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Hemorrhoids – May Webinar Transcription

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New York Gastroenterology Associates

May Webinar
Hemorrhoids: Getting To The Bottom Of It – Transcription

 

Ugo Iroku, MD, MHS

Good evening, everyone, and welcome to New York Gastroenterology Associates webinar today we’ll be talking about hemorrhoids getting to the bottom of it. My name is Dr. Ugo Iroku and I’am pleased to be here with my two co panelists, Dr. Dan Adler, who will get to hear from later on in the presentation, and Suzie Finkel, a registered dietitian extraordinaire, who will also be presenting and fielding some of your questions regarding hemorrhoids and the treatment of those. All right. So we’re going to go ahead and get started. Okay. So I’m going to share my screen here, hopefully successfully to start off with, of course, we’re going to ask the question and hopefully answer sufficiently, what are hemorrhoids? They go by a number of names, depending on what part of the country you come from. Sometimes they’re just called rectal lumps. Sometimes they’re called piles. You can feel them as lumps in the rectum. But the formal definition, of course, are the dilation and enlarged veins in the lower portion of the rectum or anus. Okay. And this diagram helps to give you a view of what hemorrhoids look like up close. So if you notice here, this purple coloration here is meant to depict external hemorrhoids.

There are internal hemorrhoids that can exist as well, deeper into the rectal canal. And sometimes those hemorrhoids can prolapse outwards and be seen outwards. So if you have bumps on the outside of the rectum, they could represent external or internal hemorrhoids. And we’ll get into more detail about this anatomy in a few more slides as well. All right. So for those of you who want a little bit more detail, there are three major cushions of these hemorrhal veins that exist in the inner sphincter area. There’s left lateral, so there’s a big cushion to the left, and on the right side there’s right interior and right posterior. So there are three major components where people can have internal hemorrhoids. And then there are some additional smaller bundles of veins or vessels between those two as well that can contain prominent hemorrhoids. Sometimes about 10 million of us will have hemorrhoids. Peak ages are aged 45 to 65. The stats show that for adults 50 years or older, you’re 50% likely to have hemorrhoids. It’s very common amongst many stages of life, including pregnancy as well. So what causes hemorrhoids? It can be caused by many reasons.

And we’ll try to fly through some of these or chronic trauma to the area. Constipation and straining and the irritation to the area diarrhea similar constant irritation to that rectal area, sitting for a prolonged period of time, standing for a prolonged period of time, but especially sitting in occupations that involve that obesity adds to the risk, heavy lifting, pregnancy and aging as well, as we mentioned earlier. So these are a lot of words, but they’re all just to say, hemorrhoids can form by the swelling of the blood vessels that exists in the bottom of the rectal area. We all have these hemorrhoidal veins. Every human being does these labyrinths, these plexus of blood vessels, and we call it hemorrhoids. When these blood vessels get swollen and dilated, chronic straining again to the area with the constipation and diarrhea, like we mentioned, can cause trauma and cause inflammation and can cause swelling. And these cushions of blood vessels, like I mentioned before, can sometimes detach from the area of the rectal wall that they’re tacked to and actually prolapse downward towards the toilet bowl. So they’re swollen and they have the risk of leaving our body prolapsing and moving outwards towards the rectum annual area.

All right. And then as you have continued trauma to these blood vessels, that’s what leads to bleeding. These blood vessels have blood, of course, on the inside. So the more trauma you have to these cushions of blood vessels that exist at the bottom of the rectum, the more likely you are to have the bleeding interior. So this is another pictorial depiction of internal hemorrhoids. This line here represents what we call the dentate line. And anything that originates above the dentate line represents internal hemorrhoids. When it’s below that, it represents external hemorrhoids. What’s one key significant difference between the two hemorrhoids above the dentate line tends not to be in a very tender place. The nerve innervation above the dentate line is very sparse. And so it’s not as painful when you have hemorrhoids or intervention to the hemorrhoids below the dentate line. They’re very significantly they can be painful at times. And so we manage that appropriately in the way we treat external hemorrhoids. All right. So when it comes to internal hemorrhoids, you might have heard of different classes of internal hemorrhoids. And just to quickly walk you through that class, one is typically where you have internal hemorrhoids and it’s in place.

It is not prolapsed type two. Grade two is when the hemorrhoids can prolapse. So leave the anal canal and be seen on the outside, but then it spontaneously goes back. Grade three is where it prolapsed, but then it stopped there and it only goes back if you push it back in, you or your physician pushes it back in. And grade four internal hemorrhoids or whether prolapses and you cannot get it back in. And so these are different grades of the severity of internal hemorrhoids that we have to treat from time to time. All right. What are the symptoms of hemorrhoids? We know those could be bleeding, red blood in the stool, pain with bowel movements, that itchiness, difficult hygiene, a sense of incontinence or smearing in the underwear, the prolapse, like I mentioned, the rectal tissue leakage as well. And then thrombosis, which is where you have some clot formation in the blood vessels there. All right. So we can skip over these as well in the interest of time. So when it comes again to hemorrhoids, we expeditions like to do what we have what we call a differential diagnosis. And what does that mean? It means that even as we’re considering that your symptoms may be hemorrhoids, we’re also thinking about some other disorders that could present in similar ways when you come in with your severe pain that recently started.

