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.
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