Hemorrhoids (piles)

1. Hemorrhoids(piles)

2. General information Definition: abnormally large bulging symptomatic clusters of dilated blood vessels supporting tissues and overlying mucous membranes, present in the lower rectum(internal hemorrhoids) or anus(external hemorrhoids) simply represent downward displacement of anal cushions that contain arteriovenousanastomoses.

3. Types of hemorrhoids 1.internal hemorrhoids: exaggerated vascular cushion with an engorged internal hemorrhoids plexus located above the dentate line and covered with a mucous membrane.

4. 2.external hemorrhoid :dilated vein of the inferior hemorrhoidal plexus located below the denate line and coverd sq epithelium. 3.mixed hemorrhoid a baggy swelling and exhibits simultaneous characteristics of the internal and external hemorrhoid.

5. Origin and cause : Increase venous pressure in the hemorroidal plexus (chronic straining . Small , hard stool prolong sitting on the toilet (.occupations the routinely require heavy lifting, pelvic tumors Pregnancy the most cause in women The hemorroidal veins are pushed downward during defecations or straining they dilated and become engorged. over time the hemorroidal veins stretch and result in prolapse.

7. Signs and symptoms 1.painless bleeding:during bowel movement ,bright red blood on stool,toilet tissue or the water in the toilet. 2.prolapse: protrusion during defecation .replace manually .complain dull and aching feel 3.pain in thrombosis usually in external tissue 4.discomfort.soeness.pruritus.swelling.burning,seepage

8. Other condition may mimic hemorrhoid 1.anal abscess. S.coccus 2.cryptitis. 3.anal fissure 4.anal fistula 5.inflamatory bowel disease 6.polyp: tumors in the large intestine 7.colorectal cancer

9. Grades of internal hemorrhoid first-degree : doesn’t descend or prolapse, painless bleeding Second-degree : descend but returns spontaneously with relaxation, mild discomfort ,bleeding Third-degree :manual replacement into the rectum, pain bleeding discharge of mucus fourth-degree :prolapsed and cannot manipulated manually . thrombosis occurs

11. Treatment: depend on degree of internal hemorrhoid • First and second internal hemorrhoid that bleed minimally conservative approach can usually be taken. • A. reduce straining, downward pressure on hemorrhoid • B. correction of constipation is of paramount importance by eating high fiber diet ↑ water intake , physical activity ,bulk forming laxative,

12. C. sitz bath for 15.min three to four times a day, can sooth the anal mucosa .tepid water should be use. Prolong bathing should be avoided . Epsom salts ,ice pack can help reduce swelling of an edematous or clotted hemorrhoid • D. OTC hemorrhoidal ointment, creams, foams ,suppositories may also help

13. Higher grade internal hemorroids Hemorrhoid banding for grade 2 and 3 this procedure is performed through an anoscope. A rubber band ligature is placed on the rectal mucosa above the hemorrhoids . Infrared photocoagulationfor grade 2 less effective than banding sclerotherapy (injection of a sclerosing agent to hemorrhoids or freezing( oldest therapy)

14. D. surgical hemorrhoidectomy. should be only in grade3 and grade 4. even traditionally or by laser there is a discomfort disability after operation. 3/external,throbosed hemorrhoids can be excised in office setting . clinic. operating room

15. Nonprescription medication for hemorrhoids FDA has identified several ingredients as safe and effective to alleviate burning, discomfort, inflammation, irritation, itching, pain, and swelling. this drugs not to cure they are palliative. if the products not improve symptoms within 7days doctor should be consulted and if there bleeding , prolapse, seepage of feces or mucous , thrombosis, sever pain ,patients less than12 not to be self treatment .

16. Nonprescription Ointment vs suppositories Local anesthetics Vasoconstrictors Protectants Astringents Keratolytics Analgeics,anesthetics,andantipruriics Hydrocortisone(.25%-1%)

17. Ointment vs suppositories Superior to a suppository ,should be wash by a mild soap and worm water then dry it before use, patients can use an OTC anal cleansing pad, help patient to apply it directly to the rectum and help to converge a large area, may cause traumatized if not insert properly

18. Local anesthetics Block nerve impulse trans mission Examples :benzocaine, pramoxine, benzyl alcohol, dibucaine, dyclonine ,lidocaine , tetracaine Administration use of symptoms of pain , itching, burning ,discomfort, and irritation in the perianal canal. not use in the braded skin will increase systemic absorption.

19. Adverse effect: hypersensitivity reaction with burning and itching , paramoxine less hypersensitivity reaction, Warning: allergy in some patients &not use longer than 7 days

20. Vasoconstrictors Arteriole constriction in the anorectal area after topical application, not approve to control minor bleeding, to relief itching, discomfort, irritation, unknown mechanism Agents: ephedrine sulfate in aqsoln, epinephrineHCL in aqsoln, phenylephrineHCL in aqsoln, can be in ointments and suppositories

21. Adverse effect :nervousness , tremor, sleeplessness, nausea, loss appetite, cardiac arrhythmias, elevating blood pressure, Warning &C\I: cardiovascular diseases, high blood pressure ,hyperthyroidism, diabetes, prostate enlargement

22. Protectants Protective coating over skin or mucous membranes, relief itching, irritation, discomfort, and burning. And prevent loss of water from stratum corneum Examples :Al hydroxide gel, cocoa butter, kaolin, lanolin, hard fat, mineral oil, shark liver oil, and Zink oxide. Glycerin external use, topical starch . Lanolin may be allergic to susceptible individuals.

23. They work as: Absorbents: take up fluids Adsorbents: attach to substances secreted Demulcents: form colloidal solution protect skin Emollients: soften or protect internal body surfaces

24. Astringents Action is limited to surface cells Relief itching, discomfort, irritation, and burning. Examples: calamine, witch hazel (external use only) zinc oxide

25. keratolytics Desquamation of the surface cells of the epidermis Relief discomfort, itching Examples: AL chlorhydroxyallantoinate, resorcinol (not use in open wound owing to the potential for serious hypersensitivity reaction External use only

26. Analgeics,anesthetics,andantipruritics Relief burning, discomfort, itching, pain, and soreness. Safe external use are : menthol, juniper tar, camphor, Not use in the internal hemorrhoids

27. Wound healing agent Live yeast cell derivative LYCD, water soluble brewers yeast extract, as preparation H LYCD remove from safe and effective active ingredient FDA preparation H removed from it LYCDand contains in protectants or vascoconstictorphenyephrine

28. Hydrocortisone(.25%-1%) Causes vasoconstriction, stabilization of lysosomal membranes, and antimitotic effect Reduce itching, discomfort in the anorectal area. As this agent mask the symptoms of bacterial or fungal infections ,the only prescribe is less than 1%

29. Drugs : Hydrocortisone acetate: Hemoral-H-C® BJP oint\supp (+ lidocain, zinc oxide) cortifoam® perrigo aerosol proctofoam® perrigo recto aerosol (+ parmoxine)

30. flucinolone acetate +lidocain proctocare® pharmacare ointment bismuth subgallate + lidocaine + zincoxid hemo® rekah ointment

31. tribensoid + lidocaine procto-med® BPC cream\supp procto-glyvenol® novartis cream\supp\oint pramoxine + phynylohrene hemorid® pizer cream\ oint

32. Thanks you for attention