We don’t just consider it hemorrhoids. We also wonder whether or not it’s a fissure, a little tear to the area, an abscess fistula, a burrowing tunnel caused by underlying disease or thrombosed hemorrhoid, a clot formation within those hemorrhoids. Sometimes the pain is chronic. Again, we’re thinking about more and more things depending on which symptoms you have. And so we’re never just assuming it’s hemorrhoids, but we always want to keep a differential diagnosis, an open mind to the other things that might be causing similar symptoms. And so if you do have chronic pain, bleeding, itchiness discharge and a lump to the area. Don’t be surprised if at some point your doctor, if these symptoms are not resolving, would like to do a few more additional tests to make sure there’s nothing more severe going on. All right. So don’t be surprised. Again, we normally have you in the left lying on your left side and examine the area on the outside. We want to look to see if there are any tail, tail rashes or skin Tags, any evidence of fissure, injury to the rectal, anal area, any evidence of abscesses or drainage to the area. We want to make sure your sphincter is functioning properly when we do our rectal exam.

That’s one of the things we’re feeling for. And we want to make sure there’s no sign of tumors there. All right. And we’re going to go into what are some of the treatment options as well for our internal and external hemorrhoids. Again, we’re lucky enough to have Suzie Finkel on the line here, so she will, at the end of my talk, go into deeper detail about really what’s the mainstay of treatment for hemorrhoids, which is the dietary management. So we’ll fly through some of those dietary slides, but there are also some other approaches that we will address as well. All right. As you’ll go into fiber is a major component of the diet. And again, I’ll fly through my slides because she’ll go into all of this detail. You already know that you should be getting about 20 to 30 grams at least, of fiber in your daily diet, supplemented. If your diet is not sufficient, we’ll go over insoluble and soluble fibers. But one other component of the first line therapy is making sure you’re practicing proper bowel movement habits. So one important thing is to avoid straining. And that’s in some ways, in some ways, a lot of the reasons why we give you a high fiber diet, I recommend you do a lot of fluid intake so that when you’re sitting down, you’re able to move your valves promptly.

Sitting in that position, in the seated position favors the pooling of blood in those hemorrhoidal veins, as you can imagine. Just from the anatomy I showed you earlier. And so we want you to have bowel movements that don’t require you to stay on the toilet for a prolonged period of time, don’t cause a lot of constipation and straining and irritation to those hemorrhoidal veins and don’t lead to other complications like bleeding. All right, so there are also additional non surgical options that we use when the dietary methods, when you drink fluids, when you practicing proper bathroom hygiene is not working. They’re over the counter creams and suppositories that contain hydrocorticone. These are designed to reduce the inflammation that are going on in those hemorrhoidal areas. We’d like you to keep, of course, that area very clean. There are sitz baths available, of course, over the counter. We want to make sure that area is nice and clean. And if you need to use a sitz bath that’s an over the counter option for cleaning and soaking that area for relief. And for some people who have severe pain and discomfort in their area and have a platform while you’re waiting for treatment of that, sometimes even cold compresses can be of some relief.

But again, coming to see your doctor so we can definitively treat this is really the primary method of management. Like I mentioned, if you have a hemorrhoid that’s internal that’s popped out, you can see whether or not you can gently push it back in if you meet great resistance. Of course, we don’t want you to injure yourself, so do no further pressure. But if you can, it’s okay to gently reduce to move back in hemorrhoids if they popped out. And like I mentioned, sitz baths, Tucks wipes, these are all options, over the counter options for treating the area, for comfort and cleanliness. All right, so when it comes to further management, what are some additional treatments we have to offer for our patients who come in with varying grades of hemorrhoidal stages, especially internal hemorrhage? So we’ll start with that. So internal hemorrhoids again, because they’re not very sensitive in that area above the dentate line, there are more things we can do to treat you and to get your hemorrhoids feeling better in the office. Again, when it comes to grade one hemorrhoids that are in place, they’re not popping outwards. We’ll always start with talking to you about high fiber, a lot of fluids.

And then there are additional therapies, including rubber band therapy, floral therapy, and even infrared coagulation that we bring to bear. The more severe of a great internal hemorrhoids you have, the more we bring in these additional words that likely will be referring you to the surgeon to help us manage hemorrhoidopexy and then also staple and excisional hemorrhoidopexy options. And we’ll go into more details of these words in a few slides. All right, so just moving along. Again, like I mentioned, one option we have for treatment is the rubber band ligation. This is a treatment that often we refer to our surgical friends for treatment of more severe internal hemorrhoids, or if there are conditions where they have both internal and external. Sometimes our surgical allies will help manage these types of hemorrhoids. And what does it mean to undergo a rubber band ligation? It really is exactly contained in the phrase. So the rubber band is what’s used to kind of tie off the blood vessels that would form the hemorrhoids. And ligation just means the tying off. So rubber band ligation just refers to the fact that these small rubber bands are deployed on the inside to the internal hemorrhoids that are problematic to prevent them from swelling and to ultimately cause that hemorrhoid to fall off.

