Hemorrhoids (1 of 8)

1 Patient presents w/ symptoms of hemorrhoids

2 DIAGNOSIS No ALTERNATIVE Hemorrhoids conﬁ rmed & other DIAGNOSIS causes of rectal bleeding excluded?

Yes

Internal or external External TREATMENT hemorrhoids? hemorrhoids See page 3

Internal hemorrhoids

3 GRADE HEMORRHOIDS

A Dietary modiﬁ cation & supportive measures B Pharmacological therapy

Grade I - II Grade III Grade IV

Yes Response to C Ablative oﬃ ce procedures therapy? D Surgical hemorrhoidectomy

CONTINUE No TREATMENT

C Ablative oﬃ ce procedures

Yes Response to No D Surgical hemorrhoidectomy ©therapy? MIMS

B1 © MIMS 2019 HEMORRHOIDS • • IV Grade • III Grade • II Grade • I Grade • • • History Medical • • • • • • Examination Physical • • • • Visualization Procedures Other • Anoscopy • • • Internal Hemorrhoids • • • External Hemorrhoids • • InternalExternal Hemorrhoids vs • Usually have internal both components &external &are continuous skin tag from toinner analcanal Permanently manual isnoteff reduction prolapsed; ective Prolapse w/Valsalva orstraining&require maneuver manual reduction Prolapse w/Valsalva orstrainingbutreduce maneuver spontaneously Prominent noprolapse that hemorrhoidal vessels usuallybleed, Internal hemorrhoids are classificause symptoms they of on severity the ed based - fordevelopment ofhemorrhoidal symptoms factors risk Elicit possible presence about timing&reproducibility ofprolapsing tissue,its Ask - amount its &frequency bleeding, about Ask - ofsymptoms nature, duration &severity Assess Anal itching Anal pain orlump protrusion duetorectal Discomfort - common Most presenting symptom - bleeding Rectal - &the the distalanalcanal anoderm Gently tovisualize the spread buttocks - the patient Reassure him/her doingany before maneuvers &warn - the entire area Inspect perianal evaluation anorectal Perform acareful colonic evaluation foramore detailed may indicate aneed which syndromes, colorectal neoplastic offamilial possibility toassess history medical family Obtain agood other ofpathology causes Thsymptomsspecifi of hemorrhoids are not & esigns betakencare so to must avoidmissing ctodisease, the age Advanced - Pregnancy - sitting which Prolonged may on atoilet aproblem cause inthe area venous inthe return perianal - Some experts recommend that orfl anoscopy experts Some be doneforallpatients bleeding w/ rectal sigmoidoscopy exible Anemia - Noidentifisourceed anal ofbleeding - Patient w/signififactors for cantrisk colonic malignancy - dark blood w/feces, admixed blood eg that isnotcharacteristic ofhemorrhoids, Bleeding - situations: inthe following enema orbarium needed mayColonoscopy be patient Instruct todoaValsalva prolapse toobserve maneuver - internal hemorrhoids It forevaluating iscompulsory - ofhemorrhoids toestablish isrecommended theAnoscopy diagnosis &analpruritus mucus soiling discharge, fecal Prolapse ofinternal hemorrhoids may bleeding, cause pain cutaneous notcause Do the dentate above Originate line&are ortransitionalmucosa covered w/rectal &apalpable lump are area analpainofacuteonset symptoms intheCommon perianal tolarge which rise skintags makehygiene give diﬃ orwhen they onlywhenProduce thrombosed symptoms cult tothe closer analverge &areLocated covered epithelium w/squamous Hemorrhoids are classified according to relativetheir location to the dentate line diffIf hemorrhoids are present, erentiate &internal external hemorrhoids between ofinduration orulceration areas able May toidentify be - exam rectal Perform adigital fi forother area eg lesions Inspect abscess, dermatitis, perianal ssures, condylomata neoplasms, stula, fi -

