Post on 02-Apr-2015
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.