Skills Anorectal Disorders

Front 1

Types of Hemorrhoids

Back 1

Internal--> 4 degrees

External

If the hemorrhoid is above the denate line, the hemorrhoids will not be associated with discomfort and considered to be internal hemorrhoids. If the hemorrhoid is below the denate line, the hemorrhoids will be associated with discomfort and considered to be external hemorrhoids

Front 2

Internal Hemorrhoids

Back 2

occur above the dentate line and are covered with columnar epithelium and lack sensory fibers.
1st degree: enlarged but do not prolapse into the anal canal
2nd degree: protrude into the anal canal but return spontaneously upon defecation
3rd degree: protrude into the anal canal upon defecation but can be returned manually
4th degree: permanently prolapsed and cannot be reintroduced into the anus

Front 3

External Hemorrhoids

Back 3

occur below the denate line and are covered with squamous epithelium and have sensory fibers

Front 4

Signs and Symptoms
Hemorrhoids

Back 4

Internal Symptoms: Blood in stool

External Symptoms:
Itching Discomfort
Irritation Burning
Inflammation Swelling

Front 5

Signs and Symptoms
Anal Abscess

Back 5

Fever with continuous painful bulge in the rectal area

REFER

Front 6

Signs and Symptoms
Anal Fistula

Back 6

Chronic with bleeding upon defecation

REFER

Front 7

Signs and Symptoms
Anal Fissure

Back 7

Pain during and after defecation often accompanied by bleeding

REFER

Front 8

Signs and Symptoms
Anal Neoplasm

Back 8

Bleeding and changes in bowel habits

REFER

Front 9

Signs and Symptoms
Polyps

Back 9

Bleeding

REFER

Front 10

Signs and Symptoms
Pruritis Ani

Back 10

Persistent itching in perianal region

REFER

Front 11

Exclusion Criteria
Anorectal Disorders

Back 11

•Anorectal disorders, including hemorrhoids, in patients <12 years
•Dx GI diseases associated with colorectal bleeding (ulcerative colitis, Crohn’s disease)
•Family history of colon cancer
•Potentially serious anorectal disorder such as a abscess, fistula or fissures, neoplasm or malignancy, polyps, or anorectal disorders previously diagnosed by PCP
•Anorectal signs or symptoms such as severe pain, bleeding, seepage, prolapse, thrombosis, black tarry stools, and moderate to severe itching, burning, inflammation, swelling, and discomfort.
•Minor anorectal symptoms that do not respond to 7 days of self-treatment (pharm or non-pharm treatment)

Front 12

Corticosteroids
(Hydrocortisone)

Back 12

MOA:
Anti-inflammatory and antipyretic
Onset: 12 hrs
EXTERNAL USE

SE: May mask symptoms of infection (fungal and bacterial)

Not for long term use

Front 13

Vasoconstrictors
(ephedrine, epinephrine, phenylephrine)

Back 13

MOA: Vasoconstriction—alpha-adrenergic receptor stimulation results in constriction of the arterioles, which reduces swelling. Additional anesthetic effect occurs through an unknown mechanism. Vasoconstrictors decrease discomfort, itching, and swelling—
EXTERNAL (ALL)
INTERNAL (NOT EPINEPHRINE)
Onset: 30 min

SE: Nervousness, tremor, sleeplessness, nausea, anorexia
↑ BP, aggravation of hyperthyroidism, cardiac arrhythmias & irregular HR (these symptoms are uncommon at recommended doses).
Prolong use may result in anxiety or paranoia, and more commonly, rebound vasodilation.
Contact dermatitis may also occur.

Drug-disease interactions:
-Pregnancy
-Diabetes
-Thyroid disease
-Hypertension
-Angina pectoris (CVD)
-Enlarged prostate
(w/ these diseases, use external products only)
Drug-drug interactions:
-TCA antidepressants
-Cardiac medications
-Antihypertensive meds

Front 14

Local anesthetic
(benzocaine, benzyl alcohol, dibucaine, lidocaine, pramoxine, tetracaine)

Back 14

MOA: Reversibly block the transmission of nerve impulses which results in decreased discomfort, itching, pain, soreness and burning—use for EXTERNAL USE (below the denate line)

SE: Contact dermatitis (more common with benzocaine).
Local allergic reaction (burning and itching).
Absorption is minimal unless the skin is abraded—risk of cardiovascular and CNS reaction if systemically absorbed.

- Keep out of reach of children—dibucaine can be deadly if ingested.
-Pt with adverse reaction to benzocaine
-Avoid Prolonged use

Front 15

Protectants
(Al hydroxide gel, cocoa butter, glycerin, hard fat, kaolin, lanolin, mineral oil, white petrolatum, cod liver oil, calamine, zinc oxide)

Back 15

MOA: Provides a protective barrier, which prevents irritation of anorectal area and decreases water loss from anal mucosa.
All protectants (except glycerin) can be used for INTERNAL (NOT GLYCERIN), EXTERNAL (ALL).

SE: Minimal adverse effects because these agents are minimally absorbed, (good during pregnancy or lactation). Lanolin may cause lanolin allergy

Remove greasy ointments that contain petrolatum prior to using anorectal products that contain aluminum hydroxide gel and kaolin—ointment will decrease absorption of anorectal product

Front 16

Astringent
(Calamine, zinc oxide, witch hazel)

Not often used

Back 16

MOA: Promotes coagulation of skin cells to protect underlying tissue and reduces itching, burning, discomfort and irritation by causing contraction, wrinkling, blanching and decreasing secretions. May be used for INTERNAL AND EXTERNAL use

SE: Prolonged use of calamine or zinc oxide can possibly place the patient at low risk for systemic zinc toxicity (nausea, vomiting, lethargy and severe pain).
Witch hazel can cause contact dermatitis and slight stinging

Some pain with Zinc Oxide

Front 17

Keratolytics
(Al chlorhydroxy allantoinate, resorcinol, H2O2)
Not often used
(Not recommended by itself)

Back 17

MOA: Cause desquamation and debridement, or sloughing, of surface cells promoting cell turnover.
May be used for EXTERNAL use.

SE: Systemic absorption of resorcinol can cause ringing in the ears, increase HR, sweating, SOB and can be deadly at high doses

Do not use if the patient has open wounds near the anus
Not for prolonged use

Front 18

Analgesic/
anesthetics/
antipruritics
(Menthol, camphor and juniper tar)
Not often used

Back 18

MOA: Produces a local sensation of cool, warmth, or tingling that distracts the patient from anorectal symptoms (counterirritant effect). May be used for EXTERNAL use

SE: Allergic reaction to menthol. Menthol applied to large areas of the body can result in systemic absorption and side effects—use menthol sparingly