Letcure 12: Hemorrhoids, Pinworms and Intestinal Gas Flashcards
Rectum
Semipermeable membrane
Dentate Line
- Columnar cells
- Squamous cells
Where you find Sensory pain fibers
Anal Canal
Connects rectum and outside of the body
Perianal area
- Portion of skin surrounding the
anus - Protective barrier
Internal Anal Sphincter is
voluntary
External Anal Sphincter is
involuntary
Anal (or perianal) abscess
Bacterial infection; pus and bacteria collect and obstruct the anal glands
Anal (or perianal) abscess - Signs/Symptoms
- Pain (worsens with sitting and defecation) - perirectal swelling - discharge - fever - chills
Anal fissure
Slit-like ulcer in anal canal from a traumatic tear (e.g passage of stool; anal intercourse)
Anal fissure -Signs and Symptoms
Severe or burning pain during/after defecation, lasting several minutes to hours; anal spasms; blood may be seen on toilet tissue
Anal fistula
Abnormal internal opening that connects with the external opening
Anal fistula- Signs and Symptoms
Chronic, persistent drainage; pain; possible bleeding on defecation; perianal itching; stool seeping through
external opening
Anal neoplasm
Anal cancers
Anal neoplasm- Signs and Symptoms
- Rare and usually asymptomatic
- bleeding
- changes in bowel habits
- anal discharge
- anal mass
- pain
- pruritus
- rash
Pathophysiology of Hemorrhoids
- Defecation = downward pressure on blood vessels, smooth muscle, and connective tissue in anal canal
- Weakening and displacement of tissues
- Blood vessels become inflamed, bleed, and protrude
- Ultimately leads to hemorrhoids
Causes/Risk Factors of Hemorrhoids
- Age (45-65 years at greatest risk)
- Anal intercourse
- Chronic diarrhea or constipation
- Lack of physical activity
- Obesity
- Poor bowel habits (i.e. prolonged sitting, straining during defecation)
- Pregnancy
Clinical Presentation for Hemorrhoids
Burning Discomfort Inflammation Irritation Pruritus Swelling
Bleeding Change in bowel pattern Pain Prolapse/Protrusion Seepage Thrombosis
Exclusions to Self-Care: Hemorrhoids
- Age < 12 years
- Diagnosed gastrointestinal diseases associated with
colorectal bleeding
• Crohn disease, ulcerative colitis - Family history of colon cancer
- Potentially serious anorectal disorder
• Abscess, fissure, fistula, malignancy/neoplasm - Severe associated signs/symptoms:
• Black, tarry stools, bleeding, pain, prolapse, seepage, thrombosis
• Burning, discomfort, inflammation, pruritus, swelling - Minor symptoms that do not respond to 7 days of self treatment
Hemorrhoids: Goals of Self-Treatment
- Maintain soft stools and preventing straining during
defecation. - Alleviate and maintain remission of anorectal symptoms.
- Prevent anorectal complications.
- Prevent and manage unwanted effects of medications
Hemorrhoids are:
A. Harmless growths
B. Infected tissue
C. Swollen Veins
C. Swollen Veins
_________ may promote hemorrhoidal bleeding?
A.acetaminophen B.diphenhydramine
C.guaifenesin
D.naproxen
D.naproxen
Aspirin and NSAIDs
Non-Pharmacologic Therapy: Hemorrhoids
Diet
- Increase dietary fiber (25-40 grams per day)
- Increase fluid intake
- Proper Bowel Habits
- Avoid “holding it”
- Avoid sitting on toilet for long periods
- Proper anal hygiene
- Avoidance Measures
- Avoid lifting heavy objects
- Discontinue aggravating foods/beverages
- Alcohol, caffeine, spicy foods
- NSAIDs and Aspirin may promote bleeding
Pharmacologic Therapy
Topical Products § Analgesics § Antipruritics § Astringents § Corticosteroids § Keratolytics § Local anesthetics § Protectants § Vasoconstrictors
Analgesics, Anesthetics, Antipruritics Products and Dosing
Camphor
Juniper Tar
Menthol
- Up to 6times/day
Analgesics, Anesthetics, Antipruritics Purpose
Relief for itching and inflammation
Analgesics, Anesthetics, Antipruritics MOA
Provides a cool, warm, or tingling sensation
Analgesics, Anesthetics, Antipruritics Warnings/Precautions
- Do not use internally
- Use sparingly/ not frequently- in small amounts
Astringents Products and Dosing
Calamine
Witch Hazel
Zinc Oxide
-Up to 6times/day or after each bowel movement
Astringents Purpose
- Promoted coagulation of protein in skin cells to protect underlying tissue
- Dries affected area
Astringents MOA
- Decrease cell volume
Astringents Warnings/Precautions
Zinc oxide: systemic zinc toxicity potential with
overuse (nausea, vomiting, lethargy)
Astringents Adverse Effects
- Witch hazel contains alcohol
• May cause stinging - Contact dermatitis (rare)
Corticosteroids Product and Dosing
Hydrocortisone 1%
Up to 3-4 times/day
Corticosteroids Purpose
Relief of itching and irritation
Corticosteroids MOA
Vasoconstrictor and antipruritic (anti-itch)
Corticosteroids Warnings/Precautions
May mask symptoms of bacterial and fungal infections
Corticosteroids Adverse Effects
Skin atrophy and reactions (rare)
atrophy- wasting away or diminution (reduction)
Corticosteroids PK
- Onset of action: up to 12 hours
- Duration of action: longer lasting than other agent
Keratolytics Product and Dosing
Alcloxa
Resorcinol
Up to 6 times/day
Keratolytics Purpose
Debridement of epidermal surface cells
Keratolytics MOA
Fosters cell turnover and loosens surface cells
Keratolytics Warnins/Precautions
Do not use internally
- May expose underlying tissue
- Systemic absorption
- Exfoliative dermatitis, methemoglobinemia
Keratolytics Notes
Balance between benefits and adverse effects
Local Anesthetics Product and Dosing
Dibucaine-Up to 3/4 times/day
Pramoxine- Up to 5 times/day
Benzocaine, Lidocaine and Tetracaine- Up to 6 times/day
Local Anesthetics Purpose
Temporary relief of external anal symptoms
Local Anesthetics MOA
Inhibit conduction of nerve impulses
Local Anesthetics Warnings/Precautions
- May mask pain in more severe disorders
-Do NOT place on open sores - Systemic absorption -> CV and CNS
Cardiovascular and Central Nervous System
Local Anesthetics Adverse Effects
Burning and stinging
Protectants Products and Dosing
Cocoa Butter Glycerin Lanolin Mineral Oil White petrolatum
Up to 6 times/day or after each bowel movement
Protectants Purpose
Protective barrier and softening of anal canal
Protectants Mechanism
Lubricant
Protectants Warnings/Precautions
Lanolin: obtained from sheep
• High risk of allergies
- Greasy feel with ointments
Protectants Adverse Effects
Minimal
Vasoconstrictors Products and Dosing
Ephedrine
Epinephrine
Phenylephrine
Up to 4 times/day
Vasoconstrictors Purpose
Relief of itching, discomfort, irritation, swelling
Vasoconstrictors Mechanism
Stimulation of alpha-adrenergic receptors in vascular beds to
constrict arterioles and reduce swelling
Vasoconstrictors Adverse Effects
- Increased cardiac rate/contractility
- Increased blood pressure (if absorbed systemically)
- Contact dermatitis
Vasoconstrictors Do NOT use for Self-care: Contraindications
Antidepressants, cardiac medications, Diabetes Mellitus (DM), enlarged prostate, heart disease, HTN( Hypertension), thyroid disease
Topical Considerations for Pharmacologic Therapy
§ Applicators § Creams § Foams § Ointments § Suppositories- NOT first line – may migrate from affected anal region easily; slower onset of action
Combination products- Often a good choice
Patient Education: Non-pharmacologic measures
- Avoid constipating medications
- Bowel habits
- Maintain hydration and healthy diet
- Proper anal hygiene
