HEMORRHOID(case study)

HEMORRHOID NORAINI GROUP 64 JANUARY 2007 SEMESTER 3

CONTENTS ACKNOWLEDGEMENT…………………………. PATIENT PROFILE………………………… • Patient profile • Reason for admission • Past medical history • Past surgical history ANATOMY & PHYSIOLOGY OF ANUS…… HEMORRHOIDS……………………………… • What is hemorrhoid • Etiology & patophysiology • Clinical manifestation • Investigation • Diagnosis finding • Medical & surgical treatment • Pre-operative management

• Post-operative management • Nursing intervention • Health teaching • Conclusion REFERENCE………………………………

ACKNOWLEDGEMENT I would like to thank Mr Goh Hin An for giving me opportunity to use his case’s for my case study.from this case study,I’ve learnt a lots of things about hemorrhoid especially about the causes and treatment. Thanks also to tutors for giving me guide line for doing this case study. For friends which helping me,special thanks for you all,hopefully you all also done well for your case study.

NORAINI

PATIENT PROFILE NAME : Goh Hin An @ Ah An AGE : 63 years SEX : Male RN : 00847295 ROOM : ME-R15 PHYSICIAN : Dr.Vijeyasingam DIAGNOSIS : STAPLE HEMORRHOIDECTOMY

REASON FOR ADMISSION H/O PR bleeding –fresh blood since 5pm 2/8/08,staining @ stools Constipation 3/7 On admission :conscious,alert Bp :140/90mmhg T :36.4°c P:78bpm R:20/min RBS :12.1mmol

PAST MEDICAL HISTORY Hypertension

Tung Shin Hospital for 20 years,on Adalat

LA 30mg daily. Diabetic – on diet control

PAST SURGICAL HISTORY Piles for 20 years,under treatment rubber banding 5 years ago and more recently last month at Tung Shin Hospital.

ANATOMY & PHYSIOLOGY OF ANUS

To understand hemorrhoids, we need to review the anatomy of the digestive system (start backward - from the anus)

The anus is the end-point of the digestive system. It contains sweat and oil glands, hair follicles, as well as many nerve endings, which make it very sensitive to pain and erotic stimulation. The anal opening is an oval opening located about an inch in front of the spine. When closed, the anus is about an inch in

circumference - however, the external sphincter muscle that circles it can stretch to about five times the size.

Inside the anal opening is the anal canal. It is approximately two inches deep, with an encircling internal sphincter muscle that controls the passage of stool in the elimination process On top of the anal canal, there is a ring of tissue fold arranged in zigzag or sawtooth pattern called the dentate line. Underneath this line lies some vestigial glands - in our evolutionary ancestors, these glands secrete odors that attract mates. Now, however, these glands are empty and unused. About an inch above the dentate line is the rectum, or the last holding place for feces in the elimination process. The rectum is approximately six inches long, with folds called the valves of Houston. These valves serve as shelves where the feces rest between bowel movements. When the stool becomes heavy, the valve presses against the rectal wall, which results in the "the call of nature" signal or the urge to defecate.

On top of the rectum lies the large intestine (also known as the colon or bowel). It is six foot in length, and is divided into four components: the sigmoid colon, the descending colon, the transverse colon, and the ascending colon. The ascending colon is connected to the small intestine by a structure called the ceccum.The digestive process of food stops at the small intestine and the fecal waste water-removal process starts at the ascending colon. Fecal matter starts as liquid waste at the cecum and ends up as solid waste in the sigmoid colon.

Hemorrhoids

What are hemorrhoids? The term hemorrhoids refers to a condition in which the veins around the anus or lower rectum are swollen and inflamed.

