One study of 180 HIV-positive patients with anorectal symptoms showed that 57 percent complained of pain, mainly due to anal ulceration.58 One-third had anal ulcers, mostly idiopathic but some secondary to HSV or CMV infection. Other causes of pain included fistulae, abscesses, hemorrhoids, and malignancy (Kaposi's sarcoma, NHL, and squamous cell carcinoma). In addition, 43 percent had anal warts.
Summary Flexible sigmoidoscopy remains a common tool used for the periodic screening of colorectal cancer. This article reminds family care physicians of the recommendations for the use of flexible sigmoidoscopy. Most organizations recommend screening at three to five year intervals beginning at age 50 for persons with average risk. Extensive training in endoscopic maneuvering, colorectal anatomy, and pathologic recognition is required. Most physicians report comfort performing the procedure unsupervised after 10 to 25 supervised sessions. The procedure itself involves the insertion of the sigmoidoscope through the anus and distal rectum and advancement of the scope tip to an average depth of 48 to 55 centimeters in the sigmoid colon. Once the sigmoidoscope has been appropriately advanced, the scope is slowly withdrawn, allowing for the inspection of colon mucosa during withdrawal. Polyps less than 5 millimeters in diameter should be biopsied. Polyps 5 to 10 millimeters or greater can...
Bulk-forming laxatives are useful in the management of patients with colostomy, ileostomy, haemorrhoids, anal fissure, chronic diarrhoea associated with diverticular disease, irritable bowel syndrome, and as adjuncts in ulcerative colitis (section 1.5). Adequate fluid intake must be maintained to avoid intestinal obstruction. Unprocessed wheat bran, taken with food or fruit juice, is a most effective bulk-forming preparation.
Anal and perianal pruritus, soreness, and excoriation are best treated by application of bland ointments and suppositories (section 1.7.1). These conditions occur commonly in patients suffering from haemorrhoids, fistulas, and proctitis. Cleansing with attention to any minor faecal soiling, adjustment of the diet to avoid hard stools, the use of bulk-forming materials such as bran (section 1.6.1) and a high residue diet are helpful. In proctitis these measures may supplement treatment with corticosteroids or sulfasalazine (see section 1.5). When necessary, topical preparations containing local anaesthetics (section 1.7.1) or corticosteroids (section 1.7.2) are used, provided perianal thrush has been excluded. Perianal thrush is treated with a topical antifungal preparation (section 13.10.2).
Soothing preparations containing mild astringents such as bismuth subgallate, zinc oxide, and hamamelis may give symptomatic relief in haemorrhoids. Many proprietary preparations also contain lubricants, vasoconstrictors, or mild antiseptics. Local anaesthetics are used to relieve pain associated with haemorrhoids and pruritus ani but good evidence
Corticosteroids are often combined with local anaesthetics and soothing agents in preparations for haemorrhoids. They are suitable for occasional short-term use after exclusion of infections, such as herpes simplex prolonged use can cause atrophy of the anal skin. See section 13.4 for general comments on topical corticos-teroids and section 1.7.1 for comment on local anaesthetics. Children Haemorrhoids in children are rare. Treatment is usually symptomatic and the use of a locally applied cream is appropriate for short periods however, local anaesthetics can cause stinging initially and this may aggravate the child's fear of defaecation. Dose haemorrhoids and proctitis, 1 applicatorful (4-6 mg hydrocortisone acetate, 4-6 mg pramocaine hydrochloride) by rectum 2-3 times daily and after each bowel movement (max. 4 times daily) do not use for longer than 7 days CHILD not recommended
Crude drugs containing these alkaloids have been used since early times for their marked medicinal properties, which largely depend on inhibition of the parasympathetic nervous system and stimulation of the higher nervous centers. Belladonna, probably as a consequence of the weak local anesthetic activity of atropine, has been used topically for its analgesic effect on hemorrhoids, certain skin infections, and various itching dermatoses. Application of sufficient amounts of belladonna or its alkaloids results in mydriasis. Internally, the drug causes diminution of secretions, increases the heart rate (by depression of the vagus nerve), depresses the motility of the GI tract, and acts as an antispasmodic on various smooth muscles (ureter, bladder, and biliary tract). In addition, it directly stimulates the respiratory center. The multiplicity of actions exerted by the drug is looked on with some disfavor, because the physician seeking one type of response unavoidably also obtains the...
