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Interviewer: Will a hernia go away on its own? Dr. Rodney Barker is a hernia expert. So do hernias eventually heal without surgery?

Dr. Barker: No, they don't. It's a defect in the abdominal wall. It's a mechanical issue, and it needs a mechanical fix. Physical therapy, medication won't do anything for it.

Interviewer: If a person has a hernia, should they go in and get it fixed right away?

Dr. Barker: Not necessarily right away. They should have it checked and make sure that's what it is and it's not some other diagnosis. The repair will be a discussion between them and the surgeon as to when it's most desirable to do it.

Interviewer: And sometimes, if somebody notices a small bump that's not giving them any problem that's a hernia, do you ever take a wait-and-see approach?

Dr. Barker: We do. Again, we want to confirm that small bump is a hernia and not an enlarged lymph node or something else. But watchful waiting is an appropriate response.

updated: October 28, 2021
originally published: August 21, 2019

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Interviewer: Hernias are extremely common and millions of people have them, and symptoms can vary from men to women. They also vary depending on the type of hernia you have. And if you have one, you should get it treated.

Dr. Rodney Barker is a surgeon and hernia specialist at University of Utah Health. And let's start out with a very basic thing here as we go through our journey. What is a hernia?

Dr. Barker: A hernia is a defect in the abdominal wall. Some people call it a hole in the muscle, but it's more complicated. There's muscle. There's connective tissue that holds muscles and tendons together. When we get a defect there, it allows something that normally belongs in the abdomen to protrude through that defect, and that is the process of herniation.

Interviewer: And is it a genetic reason that I would have this defect? Does everybody have the defect?

Dr. Barker: It's genetic to the human condition, but there are natural weak spots where they typically occur.

Interviewer: All right. So everybody has the possibility of getting a hernia?

Dr. Barker: Correct.

Interviewer: Nobody is completely immune.

Dr. Barker: That's correct.

Interviewer: All right. So you've mentioned one of the symptoms I think, is there is that weakness in the abdominal wall and all that tissue, the more complicated version, and something kind of pokes out. Is there a noticeable bump?

Dr. Barker: In most people, yes. That's what they first notice. But if someone has a very small hernia and they're large, they may not feel or notice the bump themselves.

Interviewer: Okay. I've heard kind of the classic way is you go to pick something up or you're lifting something or pushing some weight and you feel a pop. Is that kind of the traditional way most people would experience . . .

Dr. Barker:That's probably a minority of the patients that I see. It is still fairly common, but most people are in the shower or they're doing something and they incidentally find this bump.

Interviewer: Okay. And didn't even realize, at the time, that they did anything.

Dr. Barker: That's correct.

Interviewer: All right. So I was told that hernias are a little different in men than they are in women. How is that?

Dr. Barker: Most hernias are the same. Inguinal hernias, which are the commonest type that we fix, tend to be more noticeable in men and easier to diagnose because of the difference in anatomy. In women, they don't get the same degree of outward bulging. It's not often as easy to palpate or feel it.

Interviewer: And as a result, are there more women that are walking around with hernias that don't realize it than perhaps men?

Dr. Barker: No way to know that.

Interviewer: Okay, fair enough.

Dr. Barker: Probably not. Men are more prone to getting inguinal hernias than women.

Interviewer: All right. So you could have a hernia and not even know that you have a hernia.

Dr. Barker: That's correct.

Interviewer: Yeah. So then could it possibly heal on its own?

Dr. Barker: No, it won't heal on its own, but if it's there and it's not bothering you and you don't know about it, it's not a dangerous problem.

Interviewer: Okay.

Dr. Barker: It's not something you need to worry about or run and see your doctor and say, "Do I have a hernia?"

Interviewer: So if it's something that it's not giving you any sort of complications, you're not feeling any . . . like, what would be an indication that this is actually a hernia I should be concerned about?

Dr. Barker: So if you feel the bump or the bulge or you're having discomfort or you're questioning that, that's something to get checked, and you could see your doctor and check for that.

Interviewer: Are there any dangers of not treating after you realize that there's a bump there or you have some discomfort?

