Hemorrhoids

Hemorrhoidal varices are part of the normal anatomy. Dilation and enlargement of the superior plexus of the superior hemorrhoidal veins located above the dentate line produce internal hemorrhoids. Enlargement of the plexus of the inferior hemorrhoidal veins located below the dentate line produces external hemorrhoids. External hemorrhoids may protrude from the rectum. Hemorrhoids occur in both sexes. Incidence is generally highest between ages 20 and 50.

Causes

Hemorrhoids result from activities that increase intravenous pressure, resulting in distention and engorgement. Predisposing factors include prolonged sitting, straining at defecation, constipation, low-fiber diet, pregnancy, and obesity.

Other factors include hepatic disease, such as cirrhosis, amebic abscesses, or hepatitis; alcoholism; and anorectal infections.

Signs and symptoms

❑ Internal hemorrhoids may produce no symptoms. They characteristically cause painless, intermittent bleeding during defecation. Bright red blood appears in stools or on toilet paper because of injury to the fragile mucosa covering the hemorrhoid.

❑ When hemorrhoids prolapse, they’re usually painless and spontaneously return to the anal canal after defecation.

❑ External hemorrhoids cause constant discomfort and prolapse in response to any increase in intra-abdominal pressure. They can be manually reduced. Thrombosis of external hemorrhoids produces sudden rectal pain and a large, firm, subcutaneous lump that the patient can feel.

Hemorrhoids seldom cause severe bleeding leading to anemia.

Diagnosis

Physical examination confirms external hemorrhoids. Anoscopy or proctoscopy provides for visual examination of internal hemorrhoids.

Treatment

Treatment depends on the type and severity of the hemorrhoids.

Nonsurgical treatments

Nonsurgical treatments include measures to control pain, combat swelling and congestion, and regulate bowel habits. Patients can relieve constipation by consuming a high-fiber diet and increasing fluid intake by drinking eight to ten 8-oz glasses of water per day or by using bulking agents such as psyllium.

Venous congestion can be prevented by avoiding prolonged sitting on the toilet; local swelling and pain can be decreased with local anesthetic agents (lotions, creams, or suppositories) or astringents. Hydrocortisone suppositories may be used for edematous, prolapsed hemorrhoids in combination with warm sitz baths.

Hemorrhoids may be treated with injection sclerotherapy and rubber band ligation. Infrared photocoagulation bipolar diathermy may be used to affix the mucosa to the underlying muscle.

Clinical tip  There’s no evidence that topical cleaners or lotions (pads, foams, ointments) cause symptomatic hemorrhoids to shrink; they only provide relief by soothing the area.

Hemorrhoidectomy

Hemorrhoidectomy is performed for patients with severe bleeding and those with thrombosed hemorrhoids. This procedure is contraindicated in patients with blood dyscrasias (acute leukemia, aplastic anemia, or hemophilia) or gastric cancer and during the first trimester of pregnancy.

Special considerations

❑ To prepare the patient for outpatient hemorrhoidectomy, tell him that he may receive an enema the night before and morning of surgery.

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

❑ Before discharge, tell the patient that he can resume his regular diet.

❑ Instruct the patient to take a bulking agent, such as psyllium, about 1 hour after the evening meal to help ensure a daily bowel movement. Advise him to maintain regular bowel habits and avoid straining.

❑ Instruct the patient to avoid vigorous wiping and harsh soaps.

Book Source Details

• Book Title: Handbook of Diseases
• Author(s): Springhouse
• Year of Publication: 2003
• Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Handbook of Diseases, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5

 » Next page: Hematochezia (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

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