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Overview |
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Definition |
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Hemorrhoids are a varicosity of the rectal venous plexus, classified as
either internal or external to the anal verge.
- External skin tags at the anal verge
- External hemorrhoids, possibly thrombosed
- Internal hemorrhoids: first degree—bulging
into anal canal and causing bleeding; second
degree—prolapsing during defecation and reducing
spontaneously; third degree—prolapsing and requiring
manual reduction; thrombosed—prolapsing and may be
strangulated
Hemorrhoids are uncommon before age 25 (except in women who have been
pregnant) and thereafter increase in prevalence by age. After age 50, about 50%
of the population have asymptomatic hemorrhoids and 5% have symptomatic
hemorrhoids. |
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Etiology |
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Hemorrhoids are caused by dilation of veins within the rectal venous plexus.
Prolapse in internal hemorrhoids may be caused by shearing forces from passage
of large, firm stool or urgent defecation; the prolapse may become entrapped by
the internal anal sphincter. |
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Risk Factors |
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In most cases, there is no obvious predisposing factor. The following factors
increase a patient's risk.
- Family history
- Age
- Irritable bowel syndrome
- Portal hypertension
- Pregnancy
- Constipation
- Obesity
- Regular prolonged sitting
- Congestive heart failure
- Pelvic inflammatory disease or neoplasms
- Carcinoma of the rectum
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Signs and Symptoms |
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- Constipation
- Straining while defecating
- Anal fissures
- Stool mucus
External hemorrhoids:
- Discomfort, pain
- Tender perianal lump
- Possible bleeding
- Pruritus
Internal hemorrhoids:
- Intermittent or sustained bleeding
- Pain (if thrombosed or strangulated)
- Sensation of fullness (if
prolapsed)
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Differential
Diagnosis |
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- Hypertrophied anal papillae from anal fissure, Crohn's disease, or
other cause
- Anal skin tags from previous hemorrhoids or Crohn's
disease
- Prolapsed rectal mucosa
- Rectal or anal tumors, polyps
- Endometriosis
- Condyloma
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Diagnosis |
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Physical Examination |
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External hemorrhoids appear as a mass outside the anal verge, which may be
soft and painless or, if thrombosed, firm and tender with blue coloration.
Internal hemorrhoids may be visualized with buttocks retracted and the patient
straining. Sigmoidoscopy or colonoscopy may be performed when there is bleeding
or if carcinoma is suspected as a cause of the hemorrhoids. |
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Imaging |
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In cases of significant or repeated bleeding, barium enema may be
performed. |
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Other Diagnostic
Procedures |
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Since hemorrhoids usually do not produce significant bleeding, question the
patient carefully about any bleeding as well as about any constipation
experienced. Assess the level of pain, as severe pain may indicate strangulation
and the need for immediate surgical referral. Rectal examination.
Sigmoidoscopy. |
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Treatment Options |
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Treatment Strategy |
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The goal is to alleviate symptoms and promote healing. Surgery may be needed
in severe cases, but most cases respond well to other measures.
- Treating any underlying condition
- Preventing direct pressure (positional changes, sitting on an
inflatable ring)
- Avoiding straining on defecation
- Limiting the amount of time sitting on the toilet
- Sitz baths with soapy water or Epsom salts 2 to 3 times daily for 15
to 20 minutes
- Stool softeners and high-fiber foods reduce straining and
prolapse
- Topical preparations for pain or pruritus
- Analgesics (rectal or systemic) for
pain
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Drug Therapies |
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- Stool softeners, such as docusate sodium (Colace, 200 mg) help reduce
straining and prevent hard stools; side effects include nausea, cramps,
diarrhea; contraindicated in obstruction and fecal impaction.
- Bulk laxatives, such as psyllium (Effer-Syllium, Metamucil, 1 to 2
tsp. in water bid to tid, or premeasured packets), help prevent hard stools;
side effects include nausea, vomiting, diarrhea; contraindicated in obstruction,
abdominal pain, and fecal impaction.
- Rectal preparations, such as hydrocortisone (Anusol-HC cream,
ProctoFoam-HC aerosol, or Wyanoids-HC ointment), relieve itching and discomfort;
side effects include local irritation, burning, blistering.
- Topical anesthetics, such as dibucaine hydrochloride (Nupercainal,
applied topically qid as needed) or lidocaine 2.5% (Xylocaine, applied topically
tid to qid), relieve rectal discomfort; side effects include contact allergy
symptoms.
- Systemic analgesics, such as oxycodone (Tylox, 5 to 10 mg every 6
hours), for severe pain of thrombosed hemorrhoids; side effects include
drowsiness, dizziness, sedation, nausea, vomiting, constipation; contraindicated
in addictive personality.
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Surgical Procedures |
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Surgery is indicated if conservative measures fail or for persistent
bleeding, severe pain with thrombosis, prolapse, strangulation, ulceration, or
perianal infection. Surgical methods include the following.
