DOCSLIB.ORG

I Think I Have Hemorrhoids

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
I Think I Have Hemorrhoids I Think I Have Hemorrhoids Farrell Adkins, MD FACS FASCRS Colon and Rectal Surgery Assistant Professor of Surgery, VTC School of Medicine 71st Annual Spring Symposium Carilion Clinic APRIL 22, 2021 Disclosures • No financial disclosures Objectives • Recognize common anorectal symptoms attributable to hemorrhoids • Describe initial non-surgical management options for treatment of hemorrhoids • Recognize surgical options for treatment • Increase awareness of alternative pathologies commonly misattributed to hemorrhoids Hemorrhoidal disease • Common in industrialized nations • Greater than 2.2 million outpatient evaluations per year in US1 • Greater than 2 million prescriptions for hemorrhoid therapies per year2 • Important to identify hemorrhoids as source of symptoms 1Peery AF, Crockett SD, Barritt AS, et al. Burden of gastrointestinal, liver, and pancreatic diseases in the United States. Gastroenterology. 2015;149:1731–1741.e3. 2Everhar, JE, ed. ”The burden of digestive diseases in the United States” US Dept of Health and Human Services, 2008. St. Fiacre (d.670 AD) Origins • The term “hemorrhoids” first coined by Hippocrates, approximately 400 BCE • “The disease of the hemorrhoids is formed in this way: if bile or phlegm be determined to the veins in the rectum, it heats the blood in the veins; and these veins becoming heated attract blood from the nearest veins, and being gorged the inside of the gut swells outwardly, and the heads of the veins are raised up, and being at the same time bruised by the faeces passing out, and injured by the blood collected in them, they squirt out blood, most frequently along with the faeces, but sometimes without faeces.” Medieval painting circa 1200 ACE German wood cutting 15th century Hemorrhoids • Ubiquitous but frequently misunderstood • Hemorrhoids are normal but hemorrhoidal disease is not • Patients have very little understanding of anorectal complaints • Many providers may have minimal training in anorectal diseases Internal hemorrhoids Anatomy and physiology • Proximal/confluent with dentate line • Vascular cushions • Elastic and connective tissue • Treitz’s suspensory muscle • “Corpus cavernosum recti” • AV shunts and sinusoids • Superior rectal aa. terminal branches • Predominantly arterial • Columnar epithelium • Poorly innervated • 15-20% of resting anal pressure • Augment pressure (cough, Valsalva) External hemorrhoids Anatomy and physiology • Distal to the dentate line • Confluent with the anal verge • Somatic sensory branches of the pudendal nerve • Fewer, but larger sinuoids • Predominantly venous blood flow • Squamous epithelium (anoderm) 3Aigner et. al. “The Vascular Nature of Hemorrhoids” J GI Surg 2006; 10:1044-1050. 4Schumann et. al. “Anatomical branches of the superior rectal artery in the superior rectum” Colorectal Dis 2009; 11:967-971. Hemorrhoidal disease pathophysiology Bowel habits Deterioration of Straining Treitz’s muscle Diet Vascularity Inflammation Hypertonicity Chronic dilation Enzymatic Downward tissue of hemorrhoidal displacement imbalance plexus AV anastomosis distention Adapted from 5Corman MI. ”Hemorrhoids” in Colon and Rectal Surgery, 1998. 