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. 

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.