Then the ulcer that’s formed after the hemorrhoid falls off scars, over. And even that scarring process helps to prevent any further swelling of the hemorrhoid in that particular area. Kind of tax it pushes the blood, the vessels to the rectal wall, preventing recurrence. All right. And I think I just said it’s successful in a large fraction of patients, two thirds to three quarters of patients will find successful treatment with rubber band ligation. The truth in advertising is that, yes, there can sometimes be some pain in people who undergo rubber band ligation. And the reason why is, again, it’s an aggressive therapy. It’s meant to fall above the dentate line, which, as you remember, is the area of the rectum that does not have the nerves. But every now and then there can be some tautness or still some pressure that is felt by the nerve endings that begin lower down in the anal canal. But that can be interpreted as pain. Usually our surgical colleagues try to assess as to whether or not the deployed band is causing whether or not the band is causing pain before they finally deploy it. And so if they notice that they’re on the examination table that you’re having pain, they’ll take it off and reposition it before they finally deploy it.

And usually people are able to get back to work right away. You might have a feeling of some sort of sense of difference in the emptying of your bowel subsequently. And then typically they don’t like to use this if you’re on a blood thinner. All right. And so hopefully you either have eaten your dinner already or you’re far from it. But you can tolerate this picture a little bit. But for those of you can tolerate the graphic nature of it and want a little bit more details to what it looks like. Yes. That left side of the image shows them accessing the internal hemorrhoids, and then the right side shows that you can make out that band that’s deployed and is now helping to, in a sense, cut off that blood vessel that was causing the hemorrhoid swelling overtime. The hemorrhoid falls off over the next five to seven days, and you just have an ulcer that continues to heal up after that without difficulty. All right. Typically, you might have gone to see a surgeon or a colleague, and you might have been surprised that they didn’t treat the left lateral, the right interior, the right posterior, all the cushions of your internal hemorrhoids all at once.

And that is correct and typical. Typically, they’ll go after one or two columns per visit. That’s safer and more tolerable for a single visit. And so that’s entirely appropriate if that’s the approach that your doctor took. All right. We do note, of course, that because every human being has these hemorrhoidal veins that exist at the bottom of the rectum, there is always a recurrence rate probability, and they can be as high as 68%. However, that’s looking out five years into the future. In the short term, these treatments are very effective. But, yes. Can you potentially need recurring treatment in the future? The answer is yes. For people who have need multiple treatments, of course, they might undergo multiple treatments in a given year as well. And the good news is that speaking to the efficacy of this option, only five to 10% of patients need a more aggressive surgical approach to the hemorrhoid care who are sent for the rubber band ligation. All right. And again, this is just digging into the possible complications. Again, just looking at the fine print. Yes, there’s a possibility of pain again, in better hands, the numbers are even better than this.

But this is all comers across the country. There was a very rare risk of infection in that area, and there was about a 1% chance of bleeding in that area. And studies that have been done. All right. And so when it comes to office infrared coagulation, this is an option that many of you have had the opportunity to have performed at our offices in Midtown or the Brooklyn office. As of right now, the way this works is that we are again treating those hemorrhoidal veins on the inside to treat the blood vessels that are leading to the internal hemorrhoids that make them less likely to be prominent. Right. So we’re generating an infrared radiation which essentially clots off the blood vessels and the blood vessels leading to the hemorrhoids smoke beneficial in your grade one, grade two internal hemorrhoids. The more severe hemorrhoids are sometimes again, we’ll see whether or not we think you need more aggressive therapy, like with the rubber band ligation. And we will do a number of applications right there. And then we usually do try to treat circumferentially. So throughout the whole area, all cushions with our treatment. But, of course, if they’re very prominent, sometimes there is a risk of pain.

But I will say that the risk of discomfort is almost minimal, especially in better hands. And our patients, I think, will largely attest to the fact that they’re able to get back to work the same day largely without any difficulty at all, the only discomfort being during the actual exam itself, which may feel a bit like a rectal exam, but beyond that, they feel fine. All right. This graphic just tries to give you a little bit of an imaging of what we’re actually doing. Again, we apply our probe on the inside of the rectum, and we’re treating the area above that dentate line that represents the origin of internal hemorrhoids. Again, treating it and making it less likely to actually shrinking it. It should be noted that the effect of the infrared coagulation progresses over time. So we treat you on one day. And with every passing day, the clotting off and the sclerosing is the term of the blood vessels leading to those blood hemorrhoids increases over time, so it becomes more and more efficacious with every passing day, less and less likely that you’ll have your symptoms that you came in with. All right.

And our recent randomized controlled trials have shown that our infrared coagulation is just efficacious just as powerful as the banding techniques on the order of about 81% symptom control in general in all-comers. So that’s great news for our patients as well. All right. And there are additional options that you might have heard of. I’m just going to go through these quickly. There’s something called office sclerotherapy that was used more in the past. This involves injecting a needle into that internal hemorrhoid area to have with a number of sclerosing agents, including phenyle or sodium tetradecyl sulfate with the idea, again, like the infrared coagulation of sclerosing, cutting off those blood vessels that cause the hemorrhoids. We find in general, that patients tolerate our infrared coagulation option better. And so in our office, we don’t offer the sclerotherapy option, but that’s something you should be aware of, just in case you hear of that. All right. Now, of course, for people who have persistent symptoms, whether it’s the itchiness bleeding, pain, left cost, infections, or external hemorrhoid involvement, sometimes it is time to proceed to the surgeon to get more surgical therapy called hemorrhoidectomy. Of course.