6Thomson, WH “The Nature of Hemorrhoids” Br J Surg 1975; 62:542-52; 7Ganz, RA “The Evaluation and Treatment of Hemorrhoids” Clin Gastroenterol Hepatol 2013; 11(6) 593-603. Internal hemorrhoids Presentation and evaluation • Bleeding (60%) • Itching (55%) • Protrusion/prolapse • Seepage (10%) • Pain • Worrisome mass • Vague, difficult to describe • Pins & needles/burning/dull • Timing Internal hemorrhoids Presentation and evaluation • Must evaluate bowel habits • Frequency • Character of stools • Straining • IBS? • Continence issues • Gynecologic history • Surgical history Internal hemorrhoids Presentation and evaluation Internal hemorrhoids Presentation and evaluation Internal hemorrhoids Severity Internal hemorrhoids Severity Internal hemorrhoids Severity Internal hemorrhoids Severity Does all hematochezia require a colonoscopy? Outlet Bleeding •Bright red blood during/after BM, on toilet paper or in toilet bowel •No change in bowel habits •No family or personal history of neoplasia Suspicious Bleeding •Dark red blood •Mixed with stool •Any personal or family history of neoplasia Hemorrhage •Large volume bleeding requiring hospital admission/transfusion Occult Bleeding •Anemia •Positive FOBT 8Marderstein and Church. “Classic outlet rectal bleeding does not require full colonoscopy to exclude significant pathology” DCR 2008;51:202-206. Does all hematochezia require a colonoscopy? 8Marderstein and Church. “Classic outlet rectal bleeding does not require full colonoscopy to exclude significant pathology” DCR 2008;51:202-206. Does all hematochezia require a colonoscopy? Yes No • Screening guidelines • Young age • Personal/Family history • Outlet bleeding • Alarm symptoms • Confirmed anorectal source • Refractory bleeding • Recent colonoscopy • Bleeding ceases with treatment Internal hemorrhoids Treatment • Dietary and Behavioral • Surgical procedures • Bowel management program • Hemorrhoidectomy • Sitz baths • Open or Closed • Medical Therapy • Stapled hemorrhoidopexy • Over the counter • Topical/suppository • Arterial ligation • Office based procedures • Doppler guided • Rubber banding • Anatomic • Infrared coagulation • Sclerotherapy • Bipolar ligation Dietary and bowel management program • USDA and HHS recommends 25g/day for women and 38g/d for men • Average American fiber intake 15g/d • 90% of women and 97% of men fail to meet recommendations • Alonso-Cuello (2006) meta-analysis (7 studies) • Fiber improved bleeding (50%) • Fiber improved prolapse (20%, *NS) • Fiber improved pain (70%, *NS) • Pooled analysis risk of recurrent symptoms decreased by 47% with fiber therapy 9US Department of Agriculture and Health and Human Services “Dietary Guidelines for Americans 2020-2025” 10Alonso-Cuello et. al. “Fiber for the treatment of hemorrhoid complications: A systematic review and meta-analysis” Am J Gastroenterol 2006; 101:181-188. Sitz baths 11Shafik et. al. “Role of Warm Water Bath in Anorectal Conditions” J Clin Gastroenterol 1993; 16(4)304-8. Internal hemorrhoids Medical management • Huge market • Easy to recommend over the counter or prescribe • Paucity of data to suggest effectiveness of topical therapies • Witch hazel (Tucks) • Phenyephrine (Preparation H) • Hydrocortisone +/- pramoxine (Anusol, Pramasone, Proctofoam) Internal hemorrhoids Medical management • Flavinoids (Diosmin, troxerutin, hesperidin) • Venotonics, mechanism unclear • Lower extremity venous insufficiency • No FDA-approved formulations in the US • May be used by patients previously treated outside the US • Some availability as an over the counter herbal supplement • Improved pain and bleeding but not prolapse12 12Giannini et. al. “Flavinoids mixture in the treatment of acute hemorrhoidal disease: A prospective, randomized, triple-blind controlled trial.” Tech Coloproctol 2015; 19:339-45. Internal hemorrhoids Rubber band ligation Illustration from Jacobs,“Hemorrhoids” NEJM 2014; 371:944-51. Internal hemorrhoids Rubber band ligation • 25-year retrospective review • 805 patients, 2,114 bandings • Mean follow-up: 3.5 years • Post-procedural pain: 9% • Complications: 4.7% • Thrombosis (2%) • Sepsis (1 patient, 0.09%) • Bleeding (3%) 13Iyer et. al. “Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids.” DCR 2004; 47:1364-70. Internal hemorrhoids Rubber band ligation 13Iyer et. al. “Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids.” DCR 