How To Prevent Piles Naturally
Rectal prolapse is an uncommon condition defined as complete protrusion of the entire thickness of the rectal wall through the anus. It is seen far more commonly in women than in men and generally after the age of 40 (15). Pathologic defects noted are a diastasis of the levator ani muscles, an abnormally deep cul de sac, an elongated sigmoid colon, and loss of the rectal fixation to the sacrum. Prolapse can secondarily result in incontinence caused by a patulous anus. Numerous procedures have been described for correction of rectal prolapse, including both abdominal and perineal approaches. Neither approach requires specialized facilities and the choice of approach is generally determined by patient risk factors. One of the most common abdominal operations employed is the Ripstein procedure. It is indicated for the repair of complete rectal prolapse in a patient considered being an acceptable risk for abdominal surgery. Contraindications include an excessively redundant sigmoid colon...
Operative hemorrhoidectomy and rubber band ligation are the two most-common interventions for symptomatic hemorrhoids today. Both are highly effective when utilized properly. Hemorrhoidectomy refers to the operative excision of the hemorrhoids, usually in the outpatient surgical suite, whereas rubber band ligation is performed in the office setting. Hemorrhoids are generally symptomatic with either bleeding (typically bright red, painless, and commonly dripping into the toilet bowl) or protrusion (occasionally associated with discomfort, itching, or irritation and burning). Pain is usually not a symptom of hemorrhoids unless thrombosis or strangulation has occurred.
Rubber band ligation is performed for internal hemorrhoids with bleeding or minor degrees of protrusion. It is not performed for external hemorrhoids in patients with coagulopathies, or generally in patients taking anticoagulants (banding is performed in the office or the outpatient clinic and requires no specific preparation). The patient is placed in the knee-chest or lateral position, an anoscope is inserted, and the hemorrhoidal group to be ligated is visualized. Using a ligator placed through the anoscope, the redundant portion of the mucosa at the upper portion of the hemorrhoid is grasped and a constricting elastic band is placed around it. If the band is placed lower, significant pain may result (Fig. 6). The hemorrhoid will slough in 7-10 d leaving a small, ulcerated area to heal.
Hemorrhoids are a common medical and surgical problem (1). They are the cause of symptoms in a large portion of adults in the United States (2,3), and estimates of prevalence range from 4.4 to as high as 50 of the adult population (4). The peak age distribution for hemorrhoids is between age 45 and 65 years (5). Internal hemorrhoids rank as the most common cause of self-limited bleeding in ambulatory adults (6). Rarely, hemorrhoid bleeding can be quite severe, requiring urgent evaluation and therapy.
The most commonly complained of rectal pain is intermittent severe rectal pain that is not associated with defecation but may wake the sleeping patient. It is difficult to explain and does not usually result from organic disease. In men prostatitis is a common cause of rectal pain symptoms include perianal pain. Rectal pain will be worse on defecation (Hopcroft & Forte, 2003).
Endoscopic variceal ligation (EVL), also referred to as variceal banding, is an endoscopic therapy for acute esophageal variceal bleeding, and for elective eradication of varices after the initial episode of hemorrhage. EVL technique for the esophageal varices is similar to endoscopic treatment of rectal hemorrhoids. The ligation is accomplished by placement of an elastic band on the varix, which strangulates a blood vessel, resulting in vessel thrombosis. The thrombosed varix undergoes necrosis and sloughs off, to be replaced by fibrous tissue in the process of mucosal healing.
Another DPPIV inhibitor, CP-867534-01, 5 (IC50 100 nM), showed good efficacy in ob ob and Balb c mice at 10 mg kg po and inhibited DPPIV activity in fed mice resulting in increased GLP-1 levels. Interestingly, CP-867534-01,5 was associated with bloody stools in dogs after 5 mg kg i.v. dosing. Although further investigation showed the effect is species-specific and not linked to DPPIV inhibition, 5 is no longer under development 19 .
