G.N. Tse, MB, BS, FRCS(C)

Practical Management of Hemorrhoids:Myths, Pitfalls, and Plain Sailing

RSU

RESUMEThis article is not meant to be a comprehensivereview of the surgical literature on treatmentof hemorrhoids but rather a practical common-sense guide to the management of the patientwho presents to a primary-care physician'soffice complaining of this disorder. The authordiscusses the probable differential diagnosis ofthe common symptoms of hemorrhoids, andsuggests a rational approach to themanagement of internal and external forms ofthis disorder. The author's opinions are basedon 16 years of clinical experience in acceptingreferrals of thousands of patients withhemorrhoid-related complaints. (Can FamPhysician 1988; 34:655-659.)

Cet article ne se veut pas une revue globale de lalitterature chirurgicale touchant le traitement deshemorroides mais plut6t un guide therapeutique pourresoudre le probleme du patient qui consulte le medecinde premiere ligne pour un tel desordre. L'auteur discute dudiagnostic differentiel probablement responsable de lasymptomatologie habituelle des hemorroides et suggereune approche rationnelle au traitement des formes interneset extemes de cette affection. L'auteur base ses opinionssur ses 16 ans d'experience clinique au cours desquelles il atraite des milliers de patients souffrant d'hemorroides.

Key words: hemorrhoids, office management, elastic bandingss ~M

Dr. Tse has trained in generalsurgery in Ottawa, and in colorectalsurgery at Temple University,Philadelphia, and St. Mark'sHospital, London, England. He nowholds the post of active attendingsurgeon at Ottawa Civic Hospital,with special interest in colorectalsurgery. He is also assistant professorof Surgery in the University ofOttawa. Requests for reprints to: Dr.G.N. Tse, 737 Parkdale Avenue,Ottawa, Ont. KlY 1J8

WHAT A PATIENT termsI

'haemorrhoids' means a greatdeal more than the pathological entityofvaricosity ofhemorrhoidal veins. Tothe lay public the term 'hemorrhoid'may encompass any condition andsymptom related to the bowels and anyproblem affecting the rear end. Suchproblems may range from itchiness,pain, swelling, protrusion, bleeding,constipation, and difficulty evacuat-ing, to large fungating masses or pro-lapse of the entire rectum. As the pa-tient often can barely see the area,practically all symptoms related to the

CAN. FAM. PHYSICIAN Vol. 34: MARCH 1988

anus, rectum, and perianal region havebeen described as 'hemorrhoids'.The role of the physician in dealing

with a patient who presents with suchcomplaints or problems is not only toprescribe appropriate treatment to re-lieve the symptoms or the pathology,but also to determine exactly what thepatient means by the terms he or sheuses in describing the complaint. Thephysician also has a responsibility tomake a differential diagnosis, and toperform examinations and investiga-tions to reach a definite diagnosis andto rule out more serious problems. Inthe case of some patients, especiallyolder persons who present to the physi-cian's office complaining of recentonset of hemorrhoidal symptoms, thephysician should always ask her/him-self why the patient has not com-plained earlier: Is a new or more se-rious problem developing thataggravates the hemorrhoidal veins? Al-though hemorrhoidal problems seemto be such a simple, common, andminor difficulty, their practical man-agement includes the following steps.The physician should:

* determine the exact meaning ofthepatient's complaints and symptoms;* formulate the possible differentialdiagnosis that can be attributed tothese symptoms;* perform examinations and orderinvestigations to make a definite diag-nosis, to rule out more serious prob-lems, and to detect the precipitating oraggravating factors of thehemorrhoids;* determine whether the symptomsmatch the findings (i.e., determine thatthe hemorrhoids found are responsiblefor the patient's symptoms).* If the physician is satisfied that thepatient's problems are, in fact, relatedto hemorrhoids, the final step is to pre-scribe or recommend appropriatetherapy, keeping in mind that the man-agement of hemorrhoids consistsmainly of treating the symptoms andnot the hemorrhoids per se.

