Understanding Hemorrhoids

Podcast Transcript

Scott Steele: Butts & Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the president of main campus and colorectal surgeon here at Cleveland Clinic in beautiful Cleveland, Ohio. And this is the episode that I know many of you out there have been waiting on. We're going to talk today about hemorrhoids, specifically about causes and symptoms and current treatment options. And I'm very pleased to welcome one of our own in colorectal surgery, Dr. Shreya Gupta, who's a colorectal surgeon in DDI, Digestive Disease Institute at Cleveland Clinic South Pointe Hospital. Shreya, welcome to Butts & Guts.

Dr. Shreya Gupta: Thank you so much for having me, Dr. Steele. I'm so delighted to be here.

Scott Steele: We always like to start out a little bit by just saying where did you train, where are you from, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Shreya Gupta: I started, went to school in Pittsburgh, went to medical school in Philadelphia at Jefferson Medical College and then came to Cleveland. I did my residency at University Hospitals across the street and actually got in touch with you. And we ran a podcast together for quite many years and I, during my residency, decided that I wanted to lean into more about colon and rectal cancer and that was my niche. And after two years at NIH, I decided to pursue fellowship in colorectal. Did that in Minnesota and here I am back to serving our community in Cleveland.

Scott Steele: Fantastic. And we're so glad that you came back. And so today, as I said, we're going to talk a little bit about hemorrhoids. So to start, can you give us a little bit about... I think there's a lot of misperceptions about hemorrhoids, so what are they, how common are they to the general population?

Dr. Shreya Gupta: I love this question because I get this asked by my patients every single day. Hemorrhoids, we are all born with hemorrhoids. They are anatomical structure. They are the special blood vessels at the end of the anal canal and there are three of them right at the anal canal serving a purpose. So we all have them. However, I would say hemorrhoidal disease is quite prevalent, almost underestimated because people don't get medical help for that. But if I had to quote a number, I would say about 5% of people around in this country are affected by hemorrhoidal disease.

Scott Steele: Fantastic. So we all got them, but sometimes they flare up and give us all sorts of trouble. And I know we're going to talk about that a little bit, but in the textbooks and maybe people online reading about hemorrhoids, we'll talk about the different types of hemorrhoids. Can you talk a little bit about that?

Dr. Shreya Gupta: Mm-hmm. So two main categories, you got the internal and you got the external. They are the same thing, but they are divided by a very specific line called the dentate line. You can have internal problems and they come with some different slew of symptoms. And then you can have external hemorrhoids, which are more palpable, more easy to diagnose by yourself. And then you also have a special category that's mixed. It's self-explanatory, you have an internal and an external component.

Scott Steele: Fantastic. And so I know you alluded to this a little bit before about when they are thought of having problems associated with hemorrhoids, oftentimes they become engorged, inflamed, they may even thrombose, we'll get into that, but do they actually serve a normal function in the body and what may that be?

Dr. Shreya Gupta: Yes, they absolutely do. So we all know that we have continence and the muscles down there provide the majority of the continence, but hemorrhoids actually provide us with 20% of that added cushion, added continence. Think of these as the passive buttress. It provides you that extra control to your gas, to your stool.

Scott Steele: So that last little line of defense against some leakage they do out there. So what are the more common signs and symptoms of hemorrhoids and are there any that are maybe less commonly recognized symptoms that might not immediately be associated with hemorrhoids?

Dr. Shreya Gupta: Yes. Let me address your first question. So most commonly you fall into two categories. You either have bleeding and that's painful or you have bleeding that's painless. And that's one of the striking features that gets patients, "Oh, something's wrong." Some of the other common symptoms, I would say, would be itching, irritation, not able to clean yourself. And some of the rare ones are mostly with females, feelings of pressure, just anal pressure, rectal pressure. And sometimes that pressure can go undiagnosed as it's not a slam-dunk bleeding from a hemorrhoid.

Scott Steele: Can you talk a little bit about what a thrombosed hemorrhoid is? I know that's something that people may experience. And as you know, one of the issues with hemorrhoids, we'll get into a little bit later, is that they may mimic some of the other scarier diseases that might be in patients. It's not readily available to take a look at it like you would look at something on your arm. So what is that thrombosed hemorrhoid and is it benign? Is it cancerous? What is it?

Dr. Shreya Gupta: So a thrombosed hemorrhoid is a fancy way of saying that you had a hemorrhoid that bled and now it has a blood blister. And it is not cancerous, but it can be very, very painful and it definitely makes patients go to the ER and get medical care pretty promptly.

Scott Steele: Yeah, I think that's a good point, specifically because it's kind of a scary thing because it hurts and there's some extra tissue and for many people it feels a little bit like a grape or something is down there, or a marble I've heard in the past. So can the symptoms of hemorrhoids, especially you spoke about painless and painful rectal bleeding, be mistaken for symptoms of other medical issues?

