HEMORRHOIDS

1. HEMORRHOIDS Nga Vu, MD PGY3 Emory Family Medicine 11/18/10

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

3. 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

5. 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

6. Rectal exam • Left lateral decubitus position for this examination and for almost all anorectal procedures. • Traditional head-down “jackknife” position

7. 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%).

8. 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.

11. External hemorrhoid after seven days of thrombosis

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

13. 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.

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

15. Pruritis Ani • Systemic illness • Diabetes mellitus • Hyperbilirubinemia • Leukemia • Aplastic anemia • Thyroid

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

17. 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

18. Chronic Pruritis Ani

19. 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

20. 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.

21. 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

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

23. 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.

24. 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

25. 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.

26. 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

27. 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

28. 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.

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

30. 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.