The What, Why, and How of Hemorrhoids

What are hemorrhoids?

Hemorrhoids are normal vascular structures found in every individual. They are a collection of vessels (arteriovenous channels) that are located both within the rectum (internal hemorrhoids) and below the rectum around the anus (external hemorrhoids).  Hemorrhoids are located below the superficial layers of the mucosa (internal hemorrhoids) lining the rectum and skin around the anus (external hemorrhoids) that drain into the deeper larger vessels within the abdomen.  

Despite being present in everyone, the term “hemorrhoid” has taken on more of a pathologic or disease state e.g. when they become enlarged causing bleeding, itching, prolapse (internal hemorrhoids) or thrombosed causing pain (external hemorrhoids)

What function do hemorrhoids serve?

Classically, these veins are thought to form a cushion to aide in continence. Other than helping blood flow in the area that they don’t serve much greater purpose that we know of.

Are hemorrhoids the cause of my issues?

Many patients attribute “hemorrhoids” as a cause of any symptom of the rectum/anus they may encounter but they are not always involved. A careful history and exam can find anal fissures, inflammation of the rectum (proctitis), an STD like herpes or chlamydia, anal or rectal cancer!

What are the differences between external and internal hemorrhoids?

There are some important differences between the two main types of hemorrhoids. These differences are useful in determining what symptoms means.  Typically, external hemorrhoids do not cause bleeding as their initial symptoms. These actually can become enlarged and very painful as they are located just outside the anus. They can’t be pushed back in. They can bleed if they rupture and a clot usually can be seen when bleeding. External hemorrhoids are very painful as they are covered by skin which has nerve endings that signal pain. Internal hemorrhoids do not typically present with pain rather they present as painless rectal bleeding. When large enough they can prolapse out of the rectum and get trapped and ischemic due to pressure form the anal canal. In general though, there usually is no pain involved. Itching can be seen when fecal matter gets trapped around the anus and hygiene becomes a problem due to their presence in the anal canal. The skin around anus in contact with the prolapsed internal hemorrhoids can become inflamed from the irritation caused by trauma in the anal canal, mucous expressed by the cells of the colon that cover the internal hemorrhoid or from bacteria/feces that irritates the perianal skin.  You can see itching with external hemorrhoids form the similar reason but mostly due to inability to clean well.

What causes hemorrhoids?

Hemorrhoids exist in everyone but the reason for formation of symptomatic hemorrhoids is not entirely clear. Classic teaching suggests they form from excessive straining, during pregnancy from changes in blood flow and effect of pregnant uterus on the pelvis, prolonged sitting, heaving lifting, constipation, or even frequent bowel movements.  With external hemorrhoid the most common idea is that poor blood flow due to mechanical forces leads to slowing in blood flow and then thrombosis or clotting while changes in connective tissue in the rectum or increased pressure in the rectum due to hard stools or frequent stools leads leads to swelling of internal hemorrhoids. Interestingly, many of my patients deny straining, diarrhea or constipation. Unfortunately, we can only use careful history taking to try to ascertain clues as to why.  For a patients, it's a very uncomfortable experience but they ultimately can be treated and patients can experience relief in time.

How do you treat hemorrhoids?

External hemorrhoids are acutely painful and excision of the clot can provide immediate relief but quickly finding a surgeon or gastroenterologist (one comfortable to do this) is not easy.

In general, an osmotic laxative like Miralax can be used daily to prevent hard painful stools. Topical and systemic pain relief as well as warm water baths (sitz baths) can be helpful. I typically recommend topical lidocaine 3-4 times per day, motrin/ibuprofen, and sitz baths twice a day. Warm water baths are soothing. Eventually the clot will resorb and the pain and swelling will dissipate. Often, patients can be left with an external skin tag as a result. This is stretched anal skin overlying the hemorrhoid. This skin tag may not cause any symptoms but when it does could be removed surgically.

