Melanie Cole, MS (Host): Welcome to GW Hospital DocPod, a peer to peer podcast for medical professionals with the George Washington University Hospital. I'm Melanie Cole. And joining me today to highlight hemorrhoids and benign anorectal diseases is Dr. Marian Khalili. She's a fellowship-trained colorectal surgeon specializing in the minimally invasive and robotic treatment of colon and rectal diseases at the George Washington University School of Medicine and Health Sciences. And she's affiliated with the George Washington University Hospital. Dr. Khalili, thank you so much for joining us today. I'd like you to start with covering the prevalence of hemorrhoids and benign anorectal diseases, how common they are. What do you see in your practice?

Dr Marian Khalili: Thank you so much for having me. So, hemorrhoids are probably the number one complaint that I see in my practice. Of note, oftentimes we get patients sent over to us who have a complaint of hemorrhoids, but they have other anorectal issues going on. And sometimes, things that are more problematic and need prompter treatment like anal cancers. But yes, hemorrhoid is the number one complaint that I see.

Melanie Cole, MS: Then, let's talk about causes and risk factors. We've heard pregnancy is a big cause. But there's both internal and external hemorrhoids, doctor. So, speak about some of the risk factors and if they're different depending on the location of the hemorrhoids.

Dr Marian Khalili: Sure. So, that's a great question, hemorrhoids, first, we could talk about what exactly they are. They're actually a normal part of our anatomy. They are the sinusoids in the rectum where blood pools. And they become problematic when they become enlarged or inflamed. They can prolapse. There are internal and external hemorrhoids. The internal hemorrhoids are kind of defined as being above the dentate line in the insensate part of the anal canal. And the external hemorrhoids are below the dentate line, and they are in the sensate part of the anal canal.

And the risk factors for hemorrhoids do apply to both internal and external hemorrhoids, You could probably put them into different categories. I mean, there is definitely just a genetic component. There are things that we can modify, like how we strain in our bowel movements, the consistency of our bowel movements. And oftentimes, there are other modifiable risk factors that are just characteristic of patients who have hemorrhoids, so anything that increases the pressure in your pelvis, whether that's obesity, pregnancy, and pregnancy is actually two reasons why people get hemorrhoids from pregnancy. One, you have that increased pressure in your pelvis, but also that increased pressure is causing a decreased venous return and causing blood to pool in those hemorrhoidal sinusoids. And there are also things like sitting for prolonged periods of time, heavy lifting, everybody knows about constipation, but also diarrhea causes the hemorrhoids to be inflamed. So, I think those are kind of the basics.

Melanie Cole, MS: What are some symptoms? As people who are suffering with hemorrhoids, usually the primary care provider is their first stop, and they describe some symptoms and then get sent over to Gastroenterology. Can you tell us a little bit about those symptoms that a primary care provider might notice that would prompt a referral.

Dr Marian Khalili: Yes. The number one symptom that people have is actually rectal bleeding. Now, rectal bleeding can be more than just hemorrhoids, but internal hemorrhoids in particular bleed. And people describe bleeding found in the toilet bowl, on the toilet paper, it can vary. And just to keep things clear, a little bit of blood in the toilet bowl can look like a lot of bleeding. So, people sometimes think that they're hemorrhaging, but only a tiny drop in the toilet bowl goes a long way.

Other than bleeding, you have symptoms of itchiness, difficulty with hygiene. There can be a sensation that there is a mass in your bottom. They can be painful, particularly when they become thrombosed. So, that's when there is a blood clot that develops in the hemorrhoid that's prolapsed, but typically not very painful. They're just uncomfortable. They can have drainage of mucus, so people complain about that as well.

Melanie Cole, MS: Before we talk about treatment options that are available, diagnosis, is this made mostly on observation? Is colonoscopy or another internal exam required generally? How do you diagnose that that's what it is? Because for patients that are going to their provider, that blood you described can be quite scary and, right away, the mind goes to colon cancer.

Dr Marian Khalili: Absolutely. So, the first thing you want to do is to get a really good history. And in the history, that includes a patient's age, of course, and that can determine whether or not you're going to push more towards getting a colonoscopy, but you also want to look for those, scary symptoms that people have who have colon cancer. So, you want to make sure that they're not having weight loss. You want to make sure you ask questions about their family history, and you want to find out more about their bowel habits, if there has been a recent change in their bowel habits. So, those are the signs that you might be more concerned about something more than just hemorrhoids.

And also, the symptoms and what people describe can get you a good idea of whether you're dealing with a hemorrhoid versus a fissure. As I said before, hemorrhoids, if they're internal, they tend to bleed. If they're external, they tend to be uncomfortable. They can become thrombosed and be painful, but unusual for them to be painful. If somebody's saying that they're passing glass from their bottom, it's not a hemorrhoid. It's most likely a fissure. So, there's very specific things people tell you when they're complaining about hemorrhoids. So, the history goes a very long way. And when we see these patients, we do an anoscopic exam in clinic. So first, we do a digital rectal exam just to make sure that there are no obvious masses. And we take a look on the inside and we are able to identify hemorrhoids on the exam. And we could see if they're internal or external, we could see if they're prolapsed.

Melanie Cole, MS: So now, speak about treatments. Do they always have to be treated or is this something that many people just assume you live with? And If you do decide to treat them with a shared decision-making with your patient, what are some of those options?