A Patient's Conceptof Hemorrhoids

It is not uncommon for the averagepatient to attribute almost any prob-

655

SUMMARY

m

lem with the rear end and bowel move-ments to piles or hemorrhoids. 'Hem-orrhoids' is a term used verycommonly to mean one or more of anumber ofconditions including the ap-pearance of bright red blood withbowel movements, prolapse or swell-ing of the anus, itchiness, pain, dis-charge, difficulty in evacuation, analtightness, lumps, and difficulty incleaning. Sometimes the patient mayblame the hemorrhoids for unlikely yetrather serious symptoms such as ten-esmus, narrowing of stools, passingtissue and clots, and obstipation withbowel-obstruction symptoms. The firststep for the primary-care physician,therefore, is to find out from the patientwhat he or she really means by the term'hemorrhoids' and to rule out more se-rious pathology that the patient mis-takenly conceives to consist ofhemor-rhoids only.

Differential Diagnosisof Common SymptomsAttributed to HemorrhoidsRectal bleedingWhile internal hemorrhoids are

probably still the most common causeofbright red rectal bleeding, an equallycommon pathology of that area unre-cognized by most patients is the analfissure, which is almost always associ-ated with pain on defecation, andwhich requires entirely different man-agement. Neoplasms, benign polyps,and carcinomas may present with thesame symptoms as bleeding hemor-rhoids and can sometimes aggravatepreviously asymptomatic hemor-rhoidal veins. Occasionally, distalproctitis can produce blood simulatingthat typical ofblood produced by inter-nal hemorrhoids. Dark clots or bloodymucous mixed with stools should alertthe physician to other possibilities andto sources of bleeding above the analcanal. Hemorrhoidal bleeding does notcome directly from the venous plexus,but rather from arterioles and capill-aries on the surface of the mucosa.Hemorrhoidal blood should thereforebe bright red.

PainAs there are no pain-sensing nerve

endings in rectal mucosa above thepectinate line, internal hemorrhoids donot, of themselves, cause pain. Whenpain is a prominent symptom, the

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physician should rather suspect fis-sures, thrombosed external hemor-rhoids, or abscesses. Internal hemor-rhoids can be painful if they becomestrangulated or thrombotic, as themass distension causes anal sphincterspasm.

ItchinessItchiness is often equated by patients

with the presence ofhemorrhoids, butin fact, the most frequent cause ofitchiness is scratching, for itchiness isthe result of a skin condition ratherthan a disorder ofthe anal canal. Treat-ment of hemorrhoids often fails to re-lieve the itchiness until the viciousitch-scratch cycle has been broken.Very often, common proprietary oint-ments and suppositories for hemor-rhoids may further sensitize and irri-tate the surrounding skin, causingmore itchiness than ever. Prolongeduse of strong steroids causes skin atro-phy and even more itchiness. The heal-ing and scarring process that follows anill-advised hemorrhoidectomy mayproduce more itchiness than existedbefore the surgery.

Prolapse, protrusion, and lumpsEven the most highly educated pa-

tient would have difficulty telling aprolapsing polyp, a pedunculated wart,a full-thickness rectal prolapse, or abunch of anal skin tags from genuineprolapsing hemorrhoids. As the patientcannot see the disorder, it is the role ofthe primary-care physician to deter-mine what is actually prolapsing.

DischargeWhile large prolapsing internal hem-

orrhoids can increase mucous secre-tion and seepage of fecal-stained fluid,the physician should be alert to thepossibility of fistulae, inflammatorybowel disease, and the "wet" forms ofdermatitis of the perianal skin.

Difficulty in evacuatingContrary to most patients' belief,

large bulging and prolapsing hemor-rhoids will not "block" the anus. Thephysician should look out for causes ofanal stenosis, the most common ofwhich are the chronic anal fissure andprevious surgery or injury to the area.A less common but serious possibilityis neoplasm of the lower rectum andsigmoid colon.

