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 bleed
Grade II - Prolapse and reduce spontaneously
Grade III- Prolapse requiring replacement
Grade 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
Fixation of mucosa
 Infrared coagulation
 Elastic band ligation Fixation of mucosa &
removal of redundant
 Cryotherapy internal component

 Hemorrhoidectomy
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)
 SUPPOSITORIES (con’t)
 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
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 CHOICE
Method Grade I Grade II Grade III Grade IV
Diet √ √
Medical treatment √ √
Sclerotherapy √ √
Infrared √ √ √
coagulation
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.
Phlebolymphology No31:10-15