Hemorrhoids

Published on 06/06/2015 by admin

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Chapter 29 Hemorrhoids

INTRODUCTION

Description: A hemorrhoid is a symptomatic dilation of the hemorrhoidal venous plexus resulting in perianal swelling, itching, pain, hematochezia, and fecal soiling.
Prevalence: Fifty percent to 80 percent of all Americans.
Predominant Age: Adult, more common after pregnancy.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Dilated rectal venous plexus with varying degrees of inflammation.
Risk Factors: Pregnancy, obesity, chronic cough, constipation, heavy lifting, sedentary work or lifestyle, hepatic disease, colon malignancy, portal hypertension, loss of muscle tone resulting from age, surgery, episiotomy, anal intercourse, or neurologic disease (multiple sclerosis).

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Rectal bleeding
• Anal protrusion
• Anal itching and pain (especially with thrombosis or ulceration)
• Constipation and straining for bowel movement
• Rectal incontinence and soiling
• Hematochezia and stool mucus
• Anal fissure, infection, or ulceration
• Hemorrhoidal thrombosis

DIAGNOSTIC APPROACH

Differential Diagnosis

• Colon cancer
• Colon polyps
• Soiling caused by loss of anal tone (anal intercourse, multiple sclerosis, episiotomy)
• Pinworms
• Rectocele
• Fecal impaction
• Anal fissure or fistula

Associated Conditions: Liver disease, pregnancy, portal hypertension, and constipation.

Workup and Evaluation

Laboratory: No evaluation indicated.
Imaging: No imaging indicated.
Special Tests: None indicated.
Diagnostic Procedures: History and physical examination.

Pathologic Findings

Enlarged hemorrhoidal veins with stasis and inflammation are common.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Stool softeners, bowel movement regulation, and topical medications.
Specific Measures: Surgical therapy is appropriate for those patients with debilitating symptoms or for whom medical therapy has failed (15% to 20% of patients). Banding of internal hemorrhoids is better accepted by patients than traditional surgical therapy. Hemorrhoidal banding requires a minimum of equipment and is well suited to the office or outpatient surgical setting. Some aching is generally experienced for several days after hemorrhoid banding procedures. Sitz baths and topical analgesics such as witch hazel are generally sufficient.
Diet: Increased dietary fiber.
Activity: Avoid prolonged sitting, straining, or heavy lifting. Encourage physical fitness.
Patient Education: Reassurance, diet instruction.

Drug(s) of Choice

Dietary fiber supplements.
Stool softeners—docusate sodium (Colace, Dialose, Sof-Lax) 50 to 300 mg PO daily (larger doses are generally divided over the day).
Topical analgesic sprays or ointments—benzocaine (Americaine, Hurricaine) 20% spray or gel, dibucaine (Nupercainal) 1% ointment.
Antipruritics and antiinflammatory agents—hydrocortisone (Anusol-HC, Analpram-HC, Cortenema, Cortifoam, Epifoam, Proctofoam-HC), pramoxine 1% (Fleet rectal pads, Analpram-HC), witch hazel 50% (Tucks pads or gel).
Astringents—Preparation H.
Contraindications to Surgical Therapy: Acquired immunodeficiency syndrome (AIDS) or immunocompromise, anorectal fissures, bleeding diathesis or blood dyscrasia, inflammatory bowel disease, portal hypertension, rectal prolapse, undiagnosed anorectal tumor, undiagnosed rectal bleeding.
Precautions: See individual agents.
Interactions: Docusate sodium may potentiate the hepatotoxicity of other drugs; see individual agents.

Alternative Drugs

Flavanoids have been advocated but a recent meta-analysis was unable to document efficacy.

FOLLOW-UP

Patient Monitoring: Normal health maintenance.
Prevention/Avoidance: Avoidance of constipation (bowel regularity); weight loss (if appropriate); physical fitness; avoidance of prolonged sitting, straining, or heavy lifting.
Possible Complications: Thrombosis, bleeding, secondary infection, ulceration, anemia, and rectal incontinence.
Expected Outcome: Resolution (spontaneous resolution or with medication), recurrence common.

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MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy. Hemorrhoids are extremely common as pregnancy progresses. Dietary prophylaxis and symptomatic therapy early reduce the severity of symptoms. At least partial resolution after delivery is expected.
ICD-9-CM Codes: 455.6, 455.3 (External), 455.0 (Internal), 455.7 (Thrombosed).

REFERENCES

Level II

Alonso-Coello P, Mills E, Heels-Ansdell D, et al. Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am J Gastroenterol. 2006;101:181.

Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, et al. Meta-analysis of flavonoids for the treatment of haemorrhoids. Br J Surg. 2006;93:909.

Quijano CE, Abalos E. Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium. Cochrane Database Syst Rev. 20(3), 2005. CD004077

Level III

Bleday R, Pena JP, Rothenberger DA, et al. Symptomatic hemorrhoids: current incidence and complications of operative therapy. Dis Colon Rectum. 1992;35:477.

Gearhart SL. Symptomatic hemorrhoids. Adv Surg. 2004;38:167.

Mazier WP. Hemorrhoids, fissures, and pruritus ani. Surg Clin North Am. 1994;74:1277.

Medich DS, Fazio VW. Hemorrhoids, anal fissure, and carcinoma of the colon, rectum, and anus during pregnancy. Surg Clin North Am. 1995;75:77.

Nisar PJ, Scholefield JH. Managing haemorrhoids. BMJ. 2003;327(7419):847.

Parangi S, Levine D, Henry A, et al. Surgical gastrointestinal disorders during pregnancy. Am J Surg. 2007;193:223.

Wald A. Constipation, diarrhea, and symptomatic hemorrhoids during pregnancy. Gastroenterol Clin North Am. 2003;32:309. vii.

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