Being Well 504: Hemorrhoid treatments and surgical options

Author: Weiutv

Lori Casey: Coming up on Being Well, Dr. John Nadeau, general surgeon from Paris Community Hospital Family Medical Center, is here to talk to us about hemorrhoids and treatment options. We'll learn more about a surgical procedure that is less invasive and less painful, with an easier recovery time than more traditional methods. We've got that and more just ahead on Being Well. [Music Plays] Production of Being Well is made possible in part by: Sarah Bush Lincoln Health System, supporting healthy lifestyles. Eating a heart healthy diet, staying active managing stress, and regular check-ups are ways of reducing your health risks. Proper health is important to all at Sarah Bush Lincoln Health System. Information available at sarahbush.org.

Additional funding by Jazzercise of Charleston. Lori Casey: Thank you for joining us today for Being Well. My guest is Dr. John Nadeau from Paris Community Hospital. Thanks for coming over and talking to us. Dr. Nadeau: Thanks for having me.

Lori Casey: Tell us a little bit about your background. You've been at the hospital about a year; where were you at before that? Dr. Nadeau: Well, before this I came from Arizona. I was there for a few years. And I was looking for a practice then just, I felt I was needed a little more, and this was an area that had a need. Prior to that, I'm originally from Maine, and trained in Pennsylvania by the Philadelphia area. Then, we moved to Arizona. So, this is, I guess, my second place to practice.

Lori Casey: Okay. And you're a general surgeon at the hospital. What does that mean? I know it means different things depending on what kind of hospital you're at, but at Paris Community Hospital, what does that entail? Dr. Nadeau: We take care of anything that, well, a surgeon is, you know, by training we cut things out or cut things, so anything from simple dermatology procedures, from taking off little moles to skin cancers, all the way up to doing bowel surgery. The majority of my practice consists of doing things like hernia, gall bladder surgery, appendix and colon type surgery.

Being Well 504:  Hemorrhoid treatments and surgical options

I'm doing colonoscopies and upper endoscopies, the opposite way. I do breast surgery, not reconstructive things, but more if someone has breast cancer or lumps that need to be taken care of. That's the predominant type of practice that I have there. Lori Casey: Okay. Well, we know that you specialize in hemorrhoid surgery. And it's a topic we were talking, how do we go about this, because it's not something people really want to talk about, as you well know.

We're going to get into the surgical aspect in just a little bit about what you do. Let's actually talk a little bit about hemorrhoids: what are they? Dr. Nadeau: A hemorrhoid is kind of a hard thing to describe, but it's basically a space that is just underneath the top layer of your, the inner layer of your bowel and your anal area that fills up with blood.

Okay, so you have the circulation that comes in, that comes from your bowel, and it goes into the hemorrhoid. And then, from the hemorrhoid it goes out to the veins. But what happens is over time, maybe because of the poor diet, we have a low fiber diet, okay, so people strain to go to the bathroom. When you're straining, you're forcing more blood to the area, so it makes the area get larger. You fill it up, it makes a bigger cavity.

So, that's basically what a hemorrhoid is. Lori Casey: Okay. Now, we hear a lot of times pregnant women will get them because of the extra weight. Are there other populations or people who are more affected by them than others? Dr. Nadeau: The hemorrhoids are very rare with younger people. Most of the time, it's either someone, like I said, someone who has low fiber, poor diet, they're straining and constipated.

It tends to happen with the older population; they've been around longer. And that could be a function of, just because, as you get older, your tissues aren't as supple, or they're not as strong anymore, so you lose some of that, and the area may start to expand easier. But as for other populations specifically, nothing that we know of. Lori Casey: So, they can be uncomfortable, painful. Are there, can they be life threatening ever, or lead to other things? Dr. Nadeau: Hemorrhoids are rarely life threatening. They're more of a hassle to deal with.

As for life threatening, there are hemorrhoids that can get pretty complicated, very large. If it's going to be life threatening, it's most likely a hemorrhoid that's more internal, which I didn't discuss that yet. But, and if they get large enough, they can get twisted, and they can get necrotic, and can possibly get an infection in there. And that can be life threatening, but I personally have never seen a life threatening hemorrhoid. Lori Casey: Okay. I was going to ask you about internal and external. We've got the chart here.