Dr. Barker: The danger of a hernia, and I use that word literally, danger, is that you can get bowels stuck in it. Incarceration is what we call it. That bowel can sit there long enough, swell up, and strangulate. It sounds terrible. It is terrible, but it's very rare. Most hernias will not go on to incarcerate.

In my training, when I first started years ago, we would tell people with a hernia, "Boy, you should get that fixed because, you know, it could strangulate on you sometime." These were hernias that were often found on routine physical exams in totally asymptomatic patients.

Since then, we've learned that the rate of incarceration in a totally asymptomatic small hernia is very, very low. And we don't rush all those people to surgery anymore.

Interviewer: So do you have a lot of patients that come in with kind of initial hernia symptoms and then you just kind of watch them?

Dr. Barker: Not too many, because most of the time by the time they're seeing me, they've made that decision. But I've seen patients who have had a hernia for 10 years and they've just been watching it and now it's growing and becoming symptomatic.

Interviewer: Got you. So let's talk about how you treat a hernia. I understand there are three different ways. Two of them you kind of use now. One of them not so much anymore. Explain what those are.

Dr. Barker: Correct. The first we've talked about. We call it watchful waiting. And I use those words carefully when I talk to patients. I don't tell them, "Hey, we're just going to ignore this. Go away. Don't worry about it." We're going to watch it and we're going to wait.

The majority of people that have hernias will eventually get them fixed. One study showed that within a year, 30 percent. By five years, 70 percent, 75 percent are going to have it repaired. And that's because the hernias get bigger and they become more symptomatic or the patient changes their mind to say, "Yeah, this really does bug me. I want to get it taken care of." So watchful waiting is most of the time a temporary treatment.

The second option, and the most common thing, is we operate on them. We repair them. That is the standard of care for symptomatic hernias.

The third option is not used much anymore. I see it more in elderly patients. But 30 years ago when I started, I saw it much more frequently, and that is to wear a truss. Trusses are like little belts with a pad or a ball on them that pushes in on the hernia. And the idea is that keeps it from coming out.

The problem with trusses is they don't work very well. They are uncomfortable for most patients, and we rarely see them anymore. And I don't ever prescribe them. If I have a patient who says, "I want a truss," they can Google it and find some vendor that sells it and buy it if they want to.

Interviewer: Sure.

Dr. Barker: It's pretty rare, though.

Interviewer: And as far as surgery is concerned, what type of procedure is this? Is it a laparoscopic, you know, that small incision surgery, or is it an open surgery?

Dr. Barker: It's both and it depends on the hernia type. It depends on is it a brand new hernia or a recurrent hernia? And it depends on the preference and skill of the surgeon that's doing it.

Most hernias are still repaired with an open approach, where they make a single incision, cut through the layers, sew it up usually with a patch, get out.

Laparoscopy is done frequently. I'm primarily a laparoscopic surgeon when it comes to hernias, especially inguinal hernias. In that, we make three little incisions and go in with a camera and long skinny instruments. There's less cutting and sewing of the natural tissues. It does require a patch to be put in there to block the hole, but it works very well and it has a very acceptable recurrence rate.

Interviewer: And after a hernia surgery procedure, what type of recovery would a person expect at that point?

Dr. Barker: So the average laparoscopic repair that I do, most people within a week are back to their regular activities or close to it.

Interviewer: Wow.

Dr. Barker: I don't put any restrictions on after that first week.

Interviewer: Got you.

Dr. Barker: It's either fixed or it's not, and the patch is well set up or it's not, so lifting is not going to make any difference.

Interviewer: What about the more open type of surgery? Does that take a little bit longer?

Dr. Barker: It does. And it depends, again, on how it's done. If you bring tissues together and put stitches in them, you need to wait for that to heal. And that can take up to six or eight weeks.

It also depends on whether mesh was used or if it's just a straight-up suturing. Without any reinforcement, if we just straight up suture, I tell people six weeks of limited activity so they don't pull that apart.

Interviewer: But they can go back to work if it's not an active job within a week, two weeks?