For internal hemorrhoids, increasing fiber intake is the mainstay of therapy for improving ease of bowel movements, avoiding prolonged sitting and straining while defecating. Very large hemorrhoids that are chronically bleeding can be treated surgically via rubber banding techniques, most commonly. Over the counter remedies like preparation H and steroid creams are not useful other than to treat itching or pain.  Steroids suppositories may help reduce size but along with topical creams should not be used longer than 2 weeks. Finally, sitz baths can help increase blood flow and relax the anal sphincter to reduce pressure and allow ease of evacuation. They also reduce itching.

What can you do to prevent hemorrhoids from coming back?

I inform all my patients to add dietary and supplemental fiber to the diet as best they can. Guidelines recommend about 25-35 g per day. Other than high fiber foods, I typically favor Citrucel (methylcellulose) and Fibercon (polycarbophil) supplements as they are in pill form and when taken with lots of water 24-32 0z can add water to stools and prevent straining by easing elimination.  Other fibers are good too like psyllium husk but these tend to cause bloating, which a lot of my patient’s have already. 

Other hemorrhoid tips and information:

Readers should always consider talking to their doctors about perianal or rectal symptoms they think are attributed to hemorrhoids before taking matters into their own hands as often times patient’s are mistaken and they may instead have an anal fissure, STD, or genital wart rather than hemorrhoids. It’s important to get an exam and the right diagnosis so that the right treatment is used.

Daniel Motola, MD is a Gastroenterologist and Hepatologist at Gotham Medical Associates

Rectal and Anal Disorders: What to know, what to do

One of the most common complaints I see in the office is medical issues affecting the anus and rectum. This is a sensitive topic and probably not one that makes for great conversation around the water cooler / coffee shop/ office break room. 

Anal or rectal symptoms usually involve one or more of the following: pain, bleeding, or itching. 

Men and women can both present with these symptoms and at any age. I typically see a younger population in general so patients from the early 20s to 40s can have these issues.  

Below I break down some of the disorders I see based on symptoms. 

1.  Anal/rectal pain with bowel movements , often accompanied by bleeding upon defecation:

The most likely cause is usually an anal fissure. Anal fissures are tears of the mucosa (surface) lining the anal canal and anus (the opening of the anal canal). The pain associated with anal fissure can be excruciating. Patient's with severe pain may even avoid going to the bathroom, potentially worsening the condition as a result of formation of hards stool that become difficult to pass

Treatment of the fissure requires a prescription medication. A gastroenterologist is the best qualified to diagnose and treat an anal fissure.

Treatment is aimed at relaxing the external anal sphincter , improving blood flow to the area , treating any underlying constipation, and avoidance of straining. 


Lidocaine/Nifedepine cream 1.5%/0.3% . This cream applied twice daily to the anus will provide pain relief and relax the rectal sphincter muscles preventing muscle spasms that can exacerbate pain and cause further tearing. 

Sitz baths : A simple shallow warm water bath with or without epsom salts. Salts aren't really doing anything. Warm water can increase blood flow to the area and be soothing to the area.  Do this twice a day or more for 15 minutes.

Miralax 17 g daily: Adding an osmotic laxative should help soften/loosen stools preventing increased wall tension and straining

2. Painless rectal bleeding

Hemorrhoids are the most common cause of rectal bleeding when it occurs with defecation . However a visit to a gastroenterologist is always recommended to clarify the history, review colon cancer risk factors, and perform an in-office rectal exam/anoscopy. In certain situation a colonoscopy or flexible sigmoidoscopy is advisable. 

Hemorrhoids can be classified as internal or external.

External hemorrhoids are below the pectinate line and typically develop around the anus. The can be very painful when enlarged and thrombosed (clotted). The do not typically bleed unless the overlying mucosa is damaged or weakened. The pain of acute thrombosis may be so severe as to require urgent opening and drainage of the clot. This is performed by a colorectal surgeon. Not a gastroenterologist.  

Typically, external hemorrhoids will resolve through resorption of the blood clot and resolution of aggravating factors such as straining and hards stools.  


