Hemorrhoids

Diosmin

Alternative Therapy _______ (Hemoval) 600 mg PO TID x 4/7 then 600 mg PO BID x 3/7 AE: abdominal pain, nausea, diarrhea and headache - may help reduce pain, swelling, bleeding and overall symptom duration - horse chestnut - topical bovine cartilage

Age Standing/Sitting Dietary bulk

Contributing Factors - increasing ____ - straining at stool/prolonged sitting on the toilet - constipation - diarrhea - pregnancy - prolonged _____/_____ - physical exertion and heavy lifting (increased intra-abdominal pressure) - lack of _____

IBD Anal Fissure Pinworms

Differential Assessment Upper GI tract bleeding (dark, tarry stools, hematemesis) ______: abdominal cramping & pain, rectal bleeding & pain, diarrhea, mucus, blood _______: Painful defecation, rectal bleeding Colorectal Cancer _______: Common in young children, perianal itching especially at night, worms visible upon inspection

Am Pm BM

Frequency/Length of use & monitoring _____ & ____ use and after each ______ (usually max 5-6 times per day) Assess in ___ days: - if no improvement then refer - if symptomatic improvement then continue therapy until symptoms resolve (HC for 14 days) - if worsening (bleeding, seepage, protrusion) then refer - discuss preventative measures

Progression Complications

Goals of Therapy - to relieve symptoms - prevent ____ & _____ - promote good bowel habits & hygiene - prevent future episodes

NLPB

Hemorrhoids is a minor ailment that pharmacists can prescribe for if authorized by _______.

Anal cushion Protrudes Retracts Manually Bulge

Internal Hemorrhoids Stages: Primary- Internal swelling of ______. Secondary- at defecation, small portion of anal cushion ______ then ______ Tertiary- same as for secondary but must be pushed back _____ Quaternary- permanently ____ from anus

Bed rest

Non Pharm Therapy Activities: _____ if severe Exercise regularly Avoid sitting for long periods or prolonged - avoid heavy lifting and straining

Straining 3 dab

Non Pharm Therapy Toilet habits: - don't avoid the urge to defecate - avoid ______ - dont remain on the toilet > ___ min attempting to have a BM - clean anal area with soap & water - cleanse anal area well but gently ____ rather than wiping - cleanse with wash cloth; wipe with tucks

Sitz Baths

Non Pharm Therapy _____: Sit in tub of warm water x 15 minutes 3-4 times/day - can add epsom salts - warm water sprays - cool compresses or ice packs

Fiber 8

Non Pharm Therapy Diet: High ____ ___ glasses of water per day Avoid irritating foods

Vascular cushions

Pathophysiology _______ are part of normal anatomy & are located around the anal canal and can become problematic - we all have them but they become hemorrhoids when diseased, when there is a lot of downward pressure toward them they loosen up, swell, etc

Non pharmacological 48

Patient counselling & education - ______ treatments to all patients - management of constipation - proper use of any medication - advise that medications will only provide symptomatic relief - possible unwanted effects of medications and how to manage them - when to see some improvement (____ hours) - when it is neccessary to see a physician

Acetaminophen

Pharmacologic Therapy Analgesics - _______ - NSAIDS - caution if rectal bleeding Avoid opioids (constipation)

Psyllium Docusate Sodium

Pharmacologic Therapy For constipation: Bulk forming laxatives (_______)/ stool softeners (______) -- reduce straining Cochrane review: - fiber effective in improving symptoms of hemorrhoids - improve bleeding & possibly itching - stimulants may worsen symptoms - lactulose ok too

Pramoxine 5 7

Pharmacologic Therapy Topical Local Anesthetics: Lidocaine, Tetracaine, Dibucaine (Nupercainal) ______ (Anusol Plus- 1%) best LA: safest and least likely to cause sensitivity - not > ___ to ____ days as may mask signs of infection and increase risk of contact dermatitis (risk of sensitization) - use in perianal region and lower anal canal - evidence for pain lacking

Phenylephrine, naphazoline

Pharmacologic Therapy Vasoconstricters: ______, _______ - topical decongestants used to increase vascular tone - systemic absorption may occur if applied to abraded skin - usually NOT recommended for patients with DM, hyperthyroidism, hypertension or those taking MAO inhibitors

Nifedipine Nitroglycerin

Pharmacologic Therapy ________ 0.3% Topical ________ 0.2% Topical - topical vasodilators - may reduce pain from thrombosed external hemorrhoids

Protectants

Pharmacologic Therapy ________: glycerin, zinc oxide, lanolin, mineral oil, petrolatum, cocoa butter, shark liver oil - prevent irritation by forming a physical barrier on the skin - generally safe - commonly used as the base for topical prescription and OTC medications - lanolin may cause sensitization

50

Prevalence: 5% ____% of people over the age of 50 experienced symptoms at some point in time - equal in males and females - peaks between ages 45-65 and decreases thereafter

intermittent Straining

Signs & Symptoms - continuous or ________ -pain/itching/throbbing within anal region - bleeding: bright red blood on toilet paper --> anemia - constipation or diarrhea - _____ with defecation - prolapse of internal hemorrhoids = tissue outside anal canal = mucoid discharge, ulceration, false urges to defecate --> straining at stool

Non-pharmacologic

Treatment in pregnancy - ______ treatments (fiber, fluids, sitz baths) - external products preferred

12 Colorectal Cancer 6 weeks Bleeding Pregnant 3rd 4th 7

When to refer Child <_____ years of age - risk factors for ______ - Rectal bleeding persisting for ____ or more with or without a change in stool consistency or frequency - frequent recurrent episodes of _____ hemorrhoids - hemorrhoids causing severed discomfort in ____ patients - ____ or ____ degree hemorrhoids - symptoms have not improved despite ____ days of pharmacological treatment

Cream Ointment

Which dosage form? _____/_____ are better than suppositories as these ascend into the rectum - can use cr/ung internally or externally - consider patient dexterity

Pain Pruritis Bleeding Inflammation

Which product? - There is insufficient evidence to recommend one product over the other. Based on patient's symptoms: _____: local anesthetics, hydrocortisone ______: hydrocortisone, astringents, protectants, local anesthetics ______: astringents ______: Hydrocortisone

Internal Hemorrhoids

____: - form above the dentate line - lined with columnar epithelium - no pain fibers (not really painful when internal because there is less pain fibers)

Perianal area Anal canal Rectum Pectinate/dentate line

_____: area of the skin around the anus _____: most terminal part of the lower GI tract/large intestine, which lies between the anal verge (anal orifice, anus) in the perineum below and the rectum above ______: major anatomic feature when classifying hemorrhoids ______: line which divides the upper two thirds and lower third of the anal canal.

External

______ Symptoms - thrombosed - pain - rarely bleeding - often aymptomatic

Internal

_______ Symptoms - bleeding - prolapse - soilage --> anal itching/irritation - Pain (if 4th strangulated)

Topical Hydrocortisone

_______: Proctosedyl, Anusol Hc, Anugesic - decreases itching, pain and inflammation - caution with prolonged use --> may cause skin atrophy (thinning) - do not use for >7 days (may use up to 14 if improvement is occuring) - requires a prescription

Astringents

________ - bismuth, zinc oxide, zinc sulfate - witch hazel (hamaelis water 10%- tucks) - decrease irritation, discomfort, pruritis, burning, pain

External Hemorrhoids

________: - form below the dentate line - lined with squamous epithelium - somatic pain receptors (if they originate below then they are more painful)