Investigations and Makinga Definite DiagnosisIn clinical practice, investigations

and the establishment ofa definite di-agnosis ofhemorrhoids are just as im-portant as is their treatment. In my 16years ofpractice, I have found that onlya few more than half of the patientsreferred to me for "hemorrhoids" actu-ally have this disorder. As hemor-rhoids are a very common ailment andseemingly such a minor one, it is easyto fall into the trap of accepting thepatients' diagnosis and casually pre-

scribing some hemorrhoidal ointment,thus missing or delaying the diagnosisofa more serious condition.A correct diagnosis is also essential

to managing hemorrhoid,s appropri-ately. Besides taking a careful historyand considering the differential diag-nosis ofthe more common symptoms,the physician should also establishfrom the history whether there are

other symptoms suggestive ofmore se-rious pathologies, such as malignanciesor other causes of a disturbed bowelfunction.The importance of visual and man-

ual examination of the anus and rec-tum as part of a complete physical ex-amination cannot be overemphasized.The physician should inspect the pa-tient's anus while separating the but-tocks manually. Ifthis is not done, analfissures can remain concealed betweenfolds of the perianal skin. Asking thepatient to strain or "push down as inbowel movement" will reveal any ac-tual lump, swelling, or prolapse.Whether this is a polyp, rectal mucosa,or a full-thickness prolapse will be-come quite evident. The physicianshould also be able at this point to dis-tinguish between internal and externalhemorrhoids by identifying the pecti-nate line. Digital examination shouldbe systematic and thorough, andshould involve careful palpation ofthecomplete circumference of the lowerrectum and the superior end at the tipofthe finger. This part ofthe examina-tion is not meant to detect hemor-rhoids but to rule out more serious pa-thologies such as tumours situatedimmediately above the hemorrhoids.

Inspection is not complete without adirect look at the wall ofthe anal canalby means ofa thin-walled anoscope. Inpatients with rectal bleeding, the in-spection should not stop with the find-ing ofhemorrhoids, which may indeedbe one source of bleeding but not the

CAN. FAM. PHYSICIAN Vol. 34: MARCH 1988

sole source. A rigid sigmoidoscopywithout bowel preparation adds only afew minutes to the length of the officevisit, yet it may yield findings justbeyond the reach ofthe physician's fin-ger and the anoscope. Sampling thestool from an area above the hemor-rhoids, at the tip of the advancing sig-moidoscope, before any disturbance tothe mucosa, and testing the sample foroccult blood will eliminate the confu-sion of finding positive results fromblood from hemorrhoids or fissures. Ifthis sample contains blood, a furthersearch for the source should be madeby an air-contrast barium enema orcolonoscopy. These procedures areparticularly important in the older agegroup. Though a patient may have hadhemorrhoids for a long time, his or hermore recent concern about them couldbe a hint that some other, more seriouscondition may be aggravating the hem-orrhoids. A pelvic tumour, for exam-ple, by increasing abdominal pressureor causing straining at stool mayprovoke relatively asymptomatic hem-orrhoids into becoming symptomatic.Another easy pitfall for the unwary

physician is to make a diagnosis ofiron-deficiency anemia. Minor spot-ting of blood with defecation seldomcauses significant iron-deficiency ane-mia, and higher sources such as car-cinoma of the cecum should be sus-pected. On the other hand, it is quitepossible for hemoglobin to drop sig-nificantly from daily squirting anddripping of blood with every bowelmovement. Sometimes only treatmentof the responsible internal hemor-rhoids will eliminate the iron defi-ciency they are causing.When the primary-care physician is

satisfied that hemorrhoids are a prob-lem, and that they are not maskingsome other condition, the next impor-tant step is to distinguish between in-ternal and external hemorrhoids. Laypersons tend not to make this distinc-tion. The reason for trying to dis-tinguish the two types of hemorrhoidslies in the vast difference in the symp-toms they cause and in their appropri-ate treatment.

External hemorrhoids are vari-cosities of the external hemorrhoidalplexus below the pectinate line; theyare covered by fairly tough skin andprovided with numerous somatic sen-sory nerve endings. They are more sub-ject to acute thrombosis than are inter-nal hemorrhoids, and pain is a frequent

symptom. Recurrent thrombosis andinflammation may result in relativelypainless, soft, skin tags which couldcause hemorrhoidal symptoms bytrapping moisture and dirt, making thearea extremely difficult to clean.