Dr. Barker: Yeah. It depends on the job and how they feel.

Interviewer: Got you.

Dr. Barker: I have, you know, experience over this with part of it is their job. If you're a guy who hates your job and it requires physical activity, I won't get you back for a month. If you're a self-employed accountant and it's tax time, you'll be in the office the next day.

Interviewer: Yeah, I bet. All right. What's the bottom line when it comes to hernias, in your mind?

Dr. Barker: Well, I've done a lot of them, so it's . . .

Interviewer: That's good.

Dr. Barker: You know, they're very common. It is one of the most common operations done in the United States. About a million of them a year are repaired here. It is the most common surgical procedure I've done over the years, thousands of them.

We've changed in 30-some-odd years from fixing every single one we see because, "Gosh, you know, you're going to get incarcerated," to, "Well, let's watch it if it's not bothering you." We still fix all the hernias that are bothering people or that are at risk for incarceration.

I think the biggest controversy now or the biggest question we have is, "What's the role of mesh?" When I started, we rarely put it in. We sutured tissue together. We then switched to mesh, and now, in the 80s and 90s, almost all hernias are repaired with mesh since then and people are starting to blame the mesh for various things.

A lot of these people don't remember what I do in the pre-mesh days when we were seeing people come back with their fourth hernia at the same spot and we had no idea how to fix it because the tissue was gone. There was just nothing you could do for these people.

So I think mesh has done a lot to reduce recurrence rates, but there are questions about it. You know, it's a foreign body. Is it causing more pain? Is it causing other issues? And I think those questions need to be studied and answered.

Interviewer: What's your take on that, then, if a patient came to you and said, "I would rather not use mesh"?

Dr. Barker: We have a very frank discussion. I say, "We can fix your hernia without mesh." If it's a small umbilical hernia, we'll do it anyway without mesh. If it's a groin hernia, it's a longer discussion.

The vast majority of patients, once they hear the science behind it and once they hear their options and why we do it, opt for mesh repairs. We can do repairs without mesh, but most of us nowadays aren't that good at it. I trained doing them. I still do occasional ones, but it's not what I would choose for myself. If I had to have a hernia fixed, I would have it done laparoscopically with a mesh patch.

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Dr. Miller: You've been told that you might need a Whipple. What does that mean? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi, here with Dr. Courtney Scaife. She is a professor of surgery here in the Department of Surgery at the University of Utah. And she also specializes in cancer surgery. Courtney, what is a Whipple?

Dr. Scaife: A Whipple is an operation on the pancreas when you have a neoplasm, which can be a mass or a tumor or a cyst, those are all synonyms, in the proximal part or we call it the head of your pancreas. And the Whipple removes that part of the pancreas.

Dr. Miller: So the Whipple is the name of the type of surgery that you do. Is that pretty typical as pancreatic surgery goes?

Dr. Scaife: That's correct. Well, the Whipple is the only surgical procedure of the pancreas that's named after the doctor who first described the operation. Other pancreas surgeons are often more anatomically referenced, such as a distal pancreatectomy or an enucleation of a tumor out of the pancreas.

Dr. Miller: So Whipple has been a surgery that's been practiced for many years, I think. Is that right?

Dr. Scaife: Dr. Whipple first described the operation in the 1950s. And as first described, it was a two-day operation where the pancreas was taken apart, and the next day, everything was put back together.

Dr. Miller: My understanding is that Whipple surgery is a curative surgery for some patients with pancreatic cancer.

Dr. Scaife: That's correct. So again, Whipples are done for all types of neoplasms. And again, neoplasms can be masses, tumors, cysts in the pancreas. And so a Whipple for a non-cancerous neoplasm is obviously curative. And a Whipple for pancreas cancer can also be curative.

Dr. Miller: If one has a pancreas cancer and they're going to undergo Whipple, the purpose of that would be to cure the cancer, I think, obviously, right?

Dr. Scaife: Yes.

Dr. Miller: And once that takes place, what can the patient expect after a Whipple surgery?

Dr. Scaife: So a Whipple operation is complex. It's a six- to eight-hour operation.