Conservative (non-surgical) treatments involve Sitz baths, topical pain relievers, NSAIDs, in some situations topical steroids. Laxatives have the adjunct role of reducing pain from hard stools.

Internal hemorrhoids are above the pectinate line and are graded based on their size and whether or not they prolapse (protrude from the rectum out through the anus).  These typically bleed and are painless but can be painful the large and more swollen they are. 


Conservative treatment is similar for internal hemorrhoids as for external hemorrhoids.  I am not a fan of preparation H as the agents within them are usually not that effective for moderate to severe cases.

3. Rectal Pain, fever, drainage

Abscess, Fistula

This worries me for an abscess, a fistula, or both. This should prompt immediate evaluation by a physician as treatment requires incision and drainage and anti-biotic therapy.

STD with Herpes, Chlamydia, or Gonorrhea:

Men who have sex with men are at increased risk for STDS of the rectum. Unprotected receptive anal intercourse with a stranger is the most common risk factor I encounter. Patients report pain, bleeding, discharge, and tenesmus (rectal urgency).  Even patient's on PrEP are at risk. Some have a false sense of securityusing PrEP. PrEP , or Truvada therapy provides protection against HIV, not other STDS.

A diagnosis can be made based on a compatible clinical history and examination. A rectal swab should be obtained to confirm the disease. This require appropriate specimen collection kits available at a gastroenterologists office.  Empiric treatment is reasonable if suspicion is high. Treatment is  a single oral dose of Azithromycin and an intramuscular injection of Ceftriaxone.  However, if the swabs are negative an alternative pathology should be sought, such as proctitis.  




Medical Insurance Benefits 101

If you are a young person just coming off your parents' medical insurance or are starting a new job and need to decide what medical plan to choose during a benefit enrollment period, this primer may help explain some of the more esoteric terms you'll come across. 

Those dollar values and percent’s may not mean much to you when you signed up. I assure you they will when you are faced with a medical problem and find yourself confused as to why that lab test or procedure your doctor ordered was not "covered 100%".

I'll admit that even in my many years of medical training, through medical school, residency and fellowship, that I had no idea what a co-insurance, deductible, co-payment, or out-of-network doctor was! So don't feel bad.

Cost Sharing: 

Basically, you and the insurance plan agree to share the costs of your medical care.  Examples of cost sharing include deductibles, co-insurances, and co-payments. Cost sharing helps to keep your premiums lower. It doesn't apply to all things, so check your plan for costs of imaging, ER visits, screening tests like colonoscopy etc.  


This is the amount you pay yearly before the insurance pays their share. If the cost is $3,000 and you have a $2,000 deductible, you pay the first $2,000. Thereafter you pay your share of the remaining $1,000 and the insurance company pays its share. 


This is the percentage you pay based on cost the sharing agreement after you have paid your full deductible.  Most often the split favors you and you pay 20-30% while the plan pays 80-70%.   


This is an upfront payment typically for routine office visits with a specialist or primary care provider. Co-payments also apply to medications. Your medical insurance card typically lists these amounts. These can usually range anywhere from $10-$50.


The doctor or facility (provider) is contracted with your insurance plan. This means your provider takes your insurance and has pre-negotiated rates. 


Out-of-network benefits may be a part of your insurance plan. This allows doctors who are not contracted with your insurance plan the ability to bill your insurance. However, the fees paid by the insurance plan may be higher and thus your costs will be higher. Insurance plans typically will pass this on to you through a higher premium and cost sharing. With respect to cost sharing your deductible and co-insurance may be higher than the those for in-network providers. Some plans have no out-of-network coverage at all and you will not be able to see that provider unless you are wiling to pay cash and he or she will not be able to send bills to your insurance company for services rendered to you.  Its always best go to an in-network provider if you can. You must known the status of your provider with your insurance plan before you see them.  Actually, in the state of New York the provider must disclose this to you.

What's the deal with gluten-free (GF) food?