Low-fi ber diets cause small-caliber stools, resultinginstrainingduringdefecation&engorgement ofhemorrhoids tissue ontoilet seen amounts may orscanty into which be may orsquirt the bowl drip toilet blood red Bright © MIMSincarcerated prolapseofthe mucosa rectal hemorrhoids, external thrombosed complications possible skin tags, forhemorrhoids eg &its Examine 1 SYMPTOMS ATTRIBUTED TO HEMORRHOIDS 3 GRADING OF INTERNAL HEMORRHOIDS Hemorrhoids (2of8) 2 DIAGNOSIS B2 © MIMS 2019 HEMORRHOIDS • Other • • Hygiene • • Warm &Ice Baths • • Toilet HabitRetraining • • • ModiﬁDietary cation • • • Avoidance nonsteroidal eg anti-infl that ofmedications promote bleeding (NSAIDs) drugs ammatory Discourage shower/bath excessive during scrubbing gently analarea w/ moisttissue defecation towipe after Patients advised may be Ice may the painofacutethrombosis lessen Warm the &spasm analsphincter relaxing mechanism painby water baths perianal relieve avoided when usingthe should be Reading toilet mainly ofreminding patientsConsists toavoid sitting prolonged orstrainingwhen usingthe toilet Fiber supplements include Psyllium & Methylcellulose acondition tocontrol exacerbate which can Fiber used may diarrhea, be hemorrhoids also - upto25-30g/day gradually Fiber increased intake shouldbe - fi treatment forallsymptomatic hemorrhoids mainlyentails dietary Conservative increasing ber & uid intake fl in7-10days usually resolves is>72hr, &onset isresolving, the patient severe, If the since expectantly painisnottoo treated may pain be inamore rapidresults relief ofsymptoms inthe oﬃ onset symptom Excision w/inthe 1st48-72hrafter ce or, ifnecessary, inthe typically operating room Treatment orexcision hemorrhoids external include observation thrombosed optionsforpainful

rhoids toshrink Fiber &fl straining& constipation, hemor-causes which in &decrease turn caliber stool uidintake increase A