Dr. Miller: That's a big operation.

Dr. Scaife: Yeah. And because of the location of the head of the pancreas intimately involved with the bile duct and the first part of the small intestine, we have to rebuild all of those. So we rebuild the pancreas. We rebuild the first part of the small intestine. And we rebuild the bile duct. But in the end, the patients can eat normally. They can eat any food they like. And they do quite well after recovering from the operation.

Dr. Miller: Is there anything that you tell your patients in that preoperative period when you first meet them before they undergo the surgery?

Dr. Scaife: We frequently tell patients that the surgery, again, takes six to eight hours. They'll be in the hospital for approximately seven days. For a month after a big surgery like this, their appetite, their energy, and their strength will all be much lower than they normally expect. And it usually recovers four to six weeks after surgery.

Anything someone has before surgery gets a little bit worse and harder to manage after surgery. So diabetes, high blood pressure are all a little bit harder to manage after a big operation like this. But it recovers about a week or two after surgery and goes back to their baseline.

Dr. Miller: So that's interesting. Do you use a team approach with another physician such as an internist to help manage the patient after the surgery if they have diabetes or other complications?

Dr. Scaife: Generally we manage it on our own. Because they're short-lived, we're able to manage it on our own.

Dr. Miller: Do they ever experience diarrhea following pancreatic surgery? Is that something that they need to worry about?

Dr. Scaife: Yeah, chronic diarrhea after a Whipple operation is extremely uncommon, but not zero. Some patients get dumping syndrome, which happens in less than 10% of our patients.

Dr. Miller: What is that? What's dumping syndrome?

Dr. Scaife: It's from operating on the stomach and re-plumbing it effectively to the small intestine or rebuilding that first part of the small intestine. Some patients can have a syndrome where they eat rich foods, and the foods go through the stomach. And the next part of the small intestine, it's not used to seeing such rich foods, reacts by pouring a lot of water into the intestine.

And that neurologic response can result in almost like a hot flash-type symptom. And then after all of that water gets emptied into the intestine, 30 to 60 minutes after a meal, patients can have diarrhea from the water flushing through their system.

Dr. Miller: Now, generally, that resolves in a couple of weeks? Or does that continue?

Dr. Scaife: In 10% of our patients, after the Whipple surgery, they experience that. Fewer than 1% of the patients have a long-term problem with that. It normally resolves on its own and the few patients that it doesn't, learn to eat around it so they don't stimulate those symptoms.

Dr. Miller: So over time, people who have a Whipple procedure, they potentially are cured of their cancer. Do they end up keeping the same weight that they had before? Do they lose weight after a Whipple where part of the pancreas is taken out? And as I understand it, the pancreas is very important in digestion.

Dr. Scaife: That's right. So the answer to the first part of your question is that most of our patients, 80% of our patients, do well and maintain their normal appetite, normal diet, and normal weight. We do have different ends of the spectrum, obviously. There are some people who gain weight and some people who don't eat as well after the operation, but that's very unusual.

The second part of your question, the pancreas does two things. It manages your blood sugars and it helps you with digestion. And so after we remove part of the pancreas, it's very uncommon to cause someone to be a diabetic from a pancreas surgery. You only need 10% of a normal pancreas to manage your blood sugars normally. So very few people become diabetic as a result of the operation.

Dr. Miller: So you're not taking out the entire pancreas during the Whipple.

Dr. Scaife: Correct, correct. And really about a third to only 20% of the pancreas comes out with the operation.

Dr. Miller: Now, this is a big operation, as you've outlined. Do patients experience much pain postoperatively or in the several months following surgery?

Dr. Scaife: No, we're really able to manage the pain very well. We use local anesthesia in the incision or an epidural in the postoperative care. And then patients actually recover quite well in usually one to two weeks out from surgery. They're off of any pain medications and starting to resume their normal activities and functions.

Dr. Miller: Can you give us a wrap-up about who comes to you for potential surgery?

