Mixed Hemorrhoids

Hemorrhoids are swollen and inflamed blood vessels in the anus and lower rectum. Mixed hemorrhoid is a
combination of both internal and external hemorrhoids which means that its location is inside the rectum and under
the skin around the anus.

Causes

Strenuous or extended physical activity

Heavy lifting, including working out / weightlifting
Pregnancy / labor strains
Straining during bowel movements
Sitting for long periods of time on the toilet
Frequent constipation or diarrhea
Low-fiber diets
Poor bowel habits
Extended periods of sitting
Obesity
Genetics
Aging

Hemorrhoids are more likely as you get older because the tissues that support the veins in your rectum and anus can weaken and
stretch with aging.

Pathophysiology
The veins around your anus tend to stretch under pressure and may bulge or swell. Swollen veins (hemorrhoids) can develop
from an increase in pressure in the lower rectum.

Hemorrhoids develop when the supporting tissues of the anal cushions disintegrate or deteriorate. There is
an occurrence of downward displacement of the anal cushions causing venous dilatation.

There are typically three major anal cushions, located in the right anterior, right posterior and left lateral aspect
of the anal canal, and various numbers of minor cushions lying between themThe anal cushions of patients with
hemorrhoids show significant pathological changes. These changes include abnormal venous dilatation, vascular
thrombosis, degenerative process in the collagen fibers and fibroelastic tissues, distortion and rupture of the
anal subepithelial muscle. In addition to the above findings, a severe inflammatory reaction involving the
vascular wall and surrounding connective tissue has been demonstrated in hemorrhoidal specimens, with
associated mucosal ulceration, ischemia and thrombosis.

Signs and Symptoms

Pain and discomfort around the anus
Moist, pink pads of skin protruding from the anus; sometimes they may appear purple or blue.
Bleeding from the anus
Itching or irritation in your anal region
Swelling around your anus
A lump near your anus, which may be sensitive or painful
Leakage of feces
When symptoms do occur, they include bleeding, itchiness, discomfort and pain. In some cases,
haemorrhoids can enlarge so much that they stick out of the anus. This is known as a prolapse.
Complications
 Complications of hemorrhoids are rare but include:

Anemia. Chronic blood loss from hemorrhoids may cause anemia, in which you don't have enough
healthy red blood cells to carry oxygen to your cells. This may result in fatigue and weakness.
Strangulated hemorrhoid. If blood supply to an internal hemorrhoid is cut off, the hemorrhoid may be
"strangulated," which can cause extreme pain and lead to tissue death (gangrene).

excessive bleeding
infection
faecal incontinence, where you lose voluntary control over your bowel movements this
is is rare, and can sometimes be corrected with another operation
anal fistula, which is a small channel that develops between the inside of the anus and
the surface of the skin near the anus.

Tests & Diagnosis

Examination of your anal canal and rectum for abnormalities. During a DIGITAL RECTAL EXAM, your
doctor inserts a gloved, lubricated finger into your rectum. He or she feels for anything unusual, such as
growths. The exam can give your doctor an indication of what further testing might be appropriate.
Visual inspection of your anal canal and rectum. Because internal hemorrhoids are often too soft to be
felt during a rectal examination, your doctor may also examine the lower portion of your colon and
rectum with an anoscope, proctoscope or sigmoidoscope. These are scopes that allow your doctor to
see into your anus and rectum.

Digital rectal examination, where your doctor puts on gloves and places a lubricated
finger inside the back passage to gently feel for any abnormalities. This is likely to be
uncomfortable but will probably not be painful.
Proctoscopy, where your doctor examines the inside of the rectum using a proctoscope
(a hollow tube with a tiny light at the end) to look for any swelling or other symptoms.
Again, this may be uncomfortable but will probably not be painful.

Your doctor may want to do a more extensive examination of your entire colon using colonoscopy. This
might be recommended if:
Your signs and symptoms suggest you might have another digestive system disease
You have risk factors for colorectal cancer
You're older than age 50 and haven't had a recent colonoscopy
Treatment
MINIMALLY INVASIVE PROCEDURES

If a blood clot has formed within an external hemorrhoid, your doctor can remove the clot with a simple
incision, which may provide prompt relief.