There are two types of hemorrhoids: External hemorrhoids Hemorrhoids located outside of the anus are called external hemorrhoids. Here, swollen veins cause a soft lump around the anal opening. These lumps can turn hard if blood clot develops, and become painful thrombosed hemorrhoids. Since the anus has many nerve endings, external hemorrhoids can be very painful or itchy. Sometimes, the clot may even break out of the hemorrhoid by itself or dissolve back into normal blood circulation. Internal hemorrhoids

Internal hemorrhoids are located inside the rectum or anal canal, and are usually not painful. This is because the anal canal does not have many nerve endings. Indeed, most people are not aware that they have internal hemorrhoids until a hard stool rubbing against them cause these hemorrhoids to rupture and bleed. Left untreated, some internal hemorrhoids can "prolapse" or be pushed out of the anal opening. Sometimes, the sphincter muscle can close shut in a spasm and trap this prolapsed hemorrhoid outside the anus. This cuts off the blood circulation, and creates a strangulated hemorrhoid. Some prolapsed hemorrhoids can be manually "pushed" back inside the anus. Advanced cases of prolapsed hemorrhoids, however, must be surgically treated. Prolapsed and strangulated hemorrhoid are a serious medical condition that requires immediate attention. Also, bleeding of any amount should be checked by a doctor since it may be an indication of more serious conditions, such as colorectal cancer

ETIOLOGY AND PATOPHYSIOLOGY OF HEMORRHOID

We all have hemorrhoidal veins in the anus, anal canal, and rectum. These veins do not have valves, which would normally help support and distribute the weight of the blood. Many factors can cause undue pressures on these veins, which can then cause these veins to become distended and swollen hemorrhoids. Below are some factors that can cause hemorrhoids:

Straining during bowel movement One of the most frequent causes of hemorrhoids is straining during bowel movements. Forcing for too long or too hard, because of diarrhea, constipation, or bad bathroom habits (such as reading on the toilet) is actually attributed to the majority of hemorrhoids cases. It is interesting that some have argued that the design of the sitting toilet actually contributes to straining hemorrhoids are virtually unknown in countries with squat toilets

Genetics Inherited characteristics such as weak vein walls can result in tendencies to develop hemorrhoids. Heredity

alone, however, does not usually lead to a hemorrhoid without additional factor(s), such as a bad bathroom habit or a job that requires standing or sitting for prolonged periods. Diet foods that are lacking in fibers actually create stool that is harder to pass. This results in straining during a bowel movement, and thus hemorrhoids. Pregnancy Another of the most common causes of hemorrhoids in women is pregnancy: the extra weight of the uterus adds great pressure on the rectal veins. For women who already have hemorrhoids, pregnancy can definitely make their hemorrhoid condition worse. Even women who do not develop hemorrhoids during pregnancy can still get them because of long and arduous labor and delivery, or because of constipation that arise after childbirth. For example, in the days and weeks after vaginal delivery, some women regularly postpone bowel movements because of tenderness in the anus and perianal area.

Postponing bowel movement Sometimes when "nature calls", there is no toilet nearby. Usually, by postponing bowel movement, the urge to

defecate goes away and does not return until after eating another meal. While occassionally postponing bowel movement does no harm, doing it regularly can contribute to hemorrhoids. Here's why: the longer fecal matter remains in the colon, the drier it becomes and therefore the harder it is to pass without straining. Repeated inhbition of the urge to defecate can also result in weaker signals to the rectal muscles to pass stool. Eventually, it may be difficult to pass stool naturally without some straining. Also, a colon filled with fecal matters is heavy and exerts pressure on the blood vessels and veins of the anus and rectum. This can cause these veins to swell and become hemorrhoids. Diseases There are several diseases that can actually lead to the development of hemorrhoids. Of these, the most serious is rectal cancer, which causes a false "call of nature", thus encouraging the patient to go to the bathroom and strain unnecessarily. Enlargement of the liver, often found in people who abuse alcohol, can create extra pressure on the hemorrhoidal veins. Other digestive diseases, such as intestinal tumor and irritable bowel syndrome, can interefere with normal elimination or cause constipation.

