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This hypothetical consultation about hemorrhoids is presented for purposes of general information. If you think you may have this condition, please see your doctor to discuss your individual case and the exams and treatments that are best for you.
Doctor: Hi, how are you?
Patient: Well, I have a problem and I’ve had it for a long time. It’s really embarrassing and I don’t like to talk about it. I think maybe I have hemorrhoids. I have been having a lot of bleeding and I don’t know if it’s something serious.
Doctor: What kind of work do you do?
Patient: I am a truck driver.
Doctor: Can you tell me when you have the bleeding?
Patient: Usually I bleed when I have a bowel movement. It’s worse when I am constipated or when I have hard stools.
Doctor: Do you experience pain with the bleeding?
Doctor: Is the blood bright red or dark in color, and is it on the toilet paper or in the stool?
Patient: It’s in the stool, it’s everywhere I sit, and on everything I wear. It’s bright red blood.
Doctor: Can you tell me about how much you bleed? Is it spotting, or more like a tablespoon, or a cup?
Patient: It’s more than spotting. Every day in the truck, I stain my pants and sometimes the toilet water is bright red. Sometimes there are even clots.
Doctor: Are you experiencing any other symptoms moving your bowels? Is there any abdominal cramping, pain, change in the caliber, size or thickness of your stools, change in your weight or nausea?
Doctor: How often do you move your bowels?
Patient: Every morning once a day.
Doctor: Do you have hard stools from time to time?
Patient: Sometimes my stools are hard.
Doctor: Do you strain when you’re having a bowel movement?
Patient: Yes, often.
Doctor: How old are you?
Patient: 49 years old.
Doctor: Have you ever had a colonoscopy before?
Patient: No, I haven’t had one. I read that you don’t need one until you’re 50 years old.
Doctor: Do you have a family history of polyps, colorectal cancer or inflammatory bowel disease?
Patient: I’m not sure I know what all those names mean, but no, not that I know of.
Doctor: Well, the first thing I’ll suggest is that we examine you here today. Sometimes what people think are hemorrhoids turn out to be something different, which is why it’s really important for us to examine you on the outside and also do an internal exam with a finger, which is called a digital exam. Then I’ll use a small anoscope to look inside.
Patient: What is an anoscope? It’s not that colonoscopy tube, is it?
Doctor: No. An anoscope is a small, short instrument to look at the inside of your anus. Internal hemorrhoids are rarely painful, but they may cause troublesome bleeding, and they sit on the inside of the anus. External hemorrhoids sit just outside the anus and can present as a painful swelling. What you are describing are classic symptoms of internal hemorrhoids, so we’ll do the internal exam. And then, it’s not a bad idea to schedule you for a colonoscopy to make sure that everything is okay on the inside and that we are not missing any polyps or inflammation that may be the source of bleeding.
Patient: Some of my friends have had a colonoscopy and it sounds awful. I don’t really want to have one.
Doctor: I understand your fears, but it is necessary to be sure you don’t have any other reason for bleeding. We’ll give you strong drugs to sedate you and to prevent discomfort, so it won’t hurt. In fact, most patients are not aware that the examination’s going on.
Doctor: Please undress from the waist down so that I may examine you. I will be back in two minutes with a chaperone to take a look.
Exam: On the outside of the anus, the patient had some external skin tags that appeared benign, and no other abnormalities. On digital exam there was obvious blood. On anoscopic exam, there were moderate-size hemorrhoids that appeared to be inflamed.
Doctor: I’ve completed your exam. It appears that you have bleeding from internal hemorrhoids. You have some external hemorrhoids that look very benign; those are not the problem. The internal hemorrhoids are inflamed and are most likely the cause of your bleeding.
Patient: What now?
Doctor: There are several different ways we treat hemorrhoids. The most simple and the most effective for preventing relapse is to start a high-fiber diet.
Patient: What is high fiber?
Doctor: Foods like vegetables and oatmeal are high in fiber.
Patient: I don’t like oatmeal.
Doctor: Well, you’ll have plenty of other choices. There are many high-fiber foods. My nurse will give you a list of them. I am sure you and your wife can find some things you will like. In addition, you should increase your hydration.