What are the risks? Of course, you now have to deal with anesthesia. There’s always a risk of bleeding, infection, and scarring of the area due to surgery. But these are risks. Usually patients have great outcomes when they need surgical management. There are a number of different types of surgical options, and we’ll go through some of these quickly. One very common situation is that of a thrombosed hemorrhoid that I wanted to go over as well. So for patients who have an external hemorrhoid, you have to remember that on the inside of these blood vessels is blood, and blood can clot. And we call that a thrombosed hemorrhoid. And when you have a thrombosed hemorrhoid, it can be very painful, very tender to touch, present as a very inflamed and tender mass. In general, we like to have you come in to report these to us within 72 hours so that we can get you plugged in with our surgical colleagues so that they can actually excise, take out the clot that’s formed and make sure that you’re not suffering in pain. Sometimes people do stick through their external hemorrhoids. They’ll just kind of bear through it. And in those cases, sometimes they just continue to find that their symptoms gradually dissipate.

There are some surgeons who, after the 72 hours Mark, will not proceed to try to do the treatment of the thrombosed hemorrhoid. I will just manage people conservatively, but every doctor manages these a little differently. So if you have pain, don’t suffer at home. Come to you right away because there is a time component that’s involved in managing these as well. All right. Of course, we don’t want you to undergo any complications like necrosis, which is when the tissue around the area is not receiving adequate amount of blood supply. All right. Let me try to speed this up so we get to cover everything. Yes, there are some complications with more aggressive therapeutic options involving both your genetic urinary tract, bleeding, stricter infection and rarely incontinence. So, yes, for people who require more aggressive surgeries, there are some risk. But again, in better hands, we’re seeing excellent outcomes. All right. But in general, of course, we’d prefer you get to prevent all these complications and never get a chance to see us. And so how can you do that? You want to make sure you’re getting your 25 grams of fiber if you’re a female or 35 plus grams of fiber as a male, a lot of fluid, 6 to 8 glasses of water.

Again, we’ll go into more detail with that. We want to make sure you’re exercising, keeping your bowels moving perfectly. Avoid long periods of standing or sitting, especially sitting, including on the toilet bowl. That can cause a pooling of blood in the hemorrhoid area. Don’t strain. That causes irritation. That’s not the way you want to move your bowels and go as soon as you feel the urge, because part of what your colon does is to convert the liquid stool that starts off in the beginning of the colon. The colon dries it out to the form where it’s solid stool ready to go to the toilet bowl. So when you leave stool in your colon, your colon just continues to dry out, whatever is there. And so the longer you leave it there, the more likely it is to be constipated and caused straining and then irritation and inflammation on the way out. All right. So I think that’s the end of my section of this presentation. And so now we will bring on the amazing Suzie Finkel for part two.

 

Hemorrhoids & Diet

 

Suzie Finkel, MS, RD, CDN

Thank you. And I’m just going to share my screen here. So now we’ve learned so many details, all of the details you’d probably be wondering about the hemorrhoid situation and anatomy. I learned a lot, even from the technical pieces there. So really good to know. And if you’re wondering about how diet can impact this. We really want to just think about on the most basic level, that what goes in us comes out of us. And if you’re a parent of a human or maybe an animal, you’ve probably done some inspection of fecal matter and realize that a bit more than inspecting your own stool. But you can see evidence of previous meals sometimes, and particularly when that meal contains some plant fiber, which I’m going to talk a bunch about for a few minutes. But the big concept here is really that what we eat has the ability to affect our stool texture in the ease of evacuation and stool hygiene. And that, in turn, can affect hemorrhoids in terms of active hemorrhoids and hemorrhoid prevention. And so you may have seen this stool chart here. If you’re an NYGA patient, the Bristol stool chart can be very famous around here.

And what it shows is some different stool outcomes. If you will type one all the way at the top to type seven all the way at the bottom, we see two ends of the poop pendulum. That’s what I’ll call it. And basically being at either end, either extreme of that pendulum is something that can aggravate hemorrhoids. Hemorrhoids are often associated with constipation and chronic straining. But hyper defecation and loose bowel movements can also cause issues. And so what we really want to focus on is how we can treat those problems dietarily, but also if there’s something in your diet that is causing a sort of suboptimal poop scenario. And so one primary tool in someone’s diet that can help with hemorrhoids is fiber. So you may have heard eat more fiber, and that’s because fiber can really affect the texture of our stool. But there’s a little more nuance than just eat more fiber. We want to customize it a little bit depending on what’s going on. So fiber is a component of plant foods, and the body doesn’t fully digest it, and therefore, it arrives intact in the colon and then gets excreted. So it plays an important part in the structure of the stool and its ultimate landing place.

