 There's Relief with Lactulose
Patients don't have to just sit on the pain hemorrhoids bring
The frequency of its occurrence occasionally leads Filipinos to forget that it is a disease. Hemorrhoids may not be that uncommon that they possess a name in the vernacular (almoranas), but their debilitating effects and the availability of a definitive treatment warrant for them the attention of the sufferer.
Hemorrhoids are vascular and connective tissue cushions found either above (internal hemorrhoids) or below (external hemorrhoids) the dentate line. Normally, these tissues act as protective pillows that guard the anal canal from direct injury as the stool passes. However, with repeated, prolonged, and increased pressure on the pelvic floor--as in straining, lifting, and standing--these vascular complexes become chronically engorged and hemorrhoidal disease ensues.
External hemorrhoids are usually asymptomatic, although thrombosed external hemorrhoids are often described as extremely painful, as the overlying skin is richly subserved by nerves. Internal hemorrhoids typically bleed, but are only rarely painful: patients usually complain of rectal fullness and mucous discharge. Surgeons further subdivide internal hemorrhoids into the following: first degree, where the only symptom is bleeding; second degree, where the hemorrhoids bleed, protrude into the anal orifice during defecation, but reduce spontaneously; third degree, where hemorrhoids bleed, protrude into the anal orifice, and require manual reduction; and fourth degree, characterized by bleeding hemorrhoids that are permanently prolapsed.
MANAGEMENT STRATEGIES
Except for symptomatic thrombosed cases, initial management of hemorrhoids is nonsurgical. Sitz baths to improve hygiene and stool softeners and bulk agents to minimize constipation and straining are frequently prescribed. First- and second-degree hemorrhoids are usually responsive to such protocols. For cases resistant to conservative intervention, elastic-band ligation and injection sclerotherapy are nonoperative alternatives. Other nonoperative but less commonly used options include cryotherapy, bipolar diathermy, infrared coagulation, and direct current therapy.
Hemorrhoidectomy remains the most effective surgical treatment, particularly for prolapsing hemorrhoids. This operative procedure is also indicated for bigger third- and fourth-degree hemorrhoids, mixed hemorrhoids, and incarcerated internal hemorrhoids. Performed under general, regional, or local anesthesia, the technique involves suturing, and sub-sequently ligating the diseased vascular and connective tissue structure. Although numerous techniques all classified as hemorrhoidectomies exist, a review on evidence-based practices for hemorrhoidectomy by Cheetham and Phillips indicates "little evidence to support the use of one surgical technique over another."
LACTULOSE AND PAIN RELIEF
A significant postoperative complication of hemorrhoidectomy is severe pain. Numerous studies have proposed and investigated a number of regimens designed to reduce postoperative pain, says the same review, among them randomized controlled trials on the benefits of preoperative lactulose. A paper by London, Bramley, and Windle published by the British Medical Journal in 1987 demonstrated that lactulose given preoperatively for four days markedly decreases posthemorrhoidectomy pain.
Lactulose is a synthetic sugar that acts as a laxative. Its breakdown products in the colon effectively pull out water from the body into the bowels--softening stools and preventing fecal impaction. Among its myriad uses are the reduction of ammonia in patients with liver disease and the symptomatic relief of constipation. Other studies, currently underway, seek to determine other possible indications for the liquid.
This study on lactulose's role in posthemorrhoidectomy pain involved 42 patients randomized into a treatment group receiving lactulose (20) and a placebo group (22). Both groups were instructed to take 15mL of liquid containing either lactulose or placebo three times a day for four days prior to admission. Upon admission and until discharge, all 42 patients received lactulose three times daily.
The study evaluated pain using a verbal response and a visual analog scale. In the former, a patient has four response options: no pain, mild pain, moderate pain, or severe pain. The visual analog scale is a continuous 10-cm line with "no pain" on the left-hand side and "worst pain imaginable" on the right. Mean daily scores were reported in centimeters.
Results showed that patients who had received preoperative lactulose experienced markedly less pain on defecation for the first four days that they moved their bowels. Visual analog scores for the treatment group versus the placebo group consistently depicted a less painful postoperative course. Verbal response scores, meanwhile, told researchers that patients who received lactulose suffered less pain during the first 24 hours. Those who received preoperative lactulose used a smaller amount of pain relievers daily after defecation.
PREVENTING COMPLICATIONS
Other complications of hemorrhoidectomy include urinary retention, bleeding, and fecal impaction. Limited intraoperative intravenous-fluid administration prevents urinary retention. Attention to proper surgical technique addresses bleeding. Postoperative Sitz baths reduce the occurrence of both complications.
Preventing the recurrence of hemorrhoids is paramount but accomplishing this involves addressing the patient's bowel habits--which as any physician will agree is no small feat. Behavioral modification-increasing dietary-fiber intake, decreasing consumption of food frequently implicated as causing constipation, limiting straining time in the toilet, and introducing pro-per exercise--serves to minimize the risk for recurrence.
The enormous benefits of a better appreciation for hemorrhoids and their effects on the quality of life should be stressed. The war medicine wages on various pathologies will be fought in many fronts. And it will serve humanity best if battles that can be won actually are.
C. Russel Y. Cruz, MD
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