Dr. Shreya Gupta: Yes, and that is why podcasts like this are extremely helpful is to spread this awareness that any type of anal rectal bleeding should be promptly looked at and sought medical care for. Some of the things that we are seeing on the rise is actually young onset cancers and a lot of young folks, young males, 30s, in their 40s, don't want to go to the doctors, have a little bleeding, think that it's a hemorrhoid and likely it is, but sometimes these can mask other big things and especially cancer, colon cancer, rectal cancer, and sometimes even other things like colitis, inflammatory bowel diseases, Crohn's, ulcerative colitis. These are all things that need to get checked out immediately. So if you have a family history, you have some bleeding that is ongoing, do not disregard that.

Scott Steele: That's fantastic. And I know for regular listeners of this podcast, we've had special episodes. I encourage everybody to go take a look back at that. And I think one of the important points Dr. Gupta and I wanted to have out there is that whereas the vast majority of those patients that have rectal bleeding or a little bit extra tissue have benign conditions, they're not to be ignored and it's important to get them checked out because we don't want you leaving thinking that if you have rectal bleeding, you have either hemorrhoids or cancer or one or the other, but it could be a mixture of things. So go ahead and get it checked out by your provider. You mentioned cancers. Are there any other more common benign conditions that might present with bleeding, specifically more painful bleeding that you mentioned before?

Dr. Shreya Gupta: Yes, and one of the big ones is going to be anal fissures. That is a pain that patients say that they're pooping razor blades. And so that's a very painful bleed that I most often see in my clinic. There can be other things too. Like I said, polyps, just diverticulitis, in older patients, diverticula, and these can be some other non-cancerous causes of anorectal bleeding.

Scott Steele: Okay, so let's dig in right now to just hemorrhoids and hemorrhoids only. So what are the most common causes and risk factors that can lead to hemorrhoidal development?

Dr. Shreya Gupta: Straining, that would be my number one, constipation. So if you are passing hard stools or you have pelvic outlet dysfunction that you've been diagnosed with, you are at a higher risk of developing hemorrhoids. One of the other populations that are at a higher risk of developing hemorrhoids would be people who do chronic weightlifting or chronic coughing. So patients who have asthma, COPD can be particularly higher risk of developing hemorrhoids. And the last thing I'd like to plug in here is pregnancy. Late pregnancy puts a lot of pressure on these hemorrhoidal plexus and can develop pregnancy related hemorrhoids.

Scott Steele: How are hemorrhoids diagnosed?

Dr. Shreya Gupta: I learned this in medical school. A thorough history goes a long way. Talking to your patients, talking to them about their stool habits, the description of the pain that they're telling you, the description of the bleeding pattern that they're telling you. Is this bright red? Is this squirting at the end? Is this on the stool or on the toilet paper? Those are all very good questions that cue you into hemorrhoidal disease. A physical exam done in the office, perhaps even an anoscopy, which is a small scope exam, is a very definitive way to diagnose hemorrhoids.

Scott Steele: So what are the most effective over-the-counter treatments and home remedies for mild hemorrhoids? It seems like you can't turn on the television or go through the checkout aisle in a grocery store and not see something geared towards some of these anorectal complaints we have.

Dr. Shreya Gupta: Yes, it is a very common problem and a very common solution is the answer to this, which is fiber. So if you're going down the aisle looking for something to treat your hemorrhoids, I would say grab a bottle of fiber. Any fiber supplement, it could be Metamucil, Benefiber, and a high fiber diet in general is the key. Something other than fiber would be lots and lots of water and hydration. If you are still looking for some symptomatic relief, over-the-counter stuff like Preparation H and Tucks are great over-the-counter local relief medications.

Scott Steele: So when should a patient or somebody listening here encourage someone to go and see a healthcare provider about these hemorrhoidal symptoms rather than just trying these home remedies?

Dr. Shreya Gupta: I would say as soon as you develop symptoms of bleeding, pain, pressure, all the things that we mentioned, go get medical advice promptly. We love to Google our symptoms and Google is getting better by the day. We can plug in our symptoms and get a very reasonable diagnosis out of it, but there's nothing better than getting checked out by a provider who can take a good history and do a physical exam.

Scott Steele: Okay, so walk me through. I'm a patient there and it's scary enough to think that you have something that may be on your backside. It could be extra tissue or bleeding or a lump or any one of the other symptoms that you talk about can be scary and worrisome. And now it's even scarier, you got to go see a colorectal surgeon, not knowing what that is. So can you walk the listeners through what they could expect if they have an office visit to you and what would they type to do and what are potential current treatment options that could happen right there in the office for hemorrhoids?