The majority of my patients come to me already with some vague knowledge about gluten-free (GF) foods. However, many do not know what gluten is or why GF items have been inserted into menus everywhere. I often spend time explaining how gluten causes disease in Celiac disease (CD) patients and why non-celiac disease patients feel better when they stop eating gluten. This conversation often leads further into a discussion of the difference between food allergy and food intolerance. The main misconception I have seen is that many patients without CD feel they have a food allergy when in fact they have a food intolerance.  

What is gluten?

Gluten is not that mysterious. It is a collection of proteins that are found in wheat, barley, and rye. Gluten is important clinically as it is the main cause of CD.  An individual with CD needs to completely avoid Gluten in order to heal from the disease. CD is an autoimmune disease.  Autoimmune diseases are characterized by an inappropriate activation of the immune system. Self or endogenous antigens (markers of self) are 'perceived' as foreign. Once activated, the immune system leads to the destruction of the absorptive surface of the small intestine. 

CD is common, found in approximately 1% of the population. I typically tell patients that it is less common than irritable bowel syndrome (1 out of 7), but more common than Crohn's disease (1 out of 500-1000 patients).

If it's only 1% of the population, why are gluten-free foods so ubiquitous? Well, certainly CD patients should be afforded the same rights to eat as safely as non-celiac patients. However, many people without celiac disease have found that removing gluten from their diets makes them feel less full, less bloated, and less fatigued. Clinically, this has been called non-celiac gluten sensitivity (NCGS). It is not clear if there is a distinct biological entity that results in pathological changes other than those seen in CD.

If these patients are ill but do not have CD, why do they feel better when they remove gluten? What is more likely happening is that people are responding to the removal of something from their diet that gluten is associated with, rather than the gluten itself. This has actually been shown in a clinical study. My bet is that these patients are responding to the FODMAPs found in foods made with wheat, rye, and barley. 

What are FODMAPS?

Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols. These are all forms of carbohydrates or sugars in varying shapes and sizes that are poorly absorbed or not well digested. FODMAPs are fermented in the colon by bacteria which results in the production of hydrogen gas (flatus, bloating, abdominal distention, pain), short chain fatty acids, and causes an osmotic effect to draw in water to the stool (diarrhea). 

If you or someone you know has responded to a Gluten-free diet make sure they see a gastroenterologist to learn whether they in fact have an intolerance to foods containing gluten or have CD.  CD can be tested by obtaining measurements of circulating antibody markers. Those that have excluded all gluten from their diet will need to be re-challenged with it for 6 weeks with at least 1-2 slices of bread a day. This is because patients with CD lose the diagnostic serum markers of the disease while on a gluten-free diet.  If markers are positive, confirmation will be needed by obtaining small intestine biopsies during an upper endoscopy.

What markers are most sensitive and specific?  In the presence of normal serum IgA levels, I have found that the IgA anti-tissue transglutaminase antibody is most sensitive and specific. Others tend to have low positive predictive values. 

Is there a genetic test? Yes and no. The test is only useful to exclude celiac disease. I utilize HLA DQ2/DQ8 allele testing when results of testing are ambiguous, or their is a high suspicion despite conflicting test results (i.e. positive markers, negative biopsy). A positive test (presence of both alleles) is seen in 99.9% of CD patients while only 40-50% of the general population tests positive. Thus, a positive value does not diagnose CD. Rather, it is the absence of these alleles (negative result) that excludes CD. 

What's causing my abdominal pain? When size does matter!

Abdominal pain is a common reason to visit a gastroenterologist's office.  The most common scenario I encounter is a patient presenting with right sided abdominal pain after eating.  The intensity and temporal relationship to their meals often allows me to more easily determine the cause. Patients often report pain within 30 minutes to 1 hr of eating.  They find the discomfort peaks after meals and then decreases towards the start of the next meal. They often wake up feeling well. The pain is also often described as a discomfort rather than pain.  Patients often do not have associated symptoms of reflux such as heartburn or regurgitation.  Warning signs such as vomiting, weight loss, diarrhea, prompt a different conversation and work up.

