Hemorrhoids- Test 4

How can patients with hemorrhoids present?

- Anal itching - Bright red blood on toilet tissue or in toilet bowl or as dark blood in stool - Anal ache or pain, especially while sitting or during bowel movements

What are flavonoids?

- Diosmin, hidrosmin, hesperidin, rutosides - Inhibit release of Pg's - Found in tea, wine, dark chocolate, ginkgo biloba - Home remedies for hemorrhoids

What is the general approach to caring for external hemorrhoids?

- Reassurance - Proper anal hygiene- delicate washing of anal area and avoidance of aggressive wiping with harsh toilet tissue - Other non-pharmacologic options **** Start with non pharmacologic treatment first then progress to pharmacologic.

In general what is the onset of action of local anesthetics

1-15 minutes

List lifestyle modifications for non pharmacologic treatment options

1. Avoid reading, other leisure activities while on toilet 2. Use the squatty Potty 3. Increased fiber intake (with fluids) 4. For relief of pain: Warm baths, Sitz baths, Ice packs relieve swelling, Witch hazel (Preparation H® wipes, Tucks® pads)

What things cause hemorrhoids?

1. Constipation and stressing 2. Obesity 3. Heavy lifting 4. Sitting for long periods

What is the general treatment approach?

1. Treat symptoms 2. Avoid surgery- because look at the picture....

Incidence of hemorrhoids?

10-25% but we expect higher because people are to afraid to say they have them

______% hydrocortisone is Rx only

2.5%

Pramoxine starts working in ________

3 minutes

Apply local anesthetics to perianal area and anal canal ______ times per day

3-6 times per day

Peak incidence of hemorrhoids?

45-65 years old

Which internal hemorrhoid grade requires surgery

4th degree

What protectants are used for hemorrhoids?

Aluminum hydroxide, cocoa butter, glycerin, hard fat, kaolin, lanolin, shark liver oil, mineral oil

Lidocaine + Hydrocortisone Topical Solution

Anamantle HC

Directions for applying hydrocortisone?

Apply QD to BID to affected area

Directions for applying protectants

Apply liberally to affected area

Directions for local anesthetics

Apply ointment as a thin layer to the perianal area and the anal canal 3-6 times/day

How does witch hazel work?

Astringent- shrinks tissue and relives pain

How do we treat internal hemorrhoids?

Based on grade- non pharmacologic treatment +/- pharmacologic treatment. Surgery is last option

What is a sitz bath

Bath that sits right on top of the toilet.

What are local anesthetics used for hemorrhoids?

Benzocaine, benzyl alcohol, dibucaine, dyclonine, lidocaine, pramoxine, tetracaine

MOA of local anesthetics

Blocks nerve impulses at the sensory nerve endings in the skin and mucous membranes --> temporarily relieves pain, itching, and irritation

Are hemorrhoids internal or external?

Both

What is in the preparation H suppositories?

Cocoa butter/ phenylephrine/ shark liver oil

Hydrocortisone ointment _______

Cortifoam

Name hydrocortisone ointment

Cortifoam

When we say pain we are talking about _____ hemorrhoids

External

Is anal itching more common with external or internal hemorrhoids

External but it is seen with both

Internal hemorrhoids is classified by grade, name the grades.

First degree Second degree Third degree Fourth degree

What is in the preparation H cream with pain relief?

Glycerin/ phenylephrine/ pramoxine/ white petroleum (base)

What corticosteroid is used for hemorrhoids?

Hydrocortisone

Proctofoam HC

Hydrocortisone + Pramoxine

What are hemorrhoids?

Increased pressure of veins located within tissues of the lower portion of the rectum or anus --> veins bulge and expand causing symptoms.

MOA of hydrocortisone cream

Inhibits release of phospholipase A2, decreases release of interleukin 1α --> Anti-inflammatory effects

_____ hemorrhoids can give you blood but NO pain, whereas _____ hemorrhoids can give you pain but NO blood

Internal External

If we see blood, do we have internal or external hemorrhoids?

Internal hemorrhoids

MOA for protectants (emollients) ?

Lubricates tissues --> prevents irritation and water loss

What is in the preparation H ointment?

Mineral oil/ shark liver oil/ phenylephrine/ white petroleum (base)

Do we see blood with external hemorrhoids?

No but we have pain

How do we diagnose hemorrhoids?

PE +/- anoscopy to rule out colorectal cancer. This is 99% effective to diagnose hemorrhoids. He said this is like taking an ice cream scoop to scoop up the hemorhoids

Lidocaine + Hydrocortisone Cream

Peranex HC Xyralid RC

What is in the Preparation H cooling gel?

Phenylephrine/ witch hazel

What are third degree internal hemorrhoids?

Prolapse through anal cavity at any time, especially with defecation (lazy turtle)

What are second degree hemorrhoids?

Prolapse with defecation (turtle popping it's head out)

What are fourth degree internal hemorrhoids

Prolapsed permanently- always hanging out

Name hydrocortisone creams

Tucks HC Proctocort (also available as suppositories) Preparation H Hydrocortisone

What agents/ wipes can be used to relive pain?

Witch hazel- Preparation H wipes, Tucks pads

Lidocaine + Hydrocortisone Lotion:

Xyralid LP

_____ is the local anesthetic with the fastest onset of action

benzocaine

What are first degree internal hemorrhoids?

confined to anal canal