Dr. Scaife: Most of our consults for pancreas neoplasms are simple cysts or benign cysts in the pancreas. And so 80% of our patients don't need an operation, even though they're referred to us for evaluation. Of the few that do need an operation, those patients do extremely well. They don't all need Whipples. There are other less invasive operations of the pancreas that can be done. And all of those patients, including the patients who do Whipples, ultimately return to a very normal lifestyle.

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Dr. Miller: Fecal incontinence, oops, that happened again. We're going to talk about how to treat that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi I'm here with Dr. Bartley Pickron, and he's a surgeon here at the University of Utah and specializes in colorectal surgery. Bartley, tell us a little bit about how you fix fecal incontinence, and for the audience fecal incontinence is leakage of stool.

Dr. Pickron: Well it ultimately depends on what the cause is. I mean most of the time we see patients with either weak or damaged anal sphincter muscles, and we have to go about and try to restore that normal anatomy.

Dr. Miller: Fecal incontinence usually occurs in people who are a bit older.

Dr. Pickron: Usually, but we're also starting to see it in some of the younger patients as well, as it gets a little bit more . . . a little bit less public taboo.

Dr. Miller: Right, well it's obviously an embarrassing subject for people who have it. They're going to feel guilty but if they make their way to your office, what kinds of treatments do you offer to them?

Dr. Pickron: Well it depends on the underlying problem. I mean, what we would like to do if at all possible is if the muscle is torn and damaged then there is surgery to repair that. There are also other options if it's just some weakness problems, for example, we can put in a device called a Sacral Nerve Stimulator.

Dr. Miller: And that is a device that uses electric current to tighten muscle. Is that what that does?

Dr. Pickron: Yeah it's pretty similar to . . . it kind of works along the same principles a pace maker does for the heart. This is a little device, it's implanted in a little tissue pocket on the buttock, and it has a lead that goes through one of the holes in the tail bone, and it just adds an extra stimulus to the nerves that go to the pelvic muscles to add some extra tone and strength.

Dr. Miller: In 2015 these are new treatments? I mean is the field advanced since the middle of the last decade?

Dr. Pickron: The Sacral Nerve Stimulator is certainly a new treatment for fecal incontinence. The urologist have been using it for urinary incontinence for some time, and one of the side benefits they saw when they first started using it was an improvement in bowel function, so then is subsequently got approved for the treatment of fecal incontinence too.

Dr. Miller: Do you use and sling procedure like the gynecologists use for urinary incontinence sometimes?

Dr. Pickron: Not currently. There's a couple of those coming down the pipeline through still in the experimental phase, but hopefully in the next couple of years we'll have an answer on that.

Dr. Miller: Now once you're working with people with fecal incontinence, how well do these treatments work? I mean can they expect to be incontinence free, or can they expect to have no leakage after these surgeries or treatments?

Dr. Pickron: You know, making a bad muscle perfect is a big challenge.

Dr. Miller: But you can definitely make it a little better with some.

Dr. Pickron: We can definitely make it a lot better.

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Dr. Miller: You have Barrett's Esophagus? When do you need surgery, or do you even need surgery? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.
Dr. Miller: We're here today with Dr. Courtney Scaife and she's a Professor of Surgery here in the Department of Surgery at the University of Utah. She also specializes in cancer surgery. Courtney, tell us a little about a patient who might need surgery on the esophagus. I understand that patients with Barrett's Esophagus mostly don't need surgery, but there are times when they do. When would that time be?

Dr. Scaife: Patients who have Barrett's Esophagus are usually managed by gastroenterologists. And they're well managed with oral medications or sometimes requiring interventional procedures. But if that Barrett's progresses to high-grade dysplasia or an invasive cancer, high-grade dysplasia is a pre-cancer change to the cells in the esophagus. So if a patient has pre-cancerous changes that can't be managed by the gastroenterologist's limited interventions, meaning limited intervention to the esophagus or they've regressed to full cancer, those patients do need a surgery of the esophagus.

Dr. Miller: Now, that's not typically common in Barrett's but it does occur.

Dr. Scaife: That's correct, it's uncommon.