A kind of death place, I call it is the toilet. It’s not meant to live in us. It’s going to come out. And if you’ve listened to some past webinars of ours, you might already know a couple of facts about fiber. There’s two main types. We have dietary fiber that can be soluble, which gels with water, and then insoluble fiber, which does not dissolve in water. And these fiber forms affect the texture of your stool, and they can also affect the speed of the contents moving through your bowels. Soluble fiber turns into a kind of Jello type texture and can work to actually consolidate sort of fragmented pieces of stool. I can kind of slow things down in the bowels, whereas insoluble fiber adds more of a coarse bulk, and it can be stimulating to speed up evacuation. So if you have active hemorrhoids, we can leverage certain fiber types to manage a suboptimal stool texture or bowel movement frequency. Right to help give those blood vessels some relief. But we can also use fiber as a preventative tool to keep you regular in the bathroom and avoid hemorrhoid risk. So just to talk about some scenarios that can aggravate or lead to hemorrhoids, one kind of umbrella category is having diarrhea, loose or urgent stools, excessive evacuation through the day.

Anything that causes us to spend a lot of time on the toilet or excessive wiping can be that hemorrhoid risk or agitator. So if this describes something that’s going on with you, foods that are rich in soluble fiber are great starting place because they can absorb excess water in the bowels without being overly stimulating. Think of a soft kind of slug moving through, rather than lots of insoluble or aggressive roughage that’s pressing on the colon walls. And then it’s coming out of your anus. Soluble fiber rich foods include oats and barley, as well as the flesh of sweet potato, avocado, carrots and winter squashes. So skinless, fleshy fruits are also great. These are all smooth, soft textures with a nice gelling capacity. And if you eat insoluble fiber, changing the texture of that fiber can be a helpful modification, too, to make it less abrasive. For example, taking nuts and thinking more so towards the smooth, nut butter version of it, or pureed beans instead of whole beans, smoothies things like berries or kale and so on. And so that’s sort of a texture piece that we can play with. But if you’re having chronic diarrhea or urgency, we also want to consider if there’s a dietary factor that’s driving that pattern.

Many different dietary issues can cause that abnormality in the stool pattern. And so this is where dietitians come in to work with a patient to investigate the possibilities here, such as malabsorbing, something like a sugar lactose intolerance or fructose intolerance. If that’s causing diarrhea for you every day, that’s something that we want to be able to identify. Other things like a food chemical intolerance. There’s something called histamine intolerance that can cause some pretty disruptive changes to bowel movements. Triggers of IBSD, IBS with diarrhea, sometimes that could be fatty foods, spicy foods. Those can vary for individuals. And we want to kind of identify what the pattern is for you. So variety of drivers of the issue, something we want to do some Detective work on. So other kind of big umbrella category here, constipation infrequency hard stools, straining, all these things can be associated. Your fiber plan might look a little bit different to balance both fiber types soluble and insoluble. We like a nice balance here. Both so insoluble fiber like we see green and berries. Those are the examples in this case. But there’s lots of different forms. Nuts and seeds, many different types of foods with mostly insoluble fiber.

But these can stimulate the colon walls and that can kind of trigger some emptying and keep things moving. But a diet of only insoluble fiber, right. A lot of this kind of roughage would produce potentially lots of small, hard or stringy pieces of stool rather than something consolidated. So soluble fiber plays this important role here because it can kind of gel everything together and make it easier to pass with active hemorrhoids. That’s particularly helpful, right? We want something that’s soft, well formed, easy to pass, and also preventing straining. So we want it to come out without too much struggle. So soluble fiber because it holds moisture. It’s a great tool for diarrhea, as I mentioned, but it can also be this preventative tool for constipation or pebble like stool. But important note here is that if you have active constipation, you might want to consider a supportive laxative regimen to evacuate a stool build up. It’s been a while since you’ve gone before adding a bunch of fiber, or else you can kind of further back yourself up. Adding more bulk here to a traffic jam can make things worse and potentially aggravate that pressure.

So really want to clear out a potential big stool burden and then really gradually adding fiber of these different types so you can get used to it. And so just kind of quickly. Doctor Iroku mentioned some tools that we have that are home remedies and over the counter options, but alongside changes to our food, and especially when diet alone is not producing an optimal stool texture frequency, over the counter supplements can work some magic to create a more comfortable toileting experience. Fiber supplements that can help to consolidate stool and add salt soft bulk. It can be helpful help to whipe, clean and really have something that’s a more optimal texture if we kind of can’t achieve that through some diet change or food texture change alone. So these are products like citracel that’s a pure soluble fiber product or more absorbent products. Bulking agents like psyllium, husk and fiber Con are ones that we use quite often. Laxatives and stool softeners may also be helpful, depending on what’s going on for you. If there’s an underlying constipation or an evacuation issue like a pelvic floor dysfunction or a motility issue, we might incorporate those as well.

And finally, thinking about the pooping environment. Right. That should not be overlooked. I don’t mean like lighting candles, but I don’t see why not. But more so, like the toileting position is a really important thing to think about. Setting yourself up for easy passage, elevating your feet is a really important part of that. Having your knees kind of at this 60 degree angle so that you’re more anatomically appropriate at this position to get a stool out. And so you’ll see in this picture here products that are common called Squatty potty, but you can really use anything. You can use a stack of books, you can flip over a trash can, lots of different ways to get in that position and over the toilet day attachments or sprayer attachments. Those can, frankly, be life changing because you’re reducing wiping and you’re reducing that potential irritation and saving some toilet paper use, too. So not a bad thing. They’re relatively inexpensive. So consider that supportive bowel regimen for hemorrhoid management and prevention. And I think we’ll move on with some questions now.

