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

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 yet still allows adequate visualization and access for the examiner

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%). is gradually withdrawn while rotating right and left to allow inspection of the mucous membrane.

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 Dermatologic conditions 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 Many patients believe pruritus ani is caused by poor hygiene and are overzealous in their attempts to clean the perianal area. Excessive cleaning, and particularly the use of brushes and caustic soaps, aggravates the sensitive tissues and exacerbates the condition

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 Preparation H Tucks- Anusol Witch Hazel 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 Hemorrhoidectomy Stapling technique 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.