HEMORRHOIDS

Nga Vu, MDPGY3

Emory Family Medicine11/18/10

Causes

chronic straining secondary to constipation

diarrhea tenesmus long periods trying to defecate common during pregnancy and

child-birth

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 I—Protrudes into the anal canal but does not prolapse

Grade II—Reduces spontaneously Grade III—Manual reduction Grade IV—Irreducible prolapse

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

Rectal exam

Left lateral decubitus position for this examination and for almost all anorectal procedures.

Traditional head-down “jackknife” position

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%).

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.

External hemorrhoid after seven days of thrombosis

DDx

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

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.

Cancer

Rectal bleeding can mask the diagnosis of cancer.

Elderly Family or personal history of

colorectal cancer Fatigue, weight loss, palpable

tumor, anemia

Pruritis Ani

Systemic illness Diabetes mellitus Hyperbilirubinemia Leukemia Aplastic anemia Thyroid

Pruritis Ani

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

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

Chronic Pruritis Ani

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

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.

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

Constipation

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

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.

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

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.

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

NNT=2.8 for reduction of rectal bleeding and 3.6 for pain relief

Treatments SOR A

Office procedures Rubber band ligation was more effective and required fewer

additional treatments for symptomatic recurrence than did infrared coagulation (NNT=9) and sclerotherapy (NNT=6.9); but rubber band ligation produced more complications than did infrared coagulation (pain: NNH=6)

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

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.

Prognosis

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

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 15;63(12):2391-2398.

JOHN L. PFENNINGER, M.D., GEORGE G. ZAINEA. “Common Anorectal Conditions: Part II. Lesions”. Am Fam Physician. 2001 Jul 1;64(1):77-89.