HEMORRHOIDS

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HEMORRHOIDS

• Nga Vu, MD
• PGY3
• Emory Family Medicine
• 11/18/10

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Causes

• chronic straining secondary to constipation
• diarrhea
• tenesmus
• long periods trying to defecate
• common during pregnancy and child-birth

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Anatomy

• Dentate line, divides hemorrhoids anatomically
  into internal (above the junction) and external
  (below)
• external pain fibers end at this point, and most
  people have no sensation above this line.
• Hemorrhoids originating above the junction, are
  divided into 4 categories depending on the grade
  of prolapse
• Grade IProtrudes into the anal canal but does
  not prolapse
• Grade IIReduces spontaneously
• Grade IIIManual reduction
• Grade IVIrreducible prolapse

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Symptoms

• The most common symptoms of hemorrhoids are
  bleeding and prolapse. Less frequently, symptoms
  also include discomfort, pain, soiling, or
  itching.
• Every patient with anorectal symptoms, especially
  those with rectal bleeding, must have an
  assessment that includes, at a minimum, digital
  rectal examination and visual inspection by
  anoscope

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Rectal exam

• Left lateral decubitus position for this
  examination and for almost all anorectal
  procedures.
• Traditional head-down jackknife position

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Anoscopy

• Insert the anoscope
• Hemorrhoids appear as pink swellings of the
  mucosa
• Improve visualization
• Two prospective studies found that anoscopy
  detects a higher percentage of lesions in the
  anorectal region than does flexible sigmoidoscopy
  (99 vs 78).

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Anoscopy

• Even if endoscopic examination includes
  retroflexion of the scope to inspect the anal
  canal, optimal visualization is obtained with the
  Ive's slotted anoscope.

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External hemorrhoid after seven days of thrombosis
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DDx

• anal fissures, pruritus ani, abscess, fistula,
  and condyloma should be ruled out by examining
  the anus, the perianal region, and the anal canal

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DDx

• Anal cancers more commonly cause pain after
  invasion of the sphincter muscle.
• Anorectal pain that begins gradually and becomes
  excruciating over a few days may indicate
  infection.
• A localized area of tenderness could signal an
  abscess.
• Anal pain accompanied by fever and inability to
  pass urine signals perineal sepsis and is a
  medical emergency.

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Cancer

• Rectal bleeding can mask the diagnosis of
  cancer.
• Elderly
• Family or personal history of colorectal cancer
• Fatigue, weight loss, palpable tumor, anemia

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Pruritis Ani

• Systemic illness
• Diabetes mellitus
• Hyperbilirubinemia
• Leukemia
• Aplastic anemia
• Thyroid

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Pruritis Ani

• Mechanical factors
• Chronic diarrhea/constipation
• Soaps, deodorants, perfumes
• Prolapsed hemorrhoids
• Anal fissure, Anal fistula
• Tight-fitting clothes
• Allergy

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Pruritis Ani

• Foods
• Tomatoes
• Caffeinated beverages
• Beer
• Citrus products
• Milk products
• Dermatologic conditions
• Psoriasis
• Seborrheic dermatitis
• Lichen
• Erythrasma (Corynebacterium)
• Herpes simplex virus Human papillomavirus
• Pinworms (Enterobius)
• Medications- Colchicine
• Quinidine

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Chronic Pruritis Ani
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Itch/scratch cycle

• Antihistamine such as hydroxyzine hydrochloride
  (Atarax) taken before bedtime
• Topical corticosteroids are usually necessary to
  control pruritus ani but must be limited to
  short-term use to avoid thinning of the perianal
  tissues.
• Topical 5 percent xylocaine ointment (Lidocaine)
  can also reduce the itching sensation and break
  the cycle.
• It should be noted that uncomplicated hemorrhoids
  rarely cause pruritus ani

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Fissure

• Pain during bowel movements that is described as
  being cut with sharp glass usually indicates a
  fissure
• Bright red rectal bleeding and often begins after
  a hard, forced bowel movement.