Lastly, although heart attack does not cause hemorrhoids, it does increase venous pressure and therefore can make an existing hemorrhoid worse. Bouts of diarrhea Diarrhea is the body's way of getting rid of bacteria from its digestive system. It is commonly caused by contaminated food. However, diarrhea can also be caused by an allergic reaction to food and milk, by stress and anxiety, as well as by an adverse reaction to medication and laxatives. In the case of diarrhea, the expulsive force of the watery stool can damage rectal veins and lead to hemorrhoids. Constipation Paradoxically, the opposite of diarrhea can also lead to hemorrhoids! Constipation is defined as infrequent bowel movements or the difficulty in passing stool. The longer the stool remains in the colon, the drier it gets. After a certain point, usually a fair amount of straining is required to pass the dry and hard stool. A common condition in the elderly, constipation is one of the major causes of hemorrhoids in this segment of the population. Extreme physical exertion Laborers and weightlifters often hold their breath or grunt while lifting heavy objects. This forces air downward in the

lungs and exerts pressure on the diaphragm, which in turn exerts pressure on the abdominal organs and rectal veins. Note that weightlifters can also get hemorrhoids because they eat a lot of animal proteins in order to gain bulk and mass. Prolonged sitting or standing and lack of exercise Sedentary lifestyle, lack of exercise, as well as jobs which require prolonged periods of sitting and standing can lead to, or exacerbate, existing hemorrhoids.

CLINICAL MANIFESTATION OF HEMORRHOID

Hemorrhoidal symptoms are divided into internal and external sources. Internal hemorrhoids cannot cause cutaneous pain, as they are above the dentate line and are not innervated by cutaneous nerves. They can bleed, prolapse and cause perianal itching and irritation. Irritation and itching is caused by deposition of an irritant onto the sensitive perianal skin. Internal hemorrhoids can cause perianal pain by prolapsing and causing spasm of the sphincter complex around the hemorrhoids. This spasm results in discomfort while the prolapsed hemorrhoids are exposed. This muscle discomfort is relieved with reduction. Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. Again, the pain is related to the sphincter complex spasm. Strangulation with necrosis may cause more deep discomfort. When these catastrophic events occur, the sphincter spasm often causes concomitant external thrombosis. External thrombosis causes acute cutaneous pain. This consternation of symptomsis referred to as acute hemorrhoidal crisis. It usually requires emergent treatment. Internal hemorrhoids most commonly cause painless bleeding with bowel movements. The covering epithelium is damaged by the hard bowel movement and the underlying veins bleed. With spasm of the sphincter complex elevating pressure, the internal hemorrhoidal veins can spurt. Internal hemorrhoids can deposit mucus onto the perianal tissue with prolapse. This mucus with microscopic stool

contents can cause a localized dermatitis, which is called pruritus ani. Generally, hemorrhoids are merely the vehicle by which the offending elements reach the perianal tissue. Hemorrhoids are not the primary offenders. External hemorrhoids cause symptoms in 2 ways. First, acute thrombosis of the underlying external hemorrhoidal vein can occur. Acute thrombosis is usually related to a specific event, for example, physical exertion, straining with constipation, a bout of diarrhea, or a change in diet. These are acute, painful events. Pain results from rapid distension of innervated skin by the clot and surrounding edema. The pain lasts 7-14 days and resolves with resolution of the thrombosis. With resolution of the thrombosis, the stretched anoderm persists as excess skin or skin tags. External thromboses can occasionally erode the overlying skin and cause bleeding. Recurrence occurs approximately 40-50% of the time, at the same site. This occurs at the same site because the underlying damaged vein remains present. Simply removing the blood clot and leaving the weakened vein in place, compared with excision of the offending vein with the clot, will predispose to recurrence. External hemorrhoids can also cause trouble with hygiene. The excess redundant skin left after an acute thrombosis (skin tags) is actually accountable for these problems. External hemorrhoidal veins found under the perianal skin obviously cannot cause hygiene problems; however, excess skin in the perianal area can mechanically interfere with cleansing.

INVESTIGATION

Lab Studies •

•

Hematocrit testing is suggested if excessive bleeding with concomitant anemia is suspected. Coagulation studies are indicated if the history and physical examination suggest coagulopathy.

Imaging Studies •

Barium enema study or virtual colonoscopy is suggested if proximal colonic and intestinal diseases must be excluded and if endoscopy is not helpful.