Dr. Miller: So by the time the patient gets to you, they usually have advanced Barrett's or adenocarcinoma of the esophagus that isn't remedial by any of the topical treatments that the gastroenterologists use.

Dr. Scaife: That's correct.

Dr. Miller: And so what do you tell the patient initially and what can they expect undergoing surgery?

Dr. Scaife: The first thing that is important to evaluate is if they progressed to cancer, but it's a very early stage, they need the surgery we're talking about. If they have a slightly later stage or more advanced cancer, we routinely treat those patients with radiation and chemotherapy before surgery. There are actually two types of cancer of the esophagus, two different cellular types. And one is more likely caused by smoking, the other is the kind, adenocarcinoma that is related to Barrett's and chronic reflux. And we do treat that in more advanced stages with neoadjuvant, meaning treating the patient with chemotherapy and radiation before surgery. Therapy.

Dr. Miller: Patients can develop Barrett's Esophagus after many years of esophageal reflux or acid reflux or otherwise known as heartburn. And so if you have heartburn and you've had it for five years or over the age of 50, you should see your primary care physician to have that treated and possibly looked at by a gastroenterologist.

Dr. Scaife: Yes, we agree. And screening in patients who have chronic reflux is important to identify Barrett's and to monitor that Barrett's does not progress to those pre-cancerous or cancer changes.

Dr. Miller: Now, removing the esophagus, or otherwise known as an esophagectomy, sounds like a pretty big surgery. What would a patient expect, following that?

Dr. Scaife: It is a big surgery and, unfortunately, there are several different ways to do the operation. The operation can be done through the abdomen and the neck, it can be done through the abdomen and the chest, or it can be done through the abdomen, the chest, and the neck. And then minimally invasive techniques can be added as well. And so many surgeons use different techniques. But really there's no data that shows that either approach is different. And you want the surgeon to do the operation that they are most comfortable with and that they do that operation most frequently. But all of the techniques of the operation, the outcomes are effectively the same.

Dr. Miller: Does it at all depend on the type of patient? Their size, their body physiology? Does that sway you in terms of the type of surgery that you do if their large, small, or . . .

Dr. Scaife: Usually not. There may be some unusual cases where that influences the decision, but usually not. When we do esophagus surgery, we don't just take out a piece of the esophagus. Particularly in this case because it's for cancer. So we need a wide margin around the cancer. So effectively the patient's entire esophagus is removed. So in that approach, and the reason that all of those approaches included an abdominal portion of the surgery, is that we need to choose a part of the abdomen, another part of the intestinal track to replace the esophagus.

Dr. Miller: So it's like a graft.
Dr. Scaife: That's exactly right. So the choices most commonly are the stomach, a piece of the small intestine or the piece of the colon. And I would say, in 2015, the most common approach is to use the stomach as a replacement for the esophagus.

Dr. Miller: Do you need to use the whole stomach or part of it?

Dr. Scaife: Yes, so in order to get the stomach to reach up into the neck, to reach where you're replacing the esophagus, it's as though they've had a stomach removal or almost like a gastric bypass surgery. So their stomach is made to be a very narrow tube and pulled up into their chest so effectively they don't have a reservoir to store their meal. And so patients eat four to six frequent small meals a day instead of eating Thanksgiving dinner.

Dr. Miller: And so do they tend to lose weight in the long run?

Dr. Scaife: Fortunately, we're able to train patients to eat really well. The majority of patients that we operate on, having so many symptoms before surgery that they admit they've been eating that way before surgery. So most patients do not lose weight and actually do well after surgery.

Dr. Miller: Now, Courtney, you mentioned that there are two types of cancers encountered in esophageal cancers, and I think one is above and one is below. Does that affect the type of operation that you do?

Dr. Scaife: It does. If we frequently . . . squamous cell carcinoma, we've been mostly talking about adenocarcinoma of the esophagus.

Dr. Miller: Squamous cell is more associated with smoking and alcohol.

Dr. Scaife: That's right. So Squamous cell carcinoma more associated with smoking is frequently more in the more proximal, closer to your mouth part of the esophagus. Sometimes that can be treated with chemotherapy and radiation only. If it persists after the chemotherapy and radiation, we do an esophagectomy. And often that procedure necessitates opening the chest to get an appropriate section of the higher part of the esophagus.

