Case Study: Hemorrhoids and other Anorectal Conditions

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  Hemorrhoids are vascular masses that protrude into the lumen of the lower rectum or perianal area.
  
  
  
• They result when increased intra-abdominal pressure causes engorgement in the vascular tissue lining the anal canal.
• Loosening of vessels from surrounding connective tissue occurs with protrusion or prolapse into the anal canal.
• There are two main types of hemorrhoids: external hemorrhoids appear outside the external sphincter, and internal hemorrhoids appear above the internal sphincter.
• When blood within the hemorrhoids becomes clotted because of obstruction, the hemorrhoids are referred to as being thrombosed.
• Predisposing factors include pregnancy, prolonged sitting or standing, straining stool, chronic constipation or diarrhea, anal infection, rectal surgery or episiotomy, genetic predisposition, alcoholism, portal hypertension (cirrhosis), coughing, sneezing, or vomiting, loss of muscle tone attributable to old age, and anal intercourse.
• Complications include hemorrhage, anemia, incontinence of stool, and strangulation.
• Hemorrhoids are the most common of a variety of anorectal disorders.

Assessment:

1. Pain (more so with external hemorrhoids), sensation of incomplete fecal evacuation, constipation, and anal itching. Sudden rectal pain may occur if external hemorrhoids are thrombosed.
2. Bleeding may occur during defecation; bright red blood on stool caused by injury of mucosa covering hemorrhoid.
3. Visible and palpable masses at anal area.

Diagnostic Evaluation:

1. External examination with anoscope or proctoscope shows single or multiple hemorrhoids.
2. Barium edema or colonoscopy rules out more serious colonic lesions causing rectal bleeding such as polyps.

Therapeutic Interventions:

1. High-fiber diet to keep stools soft.
2. Warm sitz baths to ease pain and combat swelling.
3. Reduction of prolapsed external hemorrhoid manually.

Pharmacologic Interventions:

1. Stool softeners to keep stools soft and relieve symptoms.
2. Topical creams, suppositories or other preparation such as Anusol, Preparation H, and witch-hazel compresses to reduce itching and provide comfort.
3. Oral analgesics may be needed.

Surgical Interventions:

1. Injection of sclerosing solutions to produce scar tissue and decrease prolapse is an office procedure.
2. Cryodestruction (freezing) of hemorrhoids is an office procedure.
3. Surgery may be indicated in presence of prolonged bleeding, disabling pain, intolerable itching, and general unrelieved discomfort.

Nursing Interventions:

1. After thrombosis or surgery, assist with frequent repositioning using pillow support for comfort.
2. Provide analgesics, warm sitz baths, or warm compresses to reduce pain and inflammation.
3. Apply witch-hazel dressing to perianal area or anal creams or suppositories, if ordered, to relieve discomfort.
4. Observe anal area postoperatively for drainage and bleeding.
5. Administer stool softener or laxative to assist with bowel movements soon after surgery, to reduce risk of stricture.
6. Teach anal hygiene and measures to control moisture to prevent itching.
7. Encourage the patient to exercise regularly, follow a high fiber diet, and have an adequate fluid intake (8 to 10 glasses per day) to avoid straining and constipation, which predisposes to hemorrhoid formation.
8. Discourage regular use of laxatives; firm, soft stools dilate the anal canal and decrease stricture formation after surgery.
9. Tell patient to expect a foul-smelling discharge for 7 to 10 days after cryodestruction.
10. Determine the patient’s normal bowel habits and identify predisposing factors to educate patient about preventing recurrence of symptoms.

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