DIAGNOSIS FINDING BUSE

Urea

5.7mmol/L

5.2-8.0mmol/L (normall range)

Sodium

138mmol/l

137-150mmol/l (normall range)

Potassium

3.7mmol/L

3.5-5.3mmol/L (normall range)

Chloride

97mmol/L

99-111mmol/L (normall range)

FULL BLOOD COUNT Red cell count

4.0×10^12/L

4.5-6.0×10^12/L (normal range)

Haemoglobin

13.1g/dL

13.7-18.0g/dL (normal range)

Haematocrit

40%

40-54% (normal range)

MCV

99fL

82-100fL (normal range)

MCH

33pg

27-32pg (normal range)

MCHC

33g/dL

32-36g/dL (normal range)

Platelet

151×10^9/L

150-400×10^9/L (normal range)

White cell count

7.0×10^9/L

4.0-11.0×10^9/L (normal range)

DIFFERENTIAL COUNT Neutrophils

50.1%

40-75% (normal range)

Lymphocytes

17.4%

15-45%

(normal range) Monocytes

5.3%

2-10% (normal range)

Eosinophils

2.7%

1-6% (normal range)

basophil

0.3%

0-1% (normal range)

ECG-SHOW NORMAL

Medical and Surgical Treatments for Hemorrhoid Fortunately for many people, hemorrhoids can heal by themselves and all that is needed is temporary relief from their symptoms. For these people, self-care of this condition is usually sufficient.

Aggravation of hemorrhoids can be avoided using similar steps to that used for preventing them. These steps include: • • • • •

Eat fiber-rich food Drink plenty of water Do not postpone bowel movement Do not strain during defecation Exercise

In order to alleviate the symptoms of hemorrhoids, you can: Take a warm sitz bath A sitz bath of warm water for 10 to 15 minutes, either in the bathtub or in a special basin that is placed on top of the toilet, can provide a quick relief from the swelling and pain of hemorrhoids. The bath water should be warm or hot, but not burning hot. Also, do not add soap, Epsom salt, bath oil, or anything else as they can irritate the hemorrhoids.

Use a cold or warm compress In the last months of pregnancy, a sitz bath is not recommended as water can seep into the vagina. Instead, a cold or warm compress can be used. Use a moist wipe

Instead of toilet paper, try a moistened wipe to clean yourself after going to the bathroom. Some commercially available wipes are medicated with witch hazel, a natural astringent that can reduce the swelling and ease the pain of hemorrhoids. Use a bidet If available, you can use a bidet or stream of warm water to clean yourself after bowel movement. Use stool softener and lubricant A hard, dry stool can be difficult to pass, and may irritate the hemorrhoids to cause bleeding. A fiber-based stool softener can be used to create a stool that is bulkier, moister, and easier to pass. Another way to make it easier to pass stool is to use finger to lubricate the anal opening and canal with petroleum jelly or other lubricants such as K-Y Jelly.

Use over-the-counter analgesics or suppositories Topical hemorrhoid creams and suppositories work as lubricants to reduce friction and ease the irritation of hemorrhoids. They usually contain ingredients such as cocoa butter, lanolin, glycerin, cod-liver oil, and vegetable oil.

Some have additional ingredients that deaden pain sensation, to give a potent but temporary relief. Usually, these analgesics contain benzocaine, lidocaine, or other -caine derivatives. Other creams may contain astringents such as tannic acid, bismuth, and witch hazel to reduce swelling. Medicated creams, available with your doctor's prescription, may contain steroids to reduce inflammation. Note that some people are allergic to the ingredients in these analgesics and astringents. Using them may actually worsen hemorrhoids.

An advanced or severe case of hemorrhoids often can only be treated by surgical procedures. These treatments include:

Anal Dilation Although this technique is no longer commonly used, when properly used, anal dilation can help relieve the pain and promote healing of hemorrhoids. In this anal dilation procedure, the anal sphincter muscle is stretched or dilated to prevent hemorrhoids from increasing rectal

pressure, as well as to reduce the need of straining to pass stool. Because of its potential side effect of fecal incontinence or anal leakage, this procedure not be used for eldery patients or those with weak sphincter muscle.