Internal hemorrhoids, by contrast,are varicosities above the pectinateline, covered by much thinner and laxpink mucosa; they are painless, sincethey lack pain-sensing nerve endings.Blood from internal hemorrhoids isusually arterial and thus bright red incolour. The presence of pain shouldraise suspicions about the presence offissures, thromboses, or abscesses.

The Rational Managementof HemorrhoidsOnce the diagnosis is established

and other causes are ruled out, the ac-tual treatment ofhemorrhoids is basedon the symptoms to a greater extentthan on the findings. As hemorrhoidsseldom pose any immediate threat tolife, the principle of their treatment isto relieve symptoms without produc-ing any adverse side-effects or mor-bidity which may be worse than thesymptoms. The mere presence ofhem-orrhoids without significant symp-toms, no matterhow horrible they lookto the physician, is no reason to pre-scribe any treatment. The physicianshould always keep in mind the"golden rule" that no treatment shouldproduce more side-effects than bene-fits. This rule applies particularly to thetreatment of elderly patients with con-current and more serious problemsthat increase the risk of any interven-tion relating to their hemorrhoids.The management of hemorrhoids

can be divided into the management ofexternal hemorrhoids only, internalhemorrhoids only, and a combinationof the two types. The correct principleoftreatment is to choose the treatmentthat corresponds best to the symptomsand diagnosis. Another easy pitfall, forinstance, is to prescribe an anestheticointment for a painless, bleeding, inter-nal hemorrhoid and an equal disasterto try to manage an external haemor-rhoid by means of elastic ligation.

Managing external hemorrhoidsThe main indication for treatment of

external hemorrhoids is acute throm-bosis. This event may occur spon-taneously, for although strenuous exer-cise often precedes an acute external

hemorrhoidal thrombosis, many otheroften-cited factors, such as hot or coldseats, constipation, and diarrhea, areactually related more through myththan through fact.An acute thrombosis typically oc-

curs very suddenly, and the lesion isvery easy to recognize, as the clottedvarix distends and stretches skin, thusshowing the typical bluish-purple,globular, irreducible, tender lump atthe edge ofthe anus. Ifthis lump is leftalone, the pain often subsides in five toseven days, and the swelling resolves intwo to four weeks.The successful treatment ofan acute

hemorrhoidal thrombosis can be amost gratifying experience for the pa-tient and the physician. Their mutualsatisfaction with the treatment caneasily be attained in the office by excis-ion (rather than incision and evacua-tion), under local anesthesia, ofthe en-tire thrombosed varix, within the firsttwo days of the onset of symptoms.The physician who undertakes this

procedure should inject a mixture of1% Xylocaine and 0.5% Marcaine withepinephrine around the base of theswelling up to the anal verge. Using apair of blunt-tipped scissors, he or sheshould then excise an eliptical piece ofthe overstretched skin, together withthe entire underlying varix, includingthe vein wall. The upper end of thevarix, at the anal verge, can simply bedivided without ligature, as the veinhas already clotted. The resulting skindefect is not sutured but left open sothat there is free drainage of the fluidcausing the edema. With relaxation ofthe traction on this area, the woundwill become a very tiny split in theperianal skin. Sitz baths following thesurgery will keep the area clean. Heal-ing is usually uneventful, for infectionof the open draining wound is ex-tremely rare. Relief of pain is almostimmediate following the procedure,and recurrence over the same area ispractically impossible, as the offendingvarix has been removed.One easy error the physician may

make is to attempt evacuation ofa five-or six-day old thrombosed externalhemorrhoid when a great deal of fluidis already settling in the overlappingskin and the pain is already starting tosubside. Rather than bluish, the swell-ing is whitish and transluscent. Excis-ion or evacuation at this stage is tech-nically difficult, messy, and bloody, asthere is new vasculature, and partial

