Kembara Xtra - Medicine - Hemorrhoids

Kembara Xtra - Medicine - Hemorrhoids 
Introduction 
External hemorrhoids: Somatic innervation (painful); covered by squamous epithelium; below (distal to) the dentate line; varicosities of the hemorrhoidal venous plexus
Internal hemorrhoids are covered by columnar epithelium and are above (proximal to) the dentate line. They have visceral innervation, which is painless.
– Internal hemorrhoids are categorized (1) as follows: Hemorrhoid vessel bulges in Grade I cases but does not prolapse.
Hemorrhoid prolapses when you strain it, but it decreases on its own.
Hemorrhoid prolapses with strain and needs to be manually reduced in Grade III.
Grade IV: Prolapsed for a long time and cannot be reduced
Hemorrhoids, both internal and external, frequently coexist.
Hemorrhoids can cause itchiness, bleeding, soilage, prolapse, or pain, though they are frequently asymptomatic. External hemorrhoids are more likely to cause pain and thrombosis than internal hemorrhoids. 
Aspects of Geriatrics
In the elderly, hemorrhoids and rectal prolapse are more prevalent.
Child Safety Considerations

 Rare in children and newborns; most often caused by chronic liver disease; other symptoms (rectal polyps, skin tags, condyloma) sometimes mistaken as hemorrhoids.
Hemorrhoids can develop in adolescents who have chronic constipation and extended bathroom visits.
pregnant women's issues
Common during pregnancy Usually goes away after birth No treatment is necessary unless it is excruciatingly uncomfortable


Adults are the predominant age group, peaking between the ages of 45 and 65.
Males predominate over females.
Hemorrhoidal disease is a common cause of office visits in the United States, with over 3.5 million visits per year. 
39% prevalence on standard screening colonoscopies compared to a frequency of 4–5% in the entire US population

Pathophysiology and Etiology 
Unknown pathophysiology in detail. The left lateral, right anterior, and right posterior hemorrhoidal cushions are the three main hemorrhoidal cushions. Hemorrhoidal cushions increase the pressure required to close the anal sphincter and safeguard it when a stool is being passed through. Increased intra-abdominal pressure causes the hemorrhoidal cushions' pressure to rise during a Valsalva maneuver. The following are mechanisms linked to symptomatic hemorrhoidal disease: - Prolapse of the cushions and the surrounding connective tissues - Dilated hemorrhoidal plexus veins - Tight internal anal sphincter - Unusual distention of the arteriovenous anastomosis
Genetics
No genetic pattern is known.

Risk factors include: pregnancy, pelvic space-occupying lesions, liver disease, portal hypertension, prolonged sitting jobs, loss of perianal muscle tone from aging, rectal surgery, birth trauma/episiotomy, and anal sex, obesity, and chronic diarrhea.


Prevention 
Avoid extended sitting or straining on the toilet, eat a high-fiber diet (>30 g/day), and stay properly hydrated to prevent constipation.

Constipation, pregnancy, cirrhosis, and liver disease are all associated conditions.


Diagnosis A simple diagnosis may usually be made by taking a history, looking at the perineum, performing a rectal exam, and anoscopy.

Symptoms of Bleeding in the History of Present Illness (60%)
- Traditionally, brilliant red blood per rectum, which can range from little to a lot of blood in the toilet bowl and on the toilet paper. - Pruritus (55%)
- Pain in the perianal region (20%)
-10% of soiling
- Diarrhea or constipation - Straining while urinating
External hemorrhoids cause pain, pruritus, irritation from poor hygiene, and occasional bleeding on stools or toilet paper. More severe internal hemorrhoids have a feeling of incomplete eviction.
Hemorrhoids that have thrombosed manifest as an acute uncomfortable lump.
Ask about your nutrition (fiber, fluid consumption), bowel habits (prolonged sitting), change in stools, systemic symptoms (weight loss, pain, fever), and bowel patterns (frequency, consistency, incontinence).
Inquire about past medical conditions and family history (colorectal cancer, gastrointestinal disorders).

clinical assessment 
Visual anorectal examination with and without the Valsalva maneuver
Internal hemorrhoids show up as purple masses on the lumen wall during a digital exam with anoscopy; concomitant anorectal pathology (skin tags, masses, abscesses, fissures, and fistulas) should also be checked for.
Make an effort to get rid of prolapsed hemorrhoids.
Abdominal examination to rule out bulk

 Caput, telangiectasias, and palmar erythema are examples of the peripheral cirrhosis and portal HTN stigmata.

Differential diagnoses include inflammatory bowel illness, skin tags, anal fistulas, fissures, or abscesses, rectal polyps, and rectal prolapse.

Laboratory Results 

Initial examinations (lab, imaging)
Unless anemia is suspected, not recommended
Diagnostic Procedures/Other Depending on the risk factors for malignancy in patients with rectal bleeding, sigmoidoscopy or colonoscopy may be performed.

Stool softeners, sufficient hydration, fiber supplements, and anal hygiene are all forms of management and prevention.

General Actions 

Even after surgical excision, hemorrhoids are a reoccurring condition. The use of preventive measures should never end.
Avoid spending too much time sitting down during bowel movements for prevention or moderate symptoms; the impact of squatting is not known.
• Try not to strain.
- Eat a high-fiber diet or use fiber supplements to prevent constipation; if necessary, take regular stool softeners.
- Regular exercise and, if necessary, weight loss
Constipation relief, anal cleanliness, local ointments, and sitz baths are beneficial during the stage of easy reduction (grade II). Pruritus or moderate discomfort after stooling may respond to topical corticosteroid ointment, anesthetic ointments or sprays, and heated sitz baths. More advanced stages frequently call either surgery or ligation.