 

Questions & Answers

 

Great. So welcome, everyone. This is a time where you’re welcome to jump in with questions in the Chat area, so you can just click on Chat and type in your questions, and we’ll make sure our panel gets that. And while the questions are coming in, I have a question I’m going to pose to you, Dr. Dan Adler. So when should a person who has frequent blood in the stool and they say it’s from hemorrhoids and maybe their primary doctor says it’s from hemorrhoids and it’s year zero, it’s year one, it’s year two, and it’s the same thing. There’s blood in the stool. At what point should they start getting concerned that there’s something else? There could be something else. How do you manage that in your office?

Dan Adler, MD

It’s a great question. So certainly before too many years click by. A lot of blood in the stool, of course, is very common. And it’s very easy to jump to a conclusion that this is coming from hemorrhoids without really investigation. A lot of this goes by age and symptoms for young people, pregnant women who’ve recently delivered, guys who go to the gym and lift heavy weights. Those are good indicators that they may. But the most important thing is to really get an examination. What I do when I take a look inside is that if clearly hemorrhoids are inflamed angry looking, we see that they’ve recently bled. I feel comfortable most of the time treating the hemorrhoids with the caveat that if symptoms do not go away as prescribed, it’s very important that patients be back in touch with us within a few weeks after treatment. And we are unfortunately seeing colon polyps and colon cancers in younger and younger people. That is not to scare people, but the majority of the time this is hemorrhoids. But you need to sort of have a good nose for when the next step should be taken. So at the end of a hemorrhoid treatment, I always tell my patients that if they’re doing everything right and their bowel movements are soft and well regulated and they continue to see bleeding, they must reach back to us.

And we decide whether it’s appropriate to get a colonoscopy and look further into the colon. Not so much to look for hemorrhoids because we know they were already there. But it’s to make sure there isn’t anything else going on that can mimic the same kind of bleeding that we see with hemorrhoids. Obviously, for older and middle aged people, if, let’s say, someone’s 45 or 50 and they’ve never had a colonoscopy before they are overdue and the colon needs to be checked.

 

Ugo Iroku, MD, MHS

Great. Excellent answer. All right, Suzie, this one’s for you. I’ve seen recent information that fiber reduction is better for constipation than increasing fiber. What are your thoughts about that?

 

Suzie Finkel, MS, RD, CDN

Yeah. So that’s a great question. With fiber, just like stool, we don’t really want to be at either end of the spectrum. We don’t want to have a no fiber diet. We also want to have a diet that’s excessive in fiber if there’s constipation going on. And so we really like the balance of those fiber types, insoluble, which doesn’t gel with water, insoluble with gels with water. But depending on the nature of the constipation. Right. There’s like different sort of thing forms of stool that can be happening constipation, we’re going to customize the fiber a bit. So if it’s constipation, where you’re letting out really small pieces of stool at a time, sort of pebble like stool, we like this soluble kind of bulking fiber because it’s going to hydrate the stool and actually help to sort of sew that together. But if you’re not going for days at a time and we just kind of add a bunch of fiber at once and you have fiber in your diet that could further back you up. So it can kind of depend what your baseline is. Right. If you have a high fiber diet, then the answer may not be to add more fiber.

If you have a low fiber diet, we certainly want to add some fiber. We want to have some bulk to the stool. So it’s important that there’s soft structure, but it is going to depend a little bit about what your baseline diet looks like and what the pattern of constipation is for you.

 

Ugo Iroku, MD, MHS

Excellent. All right, next question for you, Doctor Adler. This patient wants to know how long should I try repositories and other over the counter options before I give up and come into my doctor or gastroenterologist?

 

Dan Adler, MD

So the answer, I think, is a few weeks hemorrhoids, no matter what you do for them, nature takes a bit, of course, and takes time to calm down. And you can’t expect to use repositories for two days and have a miracle. It just doesn’t occur that quickly. But certainly if a month, six weeks go by and you’re diligent and done everything you need to do, and if your symptoms are there, then it’s time to get an opinion.

 

Ugo Iroku, MD, MHS

Okay, great. This question goes. Please discuss the role of meat in the diet and hemorrhoids. I’ve noticed that it toughens my stool up immediately.

 

Suzie Finkel, MS, RD, CDN

Yeah. So meat and we could even lump in proteins here. In general, things like fish and eggs don’t necessarily cause constipation or cause a sort of tough stool, but without fiber, it means that they’re not really providing any structure. So when they reach the colon, they can almost be something that is just a very structureless mass right there’s. Nothing that kind of holds it together. So it can really depend on what you’re pairing with that meat, like a plate of steak or a plate of fish on its own is not going to have kind of anything to help to give it a nice structure that’s easy to pass. So you might want to think about balancing it with fiber on the plate. So we’re looking for a little bit of both plant foods and the protein to go together.

 

Ugo Iroku, MD, MHS

Great. All right. This question is, should I come in for an exam if I know I have stage two hemorrhoids and they feel manageable to me?