CAN. FAM. PHYSICIAN Vol. 34: MARCH 1988 657

organization of the thrombosis. Theprocedure might also increase the pa-tient's pain.The same precautions should be ob-

served when a patient presents withmultiple, edematous, thrombosed, ex-ternal hemorrhoids completely sur-rounding the anus, as adequate excis-ion of these hemorrhoids might leavethe area without skin coverage. At thislate stage, multiple edematous externalhemorrhoids are best treated symp-tomatically with hemorrhoidal oint-ments and sitz baths, and allowed totake their natural course, becomingsoft skin tags which seldom warrantany treatment.A single soft skin tag is seldom the

cause of any symptoms and shouldusually be left alone. However, a pos-terior or anterior midline skin tag maybe the sentinel pile of a chronic analfissure. In this eventuality, the physi-cian should treat the fissure rather thanthe external hemorrhoid.The physician should also be cau-

tious in recommending excision ofmultiple skin tags unless there is defi-nite evidence that these tags are trap-ping moisture and dirt, and aggravat-ing pruritus ani. These skin tags have arich supply ofpain-sensing nerve end-ings, and any excision carries a smallprice ofsome pain immediately follow-ing the excision. Patients who demandthat their multiple, painless, non-bleeding, skin tags be excised should bewarned about this usual aftermath ofsurgery.

Management of internal hemorrhoidsThe choice of treatment of totally

internal hemorrhoids depends onwhich symptom(s) is/are most promi-nent and bothersome to the patient.The principle in adopting a treatmentis that the most appropriate therapy isthe one that will relieve the patient'schief complaints rather than one thatwill merely eliminate a condition thatlooks abnormal to the physician.There are many different modalities

of treatment of hemorrhoids that aresuitable for relieving the differentsymptoms or combinations of symp-toms of this disorder. The most com-mon symptom complex of totally in-ternal hemorrhoids is rectal bleedingand prolapse without complications orthe concurrent presence of externalhemorrhoids or fissures. For bleedingand/or prolapsing internal hemor-rhoids the "gold standard" developed

over the last 10to 20 years is the elastic-band ligature that can be applied in thephysician's office.The application of a tight, small,

elastic band on the pedicle ofan inter-nal hemorrhoidal mass above the pec-tinate line immediately stops anybleeding from the surface ofthe ligatedmass. The redundant ligated tissuethen sloughs off, leaving a small ulcerthat heals by fibrosis. This process, inturn, holds down the lax mucosa, thuspreventing further prolapse. The pro-cedure can be done on an out-patientbasis without any anesthetic, as themucosa above the pectinate line has nopain-sensing nerve endings. Most pa-tients, however, experience a sensationof tightness, tenesmus, or distensionfor two to three days. Less than 3% ofpatients treated this way have any sig-nificant pain. Usually only one internalhemorrhoidal mass can be ligated atone time, and an interval ofabout threeweeks is usual between repetitions ofthis procedure. Multiple simultaneousligations may not only cause significantdiscomfort but also increases the like-lihood of circumferential coalition ofthe resultant ulcers that would causemucosal stenosis. Although tens ofthousands of these procedures havebeen carried out successfully in thephysician's office, there have been rareoccurrences of massive secondarybleeding, severe pain, and urine reten-tion, and one death from septecemiaresulting from an unrecognizedmucosal abscess has been reported.These rare complications are relativelyeasy to correct or avoid as long as thetreating physician is aware ofsuch pos-sibilities and able to recognize themearly. In the long run this simple officeprocedure reduces the necessity andcost of hospital admission.

Other treatments ofinternal hemor-rhoids include sclerosing injections,cryosurgery, anal dilation, and fullhemorrhoidectomy. Sclerosing injec-tion uses almost the same principle asdoes elastic banding. The sclerosingagent is injected in the submucosal in-tervenal space above the pectinate line,causing fibrosis and fixation of the laxmucosa and reducing the vascularity.In this case, however, the redundantmucosa is not eliminated, and suc-cessful sclerosis is not always achieved.The control of bleeding is often not ascomplete as it is in elastic bandings,and recurrent symptoms occur earlierand more frequently.

