Hemorrhoids

Hemorrhoids are varicosities in the superior or inferior hemorrhoidal venous plexus. Dilation and enlargement of the superior plexus produce internal hemorrhoids; dilation and enlargement of the inferior plexus produce external hemorrhoids that may protrude from the rectum. (See Types of hemorrhoids.) Hemorrhoids occur in both sexes; incidence is usually highest between ages 20 and 50.

Causes and incidence

Hemorrhoids probably result from increased venous pressure in the hemorrhoidal plexus. Predisposing factors include occupations that require prolonged standing or sitting; straining due to constipation, diarrhea, coughing, sneezing, or vomiting; heart failure; hepatic disease, such as cirrhosis, amebic abscesses, or hepatitis; alcoholism; anorectal infections; loss of muscle tone due to old age, rectal surgery, or episiotomy; anal intercourse; and pregnancy.

Hemorrhoids are more common in whites, in persons of higher socioeconomic classes, and in persons who live in rural areas. However, actual incidence figures are unknown because many patients with hemorrhoids self-medicate.

Signs and symptoms

Although hemorrhoids may be asymptomatic, they characteristically cause painless, intermittent bleeding, which occurs on defecation. Bright red blood appears on stool or on toilet paper due to injury of the fragile mucosa covering the hemorrhoid. These first-degree hemorrhoids may itch because of poor anal hygiene. When second-degree hemorrhoids prolapse, they’re usually painless and spontaneously return to the anal canal following defecation. Third-degree hemorrhoids cause constant discomfort and prolapse in response to any increase in intra-abdominal pressure. They must be manually reduced. Thrombosis of external hemorrhoids produces sudden rectal pain and a subcutaneous, large, firm lump that the patient can feel. If hemorrhoids cause severe or recurrent bleeding, they may lead to secondary anemia with significant pallor, fatigue, and weakness; however, such systemic complications are rare.

Diagnosis

Physical examination confirms external hemorrhoids. Proctoscopy confirms internal hemorrhoids and rules out rectal polyps.

Treatment

Treatment depends on the type and severity of the hemorrhoid and on the patient’s overall condition. Generally, treatment includes measures to ease pain, combat swelling and congestion, and regulate bowel habits. The patient can relieve constipation by increasing the amount of raw vegetables, fruit, and whole grain cereal in the diet or by using stool softeners. Venous congestion can be prevented by avoiding prolonged sitting; local swelling and pain can be decreased with local anesthetic agents (lotions, creams, or suppositories), astringents, or cold compresses, followed by warm sitz baths or thermal packs. Rarely, the patient with chronic, profuse bleeding may require a blood transfusion. Other nonsurgical treatments are injection of a sclerosing solution to produce scar tissue that decreases prolapse, manual reduction, and hemorrhoid ligation or laser ablation.

Hemorrhoidectomy, the most effective treatment, is necessary for patients with severe bleeding, intolerable pain and pruritus, and large prolapse. This procedure is contraindicated in patients with blood dyscrasias (acute leukemia, aplastic anemia, or hemophilia) or GI carcinoma and during the first trimester of pregnancy.

Special considerations

Patient care includes preoperative and postoperative support.

❑ To prepare the patient for hemorrhoidectomy, administer an enema, as ordered (usually 2 to 4 hours before surgery), and record results. Prepare the area as ordered.

❑ Postoperatively, check for signs of prolonged rectal bleeding, administer adequate analgesics, and provide sitz baths as ordered.

❑ As soon as the patient can resume oral feedings, administer a bulk medication, such as psyllium, about 1 hour after the evening meal, to ensure a daily stool. Warn against using stool-softening medications soon after hemorrhoidectomy because a firm stool acts as a natural dilator to prevent anal stricture from the scar tissue. (The patient may need repeated digital dilation to prevent such narrowing.)

❑ Keep the wound site clean to prevent infection and irritation.

❑ Before discharge, stress the importance of regular bowel habits and good anal hygiene. Warn against too-vigorous wiping with washcloths and using harsh soaps. Encourage the use of medicated astringent pads and white toilet paper (the fixative in colored paper can irritate the skin).

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Book Source Details

• Book Title: Professional Guide to Diseases (Eighth Edition)
• Author(s): Springhouse
• Year of Publication: 2005
• Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X

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