Can you kind of explain the difference between an internal and external hemorrhoid? Dr. Nadeau: So, what we have is when you look at the anatomy coming in, okay, this is the outside here, this is inside the bowel. And what happens is the skin, this is like normal skin from the outside, and as they come in, this is your muscle, okay, so the sphincter that controls things. When the, the tissue out here has a lot of nerve endings into it, and that tissue is very sensitive. There are certain places in your body that tend to be more sensitive: your lips, fingertips, down here, okay? And then, once the tissue goes in, there's a little area that has a little wavy line there; this is a little more obvious, and a lot of times, I see it. But the wavy line is a transitional point from the outside kind of tissue to the tissue that's... [No Dialogue] ...Where you don't feel pain, as if you had a cut in it.

You feel pain if it stretches, okay? So, that lining is what's called the dentate line, so whenever you have external hemorrhoids, they're from this little line out. And then, if you have internal hemorrhoids, they're from this little line up. Lori Casey: Okay. Dr. Nadeau: Okay? So, the external hemorrhoids are the ones that usually hurt, and the internal hemorrhoids a lot of times you may not even know you have them until you have symptoms, and it's usually from bleeding. Lori Casey: Okay. So, you had mentioned earlier that, you know, sometimes our poor diet causes them.

You know, that's one cause. Are they hereditary? I mean, if your mom and dad had them, will you maybe have them? Dr. Nadeau: You know, to be honest with you, I don't believe they are hereditary. I think it's more related to the diet or if you're lucky to get them. As for being generation-wise, that could be more related to the diet from the family.

Lori Casey: So, watch what you're eating. Increase your fiber. Dr.

Nadeau: Watch what you're eating; it's very important. That's correct. Lori Casey: Okay.

So, generally some, if you experience them, some over-the-counter medications can help alleviate them. Are there prescription medications that are, that can be taken? Dr. Nadeau: There are prescription medications that are probably a little stronger than what you get over-the counter, and can help with the swelling, to take the swelling down if you have a hemorrhoid attack, let's say, and it hurts while... A lot of the pain is related to the hemorrhoid being filled up with blood and stretching, but you also get some stretching that's just the tissue has gotten swollen. So, this helps with that. There are also medications that have a little bit of numbing types of medication. That helps take the edge off of the pain you have. Lori Casey: Okay.

So, if you've never had them before, maybe had them for the first time, and you said you have an attack, how long generally will that take for that tissue to shrink if you use some over-the-counter medications or some prescriptions? Dr. Nadeau: It varies per person. I see them in the office where people will start with an episode, and they'll take the medication to help shrink it, and it may go away in a day or two. But then, there are people who have hemorrhoids that are usually there, even if they're not swollen.

So, it's kind of hard to say how far down they'll go because it's there all the time. So, but for the swelling part, hopefully in a couple days you'll start to feel better. Lori Casey: Okay. So, there are surgical options available. At what point, well, I should ask this first, at what point should someone see their doctor? Dr. Nadeau: Well, if you have bleeding, okay, from below, a lot of times they may be hemorrhoids, okay? But bleeding from below is not a normal thing, and there are other sources for bleeding.

Lori Casey: I think about colon cancer. Dr. Nadeau: Colon cancer is a big deal. And, but there are also diseases. You have Crohn's Disease, you can have malformations of vessels inside your bowel that may be bleeding, and diverticula might bleed. So, there are a lot of sources that could be bleeding, and you want to rule that out, okay? So, if you already know that you have hemorrhoids and it's already been proven, and then you have bleeding, that's probably fine at that point to treat them as hemorrhoids. But if you don't really know why you have blood there, you need to be checked out by your physician.

But as for once you have the hemorrhoids, when to get treated by a doctor is when they start to cause you to have issues you can't control at home. Lori Casey: So, real quick, I know that a lot of times, like, dark brown blood is more a sign of something else; is hemorrhoid blood more red? Dr. Nadeau: Red, the hemorrhoids tend to have bright red blood.

Lori Casey: Okay. Dr. Nadeau: A lot of times, people will have blood on their tissue when they're wiping, that's the majority of the time that I hear about it, or they'll go to the bathroom and they'll have blood in the toilet. A lot of times, the blood in the toilet is not as bad as, they think they're hemorrhaging. But one drop of blood in the toilet is not as much blood as you think it is.

It looks worse. Lori Casey: So, Doctor, what if the blood is really dark brown? Dr. Nadeau: Okay. So, if you have dark blood, usually it means the blood has been somewhat digested, okay? So, that tends to be an issue that's further up the bowel, okay? So, it can be anywhere from your stomach, all the way down to in your small bowel, to maybe part of your colon, where you first start having, you know, your colon, okay? But bright red blood tends to happen further down the bowel line, because it hasn't had time to be digested or absorbed, or any work done by the colon.

