HEMORRHOIDS

Presented by:Pauline Teo

Pharmacy Department, Hospital Miri

OUTLINE Introduction Causes Symptoms Complications Investigations Treatment Prevention

INTRODUCTION A mass of dilated veins in swollen tissue

at the margin of anus or nearby within the rectum

Alternative Names Rectal Lump Piles Lump in the Rectum

Peak ages: 45-65 years

Common among pregnant women Temporary

INTRODUCTION (con’t) Two Types:

Internal- inside the lower rectum External- under the skin around the anus

Classification of internal hemorrhoids:Grade I - Hemorrhoids only bleedGrade II - Prolapse and reduce

spontaneouslyGrade III- Prolapse requiring replacementGrade IV - Permanently prolapsed

FIGURES

CAUSES Constipation or diarrhea Pregnancy Heavy lifting Prolonged standing or sitting Decreased physical activity Advancing age

SYMPTOMS Painless bleeding Itching in the anal region Prolapse Swelling Pain Leakage of feces

COMPLICATIONS Blood in the enlarged veins may form

clots and the tissue surrounding the hemorrhoids can die (Necrosis) Painful lumps in the anal area

Continuous bleeding can cause anemia

INVESTIGATIONS FBC (Hemoglobin & Hematocrit) Stool guaiac test Barium enema examination Colonoscopy Sigmoidoscopy Anoscopy Proctoscopy

TREATMENT Drugs: Daflon, suppositories (Anusol®,

Xyloproct®) Sclerotherapy Infrared coagulation Elastic band ligation Cryotherapy Hemorrhoidectomy

Fixation of mucosa

Fixation of mucosa & removal of redundant

internal component

DAFLON Diosmin 450mg & Hesperidin 50mg Fight simultaneously all the

pathophysiological aspects of venous disease, affecting the veins, lymphatics & microcirculation

Highly effective in acute hemorrhoidal attacks from 2nd day of tx in improving all signs & symptoms

MOA: Daflon Improves capillary function

Reinforces venous tone by prolonging the activity of parietal NA

Inhibits the release of mediators

Improves lymphatic drainage

DAFLON (con’t) S/E: minor gastrointestinal & autonomic

disorders Dose:

Chronic hemorrhoids: 2 tab daily Acute hemorrhoidal attacks: 6 tab daily in 2 divided doses for 4 days, then 4 tab daily in 2 divided doses for 3 days, then 2 tab daily

To be taken after meals

SUPPOSITORIES Anusol®

Generic: Anucare Contains Zinc Oxide 300mg, Balsam Peru 50mg &

Benzyl Benzoate 33mg Mild antiseptic, protective and astringent properties Relief of pain, itching, burning & soreness of

hemorrhoids Insert 1 suppository morning and night, and after

every bowel movement Do not use for longer than 7 days S/E: allergic reactions, local reactions (burning,

itching, irritation, dryness)

Xyloproct®

Generic: Doproct Contains Hydrocortisone Acetate 7.5mg, Benzocaine

40mg & Zinc Oxide 250 mg Properties:

Hydrocortisone: anti-inflammatory & anti-pruritic Benzocaine: local anaesthetic Zinc Oxide: mild astringent, soothing & protective application

For anorectal pain, pruritis, inflammation & irritation 1 suppository to be used once or twice daily. Not for

prolonged use

SUPPOSITORIES (con’t)

SCLEROTHERAPY A submucosal injection of sclerosants directly

into the hemorrhoidal tissue Eg: Sodium Tetradecyl Sulphate 1 % or 3%

Injection (Trombovar®) Causes thrombosis of vessels, sclerosis of

connective tissue, and shrinkage and fixation of overlying mucosa

Complication: urinary retention, impotence, abscess

May be less effective than rubber band ligation

INFRARED COAGULATION Recent innovation Less invasive & fewer side effects Risk of secondary hemorrhage is small &

postoperative pain is rare, but more expensive

ELASTIC BAND LIGATION Most widely used technique By applying a tight elastic band above the

internal hemorrhoid & the mucosa above it Remove some of the redundant mucosa & fixes

the mucosa at the site of banding to the underlying muscle by scar tissue

Usual to band 2 hemorrhoids at any one time, further bands after 4 weeks

Complications: pain, hemorrhage, abscess, urinary retention, band slippage, prolapse & thrombosis of adjacent hemorrhoids

