What's the deal with gluten?

Gluten free foods seem to be everywhere. What is gluten and why are so many people avoiding this wheat protein? What is gluten and how does it relate to celiac disease and wheat sensitivity? Find out more in this article.

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The What, Why, and How of Hemorrhoids

What are hemorrhoids?

Hemorrhoids are a collection of vessels (arteriovenous channels) that are located both within the rectum (internal hemorrhoids) and around the anus (external hemorrhoids). 

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 enlarge to cause pain due to thrombosis (clot formation in external hemorrhoids).

What are the differences between external and internal hemorrhoids?

External hemorrhoids do not cause bleeding as their initial symptom. When enlarged, they are noticeable just at the opening of the anal canal (anus) and can be tender and painful. If they are large enough, they can bleed if the overlying skin tears. Sometimes a clot is seen with bleeding. External hemorrhoids are painful as they are covered by skin which is heavily innervated with somatic nerve endings.

Unlike external hemorrhoids, internal hemorrhoids do not typically cause pain, as there are no nerves around them. Rather they cause painless rectal bleeding during defecation when enlarged. When large enough they can prolapse (fall) outside the rectum into the anal canal and can be pushed back in, though sometimes they can't. Itching is another symptom of internal hemorrhoids, as mucous from within the rectum or fecal matter comes in contact with the skin around the anus. You can see itching with external hemorrhoids too if it becomes difficult to clean due to pain.  

What causes hemorrhoids?

Everyone has hemorrhoids. However, they are not noticed until they become enlarged and create symptoms.  It is believed that they form from repeated excessive straining during defecation, during pregnancy as a result of changes in blood flow and pressure of the uterus within the pelvis, prolonged sitting, heaving lifting, constipation, frequent bowel movements, or some combination of the above. Mechanical forces may lead to slowing in blood flow resulting in thrombosis or clotting, which leads to enlargement of external hemorrhoids. Increased pressure in the rectum due to straining, hard stools, or frequent stools, leads to swelling of internal hemorrhoids.  

How do you treat hemorrhoids?

In general, the goal of treatment for either type is to ease evacuation and reduce pain. An osmotic laxative like Miralax can be used daily to prevent constipation or hard stools. Topical lidocaine (2-4%) used 3-4 times per day, Motrin/Ibuprofen, and warm Sitz baths twice a day can ease pain and swelling. In the case of external hemorrhoids, the clot will eventually reabsorb, and pain and swelling will dissipate over 1-3 weeks. 

External hemorrhoids that are acutely painful can be quickly relieved by excision of the clot, but quickly finding a colorectal surgeon to do this is not easy. Very large internal hemorrhoids that are chronically bleeding can be treated surgically or via rubber banding techniques. I refer my patients to a colorectal surgeon or other gastroenterologist with experience in these techniques. Steroids suppositories may help reduce size and itching of internal hemorrhoids. I do not recommend topical steroids for external hemorrhoids unless there is severe itching around the anus.   

What can you do to prevent hemorrhoids from coming back?

I inform all my patients to increase dietary or supplemental fiber in the diet. Guidelines recommend about 25-35 g per day. For supplementing, I typically recommend Citrucel (methylcellulose) and Fibercon (polycarbophil) taken in pill form with 8 ounces water. This can add some bulk and water to stools and facilitate ease of elimination. Other fibers like psyllium husk (metamucil) are suitable too but can cause bloating. All are available over the counter. 

Other hemorrhoid tips and information:

Many patients attribute “hemorrhoids” as the cause of any symptom of the rectum/anus but they may not always be involved. A careful history and exam can help to make the right diagnosis. Readers should always consider talking to their doctors about lingering perianal or rectal symptoms they think are attributed to hemorrhoids before taking matters into their own hands to ensure an accurate diagnosis and treatment.   

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. 

Treatment:

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.  

Treatments

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. 

Treatments:

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.  

 

 

 

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.