Hemorrhoids

My doctor says I have hemorrhoids. Can you please tell me more about this subject? What is the treatment for hemorrhoids?

Answer: We all have hemorrhoids. Hemorrhoids are vascular cushions in the anal canal. External hemorrhoids are in the margins of the anal canal. Internal hemorrhoids are at the junction of the rectum and the anal canal. There are three internal hemorrhoidal cushions at three, seven and 11 o’clock.

It is important to remember that hemorrhoids are not always symptomatic and all problems in the rectal area are not due to hemorrhoids. It is difficult to estimate the true incidence of symptomatic hemorrhoids.

The earliest writings on the subject of symptomatic hemorrhoids occurred in 400 BC by Hippocrates. It was thought that the hemorrhoidal symptoms were due to infection of the veins in the rectum due to passage of stool. Red-hot iron was used to cauterize the hemorrhoids!

Napoleon was finally defeated by the British at the Battle of Waterloo in 1815. Several accounts by those who were close to him have indicated that the battle was lost because Napoleon was too busy treating his hemorrhoids. He routinely treated his hemorrhoids with three to four leeches!

There are two main reasons why people get symptomatic hemorrhoids: there is a history of straining while having a bowel movement and the aging process makes the supporting tissues in that area lax. Increased intra-abdominal pressure (for example in pregnancy) and increased congenital internal anal sphincter pressure can give rise to symptomatic hemorrhoids.

Internal hemorrhoids are classified by the degree of prolapse:
-First-degree hemorrhoids do not prolapse with straining, but can be associated with bleeding.
-Second degree hemorrhoids protrude during straining but will spontaneously retract.
-Third degree hemorrhoids protrude outside the anal canal with straining and require manual reduction.
-Fourth degree hemorrhoids remain prolapsed independent of straining and are irreducible.

Patients with hemorrhoids have no symptoms or present with variety of symptoms such as bleeding, prolapse, feeling of incomplete evacuation, soiling, irritation and itching. Severe pain in the rectal area is due to thrombosed hemorrhoid, fissure or cancer.

The diagnosis of symptomatic hemorrhoids is usually made with digital rectal examination and direct visualization with an instrument. If patient presents with rectal bleeding then other causes of bleeding should be ruled out by endoscopy.

Treatment of hemorrhoids includes dietary and lifestyle changes, rubber band ligation of hemorrhoids and surgery.

High fiber diet and fiber supplement reduces the bleeding and discomfort from hemorrhoids. Fiber causes bloating and flatulence so it should be increased gradually. Avoid straining at the time of defecation. Use hemorrhoidal ointment to lubricate the anal canal before and after bowel movement.

Hot baths help relax the internal sphincter and ease discomfort in the anal area. In 1963, Barron described rubber band ligation for second and third degree hemorrhoids. After the procedure the patient may experience a feeling of pressure or rectal fullness for a period of 24 to 48 hours. There are other complications but they are rare and occur in less than three to four per cent of people.

For fourth degree hemorrhoids, surgical excision is the best option for relief of symptoms. Likely post-operative complications are pain, bleeding and urinary retention. But these treatment options are better than using leeches or red-hot iron rod!

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Vitamin B12

Dear Dr. B: What is the importance of vitamin B12? What are the causes of its deficiency?

Answer: Our body needs vitamin B12 to make blood cells. It is also important for normal function of nerve cells in the brain and the peripheral nerves.

Vitamin B12 deficiency frequently occurs in elderly people although it may also be present in the young, particularly women. It is estimated that 30 per cent of the adults older than 50 may have vitamin B12 deficiency.

Lack of vitamin B12 causes anemia and causes damage to the spinal cord and the peripheral nerves. The symptoms of these conditions may be obvious or quite subtle. Screening for B12 deficiency (by way of a blood test) is recommended in the following groups of people:
-all elderly patients who are malnourished
-all patients in institutions and psychiatric hospitals
-all patients who have blood disorders, neurological or psychiatric problems.

Vitamin B12 is an important vitamin that we usually get from our food. It is mainly found in meat and dairy products.

There are various reasons why a person is low in vitamin B12. There may not be enough of it in our diet. Especially vegetarians who do not eat meat or dairy products are at risk for vitamin B12 deficiency. But the vegetarians can get enough of it from legumes.

Quiet often the cause of B12 deficiency is not poor diet but problems with absorption in the gastro-intestinal tract.

The vitamin is absorbed through the last part of our small intestine. It can be absorbed after a protein called intrinsic factor attaches to it. Intrinsic factor is made in our stomach and attaches to vitamin B12 only if there is enough acid in the stomach.

But there are many individuals who take medication to reduce acid in the stomach in cases like gastritis, gastro-esophageal reflux disease or bacterial infection (H. pylori). These individuals are at risk of vitamin B12 deficiency if they are on these medications on a long term basis.

Pernicious anaemia is a fairly common condition in which the stomach does not have enough acid and does not make intrinsic factor normally. Absorption of vitamin B12 is also impaired in individuals who have had intestinal illness or intestinal surgery, which makes it hard for the intestines to absorb vitamin B12.

