interact with?
may interact with ASA and other antithombotics
What are the adverse effects associated with esculin?
prurits, nausea, stomach complaints, bleeding, nephropathy and allergic reactions
What are the monitoring parameters associated with hemorrhoids?
- anorectal symptom improvement: within first few doses
- if symptoms do not improve or worsen in 7 days should refer
Duration of therapy: in 1 week
What is the treatment of hemorrhoids during pregnancy?
- First line: increase fibre, stool softeners, increase liquid and improve toilet habits. Relieve of constipation and sitz baths also helpful
- OTC option is zinc sulphate
- under medical supervision, local anesthetic and corticosteroid can be used
