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Medical Intel

Dec 13, 2018

Dr. Mitesh Patel discusses what hemorrhoids are and when symptoms such as blood during a bowel movement could be signs of a more serious condition.



Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re talking to Dr. Mitesh Patel, a gastroenterologist and Director of Pancreatobiliary Services at MedStar Washington Hospital Center. Welcome, Dr. Patel.

Dr. Mitesh Patel: Thank you.

Host: Today we’re talking about how you can tell whether you have hemorrhoids or some other condition. Dr. Patel, what are hemorrhoids and what causes them?

Dr. Patel: Well, believe it or not, we’re actually born with hemorrhoids. What hemorrhoids are—essentially veins that are returning the blood from the anal rectal area back towards the heart. So, these veins are naturally there in all of us. They can misbehave as we get older because of the things we do. So, we normally have connective tissue that keeps these veins sort of tacked down, sort of like the way we have pipes underneath the sidewalk. You never see the pipes because the concrete’s laid down. But if something were to disrupt the under-surface of the concrete, now these pipes could essentially bulge up and break through the sidewalk. Well, that’s what’s happening with hemorrhoids. The vein’s normal connective tissue, the connective tissue’s thinned out and these veins are now bulging up. So, what causes connective tissue to thin? Well, pressure. And so long-standing pressure in the anal rectal area, as well as some kind of strain, can do that. Naturally speaking, people defecate. Having a bowel movement is a normal activity. Some people normally have one bowel movement a day, sometimes a few more than that. Other people can go several days without having a bowel movement. And when we look at the definition of constipation having three or fewer bowel movements a week is sort of what textbook definition of constipation is.

So, what’s going on? Well, our colon is responsible for taking liquid waste material, packaging into a solid waste material, and then evacuating it. So, if you think about it, the colon acts like a sponge. It really is absorbing water, electrolytes—encasing this thin liquid into sort of a thicker, pastier form and then eventually to a semi-solid or even a solid form that our body then holds on to. The rectum is the reservoir, so it holds our stool and this allows us to take an overnight flight and not have to worry about things. But, when it’s socially acceptable, the muscles of the sphincter relax, other pelvic floor muscles squeeze, and that promotes the act of defecation. So, when some of this gets thrown off, and the additive effect over time, can cause strain at that connective tissue level. So, the most common problems are people who are constipated with dry, firm, hard stools that get bulky, often having to strain with defecation. Because when you’re straining, you’re exerting forces into that area of the anal rectum and that can help to break down or thin the connective tissue over time. Also, spending a lot of time sitting on the toilet. Right now I’m sitting on a chair—I have support under myself—but a toilet is carved out. There’s an opening in the center and so now, the perineum, which is the area of the anal and rectal connection—the perineum actually descends. It drops down an inch or two during the act of defecation. And that kind of strain puts pressure on those fibers and that can thin out the connective tissue as well. So people who are on the commode for a long period of time, who are straining to defecate, might be putting themselves at risk for developing symptomatic hemorrhoids in the future. But there are other conditions that can happen around the anus and that includes anal fissures. An anal fissure is a little crack in the tissue and it’s believed to be high pressure, especially within the sphincter ring. When that break happens in the tissue, it’s extremely uncomfortable. It feels like a razor blade poking you. Patients often can’t even sit comfortably. They have to sort of lean on one side, the pain is so intense. And so that can also bleed and that can mimic what a hemorrhoid can do and so that’s why when there is the symptom of rectal bleeding, whether it’s painful or painless, it’s worthy of getting it checked out by a specialist.

Host: Since we’re all born with the propensity to develop this condition, how common are those symptomatic hemorrhoids?

Dr. Patel: Well, it’s estimated that, in one’s lifetime, 75 percent of people are gonna have some degree of a symptomatic hemorrhoid. Now, that’s a big number but really only about a third of that number are patients that are probably going to need some kind of medical attention. The fact of the matter is diet alone can really be beneficial in the form of increasing the amount of fiber in the diet, as well as the amount of fluid that you take in each day. There are a lot of people who work in an office job setting who may not have…be going to the water cooler as much as they need to. They’re so busy with their work, they’re maybe not exercising regularly. And the diet may not be full of vegetables and fruits. It could be more processed foods. And we know that when that happens we shift away from the high fiber diet. And we get into some of these issues where people can then develop constipation. Vegetables and fruits, especially fruits with peels on them, can be very beneficial for increasing fiber. Bran and oat are another great way of getting fiber into the diet. A lot of people add flax seeds to food because that’s also a naturally derived fiber.