2004; 47:1364-70. Internal hemorrhoids Rubber band ligation 13Iyer et. al. “Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids.” DCR 2004; 47:1364-70. Internal hemorrhoids Injection Sclerotherapy • Sclerosing agents • Phenol • Quinine • Sodium morrhuate • Safe, minimal pain • Inferior to RBL • Limited durability • Ineffective for prolapse • May be useful for grade I patients unable to stop anticoagulants or anti- platelet therapies Internal hemorrhoids Infrared Coagulation • Infrared light thrombose and coagulate vessels • Selective IRC of inflow arterial vessels • Easy, fast, and relatively painless • Inferior to RBL across all hemorrhoid grades14 • Frequently requires more repeat treatments14 14MacRae and McLeod “Comparison of Hemorrhoid Treatment Modalities: A Meta-Analysis: DCR 1995: 38:687-694. Internal hemorrhoids Doppler-guided arterial ligation Excisional hemorrhoidectomy • Closed technique “Ferguson” Excisional hemorrhoidectomy • Complications • Pain • Urinary retention (2-36%) • Sitz baths • UTI (3.3%) • Bowel management • Bleeding (0.03-6%) • Fecal impaction (2.4%) • Topicals • Anal stenosis (0-6%) • Local anesthetics • Fecal incontinence (0-12%) • Topical metronidazole • Anal fistula (1%) • Nifedipine • Sucralfate Stapled Hemorrhoidopexy Procedure for Prolapsing Hemorrhoids (PPH) Stapled Hemorrhoidopexy Procedure for Prolapsing Hemorrhoids (PPH) • Not a true hemorrhoidectomy • Does not treat external hemorrhoids • Less painful than traditional hemorrhoidectomy • Return to work: 6 vs. 15 days15 • Rare, but horrific complications • Rectovaginal fistula • Pelvic sepsis • Chronic pain and tenesmus 15Girodano et. al. “Long-term Outcomes of Stapled Hemorrhoidopexy vs. Conventional Hemorrhoidectomy: A Meta-analysis of Randomized Controlled Trials. Arch Surg 2009; 144(3)266-272. Stapled Hemorrhoidopexy Procedure for Prolapsing Hemorrhoids (PPH) 15Girodano et. al.
Load more

Recommended publications
  • Lower Gastrointestinal Bleeding
    Journal of Experimental and Clinical Medicine https://dergipark.org.tr/omuJecm Re view Article J Exp Clin Med 2021; 38(S1): 23-32 doi: 10.52142/omujecm.38.si.gastro.3 Lower gastrointestinal bleeding Serkan ÖCAL1,* , Mehmet Mutlu ÇATLI2 1 Department of Gastroenterology, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey 2Departmant of Internal Medicine, Antalya Training and Research Hospital, Antalya, Turkey Received: 13.12.2020 • Accepted/Published Online: 09.01.2021 • Final Version: 18.03.2021 Abstract Bleeding from the lower part of the digestive system that appears as hematocheZia (fresh blood, clot or cherry-colored stool) or melena (dark- colored tarry stool) is called lower gastrointestinal tract bleeding (lower GI bleeding) (or colonic bleeding). In the traditional definition, lower GI bleeding was generally classified as bleeding distal to the TreitZ ligament (duodenojejunal junction) as the border. In the last decade, GI bleeding has adopted three categories in some recent publications: Upper, middle, and lower. According to this category, bleeding from a source between the TreitZ ligament and the ileocecal valve is classified as middle GI bleeding, bleeding from the distal of the ileocecal valve is classified lower GI bleeding. Lower GI bleeding and hospitalization rates increase with aging. Currently, physicians managing lower GI bleeding have many different diagnostic and therapeutic options ranging from colonoscopy and flexible sigmoidoscopy to radiographic interventions such as scintigraphy or angiography. Lower GI bleeding often stops spontaneously and less common than upper GI bleeding. Even though no modality has emerged as the gold standard in the treatment of lower GI bleeding, colonoscopy has several advantages and is generally considered as the preferred initial test in most of the cases.