Dr Marian Khalili: So, they are definitely treatable and they can be actually treated quite effectively with medical management alone often, not always, often. So, there are different grades of hemorrhoids. There is grade 1 through 4, and that's also mostly dependent on the patient history.

Grade 1 hemorrhoids do not prolapse, they cause bleeding. Grade 2 hemorrhoids may prolapse when you have a bowel movement or you strain, but they go back in on their own. Grade 3 hemorrhoids prolapse and you can push them back in. And grade 4 hemorrhoids are just out and you cannot push them back in. And so for grade 1 through 4 hemorrhoids, your first line of therapy should be medical management. And that includes increasing the fiber in their diet, and you can also consider fiber supplements. You want 25 to 50 grams of fiber a day. And when I speak to patients about that, you know, I think people don't recognize how much fiber that is. So, I think most people actually require fiber supplements as well.

We discuss their toileting habits and how much time they spend on the toilet. I tell patients a maximum of three minutes on the toilet. You don't want to be straining. And I speak to them that when your hemorrhoids are inflamed, you have this sensation that you still have to poop, but there's actually no poop left. It's just the inflamed hemorrhoids that are fooling you. So, I tell them, "Three minutes max, get up off the toilet, do something else. If you still feel the sensation that you need to go back to the bathroom, you can always do that."

I am not a huge fan of the topical agents like the Anusol suppositories, Preparation H, lidocaine. There isn't great evidence that they're effective and you're definitely not supposed to use them for more than seven days because, depending on whether or not they have steroids, they can cause thinning of the already very delicate anoderm. And it also just causes excoriation of the area.

And then, just for symptom management, I recommend sitz baths. So, those are the conservative medical managements of hemorrhoids. Now, I tell people when they first see me, go do that, try it for two months, and then come back. If you continue to have problems, the other options, it depends on where the hemorrhoids are.

So if they are internal hemorrhoids, they are often amenable to in-office procedures. One of my favorite things to do for internal hemorrhoids that bleed is rubber band ligation that can be done in the clinic. It's important not to do that if the patient is on Plavix in particular and other kinds of anticoagulation, because you put a rubber band around that hemorrhoid column, and that rubber band actually falls off five to seven days later, and they might have delayed bleeding at that point. So, it's a relative contraindication. Now, whether or not aspirin is a contraindication is more of a controversy. And the risk for rubber band ligation, the worst thing that can happen, although it's exceedingly rare, is pelvic sepsis. And people have different ideas about how many rubber bands you should place at the same time. I often do one for the first time to see if the patient tolerates it well. And if they tolerate it, then I do the next three.

There is also sclerotherapy. So, that is when we inject a sclerosant agent. So, that can include 5% phenol and almond or vegetable oil. It could be hypertonic saline. This is really useful for patients who are on anticoagulation. It's efficacy is less than rubber band ligation, but they don't have the risk of delayed bleeding. And this is actually often what I do when I get called about patients in the hospital who have hemorrhoids that are bleeding, because they're often sick and have other reasons for bleeding, like being on anticoagulation or liver disorders. There's infrared coagulation, and that causes ischemia of the internal hemorrhoidal vascular complex. And those are the in-office procedures.

The surgical procedures involve excising the hemorrhoid columns. So, those are the things that we do in the operating room. The number one thing that I warn patients before I take them for a hemorrhoidectomy is that it's extremely painful. It is one of the most painful surgeries that we do. And there are complications such as urinary retention, up to 25% of men end up having urinary retention in the immediate postoperative period; postoperative hemorrhage, which may require a re-operation. If you take more than you're supposed to of the hemorrhoids, you can end up getting anal stenosis. Very rare, but also can cause fecal incontinence. And again, with any kind of procedure that we do in the anal canal, there is a risk of postoperative infection and pelvic sepsis, very rare though.

Melanie Cole, MS: Thank you so much for that very comprehensive explanation of the treatment options available. As we get ready to wrap up, Dr. Khalili, what would you like other providers to know about referral, when it's important to refer to the specialists at the George Washington University Hospital, and really what you'd like them to know about the multidisciplinary approach for people with hemorrhoids and benign anorectal diseases and any complex versions of those?

Dr Marian Khalili: It's important to always do a rectal exam, because again, I think patients when they have any kind of anorectal symptom, their immediate thought is that they have hemorrhoids and often it's not hemorrhoids. So, getting a really good history and also doing an anorectal exam goes a really long way. We are happy to see anybody with hemorrhoids that you send our way.

The other thing that, you know, I think would be really beneficial to patients is when we speak to them about the medical management to be really clear about how much, because you can't just say, start taking fiber. You have to be really clear about the directions that you give patients. So, how much fiber should they take? Should they change their diet? You should really speak to them about their toileting habits. And we often say constipation is the culprit. But often, it's actually having not very well-formed bowel movements that cause hemorrhoids. So, you need to get those Bristol 3 stools, and how you get that through increasing the insoluble fiber in their diet. So, I think those are kind of the big pieces of advice I would give to primary care doctors managing hemorrhoids.

Melanie Cole, MS: Thank you so much, doctor, for joining us today. And to refer your patient, please call 1-888-4GW-DOCS. That concludes this episode of GW Hospital DocPod, a peer to peer podcast for medical professionals with the George Washington University Hospital. I'm Melanie Cole. Thanks so much for tuning in.

Physicians are independent practitioners who are not employees or agents of the George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks associated with any surgical procedure. Please speak with your physician about these risks to find out if this procedure is right for you.