Patient Education: Pharmacologic products
- Select ingredients needed to relieve specific symptoms
- Reduction or relief of symptoms should occur within a few days
- Appropriate use of dosage form based on patient’s preference
Hemorrhoids: Refer if
Presence of serious/severe symptoms and progressive
worsening of symptoms
Symptoms persist beyond 7 days of self treatment
Pinworms are called
Enterobius vermicularis
Enterobius vermicularis
Small, thin, white roundworm
- Intestinal helminth/nematode (roundworms) cause enterobiasis (pinworm infection)
- Parasite
- Most common worm infestation in the United States
- Mostly commonly affects children (5-14 years) and
household members
- High prevalence in day care settings and urban areas
- Transferable only among humans
Pinworm Lifecycle
- Ingestion of pinworm eggs
- Adult female matures (1-2 months)
- Adult female migrate to colon at night
- Lays eggs around the anus and female dies
- Larvae in eggs develop in 4-6 hours
* cycle continues*
Pinworm Pathophysiology
- Eggs can be transmitted via fomites/contaminated hands - Eggs are very small • Can ingest while breathing •Larvae may return to colon through anus (retroinfection)
- Reinfection is common
- Eggs are viable for 20 days
outside intestinal tract
Clinical Presentation of pinworms
- Often asymptomatic
-Pruritus ani
•Typically at night
• Inflammatory reaction of pinworm on skin
-Major infestations
- Abdominal pain, anorexia, insomnia, intractable itching
- Psychosocial trauma
- Complications
- Bacterial infection secondary to scratching
•Female genital tract
•Perianal and perineal regions
•Urinary tract infections
Diagnosis Options
- Tape test
- Touch perianal skin with clear tape first thing in morning
- Perform on 3 consecutive mornings before any washing/hygiene
- Provider examines tape with microscope
Diagnosis Options 2
- Visual inspection
- Look for pinworms overnight at least 2-3 hours after infected
person is asleep
- Worms are 3-7 mm
Diagnosis Options 3
- Fingernail examination
- Look at fingernails under microscope
Exclusions to Self-Care: Pinworms
- Age < 2 years or weight < 25 pounds unless PCP has
approved OTC treatment - Breastfeeding/ Pregnancy
- Helminthic infections other than pinworms
- Hypersensitivity to pyrantel pamoate (option that treats this)
- Liver disease
- Need for repeat dosing
- Vague symptoms and negative visual inspection
Goals of Self-Treatment: Pinworms
- Relieve symptoms of pinworm infection.
- Eradicate pinworms from patient and household.
- Prevent and manage unwanted effects of medications.
- Prevent reinfection and transmission.
Non-Pharmacologic Therapy: Pinworms
Proper hygiene § Wash hands with soap and water § Keep fingernails short and clean § Discourage biting nails and scratching perianal area § Daily showers
- Wash bedlinens, underwear, and towels
§ Use hot water for washing and hot drying cycle
§ Pinworm eggs are killed by temperatures > 131 ℉
§Change underwear, clothes, and bedlinens daily for several days after treatment
Pinworms are killed by temperatures
greater than 131 ˚F
Pharmacologic Therapy: Pinworms
Pyrantel pamoate
§ May not reliably kill pinworms
§ Second dose often used to prevent reinfection
§ Variable efficacy due to effect on eggs and egg viability for up to
20 days
Pyrantel Pamoate Brand Name
Pin-X,
Reese’s
Pyrantel Pamoate MOA
Depolarizing neuromuscular agent
This paralyzes adult worms Which loosens worms’ hold on intestinal wall
Then results in worm passed in stool before eggs are laid
Pyrantel Pamoate Contraindications
Hypersensitivity
Pyrantel Pamoate Precautions
Hepatic impairment
Pyrantel Pamoate Adverse effects
Common: abdominal cramps; diarrhea; nausea; vomiting
Less common: dizziness; headache; rash
Pyrantel Pamoate Dosing
11 mg/kg by mouth as a single dose
§ Maximum single dose = 1 gram
§ Dose can be repeated in 2 weeks if symptoms do not resolve
(consult PCP)
Pyrantel Pamoate Patient Education
Take with or without food at any time of day
• May mix with juice or milk
- Treat ALL members of the household to ensure elimination of the
infection - Administered as a SINGLE dose
- Weight-based dosing is the same for all patients ≥ 2 years
Evaluation of Patient Outcomes
Refer if Symptoms persist beyond 2 weeks after initial dose of pyrantel pamoate
-PCP may recommend a second dose
Intestinal gas pathophysiology
Colonic fermentation is the primary process for intestinal gas generation
- Influenced by type and quantity of food ingested
- Amount of air entering the upper GIT with swallowing