- Excision hemorrhoidectomy
- Rubber band ligation
- Cryosurgery
- Injection of sclerosing agents
- Laser therapy
- Infrared photocoagulation
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Complementary and Alternative
Therapies |
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Nutritional support, topical preparations, and sitz baths may be effective in
restoring the integrity of the vasculature, reducing hemorrhoids, and minimizing
recurrence. |
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Nutrition |
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- Take time to eat in a relaxed atmosphere, breathing and chewing food
thoroughly.
- Eat smaller, more frequent meals and avoid overeating at one
sitting.
- Decrease low-fiber foods and foods and drinks that cause excess
urination (refined foods, sugars, caffeine, alcohol, meat, and dairy products),
which leads to harder stools. Increase foods that are high in fiber (fresh
fruits and vegetables, whole grains) to soften stools. Increase water
intake.
- Decrease saturated fats (animal products) and increase
polyunsaturated fats (cold-water fish, nuts, and seeds).
- Stewed or soaked prunes, one to three/day have a slightly laxative
effect and may help soften stools.
- Flaxmeal, 1 heaping tsp. in 8 oz. of apple juice, provides fiber and
essential fatty acids to help relieve constipation and soothe the digestive
tract. Follow with an additional 8 oz. of water. Flaxmeal can be made by
grinding flaxseeds in a blender.
- Vitamin C (1,000 mg bid to tid) supports the integrity of connective
tissue.
- Vitamin E (400 to 800 IU/day) promotes normal clotting and
healing.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
Flavonoids, a constituent found in dark berries and some plants, help restore
the integrity of the vasculature. The following are flavonoids that may be taken
in dried extract form as noted.
- Catechin (150 mg bid to tid), quercetin (250 mg tid to qid),
hesperidin (250 mg tid to qid), and rutin (250 mg tid to qid).
- Rose hips (Rosa canina) and green tea (Camellia
sinensis) are also high in flavonoids and either one may be used as a tea.
Drink 3 to 4 cups/day.
- Stone root (Collinsonia canadensis) and horse chestnut
(Aesculus hippocastanum) can be used to strengthen blood vessel walls (60
drops tincture bid).
Topical applications may relieve itching and burning, as well as promote
healing. Apply one of the following bid to qid.
- Witch hazel (Hamamelis virginiana) is an astringent that may
reduce swelling (commercially available as Tuck's pads).
- A salve containing comfrey (Symphytum officinale) and/or
marigold (Calendula officinalis) soothes and promotes healing.
- A poultice made from grated potato is astringent and
soothing.
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Aesculus for burning hemorrhoids with a sensation of a lump in
anus and aggravations from walking
- Aloe for a sensation of pulsation in the rectum with large,
external hemorrhoids
- Collinsonia for chronic, itchy hemorrhoids with obstinate
constipation
- Hamamelis for large bleeding hemorrhoids with raw feeling in
the anus
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Physical Medicine |
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Contrast hydrotherapy: Contrast sitz baths may relieve symptoms and promote
circulation, relieving pelvic vascular congestion. You will need two basins that
can be comfortably sat in. Fill one basin with hot water, one with cold water.
Sit in hot water for three minutes, then in cold water for one minute. Repeat
this three times to complete one set. Do one to two sets per day three to four
days per week. |
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Acupuncture |
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Acupuncture may be effective in resolving stagnant, congestive
conditions. |
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Patient Monitoring |
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If the hemorrhoids do not resolve in one to two weeks, reevaluate the
patient's condition and consider additional
therapy. |
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Other
Considerations |
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Patients with severe congestive heart failure, portal hypertension, or
debilitating disease should consider options outside of surgery and be treated
with general measures. |
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Prevention |
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A high-fiber diet and avoiding prolonged sitting may help prevent hemorrhoids
in susceptible individuals. |
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Complications/Sequelae |
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- Secondary infection
- Ulceration
- Thrombosis
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Prognosis |
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Untreated, the symptoms of hemorrhoids often resolve within days to weeks,
though they are likely to recur. If a thrombosed hemorrhoid strangulates,
however, it may ulcerate and cause infection. |
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Pregnancy |
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Nutritional support, topical herbal applications, and homeopathic remedies
for hemorrhoids are safe in pregnancy. Hemorrhoids often resolve after
childbirth. |
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References |
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Balch JF. Prescription for Nutritional Healing. 2nd ed. Garden City
Park, NY: Avery Publishing, 1997.
Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory
Medicine. 4th ed. Baltimore, Md: Williams & Wilkins; 1995:1347-1361.
Duke JA. The Green Pharmacy. Emmaus, Pa: Rodale Press; 1997.
Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal
Medicines. Montvale, NJ: Medical Economics Co; 1998.
Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North
Atlantic Books; 1992:181-183.
Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed.
Rocklin, Calif: Prima Publishing; 1998.
Olshevsky M, Noy S, Zwang M. Manual of Natural Therapy: A Succinct Catalog
of Complementary Treatments. New York, NY: Facts on File; 1989.
Stein JH, ed. Internal Medicine. 4th ed. St. Louis, Mo: Mosby-Year
Book; 1994:486-492.
United States Pharmacopeial Convention, Inc. Advice for the Patient.
15th ed. USPDI; 1995:2. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |