Haemorrhoids

There are two different mechanisms behind ordinary causes of constipation, functional and outlet obstructions. Functional constipation is caused by the slower movement of the colon, peristalsis, which comes with old age, often in combination with less physical activity and less intake of fibre containing food. Outlet obstruction is a result of incapacity to empty the rectum from faeces often due to too large masses of stool blocking the anus. It can also be caused by anal stricture from haemorrhoids or scar tissue caused by fissures. 

Besides causing loss of appetite and quality of life, longstanding and severe constipation can lead to diverticulosis, diverticulitis and in worst cases perforation of the large intestine with life threatening peritonitis (McConnell et al. 2003). Diverticulosis, irritable bowel syndrome and haemorrhoids are caused by chronic constipation and can lead to bleeding and anaemia. 

Constipation bulk-forming laxatives by increasing faecal mass tend to soften stools and relieve constipation, and have value in a range of symptomatic problems associated with anal fissure, haemorrhoids, and with ileostomy and colostomy dysfunction. Faecal softeners, lactulose and macrogols (polyethylene glycol) retain fluid in the bowel. Stimulant laxatives, such as the anthraquinone, senna, and bisacodyl, increase motility and can cause colic verdoses can cause diarrhea and electrolyte depletion. Chronic treatment for constipation is seldom needed, but may be in children with a tendency to faecal impaction, specialist advice should be sought. 

Betamethasone valerate is analysed in a sample of ointment used for treating haemorrhoids, the related steroid beclomethasone dipropionate is used as an internal standard. The following data were produced ... 

It is an anionic detergent which softens the stool by water accumulation in intestinal lumen and emulsifies the colon contents. It is indicated in obstetric, habitual, geriatric, paediatric constipation or when straining is to be avoided (recent myocardial infarction, severe hypertension, post-operative cases, abdominal hernia), fissures, haemorrhoids and bed ridden patients. Dose 100-200 mg/day. 

It is indicated in all forms of constipation, e.g. in bedridden patients, due to change of food or environment, illness or digestive disorders relief of evacuation in painful conditions such as haemorrhoids pre and postoperatively pre-paration for barium enema preparation of colon for proctosigmoidoscopy. Dose DULCOLAX 5-15 mg HS oral and suppository (5-10 mg). 

Clinical use Bufexamac (Brogden et al., 1975) is a nonsteroidal anti-inflammatory drug used in topical formulations for mild skin disorders and as suppositories (250-500 mg/day) for haemorrhoids. 

Various natural, chemically modified and mixtures of flavonoids are widely used therapeutically as venous protective or venotonic drugs in chronic venous insufficiency and haemorrhoidal attacks. Flavonoids have been found to inhibit increased vessel wall permeability, fluid changes in the capillary bed and diffusion of plasma proteins. In addition, they may exert a protective effect on the perivascular tissues due to their antihyaluronidase effect and the inhibition of lysine oxidase (producing crosslinks in collagen and elastin) and lysosomal hydrolases (degrade glycosamines). All these effects may account for the venotonic effects of these drugs [5]. However, the venous effects of flavonoids are out of the scope of the present review. 

Lyseng-Williamson KA, Perry CM. 2003. Micronised purified flavonoid fraction A review of its use in chronic venous insufficiency, venous ulcers and haemorrhoids. Drugs 63 71-100. 

Benzocaine has been used as a component of appetite suppressants astringents analgesics burn and sunburn remedies cough tablets, drops, and lozenges haemorrhoidal creams, suppositories, and enemas oral... 

Faecal softeners (such as docusate, which is stimulating but which also has softening properties). These can be useful where passing stools may be uncomfortable e.g. with haemorrhoids... 

HT-R antagonist (HIS-R) [for oedema, chronic venous insufficiency haemorrhoids] 5HT-R antagonist - 5HT2-R (HIS-R) [for oedema, chronic venous insufficiency haemorrhoids T GI transit]... 

HIS-R antagonist (5HT-R) [for oedema, chronic venous insufficiency haemorrhoids]... 

Psyllium preparation (polysaccharide) Plantago psyllium (Plantaginaceae) HypoGlc (NIDDM human) [anti-constipation, anti-haemorrhoid, water-absorbant]... 

P. T. Paul, Hippocrates, Vol. VIII Places in Man, Glands, Fleshes, Prorrhetic 1-2, Physician, Use of Liquids, Ulcers, Haemorrhoids and Fistulas , Harvard University Press, Cambridge, MA, 1995. 

Sclerosing agents. Chemicals may be used to cause inflammation and thrombosis in veins so as to induce permanent obliteration, e.g. ethanolamine oleate injection, sodium tetradecyl sulphate (given i.v. for varicose veins) and oily phenol injection (given submucously for haemorrhoids). Local reactions, tissue necrosis and embolus can occur. 

The softening properties of these agents are useful in the management of anal fissure (see below) and haemorrhoids. 

Blood from the haemorrhoidal venous plexus passes via the azygous superior rectal vein into the inferior mesenteric vein and thereafter into the portal vein. By contrast, the paired middle rectal vein and inferior rectal vein discharge their blood via the iliac vein into the inferior vena cava. In portal hypertension, anorectal varices are found in the region of the rectum, the anal canal and the external anal region. Haemorrhoids are distended and dislocated cavernous bodies in the rectum, which have no connection to the portal venous system. Although haemorrhoids and anorectal varices are two different clinical pictures, it is quite possible for them to occur simultaneously. The frequency of anorectal varices (40-80%) is dependent upon the extent and duration of portal hypertension. The bleeding tendency is low (7-14%). However, there have also been reports of massive haemorrhages. (21,45,55,66,83,105,156) (s. tab. 14.10)... 

Following the propagation of rubber band ligation for haemorrhoids by J. Barron (1963), oesophageal varix ligation was later introduced by G. Van Stiegmann et al. in 1986. 

Rectal examination Rectal examination by way of inspection and palpation of the anus and rectum (especially after straining) is imperative. The presence of haemorrhoids should not be accepted as a potential source of bleeding without further diagnostic clarification. 

Allain H, Ramelet AA, Polard E, Bentue-Ferrer D. Safety of calcium dobesilate in chronic venous disease, diabetic retinopathy and haemorrhoids. Drug Saf 2004 27(9) 649-60. 

Figure 9.52 shows the blood supply to the rectal area. The main artery to the rectum is the superior rectal (haemorrhoidal) artery. Veins of the inferior part of the submucous plexus become the rectal veins, which drain to the internal pudendal veins. Dmg absorption takes place through this venous network. Superior haemorrhoidal veins connect with the portal vein and thus transport dmgs absorbed in the upper part of the rectal cavity... 

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