Hemorrhoids Flashcards
2024 (165 cards)
1
Q
What are hemorrhoids?
A) Abnormal growths in the rectum
B) A common condition characterized by rectal bleeding, sometimes pain and itching due to inflammation of the blood vessels within the anal canal
C) Severe sharp pain which always occurs during defecation; small amounts of red blood can be seen on tissue or in stool
D) Varicose veins in the rectum
E) A type of cancerous lesion
A
B) A common condition characterized by rectal bleeding, sometimes pain and itching due to inflammation of the blood vessels within the anal canal
Hemorrhoids are when the veins or blood vessels in and around your anus and lower rectum become swollen and irritated.
2
Q
Symptomatic hemorrhoids are experienced by approximately ______% of individuals at some point in their lives.
A
According to MedSask (2023), symptomatic hemorrhoids are experienced by 58–86% of individuals at some point in their lives.
- Approx 75% of population will have hemorrhoids at some point in their lifetime at least once.
Actual prevalence is assumed to be under-reported since many people self-treat.
3
Q
When are hemorrhoids cautioned to be a medical problem? (4)
Not necessarily red flags btw
A
Only if they become
- enlarged — If hemorrhoids become enlarged, they can cause symptoms like bleeding, itching and burning around the anus,
- thrombosed (i.e., obstructed or affected by a clot of coagulated blood),
- prolapsed (abnormal downward displacement), or
- start bleeding
4
Q
Hemorrhoids are sometimes INCORRECTLY referred to as ________ in the anal canal.
A
Varicose veins
5
Q
Hemorrhoids become medical problems only if they become enlarged, __________, prolapsed, or start bleeding
A
Thrombosed
6
Q
Symptoms of hemorrhoids are often self-limiting, usually resolving without treatment within ________ [time frame].
A
2 weeks.
7
Q
_________ in the anal canal are a normal part of human anatomy, and these cushions or plexus normally help to seal the upper anal canal and contribute to continence.
A
Hemorrhoidal cushions
8
Q
What are hemorrhoids [anatomical term]?
A) Abnormal growths in the anal canal
B) Vascular structures located in the anal canal
C) Varicose veins in the rectum
D) A type of cancerous lesion
A
B) Vascular structures located in the anal canal
Hemorrhoids [anatomical] are vascular structures located in the anal canal and consist of normal anatomic features, including connective tissue, an arteriovenous plexus, and smooth muscle.
9
Q
T/F: Internal hemorrhoids are typically painful.
A
False!
INTERNAL Hemorrhoids originate ABOVE the Dentate line (also called pectinate or anorectal line) and should not cause pain UNLESS complications develop, since this area has NO NERVE FIBRES.
Internal hemorrhoids usually will involve painless bleeding with the bowel.
10
Q
Hemorrhoids contribute to continence by aiding in the closure of the __________.
A
Anal opening.
11
Q
What are the (3) Goals of Therapy for Hemorrhoids?
A
i) Relieve symptoms
ii) Prevent complications
iii) Prevent future episodes by promoting good bowel habits and hygiene
12
Q
What is the location of internal hemorrhoids?
A) Above the dentate line
B) Below the dentate line
C) Outside the anal canal
D) In the skin around the anus
A
A) Above the dentate line.
Has no nerve fibres and is why internal hemorrhoids are usually painless bleeding.
13
Q
T/F: External hemorrhoids can develop a blood clot, leading to thrombosis.
A
True! This is why external hemorrhoids can be painful.
External hemorrhoids can become painful, especially if they develop a blood clot, a condition known as thrombosis.
14
Q
Symptoms of hemorrhoids may include _________, itching, discomfort, pain, and swelling around the anus.
A
Rectal bleeding
15
Q
Symptoms of hemorrhoids reported by patients may include rectal bleeding, _______, discomfort, pain, and swelling around the anus.
(What are some common things patients might tell me about it)
A
Itching
16
Q
Symptoms of hemorrhoids may include rectal bleeding, itching, _______/______, and swelling around the anus.
A
Discomfort / Pain
17
Q
Symptoms of hemorrhoids may include rectal bleeding, itching, discomfort, pain, and ________ around the _______.
A
Swelling ; Anus
18
Q
What factors can contribute to the development of hemorrhoids?
A) Prolonged sitting or standing
B) Regular exercise
C) Drinking plenty of water
D) Avoiding fiber-rich foods
E) All of the above
A
A) Prolonged sitting or standing
19
Q
Hemorrhoids can be classified as internal, external or mixed.
How does one classify Internal hemorrhoids vs. External hemorrhoids?
a) Based on if patient experiences pain and the severity of the discomfort
b) Based on the location where the hemorrhoid originates from
c) Based on age and demographic
d) Based on after other serious differential diagnoses, such as colorectal cancer or IBD has been ruled out.
e) All of the above.
A
b) Based on the location where the hemorrhoid originates from
Internal and External hemorrhoids are classified based on its location above or below the dentate line, respectively.
- Internal hemorrhoids originate above the dentate line.
- External hemorrhoids originate and are located below the dentate line and can be painful (especially if thrombosed). Note: they are not necessarily outside the anal canal, just below the dentate line.
20
Q
What are the symptoms of symptomatic hemorrhoids?
A) Rectal bleeding (bright red) and itching
B) Pruritus or burning, pain and swelling around the anus
C) Discomfort during bowel movements (straining)
D) All of the above
A
D) All of the above
- pruritus or burning, swelling, rectal bleeding (often during or immediately following a bowel movement), and possibly pain.
Hemorrhoids are the most common cause of rectal bleeding.
Bright red blood is characteristic of hemorrhoids. The bleeding may vary from light spotting on the toilet paper to drops in the toilet bowl, and most often occurs during or immediately following defecation.