In the absence of warnings signs or signs suggestive of a peptic process or reflux I typically find these patients are over-eating and/or are eating too quickly. Many have a history of anxiety, depression, or other mood disorder.  I will typically have patients try a proton-pump inhibitor for 2-4 weeks and if there is no improvement I have them focus on portion size, time spent eating, and have them reduce the fat and carbohydrate contents of their meals. 

I hypothesize that many of these patients have visceral hypersensitivity. They further have anxiety and busy jobs that require long hours and little time for relaxation.  These factors lead to overeating and rushing. Latenight overeating is also a factor so I encourage each of these patients to take a good look at the quality of their life and encourage them to take more time for themselves.  I remind them to eat protein and complex carbohydrate rich breakfast (fruits , granola, and yogurt) and to have a good sized lunch. They should be cautious to eat slowly and to chew well. I recommend smaller portions at night so they avoid eating large heavy meals prior to laying down. Avoidance of seltzer and sodas is also helpful.

If medication, life-style changes, or dietary modifications do not help I will obtain an abdominal ultrasound and upper endoscopy to assess for organic causes.  There are a select group of patients who have already had these tests so I do not repeat them.  If these tests are unrevealing I will recommend a 4-8 week trial of a tricyclic antidepressant, which will treat the underlying visceral hypersensitivity by modulating the output of the enteric nervous system to the central nervous system. Signals representing stretching of the walls of the digestive tract will dampen and patients will have less discomfort with meals. 


Practical Information for someone with Acute Diarrhea

What is acute diarrhea? 

Acute diarrhea is a diarrheal illness occurring for up to two weeks. Once diarrhea lasts beyond 2 weeks it is called Persistent Diarrhea. If diarrhea persists beyond 4 weeks it is called Chronic Diarrhea.

  1. What causes acute diarrhea? Acute diarrhea can be caused by one of many food-borne pathogens due to ingestion of undercooked foods such as beef and poultry. Some bacteria create bacterial toxins which result in rapid onset of symptoms after ingestion of toxin-containing foods. Other infectious agents includes particular viruses, parasites, travel-related bacteria diarrhea. Non-infectious agents include simple food intolerances. Typically, a careful history taking such as recent travel, use of antibiotics, sick contacts, 
  2. When should you seek medical attention?: If your diarrhea becomes bloody this may be a sign of dysentery caused by Shigella bacteria or the amoeba E. histolytica. Severe signs of illness include fever > 100.3, abdominal pain, nausea or vomiting. If you develop fever, abdominal pain, or inability to tolerate oral hydration immediately seek the assistance of a gastroenterologist or internal medicine provider.  As an alternative, there are a number of urgent care centers around New York City. The doctor will ask you to provide stool samples to perform a stool culture which can take 2-3 days to result.  
  3. What is the possible outcome from acute diarrhea? Most cases of acute diarrhea resolve spontaneously and are difficult to attribute to a single pathogen or cause. Acute bloody diarrhea should be promptly evaluated for Shigella species and Entamoeba Histolytica
  4. Is it safe to use imodium? This question is best answered by a physician that can completely evaluate you by history, physical exam, and blood/stool testing. Once infectious etiologies are rule out by stool testing it may be safe to use imodium or other anti-diarrheals. Be sure to check with your doctor before starting any medications. 
  5. What is safe to eat when dealing with diarrhea? Its best to avoid products containing dairy, high fat content, or rich foods. Its most important to stay well hydrated to keep up with losses of fluids in the stools. The BRAT diet is typically suggested.

Cyclospora on the rise as cause of watery diarrhea

The CDC just announced that gastrointestinal infections with Cyclospora are on the rise.  

Patients with acute diarrhea, or diarrhea that persists beyond 2 weeks should be tested for this pathogen. 

Doctors need to keep in mind that Cyclospora must be requested specifically as typical stool examinations for ova and parasites do not test for it.