Rubber Band Ligation

CRYOTHERAPY The application of special probes cooled

with liquid nitrogen (-180OC) causes freezing, necrosis, and subsequent fixation of the hemorrhoidal cushion

For destroying enlarged internal hemorrhoids

High complication rate: prolonged pain, foul-smelling discharge

No longer recommended

HEMORRHOIDECTOMY Removal of enlarged veins around the anus Criteria used in the selection of patients with

hemorrhoidectomy: Large prolapse with areas of squamous epithelial

change & a large external component Not responded to other treatment Recurrent episodes of thrombosis in the external

component Patient’s preference

Complications: pain, retention of urine, fecal impaction, secondary hemorrhage, impaired healing of anal wounds, infection

TREATMENT: Non-Pharmacological

Take a warm sitz bath for 10-15mins Use warm water to clean after bowel

movement Use stool softener & lubricant If prolapse, gently push back into anal canal Apply ice packs or compresses x 10min Use moist or wet wipe instead of dry

toilet paper Drink plenty of fluids High-fiber diets Improve local hygiene Increase physical exercise

TREATMENT CHOICEMethod Grade I Grade II Grade III Grade IV

Diet √ √

Medical treatment √ √

Sclerotherapy √ √

Infraredcoagulation

√ √ √

Elastic band ligation

√ √ √

Cryotherapy √ √

Hemorrhoidectomy √ √ √

PREVENTION Eat high fiber diet Drink plenty of fluids Complete bowel action within a few minutes Avoid lifting heavy weights Exercise Avoid long periods of standing Do not strain Go to toilet as soon as one feels the urge Keep anal area clean

REFERENCES American Society of Colon & Rectal Surgeons (ASCRS) 2008: Hemorrhoids. Adapted from

http://www.fascrs.org/patients/conditions/hemorrhoids/ Chan EL, McCafferty MH & Galandiuk S 2003. Diagnosis and Contemporary Management of

Hemorrhoids. Practical Gastroenterology MIMS Malaysia: Xyloproct® [supp]. Adapted from http://www.mims.com/ Altomare DF et. al. 2006. The treatment of hemorrhoids: guidelines of the Italian Society of

Colo-Rectal Surgery. Tech Coloproctol 2006;10:181–186 Frangou C 2009. Which Hemorrhoid Therapy? Expert Reviews Options. Gastroenterology &

Endoscopy News 2009;60:05 Global Information Hub on Integrated Medicine 2009. Hemorrhoids. Adapted from

http://www.globinmed.com/IMRContent/ReviewContent.aspx?mgid=63 eMedicineHealth. Hemorrhoids. Adapted from

http://www.emedicinehealth.com/hemorrhoids/article_em.htm Hemorrhoid Information Center. Hemorrhoid treatment. Adapted from

http://www.hemorrhoidinformationcenter.com/category/hemorrhoids-treatment/ National Digestive Diseases Information Clearing House (NDDIC) 2004. Hemorrhoids.

Adapted from http://digestive.niddk.nih.gov/ddiseases/pubs/hemorrhoids/ Alonso-Coello P & Castillejo MM 2003. Office evaluation and treatment of hemorrhoids. The

Journal of Family Practice;52:5:366-374 Acheson AG & Scholefield JH 2008. Management of haemorrhoids. BMJ  2008;336:380-383  Cospite M & Millo G 2001. Overview of pharmacological treatment of acute hemorrhoids.

Phlebolymphology No31:10-15