Numerous randomized trials have suggested that the incidence of stress-related GI hemorrhage is lower in those receiving medical prophylaxis with antacids, intravenous H2 receptor antagonists, or sucralfate. Most include small numbers of patients, however, and many do not include no treatment or placebo groups. Furthermore, definitions of bleeding vary widely and include occult blood in nasogastric aspirates, overt GI bleeding of all types (hematemesis, bloody gastric aspirate, hematochezia), and clinically important bleeding, often defined as overt bleeding accompanied by evidence of hemodynamic instability or a significant decrease in hemoglobin requiring transfusion. No individual study has definitively established whether prophylaxis significantly decreases clinically important bleeding, nor has one modality been shown to be clearly superior to another. Furthermore, although patients developing GI bleeding in the ICU setting have a high mortality rate, no study has determined that...
Blood spotting after anal sex and or blood spotting on the toilet paper is a common compliant in the GU clinic, and is usually the symptom of minor conditions such as haemorrhoids, anal fissures, genital trauma, or genital warts -which can be associated with pruritus (Rhodes & Hsin, 1995). Blood separate from faeces is most commonly due to haemorrhoids, but may also be due to a variety of other causes, including rectal carcinoma and proctitis, which can be associated with a mucous discharge. Is the blood fresh - bright red, or old - darkish brown this can help indicate where the bleeding is from. When does the patient notice it A proctoscopy should be carried out, but it may be that further investigation may be needed outside of our realm of care, in which case refer appropriately. Blood mixed with faeces may be due to Crohn's disease, or inflammatory bowel disease, carcinoma or vascular abnormalities, and the patient should be referred for careful investigation via a...
Small carcinomas, anorectal varices, and rectal prolapse can be easily confused with hemorrhoids. Any unusual-appearing hemorrhoid warrants referral to an experienced surgeon to confirm the diagnosis. Although this may require only simple reinspection, endoscopy, biopsy, or examination under anesthesia may be necessary. Referral to a gastroenterologist or a surgeon is appropriate if pruritis, prolapse, or bleeding symptoms persist despite conservative therapy. Most grade 3 (prolapsing requiring manual reduction) and all grade 4 (irreducible) hemorrhoids require referral for an interventional or surgical approach. Severe pain associated with an acutely thrombosed external hemorrhoid may demand immediate surgical evacuation of clot. Any signs or symptoms of abscess or fistula associated with hemorrhoidal disease should prompt a surgical evaluation. Particular diligence is necessary in evaluating and treating hemorrhoidal disease in immunosuppressed patients and in those with...
Acute radiation injury produces symptoms of tenesmus, diarrhea, mucus production, and spotty bleeding. These nearly always resolve within days or weeks, and specific therapy is usually not necessary. Massive rectal bleeding, typically caused by a friable ulcer, may rarely occur as an early complication of radiation mucosal damage (61). Chronic radiation proctopathy, although less frequent, is a more difficult problem. Complaints may include tenesmus, low-volume diarrhea, rectal pain, ulceration, and (rarely) even fistulous tracts into adjacent organs (62). Hemorrhage is the most common feature of chronic radiation injury (62). Bleeding, characteristic of a distal rectal source, is described as coloring the toilet tissue, coating the stool, or dripping into the toilet bowl. It ranges from an occasional mild spotting of little clinical concern to reddening of the toilet water with clots after every bowel movement, causing iron deficiency anemia or transfusion dependence (63).
Upper abdominal pain or distress of insidious onset, often localized to the midepigastrium is the most frequent symptom (4). Expansion of the pseudocyst may likewise result in duodenal or biliary obstruction, vascular occlusion, or fistula formation into adjacent structures such as the viscera, pleura, or pericardium (6). Leakage from the pseudocyst or pancreatic duct with concomitant fistula formation can result in pancreatic ascites or a pleural effusion. Pseudocyst rupture occurs in less than 3 of patients (7), and may be clinically asymptomatic. However, rupture into the peritoneum can present as an acute abdominal event necessitating emergent surgery, which is often fatal (8). Erosion into the gastrointestinal tract may result in hematemesis, melena, or massive hematochezia (9). Massive bleeding into the gastrointestinal tract occurs in approx 5-10 of patients (10,11), and occurs as a result of pseudocyst erosion into a major pancreatic or peripancreatic vessel, leading to free...