21
Q
_______ hemorrhoids are located beneath the skin around the anus.
A
External hemorrhoids
22
Q
T/F: Hemorrhoids are only symptomatic when they become thrombosed.
A
False.
Hemorrhoids can become symptomatic when they are enlarged, inflamed, prolapsed, or thrombosed.
23
Q
What is the junction between the rectum and the anal canal called?
A) Perianal region
B) Dentate line
C) Anorectal ring
D) Anal sphincter
A
B) Dentate line
(also called pectinate or anorectal line)
24
Q
Hemorrhoids can become symptomatic when they are __________, inflamed, prolapsed, or thrombosed.
A
Enlarged.
25
T/F: Straining during bowel movements is not a factor contributing to the development of hemorrhoids.
False!
Straining during bowel movements is indeed a factor contributing to the development of hemorrhoids, as well as it is another symptom of hemorrhoids.
26
What is the term for hemorrhoids that have both internal and external components?
A) Symptomatic hemorrhoids
B) Mixed hemorrhoids
C) Thrombosed hemorrhoids
D) Prolapsed hemorrhoids
B) Mixed hemorrhoids
27
Hemorrhoids can become symptomatic when they are enlarged, inflamed, ______, or thrombosed.
prolapsed
28
Bleeding is one of the characteristics of hemorrhoids; however, not all kinds of bleeding indicates hemorrhoids and/or requires MD referral.
Which of the following statements warrants an MD referral (and no longer pharmacist territory)?
a) Bright red blood
b) Drops of blood in the toilet bowl during or after a bowel movement
c) Dark blood or blood mixed with fecal matter
d) Any blood that is found on toilet paper upon wiping
e) All of the above
c) Dark blood or blood mixed with fecal matter should be suspicious of an alternate diagnosis and is to be referred to MD as can be indicative of something like Upper GI Bleed.
Black, tarry stool is also a red flag and should be referred.
## Footnote
Any form of rectal bleeding is something pharmacists know we can't do much about, but we still dive in a bit and try to lay the ground work and see how serious it is and let patient decide when to see MD with our help.
29
T/F: Constipation refers to the condition where there is difficulty in passing stool, while hemorrhoids refer to the swelling of blood vessels in the anal canal.
True!
30
T/F: Hemorrhoids can cause rectal bleeding, while constipation cannot
False!
Both hemorrhoids and constipation can cause rectal bleeding.
31
Which of the following may contribute to the development of both hemorrhoids and constipation?
A) Drinking plenty of water
B) Regular exercise
C) Prolonged sitting or standing
D) Eating a high-fiber diet
C) Prolonged sitting or standing
32
T/F: Hemorrhoids and constipation are mutually exclusive conditions and cannot occur simultaneously.
False.
Hemorrhoids and constipation can occur simultaneously, and one condition does not exclude the other.
| BUT not necessarily something that is generally common to occur.
33
A patient presents with painless rectal bleeding during bowel movements. Upon examination, the healthcare provider observes swollen blood vessels located above the dentate line.
What is the most likely diagnosis?
A) Internal hemorrhoids
B) External hemorrhoids
C) Anal fissures
D) Colorectal cancer
A) Internal hemorrhoids
34
T/F: External hemorrhoids are located above the dentate line in the anal canal.
False.
External hemorrhoids are located below the dentate line.
35
A 45-year-old woman complains of itching around her anus, especially at night. She also notices small, white, thread-like worms in her stool. What is the most likely diagnosis?
a) Internal hemorrhoids
b) Constipation
c) Anal fissures
d) Cholera
e) Pinworms
e) Pinworms
Pinworms (Enterobius vermicularis) should be consider if predominant symptom is anal pruritus and there is a school-aged child in the household.
Often an entire family is infected due to transmission from the affected individual.
36
A 60-year-old man presents with unintentional weight loss, changes in bowel habits (including constipation alternating with diarrhea), and rectal bleeding. He also complains of abdominal pain and fatigue.
What condition should be suspected, and what diagnostic tests are indicated?
Colorectal cancer should be suspected.
Diagnostic tests may include colonoscopy, fecal occult blood test (FOBT), and imaging studies such as CT scans to evaluate the extent of the disease.
37
______ involves difficulty passing stool, often resulting in infrequent bowel movements or hard, dry stools.
Constipation
38
Which condition may present with melena (black, tarry stools) and symptoms of anemia such as fatigue and weakness?
A) Upper GI tract bleeding
B) Internal hemorrhoids
C) Anal fissures
D) Pinworms
A) Upper GI tract bleeding
If patient reports black, tarry stools, it is not typical of hemorrhoids and should be referred as could be possible upper GI tract bleeding, or other serious problems.
39
T/F: Hemorrhoids are typically associated with changes in bowel habits such as constipation alternating with diarrhea.
False...
Hemorrhoids themselves are not typically associated with changes in bowel habits such as constipation alternating with diarrhea. Hemorrhoids primarily present with symptoms such as rectal bleeding, itching, discomfort, pain, and swelling around the anus.
Constipation and diarrhea can both contribute to the development or exacerbation of hemorrhoids due to the strain and pressure exerted during bowel movements. However, hemorrhoids are not the primary cause of changes in bowel habits. Conditions such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and certain dietary factors are more commonly associated with alterations in bowel habits.
40
A 30-year-old woman complains of pain and swelling around her anus, especially after prolonged sitting. On examination, the healthcare provider observes bluish, tender lumps around the anal opening.
What is the likely diagnosis?
External hemorrhoids
41
How are hemorrhoids graded based on severity/degree of prolapse?
A) Grade A, Grade B, Grade C, Grade D
B) Grade I, Grade II, Grade III, Grade IV
C) Grade Mild, Grade Moderate, Grade Severe
D) Grade Primary, Grade Secondary, Grade Tertiary, Grade Quaternary
B) Grade I, Grade II, Grade III, Grade IV
Grade I is the least painful (or no pain), and Grade IV is the most discomforting and indicates likely chronic prolapsing.