Dr. Miller: Now, following a successful surgery, I imagine that one needs to go back in and look from time to time to make sure there are no complications. Is that true?

Dr. Scaife: We ask patients in their frequent clinic visits which, at minimum, are every six months, if patients are having symptoms with swallowing, symptoms with eating, weight loss or weight gain as you've mentioned, diarrhea, but most commonly, it's difficulties with swallowing or weight loss. If those patients are having symptoms, we refer them to a gastroenterologist for an endoscopy to evaluate the graft that we used to replace the esophagus.

Dr. Miller: So it sounds like the best way to keep from ending up in the office of the surgeon is to avoid smoking altogether, to drink minimally if you drink at all. And also, if you have acid reflux and are over the age of 50, to have that looked at.

Dr. Scaife: That's exactly right. And we recommend that if you have long-term reflux to have at least one screening and then follow up based on the recommendations of your gastroenterologist.

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Dr. Miller: I'm here today with Dr. Bartley Pickron and he is a surgeon in the department of surgery. He is also a specialist in colorectal surgery. It's good to see you. I have patients that come to me and they ask, "I've got this pain in my bottom/rectum," and they say, "I think I have a hemorrhoid." How often is it a hemorrhoid or is it something else?

Dr. Pickron: Most of the patients we see for anorectal pain don't have hemorrhoids, but everybody has hemorrhoids to some degree.

Dr. Miller: Most don't.

Dr. Pickron: Most don't, but the real causes of pain are more things like fissures, an abscess, and other things that aren't hemorrhoids.

Dr. Miller: Fissures can be incredibly painful.

Dr. Pickron: They're horrible.

Dr. Miller: What causes a fissure?

Dr. Pickron: Usually it's a tear and it happens directly in the front or directly in the back. Most of the time these things heal up just fine, but if they don't and they get deep enough to where the anal sphincter gets irritated . . .

Dr. Miller: Ouch.

Dr. Pickron: . . . then you get a spasm of that muscle and that prevents the tear from healing and then you just enter this vicious cycle that just won't quit.

Dr. Miller: So you use different therapies to try to repair that.

Dr. Pickron: Yeah, generally we focus not so much on the tear but on the muscle itself because if we could make the muscle relax and stop the spasm then the tear generally heals just fine on its own.

Dr. Miller: While hemorrhoids aren't the usual cause, as you pointed out, they're both internal and external hemorrhoids, my understanding is that the external hemorrhoids can be painful.

Dr. Pickron: They certainly can. The most common thing we see when they are painful is a thrombosis, where you get a big blood clot with the pain and swelling.

Dr. Miller: Ouch. How do you treat that?

Dr. Pickron: Most of the time, we let them these reabsorb on their own. If patients come in within the first two or three days after the event happens, then there is some benefit to removing it surgically because they'll get better faster, but usually once they're kind of over the pain curve and their symptoms are getting better, then the pain and swelling will generally just take care of itself.

Dr. Miller: After you do the treatment, is there any kind of change in diet that they might need to make? My understanding is that constipation, straining, those things can contribute to external hemorrhoids. What's your thought on that?

Dr. Pickron: Absolutely. Constipation and particularly straining or sitting on the toilet for a long time during bowel movements reading the magazine, for example, all tend to predispose people to hemorrhoids. We recommend a change in bowel habits, usually by the addition of fiber or stool softeners and staying hydrated.

Dr. Miller: When do you treat a fissure or hemorrhoids with a procedure?

Dr. Pickron: I'll talk about the fissures first and probably maybe 10 or 20% of those are actually treated surgically. We have creams that we can use that generally take care of things. If that doesn't work, Botox injection is an option. If those don't work, then the last resort is certainly surgery.

Dr. Miller: So that's treatment for fissures, how do you treat hemorrhoids?