The focus initially should be to establish the quantity and color of blood and elicit any symptoms of hemodynamic instability that would require immediate intervention. The medical history can then evaluate previous GI bleeding episodes and diagnoses associated with recurrent episodes of bleeding. These include diverticulosis, angiodysplasias, hemorrhoids, ulcers, varices, or inflammatory bowel disease. Other important history findings include comorbid diseases, coagulopathies, liver disease, nonsteroidal antiinflammatory drug use (NSAID), and radiation therapy affecting the abdomen or rectum (prostate). NSAID use is a very important risk factor, now recognized as the cause of not only upper GI bleeding, but also increased lower GI bleeding.
These examinations may be a useful early test in patients with presumed lower GI bleeding to exclude obvious distal lesions such as bleeding hemorrhoids, anal fissure, rectal ulcer, proctitis, or rectal cancer. These procedure may not reveal the source if done while bleeding is still brisk, because it is often impossible to tell whether blood is coming from above the scope or from a lesion at or below the examined level. Sigmoidoscopy is usually reserved primarily for younger patients (
Mechanical problems that cause an interruption in the blood supply to the intestine lead to mucosal injury and eventual bleeding from the area of ischemic damage, as discussed above in the Ischemic Colitis section. Volvulus or intussusception both cause a segmental strangulation of the small bowel that can be associated with the passage of currant jelly stools, a combination of mucus and blood. They both may present with crampy abdominal pain initially, followed by bloody stools. These diagnoses are often suggested by the findings on plain abdominal X-rays or barium studies. Except in the case of sigmoid or cecal volvulus that can be decompressed by colonoscopy, emergent surgery is needed for intestinal volvulus because of the risk of perforation.
Hemorrhoidal Bleeding Anorectal sources, usually enlarged hemorrhoidal veins, can be identified easily during colonoscopy and account for less than 10 of acute lower intestinal bleeding (57). Treatment by injection with epinephrine or a sclerosant, infrared coagulation, and band ligation of internal hemorrhoids is effective (58), although more proximal etiologies should also be carefully excluded.
Pruritus ani, perianal warts, perianal abscess, perianal haematoma, prolapsing haemorrhoids, thrombosed haemorrhoids, skin tags, anal discharge, anal fistulas, anal fissures, anal cancer, rectocele, rectal prolapse, threadworms, faecal soiling of the perineum are all possible findings (Rhodes & Hsin, 1995 Barkauskas, 2002). The anal tone can be observed at rest and on voluntary contraction. The patient should be asked to strain down as if opening bowels to show perianal descent, prolapsing haemorrhoids or protruding lesions such as tumours or rectal prolapse (Barkauskas, 2002).
Gamboa-Salcedo et al. (2006) assessed the outpatient management of 260 children with diarrhea in Mexico City. They found that 64 of patients that were seen by a physician received antibiotic treatment. The main reasons for prescribing an antibiotic were the following 5 bowel movements (27.3 ), 2 vomits (26.7 ), and illness duration (23 ). Fever and bloody stools were recognized as reasons for prescribing an antibiotic only in 7.3 and 3.6 of cases, respectively. In Pakistan, Nizami et al. (1996) observed the antibiotic prescribing practices of general physicians and pediatricians for childhood diarrhea. Sixty percent of GPs and 50 of pediatricians prescribed antibacter-ials cotrimoxazole was the most frequently prescribed antibacterial by both types of practitioners. These findings support the use of physician- and community-oriented educational interventions in order to achieve a more rational use of antibiotics.
The classic triad of symptoms includes abdominal distention, bilious vomiting, and bloody stools. Most patients, however, present with less specific symptoms. The onset of acute NEC has a bimodal pattern. It generally occurs in the first week of life (in newborns more than 34 weeks of gestational age), but in some it may be delayed to the second to the fourth week (mostly in those less than 30 weeks of gestational age). The affected term neonate is usually systemically ill with other predisposing maternal and individual conditions (see above). Premature babies are at risk for several weeks after birth, with the age of onset inversely related to their gestational age. The typical infant with NEC is premature and recovering from some form of stress, but is well enough to begin gavage feedings. Initial symptoms may include progressive subtle signs of feeding intolerance, and subtle systemic signs. In advanced disease, a fulminant systemic collapse and consumption coagulopathy occurs....