Cryosurgery freezes and destroys thehemorrhoidal tissue, causing fibrosisand fixation of the lax mucosa. Thedisadvantages of this method are therequirement for special and expensiveequipment, the excessive dischargethat patients experience after thawing,and the rather prolonged healing timeofapproximately five to six weeks thatis involved. These problems havemarkedly reduced the popularity ofthis once-fashionable treatmentmodality. The same disadvantages canbe cited for the more recent use ofinfra-red treatment ofinternal hemorrhoids.Forceful dilation ofthe anal canal is anempirical treatment that was claimedto be effective in reducing symptomswithout actually eliminating the hem-orrhoids. It has resulted, however, in avery significant incidence oftemporaryand permanent incontinence.

Managing a combinationof internal and external hemorrhoidsThe principle of treating a combina-

tion of internal and external hemor-rhoids again accords with relieving thesymptoms. Ifthe symptoms are mostlyrelated to internal hemorrhoids, thehemorrhoids can be ligated with elasticbandings and the external hemor-rhoids left untreated. If, however, thesymptoms are more closely related tothe external hemorrhoids, the appro-priate treatment may range from theuse of hemorrhoidal ointment and re-liance on other conservative measuressuch as sitz baths and stool softeners tofull surgical hemorrhoidectomy.The milder forms of therapy are

often the first line that can be offered byprimary-care physicians. Indicationsfor these forms oftreatment are limitedto the existence of mildly sore andedematous "inflamed" external hem-orrhoids free from overt thrombosis,with obvious prolapse and significantbleeding. The aim of these forms oftreatment is the reduction of edemaand pain. Most of the currently avail-able hemorrhoidal ointments containan astringent which draws edematousfluid from the area, thus shrinking theswollen hemorrhoid, as well as a localanesthetic or soothing agent. Oint-ments usually work much better thansuppositories, as the latter remain inthe rectal ampulla, where the medica-tion is not needed, while the anal canaland perineal skin are receiving no ex-posure to the ingredients. Sitz baths

CAN. FAM. PHYSICIAN Vol. 34: MARCH 1988658

have a soothing effect similar to that ofointment, and adding salt to the bathsmakes them even more effective indrawing fluid from an edematous hem-orrhoid. Epsom salts, however, may"overtenderize" or soften the skin. Thephysician should exercise caution inthe use of any ointments containingstrong steroids, which may cause atro-phy of the skin and more itchiness. Infact, the anti-edema effect ofsteroids isoften no stronger than that of thebismuth and zinc components ofmostofthe less expensive ointments.

Surgical hemorrhoidectomy is sel-dom required for the treatment ofmostof the patients who complain of hem-orrhoidal symptoms. Elastic bandingof internal hemorrhoids and excisionofacutely thrombosed external hemor-rhoids will effectively cure the symp-toms ofmost patients. Surgical hemor-rhoidectomy is therefore reserved forthose patients with symptomatic com-bination of internal and external hem-orrhoids that are strangulated, ulce-rated, recurrent or show evidence ofmultiple thrombosis and associatedfissures. Even in the rare instancewhere hemorrhoidectomy is required,the cost is reduced and the proceduremuch simplified by the more generaluse of short-stay surgery and spinalanesthesia.

Management ofhemorrhoidsin pregnancyHemorrhoidal symptoms are com-

mon during pregnancy and post par-tum, and may pose a challenge to thephysician. Often, both the internal andexternal hemorrhoidal plexus are con-gested. Increasing pressure of thegravid uterus and associated constipa-tion make the prolapse, edema, andfissuring worse. Unfortunately, ifthrombosis occurs, it usually involvesmore than a single site, making excis-ion under local anesthesia infeasible.The only reasonable treatment duringpregnancy, therefore, comprises theuse of sitz baths and hemorrhoidalointment, and advice to elevate the pel-vis in order to reduce pressure on thearea and provide better venous drain-age. Ifthe patient has had similar prob-lems in previous pregnancies, the phys-ician should seriously consider postpartum hemorrhoidectomy, as afterdelivery the reduction of edema, thehealing process, and the pain thresholdare more advantageous for healingthan at any other time.

