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