    [Show full text]
  • Outpatient Services
    Outpatient Services Coverage of Certain Services in the OUTPATIENT setting only* EFFECTIVE MARCH 9, 2015 bmchp.org | 888-566-0008 TO FIND A CODE OR WORD - While holding down the CTRL key, press the F key, type in Code, then press ENTER key Procedure Code Description 0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level 0214T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure) 0215T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) 0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level 0217T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure) 0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound
    [Show full text]
  • Management of Hemorrhoid Complications in Persian Medicine
    http://www.cjmb.org Open Access Review Article Crescent Journal of Medical and Biological Sciences Vol. 7, No. 4, October 2020, 457–466 eISSN 2148-9696 Management of Hemorrhoid Complications in Persian Medicine Khadijeh Hatami1, Amir-Hooman Kazemi-Motlagh1, Hossein Ajdarkosh2, Arman Zargaran1, Mehrdad Karimi1, Ali-Asghar Haeri Mehrizi3, Hoorieh Mohammadi Kenari4 Abstract Objectives: Hemorrhoid disease has been a common medical problem since ancient times. About 5%-10% of patients do not respond to conservative treatment, and surgical procedures have a 20%-25% complication rate including pain, stenosis, infection, incontinence, and the like. Thus, most patients and physicians seek alternative and complementary medicines. Persian medicine (PM) is one of the oldest traditional medicines that present different treatment methods for managing hemorrhoid complications. Accordingly, the present study reviewed these methods and their applications. Methods: This historical review surveyed the principle of management and different medicinal and non-medicinal treatments for each complication of hemorrhoid based on the main textbooks of disease-treatment and famous pharmacopoeias of PM from 10th to 18th century AD. Recent findings about their pharmaceutical properties and mechanisms of action were searched in Google Scholar, Science Direct, and PubMed databases. Results: In PM, it is believed that hemorrhoid disease is because of melancholic or sanguineous distemperament. Cleansing the body and then strengthening the gastrointestinal and the liver for more effective treatment and prevention of relapse are the first therapeutic approaches in this regard. They use herbal and non-herbal medicines with anti-oxidant and anti-inflammatory, analgesic, and phlebotonic properties. In addition, different methods of bloodletting are used for body cleansing, reducing pain, and treating bleeding or thrombotic hemorrhoids.
    [Show full text]
  • Post Hemorrhoidectomy Pain Relief; Outcome of Local Anesthesia
    PAIN RELIEF POST HEMORRHOIDECTOMY The Professional Medical Journal www.theprofesional.com ORIGINAL PROF-2998 DOI: 10.17957/TPMJ/15.2998 POST HEMORRHOIDECTOMY PAIN RELIEF; OUTCOME OF LOCAL ANESTHESIA Dr. Syed Muhammad Maroof Hashmi1, Dr. Shua Nasir2, Dr. Lal Shehbaz3, Dr. Muhammad Absar Anwar4, Ahmed Ali5 1. Senior Registrar Department of Neurosurgery ABSTRACT… Background: The aim of my study is to evaluate post-operative pain relief K.M.D.C and Abbasi Shaheed on patients who had hemorrhoidectomy. Materials and Methods: 300 patients who had Hospital Karachi. hemorrhoidectomy were divided equally in to three groups, according to anesthesia type, 2. MD Resident Department of Emergency group 1 (local anesthesia and sedation), while spinal anesthesia was group 2 and general Medicine Ziauddin University anesthesia was considered to be group 3. Pain relief, post-operative complications, hospital Hospital Karachi. staying time were measured and compared between the three groups. Period: Study was 3. MD Resident performed between Jan 2012 to Dec 2014. Results: The study showed that patients who had Department of Emergency Medicine Ziauddin University local anesthesia infiltration and sedation a significant decrease of post-operative total pain Hospital Karachi. scores at 6/12/18/24 hours of more than 50%,200/240/300/320 out of 1000 points in group II 4. House Officer as compared to 420/500/540/580,700/680/660/660 in 3rd groups respectively. The total post- DUHS and Civil Hospital, Karachi 5. Research Fellow BMU operative analgesia doses in the 3 groups were 120:140:180 respectively, total hospital staying time were 130:210:260 days, headache in the ratio of 0:8:1, urine retention in 0:6:1 patients, Correspondence Address: nausea and vomiting in 0:1:5 patients were reduced by 30 %,.
    [Show full text]
  • Hemorrhoids Brown Health Services Patient Education Series
    Hemorrhoids Brown Health Services Patient Education Series What are hemorrhoids? Causes of Hemorrhoids Include: Hemorrhoids are swollen veins in the rectum. They ● Straining during bowel movements can cause itching, bleeding, and pain. Hemorrhoids ● Chronic diarrhea or constipation are very common. In some cases, you can see or ● Obesity feel hemorrhoids around the outside of the rectum. ● Pregnancy In other cases, you cannot see them because they ● Anal intercourse are hidden inside the rectum Diagnosis Hemorrhoids do not always cause symptoms. But To diagnose hemorrhoids, your clinician will when they do, they can include: examine your rectum and anus and may insert a ● Itching of the skin around the anus gloved finger into the rectum. Further evaluation ● Bleeding – Bleeding is usually painless and may include a procedure that allows your occurs during bowel movement. You might healthcare provider to look inside the anus (called see bright red blood after using the toilet on ​ anoscopy), or evaluation by a proctologist. your toilet tissue or in the toilet bowl. ● Pain – If a blood clot forms inside a Management of Hemorrhoids hemorrhoid, this can cause pain. You may also experience: Initiate Lifestyle Changes: ● swelling around your anus One of the most important steps in treating ● A sensitive or painful lump near your anus hemorrhoids is avoiding constipation (hard or ● Leakage of feces infrequent stools). Hard stool can lead to rectal bleeding and/or a tear in the anus, called an anal Hemorrhoid symptoms usually depend on the fissure. In addition, pushing and straining to move location. Internal hemorrhoids lie inside the rectum. your bowels can worsen existing hemorrhoids and You can’t see or feel these hemorrhoids, and they increase the risk of developing new hemorrhoids.
