Your Top 10 Questions about Hemorrhoids Answered

  • hiermedia
  • May 2, 2017

Are you bleeding? Having pain? Any puffiness or swelling on the bottom? These could all be symptoms of hemorrhoids. But what are hemorrhoids and more importantly, how can they be prevented and treated? Here I answer your questions about this most common but dreaded malady.

  1. What is a hemorrhoid?

A hemorrhoid is an anal cushion of tissue containing blood vessels, muscle, and connective tissue. When this tissue is engorged or swollen, there is the possibility of discomfort or bleeding. Contrary to popular belief, a hemorrhoid is not a vein. Once the swelling from the hemorrhoid resolves, a skin tag may be left. There can be one or multiple tags present. Removal of the anal skin tag is not necessary unless they itch, bleed, or create difficulty maintaining proper perianal hygiene.

Anal Skin Tags

  1. What causes a hemorrhoid?

The exact cause of a hemorrhoid is unknown. Any action that increases pressure around the anus (such as straining to have a bowel movement, constipation, diarrhea, persistent heavy coughing, pregnancy, or lifting heavy objects) may lead to swelling or bleeding from the hemorrhoid.

  1. How common are hemorrhoids?

A report from the National Center for Health Statistics found that 10 million people in the US complained of troubles from hemorrhoids. Over 1 million prescriptions are written per year for medications for hemorrhoids. The peak age is 45-65 years of age, even though any age could potentially be affected.

  1. What are the symptoms of hemorrhoids?

Symptoms are dependent on the type of hemorrhoid.

The symptoms from internal hemorrhoids classically involve painless bright red bleeding that occurs during a bowel movement. Internal hemorrhoids may also prolapse or protrude outside of the anus when having bowel movements. They may reduce or go back in on their own; however, sometimes they require manual reduction (pushing them back into the anus). Pain is generally not a symptom of internal hemorrhoids, but if pain is present, it may be because of a prolapse or thrombosis of the internal hemorrhoid. A thrombosis occurs when the blood within the hemorrhoid clots and the hemorrhoid becomes very tender.

 

There are 4 grades of internal hemorrhoids:

Grade 1-hemorrhoids present but do not protrude

Grade 2-hemorrhoids protrude but reduce spontaneously

Grade 3-hemorrhoids protrude but require manual reduction (pushing them into the anus)

Grade 4-hemorrhoids protrude but cannot be reduced

Prolapsed internal hemorrhoids

 

The symptoms from external hemorrhoids involve swelling, discomfort, bleeding, and pain. They may become thrombosed. External hemorrhoids cannot be manually reduced. Struggling to “push them in” can cause more swelling and pain.

Thrombosed external hemorrhoid

  1. What can I do to prevent problems with hemorrhoids?

Drink adequate volumes of fluids each day and add bulk to the diet to eliminate straining. I recommend adding fruits, vegetables, and unprocessed wheat or oat bran to the diet. An alternative is to add psyllium seed or other fiber supplements, getting 20-35 g of fiber each day. Minimize extended periods of time on the toilet as doing so can increase strain and pressure around the anus. So that means put away the cellphone, magazines, and newspapers which may increase the amount of time spent on the toilet! Hemorrhoids may also be prevented by avoiding passing hard stools and avoiding straining with bowel movements or heavy lifting. The hemorrhoid itself may not go away. However, surgery may not be needed if there is no pain, bleeding, or swelling.

  1. So, I have a hemorrhoid. Now what?

Hydrocortisone creams may be helpful in improving symptoms of hemorrhoids.  If the over-the-counter versions do not provide relief, a stronger prescription from your doctor may be used. However, overuse of these products can make some symptoms like itching worse, which is why close follow up with the doctor is important. It is important to see an experienced physician. After a thorough examination, your doctor may conclude that symptoms reported from hemorrhoids could actually be from other anorectal diseases and conditions (i.e. anal fissures, anal abscesses, colorectal polyps, rectal prolapse).

  1. Do I need surgery for my hemorrhoids?

Not necessarily. The actual presence of the hemorrhoids or tags does not imply the need for surgery as long as symptoms are nonexistent, minimal, or tolerable. Your symptoms decide when and if surgery is needed.

  1. What are the most common procedures or surgeries for my hemorrhoids?

Internal hemorrhoids are most commonly treated with rubber band ligation, which is an in-office procedure to eliminate the symptomatic internal hemorrhoids. A ligation can also be performed in the operating room with suture. External hemorrhoids are excised in the office if a thrombosis is present (blood within the hemorrhoid clots and the hemorrhoid becomes very tender). If the external hemorrhoids are large, painful, bleeding, and not responding to medication, you may be a candidate for a surgical procedure called a hemorrhoidectomy. With this surgery, both large internal and external hemorrhoids are removed in the operating room with anesthesia.

