Symptoms in the Pharmacy :Gastrointestinal Tract Problems(18)

Haemorrhoids

 
Haemorrhoids (commonly known as piles) can produce symptoms of
itching, burning, pain, swelling and discomfort in the perianal area
and anal canal and rectal bleeding. Haemorrhoids are swollen veins,
rather like varicose veins, which protrude into the anal canal (internal
piles). They may swell so much that they hang down outside the anus
(external piles). Haemorrhoids are often caused or exacerbated by
inadequate dietary fibre or fluid intake. The pharmacist must, by
careful questioning, differentiate between this minor condition and
others that may be potentially more serious.

What you need to know

• Duration and previous history
• Symptoms
• Itching, burning
• Soreness
• Swelling
• Pain
• Blood in stools
• Constipation
• Bowel habit
• Pregnancy
• Other symptoms
• Abdominal pain/vomiting
• Weight loss
• Medication

Significance of questions and answers

 
Duration and previous history
As an arbitrary guide, the pharmacist might consider treating haemorrhoids
of up to 3 weeks’ duration. It would be useful to establish
whether the patient has a previous history of haemorrhoids and if the
doctor has been seen about the problem. A recent examination by the
doctor that has excluded serious symptoms would indicate that treatment
of symptoms by the pharmacist would be appropriate.

Symptoms
The term haemorrhoids includes internal and external piles, which can
be further classified as: (1) those which are confined to the anal canal
and cannot be seen; (2) those which prolapse through the anal sphincter
on defecation, then reduce by themselves or are pushed back
through the sphincter after defecation by the patient; and (3) those
which remain persistently prolapsed and outside the anal canal. These
three types are sometimes referred to as first, second and third degree,
respectively. Predisposing factors for haemorrhoids include diet, sedentary
occupation and pregnancy and there is thought to be a genetic
element.

Pain
Pain is not always present; if it is, it may take the form of a dull ache
and may be worse when the patient is having a bowel movement.
A severe, sharp pain on defecation may indicate the presence of an
anal fissure, which can have an associated sentinel pile (a small skin
tag at the posterior margin of the anus) and requires referral. A fissure
is a minute tear in the skin of the anal canal. It is usually caused by
constipation and can often be managed conservatively by correcting
this and using a local anaesthetic-containing cream or gel. In severe
cases a minor operation is sometimes necessary.

Irritation
The most troublesome symptom for many patients is itching and
irritation of the perianal area rather than pain. Persistent or recurrent
irritation, which does not improve, is sometimes associated with rectal
cancer and should be referred.

Bleeding
Blood may be deposited onto the stool from internal haemorrhoids as
the stool passes through the anal canal. This fresh blood will appear
bright red. It is typically described as being splashed around the toilet
pan and may be seen on the surface of the stool or on the toilet paper.
If blood is mixed with the stool, it must have come from higher up the
GI tract, and will be dark in colour (altered). If rectal bleeding is
present, the pharmacist would be well advised to suggest that the
patient see the doctor so that an examination can be performed to
exclude more serious pathology such as tumour or polyps. Colorectal
cancer can cause rectal bleeding. The disease is unusual in patients
under 50 and the pharmacist should be alert for the middle-aged
patient with rectal bleeding. This is particularly so if there has been
a significant and sustained alteration in bowel habit.

Constipation
Constipation is a common causatory or exacerbatory factor in haemorrhoids.
Insufficient dietary fibre and inadequate fluid intake may be
involved, although the pharmacist should also consider the possibility
of drug-induced constipation.
Straining at stool will occur if the patient is constipated; this increases
the pressure in the haemorrhoidal blood vessels in the anal
canal and haemorrhoids may result. If piles are painful, the patient
may try to avoid defecation and ignoring the call to open the bowels
will make the constipation worse.

Bowel habit
A persisting change in bowel habit is an indication for referral, as it
may be caused by a bowel cancer. Seepage of faecal material through
the anal sphincter (one form of faecal incontinence) can produce
irritation and itching of the perianal area and may be caused by the
presence of a tumour.

Pregnancy
Pregnant women have a higher incidence of haemorrhoids than nonpregnant
women. This is thought to be due to pressure on the haemorrhoidal
vessels due to the gravid uterus. Constipation in pregnancy
is also a common problem because raised progesterone levels mean
that the gut muscles tend to be more relaxed. Such constipation can
exacerbate symptoms of haemorrhoids. Appropriate dietary advice
can be offered by the pharmacist (see ‘Women’s Health’).

Other symptoms
Symptoms of haemorrhoids remain local to the anus. They do not
cause abdominal pain, distension or vomiting. Any of these more
widespread symptoms suggest other problems and require referral.
Tenesmus (the desire to defecate when there is no stool present in
the rectum) sometimes occurs when there is a tumour in the rectum.
The patient may describe a feeling of often wanting to pass a motion
but no faeces being present. This symptom requires urgent referral.

Medication
Patients may already have tried one or more proprietary preparations
to treat their symptoms. Some of these products are advertised widely,
since the problem of haemorrhoids is perceived as potentially embarrassing
and such advertisements may sometimes discourage patients
from describing their symptoms. It is therefore important for the
pharmacist to identify the exact nature of the symptoms being experi-
enced and details of any products used already. If the patient is constipated,
the use of any laxatives should be established.

Present medication
Haemorrhoids may be exacerbated by drug-induced constipation and
the patient should be carefully questioned about current medication,
including prescription and OTC medicines. A list of drugs that may
cause constipation can be found on p. 103. Rectal bleeding in a patient
taking warfarin or another anticoagulant is an indication for referral.

When to refer

• Duration of longer than 3 weeks
• Presence of blood in the stools
• Change in bowel habit (persisting alteration from normal bowel habit)
• Suspected drug-induced constipation
• Associated abdominal pain/vomiting