Hemorrhoids and Gas

Question 1

describe hemorrhoids (piles)

Answer 1

• Pillow like cluster of veins lies beneath mucus membranes lining the lowest part of the rectum and anus
• Composed of connective tissue, an arteriovenous plexus and suspensory smooth muscle
• normal anatomic feature that helps with continence
• diseased when tissue weakens: distal displacement of hemorrhoidal cushions, venous
  distension, bleeding, tissue prolapse, and potential
  thrombosis

Question 2

hemorrhoids presentation

Answer 2

Itching / burning
 Pain
 Swelling / inflammation
 Blood - In stool or on toilet tissue after defecating
 Encopresis (fecal soiling)
 Thrombosis - clots

Question 3

how are hemorrhoids classified (generally)

Answer 3

External hemorrhoids
 Originate just below the skin of the anus
 Can cause pain
 More likely a source of self-care questions

Internal hemorrhoids
 Higher, in the rectum (just above the pectinate line)
 No pain unless there are complications
 No nerve fibers in this area

Question 4

classify internal hemorrhoids (4)

Answer 4

Grade I
 No protrusion of hemorrhoids

Grade II
 Protruding hemorrhoids that spontaneously reduce

Grade III
 Protruding hemorrhoids where it is possible to push them back in manually

Grade IV
 Protruding hemorrhoids that can no longer be pushed back manually

Question 5

hemorrhoids - risk factors

Answer 5

Constipation / straining while defecating - blocking venous return from anal canal leading to swollen veins
- shearing of small firm stools causes loosening of underlying connective tissue
 Diarrhea - straining to pause defecation
 Pregnancy - increased ab pressure, increased const
 Spinal cord injury
 Increased abdominal pressure
 Physical exertion or type of work
 Advanced age - tissue tends to weaken and stretch
 Diet - high in white flour, sugar

Question 6

hemorrhoids - red flags

Answer 6

 Severe pain
 Rectal bleeding / melena (black tarry stool)
 Fecal soiling / seepage
 Less than 12 years of age
 Family history of colon cancers
 Patients with Grade III or IV hemorrhoids
 Severe prolapse
 No response after 7 days of treatment

Question 7

goals of therapy (3)

Answer 7

• relieve symptoms
• prevent complications
• promote good bowel habits, anal hygiene

Question 8

hemorrhoids non-pharm

Answer 8

1. avoid constipation - most important
   - review diet, fiber supplementation, fluids
2. bowel habits
   - Avoid remaining on the toilet for longer than 1-2 minutes (and avoid straining)
   - Any prolapsed hemorrhoids must be replaced using a
   moistened tissue. After each bowel movement, the anorectal area should be cleaned with mild soap and water and gently wiped with a wet toilet tissue.
3. Sitz bath 3-4 times daily
   - relieve irritation, itch
   - tub of warm water, sit for 15 minutes at a time, fitted over toilet seat

Question 9

How to increase fiber?

Answer 9

grains and cereals:

• include at least 1 serving of whole grain
• brown rice, whole grain bread, 5 g of fiber in cereal

legumes and beans
- kidney beans

fruits and veggies

• fresh fruit, eat peel
• no juice

Question 10

hemorrhoids pharm

• purpose?
• name 5 types of ingredients in combination pdts
• what are some dosage forms that can be used?

Answer 10

• short term relief of pain, burning, itch, discomfort, not cure

- Combination products include:
 local anesthetics
 Astringents
 anti-inflammatory agents
 Protectants
 Vasoconstrictors

Available as:
 Creams
 Ointments
- creams and ointments preferable to supp.
 Foams - rapid absorption, may not remain on affected area, diff conc in bubbles
 Suppositories
 Prescription, schedule 2 and unscheduled
 Generally use each morning and evening and after each bowel movement

Question 11

protectants

• name 2
• how does it work?

Answer 11

• glycerin, petrolatum
• Form a physical barrier on the skin to prevent irritation, itching, pain, and burning
• May have a lubricating effect
• Very safe!