Rubber Band Ligation Basically, the idea behind this method has not changed since Hippocrates tied thread around an internal hemorrhoid to cut off its blood circulation. The doctor would use an applicator to apply a special rubber band onto the base of the hemorrhoid.The band will cut off blood circulation to the hemorrhoid, which will shrivel and fall off in about one week along with the band.This medical procedure is usually done for bleeding internal and prolapsed hemorrhoids. It can be done without any special preparation, in doctor's room. In case of multiple hemorrhoids,doctor would normally ligate or band them one at a time over a period of time. Typically, separate hemorrhoids are treated about one month apart.Because there are few nerve endings in the anal canal, this procedure is usually not painful. However, some people do experience discomfort and a dull ache after the procedure. To avoid further irritating the hemorrhoid, it is recommended that you drink plenty of water, eat a fiber-

rich diet, and take a stool softener.In rare instances, side effects and complications such as clotting of an external hemorrhoid and bleeding can happen. Stapled Hemorrhoidectomy Stapled hemorrhoidectomy is the newest surgical technique for treating hemorrhoids. Stapled hemorrhoidectomy is a misnomer since the surgery does not remove the hemorrhoids but, rather, the abnormally lax and expanded hemorrhoidal supporting tissue that has allowed the hemorrhoids to prolapse downward.For stapled hemorrhoidectomy, a circular, hollow tube is inserted into the anal canal. Through this tube, a suture (a long thread) is placed, actually woven, circumferentially within the anal canal above the internal hemorrhoids. The ends of the suture are brought out of the anus through the hollow tube. The stapler (a disposable instrument with a circular stapling device at the end) is placed through the first hollow tube and the ends of the suture are pulled. Pulling the suture pulls the expanded hemorrhoidal supporting tissue into the jaws of the stapler. The hemorrhoidal cushions are pulled back up into their normal position within the anal canal. The stapler then is fired. When it fires, the stapler cuts off the circumferential ring of expanded hemorrhoidal tissue trapped within the stapler and at the same time staples together the upper and lower edges of the cut tissue

Internal Hemorrhoids in Anal Canal

Hollow Tube Inserted into the Anal Canal and Pushing up the Hemorrhoids

Suturing the Anal Canal through the Hollow Tube

Bringing Expanded Hemorrhoidal Supporting Tissue into the Hollow Tube by Pulling on Suture

Hemorrhoids Pulled Back Above Anal Canal after Stapling and Removal of Hemorrhoidal Supporting Tissue

During stapled hemorrhoidectomy, the arterial blood vessels that travel within the expanded hemorrhoidal tissue and feed the hemorrhoidal vessels are cut, thereby reducing the blood flow to the hemorrhoidal vessels and reducing the size of the hemorrhoids. During the healing of the cut tissues around the staples, scar tissue forms, and this scar tissue anchors the hemorrhoidal cushions in their normal position higher in the anal canal. The staples are needed only until the tissue heals. They then fall off and pass in the stool unnoticed after several weeks. Stapled hemorrhoidectomy is designed primarily to treat internal hemorrhoids, but if external hemorrhoids are present, they may be reduced as well.

Stapled hemorrhoidectomy is faster than traditional hemorrhoidectomy, taking approximately 30 minutes. It is associated with much less pain than traditional hemorrhoidectomy and patients usually return earlier to work. Patients often sense a fullness or pressure within the rectum as if they need to defecate, but this usually resolves within several days. The risks of stapled hemorrhoidectomy include bleeding, infection, anal fissuring (tearing of the lining of the anal canal), narrowing of the anal or rectal wall due to scarring, persistence of internal or external hemorrhoids, and, rarely, trauma to the rectal wall.

PRE-OPERATIVE MANAGEMENT √ Diagnosis finding • BUSE

• FULL BLOOD COUNT • DIFFERENTIAL COUNT • ECG √ Diet • Low residual diet × 2/7 • Fluid diet one day before operation √ Fasting 12MN √ Rectal lavaj √ Shaving if necessary √ Consent

POST-OPERATION MANAGEMENT DR HOE ORDERED • IM pethidine 50 mg tds / prn

• IVD 2pint D 5%, 2 pint Dextrose Saline in 24 hours

NURSING DIAGNOSIS Problem :Pain and discomfort related surgical wound

to

Objective : To reduce and minimize the pain

Nursing intervention : 1.Asses level of pain according to pain scale level by asking the patient for further management. 2.Monitor vital sign to detect any abnormality such as blood pressure more than 140/90mmhg and tachycardia 3.Position patient on side lying position to reduce the pressure at surgical wound so that it’s can help to reduce the pain. 4.