Lori Casey: Okay, okay. So, at what point then do you as someone seeing their doctor, when is surgery advice for people? Dr. Nadeau: Surgery is usually the last thing in the chain of treatment. So, when you have hemorrhoids, you want to prove you have hemorrhoids. So, you're going to see your doctor, and he'll say yes. You may have to undergo a colonoscopy prior to anything else, just to make sure or to make sure that they are hemorrhoids that's what's bothering you.

Once you do have the hemorrhoids, to see your doctor is when what you're doing at home is just not doing it. And then, that means a few months of treatment usually. They're going to do things like fiber, they're going to do things like, you know, the creams to try to reduce the size. And usually, the fiber's a big deal. Over time, the hemorrhoids, hopefully, should resolve, or at least be manageable, okay? But if you can't manage them; now, can't manage means you're having a lot of flare ups, it really hurts a lot, you've got a lot of hemorrhoids on the outside, you've got bleeding that keeps recurring, if they do blood tests, and the bleeding you're seeing, you're noticing that the blood levels are a little bit low, those are all indications that we need to start looking at surgery, okay? When the medical stuff has failed first.

And it's usually treatment for a few months, at least, to try to treat it medically, because surgery doesn't always go without, you know, possible complications. Lori Casey: Okay. So, there are several surgical options. Can you talk about the more traditional ones; there's one that..

Dr. Nadeau: Rubber banding. Lori Casey: Rubber banding, and then we'll get into the one that you're doing. Dr. Nadeau: Okay. Well, there are things that you can do that are not in the surgery suite, okay? So, you can do things in the office; some people can do the rubber banding, which is basically, it's for internal hemorrhoids.

Because, the internal hemorrhoids, if you do something to those, they don't hurt, okay? If you did it on the external hemorrhoids and you put a band on that, that's going to hurt a lot. Lori Casey: That would be a bit uncomfortable, I would imagine. Dr. Nadeau: It would be. So, that's really reserved for the internal hemorrhoids. And that's basically done with a special instrument that, if you could think of it as it sort of sucks the hemorrhoid into itself, and then there's a very tight rubber band that gets put around it. And what happens is the rubber band stops the circulation from the hemorrhoid, and over time, the hemorrhoid will just fall off.

Okay? There are other options you could do; one is sclerosing, which is something I've never done. It's basically injecting the hemorrhoid with a liquid that causes an inflammatory reaction, causes irritation. And when you cause things to get irritated, when it starts to heal off it sticks together, okay? So, those are more in-office procedures, non-surgical, I would call.

The next step for surgery is taking the hemorrhoid out. Now, taking the hemorrhoid out is, it's in a surgical suite, you're sleeping, out cold, and we go in and find the hemorrhoid, and actually cut the tissue out and take the hemorrhoidal tissue out, and then you go home. The tough thing with that is it can be very painful. Lori Casey: It sounds painful, to be honest. Dr. Nadeau: Yeah. The internal portion is not so bad, but if you get down towards the outside, that hurts.

And I've done hemorrhoid resections before, and the difficult thing with that is you tend to treat one hemorrhoid, okay? So, if you have a lot of hemorrhoids, you can't do the whole area, because then you won’t' have anything left. But it's more of a staged procedure. We do a portion of it and let you heal off for a few months, and come back and do another section.

Personally, in my experience, when I've done one, people have never come back for the second. Lori Casey: I can't imagine why. Dr. Nadeau: Yeah, it's a hard thing to treat. Pain-wise, it can be a few weeks, and the pain coverage is a combination of different modalities, where we'll give you pain medication to go home with, we'll give you some lotion, ointment to put on there to help break, you know, feel a little better, soaking in a bathtub is helpful; it helps circulation, and the healing process, and relaxation down there, and giving you stool softener so it's easier to go to the bathroom.

All these things sort of play together to try to heal off the surgery, but it's not an overnight, "I feel better tomorrow" type thing. Lori Casey: Right. Well, and not to be gross, but it's an area that generally gets used every day, so you've had surgery down there, you can't really... I mean, if you break your arm, you can kind of avoid using it. You can't avoid that part of your anatomy. Dr. Nadeau: And it's a tough, tough thing for people to deal with, because with surgery, they don't want to go to the bathroom.

So, I say no, you've got to go because if you get constipated, it's actually worse to go to the bathroom afterwards. So, that's when I switched over to the procedure that I'm doing now. Lori Casey: Okay. And it's called THD, and it has a really long name, and I'm going to let you tell us what that is. Dr. Nadeau: So, transanal hemorrhoidal dearterialization. Lori Casey: Wow. Dr.