42
T/F: Grade II hemorrhoids prolapse through the anus on straining but spontaneously return to the normal position. This is usually a painless form of internal hemorrhoids.
True!
Grade II usually painless as it is likely that the internal hemorrhoid has prolapsed through the anus on straining, but spontaneously return to normal position.
A small part of the anal mucosa or cushion that may protrude at the anus during defecation. After the bowel movement, the tissue spontaneously returns to its normal position. Usually painless
43
Grade ___ : Swelling of the anal cushion, often with straining, and are usually painless. They do not prolapse below the dentate line
Grade I of Internal Hemorrhoids classification.
44
Grade ____: Prolapse through the anus on straining, but spontaneously return to normal position.
Grade II of Internal Hemorrhoids classification.
45
Grade _____: Remain in the prolapsed position after straining and require manual replacement. Might be painful and rectal bleeding is common in this stage.
Grade III of Internal Hemorrhoids classification.
46
Grade _____: Chronically prolapsed, creating a permanent bulge and cannot be replaced after a bowel movement. This stage is quite painful and bleeding is common. In this stage of [internal] hemorrhoids, person at risk of thrombosis and gangrene
Grade IV of Internal Hemorrhoids classification.
47
Which grade of internal hemorrhoids requires manual replacement after prolapsing?
A) Grade I
B) Grade II
C) Grade III
D) Grade IV
C) Grade III
Grade IV cannot have replaced after bowel movement.
48
T/F: Grade IV hemorrhoids are characterized by chronic prolapse, creating a permanent bulge that cannot be replaced after a bowel movement.
True!
49
Which grade of hemorrhoids is at risk of thrombosis and gangrene?
A) Grade I
B) Grade II
C) Grade III
D) Grade IV
D) Grade IV
50
T/F: Grade I of internal hemorrhoids often cause pain and discomfort, especially during bowel movements.
False.
Grade I and II are usually painless.
51
According to Orkin (1999), out of all hemorrhoid complaints reported, when seen at an MD's office, _____% of cases were not hemorrhoids but something else instead.
50% approximately
52
In SK, what age group are pharmacists required to Refer individuals who suspect themselves to have hemorrhoids?
< 12 years-old
Individuals who are under the age of 12 are to be referred.
53
List the (4) Risk Factors of Colorectal Cancer that would require SK Pharmacists to Refer people to see the MD when they suspect hemorrhoids:
1) Over 50 years of age with new onset of symptoms not diagnosed by their primary care provider (note: age alone is NOT a reason to refer btw)
2) History of inflammatory bowel disease
3) Personal history of colorectal cancer or adenomatous polyposis
4) Strong family history of EITHER cancer or polyps in a first-degree relative <60 years old OR two first-degree relatives of any age)
54
Which of the following conditions are not usually associated with the anus and/or the anal canal?
a) Constipation
b) Internal hemorrhoids
c) External hemorrhoids
d) Anal fissures
a) Constipation does NOT affect the anal and/or the anal canal...
Constipation usually affects either the colon or rectum.
55
Hemorrhoids affects which region of the body?
a) Anus
b) Anal canal
c) Rectum
d) Both a and b
e) All of the above
e) All of the above!
Hemorrhoids generally affects the anal canal. The anal canal is what is connecting the rectum to the end of the gastrointestinal system, the anus.
For example, internal hemorrhoids occurs Inside the rectum, above the dentate line... External hemorrhoids occurs beneath the skin around the anus.
56
______ May present with sharp pain during bowel movements, visible tear or crack in the skin around the anus.
a) Anal fissures
b) Internal hemorrhoids
c) External hemorrhoids
d) Consequences of straining during constipation and/or hemorrhoids.
a) Anal fissures
57
By coincidence, anal fissures can be concurrently seen in approx. ____% of hemorrhoid sufferers according to Clin Gas Hep 2013?
Approx. 20% will see concurrent incidences.
58
______ May present with abdominal bloating, cramping, discomfort, or pain, feeling of incomplete evacuation of stool
Constipation
59
_______ May present with both painless rectal bleeding and pain/discomfort around the anus
Mixed hemorrhoids
60
What are the two symptoms for hemorrhoids that can also be an indication of possible Colorectal Cancer signs?
Bleeding and Pain
Bleeding for colorectal cancer is recurrent, often darker in colour (but could still be bright or mixed with fecal matter)
Along with that, Change in bowel habits (stool consistency, frequency, narrower stools), and Unexplained weight loss are also indications that can flag possible colorectal cancer.
61
_______ can be described to be associated with Pain, itching, discomfort, swelling, palpable lump around the anus
External hemorrhoids
62
If symptoms of suspected hemorrhoids does not improve after _______ (unless worsening of symptoms, or develops red flag symptoms) of starting pharmacological treatment, patient should be referred to MD.
7 days.
63
Patients with suspected with hemorrhoids should be referred to MD if ***rectal bleeding persisting*** *after* local treatment for ____ to ____ week(s), with or without a change in stool consistency and/or frequency.
6-8 weeks
(regardless of changes in stool consistency and/or frequency)
64
___ are abnormal tissue growths that can occur in various parts of the body, including the colon, rectum, stomach, uterus, and nasal passages, among others. Usually found via scope.
Polyps
65
Proctitis vs. Hemorrhoids are very important differentials to note****
Proctitis and hemorrhoids both affect the ____ area and may share some symptoms (such as rectal bleeding), they are distinct conditions with different ____, diagnostic approaches, and ____ strategies.
Both conditions affects the **Rectal Area**.
But differ based on Different **CAUSES** and have different **TREATMENT** considerations.
66
Which demographic is more likely to see more polyps as a differential diagnosis?