Teach patient how to do breathing exercise to reduce the pain

5.Give diversional theraphy such as watching television,reading magazine so that patient do not focus on the pain. 6.Plan nursing care effectively to minimize disturbance so that patient can rest well. 7.Give analgesic such as IM Pethidine 50 mg as ordered by doctor to reduce the pain. 8.Asses effectiveness of the analgesic after 30 minutes to make sure the dosage is enough for the pain.

9.Inform doctor if pain still persist after analgesic to prevent any complication.

Evaluation :patient didn’t complain discomfort and pain.

Problem :potential bleeding related to surgical wound Objective:to prevent any signs and symptoms of bleeding Nursing intervention :

1.Inspect dressing site for any bleeding and perform pressure dressing if bleeding occurs. 2.Monitor vital signs such as blood pressure and pulse to detect any sign and symptom of bleeding such as blood pressure more than 140/90 mmhg and pulse more than 100 bpm. 3.Advise patient to take diet that are high in fiber such as fruits and vegetables in avoidance of constipation. 4.Advise patient to drink a lots of water at least 2 liter/day in avoidance of constipation. 5.give stool softener such as liquid paraffin 15mls tds @ ON as ordered by doctor in avoidence patient straining during passing motion. 6.Advise patient not to strain during passing motion to prevent any bleeding. 7.Tell patient to use soft tissue for wiping to prevent any bleeding.

Evaluation :no signs and symptoms of bleeding occurs.

HEALTH TEACHING There are simple steps to avoid getting hemorrhoids. Even if you already have them, these tips should help in preventing hemorrhoid flare-ups: Eat more fibers and drink more water

A typical Western diet is high in animal fat and protein, and is often made with refined flours with little fiber content. This fiber-poor diet makes for stool that is smaller, drier, and harder to pass as compared to fiber-rich food. To avoid hemorrhoids, add fiber to your regular diet by eating raw vegetables and fruits, as well as adding oatmeal.It is particularly good because it helps make the stool soft, moist, and easier to pass. Drinking a lot of water can also help make stool softer, especially if you are eating fiber-rich food. For the elderly, there are fiber-rich food that are not crunchy or hard to chew, such as oatmeal, steamed vegetables and stewed fruits. Drinking water during a meal, instead of between meals, can also help make fiber-rich food easier to digest. It may take sometime for your body to get used to roughage, so it is sometimes best to change your diet gradually - start by eating more roughage over a period of several weeks. Changing Bad Bathroom Habits Straining on the toilet puts a great pressure on the rectal and anal veins - causing them to distend and swell in a hemorrhoid. When "nature calls" normal bowel movement should be easy - if defecation is

difficult, don't strain. Instead, wait a while and then try again. Postponing bowel movement regularly can also help reduce the capability of the abdominal muscle to push out stool. It can also cause the stool to harden, and thus become harder to pass. So, don't wait when you get the urge to defecate. Don't read on the toilet - a normal bowel movement only takes between 2 to 5 minutes. Exercise Sitting or standing for long periods of time puts pressure on the rectal veins, so if your job requires you to sit or stand, be sure to take frequent breaks and move around to prevent hemorrhoids. People who exercise are also less prone to developing hemorrhoids. Exercising can also make you thirstier, so you naturally drink more water. It can also help improve your metabolism and aid digestion. Aging can weaken the anal sphincter muscle. Indeed, many elderly men and women have trouble passing stool because of this reason. Instead of using laxatives, which can make constipation worse, you can try "buttock" press exercises - tighten the

buttock muscles for several second and then relax them in a repeated cycle. This will strengthen the sphincter muscle. The buttock press can be done several times a day and practically anywhere - while sitting or standing. It is an especially good exercise for the elderly, pregnant women, and for those who cannot do strenuous exercise.

REFERENCE Lewis Medical Surgical Nursing • http://en.wikipedia.org/wiki/hemorrhoid • images.google.com • Lemone Medical Surgical •