  1. Do hemorrhoids lead to cancer?

No, they are not cancer and do not lead to cancer. However, symptoms from cancer may mimic those from hemorrhoids.

  1. So, what’s the bottom-line?

Just remember, there are a number of other potential causes of anorectal pain and bleeding. If you think you have hemorrhoids or have any of these symptoms, see a doctor. If bleeding and pain continue to be present despite treatment, definitely follow-up with your doctor to ensure you are getting the right treatment for the right problem.

Silent Lessons of My Grandmother

  • hiermedia
  • February 2, 2017

“I come as one. I stand as ten thousand.” – Maya Angelou

I am a surgeon. I am proud of this fact partly because I am the first in my family to go to medical school. I am also proud of this fact because I recognize that me becoming a surgeon has been less about me and more of a collective and cumulative effort of my parents, grandparents, great-grandparents, and countless other hard-working ancestors, many of whom remain nameless. More than any other, perhaps the one person that would influence my initial decision to become a physician was my grandmother. She would also later influence my decision to become a surgeon. Seeing her sprawled out on her kitchen floor after having a massive heart attack when I was 5 years old would, furthermore, influence my resolution to become that surgeon committed to wellness.

My grandmother was the center of our family. Growing up in a very traditional and conservative African-American home, I was surrounded by a large, loving, and supportive family. Family gatherings at my grandmother’s home were frequent and sometimes without any specific cause. She was generally in charge of deciding the menu items during these gatherings, many of which she prepared herself. At the time, the food was delicious and filling. In hindsight, it was oftentimes, greasy, fried, and nutritionally sparse. The paradox presented in this is that at the same time, my grandmother had many chronic illnesses. I always knew her to be diabetic and was unfazed watching by her self-administering her insulin injections. I became well-versed in hearing about her “Coumadin levels” or her “heart pills.” I knew she was not well as she had difficulty walking short distances and went to the emergency room on a frequent basis, but at the end of the day, medication was the only lifestyle modification for her problems.

Growing up in this setting, I wanted to know the “why” of her health problems. I was not satisfied with knowing generic glossed-over answers, but I constantly asked questions, which eventually led to me choosing medicine as a way to learn more and answer those questions. As most of her health problems were chronic, she was on many medications with oftentimes no immediate change. As a surgeon, I would have the ability to make almost a direct change in the patient’s health, which in addition to a love of anatomy and being in the OR, subsequently became a strong incentive to become a surgeon.

I was fortunate to train at an institution where the hospital embraced the concept of wellness with “eat right” programs and even offered discounted gym memberships. So it was never odd to have a mind towards personal wellness in this setting. I had many attendings that were great examples to me because of their own commitments to eating well and physical fitness. They themselves took time to exercise, spend time with their own families, go to church, and encouraged me to do the same. One attending was known for making climbing the stairs mandatory during rounds! Regrettably, during the early years of my residency, I struggled to find the time and energy to squeeze in exercise and make good food choices. I was at the hospital at 5 and leaving later in the evening. I made poor dietary choices and skipped out of going to the gym. This compromise resulted in weight gain and continued fatigue. Ultimately, towards the end of my training, I had to make my workouts a top priority. By doing so, I was able to foster the required discipline to train and to successfully complete my first marathon during my chief year.

Now as an attending surgeon, my commitment to maintain a sense of personal wellness continues to be a longstanding, purposeful, and intentional journey. By this, I remain in a much better position to prevent burnout and not become detached and frustrated with my patients and the care they require. I am able to handle the increasing physical and mental stressors of being a surgeon much better as I continue to recognize the value of exercise and have kept it a part of my routine. I make time to go to church and spend time with my family. Dietary changes have been the most difficult to make and maintain partly because it has required creating a complete turnaround of what I understand about food. The culture in which I grew up was not particularly health conscious, but after seeing the health problems of those I loved, I recognize that pattern was not one to observe and continue. I have gone through periods of being a vegetarian and even maintained a strict Paleo diet. Ultimately, while not 100 percent protective, my goal has been to make better dietary choices so that I reduce my risk of having health problems I observed as a child in my family.

The night that I saw my grandmother in cardiac arrest on the floor of her kitchen was fortunately not the last time I saw her alive. She was able to recover and lived another 20 years. In the end, she was unable to recover after a surgical procedure. At the point of her death, I was no longer a confused 5-year-old boy but now surgical resident with a better perspective and understanding on the various factors that contributed to her declining health. I now recognize my life as a surgeon is a composite of the invaluable and mainly unspoken lessons my grandmother taught me about health and wellness of my mind and body, and the personal responsibility to ensure I am continually taking care of them both.

