HAEMORRHOIDS(piles)

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OUTLINEWhat are haemorrhoids?

The causes of haemorrhoids

Symptoms of haemorrhoids

Treatment of haemorrhoids & products for treating

How can they be prevented & products for prevention

Complementary medications

Adjunct products

Counselling

When to refer

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Haemorrhoids are also known as piles

Haemorrhoids are engorged blood vessels (or varicose veins) that occur under the lining of the anus & appear on the inside, on or just outside the anus

They can become inflamed, painful & swollen in the lower portion of rectum or anus

The Gastrointestinal Tract

What Are Haemorrhoids?For Professional Use Only

What Are HaemorrhoidsHaemorrhoids may be inside or outside the body

Many patients have both internal and external haemorrhoids

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Incidence Of HaemorrhoidsHaemorrhoids can occur in anyone

Haemorrhoids become large in size & cause problems to only 4 % of the worlds population

It usually affects people aged 45 –65 years and decreases after age 65

Only 1 in 3 go to see a doctor about their condition

It rarely affects people <20 years old

Occur commonly during pregnancy

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DIAGNOSIS1st symptom of a haemorrhoids is bleeding from the rectum

Typically, the blood is bright red and occurs at the end of a bowel movement. The bleeding is often described as blood on the paper, dripping or spraying into the toilet bowl

The bleeding is NOT associated with any pain

However, there are many other conditions which are much more serious (including bowel cancer) which can result in bleeding

Any patient who comes into the pharmacy seeking treatment or advice regarding any fresh blood from the bowel should be referred immediately to their medical practitioner so they can be examined for both haemorrhoids and to have other serious conditions excluded

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Internal HaemorrhoidsInternal haemorrhoids occur just inside the anus, at the beginning of the rectum

are usually painless

can cause intermittent rectal bleeding during or following a bowel motion

may produce mucous discharge

may protrude (prolapse) outside the anus, & appear as small, grape-like masses

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External HaemorrhoidsExternal haemorrhoids occur at the anal opening & may hang outside the anus

can be very painful & cause hygiene problems after a bowel movement resulting in irritation and itchiness

Swelling & discomfort may occur intermittently.

External haemorrhoids sometimes develop a blood clot "thrombosis" inside after diarrhoea or constipation

In that case, it produces a sudden firm and painful swelling or lump around the rim of the anus

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Causes Of HaemorrhoidsThe exact cause of symptomatic haemorrhoids is unknown however contributing factors include:

Straining during bowel movements

Irregular bowel habits constipation or diarrhoea

Sitting for long periods of time

Genetics

Anal infections

Certain diseases - liver cirrhosis, Irritable Bowel Syndrome, Crohn’s Disease and Ulcerative Colitis

Lack of exercise

Obesity

Pregnancy pressure from the foetus and hormonal changes cause many blood vessels to swell including the haemorrhoidal vessels

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Symptoms Of HaemorrhoidsAnal itching and/or burning This is related to leaking of mucous from the engorged blood vessels which can lead to itchiness and burning discomfort in the skin around the anus

Anal ache or pain, especially while sitting

Bright red fresh blood on toilet tissue, stool, or in the toilet bowl

Pain during bowel movements

One or more hard tender lumps near the anus

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Duration Of Haemorrhoid Symptoms

Haemorrhoid flare-ups, (swelling, irritation & mild discomfort) are usually brief & most symptoms disappear within a few days

Pregnant women symptoms usually improve dramatically or disappear after childbirth

Intermittent slight bleeding from haemorrhoids may carry on for months or years

Painful swelling from thrombosis of an external haemorrhoid usually resolves over a period of days to weeks

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Treatment Of HaemorrhoidsForms of treatment available

Ingredients include:ProtectantsBarrier medicationsCorticosteroidsLocal anaestheticsStool softenersWitch hazel

Sitz bathCold compresses

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SuppositoriesRectal gelsRectal ointments

OINTMENT & SUPPOSITORIESAnusol

Anusol is available as an Ointment & Suppositories Unscheduled or an open seller

Contains: Zinc Oxide mild antiseptic

used to discourage growth of certain bacteria

Peru Balsam very mild antiseptic action to prevent bacterial infection

Benzyl Benzoate associated with inflamed, oozing haemorrhoids

normally used in scabies as it can kill these parasites

it also has mild antiseptic properties which may protect against developing infections

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OINTMENT & SUPPOSITORIES How to use Anusol

Anusol Ointment 1st clean & dried the area as much as is possible

Apply to the area every 4 hours as needed or after each bowel motion

Attach the nozzle to insert ointment internally

Anusol Suppositories Insert ONE suppository into the rectum in the morning and the evening

Application is preferable after a bowel motion though this may be difficult to predict