© DIETARY MODIFICATION & SUPPORTIVEMIMS MEASURES B A Pharmacological therapy Pharmacological modifi Dietary measures &supportive cation 4 EXTERNAL HEMORRHOIDS CLINICAL DECISION Hemorrhoids (3of8) Symptoms present for Symptoms present D Symptom onset Symptom onset Local excision Local DECISION thrombosis? CLINICAL CLINICAL <48-72 hr? pain from from pain <48-72 hr Acute Acute B3 Yes Yes 4 present for>48- present No Symptoms 72 hr No TREATMENT CONTINUE © MIMS 2019 HEMORRHOIDS • • • • • orCautery Diathermy Bipolar • • • • • Sclerotherapy • • • • • • • • • Ligation Band Rubber • • • • • ofPrinciples erapy • Agents Other • • • Biofl avonoids • • Corticosteroids • • Analgesics • • • 1 Various the forspecifi latest MIMS &purgatives forhemorrhoidssee are available. laxatives Please cformulations &prescribing information. Complications include pain, bleeding, fiComplications include pain,bleeding, of ssurethe internal orspasm sphincter afiAbout fth ofpatients still excisionalrequire hemorrhoidectomy Usually multiple requires applications tothe samesite of20Ware until applied underlying tissuecoagulates pulses infi resulting 1-sec & brosis xation oftissue fi hemorrhoids orIII I,II forgrade used May be retention &abscess impotence, w/injection, Complications urinary include pain,bleeding natureMinimally invasive isanadvantage Vessel w/sclerosis ofconnective tissue&fi thrombosis, xationoverlyingresults of mucosa, A sclerosing agent into the ofthe isinjected apex hemorrhoid hemorrhoids IorII forgrade Used Avoid diathesis receiving antiplatelet orthose inpatients w/bleeding oranticoagulant agents ligations repeat by relieved mayRecurrent symptoms be commonMost complication isminorpain the notaddress hemorrhoidal external componentLimitation ofthe Does procedure: inonesession banded Up be to3hemorrhoids can - Single ormultiple session doneper bandingmay be that fiScar forms the prolapse wall & resolves tissueto xes the connective rectal to the dentate line connective tissue&hemorrhoidal are mucosa, Redundant complex vessels tightly encircled blood well proximal Usually the eff most ective option hemorrhoids orIII I,II forgrade commonlyMost used onthe partly Choice physician’s depends ofprocedure experience &preference cushion tothe wall rectal fi hemorrhoidal volume&increase vascularity, decrease Decrease oftherapy: Goals xation of the brovascular fi Ablation ofthe ofthe mucosal hemorrhoidal complex notrequire anesthesia portion does hemorrhoids Th on for the treatmentpatient’sneed based of e is hemorrhoids symptoms ¬on the of appearance the procedures Patients hemorrhoids are w/intractable the foroffi orIII usualcandidates I,II grade (outpatient)ce-based softeners Stool permeability capillary resistance; venous tone,lymphatic normalize drainage Increase &capillary Actions: improve symptoms Control bleeding, rectal purifiOral, micronized, ed, been studied fruits have from citrus fraction derived avonoid fl Avoid ofpotent corticosteroids use prolonged Topical corticosteroids infl reduce perianal can seepage poor hygiene, ammationmucus discharge dueto orfecal thrombus by paincaused torelieve (egOral analgesics Paracetamol) used may be Cinchocaine Lidocaine, Includes - Topical pain&pruritus local torelieve used may analgesics be todemonstrate their defiMore studies are needed nite role in the treatment ofhemorrhoids preparations forhemorrhoidal relief pharmacological are availableSeveral Suppositories may thus defecation, help during inlubrication avoidingSuppositories straining

1 © MIMS role have inhemorrhoid therapy alimited Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specifiprescribing c C B ABLATIVE OFFICE PROCEDURES PHARMACOLOGICAL THERAPY Hemorrhoids (4of8) B4 © MIMS 2019 HEMORRHOIDS • • • • • Hemorrhoidectomy Stapled • • • • Hemorrhoidectomy orClosed Open forSurgical Options erapy • • • • Hemorrhoidectomy forSurgical Indications • • • ofSurgical Principles erapy • • Cryotherapy • • • Coagulation Infrared • • • • Electrotherapy Current Direct Rates ofcomplicationRates are similarw/excisional hemorrhoidectomy Ineff hemorrhoids largeective against hemorrhoids or external &skintags thrombosed amodifiUses ed, circular, stapler anastomotic that mucosa through ofredundant rectal segment the goes excised fl are ofprolapsing the blood tissueback re-suspension Goals w/inthe &interruption ofarterial analcanal ow alternative forpatientsNewer w/significant prolapse Th incontinence, &analstenosis retention, infection, urinary include bleeding, ese - areComplications usuallyminorbutmay ofsurgery occur frequently - the component external Th excision of by local treated best present for<48-72hris been hemorrhoids ofexternal which has rombosis - Suturing orbandinginternal hemorrhoids &excising component external - Excisinginternal components &external - Involves any ofthe following: laser, ordiathermy scalpel, usingasurgical scalpel ultrasonic performed May be w/signifi III-IV) &internal external hemorrhoids (grade Combined cant prolapse Acutely hemorrhoids incarcerated &thrombosed skintags from symptoms hemorrhoids symptomaticexternal including whohave those hemorrhoids, Patients orIV w/large III grade Patients tolerate that toorcannot ablative donotrespond oﬃ procedures ce-based disability more pain&postoperative complications, w/ isassociated surgery Outpatient because are ablative when preferred procedures possible (non-surgical) hemorrhoids III-IV for grades Surgical hemorrhoidectomy is considered the eff most ective treatment for hemorrhoids in general & particularly hemorrhoids Th on for the treatmentpatient’sneed based of e is hemorrhoids symptoms ¬on the of appearance the ofsignifi because Rarely used cant adverse eff ects Employs cold coagulation Recurrence iscommon prolapse inhemorrhoids w/marked ofhemorrhoidal inprotein tissue,resulting necrosis are directly tothe applied waves base Infrared hemorrhoids IorII forgrades used May be Disadvantages treatment are extended control time&limited disease ofprolapse inmore severe multipleRequires applications tothe athird samesiteinabout ofpatients Involves application prolonged current ofthe of110Vdirect hemorrhoidal complex tothe base hemorrhoids orIII I,II forgrade used May be