Elderly patients.
67
Which of the following observations is one of the most common things to see with hemorrhoids due to seepage?
Anal itch - is the 2nd most common anal symptom.
Because there isn't a good "seal" taking place which means some of the contents from bowel movements and such are coming out and symptoms associated with hemorrhoids can result.
68
T/F: Pregnant women are immediate referrals when suspected of hemorrhoids.
False. Pharmacists can still assist pregnant women suspected of hemorrhoids unless they present with severe symptoms, or have any of the red flags mentioned for other patients, OR if they have never been formally assessed and diagnosed.
69
The most important preventive measure is to avoid _______.
avoid Constipation
70
What is the general recommended daily fibre intake for:
Women ages 19–50 years-old [purposes of bowel movements]?
**NEED TO KNOW FOR EXAMS - 154 and 123**
25 grams of fibre
71
What is the general recommended daily fibre intake for:
Men (19–50 years-old)
[purposes of bowel movement]
**NEED TO KNOW FOR EXAMS - 154 and 123**
38 grams of fibre
72
What is the general recommended daily fibre intake for:
Women ≥ 51 years-old
[purposes of bowel movement]
**NEED TO KNOW FOR EXAMS - 154 and 123**
21 grams of daily fibre intake... This is a reduction from earlier ages for women.
73
What is the general recommended daily fibre intake for:
Women
19-50 yo vs. ≥ 51 years-old
[purposes of bowel movement]
**NEED TO KNOW FOR EXAMS - 154 and 123**
Women who are 19-50 yo: 25 g
vs.
Women ≥ 51 years-old: 21 g
74
What is the general recommended daily fibre intake for:
Men ≥ 51 years-old
[purposes of bowel movement]
**NEED TO KNOW FOR EXAMS - 154 and 123**
30 grams of daily fibre intake (reduced amount when compare the 19-50 age group for men)
75
What is the general recommended daily fibre intake for:
Pregnant women
[bowel movement purposes]
**NEED TO KNOW FOR EXAMS - 154 and 123**
28 grams
76
What is the general recommended daily fibre intake for:
Breastfeeding women
[bowel movement purposes]
**NEED TO KNOW FOR EXAMS - 154 and 123**
29 grams
77
What is the general recommended daily fibre intake for:
Men
19-50 yo vs. ≥ 51 years-old
[bowel movement purposes]
**NEED TO KNOW FOR EXAMS - 154 and 123**
Men (19-50 yo): 38 grams
Men (51+ yo): 30 grams
78
What is the general recommended daily fibre intake for:
Pregnancy vs. Breastfeeding
[bowel movement purposes]
**NEED TO KNOW FOR EXAMS - 154 and 123**
Pregnancy: 28 grams
Breastfeeding: 29 grams
79
What is a first-line therapy for patients with hemorrhoids?
A) Topical corticosteroids
B) High-fiber diet
C) Oral antibiotics
D) Surgical intervention
B) High-fibre diet
80
T/F: Fibre may help improve constipation, pruritus due to fecal soilage, and bleeding associated with hemorrhoids.
True!
81
Hemorrhoids affects approximately _____% of people at some point in their lives.
~ 75%
82
Which age demographic is less likely to suffer from hemorrhoids?
Individuals who are <20 years old
83
What age demographic is likely to see a peak in hemorrhoids?
People ages 45-65 years old.
84
What is the recommended daily dietary fiber intake for women aged 51 and above in Canada?
A) 25 grams
B) 21 grams
C) 38 grams
D) 30 grams
B) 21 grams
85
Patients are recommended to slowly increase their __________ intake to minimize problems with bloating and abdominal discomfort when increasing fiber intake.
fibre
| Applies to both dietary fibre AS WELL AS use of Bulk-Forming Agents
86
T/F: Patients must ensure adequate fluid intake, such as 2 L of water per day, while increasing fibre intake.
True... But keep in mind, this is not exclusive to just drinking liquids.
Fluid intake can also be done via diet and the food we eat.
87
What is the recommended daily dietary fibre intake for pregnant women in Canada?
A) 25 grams
B) 21 grams
C) 28 grams
D) 29 grams
C) 28 grams
88
What is the recommended daily dietary fibre intake for breastfeeding women in Canada?
A) 25 grams
B) 21 grams
C) 28 grams
D) 29 grams
D) 29 grams
89
If the amount of dietary fibre cannot be increased adequately, commercial fibre supplements such as _____, can be considered... but note that fibre supplementation can take up to ____ weeks to significantly improve bowel movements
Psyllium ; 6 weeks
90
Presentations of new onset of rectal bleeding should be referred to by the MD as ____ to ___% of such cases are at high risk of colorectal cancer. We don't want to miss catching this earlier on.
## Footnote
This is why undiagnosed peoples should be referred to MD first for visual examination and formal diagnosis.
2.4 to 11%
91
T/F: Anal fissures and hemorrhoids are almost the same in terms of anatomical distinctions.
FALSE!
Anal Fissures are COMPLETELY DIFFERENT (anatomically) in comparison to both external and internal hemorrhoids.
* Anal fissures have *visible* **tears or cracks in the skin *around* the anus**
* External hemorrhoids *might* have visible indications ***outside* the anus**.
* Internal hemorrhoids rips the anal wall.
92
While anal fissures are more commonly seen in ______, anal fissures can also occur in ________, especially in ______ and ________.
- More common in ADULTS
- But can occur among children, especially for toddlers and infants.
93
______ refers to a child's intentional refusal or reluctance to have a bowel movement. This behavior is commonly associated with constipation and can exacerbate the problem by leading to the retention of stool in the colon and rectum.
Withholding Behaviours in children.