A potent modifier of behavioral, neuronal, autonomic, and motor responses to visceral stimulation in experimental models inflammation has been commonly used to produce visceral hypersensitivity. The presence of inflammation in visceral structures frequently, but not universally, leads to reports of pain and sensitivity to mechanical and chemical stimuli. Cystitis, esophagitis, gastritis, duodenitis, ileitis, colitis, and proctitis all have evidence of mucosal inflammatory changes, as a hallmark finding. However, profound inflammatory changes of the mucosal lining, such as occurs with ulcerative colitis, may present with nonpainful, bloody stools.
Liquid paraffin, the traditional lubricant, has disadvantages (see below). Bulk laxatives (section 1.6.1) and non-ionic surfactant 'wetting' agents e.g. docusate sodium (section 1.6.2) also have softening properties. Such drugs are useful for oral administration in the management of haemorrhoids and anal fissure glycerol (section 1.6.2) is useful for rectal use.
Dibucaine is a topical amide anesthetic available in over-the-counter creams and ointments used to treat minor conditions such as sunburns and hemorrhoids. Dibucaine has been found to be highly toxic when taken orally, inducing seizures, coma, and death in several children who accidentally ingested it.99 Metabolites of dibucaine identified in the urine of rats, rabbits, and humans included hydroxyl-ated metabolites of the quinoline ring, monohydroxylated and dihydroxylated metabolites of the O-alkyl side chain (2'- and 3'-position), and the N-de-ethylated dibucaine metabolite.100
There are many variants of presentation for endome-triosis including dyspareunia, urinary urgency, increased frequency, bladder pain, back pain, rectal pain, and pain radiating to the thighs, perineum or vagina. It may produce hormonal alterations causing abnormal uterine bleeding or infertility. Hematuria and bowel or ureteral obstruction can occur from the erosion of endometrial tissue into neighboring viscera or compression of tubular structures. A pelvic exam may demonstrate multiple, focal sites
The disorders of pancreatic cancer, chronic pancreatitis, IBS, and IC have been presented as archetypal examples illustrative of most of the problems facing the clinician in the diagnosis and management of this type of pain. In the case of pancreatic cancer, we have a disorder that has definable histopathology, is accepted as pain-producing by all caregivers, and elicits intensive and aggressive treatment. Palliative surgery, high dose narcotics, and therapeutic interventions such as neurolysis are considered standards of care. This contrasts with IC and IBS, disorders for which reassurance and watchful waiting'' are considered appropriate care, with aggressive treatments reserved for the patients who complain loudest and longest. For these disorders narcotics have been viewed as controversial at best and contraindicated in many patients. Chronic pancreatitis is somewhere intermediate to these other disorders in that definable pathology is present but this pathology does not correlate...
Indications constipation, adjunct in abdominal radiological procedures Cautions see notes above do not give with liquid paraffin rectal preparations not indicated if haemorrhoids or anal fissure Contra-indications see notes above Pregnancy not known to be harmful manufacturer
Misconceptions about bowel habits have led to excessive laxative use. Abuse may lead to hypokalaemia. Thus, laxatives should generally be avoided except where straining will exacerbate a condition (such as angina) or increase the risk of rectal bleeding as in haemorrhoids. Laxatives are also of value in drug-induced constipation, for the expulsion of parasites after anthelmintic treatment, and to clear the alimentary tract before surgery and radiological procedures. Prolonged treatment of constipation is sometimes necessary.
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