describe hemorrhoids (piles)
- Pillow like cluster of veins lies beneath mucus membranes lining the lowest part of the rectum and anus
- Composed of connective tissue, an arteriovenous plexus and suspensory smooth muscle
- normal anatomic feature that helps with continence
- diseased when tissue weakens: distal displacement of hemorrhoidal cushions, venous
distension, bleeding, tissue prolapse, and potential
thrombosis
hemorrhoids presentation
Itching / burning Pain Swelling / inflammation Blood - In stool or on toilet tissue after defecating Encopresis (fecal soiling) Thrombosis - clots
how are hemorrhoids classified (generally)
External hemorrhoids
Originate just below the skin of the anus
Can cause pain
More likely a source of self-care questions
Internal hemorrhoids
Higher, in the rectum (just above the pectinate line)
No pain unless there are complications
No nerve fibers in this area
classify internal hemorrhoids (4)
Grade I
No protrusion of hemorrhoids
Grade II
Protruding hemorrhoids that spontaneously reduce
Grade III
Protruding hemorrhoids where it is possible to push them back in manually
Grade IV
Protruding hemorrhoids that can no longer be pushed back manually
hemorrhoids - risk factors
Constipation / straining while defecating - blocking venous return from anal canal leading to swollen veins
- shearing of small firm stools causes loosening of underlying connective tissue
Diarrhea - straining to pause defecation
Pregnancy - increased ab pressure, increased const
Spinal cord injury
Increased abdominal pressure
Physical exertion or type of work
Advanced age - tissue tends to weaken and stretch
Diet - high in white flour, sugar
hemorrhoids - red flags
Severe pain Rectal bleeding / melena (black tarry stool) Fecal soiling / seepage Less than 12 years of age Family history of colon cancers Patients with Grade III or IV hemorrhoids Severe prolapse No response after 7 days of treatment
goals of therapy (3)
- relieve symptoms
- prevent complications
- promote good bowel habits, anal hygiene
hemorrhoids non-pharm
- avoid constipation - most important
- review diet, fiber supplementation, fluids - bowel habits
- Avoid remaining on the toilet for longer than 1-2 minutes (and avoid straining)
- Any prolapsed hemorrhoids must be replaced using a
moistened tissue. After each bowel movement, the anorectal area should be cleaned with mild soap and water and gently wiped with a wet toilet tissue. - Sitz bath 3-4 times daily
- relieve irritation, itch
- tub of warm water, sit for 15 minutes at a time, fitted over toilet seat
How to increase fiber?
grains and cereals:
- include at least 1 serving of whole grain
- brown rice, whole grain bread, 5 g of fiber in cereal
legumes and beans
- kidney beans
fruits and veggies
- fresh fruit, eat peel
- no juice
hemorrhoids pharm
- purpose?
- name 5 types of ingredients in combination pdts
- what are some dosage forms that can be used?
- short term relief of pain, burning, itch, discomfort, not cure
- Combination products include: local anesthetics Astringents anti-inflammatory agents Protectants Vasoconstrictors
Available as:
Creams
Ointments
- creams and ointments preferable to supp.
Foams - rapid absorption, may not remain on affected area, diff conc in bubbles
Suppositories
Prescription, schedule 2 and unscheduled
Generally use each morning and evening and after each bowel movement
protectants
- name 2
- how does it work?
- glycerin, petrolatum
- Form a physical barrier on the skin to prevent irritation, itching, pain, and burning
- May have a lubricating effect
- Very safe!
local anesthetics
name 3
AE?
- benzocaine, dibucaine, petrolatum
- Offers temporary relief of symptoms by blocking nerve
transmission - Is relatively safe if used for up to 7 days
- Low absorption unless the skin is abraded
Cautions / adverse effects:
Evidence of efficacy is lacking
Can mask the pain of more severe anorectal disorders
Greater absorption may lead to CNS and CV effects
May produce local reactions. These may be similar to
hemorrhoid symptoms. Pramoxine has a lower
incidence of this.
astringents
name 2
how does it work?
how should zinc be used vs witch hazel?
- Zinc sulfate, witch hazel
Produce a drying effect, which helps to relieve symptoms, especially itching and burning
Form a protective layer by coagulating proteins in skin cells of the perianal skin or lining of the anal canal
Zinc can be used internally or externally on hemorrhoids, while witch hazel should only be used externally
corticosteroids
name 1
AE?
Hydrocortisone
- Rx available in combination products
- Onset can take up to 12 hours but effect lasts longer than other therapies
Cautions / adverse effects
Do not recommend longer than 7 days, however if finding
improvement can use longer (i.e., 2 weeks)
Long term use could lead to mucosal atrophy.