94
If a parent comes in and reports their 3-year-old has a bit of blood found on the toilet paper, what can we suspect?
a) constipation
b) hemorrhoids
c) anal fissures
d) dehydration
e) Options a, b, and c are all correct
c) anal fissures
This is likely to do with Stool Withholding Behaviours, or things like introducing solid foods, straining, constipation, etc., that can influence anal fissures among younger children like toddlers and infants.
95
List 3 factors that can influence incidents of anal fissures among younger children (toddlers and infants).
- Straining during bowel movements,
- Constipation, and
- The introduction of solid foods can contribute to the development of anal fissures in this age group.
96
What is a common cause of anal fissures in infants and toddlers?
A) Excessive fiber intake
B) Straining during bowel movements
C) Sedentary lifestyle
D) Lack of fluid intake
b) Straining during bowel movements
97
What is a recommended management approach for anal fissures in children?
A) Reducing fibre intake
B) Encouraging straining during bowel movements
C) Increasing fluid intake and fibre-rich foods
D) Increasing daily physical activity minutes and increasing fluid intake while decreasing amount of solid foods ingested until resolved
C) Increasing fluid intake and fibre-rich foods
98
What is a common reason for withholding behaviors in children?
A) Fear of using the toilet
B) Excessive fluid intake
C) Lack of supervision
D) Regular toilet routines
A) Fear of using the toilet
Associated with hard stools to pass from the past scares them from experiencing this again but this results in pulling away more of the moisture from their fecal matter even more.
99
What symptom is associated with withholding behaviors in children?
A) Frequent bowel movements
B) Abdominal pain or discomfort
C) Excessive fluid intake
D) Relaxed toilet environment
B) Abdominal pain or discomfort
There's also the poop dance (constipation), too. As well as fear of using the toilet.
100
What are the 2 possible reasons why anal itch common in hemorrhoids?
- Seepage
- Poor hygiene (due to tenderness of the area)
101
Besides hemorrhoids, what is also linked to anal itch?
- Certain skin conditions (such as psoriasis)
- Irritation from diarrhea (often can be seen in IBS patients)
**Mechanical irritation **
102
______ refers to inflammation at the lining of the rectum.
This is caused by various factors, including infections (such as sexually transmitted infections like gonorrhea, chlamydia, or herpes), inflammatory bowel disease (such as ulcerative colitis or Crohn's disease), radiation therapy, autoimmune conditions, or trauma.
Proctitis
**important to know this**
103
Rectal pain,
Mucous/discharge,
Increased bleeding,
Urgency,
Frequent bowel movements, and bloody diarrhea,
along with recent unprotected sexual intercourse, are suggestive of what ailment?
Infectious proctitis, possibly due to sexually transmitted infections (STIs) such as gonorrhea or chlamydia.
However, note that a person does NOT need to have an STI to contract proctitis. Just in this case, it is likely to be an infectious form of the rectal ailment.
104
A 45-year-old woman presents with complaints of rectal bleeding and discomfort during bowel movements. She reports noticing bright red blood on the toilet paper and occasional blood in the toilet bowl after passing stool. She denies any abdominal pain or changes in bowel habits. On examination, external swelling and tenderness are noted around the anal opening. She has a history of obesity and occasional constipation.
What is her likely diagnosis?
Hemorrhoids
-- The patient's symptoms of rectal bleeding, discomfort during bowel movements, and external swelling around the anal opening are consistent with hemorrhoids. Her history of obesity and occasional constipation are common risk factors for the development of hemorrhoids.
105
A 55-year-old man presents for a routine colonoscopy screening. He has no significant gastrointestinal symptoms but has a family history of colon cancer. During the colonoscopy, multiple small, sessile polyps are identified in the sigmoid colon and rectum. Biopsy samples are taken for histological evaluation.
What does this describe?
Polyps
-- The identification of multiple small, sessile polyps during colonoscopy, especially in the sigmoid colon and rectum, suggests the presence of colorectal polyps. The patient's family history of colon cancer further underscores the importance of thorough evaluation and surveillance.
106
A 18-year-old man presents with complaints of severe pain during bowel movements and bright red blood on the toilet paper. He reports experiencing sharp, tearing pain in the anal area, especially during and after passing stool. He denies any abdominal pain or changes in bowel habits. On examination, a small, superficial tear is observed in the skin around the anal opening.
What is likely the diagnosis?
Anal fissures
-- The patient's symptoms of severe pain during bowel movements, sharp tearing pain in the anal area, and the presence of a **small superficial tear** *around* the anal opening are consistent with anal fissures. The bright red blood on the toilet paper is also indicative of anal fissures.
External hemorrhoids are outside the anus
107
A 25-year-old woman presents with complaints of rectal pain, urgency, and frequent bowel movements associated with bloody diarrhea. She reports recent unprotected sexual intercourse with a new partner. On examination, erythema and inflammation are noted in the rectal mucosa, along with pus and mucus discharge.
What is likely the diagnosis?
Proctitis
The patient's symptoms of rectal pain, urgency, frequent bowel movements, and bloody diarrhea, along with recent unprotected sexual intercourse, are suggestive of infectious proctitis, possibly due to sexually transmitted infections (STIs) such as gonorrhea or chlamydia.
108
T/F: Proctitis is always caused by an infectious disease, such as STIs/STDs.
False!
Although it is one of the causes, it is not the only one.
Along with infections (such as STIs like gonorrhea, chlamydia, or herpes), things like :
- inflammatory bowel disease (such as ulcerative colitis or Crohn's disease),
- radiation therapy,
- autoimmune conditions, or
- trauma CAN ALL BE ASSOCIATED WITH THE CAUSE OF PROCTITIS.
109
When making assessments for hemorrhoids, which kind of hemorrhoids is likely to be described as being up to the size of a pea?
External hemorrhoids
110
Which kind of hemorrhoid is likely to be located more towards the middle of the anal canal?