Question 12

local anesthetics
name 3
AE?

Answer 12

• benzocaine, dibucaine, petrolatum
• Offers temporary relief of symptoms by blocking nerve
  transmission
• Is relatively safe if used for up to 7 days
• Low absorption unless the skin is abraded

Cautions / adverse effects:
 Evidence of efficacy is lacking
 Can mask the pain of more severe anorectal disorders
 Greater absorption may lead to CNS and CV effects
 May produce local reactions. These may be similar to
hemorrhoid symptoms. Pramoxine has a lower
incidence of this.

Question 13

astringents

name 2
how does it work?
how should zinc be used vs witch hazel?

Answer 13

• Zinc sulfate, witch hazel
   Produce a drying effect, which helps to relieve symptoms, especially itching and burning
   Form a protective layer by coagulating proteins in skin cells of the perianal skin or lining of the anal canal
   Zinc can be used internally or externally on hemorrhoids, while witch hazel should only be used externally

Question 14

corticosteroids

name 1
AE?

Answer 14

Hydrocortisone

• Rx available in combination products
• Onset can take up to 12 hours but effect lasts longer than other therapies

Cautions / adverse effects
 Do not recommend longer than 7 days, however if finding
improvement can use longer (i.e., 2 weeks)
 Long term use could lead to mucosal atrophy.
 Local adverse effects could include skin atrophy with
prolonged use, may mask symptoms of infection

Question 15

hemorrhoids - common OTCs

2 types

Answer 15

Preparation H - creams and ointments
- has protectants, vasoconstrictor (limit bleeding short term with phenylephrine) and sometimes anesthetic
Anusol - creams, suppositories, ointments
- has zinc sulfate, sometimes anesthetics

Question 16

rectal products (4)

Answer 16

• Lubricated suppositories for insertion
• Applicator for creams, entire cream tube is inserted
• Liner - leakage, fecal soilage
• TUCKS - witch hazel, cleanse area and provide relief

Question 17

other treatments (not tested)

Answer 17

framacytin antibiotics
pain relief
procedures, hemorrhoidectomy most effective

Question 18

New NHPs for hem

Hemoval

Answer 18

Hemoval
- diosmin

Phlebotonic

• unknown MOA, may strengthen vessel walls, increase tone, suppress inflamm mediators
• reduce pain, edema, bleeding
• 600mg PO TID x 4 days then 600 mg PO BID x 3 days
• AE: abdominal pain, diarrhea, headache, nausea

Question 19

New NHPs for hem

Venixxa

Answer 19

• citrus bioflavonoid - antiplatelet/coagulant effects
• reduce frequency, duration, intensity of symptoms for grade I or II acute internal hem, chronic too
• acute: 3 tabs BID for 4 days, then 2 tabs BID for 3 days
• chronic 1 tab BID
• AE: allergy, GI, discomfort, dizziness, headaches, malaise

Question 20

Pregnancy hem

what is preferred?

Answer 20

• non-drug, avoid constipation
• external preps better
• protectants/astringents preferred

Question 21

monitoring

relief in how long?

Answer 21

• relief of itch, swelling, burning within 1 week

- refer in no relief, symptoms worsen

Question 22

Gas pathophys

Answer 22

• Excess gas in the GIT can be found in the
  esophagus, stomach, small intestine, or large
  intestine
• Removed via flatulence or eructation (belching)
• Average person passes gas 10-25
  times daily. More than 25 times is considered
  excessive
• nitrogen, hydrogen, carbon dioxide, methane and
  oxygen

Question 23

Causes of gas for belching, abdominal discomfort and flatus (3)

Answer 23

1. eructation (belching): aerophagia, eating quickly, excessive salivation, gum chewing, mal-fitted dental app., nausea, resp disorders, smoking, carbonated bev
2. bloating, cramping, pain: aerophag, cancer, eating disorders, GI disorders
3. flatus: celiac diseas, eating beans/complex carbs/dairy/veg, disaccharidase deficiency, pancreatic insuff

Question 24

Assessment for belching/flatulence

what to do with consumption of nonabsorbable carbs or lactose?

air wallowing, overeating?

none of the above?