Solitary rectal ulcer syndrome is a chronic benign disorder related to abnormal defecation. It is probably caused by mucosal trauma from straining, but direct digital trauma in an attempt to aid evacuation and possibly a primary neuromuscular pathology may also play a small role. Solitary rectal ulcer is stongly associated with internal intussusception of the rectal mucosa or overt rectal prolapse (90,91). Prolapsing of rectal mucosa combined with high transmural pressures during defecation may be responsible for the mucosal trauma that causes ulceration (92). Characteristic histologic findings are extension of muscularis mucosa between crypts, muscularis propria disorganization, fibrous obliteration of lamina propria, and regenerative changes in crypt epithelium (93).
A patient with portal hypertensive bleeding from varices or mucosal congestion may present with hematemesis, melena, hematochezia, or any combination of the above. In the evaluation of a patient with GI bleeding, the following historical features should increase the physician's concern that portal hypertension may be present. A history of excessive alcohol intake or chronic viral hepatitis should be noted. Additionally, any history of chronic parenchymal liver disease or cholangiopathy such as autoimmune hepatitis, hemochromatosis, Wilson's disease, a1-antitrypsin deficiency, primary sclerosing cholangitis (PSC), or PBC raises concern that symptoms of bleeding may be caused by portal hypertension. A history of hypercoagulability or intraabdominal malignancy should prompt concern for vascular thrombosis or malignant infiltration with concomitant portal hypertension. Extrahepatic processes such as cardiac failure can lead through congestion to cardiac cirrhosis. Chronic pancreatitis...
When preparing the patient for a proctoscope examination, thorough explanation of the examination is needed during the consultation and consent must be obtained. The patient should be placed in the left lateral position, with their knees drawn in to the chest. The proctoscope should be well lubricated with a water-based gel and passed gently into the anus. The patient will feel pressure as the proctoscope comes into contact with the external sphincter ask the patient to relax and gently pass the proctoscope into the rectum. If there is resistance remove the instrument and allay the patient's fear. Note on inspection Faecal matter (if present), odour and consistency. Rectal discharge, threadworms, inflammation, mucosal ulceration, bleeding, haemorrhoids and any other abnormalities. Slowly withdrawing the proctoscope observe the haemorrhoidal cushions, the dentate line, and the anal epithelium.
For patients considered a poor risk for abdominal surgery, a perineal approach to repair of rectal prolapse is indicated. Perineal rectosigmoidectomy, originally proposed by Altmeier (17) and modified by Prasad (18) is the procedure most often utilized. It is performed with the patient again in lithotomy position and either regional or general anesthesia can be utilized. Because it avoids laparotomy, hospital stay and postoperative
Anorectal afflictions have troubled the human race for millennia, but remain somewhat of an enigma to a majority of both physicians and laypersons. First described formally in the Chester Beatty Medical Papyrus, written about 1250 bc and further defined by Hippocrates around 400 bc (19), the treatment of these disorders has progressively improved with the wider dissemination of knowledge regarding them and the development of an increasing number of physicians trained specifically in their care (two of the most common anorectal conditions seen in the clinician's office are anal fissure and hemorrhoids). They are not uncommonly confused with one another as both can present with rectal bleeding. Their proper differentiation is crucial to the selection of the appropriate treatment modalities.
Despite the high prevalence of hemorrhoids, the exact etiology is still unclear. Detailed anatomic studies have demonstrated that sliding downward of the anal cushions is a likely etiology (7). The anal cushions are composed of blood vessels, smooth muscle, and elastic connective tissue within the submucosa. Hemorrhoids are associated with straining and irregular bowel habits. Although it is commonly believed that constipation is an important risk factor for the development of hemorrhoids, other studies have suggested that diarrheal disorders are more frequently associated with hemorrhoidal disease (8). Straining maneuvers related to diarrheal disease or constipation may cause engorgement of the anal cushions during defecation and tend to push the anal cushions out of the Classification of Internal Hemorrhoids canal (5). Repeated stretching of the smooth muscle causes disruption and prolapse (7). Other theories suggest that hemorrhoids share similarities with arteriovenous...