Nadeau: Big words. Lori Casey: We do have, I'm going to, I want you to walk us through this, because we actually kind of have a graphic, sort of; it's not graphic in nature. So, you can tell us how this surgery works. Dr. Nadeau: Well, the way it works is the concept is your hemorrhoids are fed by blood from arteries that come in from alongside your bowel, okay? And there are six of them, and they're located roughly, like the odd numbers on a clock.

So, if you looked at the anus, it'd be roughly at 1, 3, 5, 7, 9, 11 o'clock. So, the treatment is find these arteries before they feed into the hemorrhoids and tie them off. Lori Casey: Okay.

Dr. Nadeau: Okay? And the way this works is there's a device I have, and the procedure itself is, you go to a surgery room, so you're out cold, sleeping, okay? This is not an awake kind of procedure. And I use a special device that allows me, if you can see this image here, there's a little black dot right here, and this is a Doppler probe. So, a Doppler probe works, or people might have known it where... Lori Casey: Doppler radar for weather? Dr.

Nadeau: Well, not Doppler weather, well, it could be, but more familiar is when a woman is pregnant, and they have a little probe they put on, and she can hear the baby's heart, hear that whooshing sound; same idea. So, what this does is allows me to find the artery, and when I find it, the device allows me to put a stitch at the right depth in the right location to tie off the artery. Okay? And once an artery's tied off, which is this part of the image right here, I use the same stitch. If somebody has a lot of hemorrhoid tissue that's loose, okay, some people it's not as loose in certain areas, what I'll do is I'll take the same stitch and just take a little bit of the tissue while coming out. And then, when I tie both ends together, what it does is it pulls in all that loose, a lot of the loose tissue inside, and it flattens it out.

Lori Casey: Okay. So, does this work only on internal hemorrhoids, or do you do it for external, as well? Dr. Nadeau: It's supposed to be for internal, but actually, it works well for the external, because they're both tied together. So, they're' both fed by the same artery. The limiting factor for the external ones is that, if you have a lot of loose tissue, the idea behind putting the stitches, especially when I do that to tie the loose, tissue, we try to stay away about, from that little zigzag line where the nerve endings change from the inside to the outside, about a centimeter and a half.

We want to; I'm trying to avoid putting a stitch in a tissue that has a lot of nerve endings. Okay? And it's sometimes unavoidable because that line may not be easy to identify. So, when I try to stay away from that line, I might have a hard time pulling all the tissue inside.

But the real treatment is tying off the artery. Lori Casey: Okay, because then it loses its blood supply. Dr. Nadeau: It loses blood supply.

And we do all six arteries. We don't selectively pick one and try to treat, because you really don't know how that's feeding in. So, we do all the arteries all the way around, and try to tighten up the tissue all the way around as much as we can. Lori Casey: So, unlike the other surgery mentioned, this, you can get in and do it all at once and people generally don't have to come back.

Dr. Nadeau: Correct. About a 3 to 4% chance you may have hemorrhoids again, so there's a roughly 96, 97% chance of never having hemorrhoids again. Lori Casey: So, is this an outpatient? Are you in the hospital for just that day, and you go home that day? Dr. Nadeau: Completely outpatient. Depending how bad the hemorrhoids are, the procedure may take anywhere from half an hour 45 minutes. Once you wake up, as long as you're feeling fine, we send you home. Typically, I'll send people home on the softener to make sure they go to the bathroom when they're supposed to, and I give them some pain medication.

And then, I don't have to see anybody for about three weeks to just talk to them and see how they're feeling. Lori Casey: Yeah, so what is the recovery time typically like? Dr. Nadeau: Recovery time, it depends on the patient, and it's hard to predict how they're going to recover. If I had a hundred people, I'd say about 25 people are going to walk out of there feeling good; nothing's happened, other than knowing they went through a procedure. Maybe 50 of those people are going to have some pain or discomfort; usually, it's a feeling of pressure down in that area, because we're really wrinkling a lot of the tissue, and that’s sensation of pressure, because just like if you have to go to the bathroom, you feel pressure down there, there's something in there stretching, it's the same idea. So, you'll feel a pressure. Every once in a while, there may be a little pain because the stitch may be too close to the tissue that I'm trying to avoid, or they may get a little fissure. A fissure's like a little, think of it as a paper cut on the skin there, and that can hurt.