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OINTMENT & SUPPOSITORIES Proctosedyl

Proctosedyl is available as Ointment & Suppositories

Pharmacy Medicine

Contains: Hydrocortisone Corticosteroid

relieves inflammation & burning

Cinchocaine Local anesthetic

Numbs pain, reduces itching & burning symptoms

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OINTMENT and SUPPOSITORIESHow to use Proctosedyl

Proctosedyl Ointment can be used up to THREE times a day for the first 7 days

If used for more than seven days reduce to twice daily

Longer term use; can cause thinning of the skin because of the corticosteroid

Attach the nozzle to insert ointment internally

Proctosedyl Suppositories Insert morning and night preferably after a bowel motion

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OINTMENT & SUPPOSITORIES Rectinol

Rectinol is available as an OintmentPharmacy Medicine

Contains: Zinc Oxide is a mild antiseptic

used to discourage growth of certain bacteria

Cinchocaine Local anesthetic

Numbing affect on the tissue

reduces pain, itching & burning symptoms

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OINTMENT and SUPPOSITORIESHow to use Rectinol

Rectinol Ointment Apply up to THREE times a day and preferably after each bowel motion

Attach the nozzle to insert ointment internally

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OINTMENTHemocane

Hemocane is available as an OintmentPharmacy Medicine

Contains: Zinc Oxide is a mild antiseptic used to discourage growth of certain bacteria

Lignocaine Local anesthetic Numb the pain, reduce itching & burning symptoms

Allantoin Moisturiser which may aid in soothing any irritation

Hamamelis extract (witch hazel) Astringent has been used to relieve swelling, minor pain, burning

associated with haemorrhoids

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OINTMENTHemocane

Contains: Chlorhexidine antiseptic

Helps to reduce infections

Castor oil, Local anesthetic

Numb the pain, reduce itching & burning symptoms

Allantoin Moisturiser which may aid in soothing any irritation

Hamamelis extract (witch hazel) Astringent has been used to relieve swelling, minor pain,

burning associated with haemorrhoids

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OINTMENT and SUPPOSITORIESHow to use Hemocane

Hemocane Ointment Apply morning & night and after each bowel motion

Attach the nozzle to insert ointment internally

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OINTMENTSoov It

Soov It is available as an OintmentPharmacy Medicine

Contains: Hydrocortisone Corticosteroid

relieves swelling, inflammation & itching

Lignocaine Local anesthetic

Numb the pain, reduce itching & burning symptoms

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OINTMENTHow to use Soov It

Soov It Ointment Apply a small quantity to the fingers

Apply up to three times daily preferably after each bowel motion

Attach the nozzle to insert ointment internally

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OINTMENTHemoclin Gel

Hemoclin is available as an Ointment

Contains: A derivative of Aloes Plant Binds to bacteria, preventing bacteria form adhering to the skin or

internal mucosa of the bowel – may reduce incidence of infection

Gel also lubricates stools making them easier to pass

Gel has a cooling effect which can reduce inflammation and thus

the associated pain

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OINTMENTHow to use Hemoclin Gel

Hemoclin Gel Apply the gel using the applicator in and around the affected area

The applicator is for internal usage

Use at least twice per day or when required for a period of 2 weeks

But should NOT be used continuously for longer than 30 days for one treatment period

It has no known side effects or interactions and can be used during pregnancy and breastfeeding

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PREVENTIONConstipation and straining during bowel movements

raise the risk for developing haemorrhoids.

To prevent constipation and haemorrhoids:Stay hydrated

Drink plenty of fluids, at least eight glasses per day.

Avoid or limit alcohol and caffeine intake these promote the loss of water from your body and can cause hard stools and increase the pain of haemorrhoids.

Increase fibre intakeEat a high fibre diet - fruits, vegetables, and whole grains supply natural fibre

Consider fibre supplements – eg Metamucil, Benefiber

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PREVENTIONTo prevent constipation and haemorrhoids continued:

Stool softenersstool softeners to prevent straining - Coloxyl

ExerciseBegin a program of regular exerciseAs little as 20 minutes of brisk walking daily can stimulate your bowel to move regularly

RegularityTrain your digestive tract to have regular bowel movementsSchedule a time to sit on the toilet at approximately the same time each dayThe best time to do this is usually right after a mealDo not sit on the toilet for long periods (it tends to make haemorrhoids swell up and push out)Respond immediately to the urge to have a bowel movementDo not postpone until the time is more convenient

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FIBRE SUPPLEMENTSAlso known as bulk-forming laxatives

Fibre should be taken ONCE OR TWICE DAILY after meals, swallowed with plenty of fluid

Fibre supplements swell when they come into contact with fluids and work by increasing the volume of contents in the gut