After initial evaluation and volume resuscitation, further management depends on the results of a nasogastric tube aspirate. About 1000 mL or more of blood is required to cause hematochezia from an upper source, and hemodynamic compromise is typically an accompanying feature. If copious nonbloody bile is seen on nasogastric aspiration, the physician should proceed directly to a colonoscopy. In all other cases, however, the colonoscopy should be preceded by an esophagoduodenoscopy (EGD), because in as many as 10-15 of patients with suspected lower GI bleeding, the source is the upper GI tract. The diagnostic yield from colonoscopy ranges from 60 to 80 . Timing of colonoscopy with or without upper endoscopy has not been systematically studied, but it should be performed as soon as possible in patients with continuous hematochezia. Patients who have stopped bleeding can undergo examination on a semielective basis.
Ischemic colitis causes about 3-9 of cases of acute lower intestinal bleeding (36,39). The usual presentation is sudden onset of lower abdominal pain followed by moderate hematochezia, but occasionally bleeding is more severe. The greater frequency of ischemic colitis in the elderly suggests a relationship to degenerative changes in the vascula-ture. However, angiography plays little role in the evaluation because it rarely demonstrates significant abnormalities, and some atheromatous changes that are almost universal in the mesenteric circulation of the elderly are of uncertain pathogenic significance in ischemic colitis. Ischemic colitis is much more common, but it should be differentiated from the rarer but potentially more lethal acute mesenteric ischemia. Patients with acute mesenteric ischemia appear sicker, have more severe
Stools received for routine culture in most clinical laboratories in the United States should be examined for the presence of Campylobacter, Salmonella, and Shigella spp. under all circumstances. Detection of Aeromonas and Plesiomonas spp. should be incorporated into routine stool culture procedures. The cost of doing a stool examination on every patient for all potential enteric pathogens is prohibitive. The decision as to what other bacteria are routinely cultured should take into account the incidence of GI tract infections caused by particular etiologic agents in the area served by the laboratory. For example, if the incidence of Yersinia enterocolitis gastroenteritis is high enough in the area served by the laboratory, then this agent should also be sought routinely. Similarly, because of the increasing prevalence of disease caused by Vibrio spp. in individuals living in high-risk areas of the United States (seacoast), laboratories in these...
Anorectal varices are a result of portal hypertension and represent enlarged portal-systemic collaterals. They develop as a result of hepatofugal portal venous flow through the inferior mesenteric vein to the superior hemorrhoidal veins. An important distinction is that anorectal varices are not related to hemorrhoids, which are vascular cushions of ectatic venular-arteriolar connections of the hemorrhoidal plexus, and have no direct connection to the portal system. The prevalence of anorectal varices varies somewhat, ranging from 43 to 78 in patients with cirrhosis (103-105). Anorectal varices are usually discrete, serpentine, submucosal veins. In contrast to external hemorrhoids, varices are compressible and refill rapidly. They extend from the squamous portion of the anal canal and cross the dentate line into the rectum proper. Distinguishing hemorrhoids from varices is important because of the risk of severe, recurrent hemorrhage with varices and the different approach to therapy.
Drug toxicity may take several forms in the GI tract, including Stevens-Johnsons syndrome, a desquamating condition that may occur secondary to therapy with many drugs, most commonly antibiotics such as penicillins or sulfa-based products. Diffuse GI ulceration and sloughing may occur, leading to melena, hematochezia, or hematemesis. Extensive necrosis with lymphocytic infiltration and apoptosis occurs lesions are histologically similar to those seen in chronic GvHD. Supportive care and withdrawal of offending agents is the mainstay of management. Use of immunosuppressive agents is controversial for early disease, and these are generally not helpful for advanced disease (106).
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