 

Dan Adler, MD

So I think it’s a question of how do you know that you have a stage two hemorrhoids? And if you’ve previously been examined and you feel that the advice that you’ve gotten has been good and what’s recommended is working, the answer is no. If you’re guessing that you have stage two hemorrhoids, then absolutely you need some professional eyes on it.

 

Ugo Iroku, MD, MHS

Great. Suzie, this question is how does a low FODMAP diet affect hemorrhoids?

 

Suzie Finkel, MS, RD, CDN

Yeah. A low FODMAP diet is something that reduces these certain types of plant foods with what we call fermentable carbohydrates and for people that are sensitive to FODMAPs. Right. So hopefully you’re not following a low FODMAP diet just for fun. But that’s because you suspect that these are affecting you with some gastrointestinal symptoms and maybe changing bowel patterns. Someone that may be sensitive to FODMAPs or exploring whether they’re sensitive to FODMAPs might find that eating those foods can affect bowel patterns. Right. When you eat certain FODMAP rich foods that might lead to diarrhea or it could lead to constipation. And when we cut those foods out occasionally on these low fat masks, people accidentally unintentionally end up being low fiber because they’re avoiding lots of these plant foods that could be rich and FODMAPs. So we really want to make sure that you have still a good range of some fruit and some vegetables, and you’re not becoming overly avoidant of plant foods because there’s a variety of plant foods that are rich in FODMAPs to circle back to the hemorrhoid piece. Right. So if you’re eating low fiber unintentionally, perhaps on a low FODMAP diet, you could end up with some constipation or some straining or some stool abnormalities unintentionally so important that you have some support there just to make sure you’re eating kind of a well balanced in a well balanced way.

 

Ugo Iroku, MD, MHS

Excellent. The questions are pouring in and we’ll get through as many as we can. All right, so this question is, is Colace clear that’s Docusate a laxative? And please compare Colace to Miralax. And how many days in a row should you take either? Dan, do you want to feel that one? Sure…

 

Dan Adler, MD

So, Docusate is actually not a laxative. It’s actually something that we call it a surfactant. It actually is almost a type of a soap. And what it does is it actually stays within the gut. It is not absorbed into the bloodstream. And what it does is it attracts water and helps admits with the stool, essentially as a lubricant. And it could be very helpful in terms of changing the quality of it. It’s a very safe long term medication to be used because it’s not absorbed into the bloodstream. And if it’s effective for you, it’s potentially a way to go. Miralax, on the other hand, is actually a laxative. And what it does is it absorbs and actually causes a net increase of water to flow into the gut in the small balloon colon. It’s also a very, very good, safe product. Not a first choice for long term health. Unsupervised. I think that it’s a reasonable thing to try as an off the shelf product for a little bit. But if you find that you constantly need to resort to a laxative again, you should see your gastroenterologist for a real diagnosis and some more definitive health.

 

Ugo Iroku, MD, MHS

Great. All right, this question is for you, Suzie. I’ve heard that the six to eight glasses of water doesn’t apply to everyone. How do I know how much water I should really be consuming on a daily basis?

 

Suzie Finkel, MS, RD, CDN

Yeah. Favorite thing, the Pee test. You’re looking at the color of your urine. I really want it to be in that sort of lighter lemonade color. It doesn’t have to be perfectly clear, but lighter yellow. We’re not looking for an amber range, and that is something that’s going to vary for individuals. It’s going to vary on how much you lose in the day, if you sweat, if you work out, depending on the season. So just hydrate until your urine is looking like that light yellow.

 

Ugo Iroku, MD, MHS

Great. Does bicycle riding contribute to hemorrhoids, especially long hours of it?

 

Suzie Finkel, MS, RD, CDN

No. So not on its own, right. Biking doesn’t necessarily cause hemorrhoids, but if you have an active hemorrhoid, friction can cause irritation, and the sweat can also add to that. Right. So keeping that area somewhat dry can make things more comfortable. And Dr. Adler looks like he’s back. So you have anything to add there?

 

Ugo Iroku, MD, MHS

Yeah. The question was, does extended hours of bike riding aggravate hemorrhoids?

 

Dan Adler, MD

Sure, it potentially can, but I always take exercise over hemorrhoids. So continue with your bike riding and do what you need to do to treat the hemorrhoids.

 

Ugo Iroku, MD, MHS

That’s right. I love that answer. That’s perfect. All right.

 

Suzie Finkel, MS, RD, CDN

Padded shorts and padded bike seats. Maybe this person knows that sounds like they’re an avid biker, but those can make the situation more comfortable.

 

Dan Adler, MD

And I’ll also add to shower up and clean and dry the area in the saddle area where you’ve been sitting down after a hard workout. So you don’t walk around with the salt and sweat in the area for a long time after you finish cycling.

 

Ugo Iroku, MD, MHS

Great. All right, we have five more minutes for questions. We’ll get in as many as possible. This question is Hi. Let’s see here. Actually, could you talk about the long term use of magnesium oxide, 400 mg a day?

 

Suzie Finkel, MS, RD, CDN

All right. Either of us.

 

Dan Adler, MD

Good. Start off.