Symptoms of Cyclosporiasis include watery diarrhea that can be profuse, along with bloating, nausea, fatigue, weight loss and flatulence. Other symptoms can include fever, muscle aches (myalgia), and vomiting. The parasite is transmitted from contaminated food or water. Symptoms occur about 7 days after ingestion and can last for a few days to months if left untreated. Treatment is with Bactrim(trimetoprim/sulfamethoxazole), a sulfa drug. Unfortunately, according to the CDC, if you are allergic to sulfa drugs you will need to be monitored for recovery and provided supportive treatments.

FODMAPs in The Press!

I am pleased to see news coverage of the low fodmap "diet."

Many of my patients that I have diagnosed with either Irritable bowel syndrome (#IBS), bloating, or chronic diarrhea have found it helpful.

The term "diet" in association with fodmaps is a misnomer. I feel more like this is a road map to reducing symptoms and improving quality of life. It's important to follow this road map closely with the help of both your gastroenterologist and a dietician experienced in it. 

Keep in mind that anyone with symptoms of bloating, diarrhea, abdominal pain should seek a diagnosis first before assuming they have IBS, as its diagnosis remains at this time one of exclusion. There is no diagnostic test. A physician must first rule out other causes through careful exam and history taking. In some, blood work, imaging, and colonoscopy or endoscopy may be required. 

A Diet Low in FODMAPS Can Improve Symptoms of Bloating in Irritable Bowel Syndrome: Go Low FODMAP!

Irritable bowel syndrome (IBS) affects 1 in 6 people and is characterized by chronic abdominal pain associated with a change in bowel form or frequency. Typically pain or discomfort related to IBS is relieved with bowel movements. Bloating is often a common symptom and one of the many reasons patients come to Gotham Medical Associates. About one third of patients with IBS have a form of IBS in which they are constipated most of the time (IBS-C), while another third of patients have frequent loose stools (IBS-D), the remaining group has mixed symptoms (IBS-M).

The exact causes of IBS are unclear but likely include genetics, environment, stress levels, and diet. If you or someone you know suffers from IBS you may deal regularly with the discomfort of bloating, increased flatus, and irregular bowel movements. All of this can occur despite eating what is considered to be a “healthy diet”. The purpose of this inaugural newsletter is to introduce our patients at Gotham Medical Associates to the FODMAPS, particularly those patients with symptoms of bloating and or those who have been diagnosed with IBS.

What are FODMAPS? FOMDAPS are a group of sugars collectively called Fermentable Oligosacharides Disacharrides, Monoscharrides, and Polyols. These sugars and sugars alcohols vary in size, length and shape. They are ubiquitous in our diet and include the common Disaccharide, lactose, the Monosaccharide fructose, and well as sugar alcohols including sorbitol, xylitol and mannitol. Other less knowns FODMAPS include the fructans, which are longer molecules. 

How do FODMAPS cause symptoms? When FODMAPS are undigested, unabsorbed, or over-abundant they reach the colon and are fermented by the colonic bacteria. In the process of fermentation hydrogen gas and lactic acid are produced. This ultimately leads to bloating, loose stools, and abdominal pain.  For some, and for unclear reasons, this results in constipation and bloating.

Is Gluten a FODMAP? No, in fact, Gluten is a group of proteins found in wheat. It is hypothesized that ingestion of wheat (containing gluten) results in bloating as a result of coincidental FODMAPS found naturally within wheat. 

What is a Low FODMAP diet? The Low FODMAP diet is based on research conducted by the Monash University in Australia. A strict interpretation of the diet would be to exclude all high FODMAP-containing items from the diet for 4-6 weeks and then a “re-challenge” phase whereby foods are reintroduced one-by-one to systematically determine which foods are culprits. This strategy can be restrictive on the diet due to possible excessive dietary exclusions, and the long term risk of FODMAP exclusion is not known, thus it should only be attempted under the guidance of a nutritionist with expertise in this area. Gotham Medical Associates can link its patients up with qualified nutritionist if needed.

Visit for more details on the Low FODMAP Diet. 

If you are interested in obtaining a consultation with one of our Gastroenterologists please call 212-227-3688. Our staff will be happy to assist you, your friend or family member!