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Melanie Cole (Host):  Have you ever gone to the bathroom and noticed blood in the toilet when you were done? It can be quite scary and you’re not sure what to make of it. My guest today Dr. Eric Branstetter. He is a general surgeon at Aspirus Health System. Welcome to the show, Dr. Branstetter. I would like start by asking you:  when people see this and, as scary as it is, please give us some of the things that you tell people it could possibly be before you diagnose what it actually is.

Dr. Eric Branstetter (Guest):  A lot of people, when they see this, obviously, get concerned and most people jump right to the most worrisome thing, such as cancer.  Certainly blood in the stool, blood in the toilet water, or blood on the tissue when you wipe can be a sign of colon cancer. But, there are a lot of more common things that can cause that such as hemorrhoids. We can get what are called “anal fissures” which are tears in the anus. All those things can contribute and they are much more common for hemorrhoids or a fissure to give you problems.

Melanie:  Are there some things that can ease the mind if somebody knows that they have hemorrhoids?  You have had a couple of kids. But, I know that there are some really staggering statistics that, by age 50, that half of the population has experienced some of these symptoms. Can you give us a little bit of hope that generally that’s what it is?

Dr. Branstetter:  I think that the best place to start with most of our health concerns is with our primary care providers. Getting in and talking with them, seeing them, and letting them kind of sort some of that stuff out. Some of that can be difficult to differentiate, whether it’s hemorrhoid problems or whether it’s a fissure. When they have those difficulties with that, then they direct those patients to see usually see the general surgeon or the proctologist.

Melanie:  Before we talk about the colon itself, let’s speak about hemorrhoids. What are they? How do you get them?  What do you do about them?

Dr. Branstetter:  We all have hemorrhoids. Hemorrhoids are simply vessels in the anal/rectal area. When they give us problems, they become like varicose veins in the anal rectal area, just like you would get varicose veins in the legs. Those veins can be very superficial and they, obviously, tend to bleed at times.

Melanie:  So, these veins swell up, they bleed. Can this happen if you’re someone who sits on the toilet too long or pushes too hard? Are there certain risk factors for hemorrhoids?

Dr. Branstetter:  Sure. There are multiple things that can contribute to that. Good bowel habits is a good place to start. Making sure that you get plenty of water in your diet, plenty of fiber in your diet; that you are not sitting on the toilet for too long; that you’re not pushing for long periods of time.  Get on the toilet, get your business done and get off is probably a good place to start with that--very simple lifestyle type of things you can deal with.  

Melanie:  If it’s not hemorrhoids, and someone comes to see you, and we’ve got this wonderful preventive test – the colonoscopy. Speak about that because people are more afraid of the prep and it’s really such an easy test that can save lots of lives.

Dr. Branstetter:  Obviously, the prep, as you’ve pointed out, is probably the worst part of the colonoscopy and that’s done the day before. Each institution may be a little bit different on which preps they use, whether you do your prep at home. Some places will have you actually do a prep on-site.  That really probably varies from place to place. Our practice here at Aspirus is that you do your prep at home and then you come in the next day and have your procedure done. The prep is the hardest part, as you pointed out.

Melanie:  I would imagine people say to you, “When is it going to be over?” and you say, “It’s already done” because it is such an easy procedure. Then, we get the nice little pictures after. What are you looking for?

Dr. Branstetter:   In regards to a patient that we are concerned that has had some blood in their stool, we’re looking for a variety of things. Number one, we want to make sure they don’t have colon cancer. We’re looking for polyps in the colon. Should we find polyps in the colon, we take those polyps out. That is done at the same time as your colonoscopy. You’re not aware that any polyps have been removed. It’s an easy process to go to. You’re looking for inflammatory bowel disease for things such as ulcerative colitis, Crohn’s disease can also contribute to blood in the stool. We look for hemorrhoids, whether they be external hemorrhoids or internal hemorrhoids and we look for fissures, which are tears in the anal/rectal area as well. 

Melanie:  If you determine that it is hemorrhoids, is there anything that can be done for them?