    [Show full text]
  • Flexible Video-Endsocopic Injection Sclerotherapy for Second and Third Degree Internal Hemorrhoids
    Published online: 2019-09-26 ORIGINAL ARTICLE Flexible Video-Endsocopic Injection Sclerotherapy for Second and Third Degree Internal Hemorrhoids Sandeep Nijhawan, Udawat H, Gaurav Gupta, Anil Sharma, Amit Mathur, Bharat Sapra, Subhash Nepalia Department of Gastroenterology, SMS Medical College, Jaipur, Rajasthan, India ABSTRACT Background and objectives: Bleeding from hemorrhoids is the commonest cause of rectal bleeding in adults. Injection sclerotherapy of internal hemorrhoids is one of the non-surgical treatments, and is simple, safe and feasible. Conventionally sclerotherapy is performed with rigid proctoscope which has limitations of maneuverability, narrower field of vision and documentation compared to flexible videoendoscope. Therefore, we assessed the efficacy and safety of video-colonoscopic sclerotherapy for bleeding internal hemorrhides. Methods: Seventy-nine patients of bleeding internal hemorrhoids were subjected to colonoscopic sclerotherapy using 1.5% polidocanol in retroflexed or forward viewing positions. Success of treatment was defined as cessation of bleeding for six weeks. Patients were observed for complications and were followed up regularly for 3 months. Results: A total of 79 evaluable patients, 61 had grade II and 18 had grade III hemorrhoids. There was no statistically significant differences in achieving excellent or good results for control of bleeding between patients with grade II and grade III hemorrhoids (100% vs 94,5%; p>0.05). The number of sessions of sclerotherapy required were significantly more in grade II than grade III hemorrhoids (1.1 ± 0.3 vs 1.3 ± 0.7; p = 0.04). No significant complications were noted except for bloating in ten patients (12.6 %) and rectal pain in 6 (7.6%) patients.
    [Show full text]
  • What Is Dvt? Deep Vein Thrombosis (DVT) Occurs When an Abnormal Blood Clot Forms in a Large Vein
    What is DVt? Deep vein thrombosis (DVT) occurs when an abnormal blood clot forms in a large vein. These clots usually develop in the lower leg, thigh, or pelvis, but can also occur in other large veins in the body. If you develop DVT and it is diagnosed correctly and quickly, it can be treated. However, many people do not know if they are at risk, don’t know the symptoms, and delay seeing a healthcare professional if they do have symptoms. CAn DVt hAppen to me? Anyone may be at risk for DVT but the more risk factors you have, the greater your chances are of developing DVT. Knowing your risk factors can help you prevent DVt: n Hospitalization for a medical illness n Recent major surgery or injury n Personal history of a clotting disorder or previous DVT n Increasing age this is serious n Cancer and cancer treatments n Pregnancy and the first 6 weeks after delivery n Hormone replacement therapy or birth control products n Family history of DVT n Extended bed rest n Obesity n Smoking n Prolonged sitting when traveling (longer than 6 to 8 hours) DVt symptoms AnD signs: the following are the most common and usually occur in the affected limb: n Recent swelling of the limb n Unexplained pain or tenderness n Skin that may be warm to the touch n Redness of the skin Since the symptoms of DVT can be similar to other conditions, like a pulled muscle, this often leads to a delay in diagnosis. Some people with DVT may have no symptoms at all.
    [Show full text]
  • A 12-Years Rectal Bleeding Complicated with Deep Vein Thrombosis, Is Hemorrhoid the Real Cause?