Management ofstrangulatedhemorrhoidsMassive strangulated internal and

external hemorrhoids in patients pre-senting with large, solid, painful, black,irreducible masses that cover the analopening is a rare but very disabling andpainful condition. This is one of thefew instances when a minor ailmentdoes require emergency surgery. Theincidence of portal pyemia after emer-gency hemorrhoidectomy has beenoverestimated, however. When thesurgery is performed properly and withcaution, the good results far outweighthe very minimal risk.

Management ofconcurrenthemorrhoids andfissuresAbout half the patients referred to

me for treatment ofhemorrhoids haveanal fissures, though some have hem-orrhoids as well. In the latter cases, thesymptoms that cause the patient mostdiscomfort are painful defecation andminor bleeding. The management ofthe disorder is directed first at the fis-sure by recommendingsphincterotomy or anal dilation.Sometimes reduction in internalsphincter tone by sphincterotomy re-duces the congestion and relievessymptoms caused by the co-existinghemorrhoids that will then require nofurther treatment. By contrast, elasticligation of large, bleeding, internalhemorrhoids before a fissure is ade-quately treated may produce morepain and tenesmus and worsen the pa-tient's symptoms. If external hemor-rhoids are markedly symptomatic atthe same time that a chronic anal fis-sure is causing distress, a hemor-rhoidectomy with sphincterotomy willbe required.

OverviewThe principle of good management

of hemorrhoids in the primary-caresetting requires that the physician beaware of the myths and pitfalls sur-rounding this disorder. In order to treatpatients with hemorrhoids effectively,the family physician must understandthe diversity of patients' notions ofhemorrhoids and be able to make anaccurate diagnosis and to prescribe ap-propriate, rational, and simpletherapy. Keeping these common-senserequirements in mind, the primary-care physician will likely be able to sat-isfy patients affected by this common"lowly" ailment. i

Prescribe Ceclor' (cefaclor)BRONCHITIS 1. Johnson M.A.: Fam Pract Recertif, August1986: 1-7. 2. Gleckman R.A., Roth R.M.: Geriatrics 1984, 39(9):51-60. 3. Pennington J.E., ed: Respiratory Infections: Diagnosisand Management. New York: Raven Press, 1983, 125-134.4. Jorgensen, Doern, Thornsberry & Preston, National Prevalenceof Antimicrobial Resistance in Haemophilus Influenzae: A Colla-borative Study. Presented at the Annual Meeting of the AmericanSociety for Microbiology, March 1985. 5. 1987 BAC-DATA Bac-teriologic Reports (U.S. National Summary/Winter Reports).6. Ceclor Product Monograph.OTITIS 1. John, W.R.B., Valle-Jones, J.C.: The Practitioner, 1983,227: 1805-1809. 2. Mandel, E.M., Bluestone, C.D., et al: PedInfectDis 1982,1(5): 310-316. 3. Carson, C.: FamilyHealth, 1986,April/May: 9-11. 4. Ceclor Product Monograph.CECLOR: PRESCRIBING SUMMARYINDICATIONS: The treatment of the following infections causedby Strept. pyogenes, Strept. pneumoniae. Staphylococci (includingcoagulase-positive, coagulase-negative, and penicillinase-produc-ing strains), E. Coli, Proteus mirabilis, Klebsiella pneumoniae, H.influenzae (including ampicillin-resistant strains):1. Otitis media,2. Lower Respiratory Infections, including pneumonia, bronchitis,

and pulmonary complications resulting from cystic fibrosis.3. Upper Respiratory Infections, including pharyngitis and tonsillitis,4. Skin and Soft-Tissue Infections,5. Urinary Tract Infections.CONTRAINDICATIONS: Persons who have shown hypersensitivityto the cephalosporin antibiotics.WARNINGS: Cephalosporins should be given only with caution topenicillin-sensitive patients. There is some evidence of cross-allergenicity between penicillins and cephalosporins. Patients havebeen reported to have had severe reactions (including anaphylaxis)to both.

