Hemorrhoids
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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 bleed Grade II - Prolapse and reduce spontaneously Grade III- Prolapse requiring replacement Grade 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
anemia
bleeding can cause
INVESTIGATIONS FBC
(Hemoglobin & Hematocrit) Stool guaiac test Barium enema examination Colonoscopy Sigmoidoscopy Anoscopy Proctoscopy
TREATMENT Drugs: Daflon, suppositories (Anusol®, Xyloproct®) Sclerotherapy Fixation of mucosa Infrared coagulation Fixation of mucosa & Elastic band ligation removal of redundant Cryotherapy internal component Hemorrhoidectomy
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)
SUPPOSITORIES (con’t)
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
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: NonPharmacological
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 CHOICE Method
Grade I
Grade II
Diet
√
√
Medical treatment
√
√
Sclerotherapy
√
√
Infrared coagulation
√
√
√
Elastic band ligation
√
√
√
Cryotherapy
√
√
Hemorrhoidectomy
√
Grade III Grade IV
√
√
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
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 bleed Grade II - Prolapse and reduce spontaneously Grade III- Prolapse requiring replacement Grade 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
anemia
bleeding can cause
INVESTIGATIONS FBC
(Hemoglobin & Hematocrit) Stool guaiac test Barium enema examination Colonoscopy Sigmoidoscopy Anoscopy Proctoscopy
TREATMENT Drugs: Daflon, suppositories (Anusol®, Xyloproct®) Sclerotherapy Fixation of mucosa Infrared coagulation Fixation of mucosa & Elastic band ligation removal of redundant Cryotherapy internal component Hemorrhoidectomy
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)
SUPPOSITORIES (con’t)
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
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: NonPharmacological
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 CHOICE Method
Grade I
Grade II
Diet
√
√
Medical treatment
√
√
Sclerotherapy
√
√
Infrared coagulation
√
√
√
Elastic band ligation
√
√
√
Cryotherapy
√
√
Hemorrhoidectomy
√
Grade III Grade IV
√
√
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
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