Stimulates the muscular movement of the gut, which helps to move the stool through the intestines

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FIBRE SUPPLEMENTSIt is essential to drink plenty of water when using fibre supplements. Otherwise, the stool will not stay soft and easy to pass during a bowel movement. With none or little water the stools can become hard and even impacted. This will exacerbate haemorrhoids

There are no known harmful effects if used during pregnancy or breastfeeding

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FIBRE SUPPLEMENTS

Psyllium HuskMetamucil

Wheat dextrinBenefiber

SterculiaNormacol

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PSYLLIUM HUSKS (METAMUCIL)Powder

Recommended dose for adults is 1 rounded teaspoon

or 1 rounded tablespoon for the Smooth Texture,orange-flavoured Metamucil

Dissolve the powder in 240 mL of cool liquid (water, fruit juice, lemonade, iced tea), stir it briskly, and drink right away

CapsulesRecommended dose is FIVE capsules up to THREE times a dayTake the capsules with at least 240 mL of cool liquid. Swallow the capsules one at a time

NOTE: These products can affect how other medications are absorbed from the stomach, do not take it TWO hours before or after taking other medications

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WHEAT DEXTRIN (BENEFIBER)Powder

Mix one tablespoon with at least 250ml of any liquid

or soft food and stir well

Begin with one serve daily and increase as required

You can mix Benefiber Powder into any hot or cold beverage such as water, coffee, or juice and into soft foods such as pudding or yogurt

Add it to recipes such as muffins, sauces or soups, and it will not affect the taste or consistency.

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STERCULIA (NORMACOL)Sterculia is a vegetable gum from the karaya tree

It is not absorbed or digested in the stomach or intestines

The granules should be taken once or twice a day after meals

They should be placed dry on the tongue and swallowed immediately without chewing or crushing, with plenty of water or a cool drink

The granules may also be sprinkled onto soft food such as yoghurt and swallowed without chewing or crushing, wash down with a drink.

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Faecal SoftenersDocusate sodium (Coloxyl Tablets)

Docusate is a stool softener or emollient laxative

Is a surfactant which works by drawing water out from the surface of the intestines and thus increases the penetration of fluid into the faeces, thereby softening the stool

Take two or three tablets twice daily

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Sitz BathsHistorically, Sitz baths have been used to treat haemorrhoids

Patients would sit in either a warm or cold bath to relieve itching and inflammation. Baths could contain only water or have salt, baking powder or Epsom’s salts added to them

Patients would have to be careful if sitting in water that is too warm as this could lead to the blood vessels dilating and causing more swelling of the haemorrhoid

Salts such as baking powder can effervesce and this was expected to be soothing to the skin. There is no firm evidence that adding any salts to the bath can improve itching, swelling or inflammation

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Cold Compresses

Cold compresses can reduce the inflammation and swelling associated with haemorrhoids

More effect with external haemorrhoids rather than internal haemorrhoids because of the difficulty in accessing internal haemorrhoids with cold compresses

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COMPLEMENTARY PRODUCTS

Witch Hazel Liquid

Witch hazel is an astringent and has been used to relieve swelling, minor pain, burning associated with haemorrhoids

The liquid can be rubbed on external haemorrhoids but products available in Australia are not specifically designed for haemorrhoidal use

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Oral Pain Relief PreparationsParacetamol

Paracetamol 500mg tablets or capsules – two tablets every four hours (no more than EIGHT per day)

Nonsteroidal anti-inflammatoriesDiclofenac (Voltaren Rapid, 12.5 or 25mg)

• 50mg (4 of the12.5mg tabs or 2 of the 25mg tabs) for the first dose then 25mg every 8 hours with food. Maximum 200mg per day

Ibuprofen (Nurofen , Advil, Nurofen Zavance)• Two tablets/capsules for the first dose then one to two tablets or

capsules every 4-6 hours with food. Do not exceed six tablets per daily.

Codeine containing products are not recommended as they can cause constipation

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COUNSELLINGAvoid toilet tissue with perfumes or colors, use

baby wipes instead

Try not to scratch the area

When pregnant, lie on the left side when resting or sleeping to help reduce pressure on certain veins that can lead to vein swelling and haemorrhoids

Report to a medical practitioner if the symptoms change

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WHEN TO REFERBleeding

Haemorrhoids must first be diagnosed by a doctor

Any bleeding from the rectum could be the result of more serious conditions or conditions other than haemorrhoids

Only patients who have been diagnosed with haemorrhoids should be treated in the pharmacy

Change in symptomsf the symptoms associated with haemorrhoids changes in the patient (more severe bleeding, increased pain (with bowel motions or at other times), impacted motions or the symptoms suddenly become more severe or intense

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