- Bacterial overgrowth of small intestine
- Medical conditions and Medications can cause this
Common gas-producing foods
- Beans
§ Carbonated beverages
§ Complex carbohydrates
§ Dairy products
§ Fatty foods
§ Fruits: apricots, bananas, dried fruit, prunes
§ Vegetables: Brussels sprouts, cabbage, cauliflower, onions
Things that cause larger amounts of air swallowed
§ Chewing gum/hard candies § Drinking carbonated beverages § Hyperventilating § Poor eating habits § Poor-fitting dentures § Smoking
Medical conditions that can cause Intestinal Gas
Carbohydrate malabsorption § Lactase deficiency § Celiac disease § Diabetic gastroparesis § Irritable bowel syndrome (IBS) § Pancreatic insufficiency
Medications that can cause Intestinal Gas can/are
§ Affect GI motility, intestinal flora, or metabolism of glucose and
other dietary substances
§ Are high in fiber
§ Contain or release gas
Clinical Presentation: Intestinal Gas
Common symptoms: § Abdominal discomfort or cramping § Bloating § Excessive belching § Flatulence
Associated Symptoms
§ Audible bowel sounds
§ Dyspepsia
§ Nausea
Exclusions to Self-Care: Intestinal Gas
- Symptoms that persist for more than several days or occur more often than occasionally (several times a month)
- Severe debilitating symptoms
- Sudden change in location of abdominal pain, significant
increase in frequency/severity of symptoms - onset of
symptoms in individuals > 40 years of age - Significant abdominal discomfort or a sudden change in
bowel function - Presence of accompanying symptoms such as severe or
persistent diarrhea or constipation, GI bleeding, fatigue, unintentional weight loss, or frequent nocturnal symptoms
Goals of Self-Treatment: INTESTINAL GAS
- Reduce frequency, intensity, and duration of intestinal gas
symptoms. - Reduce the impact of intestinal gas symptoms on the
patient’s lifestyle. - Prevent and manage unwanted effects of medications.
Non-Pharmacologic Therapy:
- Avoid tight-fitting clothing and belts
- Chew food thoroughly
- Do not attempt to induce belching or strain to pass gas
- Do not lie down immediately after eating
- Eat and drink slowly
- Reduce consumption of gas-producing foods
- Wear dentures with proper fit
Pharmacologic Therapy:
Antiflatulent products
- Limited supporting evidence
- Relieve symptoms after intestinal gas has formed
- Digestive enzymes
- Symptoms associated with foods containing lactose or oligosaccharides
- Prevent gas from forming
Intestinal Gas Pharmacologic Agents
Simethicone
Alpha-Galactosidase
Lactase Replacement Products
Simethicone Brand Name
Gas-X
Mylicon
Simethicone MOA
Defoaming agent – reduces surface tension of gas bubbles embedded in GIT
Simethicone Dosing
Adults: 40-125 mg by mouth after meals and at bedtime as needed
Children ≥ 12 years: 40-125 mg by mouth 4 times daily
Children 2 to < 12 years: 40-50 mg by mouth four times daily
Children < 2 years: 20 mg by mouth four times daily as needed
Simethicone Contraindications
Hypersensitivity; suspected intestinal perforation and obstruction
Simethicone Special Pops
Children/ infants and Breastfeeding: considered safe
Pregnancy: fetal risk is minimal
Alpha-Galactosidase Brand Name
Beano
Alpha-Galactosidase MOA
Hydrolyzes oligosaccharides before they can be metabolized by colonic bacteria
Alpha-Galactosidase Dosing
Adults: 300-450 units by mouth per serving of food
Alpha-Galactosidase Contraindications
Hypersensitivity
Alpha-Galactosidase Precautions
Diabetes
galactosemia
mold allergies
Alpha-Galactosidase- Special Pops
Children and infants: avoid use
Pregnancy and Breastfeeding: consult with provider
Lactase Replacement Products Brand Name
Lactaid, Lactase, etc
Lactase Replacement Products MOA
Break down lactose, a disaccharide, into the monosaccharides
glucose and galactose, which are absorbed
Lactase Replacement Products Dosing
Adults ≥ 12 years: 3000-18,000 units by mouth at first bite of food or
drink containing lactose
Lactase Replacement Products Special Pops
No considerations listed
Simethicone
Used to treat intestinal gas AFTER it has occurred
Alpha-Galactosidase
Should be taken with foods to PREVENT intestinal gas from forming
Lactase Replacement Products
Should be taken with foods to PREVENT intestinal gas from forming
-Take at first bite of dairy or lactose-containing food
Non-pharmacologic measures
- Avoid activities known to introduce gas into GIT
- Avoid triggers
Evaluation of Patient Outcomes
- Symptoms generally self-limiting within 24 hours
- Follow-up after 1 week of self-care with dietary measures or pharmacologic therapies
