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Hemorrhoids OHHHH it Burns Mike Parenteau Soooo Angry Pathophysiology Hemorrhoids are varicosities (dilated veins) that may occur outside the anal sphincter. Can be external or internal Most common health problem in humans. Seen in ages 20 to 50 years old Etiology Factors Straining at with increased intraabdominal and hemrorrhoidal venous pressures. With repeated increased pressure and obstructed blood flow, permanent dilation occurs Stuff that causes it Constipation Diarrhea Pregnancy CHF Portal hypertension Prolonged sitting or standing Internal Internal hemorrhoids are those that occur inside the rectum. As this area lacks pain receptors, internal hemorrhoids are usually not painful and most people are not aware that they have them. Internal hemorrhoids, however, may bleed when irritated. Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids. Internal Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they are pushed outside of the anus. If the anal sphincter muscle goes into spasm and traps a prolapsed hemorrhoid outside of the anal opening, the supply of blood is cut off, and the hemorrhoid becomes a strangulated hemorrhoid. External External hemorrhoids are those that occur outside of the anal verge (the distal end of the anal canal). They are sometimes painful, and can be accompanied by swelling and irritation. Itching, although often thought to be a symptom from external hemorrhoids, is more commonly due to skin irritation. If the vein ruptures and a blood clot develops, the hemorrhoid becomes a thrombosed hemorrhoid. Clinical Manifestations The most common symptoms associated with enlarged, abnormal hemorrhoids are prolapsed and bleeding. The bright red bleeding and prolepses usually occur at time of defecation Subjective Assessment Complaints of constipation Pruritus Severe pain when dilated vain becomes thrombosed Bleeding from the rectum that is not mixed with feces (poop). Rectum darn near killed them Objective Assessment Observing external hemorrhoids and palpating internal hemorrhoids on examination Bleeding and constipation are signs of cancer of the rectum, all patients with these symptoms should have a thorough examination to rule out cancer Medical Management There is no medicine that will cure hemorrhoids, but local treatments such as warm sitz baths, using a bidet, extendable showerhead, cold compress, or topical analgesic (such as Nupercainal), can provide temporary relief. Consistent use of medicated creams (such as Anusol) during the early stages of a hemorrhoid flare-up will also provide relief and may stave off further development and irritation. Keep the area clean and dry, with some lubrication provided by hemorrhoidal creams. Suppositories are of little help since all of the symptoms come from the external tissues and not in the rectum where the suppository is placed. Medical Management Rubber band ligation: elastic bands are applied onto an internal hemorrhoid to cut off its blood supply. Within several days, the withered hemorrhoid is sloughed off during normal bowel movement. Hemorrhoidolysis/Galvanic Electrotherapy: desiccation of the hemorrhoid by electrical current. Sclerotherapy (injection therapy): sclerosant or hardening agent is injected into hemorrhoids. This causes the vein walls to collapse and the hemorrhoids to shrivel up. Medical Management Cryosurgery: a frozen tip of a cryoprobe is used to destroy hemorrhoidal tissues. Rarely used anymore because of side effects Laser, infrared or BICAP coagulation: laser, infrared beam, or electricity is used to cauterize the affected tissues. Lasers are now much less popular. Hemorrhoidectomy: a true surgical procedure to excise and remove hemorrhoids. Medical Management Stapled Hemorrhoidectomy: Also called the procedure for prolapse and hemorrhoids, it is designed to resect soft tissue proximal to the dentate line, which disrupts the blood flow to the hemorrhoids. It is generally less painful than complete removal of hemorrhoids and also allows for faster recovery times. It's meant for hemorrhoids that fall out or bleed and is not helpful for painful outside conditions. Enema: This Practice is only used to clean the rectum in some cases and only done by an M.D. Water is injected into the rectum and then flushed out cleaning the area. Doppler Guided Hemorrhoidal Artery Ligation : The only evidence based surgery for all grades of hemorrhoids. It does not involve cutting tissues or even a stay at the hospital; patients are usually back to work on the same day. Best treatment for bleeding piles, as the bleeding stops immediately. Rubber band ligation Stapled Hemorrhoidectomy Diseases with similar symptoms Symptoms associated with rectal cancer, anal fissure, anal abscess, anal fistula, and other diseases may be similar to those produced by hemorrhoids and may be reduced by the topical analgesic, so it is important to have the Doctor examine the patient.