© MIMS extensionhemorrhoid w/inthe orpatient size, canal anxiety anoffi doneas May be oflarge because setting ce require anoperating room butmay procedure sometimes Performing acircular excision ofinternal hemorrhoids &prolapsing mucosa rectal proximal to the dentate line C ABLATIVE OFFICE PROCEDURES (CONT’D) PROCEDURES OFFICE ABLATIVE D SURGICAL HEMORRHOIDECTOMY Hemorrhoids (5of8) B5 © MIMS 2019 HEMORRHOIDS 1 Various the forspecifi latest MIMS combination see are available. Please products cformulations. aescin) (Amorphous Aescin Biofl avonoids Hydrocortisone 100-500 mg slow 100-500mgslow Hydrocortisone Diosmin acu oeiae500-1000mg/day PO dobesilate Calcium Agent Sclerosing Other ethylrutoside) Trihydroxy- thylrutoside, (Hydroxye- 8-24hrly 1cap PO Troxerutin Rutin/Curcumae extr Hydrosmin extr aculeatus Ruscus Hesperidin/Vit C/ fl fraction) avonoid purifi(Micronized ed Diosmin/Hesperidin Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS 6-8 hrly inj orinfusion IV Dosage Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not 90 mg PO 8hrly 90 mgPO 8hrly or 20mgPO dose: Maintenance 8hrly PO 8hrly or180mg Initial dose:40mgPO followed by 600mg/day by PO followed x3days 1800mg/day PO attack: Acute 200-300 mg PO 12hrly 200-300 mgPO dose: Maintenance 12hrly or 500mgPO 8-12hrly 200-300mgPO dose: Initial 8hrly 400 mgPO 4-5 caps/day PO day PO x3dayscaps/day then PO 2tabs orcaps/ x4daysor caps/daythen PO 4tabs or 6tabs mgHesperidin, 450 mgDiosmin/50 HEMORRHOIDAL PREPARATIONS (ORAL) Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specifiprescribing c CORTICOSTEROID HORMONE Dosage Guidelines • • • • Instructions Special • Adverse Reactions Dosage Hemorrhoids (6of8) Long-term treatment sideeff duetoits isnotrecommended Long-term ects disorder, seizure osteoporosis, thyroid disease hepatic/renal impairment, myasthenia gravis, diseases, GI acuteMI,DM, Use w/caution failure, inpatients w/heart treatment forosteoporosis corticosteroidsPatients onlong-term shouldreceive preventive Take w/food glaucoma cataracts, bruising, easy & skinthinning tostriae leading diabetes, gain, wt imbalances, electrolyte impaired woundhealing, toinfection, susceptibility increased painorweakness, muscle wasting, osteoporosis, Adrenocortical insuffi long-term: Ifadministered Gastritis. ciency, B6 Remarks • Instructions Special • Reactions Adverse • Reactions Adverse • Instructions Special • Reactions Adverse renal disease Avoid inpatientsw/renalfailureor GI complaints neurovegetative disorders neurovegetative fl itching, skinrashes, ushing, headache, Mild GIdisturbances, Use w/ caution in severe renal failure Use w/caution insevere fever skin rash, diarrhea, nausea, GI disturbances, 1 Remarks © MIMS 2019 HEMORRHOIDS 1