 

Suzie Finkel, MS, RD, CDN

So generally very safe. I think one of the main things to consider is the health of your kidneys. If you have well functioning kidneys, you’re pretty good to take that long term. It can be a very effective we call them asthmatic laxatives. They kind of gently draw water into the colon. And we like magnesium very much in our practice.

 

Ugo Iroku, MD, MHS

Great. All right. Next question is this was regarding, does the doctor examine hemorrhoids while performing a colonoscopy? How often would you recommend an anal hemorrhoid examination if there are no severe symptoms? So a two parter.

 

Dan Adler, MD

So the answer is yes, hemorrhoids are always examined at the time of colonoscopy. Hemorrhoids are actually a part of the most lower colon. And we always make note on a colon report what we see. It’s an interesting time to examine hemorrhoids in the sense that after your colon prep, we always see hemorrhoids a little bit irritated. Now we gauge this. What’s normal irritation versus abnormal irritation, whether or not there’s active bleeding at the time. But yes, they are examined. And in answer to the second part of the question, I think that if someone is having absolutely no hemorrhoid symptoms, then there really isn’t a reason to get a hemorrhoid exam on top of it.

 

Ugo Iroku, MD, MHS

Excellent. All right. How many caplets of citrucel should you take daily for regularity and caplets are more convenient than spoonful to this attendee.

 

Suzie Finkel, MS, RD, CDN

The standard serving of citruscel, standard dose is four of these little tablets, and that’s often effective. It’s really going to be there’s not an equation for it. We do individualize the amount of a fiber supplement for people, you can always start with a smaller amount, see if you notice the difference and add more. But for tablets, often at night, because we’re sort of targeting a morning bowel movement where many adults have their most sensitive active time in the morning, that would be a good starting place.

 

Ugo Iroku, MD, MHS

What should you do if you are young, 35 to 40, a male who lifts weights and gets external hemorrhoids, no bleeding once a year. Is this normal? And is the age and frequency a concern?

 

Dan Adler, MD

So it’s certainly common among weight lifters. And I’ll reiterate what I said before that I’ll always take the exercise over the hemorrhoids. For people who tend to do a lot of standing weights, such as clean and jerk, lunges squats with a bar on the back, that will increase hemorrhoidal stress. Anything that can be done in the upper body that can be done in a sitting position on a bench, for example, in the gym, will decrease wear and tear on the hemorrhoids. And, of course, you can always back off on your total rates. Just reduce the poundage by 10% to 15%.

 

Ugo Iroku, MD, MHS

All right, Suzie, question for you. Do you like benefiber and or sunfiber I find citrusal is hard to take, taste wise.

 

Suzie Finkel, MS, RD, CDN

Yeah, so citrusal we were just talking about does come in the capslet form. Slightly more expensive, I want to say, than the powdered form, but definitely an option to make it tasteless and more convenient, unless you’re talking about the taste of the capslet. In that case, you might notice that for others, too. But benefiber and sunfiber both great products as well. Sunfiber is something that also has a gelling component to it, and benefiber can be helpful as a bulking agent. So it just depends what your issue is. But they can be comparable products, so definitely worth a try.

 

Ugo Iroku, MD, MHS

Great. So we’re running out of time currently, but I would like to end by giving all of our panelists, the two of you, an option to kind of give your final take home messages regarding any aspect of this, whether it’s dietary, symptoms management, treatment, anything that comes to mind. We’ll do. Ladies first, Suzie. So you want to give your final thoughts on this issue?

 

Suzie Finkel, MS, RD, CDN

Yeah. I mean, I think it’s what I mentioned before, very simply, what goes in us, most of it, not all of it, but a portion of it is going to come out. And so you can really think about the texture of what you’re eating, those different fiber components to try to optimize the stool that you’re going to pass and make things easy. And that’s for hemorrhoid risk prevention. But also, while you have active hemorrhoids, the whole dietitian team at Nyga is happy to work with individuals to sort of customize things and investigate what might be going on. Dietarily.

 

Ugo Iroku, MD, MHS

Yeah, that’s been one of the major godsend additions to New York Gastro Associates are amazing dietitian panel, registered dietitian. So please avail yourself of their expertise. They’re excellent. It’s worth it. Please ask your doctor, how soon can I plug in with their expertise? Dan, any final thoughts?

 

Dan Adler, MD

Sure. I think that like most medical problems, common sense goes a long way. I think there are a lot of very good over the counter products, Dietary and local treatments for hemorrhoids, and they’re all worth a short run. But if you find that you’re not getting better, don’t attempt to treat yourself. There are a lot of possibilities beyond hemorrhoids and seek professional help without suffering for a long period of time.

 

Ugo Iroku, MD, MHS

Right. Couldn’t I say it better? Myself, and I will not try to. All right. Well, thank you all for joining us this evening for our conversation about hemorrhoids getting to the bottom of it. Hopefully you did. And we’d like to see you to continue the conversation at our offices. Please reach out to us. Our website is nygacares.com, and you can call us at 212-996-6633 to get plugged in with one of our amazing dietitians or gastroenterologists. All right. We’ll see you at the next webinar.

 

Dan Adler, MD

Thank you. Bye.

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