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Proctalgia Fugax

• Proctalgia fugax is a unique anal pain. Patients
  with proctalgia fugax experience severe episodes
  of spasm-like pain that often occur at night
• Reassurance, ice, warm water, valium

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Constipation

• Constipation is regarded as fewer than three
  bowel movements per week in a person consuming at
  least 19 g of fiber daily

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Fecal impaction

• Careful administration of one or two enemas
  (Fleet) into the bolus to soften and hydrate the
  stool should be followed one hour afterward by
  the administration of a mineral oil enema to
  assist in passage of the softened stool.
• Manual disimpaction is required in most patients.
  After disimpaction, a bowel program that includes
  the use of a laxative, stool softeners and/or
  enemas should be initiated to prevent recurrence.
  If impaction recurs, it is important to rule out
  an anatomic cause of obstruction such as an anal
  or rectal stricture or tumor.

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Medications

• Proctofoam
• Hydrocortisone acetate 1
• Pramoxine hydrochloride 1
• Antipruritic, anesthetic
• Preparation H
• yeast as a live cell derivative (Bio-Dyne Skin
  Respiratory Factor) 1 and shark liver oil 3.
• Cooling gel has phenylepherine in addition
• Tucks- Anusol
• Starch
• Lowest potency corticosteroid
• Witch Hazel
• Tucks medicated pads- astringent

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Treatments

• Twenty-minute sitz baths (soaking in a tub of
  warm water)
• Anusol or Preparation H to soothe the tissues.
• It is very important that your bowel movements
  remain soft. Drink at least 6 full glasses of
  water daily.
• Take over-the-counter (nonprescription) stool
  softeners such as Colace or Surfak (2 capsules 2
  times a day)
• Take a stool-bulking agent such as Metamucil or
  Citrucel every day. These products can initially
  produce gas and bloating but can be easier to
  tolerate if the stool softeners are used
  simultaneously at the start
• Straining at stool should be avoided
• Do not sit for long periods on the toilet. Remove
  all reading materials from the bathroom.

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Treatments

• Anal stretch, or manual anal dilatation, has been
  reported to be effective in the treatment of
  hemorrhoids
• SOR B
• High-fiber diet or fiber supplements
• NNT2.8 for reduction of rectal bleeding and 3.6
  for pain relief

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Treatments

• SOR A
• Office procedures
• Rubber band ligation was more effective and
  required fewer additional treatments for
  symptomatic recurrence than did infrared
  coagulation (NNT9) and sclerotherapy (NNT6.9)
  but rubber band ligation produced more
  complications than did infrared coagulation
  (pain NNH6)
• Hemorrhoidectomy
• More effective than office procedures, but it is
  more painful and presents more complications
  office procedures are cheaper and require no time
  off from work
• United States, the Ferguson (closed)
  hemorrhoidectomy is preferred.
• Europe is the Milligan-Morgan technique (open).
• Stapling technique
• As effective as hemorrhoidectomy, is less
  painful, and requires less time off from work
  more long-term data are needed

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Treatment

• In a small randomized clinical trial, the
  addition of topical nifedipine (0.3) to a
  lidocaine ointment (1.5) was more effective than
  lidocaine alone in reducing pain and shortening
  resolution time.

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Prognosis

• 90 of patients will not require surgery to
  alleviate their symptoms (SOR B)

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References

• Pablo Alonso-Coello,, MD Mercè
  Marzo Castillejo, MD, PhD . Office evaluation
  and treatment of hemorrhoids. Journal of Family
  Practice. May 2003 Vol 52, No. 5
• JOHN L. PFENNINGER, M.D, GEORGE G. ZAINEA, M.D.
  Common Anorectal Conditions Part I. Symptoms
  and Complaints. Am Fam Physician. 2001 Jun 1563(
  12)2391-2398.
• JOHN L. PFENNINGER, M.D., GEORGE G. ZAINEA.
  Common Anorectal Conditions Part II. Lesions.
  Am Fam Physician. 2001 Jul 164(1)77-89.