Shark liver oil Rutin Ruscogenin Resorcinol Prednisolone Phenylephrine Peru balsam(Peruvian balsam) Pentosan polysulfate Neomycin Mucopolysaccharide polysulfate (Lignocaine) Lidocaine Hydrosmin Hydrocortisone Hexetidine Hamamelis virginiana Framycetin Fluocortolone Diphenhydramine Cocoa (Dibucaine) Cinchocaine Cetrimide extr asiatica Centella Bufexamac subgallate, Bismuth subnitrate compound,resorcinol Bismuth Bismuth (Bismuth salts oxide, Bismuth Betamethasone (EthylBenzocaine aminobenzoate) Aluminium subacetate (Aesculin) Aescin as creams, ointments, gels & suppositories. Please see the latest MIMS for specific formulations. the forspecific latest MIMS see Please gels &suppositories. ointments, creams, as hemorrhoidal topical agentsvarious These combination are found in preparationsThey are availablethroughout different countries. Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products Drug placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS HEMORRHOIDAL PREPARATIONS (TOPICAL) Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specific prescribing information may be found in the latest MIMS. latest the in found be may information prescribing Specific Dosage Guidelines Hemorrhoids (7of8) Emollient: Acts as a physical barrier which lubricates the which tissues lubricates aphysical barrier as Acts Emollient: agent stabilizing Capillary improves venous tone veins; Constricts underlying tissuetotherapeutic agentKeratolytic: May help toexpose swelling inflammationCorticosteroid: Reduces & Vasoconstrictor: &congestion swelling Reduces effect Mild antiseptic effects & thromboembolic anti-inflammatory forits used May be Antimicrobial agent swelling Reduces Allergic may reactions occur Temporarily anesthetic: Local pain&itching relieves agent stabilizing Capillary swelling inflammationCorticosteroid: Reduces & antiseptic &fungicidal Bactericidal itchy &hydrates skin Moisturizes dry Antimicrobial agent swelling inflammationCorticosteroid: Reduces & Topical antihistamine, may sedation cause the which tissues lubricates aphysical barrier as Acts Emollient: Allergic may reactions occur Temporarily anesthetic: Local pain&itching relieves Topical effect antiseptic Wound agent healing Topical effect anti-inflammatory Protectant swelling inflammationCorticosteroid: Reduces & Allergic may reactions occur Temporarily anesthetic: Local pain&itching relieves effect antiseptic Local agent stabilizing Capillary B7 Indications 1 © MIMS 2019 HEMORRHOIDS 1 Th hemorrhoidal topical agents ese various combination are foundin preparations throughout diff erent countries. ey are available Th hnl20m/ L3-5mLsubmucosal inj 250mg/5mL Phenol Polidocanol 1%, 3% soln Individualize dose based based dose Individualize 1%,3%soln Polidocanol Zinc oxide (ZnO) Zinc Trimebutine Tribenoside Triamcinolone Titanium dioxide as creams, ointments, gels & suppositories. Please see the forspecifi latest MIMS see Please gels &suppositories. ointments, creams, as cformulations. Drug Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed HEMORRHOIDAL PREPARATIONS (TOPICAL) & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly Available Strength All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © MIMS Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specifiprescribing c Please see the end of this section for the reference list. reference the for section this of end the see Please recommendations on manufacturer’s each may 3inj give of3mL For smallhemorrhoids, at site each Acts as aprotectant as Acts Antispasmodic permeability capillary Reduces inflCorticosteroid: Reduces swelling ammation & aprotectant as Acts SCLEROSING AGENTS Dosage Guidelines Hemorrhoids (8of8) Dosage B8 • • Reactions Adverse urinary symptoms urinary ofimpotenceFor & reports Phenol: Case skindiscoloration skin reactions, allergic burns, Irritation, reactions: Local Indications 1 (CONT’D) Remarks © MIMS 2019