W10. Hemorrhoids

Question 1

Scholar for hemorrhoids

Answer 1

• Symptoms:
  
  • wetness, itch, some bleeing
• Charcateristics
  
  • feels off
  • itch bothersome
  • bright red appears on toilet paper after wipes
• Hisotry
  
  • he has this on and off 5-10 years, normally remits and reappears
  • before OTCs ahve worked but now dont work
• Onset
  
  • starteda few days ago triggered by diarrhea
• location
  
  • anus
• Aggravating
  
  • defectation
• remitting
  
  • some creams

Question 2

rectal anatomy

Answer 2

• Rectum: upper area above opening
  
  • lacks physical sensation, no nerves but can feel fullness
  • columar epithelium lines it
• Anal canal
  
  • 4cm extends from anal verge to its junction with rectum
  • lined with nerves to can feel pain
• Dentate line separate the two

Question 3

internal vs external hemrrhoids

Answer 3

• internal = above dentate line
  
  • covered in mucos membrane so can leak -> cause the wetness
• external is below
  
  • appearance of small soft skin folds or thicker fleshier appendages
  • below dentate line have somatic innervation and causes pain
  • can be asymp ot itch, moisture and irriation

Question 4

what are hemorrhoids

Answer 4

• plexus of blood vessels that are cushions in subepithelial space of anal canal
• > blood vessels, smooth mscle and elastic and connective tissue at jucntoin of rectum and the anus
• have fucntion, provide 15-20% of resting anal pressure

Question 5

grading of internal hemorrhoids

Answer 5

1. Prominent hemorrhoidal vessels that may bleed but no prolapse
2. small aprt of anal mucosa or cushion may protude at anus during defication
3. hemorrhoids remain in prolapsed position after defecation but may be replaced manually wihtin anus
4. hemorrhoids cannot be replaced after BM and create permament blude at anus

*widely critisied bc does not consider the impact on the patient

Question 7

epidemiology of hemorrhoids

Answer 7

• close to 5% of population
• 58-86% of individuals have symptomatic hemorrhoids at some point
• related complains may be responsible for 36% of seeking caer in general medical practices

Question 8

clincila presentation

Answer 8

• rectal bleeding
  
  • identified toilet paper or in toiler
  • not mixed with stool
  • can drip or squirt out
  • exacerbated by straining
  • is usually bright red in colour
  • does not typically cause positive hemoccult test
• mucous deposition
• fecal soiling
• pain with thrombosed external hemorrhoid

Question 9

relevance of colour of blood

Answer 9

birght red is better because coming as distal source (coming from that area)

• if coming from more proximal then not coming from that area and idnication of bleed elsewhere then would be referal

Question 10

risk factors

Answer 10

both sexes: peak age 45-65

• constipation: ahrd stool and shear anal cushoins
• diarrhea

prolonged sitting on toilet

physical exertion and weight lifting

• pregnancy (due to constipation, venous stasis and hormonal factors)

* can develop in patients with no changes in their normal bowel habits

Question 11

what are not risk factors

Answer 11

spciy food, coffee, alc, participaiton in sports, ethnic/socioeconomic groups

Question 12

clincial presentation of internal hemrrhoid

Answer 12

• overed in columnar mucosa, can lead to mucous depostion on perianal skin causing itching and perianal irritation
• prolapsing tissue can also decrease abiltiy to forma tight seal at the anal verge
• fecal soiling is common
• itching and burning some will describe it as pressure

Question 13

clinical presentation of external hemorrhoid

Answer 13

• many are asymptomatic
• symptoms can be tiching, erpianal mositure, difficult cleaning it (if there is a mass there)
• skin covered external hem can be red, swollen due to scratching and cleaning
• infection rare tho

*usualy cause no pain unless thrombosis is present

• > hard nodule, non tender but super painful
• > when resolves a small or larger skin tag, typically do nto regress compeletely

Question 14

patient assessment

Answer 14

• Symptomology
  
  • nauture, duration and severety
    
    • bleeding, anal pain, swelling
  • probe about soiling or leakage
• Dietary history
  
  • inadequate intake of fiber or flid often found
  • recent change in deit or medications (causing constiaption that thne cause this)
• Bowel habits
  
  • specific regarding freq of stoof
    
    • how is your stool comapred to your normal (passings, consistency look at bristol stool chart)
    • urgencycontinence issues

Question 16

red flags

Answer 16

• prolapse that must be manually replaced
• if rectal bleeding AND: painful defeation, large amounts of blood, dark blood, recurrent bleeding, high risk of colorectal cancer
• if patinet is under 12 (abnormality, winroms, sexual abuse_
• perisitent for more than 7 days

Question 17

management for internal hemorrhoid based on grade

Answer 17

• all grade do diet and lifestyle
• pharmacotherapy in 1,2 and some 3
• office based procedure: 1,2 and some 3
  surgical: 3 and 4