Vitamin B12 is also known as cobalamin was first isolated in 1948 and was immediately shown to be effective in the treatment of pernicious anaemia. The liver contains most of the body’s B12 (about 1.5 mg), followed by the kidneys, heart, spleen, and brain. The Recommended Dietary Allowance (RDA) for vitamin B12 is 2.4 micrograms/day for persons aged 14 to 70 years. The average diet contains about 5 micrograms daily.

Treatment of vitamin B12 deficiency is by B12 injections on a regular basis for the rest of person’s life.

Thought for the week:

“Age does not protect you from love but love to some extent protects you from age.”
-Jean Moreau

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Did you know?

Here are some medical news items of interest. Enjoy!

Candles in church? Holy smoke!

A news item by Karen Birchard in the Medical Post (December 7, 2004) reports that church air, filled with the particulates from burning candles and incense, is likely a health hazard.

Dutch researchers found the air quality was worse inside the church after normal incense use coupled with daylong candle burning, than measurements taken outside in areas used by 45,000 vehicles a day

This study was published in the European Respiratory Journal. The air pollution inside the church could affect the heath of priests and perhaps devout churchgoers who might be in church several times a day.

Is Vitamin E any good?

A report in the Journal of the American Medical Association reports that taking 400 IUs of vitamin E each day did nothing to prevent heart attacks or strokes. In fact vitamin E may slightly increase the risk of heart failure.

But Vitamin E is not useless. It is known to delay the onset of macular degeneration (which causes blurred vision and ultimately blindness) and boost the immune system in the elderly.

Who makes the house call?

You won’t have to make a house call to Preda residence. Mom, Dad and triplets are all doctors. At the age of 24, the triplets graduated together as doctors from University of New South Wales, Sydney, Australia.

According to a report in the Medical Post, this is the first time triplets have simultaneously graduated in medicine anywhere in the world.

The triplets will be doing internship in the same Sydney hospital. Two of the sisters are identical and the third one resembles the other two strongly. Now how would you know who is your doctor?

Wondered about sleep sex?

A doctor in Sydney, Australia says that “sleep sex” is a recently identified condition that will likely be included in the International Classification of Sleep Disorders. “Sleep sex” is a behavioural disorder, in which the body is free to move during sleep and act out dream activities.

The Medical Post reports that Australian doctors claim to have cured a middle-aged woman who regularly left her unsuspecting partner’s bed and had sex with strangers while asleep. This was thought to be stress-related behavior which disappeared after psychiatric counseling.

For your Tuesday smile!

A guy’s wife asks him, “If I were to die, would you get married again and share our bed with your new wife?”

And he says, “I guess I might.”

“What about my car?” she asks. “Would you give that to her?”

And he says, “Perhaps”.

“Would you give my golf clubs to her, too?” his wife asks.

“No.”

“Why not?” asks the wife.

“She is left-handed!”

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Medication Awareness

Last week Thursday, Palliser Health Region’s Community Health Services organized a medication awareness session at the Medicine Hat Public Library Theatre. Speakers for the evening were Dr. Fredrykka Rinaldi, a family physician who has practiced in Medicine Hat for the past 14 years and Ken Walker, a local pharmacist, who has lived here for the last 30 years.

Yours truly was the moderator of the session. Rinaldi and Walker discussed many aspects of medication errors. I think the evening was very informative and there were many questions from the audience.

Usually the error is in communication. How we communicate with each other, how we understand each other and how we implement advice given to us.

You, as a patient, trust your doctor and pharmacist. Your doctor and pharmacist trust you. They want you to be an informed patient, to listen and remember the instructions given to you and follow them carefully.

It is a complex process.

In a perfect world life would be wonderful if everything went according to plan and everybody did what he or she was expected to do. In the real world, the one we live in, there will be mistakes and problems; there will be breakdown in communication and there will be confusion.

For the purpose of this column, let us keep it simple. Generally speaking, if you remember and follow the following five principles, you will be able to prevent errors in medication use:

-Almost every medication (prescription or purchased over-the-counter) has likely side-effects and may interact with other medications you take.

-Always carry a list of medications you take (prescription or purchased over-the-counter) and a list of allergies. Remember to present the list to a health care provider when you are seeking medical advice.

-If you are taking pills for a long time for chronic illnesses, whether it is one medication or several, always have the pills reviewed by your doctor every six to 12 months.

-Make sure you are taking the right medications, for the right reasons, in the right way and they are compatible with other medications you use. Keep them in a safe place.

-Make sure it is safe to drive while on these medications.

Concern about patient safety is growing and 33 percent of Albertans worry about medical mistakes. Research has shown that patients who take high number of prescription and non-prescription medications have more than 50 percent risk of having medication error when they are admitted to a hospital or see a physician who is not aware of what the patient takes.

As an informed patient you should be able to prevent this.

For a Tuesday smile!

Last week-end I went to a local golf course where I am a member and store my golf bag and clubs. There was a young fellow who was helping members with their bags. So I asked him if he could bring my bag as I wanted to hit some balls on the driving range. He went inside and did not show up for a while.

I got worried. I went inside to see what was happening. He was still looking for my bag. The bags are usually stored in alphabetical order. So I reminded him that my last name starts with B.

He said, ‘There are too many Bs here.’

I said, ‘I hope you have enough honey!’

He smiled. Did you?

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