    Case Report Clinical Case Reports Volume 10:11, 2020 DOI: 10.37421/jccr.2020.10.1395 ISSN: 2165-7920 Open Access A 12-Years Rectal Bleeding Complicated with Deep Vein Thrombosis, Is Hemorrhoid the Real Cause? Yi-Qun Zhang, Meng Niu and Chun-Xiao Chen* Department of Gastroenterology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P. R. China Abstract Colorectal venous malformation is a rare condition that can cause massive rectal bleeding. This is the first report of colorectal venous malformation complicated with massive bleeding and lowers limb deep vein thrombosis, and the two life-threatening conditions were both treated successfully. Keywords: Colorectal venous malformation • Rectal bleeding • Sclerotherapy • Deep vein thrombosis Introduction A 16-year-old man presented to the clinic with long-standing recurrent hematochezia and profound anemia. Per the mother, his rectal bleeding was first noticed around the age of 4 with one episode per 2-3 months that was diagnosed as hemorrhoids without specific treatment. It had worsened for 2 months with progression to 1 bloody bowel movement daily. He had no family history of hematologic disorders or vascular anomalies. The patient had accepted 600 ml red-blood cell perfusion and intravenous sucrose-iron transfusions for severe anemia with hemoglobin 5.8 g/dL, hematocrit 25.9% and MCV 69.7 fL at local hospital. Case Report Upon admission, the patient’s vital signs were within normal limits. His abdomen was supple and without tenderness. Digital rectal examination confirmed partially thrombosed, circumferential mixed hemorrhoids. Laboratory tests revealed a hemoglobin 8.0 g/L and D-dimer 15760 g/L.
    [Show full text]
  • Herbal Haemorrhoidal Cream for Haemorrhoids
    Chinese Journal of Physiology 56(5): 253-262, 2013 253 DOI: 10.4077/CJP.2013.BAB127 Herbal Haemorrhoidal Cream for Haemorrhoids Ebru Gurel1, Savas Ustunova1, Bulent Ergin1, Nur Tan2, Metin Caner3, Osman Tortum4, and Cihan Demirci-Tansel1 1Department of Biology, Faculty of Science 2Department of Pharmacognosy, Faculty of Pharmacy 3Department of Internal Medicine, Cerrahpasa Medicine Faculty and 4Department of General Surgery, Cerrahpasa Medicine Faculty, University of Istanbul Istanbul, Turkey Abstract Although hemorrhoids are one of the most common diseases in the world, the exact etiology underlying the development of hemorrhoids is not clear. Many different ointments are currently used to treat hemorrhoids; however, there is little evidence of the efficacy of these treatments to support their use. The aim of this study was to compare different herbal creams used for the treatment of hemorrhoids. Twenty-eight male Wistar albino rats, 6-8 weeks old and weighing 160-180 g, were used in this study as 1-control, 2-croton oil, 3-croton oil+fig leaves+artichoke leaves+walnut husks and 4-croton oil+fig leaves+artichoke leaves+walnut husks+horse chestnut fruit. After 3 days of croton oil application, rats were treated with 0.1 ml of cream or saline twice a day for 15 days by syringe. Tissue and blood samples were collected for histological, immunohistochemical and biochemical studies. Statistical significance was determined using one-way ANOVA followed by Tukey’s multiple comparison tests. Croton oil administration resulted in severe inflammation. The third group showed partial improvement in inflammation; however, the greatest degree of improvement was seen in the fourth group, and some recovered areas were observed.
    [Show full text]
  • National Clinical Coding Standards OPCS-4 (2018)
    OPCS Classification of Interventions and Procedures Version 4.8 OPCS Classification of Interventions and Procedures Volume I - Tabular List I - Tabular Volume National Clinical Coding Standards OPCS-4 (2018) For more information please visit: Accurate data for quality information systems.digital.nhs.uk/data/clinicalcoding ISBN 978-0-11-323048-8 Terminology and Classifications Delivery Service www.tso.co.uk 9 780113 230488 9923 OPCS 4.8 Vol I Cover v0_2.indd 1-3 31/10/2016 10:00 National Clinical Coding Standards OPCS-4 Accurate data for quality information Produced by: Terminology and Classifications Delivery Service NHS Digital Vantage House 40 Aire Street Leeds LS1 4HT [email protected] http://systems.digital.nhs.uk/data/clinicalcoding Date of issue: April 2018 Copyright © 2018 Health and Social Care Information Centre The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. OPCS-4 CONTENTS Introduction ............................................................................................................................ 3 Data Quality ........................................................................................................................... 7 National Clinical Coding Standards OPCS-4 reference book .............................................. 11 Rules of OPCS-4 ................................................................................................................. 16 Conventions of OPCS-4 .....................................................................................................