Question 18

impact of fiber

Answer 18

• hard or dry stools commonly due to inadequate fiber and fluid
• taked up to 6 weeks for it to help

can recommend supp (psyllium): start low and increase slow, ensure adequate fluid intake and aim for 25-30g fiber per day

Question 19

sitz bath

Answer 19

• helps flush water in urea around these, can provide soem relief
• 3-4 times daily may help to releive irriation and pruritis

sit in warm tub for 15 min

• this mosit heat is thought to lwoer internal sphicter and anal canal

espsom salt or bakign sode is okay, but isnt going to help

Question 20

toiler behaviour considerations

Answer 20

• straining or too much time on toilet can make worse

avoid delaying when feel urge to defecate

• reading ro using cell phoen should be avoided
• can wipe with moisened tissue to minimze abrasion but then pat dry

Question 21

topical emdical therapies

Answer 21

really dont know how well they work

mainly just symptom relief NOT curative

*CREAMAND AND OINT PREFERRED OVER SUPPOSITORIES: easily inserted too far and then dont do anyhting

Question 22

treatment with local anesthetics

Answer 22

dibucaine and pramoxine

help relief pain

0 use for less than 7 days generally safe, logner can inc risk fo contact derm

• no data to suport
• local AE occur: prolonged use to recal musosa can lead to absorption, hypersensitivity reeaction and potential CNS efffects

Question 23

• Protectants

Answer 23

• petrolatum glycerin, shark liver oil
• prevents irritation of perianal area by forming a physical barrier on skin

0 barrier thought to reduce irritation tiching, paina dn burning

• no data to support

commonly used as a base in RX and OTC

Question 24

Astringents

Answer 24

• cause clumping of proteins in cells of perianal akin or lining of anal canal
  ex: witch hazel and zinc sulfate
• promtoe dryness whcih can gelp relieve burning itching and pain
• witch hazel is available in pads that can be used to wipe the area, pre moisented so can be reliefing (can frige them and hold there will help esp preg patients to provide some relief)

Question 25

corticosteroids

Answer 25

temporary relief of itching an reuce inflammation

• nto rec or more than 7 days due to inc risk of mucosal atrophy
• no data to suppler

*in Canada topical with hydrocortisone are Rx only

Question 26

vasoconstrictors

Answer 26

topical decongestatns used to icnrease vasular tone

no data

• rapid onset but only 2-3 hour duration
• possible systemic abs and should be sued in caution in patients with hyper tension CB disease and diabetes

Question 27

Phlebotonics

Answer 27

oral product; most common class is flavenoids

• MOA unknown but can icnrease venous tone and strengthen blood rpessure wall
• very few concerns regarding safety
• Diosmin OTC in canada: 1 tab TID for 4 days and then 1 tab @D F3D

*do have some evidence, could add topical product on top of this

Question 28

rubber band ligation

Answer 28

common for recurrent grade 1 or 2 hemorrhoids, soemtimes grade 3

• highl effective
• success rates of 99% and long term 80%
• low risk of complications, urinary retention ahs been reported but generally v wel tolerated
  1. internal hem, device clamps on to pull out and slides on over. pushed down to ruber band goes right at apex (no somatic nerves here). just putting rubber band and causes it to die off/slaugh off

Question 29

Sclerotherapy

Answer 29

• inject something to kill the tissue there
• frade 1 and 2
• inject sclerosant into apex of hemorrhoid
• soft tissue reactiont aht fllows causes thrombosis of invovled vessel, sclerosis of connective tissue and refixation of prolapsing mucosa to underlying recal muscualr tissue
  ex: 5% phenol in oil, quinine and urea, hypertonic saline

pain in 12-70%

20-53% aare symptom free after 4 years

*this is considered when rubber band not effective

Question 30

infrared coagulation

Answer 30

• direct app of infrared waves resuling in protein encrosis

403 pulses of infrared energy applied, 1-2 hemorrhoids treated per sessions

• sessions repeated as req ever 2-4 weeks

*well tolerated but not as effective as rubber band

Question 31

surgery

Answer 31

only 5-10% of patients with hemorrhoidal concerns will req operative treatment

• reserved for aptients with:
• > refractory to office procedures
• > unable to tolerate office
• > with large external
• > with combined internal and external with significant prolapse

Question 32

hemorrhoids and pregnancy

Answer 32

• 85% of women in 2nd and 3rd trimesters
• 8-24% within 3 motnhs postpartum and 24$ between 3-6 months and 15-16% after 6 months
• often regradd after delivery but usally will not fully go away
• 1st line = non pharm (sitz bath, proper toileting, fiber). topical anesthetics and corticosteorids ahve been used for short term relif
• mainly directed for symptom relief but non assessed for safety