Hemorrhoids

What are hemorrhoids?

aka piles; inflamed/swollen veins in the anal canal

50% of patients will experience before the age of 50

What is an anal abscess?

collection of pus causing an obstruction of the anal glands, resulting in a bacterial infection

What is an anal fistula?

abnormal opening that connects with an external opening

What is an anal neoplasm?

a variety of histologic types classified as epidermoid carcinomas

What is pruritus ani?

itchy sensation localized to the anorectal area

Which type of hemorrhoid is painless?

internal

What is a grade 1 hemorrhoid?

they enlarge but do not prolapse into the anal canal

What is a grade 2 hemorrhoid?

protrude into the anal canal on defecation and retract spontaneously

What is a grade 3 hemorrhoid?

protrude into the anal canal on defecation but can be returned to their original position with manual manipulation

What is a grade 4 hemorrhoid?

permanently prolapsed and cannot be reintroduced into the anus

Which type of hemorrhoids get classified into grades?

internal

What type of hemorrhoid is painful?

external

What are hemorrhoid classifications based on?

dentate line

How do muscle fibers weaken leading to hemorrhoids?

vascular cushions slide, become congested, bleed, and eventually protrude (pregnancy, poor bowel habits, increased age)

How do hemorrhoids manifest?

post defecation bleeding, protrusion/prolapse, itching, discomfort, irritation, burning, inflammation, swelling, pain (can be persistent, during defecation, or cleaning post defecation), vessel thrombosis

What are exclusions to self-care for hemorrhoids?

grade 3-4 (prolapse/protrusion), moderate to serve pain, no resolution after 7 days of self-care management, <12 yo, previous anorectal diagnosis, family history of colon cancer, thrombosis or hemorrhoid, Non-hemorrhoidal anorectal disorder (discharge/bleeding), bleeding more than a dab

What are non-pharmacological treatments for hemorrhoids?

avoid heavy lifting, avoid aggravating foods, high fiber diet, stay we;; hydrated, proper bowel habits, bathe in warm water

What classes of agents are used for hemorrhoids?

local anesthetics

vasoconstrictors

protectants

astringents

keratolytics

analgesics

corticosteroids

What is the MOA of local anesthetics?

reversibly blocks transmission of nerve impulses

What place do local anesthetics have in hemorrhoid therapy?

symptoms relief; inching, irritation, burning, discomfort, soreness, and pain

What are the ADRs of local anesthetics?

allergic reactions; hard to distinguish from hemorrhoid symptoms

What should you counsel a patient about on local anesthetics?

avoid if you have open sores due to risk of systemic absorption; leave out of reach of children

Why must you leave local anesthetics out of reach of children?

risk of life-threatening lethargy, seizures, and cardiorespiratory arrest

What are examples of local anesthetics used for hemorrhoids?

benzocaine, dibucaine, pramoxine, benzyl alcohol, dyclonine hydrochloride, lidocaine, tetracaine

What is the MOA of vasoconstrictors?

stimulates alpha receptors in the vascular beds; vasoconstriction arterioles, producing a modest and transient reduction of swelling

What patients should vasoconstrictors be avoided in?

HTN, thyroid, BPH, DM, use with TCA/MAOi use

What place do vasoconstrictors have in hemorrhoid therapy?

relief of external anal symptoms; shrink and reduce swelling

What are the side effects of vasoconstrictors?

increase cardiac rate and contractility; except phenylephrine; bronchodilation; nervousness

What counseling points are important for vasoconstrictors?

rebound vasoconstriction possible with prolonged use

What is the MOA of protectants?

provide a physical protective barrier over inflamed anal tissue & soften the lining of the anal canal by preventing fecal matter from irritating or drying the perianal mucosa

What place do protectants have in therpay?

can be used for internal hemorrhoids

True or False: lanolin cannot be used if pt has a sheep allergy

true

What counseling is needed for protectants?

greasy ointments or petrolatum-based products should be removed before application so that the protectant can adhere properly to the anorectal skin area

What agents are protectants?

aluminum hydroxide gel, cocoa butter, hard fat, mineral oil, zinc oxide, glycerin

True or False: glycerin is for internal use only

false

What is the MOA of astringents?

increase coagulation of skin in the anorectal skin cells to protect the underlying tissue; leads to tightening effect; anorectal environment dries to prevent further irritation; form a thin protective layer over the injured mucosal membrane

What are the adverse events related to astringgents?

zinc toxicity (very rare)

What agents are astringents?

calamine

zinc oxide

witch hazel

What is the MOA of keratolytics?

desquamation & debridement (or sloughing) of epidermal surface cells

What is the place in therapy for keratolytics?

foster cell turnover and loosening surface cells, removing dead skin, exposing the underlying tissue; promote and expedite healing process

What are the adverse effects of keratolytics?

methemoglobinemia, exfoliate dermatitis, death in infants, and myxedema in adults; tinnitus, increased pulse rate, diaphoresis, and shortness of breath

What is the key counseling points for keratolytics?

external use only

What agents are keratolytics?

alcloxa, resorcinol

True or False: keratolytics need to be used in combo with other products

true

What is the place in therapy for analgestics?

temporary relief of burning, pain, or itching

What are the ADRs of menthol?

allergic reactions, laryngospasm, dyspnea, cyanosis

What is the counseling for analgesics?

used for external perianal disorders only

What agents are analgesics?

menthol, juniper tar, camphor

What is the MOA of corticosteroids?

vasoconstrict by producing lysosomal membrane stabilization and amitotic activity; antipruritic by producing lysosomal membrane stabilization and antimitotic activity

What place do corticosteroids have in hemorrhoids?

temporary relief of minor external anal itching

onset of action may take up to 12 hours; longer duration

What are the ADRs for corticosteroids?

rare skin reactions; skin atrophy with prolonged use

What are the key counseling points for corticosteroids?

do NOT exceed 14 days regardless of prescription, skin atrophy, steroid withdrawal reactions, and systemic absorption leading to adrenal suppression

What agents are corticosteroids for hemorrhoids?

hydrocortisone 1%

What complementary treatment is available for hemorrhoids?

diosmin + hesperidin

What is the MOA of diosmin + hesperidin?

micronized purified flavonoid fraction; anti-inflammatory effects, improve vascular tone and reducing stasis

What place does complementary therapy have in hemorrhoids?

have been used to stop acute bleeding and decrease symptoms associated with hemorrhoids; also fair evidence for venous leg ulcers and chronic venous insufficiency; patient that wants a non- topical option; patient that wants preventative care (decrease rate of relapse, reduction in symtpoms)

What are the ADRs of diosmin + hesperidin?

abdominal pain, diarrhea, dizziness, gastritis, skin inflammation, and skin redness; rare: cardiac arrythmias, hemolytic anemia

True or False: FDA does not require comparison trials between combination and individual products

true

True or False: no dosage forms are superior in hemorrhoids

true

What are the more specific non-pharm interventions for hemorrhoids in pregnancy?

warm sitz baths

increase dietary fiber

increase fluid intake

What types of hemorrhoid products should be used in pregnancy?

external use products and internal use protectants (except glycerin)

After how many days of nonprescription topical agents should a patient seek medical attention if no resolution?

7 days