Dr. Branstetter:   There are lots of things that can be done to treat hemorrhoids. It really depends on the type of hemorrhoid that you have. We have really two types of hemorrhoids and they each present a little bit differently. External hemorrhoids, typically, will bleed with pain. Internal hemorrhoids, typically, will present more commonly as painless bleeding.

Melanie:  What would you do for somebody when you have determined this is what they have and they are bothersome and they can affect the quality of life?

Dr. Branstetter:  Sure. With internal hemorrhoids, we are doing a new technique and it’s called “transanal hemorrhoidal dearterialization”. With that, we stick an ultrasound probe into the anal/rectal area. We use that probe to isolate the blood vessels in the anal/rectal area and then, we use a suture to tie these blood vessels off so that the supply of blood to these hemorrhoids gets removed. The other thing that we do is, with internal hemorrhoids a lot of times, those internal hemorrhoids can prolapse out of the rectum and with that, sometimes people will have a bowel movement. They feel like something comes out when they have the bowel movement and some people will say that they actually have to push them back in after they have a bowel movement. When we tie these blood vessels off, we’re actually able to then do what’s called a “mucopexy” where we go in, we suture the lining or the mucosa of the anal/rectal area. We pull that back up and tighten it up.

Melanie:  Do they come back after that or is this a done deal?

Dr. Branstetter: In general, any vascular problem can come back. It may not be a 20-30 year fix; it may be a 10-20 year fix. My guess is, it all really depends on the person--if they make any lifestyle changes or things that were contributing to their likelihood of getting hemorrhoids, if they eliminate those things certainly you are going to get more mileage from those types of procedures.

Melanie: Before we talk about prevention for a minute, break up this myth or whatever, about blood color. When people do see that blood in the toilet or on their toilet paper, people say, “If it’s bright red its hemorrhoids. If it’s dark and in your stool then you worry.”  Clear that up a little bit for us.

Dr. Branstetter:  There is, really, no way to determine just by looking in the water or looking at the toilet tissue what that has come from. You can certainly have colon cancer that is contributing to rectal bleeding and then, you can have a patient that has had hemorrhoids that they commonly will say, “My bleeding is just hemorrhoids.” Unfortunately, I see a lot of people in my practice who have done that. They say, “Oh, I know I have hemorrhoids. It’s just that” and they keep putting it off, and they keep putting it off and it was a colon cancer. It was something that we needed to see and evaluate before that. You can’t really determine just based on what the blood looks like as to where it’s coming from.

Melanie:  Speak about prevention. Is there anything that we can do to either prevent colon cancer or hemorrhoids?  You spoke about fiber just a little bit. So, kind of wrap it up for us. Give your best advice on prevention and healthy habits and why listeners should come to Aspirus for their care.

Dr. Branstetter:  I think that most health care really starts very basically with maintaining a good, healthy weight, eating a good diet, making sure that you are getting plenty of water, particularly for your colon, plenty of fiber. And then, following through with your basic, routine screenings that your primary care physician would recommend. For people of normal risk, you’re looking at starting with a colonoscopy at the age of 50. People who are at higher risk, for example, let’s say they have a first degree relative who has had colon cancer, those screenings are going to be done sooner. The American Cancer Society’s guidelines for that is doing it ten years before your first degree relative developed colon cancer. For example, if you have a father that developed colon cancer at 40, we would start recommending your screenings to be done at 30—again, as a general guideline.

Melanie:  Why should they come to Aspirus for their care? Tell us about your team.

Dr. Branstetter: Aspirus is a system made up of several different hospitals. One of the nice things about having your procedure done at Aspirus is that we take a very team approach to your care. The nurse anesthetists get involved with all our upper and lower endoscopies. They are monitoring you very closely and they use conscious sedation for that. Some places have the endoscopists, whether that is a general surgeon or a gastroenterologist, also sedating and doing the procedure. I can tell you from having done it both ways with trying to sedate people and do the procedure and just doing the procedure and allowing somebody else to worry about the sedation, I think it is a much better system for both patients and providers, actually, to do it with the help of the anesthetist there.

Melanie:  Thank you so much. It’s really great information and so important. You’re listening to Aspirus HealthTalk. For more information you can go to Aspirus.org. That’s Aspirus.org. This is Melanie Cole. Thanks so much for listening.