Unacceptable Cost of Silence

  • hiermedia
  • October 28, 2016

Nearly a month before our national presidential election, a video surfaced online capturing a conversation between Presidential candidate Donald Trump and reporter Billy Bush. During this 2005 “private” conversation between the two, Trump lewdly brags to Bush about kissing and groping women without their consent. He is even heard boasting he can “get away” with this behavior because of his celebrity status. Trump has been heavily criticized for his words and actions. Billy Bush, on the other hand, was criticized and fired from the “Today” show for what he did not say. There is no footage of Bush stopping and discouraging these comments by Trump. Instead, he plays along and is heard saying “whoa” and “whatever you want.” He has since apologized and expressed feeling “embarrassed and ashamed” for his lack of immediate condemnation of Trump’s suggestive comments and for playing along.

The backlash that ensued reminded me of times in my own life when I played along or remained silent in the presence of language or actions I genuinely wanted to condemn. As I spend a great deal of my time at the hospital, many of these incidences have occurred there. Unfortunately, these incidences transpire more times than most of us in the medical community would want to admit. What is the cost of our silence? In the case of Billy Bush, his inaction cost him his job and perhaps his career. When we as surgeons, fail to speak up in the presence of inappropriate behavior, injustice, and bias, what are the stakes?

The operating room is one place where I have witnessed these types of incidents. The offending culprit was the attending surgeon. Generally, the attending surgeon controls the social climate and atmosphere. So, for example, if that surgeon wants classical music playing, there will likely be classical music playing. Aside from the care the patient requires, the surgeon is the next most looked after person in the OR. When the surgeon engaged in otherwise offensive conversation, no one on the surgical team spoke up. No one expressed concern that the language or tone was inappropriate. No one changed the subject to signal that the content or nature of the conversation was not ok. At worst, the joke was countered with a similarly vulgar example. Sadly, several members of the team responded with either silence or laughter, but no one stopped or condemned the conversation.

Such derogatory, offensive, or discriminatory comments to or about another person or group are not confined to the OR. The subject of the comments have ranged from patients, nurses, hospital administration, or even other physicians with racist, sexist, or ageist undertones. My years in medical school and early years as a resident, when I was most vulnerable and the least powerful and influential in the medical hierarchy, coincide with the times I was most tolerant of this behavior.

So, regrettably, I acknowledge that I, too, have remained silent in the immediate presence of injustices, and because I did not speak up, I have continued to internally replay these moments, wishing I had responded differently. One specific example haunts me to this day. While I was on the interview trail for surgery residency, a department chairman made a racially insensitive comment to the group of interviewees, including me, an African-American, about not taking care of “tar babies” at their hospital. In the moment, I said nothing. I did nothing. In hindsight, I am ashamed of that fact.

In the ensuing years, I now understand I was unable to fully process what was happening in the moment. Partly, I was in shock. After having time to think about his comments, I think this is likely true of others who may have been in very similar situations. Several questions come to mind. What should you say? When should you say it, and how? Secondly, I believe there is a certain cost to speaking up against ethically unjust and offensive language. One could certainly not be accepted or in some cases could be detested for “stirring the pot.” It could lead to social isolation. Nevertheless, I question whether the cost of speaking up (social isolation and exclusion) may not compare to the ultimate cost of not speaking up (further discriminatory and defamatory practices, preventing forward societal progression). But regardless of the cost, I now hold myself accountable and will speak up and address, in a variety of ways, any offensive, derogatory, or discriminatory language.

The demographics of the world are changing, which is appropriately reflected in the surgical profession. Fifty years ago, blacks had great difficulty getting access to surgical residencies and women were considered primarily for degrees in nursing. Today, our surgical societies and residencies have had made progress in increasing diversity to more accurately reflect the patient population and create a culturally sensitive health care environment. This change should also be reflected in what we say and what we tolerate being said in our presence.

How would things have been different if instead of tolerating those spoken words by Trump and playing along, Billy Bush would have discouraged it or even just brought up a different topic? What if every man (and woman) who heard him relay stories of or bore witness to his behavior against women spoke up and declared it unacceptable? But Bush didn’t, no one did, and we continue to have debate and even protest about this and other offensive and derogatory words and actions of not only Trump but also others. While these protest and arguments create a great dialogue in our society, real change occurs in the exact moment and space when inappropriate, discriminatory, and ethically debased language is spoken and a courageous person makes the decision to intentionally speak up against it.