Patient: What is hydration?
Doctor: Hydration means drinking lots of water.
Patient: I drive a truck. That means I’m going to have to make stops a lot more often.
Doctor: I understand, but it’s important. You should also start a fiber supplement. It will help keep your bowels regular, keep the bowel movements soft, and prevent more trauma to your anal canal that is causing the bleeding.
Patient: That all sounds fine. What else?
Doctor: To take care of the hemorrhoids you have now, I’d like to do a hemorrhoid banding procedure. We’d do it here in my office and we’d schedule a separate appointment for it. A hemorrhoid banding is very similar to the procedure you just had. We put an anoscope inside the anus and then we clasp some of the hemorrhoid tissue and place a rubber band around that tissue.
Patient: Does it hurt?
Doctor: You’ll probably feel some pressure and discomfort during the procedure, but it is rarely painful. After the procedure, I’ll recommend that you go home and rest for the rest of the day, and then you can go about your usual activities the next day. After about 7-10 days, the hemorrhoid and the rubber band will fall out during a normal bowel movement. There can be a little bit of bleeding at the time, but over the course of several weeks you should notice that the bleeding slowly resolves. We can repeat the banding procedure several times if we need to.
Patient: Will that get rid of the hemorrhoids?
Doctor: We’ve treated thousands of patients with hemorrhoid banding, and somewhere between 60 and 80 percent of them get better. Most patients get a good result with no more than two or three bandings.
Patient: What if that doesn’t work?
Doctor: There is a small group of patients who continue to have symptoms despite these simple approaches, and for those patients we can consider an excisional hemorrhoidectomy.
Patient: What is that?
Doctor: An excisional hemorrhoidectomy is a surgery to remove the hemorrhoids. We perform it in the operating room with sedation, spinal anesthesia or general anesthesia. We remove the hemorrhoid by cutting it out, and then we use stitches which are dissolvable -- they dissolve on their own. This procedure usually takes about 30-40 minutes and you can usually go home the same day. Then, after about 4-6 weeks, you’ll notice that the hemorrhoids are gone and the bleeding has stopped. The drawback of this procedure is that it can be very uncomfortable.
Patient: You mean pain.
Doctor: Yes, but don’t worry, I would give you whatever medications you would need to be comfortable. We send all of our patients home with pain medication and stool softeners to help them get through the rough part.
Patient: What are the risks?
Doctor: The main complication of the procedure is the pain. Sometimes there is bleeding, and sometimes we even have to go back in and do another surgery to control the bleeding. Some patients experience enough discomfort and pain that they have trouble moving their bowels or even urinating. A very small percentage of patients get an infection from the procedure, and that causes fever, chills, and some foul-smelling drainage from the backside. If that happened, you would come back to see me or go to the emergency room and we would start you on antibiotics.
But we will try the more conservative treatments first, and chances are that the banding will take care of your hemorrhoids. I recommend that we schedule you for a colonoscopy just to make sure nothing else is going on, and then we’ll set up an appointment for a hemorrhoid banding here in the clinic.
Patient: And this will make the hemorrhoids go away and I won’t have any more problems?
Doctor: The banding should take care of the hemorrhoids that you have now. But in the long run, you can get more hemorrhoids if all the factors that caused the hemorrhoids in the first place are still there.
Patient: What caused them?
Doctor: Straining, difficult bowel movements, hard stool, and constipation. If you experience those things, you can get more hemorrhoids. To keep that from happening, it’s important to stay on a high-fiber diet and keep well hydrated.
Patient: I think I’m ready to have the banding. I hope it works for me so I don’t have to have the other surgery.
Doctor: My assistant will get the hemorrhoid banding procedure scheduled for you. And we’ll make sure you get that list of high-fiber foods. Remember – drink your water, even if it does mean that you have to stop your truck a little more often.
Patient: Thank you. I’ve been so worried.
Doctor: Well, it can be very frightening to have bleeding. This is a very common problem, but people can be afraid to talk with their doctors about it. I’m glad you came in to check it out.
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