Administer with caution to any patient who has demonstratedsome form of allergy, particularly to drugs. If an allergic reaction toCeclor occurs, the drug should be discontinued and the patienttreated with the usual agents. Pseudomembranous colitis has beenreported with virtually all broad-spectrum antibiotics; therefore, itis important to consider its diagnosis in patients who developdiarrhea in association with the use of antibiotics.PRECAUTIONS: Safety during pregnancy has not been established.Small amounts of Ceclor have been detected in mother's milkfollowing administration of single 500 nig doses. The effect onnursing infants is not known. Caution should be exercised whenCeclor is administered to a nursing wonman. Prolonged use mayresult in the over-growth of non-susceptiole organisms. If super-infection occurs, administration of Ceclor should cease andappropriate measures taken. Positive direct Coombs' tests havebeen reported during treatment with cephalosporins and may bedue to the drug. Administer with caution in the presence of markedlyimpaired renal function. The safe dosage is likely to be lower thanthat usually recommended. A false-positive reaction for glucosein the urine may occur with Benedict's or Fehling's solution orwith Clinitest tablets but not with Tes-Tape, (Glucose EnzymaticTest Strip, USP).ADVERSE REACTIONS: Of 1,493 patients treated with cefaclor,87 (5.8%) had adverse reactions or abnormal laboratory valuesjudged to be drug-related. These included: nausea and vomiting,dyspepsia, diarrhea, rash (including urticaria & morbilliform erup-tions), positive Coombs', eosinophilia, genital moniliasis, vaginitis,elevated SGOT, and elevated SGPT. Other adverse reactions experi-enced less frequently include: pruritus, dizziness, headache,somnolence, abdominal pain, leg cramps, abnormal taste, and fever.Leukopenia, decreased hemoglobin and hematocrit, neutrophilia,elevated alkaline phosphatase, lymphocytosis, lymphocytopenia,thrombocytosis, elevated BUN and creatinine, hematuria and pyuriahave also been reported. Cases of serum-sickness-like reactions(including skin manifestations, lever and arthralgia/arthritis),anaphylaxis, and pseudomembranous colitis have been reported.SYMPTOMS AND TREATMENT OF OVERDOSAGE: There hasbeen no experience of overdosage with Ceclor. If a large overdosehas been recently consumed, the patient should be kept underobservation and appropriate treatment undertaken as considerednecessary.DOSAGE AND ADMINISTRATION: Ceclor is administered orally.Adults - The usual adult dosage is 250 mg every 8 to 12 hours.The maximum recommended dosage is 2 g per day, although dosesof 4 g per day have been administered safely for 28 days.Children - The usual dosage for children is 20 mg/kg/day individed doses every 8 to 12 hours. In more serious infections,otitis media, and those infections caused by less susceptibleorganisms, 40 mg/kg/day is recommended, up to 1 g per day.

For lower respiratory tract infections, the total daily dosageshould be divided and administered 3 times daily. For B-hemolyticstreptococcal infections administer for at least ten days.DOSAGE FORMS:

Ceclor 250 mg Pulvules 3061. Each opaque purple and whitecapsule contains 250 mg cefaclor. Bottles of 100 capsules.

Ceclor 500 mg Pulvules 3062. Each opaque purple and greycapsule contains 500 mg cefaclor. Bottles of 30 and 100 capsules.

Ceclor 125 mg for Oral Suspension (M-5057). Strawberry fla-vored, 125 mg/5 mL.

Ceclor 250 mg for Oral Suspension (M-5058). Grape flavored,250 mg/S mL.

Reconstitute suspensions by adding 60 mL of water to each100 mL bottle or 90 mL for each 150 mL bottle in two portions.Shake well after each addition. After mixing, store in a refrigerator.The mixture may be kept for 14 days without significant loss ofpotency. Shake well before using. Keep tightly closed.

Product Monograph available on request. E

Eli Lilly Canada Inc., Toronto, OntarioLicensed user of trademarks owned by .tH

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