Internal hemorrhoids - because it's usually inside the rectum
111
If a patient with hemorrhoids initially experiences strong pain for a few days followed by rectal bleeding and then experiences pain relief, does this mean that the hemorrhoids are gone?
No, not necessarily...
It could indicate a change in the stage or severity of the hemorrhoids rather than disappearance.
Hemorrhoids can go through various stages of inflammation, thrombosis (formation of blood clots within the hemorrhoid), and eventual resolution or improvement of symptoms.
112
When completing an assessment re: hemorrhoids and hear "bleeding", pharmacists already know at that point, can't do much...
But what is our objective in asking more information about the bleeding? Or how should it be perceived?
- Determine if MD is needed for this right away without directly telling patient this... We lay the ground work and let patient decide what to do next.
- 1/7 people report rectal bleeding at least once in the past year... Most of those cases did not result in medical attention. As pharmacists, we ask patients the questions so they can decide what to do next in terms of if an MD is needed or how serious the case might be based on the bleeding alone.
113
One should never assume rectal bleeding to be always associated w/ hemorrhoids until ______:
a) has had an MD diagnose patient previously with hemorrhoids
b) has ruled out all other possible diagnoses via assessments
c) a visual exam by an MD has been done
d) colorectal cancer has been ruled out
c) a visual exam by an MD has been done
114
What 3 factors should we consider when perceiving the severity of rectal bleeding?
- Amount of blood
- Frequency - how often and how long has bleeding occurred (or reoccured)
- Other symptoms
115
In a 2015 study, it was reported that ____% of men disagreed with experts when indicated that three weeks of rectal bleeding should be referred to an MD.
50%
116
At a pharmacy angle, rank the suspected likelihood of causes of rectal bleeding from most likely reason/diagnosis to least likely when considering:
- Colorectal cancer
- Hemorrhoids
- Anal fissures
- Other reasons
Most common (likely):
#1: Hemorrhoids
#2: Anal Fissures
#3: Colorectal Cancer
#4: Other
** This is just an interpretation from Jeff's observations. #3 and #4 were pretty much tied.
Note that as people get older, we get more concerned about the worser outcomes.
117
Most cases of hemorrhoids are self-limiting (i.e., most heal on their own) within 2 weeks.
Thrombosed (painful) external hemorrhoids should improve in ________ (without treatment).
2-3 days
118
Who should we be more cautious about giving recommendations to treat hemorrhoids?
a) those who have a history of hemorrhoids and have been diagnosed in the past
b) those who have never been formally diagnosed with hemorrhoids
c) None of the above - neither groups are more or less cautious until we assess red flags
b) those who have never been formally diagnosed with hemorrhoids
^^ we are a bit more cautious if never been diagnosed as should rule out something that could be more serious or be a misdiagnosed by self.
If previously diagnosed before, likely not to be as serious and we have a bit more of a sigh of relief and therefore don't need to be as cautious compared to undiagnosed.
119
Should we recommend OTC products to individuals who are experiencing Mild hemorrhoids?
Not necessarily... Nothing besides maybe commercial fibre products for constipation symptoms IF intake via diet is not obtainable.
Mild hemorrhoids may be treated solely with changes in diet (including increasing fluid intake) and by resolving underlying constipation, if constipation is a presenting concern.
120
Which of the following is NOT a risk factor associated with hemorrhoids?
A) Pregnancy
B) Advancing Age
C) High dietary fibre intake
D) Spinal Cord Injury
E) Heavy lifting
C) High dietary fibre intake
High dietary fiber intake is actually considered a protective factor against hemorrhoids, as it helps promote regular bowel movements and reduces the risk of constipation, which is a known risk factor for hemorrhoids.
121
How can timing for showers be useful in the treatment of hemorrhoids when considering things like post-bowel movement (post-BM) cleanliness?
- IMPROVED HYGIENE PRACTICES POST-BM -- taking a shower following a BM allows you to gently clean the anal area with water, which helps remove fecal matter, bacteria, and other irritants that may contribute to discomfort or inflammation. Be sure to not use harsh soaps, scrubbing hard, or use of hot water.
- Can also provide soothing relief post-BM
122
If a person comes to the pharmacy to get help for their hemorrhoids, are Tucks Wipes (witch hazel or hamamelis) necessary to use?
No.
Witch hazel is a mild astringents that might help with mild symptoms of itch, burn and pain but it is not a "must-have" product.
123
Choice of formulation often depends on hemorrhoid type, as well as patient preference:
External hemorrhoids - _____ formulations is preferred clinically in some regards.
Ointment formulations
***Due to their ease of application, moisturizing properties, soothing effect, longer contact time, and reduced messiness. However, it's essential to choose the appropriate formulation based on individual preferences and the severity of symptoms
124
______ consists of a tub of warm water in which the individual sits for 15 minutes at a time. It can help relieve irritation and pruritus.
* can technically use cool water if can handle the discomforting temperatures as it can be anti-inflammatory.
Sitz Bath
125
How does a Sitz Bath work?
- a shallow basin ("shallow bowl") is placed on top of the toilet
- a hose connected to a bag of water will allow the water to shoot up (think of it as a bidet LOL)
126
Alternative to a Sitz Bath for example, what can a person do to take the pressure off the area PRN?
This requires absolutely no products or change in diet
Laying down in a PRONE POSITION (face down) help take the pressure off the area when needed.
127
What can a person do to provide themselves with short-term or temporary relief from a prolapsed tissue?
Can try to PUSH THE PROLAPSED TISSUE BACK IN using own finger.
Push it back in and keep it safe.
128
Hamamelis (witch hazel), zinc sulfate, calamine are all examples of ______ available commercially that promotes dryness and can sometimes help with mild symptoms of itch, burning or pain in some cases.
Astringents.