And about the last 25% of the people will have some amount of pain, because they'll get some swelling in this area. And that can usually last a week to a week and a half. It's a lot shorter time-wise, as compared to taking them out. But once they start having their bowel movements, they feel a lot better. Lori Casey: So, will, can the hemorrhoids ever come back after this surgery? Can you get them again? Dr. Nadeau: Maybe 3 to 4% of the people get their hemorrhoids back. I have had to go back before to take a look, and it never came back.

It was other issues that were going on at the time. And if they did come back, the plan would be to go back in with a probe and see if there is an artery that was missed, that wasn't tied off. But I haven't' had to do that, yet, so, it's been successful. Lori Casey: And I understand you've done several of these. You've kind of got your, I don't if I want to say is your claim to fame is the hemorrhoid surgeon, but he is. Dr. Nadeau: Yeah, it's, I guess I'll be known for that for the area. Lori Casey: That's okay.

Well, as we were talking before the show, it's something people don't really want to say, hey, I have hemorrhoids. We're just so funny about stuff like that. And do you think that's why people live with pain and discomfort for a long time, is because they don't want to say, hey, I have this? Dr.

Nadeau: I think, yeah, I think they're somewhat embarrassed about it, and if you talk to your doctor about it, it's a plus. And then, when you come and talk to em, and I see these all the time, so there's nothing to be embarrassed about. But most people that deal with it probably don't have enough issues with them yet and are just managing them. Lori Casey: Okay. Dr. Nadeau: And they probably hear, you know the stories that having hemorrhoid surgery's a very painful thing to undergo, so they try to avoid the surgery.

As long as they can manage it on their own, there's nothing wrong with that. But at some point, they want to draw a line and say I've had enough. Lori Casey: So, of the patients that you're doing this surgery on, can you give us kind of an average age? Are they 50 and up, or are you doing them on younger people? Dr.

Nadeau: Very rarely on younger people. I would have to say mostly middle aged population and a little bit older, so somewhere in the 40 range, going all the way up to 70, even 80-years old. When you get older, most of them have learned to manage these on their own. Most of the time, it's the middle population that I operate on. Very rarely do you get hemorrhoids on a younger population. And most of the time, the younger population they get a red flare-up once, and then they never get bothered by it again, so..

So, later on in life. Lori Casey: I thought, you know, our, you know, younger population, our diets seem to get worse. We may be seeing younger and younger patients; you never go. Dr.

Nadeau: It's possible, but as of right now, I haven't seen that many heal from hemorrhoids in the younger population. Lori Casey: Alright. Well, Dr. Nadeau, thank you for coming on and talking about this topic.

I said it’s something that not a whole lot of people want to talk about, but thanks for explaining it to us in a way that we can understand. And, you know, that there's treatment options there that aren't as painful, maybe, as they used to be. Dr.

Nadeau They're not as painful as they used to be, yes. Lori Casey: Thanks for coming out. It was a pleasure to have you on the show. Dr. Nadeau: You're welcome. Thank you very much.

[music] It’s one thing to want to tackle a marathon. It’s entirely another to train for one while going through treatment for breast cancer. Dennis Douda introduces us to one such marathon runner for whom the challenge of getting ready was also about getting well. When you have a cancer diagnosis, or an advanced diagnosis, everything in your life starts to unravel. For Cynthia Cycon, long distance running is a perfect metaphor for being a breast cancer survivor. Getting there is accomplished - one step at a time. It’s very important, whether you’re running a marathon or going through chemotherapy, to not think too much. It’s important to focus on what you’re trying to do right then and keep doing it.

I can recommend that anyone you know who’s making the cancer journey have a bun-cologist. Along the way… Cycon has found that others are inspired by her experiences. She talks about why she runs so tenaciously … and about her diagnosis in 2010, which doctors in her home town of Chicago repeatedly missed for over a year. You have to be your own advocate. This tumor could have been seen if one simple different view had been done in mammography.

The latest scans show she is cancer-free. Moving forward is about .. Moving. A recent survey of Mayo cancer patients found that doctor approved exercise decreases fatigue and boosts mood. Cycon’s oncologist told her .. If you want to run.. Run.

And time and time again it turned out that I actually felt better if I stuck to my normal activity than if just sat on the couch and wallowed in my discomfort. For Cynthia Cycon this seems to be the right medicine. For Mayo Clinic, I’m Dennis Douda. Production of Being Well is made possible in part by: Sarah Bush Lincoln Health System, supporting healthy lifestyles. Eating a heart healthy diet, staying active managing stress, and regular check-ups are ways of reducing your health risks.

Proper health is important to all at Sarah Bush Lincoln Health System. Information available at sarahbush.org. Additional funding by Jazzercise of Charleston. [music].

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