Local adverse effects could include skin atrophy with
prolonged use, may mask symptoms of infection
hemorrhoids - common OTCs
2 types
Preparation H - creams and ointments
- has protectants, vasoconstrictor (limit bleeding short term with phenylephrine) and sometimes anesthetic
Anusol - creams, suppositories, ointments
- has zinc sulfate, sometimes anesthetics
rectal products (4)
- Lubricated suppositories for insertion
- Applicator for creams, entire cream tube is inserted
- Liner - leakage, fecal soilage
- TUCKS - witch hazel, cleanse area and provide relief
other treatments (not tested)
framacytin antibiotics
pain relief
procedures, hemorrhoidectomy most effective
New NHPs for hem
Hemoval
Hemoval
- diosmin
Phlebotonic
- unknown MOA, may strengthen vessel walls, increase tone, suppress inflamm mediators
- reduce pain, edema, bleeding
- 600mg PO TID x 4 days then 600 mg PO BID x 3 days
- AE: abdominal pain, diarrhea, headache, nausea
New NHPs for hem
Venixxa
- citrus bioflavonoid - antiplatelet/coagulant effects
- reduce frequency, duration, intensity of symptoms for grade I or II acute internal hem, chronic too
- acute: 3 tabs BID for 4 days, then 2 tabs BID for 3 days
- chronic 1 tab BID
- AE: allergy, GI, discomfort, dizziness, headaches, malaise
Pregnancy hem
what is preferred?
- non-drug, avoid constipation
- external preps better
- protectants/astringents preferred
monitoring
relief in how long?
- relief of itch, swelling, burning within 1 week
- refer in no relief, symptoms worsen
Gas pathophys
- Excess gas in the GIT can be found in the
esophagus, stomach, small intestine, or large
intestine - Removed via flatulence or eructation (belching)
- Average person passes gas 10-25
times daily. More than 25 times is considered
excessive - nitrogen, hydrogen, carbon dioxide, methane and
oxygen
Causes of gas for belching, abdominal discomfort and flatus (3)
- eructation (belching): aerophagia, eating quickly, excessive salivation, gum chewing, mal-fitted dental app., nausea, resp disorders, smoking, carbonated bev
- bloating, cramping, pain: aerophag, cancer, eating disorders, GI disorders
- flatus: celiac diseas, eating beans/complex carbs/dairy/veg, disaccharidase deficiency, pancreatic insuff
Assessment for belching/flatulence
what to do with consumption of nonabsorbable carbs or lactose?
air wallowing, overeating?
none of the above?
consider appropriate enzyme supplementation (lactase)
educate pt
consider trial of simethicone or probitoics - if no relief, consider a trial of bismuth subsalicylate
Gas Red Flags (9)
Unintentional weight loss Blood in stool or vomit Moderate to severe abdominal pain/swelling Sudden changes in bowel habits Nausea or vomiting Dysphagia Dyspepsia Fever or chills Presence of long-standing diabetes, celiac disease, history of GI pathology
Gas Goals of Therapy
Educate patients about the normal aspects of GI gas
Relieve symptoms (belching, pain, bloating, flatulence)
Educate patients regarding preventive measures
Non pharm management of eructation?
Avoid gulping air, eat meals slowly
Adjust poorly fitting dental apparatus
Reduce consumption of gas-producing/releasing substances
Non pharm management of bloating?
Avoid large meals, overeating
Eat less and earlier in the day
Avoid dietary and pharmaceutical triggers
Non pharm management of flatulence?
Smaller, more frequent meals
Exercise
Eat foods low in FODMAPs (Fructans, fructose, galacto oligosaccharides lactose, mannitol, sorbitol)
Gas pharm treatment
Alpha-D-galactosidase (Beano)
- dose?
- used for?
- do not consume with __________
150–450 GaIU PO with the first bite of food
(300–1200 GaIU/day)
Effective in reducing flatus and abdominal discomfort associated with ingestion of non-absorbable carbs
Do not consume with hot foods
inactivates enzymes
Adverse effects: rare allergic reactions
Gas pharm treatment
Bismuth subsalicylate (Pepto-Bismol)
- dose
- used for?
- AE
524 mg QID PO (maximum 8 doses/day)
Binds sulfide gas, effective for short term relief of intestinal gas
Do not recommend at high doses or as long term therapy to avoid salicylate toxicity
Adverse effects: constipation, diarrhea, nausea, tongue discoloration, grey/black stool, vomiting
- Don’t recommend bismuth for over 3-4 weeks
Gas pharm treatment
Lactase (Lactaid)
- dose
- used for?
- AE
Can prevent flatulence in patients with lactase deficiency if taken with or prior to ingestion of lactose
Dose varies based on amount of lactose ingested
Gas pharm treatment
Laxatives
use?
Reduce symptoms of intestinal gas associated with constipation
Gas pharm treatment
probiotics
use?
Some data has shown a reduction in both short-term and long-term symptoms of abdominal distension, bloating, gas
Many available options on the market, not always consistent in quantity and type of bacterial species combined
Simethicone (Ovol, Gas X)
- dose
- use
80–160 mg per meal PO
Prevents bubbling of liquids in stomach, not absorbed in GI tract
No clear benefit in reduction of symptoms of intestinal gas but used for
treatment of flatulence and abdominal bloating
Gas - others
name the ones described here:
- no evidence, do not recommend
- not treating gas but bac overgrowth
- muscle relaxant studied in eructation, need more evidence
- Insufficient evidence for peppermint, garlic or ginger
- activated charcoal?
- antibiotics
- baclofen
- natural pdts
Monitoring
when to refer?
Refer if symptoms persist longer than 1-2 weeks despite self-care
Monitor for improvement after exclusion diets, if no change consider
other triggers
Educate and reassure patients that gastrointestinal gas is a normal
bodily process