129
Anti-inflammatory agents such as hydrocortisone, are used for temporary relief of _____ and ______ when experiencing things like hemorrhoids.
Anal itch; Inflammation
130
How might we apply Dry Skin Lotions (PRN use) to help treat some symptoms associated w/ hemorrhoids - which can be an alternative means instead of buying a commercial product marketed for hemorrhoid use?
| How would you apply or use these products
Using dry toilet paper as an "applicator" of the dry skin lotion and apply to the affected area PRN.
131
T/F: Anti-inflammatory agents/steroid agents like HC 0.5% can be used to help with inflammation and anal itch associated with hemorrhoids but can take up to 12 hours for the Onset of Action to occur.
True!
The onset of action may require up to 12 hours and offers temporary relief of inflammation and itch.
132
Dibucaine (AKA cinchocaine) and pramoxine are both classified as ________ agents that can be used in commercial hemorrhoid products.
a) Astringents
b) Anti-inflammatory
c) Vasoconstrictors
d) Local anesthetics
e) Lubricating
f) Vasodilators
d) Local anesthetics
are included in some topical hemorrhoidal preparations to relieve pain. If used for less than 7 days, local anesthetics are relatively safe; longer duration of use increases the risk of contact dermatitis. If a patient previously experienced contact dermatitis from benzocaine or lidocaine, pramoxine could be tried as it has a different chemical structure
133
Which product contains pramoxine as its local anesthetic agent in addition to zinc sulfate?
a) Anusol
b) Anusol Plus
c) Preparation H
d) Proctosedyl and Proctol
e) Anusol-HC
b) Anusol Plus
(both their ointment and suppositories contains zinc sulfate plus pramoxine)
134
Proctosedyl and Proctol has which local anesthetic in their products?
a) pramoxine
b) dibucaine (cinchocaine)
c) diosmin (Hemovel)
d) hamamelis (witch hazel)
e) zinc sulfate
b) dibucaine (cinchocaine)
135
Witch Hazel (hamamelis) can be found in all of the following product EXCEPT for:
a) Tucks Cleansing Pads
b) Preparation H-PE Gel
c) Anusol-HC or Anodan-HC
d) None of the above - they all contain witch hazel
c) Anusol-HC or Anodan-HC
^^^ contains zinc sulfate and hydrocortisone (not witch hazel)
136
T/F: Zinc sulfate is an example of an astringents found in Anusol, Anusol Plus, and Anusol-HC. It acts as the base of the agent.
True.
Zinc sulfate alone is believed to be doing most of the work in terms of helping relieve symptoms, which makes it sufficient to just get Anusol regular (without combo) in many cases.
137
Dosing Schedule for Anusol Ointment.
| CPS (2023), RXFiles (2023) vs. Packaging & Class Notes
To Clean and dry the affected anal area.
Apply ointment freely to the affected area BID [in the morning, at bedtime], as well as after each bowel movement or as needed when symptoms occur.
| Packaging says: Q4H as well as post-BMs (and our class notes)
138
Dosing Schedule for Anusol Suppositories.
Make sure affected anal area is clean and dry.
Insert 1 suppository BID [in the morning, at bedtime], and after each bowel movement or as needed when symptoms occur.
| Packaging indicates: BID [A.M. and HS] as well as post-BM FYI
139
Do pharmacists recommend citrus bioflavonoids OTC/BTC products like Hemovel and Venixxa for hemorrhoids?
No! Skepticism is super high!!!!
{how is it possible for us to take an oral pill to be helpful to treat one of the most distal areas of our GI tracts in relieving symptoms?!}
140
Things like Anusol-HC and Anugesic-HC are products SK Pharmacists can prescribe RX as Minor Ailment for hemorrhoids.
How much HC do these products have?
0.5% of HC in both of these products.
141
Things like Anusol-HC and Anugesic-HC are products SK Pharmacists can prescribe RX as Minor Ailment for hemorrhoids.
How much more benefit do these RX products hold in comparison to their OTC relatives like Anusol (regular)?
Not a significant added value with the HC 0.5%... Might be asking too much of this ingredient to help treat hemorrhoids...
Good enough to stick with the OTC version without HC. If they really wanted to have HC, just tell them to incorporate HC themselves and separately.
142
Which vasoconstrictor is in Preparation H-PE Gel hemorrhoid product?
Phenylephrine
143
Which Anusol product is not medicated?
- Identify the name of product and the current colour of packaging
Anusol (regular)
RED
144
T/F: It's basically impossible to overuse zinc oxide.
True.
| BUT if you are having to use for more than 7 days, MD time.
## Footnote
...Could be concerned about misdiagnosing self or be something more serious.
145
Anusol vs. Preparation H... Which one is better?
Meh... Anusol is favoured or recommended more by pharmacists than Prep H products. But it's okay to use either one technically.
146
T/F: Preparation H products contains BioDyne and shark liver oil
True.
147
[most] Preparation H is classified as being a _________ [drug class]
Yeast Derivative [Bio-Dyne]
- Live yeast cell derivative which is extracted from brewer's yeast.
148
Preparation H (BioDyne) claims to help in wound healing and also help shrink the tissue... Does this hold true?
NOPE!
Despite their claims, studies show next to no evidence to support such claims.
149
Which Preparation-H Product is the "black sheep" of its family and considered to be different from the rest of their products in their line?
Preparation H-PE Gel
This is a DIFFERENT from the other Prep-H products as the H-PE Gel contains the following Active ingredients (w/w):
- Phenylephrine hydrochloride 0.25%,
- [Hamamelis Water or Witch Hazel]
Hamamelis Virginiana 50%
***has no shark liver oil/Bio-Dyne in it ****
150
What makes Preparation H-PE Gel so different from the rest of the Preparation-H products?