Answer 24

consider appropriate enzyme supplementation (lactase)

educate pt

consider trial of simethicone or probitoics - if no relief, consider a trial of bismuth subsalicylate

Question 25

Gas Red Flags (9)

Answer 25

``` Unintentional weight loss  Blood in stool or vomit  Moderate to severe abdominal pain/swelling  Sudden changes in bowel habits  Nausea or vomiting  Dysphagia  Dyspepsia  Fever or chills  Presence of long-standing diabetes, celiac disease, history of GI pathology ```

Question 26

Gas Goals of Therapy

Answer 26

Educate patients about the normal aspects of GI gas  Relieve symptoms (belching, pain, bloating, flatulence)  Educate patients regarding preventive measures

Question 27

Non pharm management of eructation?

Answer 27

 Avoid gulping air, eat meals slowly  Adjust poorly fitting dental apparatus  Reduce consumption of gas-producing/releasing substances

Question 28

Non pharm management of bloating?

Answer 28

 Avoid large meals, overeating  Eat less and earlier in the day  Avoid dietary and pharmaceutical triggers

Question 29

Non pharm management of flatulence?

Answer 29

 Smaller, more frequent meals  Exercise  Eat foods low in FODMAPs (Fructans, fructose, galacto oligosaccharides lactose, mannitol, sorbitol)

Question 30

Gas pharm treatment Alpha-D-galactosidase (Beano) - dose? - used for? - do not consume with __________

Answer 30

150–450 GaIU PO with the first bite of food (300–1200 GaIU/day) Effective in reducing flatus and abdominal discomfort associated with ingestion of non-absorbable carbs  Do not consume with hot foods  inactivates enzymes  Adverse effects: rare allergic reactions

Question 31

Gas pharm treatment Bismuth subsalicylate (Pepto-Bismol) - dose - used for? - AE

Answer 31

524 mg QID PO (maximum 8 doses/day)  Binds sulfide gas, effective for short term relief of intestinal gas  Do not recommend at high doses or as long term therapy to avoid salicylate toxicity  Adverse effects: constipation, diarrhea, nausea, tongue discoloration, grey/black stool, vomiting - Don’t recommend bismuth for over 3-4 weeks

Question 32

Gas pharm treatment Lactase (Lactaid) - dose - used for? - AE

Answer 32

 Can prevent flatulence in patients with lactase deficiency if taken with or prior to ingestion of lactose  Dose varies based on amount of lactose ingested

Question 33

Gas pharm treatment Laxatives use?

Answer 33

 Reduce symptoms of intestinal gas associated with constipation

Question 34

Gas pharm treatment probiotics use?

Answer 34

 Some data has shown a reduction in both short-term and long-term symptoms of abdominal distension, bloating, gas  Many available options on the market, not always consistent in quantity and type of bacterial species combined

Question 35

Simethicone (Ovol, Gas X) - dose - use

Answer 35

80–160 mg per meal PO  Prevents bubbling of liquids in stomach, not absorbed in GI tract  No clear benefit in reduction of symptoms of intestinal gas but used for treatment of flatulence and abdominal bloating

Question 36

Gas - others name the ones described here: 1. no evidence, do not recommend 2. not treating gas but bac overgrowth 3. muscle relaxant studied in eructation, need more evidence 4. Insufficient evidence for peppermint, garlic or ginger

Answer 36

1. activated charcoal? 2. antibiotics 3. baclofen 4. natural pdts

Question 37

Monitoring | when to refer?

Answer 37

 Refer if symptoms persist longer than 1-2 weeks despite self-care  Monitor for improvement after exclusion diets, if no change consider other triggers  Educate and reassure patients that gastrointestinal gas is a normal bodily process