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Hemorrhoid No More

Hemorrhoids No More

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Patients over the age of 40 who have hemorrhoidal bleeding cannot be assumed to have no other colorectal pathology and should have further colorectal evaluation. (Chong and Bartolo, 2008) (SOR: B).

Dietary management of symptomatic hemorrhoids consists of adequate fluid and fiber intake (Alonso-Coello et al., 2005) (SOR: B). Rubber band ligation is known to be highly effective outpatient treatment for first-, second-, and some third-degree hemorrhoids (Reese et al., 2009) (SOR: B).

External Hemorrhoids

A nonpainful or painful anal swelling can represent an external hemorrhoid. Hemorrhoids should be differentiated from anal skin tags, condylomata, fissures, and

Hemorrhoids Band Instrument

Figure 28-16 Rubber band ligation for internal hemorrhoid. The band is advanced onto the end of the ligator instrument using a conical attachment (insets). The hemorrhoid is identified at a level proximal to the dentate; this area is tested for sensation before banding. Occluding the suction port of the ligator instrument draws the hemorrhoid into the open end of the ligator, and the instrument is fired. The banded hemorrhoid typically sloughs in 1 week. (Courtesy Mayo Foundation; and Nelson H, Cima RR. Anus. In Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]. Sabiston Textbook of Surgery, 18th ed. Saunders-Elsevier, Philadelphia, 2008.)

Figure 28-16 Rubber band ligation for internal hemorrhoid. The band is advanced onto the end of the ligator instrument using a conical attachment (insets). The hemorrhoid is identified at a level proximal to the dentate; this area is tested for sensation before banding. Occluding the suction port of the ligator instrument draws the hemorrhoid into the open end of the ligator, and the instrument is fired. The banded hemorrhoid typically sloughs in 1 week. (Courtesy Mayo Foundation; and Nelson H, Cima RR. Anus. In Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]. Sabiston Textbook of Surgery, 18th ed. Saunders-Elsevier, Philadelphia, 2008.)

abscesses on anal examination. Symptomatic external hemorrhoids can be excised if conservative treatment fails. The patient is placed in the lateral decubitus position with hips flexed. The external hemorrhoid or tag is identified and anesthetized at its base with buffered 1% lidocaine with epinephrine. The area is cleansed with povidone-iodine or chlorhexidine. A radially oriented elliptic incision is made around the hemorrhoid or tag and the center removed with the hemorrhoid vein. The resulting defect is frequently left open and allowed to heal. Stool softeners and topical anesthetics may be very beneficial. Because of the vascularity, healing can occur in 5 to 10 days. (See Tuggy Video: External Hemorrhoid Excision.)

Thrombosed External Hemorrhoids

An external hemorrhoid can become thrombosed and may be identified by an acute onset of perianal pain and development of a purplish nodule with or without bleeding. Thrombosed hemorrhoids can be managed conservatively with avoidance of constipation, patient analgesia, and ice or sitz baths (Cataldo et al., 2005). Office surgical excision, not incision, of a thrombosed external hemorrhoid results in a lower recurrence rate and earlier resolution of symptoms (Greenspon et al., 2004). Simple incision of the thrombosed hemorrhoid may not remove multiple clots and can result in higher recurrence rate and even extension.

To excise a thrombosed hemorrhoid, the patient is placed in the lateral decubitus position with buttocks separated for visualization. The surface can be cleansed and anesthesia provided with a local injection of buffered lidocaine or bupivacaine with epinephrine at the base of the hemorrhoid. Once anesthetized, an elliptic incision is made in a radial orientation over the hemorrhoid, and all thrombus is removed with excision of the hemorrhoidal vein at its base. Bleeding can be controlled with pressure, Monsel's solution, or careful electrocautery. More complex hemorrhoids or those associated with partial rectal prolapse should be referred to a colorectal specialist.

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Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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