    [Show full text]
  • Educational Exhibit Posters Chosen by the Annual Scientific Meeting
    Educational Exhibit Posters Chosen by the Annual Scientific Meeting Committee In advance of the upcoming annual meeting of the Society of Interventional Radiology in Washington, DC, the program committee wishes to highlight the educational exhibit e-posters that will be presented. The posters were chosen using blinded review. Authors are congratulated for their contributions. Daniel Sze, MD, FSIR Chair, 2017 Annual Meeting Scientific Program Educational Exhibit e-Posters Abstract No. 581 Etiology Technique Used Hepatic artery pseudoaneurysms: a pictorial review of Trauma Falling injury Gelfoam with intraprocedural different scenarios and managements cone-beam 3D CT imaging R. Galuppo Monticelli1, Q. Han1, G. Gabriel1, S. Krohmer1, D. Raissi1 Gunshot injury Coiling Iatrogenic Post cholecystectomy Onyx embolization 1University of Kentucky, Lexington, KY Post biliary drain Coiling PURPOSE: The focus of this educational exhibit is to present a pictorial placement review of the anatomical considerations and management in varied Post ERCP Gelfoam cases of hepatic artery pseudoaneurysms (HAPs) secondary to differ- Tumor Hemorrhage Embozene ent etiologies. Special attention is given to troubleshooting HAPs with Tumor related Post TACE N-Butyl cyanoacrylate varied anatomical presentations. Transplant related Portal hypertension iCAST covered Stent MATERIALS: Hepatic artery pseudoaneurysm (HAP) is an unusual but Idiopathic Otherwise healthy male Coiling with sandwich technique serious complication of acute or chronic injury to the hepatic artery that can potentially be fatal. HAPs are classified as intrahepatic or extrahe- patic. There are many etiologies of HAP formation, including trauma, iat- Abstract No. 582 rogenic, tumor, pancreatitis, inflammatory and idiopathic. Early detection Stenting as a first-line therapy for symptomatic and treatment is critical to decrease morbidity and mortality.
    [Show full text]
  • Chronic Metformin Therapy Is Associated with a Lower Risk of Hemorrhoid in Patients with Type 2 Diabetes Mellitus
    ORIGINAL RESEARCH published: 16 February 2021 doi: 10.3389/fphar.2020.578831 Chronic Metformin Therapy is Associated with a Lower Risk of Hemorrhoid in Patients with Type 2 Diabetes Mellitus Chin-Hsiao Tseng 1,2,3* 1Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan, 2Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, 3Division of Environmental Health and Occupational Medicine of the National Health Research Institutes, Zhunan, Taiwan Background: Metformin has anti-inflammatory property and reduces the risk of varicose vein in our previous study. Aim: To investigate the risk of hemorrhoid, another common disease involving the hemorrhoidal venous plexus, in ever vs. never users of metformin in patients with type Edited by: 2 diabetes mellitus. Giovanni Sarnelli, University of Naples Federico II, Italy Methods: This is a population-based retrospective cohort study. Patients with new-onset Reviewed by: type 2 diabetes mellitus during 1999–2005 were enrolled from Taiwan’s National Health Dan-Lucian Dumitras¸ cu, Insurance. All patients who were alive on January 1, 2006 were followed up until December Iuliu Hat¸ieganu University of Medicine 31, 2011. Analyses were conducted in both an unmatched cohort of 152,347 ever users and Pharmacy, Romania Maria Cecilia Giron, and 19,523 never users and in 19,498 propensity score (PS)-matched pairs of ever and University of Padua, Italy never users. Traditional Cox regression and Cox regression incorporated with the inverse *Correspondence: probability of treatment weighting (IPTW) using the PS were used to estimate hazard ratios. Chin-Hsiao Tseng [email protected] Results: New-onset hemorrhoid was diagnosed in 8,211 ever users and 2025 never users in the unmatched cohort and in 1,089 ever users and 2022 never users in the Specialty section: This article was submitted to matched cohort.
    [Show full text]