Hemorrhoid Overview

what is another name for hemorrhoids?

piles

define hemorrhoids

inflamed/swollen veins in the anal canal

T/F: 50% of patients will experience hemorrhoids before age of 50

true

define anal abscess

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

define anal fistula

abnormal opening that connects with an external opening

define anal fissure

slit-like ulcer in anal canal resulting from a traumatic tear during passage of stool or explosive diarrhea

define anal neoplasms

a variety of histologic types classified as epidermoid carcinomas

define pruritus ani

itching sensation localized to the anorectal area

which type of hemorrhoids are painless due to no innervation

internal

what is a grade 1 internal hemorrhoid

hemorrhoids enlarge but do not prolapse into the anal canal

what are grade 2 internal hemorrhoids

hemorrhoids that protrude into the anal canal on defecation and retract spontaneously

what are grade 4 internal hemorrhoids

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

what are grade 4 internal hemorrhoids

hemorrhoids that are permanently prolapsed and cannot be reintroduced into the anus

describe external hemorrhoids

hemorrhoids that are painful, innervated, and may cause an itching sensation

pathophysiology of hemorrhoids

muscle fibers weaken; vascular cushions slide, become congested, bleed, and eventually protrude

causes of hemorrhoids

pregnancy, poor bowel habits (prolonged sitting, straining/downward pressure at defecation), increased age

manifestations of hemorrhoids

post defecation bleeding, protrusion/prolapse; itching, discomfort, irritation, burning, inflammation, swelling, pain (persistent, during defecation, cleaning post-defecation), vessel thrombosis (purple/blue tinge)

exclusions to self-care

prolapse/protrusion (grade 3 & 4), excessive rectal bleeding, moderate-to-severe pain, no resolution after 7 days of self-care management, < 12 years old, previous anorectal diagnosis, family history of colon cancer, thrombosis of hemorrhoid (can result in ulceration), nonhemorrhoidal anorectal disorder (anal discharge, rectal bleeding)

non pharm treatments

avoid heavy lifting, avoid aggravating foods (alcohol, high fat/greasy foods, citrus foods, coffee/caffeine), high fiber foods, stay well hydrated, proper bowl habits, bathe in warm water

examples of proper bowel habits

limit time on toiler to 2-5 minutes, do not suppress or ignore the urge to defecate, proper hygiene, do not use scrub, do not use wipes.

benefits of bathing in warm water

promotes good anal hygiene, reduces pain and itching.

MOA of local anesthetics

reversibly block transmission of nerve impulses

clinical pearls of local anesthetics

leave out of reach of children d/t high risk of cardiac arrest and arrythmias

local anesthetics place in therapy

symptom relief - itching, irritation, burning, discomfort, soreness, and pain

ADRs local anesthetics

allergic reaction (hard to distinguish from hemorrhoid symptoms)

counseling points for local anesthetics

avoid if patient had open sores (systemic absorption), leave away from children (life-threating lethargy, seizures, and cardiorespiratory)

which agents are local anesthetics

benzocaine (Americaine), Dibucaine (Nupercainal), Pramoxine, Pamoxine + Zinc oxide (Trolane anesthetic), benzyl alcohol, dyclonine hydrochloride, lidocaine, tetracaine.

MOA of vasoconstrictors

alpha receptor stimulation leading to vasoconstriction producing a modest and transient reduction of swelling.

place in therapy for vasoconstrictors

relief of external anal symptoms, shrink and reduce swelling.

ADRs of vasoconstrictors

increase cardiac rate and contractility (Except phenylephrine), bronchodilation, nervousness.

avoid vasoconstrictors in:

patients with HTN, BPH, DM, use with TCA/MAOi, difficulty urinating, any thyroid disorders

counseling for vasoconstrictors

may cause rebound vasoconstriction with prolonged use

vasoconstrictor agents

ephedrine, epinephrine (do not use internally), phenylephrine

MOA of protectants

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

place in therapy for protectants

can be used for internal hemorrhoids; prevents fecal matter from irritating or drying the perianal mucosa

which protectant cannot be used internally

glycerin

counseling points 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

which agents are protectants

aluminum hydroxide gel, cocoa butter, hard fat, kaolin, lanolin, mineral oil, white pertrolatum, calamine, pertrolatum, shark or cod liver oil, zinc oxide, topical starch

MOA of astringents

increased coagulation of skin proteins in the anorectal skin cells to protect the underlying tissue - leads to a tightening effect which shrinks hemorrhoids; anorectal environment dries to prevent further irritation, form a thin protective layer over the injured mucosal membrane

ADRs for astringents

zinc toxicity (when zinc oxide is used internally) - very rare

which agents are astringents

calamine, zinc oxide, witch hazel

MOA of keratolytics

desquamation and debridement (or sloughing) of epidermal surface cells

place in therapy for keratolytics

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

ADRs of keratolytics

methemoglobinemia, exfoliative dermatitis, death in infants, and myxedema in adults, tinnitus, increased pulse rate, diaphoresis, and SOB to circulatory collapse, unconsciousness, and seizures

counseling for keratolytics

external use only (not for monotherapy)

which agents are keratolytics

Alcloxa, resorcinol

place in therapy for analgesics/anesthetics/antipruritics:

temporary relief of burning, pain, or itching

ADRs of menthol

allergic rxns, laryngospasm, dyspnea, cyanosis

counseling for analgesics/anesthetics/antipruritic

used for external perianal disorders

which agents are analgesics/anesthetics/antipruritic

menthol, juniper tar, camphor

MOA of corticosteroids

vasoconstriction by producing lysosomal membrane stabilization and antimitotic activity, antipruritic by producing lysosomal membrane stabilization and antimitotic activity

place in therapy for corticosteroids

temporary relief of minor external anal itching

onset of action for corticosteroids

up to 12 hours

T/F: corticosteroids have a longer duration of action than that of other agents

true

do not exceed ___ days of topical corticosteroids regardless of rx, skin atrophy, steroid withdrawal rxns, and systemic absorption leading to adrenal suppression

14

ADRs for topical corticosteroids

rare skin reactions - skin atropy with prolonged use

which agent is a topical corticosteroid

hydrocortisone 1%

MOA of diosmin + hesperidin

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

place in therapy for diosmin + hesperidin

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

ADRs of diosmin + hesperidin

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

which product is best for hemorrhoids?

N/A - combination products containing approved ingredients in appropriate dosages are most likely therapeutically similar to individual drug products

which dosage form is superior for hemorrhoids?

none

what are the dosage forms for hemorrhoid treatment

creams, suppositories, gels, pastes, liquids, foams, and ointments are primarily used externally

define ointments:

refers to all semisolid preparations designed for intrarectal or external use in the anorectal area for its protectant and emollient properties

facts regarding foam use in hemorrhoids

they are more expensive than ointments and do not offer any specific advantage; foams may not remain the affected area, and differences in the size of the foam bubbles may result in variable concentrations of the active ingredient

nonpharmacological interventions for pregnant women experiencing hemorrhoids

warm sitz bath, increase dietary fiber, increase fluid intake

which products are external use only

epinephrine, glycerin, witch hazel, keratolytics, analgesics, anesthetics, antipruritics, corticosteroids

therapy options for pregnant women experiencing hemorrhoids

nonpharm, external use products, internal use should be protectants with the exception of glycerin

if the topical nonprescription agents do not resolve the anorectal symptoms within ___ days, medical referral is appropriate

7