For people that are sort of hesitant to change their diet, there are fiber supplements available. And so things like Benefiber and Metamucil which are commercially available over-the-counter…products that you can just take a heaping tablespoon and add to a clear liquid or your food and ingest it that way. And so there are ways of getting fiber into the diet without making radical shifts in the diet. But definitely, not only adding fiber but then adding fluid because remember, that colon is a sponge. And so if you’re not drinking enough fluid, your cells need the water. Your kidneys help regulate that but the colon is sort of a back up to draw and hold on to water. And so the more water is removed from the fecal matter, the more at risk of bulking up, becoming dry and hard, more difficult to pass, and then we get into this vicious cycle of straining with defecation and then potentially developing symptomatic hemorrhoids.

Host: What does fiber do in the diet to promote healthy bowel movements?

Dr. Patel: Certain fibers, our body cannot digest fully and therefore they end up as a waste product. When fiber enters the colon, we have an abundance of bacteria in our colon. For example, you know, why is it that a horse or a cow can eat grass and hay but if you and I tried to do that right now we’d become violently ill. But we come close. We eat cabbage and brussel sprouts and kale. So we don’t have the makeup to break down plant sugars and plant fibers fully. We use the bacteria that live in our colon to assist with that process. The bacteria thrive on that. They actually multiply in number as they’re feeding on this plant fiber. A big percentage of our fecal matter is bacteria. And that effect of the digestion, the fermentation that’s going on inside is also generating fluid and it’s keeping the fecal matter bulky. Bulk is actually a good thing in the colon. Our colon is a, basically a hollow tube of muscle and so that muscle’s gonna squeeze rhythmically but it’s gonna be more inclined to squeeze when there’s bulk inside because it knows it has to move it along. So, adding bulk into the stool, the best way to do that is with fiber.

Host: So, when an individual has symptomatic hemorrhoids, what are some of those common symptoms that they’re going to feel?

Dr. Patel: You know, hemorrhoids—the most common manifestation of the patients that present to me is just bleeding. They notice that when they have a bowel movement and they wipe, there might be blood on the paper. Sometimes there’s actually blood coating the stool itself. In severe cases there can even be drops of blood going in to the toilet. If a blood vessel in the anus gets thrombose, means a blood clot forms in the hemorrhoid, that can be exquisitely painful. And so these patients, again, are the ones that are sort of shifting around, can’t really sit comfortably. And those patients often need either some form of first-line therapy which can be stool softening, but in extreme scenarios, they actually need to have a small office procedure to lance this blood clot and then relieve it. Other common symptoms with hemorrhoids include just anal itching, discomfort, burning, itching in the anal area. And then pain really is a manifestation, like I said, of the thrombosis of the hemorrhoid—just sort of prolonged damage to the lining of that area. The anal fissure can be a more extreme manifestation of pain, it’s a different mechanism. And that’s where a physical exam will be able to help delineate between the two.

Host: If a person chooses to just live with these symptoms and not come and seek treatment, what are some of the complications that could arise from that?

Dr. Patel: Well, talking about bleeding. There should not be bleeding from the bowels, from the GI tract. And so, when we think about a person who’s having rectal bleeding, we have to think about all the conditions that can cause bleeding. There are minor things like hemorrhoids. But there are some more aggressive things, like vascular malformations within the colon or little pouches that form in the colon that can erode and cause bleeding. And the worst-case scenario are advanced polyps or even cancer of the colon. So, when we meet a patient who has these complaints, we often take a very careful history. We examine our patients, may incorporate some lab work to see what degree of blood loss is really going on. If we lose more blood than our body has the ability to make, then we, by definition, become anemic and our blood count goes down, our stored iron gets utilized to make more red blood cells but then we may even drop the amount of stored iron we have in our body. So, there are some blood tests that are available that could help us get a sense as to how long this process is going on. Sometimes patients aren’t very good about looking at their stool or, uh, you know, and this could be going on for months and months if not years. And so that could have an additive effect and that’s where seeking medical attention could be valuable because then we can put the story together, examine patients, do some lab work and get a better feel for how long this process has been going on and whether this person could potentially be at risk of one of the more concerning findings.

Host: Should a person go see their primary care doctor or should they go straight to a gastroenterologist for this?

Dr. Patel: You know, primary care is very valuable because, this is, for the most part, hemorrhoids can be managed by an internist, you know. This is something that first-line intervention of…increasing the fiber in the diet, adding ample fluid daily—we’re talking about anywhere from 48 to 64 ounces of fluid a day—and getting a little exercise. Remember that the colon, that hollow muscle tube inside of us, well, it squeezes but, you know, it also helps when our abdominal wall muscles also are contracting periodically ‘cause that helps move things along. So, the person who walks, who takes the stairs instead of the elevator, who does aerobic activity—all of that promotes good colon health and good colon motility. So, you don’t need a specialist to get that advice. And so that’s the kind of thing that a first-line intervention could be beneficial. Now, if you tried that for several weeks and the bleeding persists, or your symptoms change, that might be the sign that seeking help from a gastroenterologist could be useful.

Host: Thank you for joining us today, Dr. Patel.

Dr. Patel: Thank you.

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