Contains:
- Phenylephrine
- Hamamelis Water
(it does NOT contain Bio-Dyne, yeast derivative like the rest of Prep-H products do)
151
When is phenylephrine show promising outcomes - in terms of what kind of indications?
When do we question PhE's claims for treatments?
Phenylephrine shows promising effects when used as a nasal decongestant; however, impacts on hemorrhoids are suspicious claims.
Using phenylephrine to treat damaged tissues is unlikely to help to shrink hemorrhoids.
152
Which Preparation-H product is likely to help with dark circles or bags under the eyes?
NONE!! Preparation-H is likely not going to have any effects on under eye bags.
(Sorry, Victor from Miss Congeniality lied to us!)
153
Herbal products in Canada discussed in class marketed for hemorrhoid treatment includes HemoClin Gel and HmR...
Herbals are often just the _____, which is fine but just stealing your money than other products we have available
Herbals are just the VEHICLE!!
154
What kind of agent and ingredient are herbal products [for hemorrhoids] likely to contain?
Witch hazel (or some type of astringent)
155
Which of the following agents cannot be prescribed by a pharmacist as it contains anti-infective agent(s) (i.e., antibiotics), local anesthetic and an astringent - and often used for surgical related purposes?
a) Proctol and Proctofoam
b) Proctol and Proctosedyl
c) Proctosedyl and Proctofoam
d) Proctol only
e) All of the above are MD territory and related to surgical indications
c) Proctosedyl and Proctofoam
156
What is the purpose of rubber-band ligation for internal hemorrhoids?
A) To inject medication directly into the hemorrhoid
B) To remove the hemorrhoid surgically
C) To apply rubber bands around the base of the hemorrhoid
D) To cauterize the hemorrhoid using heat
C) To apply rubber bands around the base of the hemorrhoid
157
Who is considered a suitable candidate for rubber-band ligation?
A) Individuals with external hemorrhoids only
B) Individuals with grade IV internal hemorrhoids and/or those with recurrent hemorrhoids in a span of 6 months or more.
C) Individuals with recurrent or treatment-refractory grades I-III internal hemorrhoids
D) Individuals with no prior history of hemorrhoids
C) Individuals with recurrent or treatment-refractory grades I-III internal hemorrhoids
158
How does rubber-band ligation work to treat internal hemorrhoids?
A) By cutting off the blood supply to the hemorrhoid, causing it to shrink and fall off
B) By directly removing the hemorrhoid tissue using a surgical instrument
C) By injecting a sclerosing agent into the hemorrhoid to shrink it
D) By applying heat to the hemorrhoid to cauterize and seal it
A) By cutting off the blood supply to the hemorrhoid, causing it to shrink and fall off
159
T/F: Surgical interventions for hemorrhoids like the rubber-band ligation is primarily used for the treatment of external hemorrhoids.
False!
Surgical interventions are typically reserved for extreme and/or treatment resistant cases of INTERNAL Hemorrhoids.
160
Why are surgical interventions to treat and remove the affected hemorrhoids not an option for many people who suffer?
Surgical removal of hemorrhoids may be the most effective treatment for hemorrhoids, but the procedure can be associated with complications and/or bleeding and is recommended in only a minority of patients (e.g., for recurrent hemorrhoids, treatment failures, grade III or IV hemorrhoids, acute thrombosed hemorrhoids).
161
The USA has hemorrhoid products that contains lidocaine plus pramoxine. Is there a limit in the number of days or weeks in which people should use agents like these for?
Yes! Do NOT use products like the lidocaine + pramoxine combo for more than a few days.
(Definitely do not use for a month for example! Warrants questioning of self-diagnosis of hemorrhoids as well as consider the possible long-term impacts of using an agent like this for THAT long)
162
Are topical analgesics like Rub A535 appropriate to use for hemorrhoids?
HELL. NO!
There are local anesthetics that can use for hemorrhoids but do not for the love of god use something like A535! Not only will it make the area more irritating, but likely to make discomforting symptoms more unbearable!
163
If a person has been experiencing constipation or has had a bad spat of constipation in the past few days, is it okay to use something like Anusol or Preparation-H to help provide some relief to the area right away?
Yes, that is okay.
164
A 18-year-old pregnant female patient comes to the pharmacy and asks for recommendations to use for what she thinks is hemorrhoids based on WebMD Symptom Checker (rectal bleeding, constipation, feels a lump when she wipes or cleans that area).
Prior to her pregnancy, she had never had hemorrhoids in her life and has to wait another month before her next MD appointment.
What would you recommend?
Refer to MD (sorry!)
- She has never been formally diagnosed before
- If she insists on getting something now, can only recommend either Anusol (red) or basic Prep H, tell her how to use, tell her to see MD in a few days if not ressolved (and mention during next appt).
- Although she meets the minimum age in which can technically do a Minor Ailment assessment in SK, keep in mind that most individuals do not experience hemorrhoids until after they are 20 yo.
165
A 26-year-old mother-to-be is experiencing hemorrhoids again in her second pregnancy. She was prescribed Anusol-HC by her OB-GYN two years ago and she said it helped. Just like last time, she has some bright red blood on her toilet paper when wiping the area, straining during BMs, pain, has constipation and unable to sit comfortably after each BM since yesterday due to a lump that is bothersome outside the anus.
She's a teacher at an elementary school and its very stressful having to take time off right now especially given the constant job actions taken right now and the changes in scheduling... She would prefer getting something off the shelf for now until her next appointment.
**What should we do? Which product(s) would you recommend (if applicable)?**
- Anusol (red package) but NOT the blue. Zinc sulfate is the base and is doing most of the work anyways and drug-free option is the way to go!!
- Can technically also recommend Preparation-H instead of regular Anusol if want. Prep-H (regular stuff) is also drug-free!
- Advise that if no improvement after 3 days of using Anusol (or Prep-H - whatever they decide) or if things worsen, to see MD.