Dr. Shreya Gupta: Absolutely. So when you come into my office, we're basically sitting down and having a chat. I am taking a very good history of what has been going on and how you're describing it to me. And I understand some of these things could be hard to describe, but a description goes a long way of pain, bleeding, pressure, et cetera, whatever it could be. After that, I'm usually doing a quick physical exam, which is usually a rectal exam, followed by a anoscopy, which is a very small little scope that allows me to visualize the last part of the anal canal. This can be done in the office. It's maybe uncomfortable, but I wouldn't call it a painful exam.

The next thing if we do find hemorrhoids right away, and these are special internal hemorrhoids that can be banded, a rubber band ligation is a minor in-office procedure that I can do right then and there. It typically takes about 10 minutes of some prep work and usually you go home within another 10, 15 minutes of recovery and typically takes care of mild to moderate internal hemorrhoid disease.

Scott Steele: So you're talking in this procedure, they get a small scope place in their bottom, and this rubber band actually goes around the hemorrhoid itself and how does it work?

Dr. Shreya Gupta: So it works by choking off the blood supply. Like I said, these are special blood vessel structures and when you choke off the blood supply, it sloughs off over the next week. And when it does that, it actually scars the hemorrhoid up. And that is the key to the treatment of getting the hemorrhoidal disease under control.

Scott Steele: And as you said, this is only for something that has internal hemorrhoids. You wouldn't want to be able to put a rubber band on the external hemorrhoids. People would have a large amount of pain associated with that. So, let's just say that they’re not amenable to any, or maybe even fail over-the-counter treatment, they're not amenable to having a band placed. Talk about surgical options for hemorrhoids.

Dr. Shreya Gupta: And this is the scary part. Hemorrhoidal surgery has a lot of myths and concerns out in the public, but a surgical intervention for a hemorrhoid is actually considered an excisional hemorrhoidectomy where you surgically remove the entire hemorrhoidal column. This is a rather painful surgery just because of the way and the nature of where this disease process is, but it is the most definitive way that we can fix a hemorrhoid.

Scott Steele: So one of the things you spoke about a little bit briefly was maybe dietary or things that we can do in terms of over-the-counter, but can nutrition and lifestyle changes actually reduce the likelihood of having hemorrhoids?

Dr. Shreya Gupta: 100%. Like I mentioned, we all have hemorrhoids and they're a wonderful addition to our anatomy. And keeping our bowel habits consistent with fiber and water and an active lifestyle can greatly contribute to keeping a healthy gut and keep your hemorrhoids happy. So nutrition and lifestyle are great contributors to keeping this problem at bay.

Scott Steele: So let's talk a little bit about if you don't treat your hemorrhoids, if they're left untreated, what potential complications could occur down the road?

Dr. Shreya Gupta: Yes, sustained or worsening symptoms. So whatever your symptoms might be, they're not going to go away, pain, pressure, itching, bleeding, and sometimes even hygiene issues. Some people, if they do not get better with their bowel habits or change their bowel habits, can worsen their symptoms and even have a grade four hemorrhoid or a strangulated hemorrhoid. And this can lead to an emergency if it's left untreated.

Scott Steele: Fantastic. A lot to break down there. A lot of good advice and a lot of good information there. So now it's time for our quick hitters, a chance to get to know you a little bit better. So first of all, what was your favorite car?

Dr. Shreya Gupta: My favorite car would be a Prius. That was my first car that I ever got and I'm a huge environmental friendly person and I loved it.

Scott Steele: Fantastic. Are you salt or sweet?

Dr. Shreya Gupta: Salt.

Scott Steele: Can you tell us about a trip that you went on or a trip you would like to go on?

Dr. Shreya Gupta: My favorite, favorite vacation was in Switzerland with my family.

Scott Steele: Any particular site in Switzerland that you can comment on?

Dr. Shreya Gupta: The Swiss Alps.

Scott Steele: That sounds amazing. I've only seen pictures. And then finally, if you could go back to your 18-year-old self or 17-year-old self, graduating from high school, what sort of, maybe, advice would you give to yourself back then?

Dr. Shreya Gupta: Be patient and savor every moment.

Scott Steele: That's fantastic. And so give us a final take-home message for our listeners about hemorrhoids.

Dr. Shreya Gupta: Fiber and water, they're your best friends. And keep your gut happy because it leads to a happy butt.

Scott Steele: That's fantastic. And so, for more information on the Digestive Disease Institute at the Cleveland Clinic, please call 216.444.7000. That's 216.444.7000. You can also visit clevelandclinic.org/digestive for more information. That's clevelandclinic.org/digestive. Dr. Gupta, thanks so much for joining us on Butts & Guts.

Dr. Shreya Gupta: Thank you so much for having me.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.