The First Line of Medicine
First-line, nonoperative treatment for symptomatic hemorrhoids involves dietary modification with adequate fluid (typically 2 L of water per day) and high fiber (25 to 35 g/day); fiber supplementation (psyllium husk) to complement diet; fiber supplementation helps relieve overall symptoms and bleeding.

To soften the stool, take a stool softener or bulk-forming laxative. To relieve pain, take a warm watersitz bath. 
Topical anesthetics (benzocaine, lidocaine, and pramoxine), steroids, and emollients have historically been used to treat symptoms, but there isn't enough support for their long-term use.
- Local anesthetics given to the perianal area (not introduced into the rectum) to relieve pain and itching - Benzocaine 20% spray, ointment; dibucaine 1% ointment (Nupercainal); lidocaine 5% (Preparation H, Tucks); pramoxine 1% foam, ointment, wipe (Proctofoam). Sprays should be used with caution because the alcohol in the product could cause burning.
Anti-inflammatory drugs (corticosteroids) such hydrocortisone ointment and cream (0.25-2.5%) (Anusol HC, Cortifoam) might reduce swelling as well as discomfort and itching.
Rectal suppositories should only be used temporarily.
Following a bowel movement, use witch hazel solution, wipes, or pads (Preparation H, Tucks) as an astringent to assist dry skin. Vasoconstrictors (0.25% phenylephrine ointment, suppository, gel) are used to reduce hemorrhoids and relieve bleeding, pain, and itching. Next Line
treatment for unique situations
External hemorrhoids that have thrombosed: if present within 72 hours after the onset of pain, it is advised to make an incision and remove the clot or to remove the entire hemorrhoid complex. Early surgical excision may hasten the resolution of symptoms and reduce the likelihood of recurrence.

Untreated irreducible hemorrhoids can develop to thrombosis and necrosis, leading to strangulated hemorrhoids.
Hemorrhoidectomy is necessary for treatment, either urgent or emergent.
Treatment for acute hemorrhoidal bleeding linked to portal HTN relies on the severity of the hemorrhoids and the amount of bleeding. Differentiate from more significant anorectal varices, which need surgical procedures (suture ligation and possible shunts) as well as medicinal care (correct coagulopathy).

Indications for surgical procedures include failure of nonoperative and medicinal treatment, grade III or IV hemorrhoids that are symptomatic and coexist with a surgically treatable anorectal disease, or patient desire.
Office-based methods for individuals with grade I, II, or III internal hemorrhoids who have not responded to conventional therapy
- The most popular and efficient office-based technique for symptomatic internal hemorrhoids is rubber band ligation (RBL). If taking anticoagulants, avoid.
- Infrared photocoagulation: Infrared light waves cause necrosis within hemorrhoids; recurrence rates are comparable to or slightly higher than those of RBL; postoperative discomfort and complications are reduced.Sclerotherapy: submucosal injections that result in local thrombosis; may be most beneficial for individuals at higher risk for bleeding (anticoagulated, advanced liver disease); caution must be given to inject in the correct location; not for advanced illness or if there is evidence of infection, inflammation, or ulceration. Due to the high likelihood of problems, cryotherapy is no longer advised.
Patients with symptomatic grade III or IV illness who have not responded to nonoperative therapy should undergo surgery.Different technologies are currently employed to excise hemorrhoidal tissue: diathermy, lasers, and ultrasonic dissectors; these are associated with less discomfort than conventional hemorrhoidectomy, closed hemorrhoidectomy, and open hemorrhoidectomy. 
Newer procedures shorten recovery times for returning to regular activities, pain in the immediate postoperative period, and urine retention.
Anoscope or proctoscope with a Doppler probe locates the hemorrhoidal artery, which is then ligated; this procedure allows for a quicker return to work than open hemorrhoidectomy (6).
[A]
- Stapled hemorhoidopexy—for internal hemorrhoidal illness that has progressed. Excises the submucosa; less healing time, but increased recurrence of disease compared to traditional hemorrhoidectomy 
– LigaThere is no one best surgical treatment for hemorrhoids; patients must be treated individually based on their symptoms and the risks and benefits of each procedure. Sure hemorrhoidectomy: shortens operating time, improves patient tolerance, and is equal to conventional hemorrhoidectomy in terms of long-term symptom control. Laser treatment for grade 2 and 3 hemorrhoids has acceptable results with less postoperative pain and bleeding than open hemorrhoidectomy.

Alternative Therapies 
Bioflavonoids taken orally have been demonstrated to reduce bleeding, pruritus, and recurrence.
A pharmacist-prepared topical medication called nifedipine can help thrombosed hemorrhoids feel less painful.
In order to reduce anal sphincter spasm in thrombosed hemorrhoids, topical nitroglycerin (0.4%) has been utilized; headache is the main adverse effect.
Botulinum toxin injection into the anal sphincter to treat thrombosed hemorrhoid discomfort and spasm 
After a hemorrhoidectomy, applying aloe vera cream to the surgical site speeds up healing and minimizes the need for analgesics.


Follow-Up: Encourage physical activity, healthy eating, and weight control. Prevent protracted sitting and uncomfortable toilet squatting.
patient observation
as required, subject to therapy

Diet 
a high fiber diet with a goal of 30 grams of insoluble fiber per day from foods like wheat bran cereals, oatmeal, peanuts, artichokes, beans, corn, peas, spinach, potatoes, apples, apricots, blackberries, raspberries, prunes, pears, and bananas; adequate fluids (6 to 8 glasses of water per day); and minimal caffeine intake.
adding more dietary fiber

Prognosis 
Recurrence and spontaneous resolution

Pelvic sepsis following hemorrhoidectomy, thrombosis, ulceration, anemia (rare) and incontinence, are the complications.

---