For persistent bleeding or painful hemorrhoids, your doctor may recommend another minimally invasive
procedure. These treatments can be done in your doctor's office or other outpatient setting.

Rubber band ligation. Your doctor places one or two tiny rubber bands around the base of an
internal hemorrhoid to cut off its circulation. The hemorrhoid withers and falls off within a week.
This procedure called rubber band ligation is effective for many people.
 Hemorrhoid banding can be uncomfortable and may cause bleeding, which might begin two to four
days after the procedure but is rarely severe.
Injection (sclerotherapy). In this procedure, your doctor injects a chemical solution into the
hemorrhoid tissue to shrink it. While the injection causes little or no pain, it may be less effective
than rubber band ligation.
Coagulation (infrared, laser or bipolar). Coagulation techniques use laser or infrared light or heat.
They cause small, bleeding, internal hemorrhoids to harden and shrivel.

While coagulation has few side effects, it's associated with a higher rate of hemorrhoids coming back
(recurrence) than is the rubber band treatment.

SURGICAL PROCEDURES

If other procedures haven't been successful or you have large hemorrhoids, your doctor may recommend a
surgical procedure. Surgery can be performed on an outpatient basis or you may need to stay in the hospital
overnight.

Hemorrhoid removal. During a hemorrhoidectomy, your surgeon removes excessive tissue that causes
bleeding. Various techniques may be used. The surgery may be done with a local anesthetic combined
with sedation, a spinal anesthetic or a general anesthetic.

Hemorrhoidectomy is the most effective and complete way to treat severe or recurring hemorrhoids.
Complications may include temporary difficulty emptying your bladder and urinary tract infections associated with
this problem.

Most people experience some pain after the procedure. Medications can relieve your pain. Soaking in a
warm bath also may help.

Hemorrhoid stapling. This procedure, called stapled hemorrhoidectomy or stapled hemorrhoidopexy,

blocks blood flow to hemorrhoidal tissue. Stapling generally involves less pain than hemorrhoidectomy and
allows an earlier return to regular activities.

Compared with hemorrhoidectomy, however, stapling has been associated with a greater risk of recurrence
and rectal prolapse, in which part of the rectum protrudes from the anus. Talk with your doctor about what might be
the best option for you.

Lifestyle and Home Remedies

You can often relieve the mild pain, swelling and inflammation of hemorrhoids with home treatments. Often
these are the only treatments needed.

Use topical treatments. Apply an over-the-counter hemorrhoid cream or suppository containing

hydrocortisone, or use pads containing witch hazel or a numbing agent.
Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water 10 to 15 minutes two
to three times a day. A sitz bath fits over the toilet. You can get one at most drugstores.
Keep the anal area clean. Bathe (preferably) or shower daily to cleanse the skin around your anus gently
with warm water. Soap isn't necessary and may aggravate the problem. Avoid alcohol based or perfumed
wipes. Gently dry the area with a hair dryer after bathing.
Don't use dry toilet paper. To help keep the anal area clean after a bowel movement, use moist
towelettes or wet toilet paper that doesn't contain perfume or alcohol.
Apply cold. Apply ice packs or cold compresses on your anus to relieve swelling.
 Take oral pain relievers. You can use acetaminophen (Tylenol, others), aspirin or ibuprofen (Advil, Motrin
IB, others) temporarily to help relieve your discomfort.

With these treatments, hemorrhoid symptoms often go away within a week. See your doctor if you don't get
relief in a week, or sooner if you have severe pain or bleeding.

Nursing Management
Administer local anesthetic as prescribed.
As needed, provide warm sitz baths or cold compresses to reduce local pain, swelling, and information.
Provide the patient with high fiber diet and encourage adequate fluid intake and exercise to prevent
constipation.
Monitor the patients pain level and the effectiveness of the prescribed medications.
Check for signs and symptoms of anal infection, such as increases pain and foul smelling anal drainage.
Teach the patient about hemorrhoidal development, predisposing factors, and tests.
Encourage the patient to eat high fiber diet to promote regular bowel movement.
Emphasize the need for good anal hygiene. Caution against vigorous wiping with washcloths and using
harsh soaps.
Encourage the use of medicated astringent pads and toilet paper without dyes or perfumes.