Dr. Pickron: Again, most of these are treated non-operatively. There are procedures in the office we do. The most common thing we do is a procedure called rubber band ligation, where we put rubber bands around the hemorrhoids on the inside. That sounds pretty painful, but truthfully the internal hemorrhoids really have no sensation, so it's a very easy procedure to do and very well tolerated. It's usually just some mild pressure for about 24 hours and that's it. The ones that do need to be treated surgically, like I said, are typically the external ones and those are, fortunately for patients, fairly rare.

Dr. Miller: It would seem to me to be rare, but are there times that the pain could be induced by something like a cancer?

Dr. Pickron: It is. That's certainly one reason that these symptoms need to be evaluated very thoroughly.

Dr. Miller: So if they're going on for weeks, that's something that probably ought to be looked at?

Dr. Pickron: Right. So any combination of pain and bleeding and particularly if there is a little mass or something that just doesn't feel right, then that absolutely needs to be checked out.

Dr. Miller: Any other causes of rectal pain? I know that there's one that is a spasm that occurs from time to time in some people.

Dr. Pickron: Some people get this kind of vague rectal pain, which as you mentioned is just kind of a spasm, it's fairly poorly understood. There are some options for it such as physical therapy, biofeedback, but these can be challenging things to treat.

Dr. Miller: It comes on suddenly and then goes away over seconds to minutes, I think, sometimes.

Dr. Pickron: Yeah, usually happens in the middle of the night. People kind of wake up and they feel this intense pressure almost like a Charley horse in their rectum, which not a pleasant sensation.

Dr. Miller: Any other causes of pain?

Dr. Pickron: Those are primarily the big ones, infections, abscesses are fairly common and those are typically treated with surgical drainage.

updated: November 25, 2020
originally published: September 22, 2015

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: Sedation is commonly used in the intensive care unit to make patients that require mechanical ventilation more comfortable and less anxious. What many don't realize is that sedation can have side effects that can endanger the patient's life. My guest is Dr. Richard Barton, Director of Surgical Critical Care at the University Hospital, and Nick Lonardo, Pharmacy Clinical Coordinator are investigating best practices for sedation use in the ICU.

Dr. Barton, what is the problem that you're concerned with?

Dr. Richard Barton: First, let me describe the patients that we have in the surgical and intensive care units. We can have patients with trauma, with sepsis, with major surgical complications. In other words, I'm describing to you some of the sickest patients in the world. Many have respiratory failure to a varying degree. Those patients require mechanical ventilation.

What really does that mean? That means we have a machine that helps the patient breathe, but in order to do this these people have an endotracheal tube, which is stiffer and bigger than a soda straw, smaller than a garden hose. But the point is it is through the patient's open mouth, through their vocal chords, and into their trachea.

Interviewer: Very uncomfortable, I bet.

Dr. Richard Barton: Yes, well, imagine what it feels like when you stick your finger down your throat; it makes you throw up. Imagine having that sensation for hours, days, weeks. So it's very uncomfortable, and yet their very life depends on these monitoring devices, and particularly upon the ventilator and the tube that's in their windpipe.

Interviewer: Sedation is important so that they can basically receive the care that they need.

Dr. Richard Barton: Yes.

Interviewer: What can you tell us about the sedatives that are commonly used in the ICU?

Dr. Richard Barton: This all really began 10 years or more ago when we had patients who had received continuous infusions of benzodiazapine drugs, who would then take days and sometimes even weeks to wake up.

Interviewer: And do you have anything to add to that?

Nick Lonardo: Patients with renal failure, patients with liver dysfunction don't clear benzodiazepines rapidly, and those patients have a prolonged, almost an oversedation picture. These patients will first of all say on a ventilator longer, because they have to be cleared mentally in order to get the endotracheal tube pulled out. And so by staying on a ventilator longer, this put them at risk for ventilator associated pneumonia and all of the other complications that come from being bedridden in an ICU, not getting up early enough and ambulating, so a lot of these things. And delirium in particular, patients would stay delirious and agitated for days on end sometimes.

Interviewer: Well, that was something I wanted to talk about. Something I find interesting is that benzodiazapine more frequently causes delirium and patients with long bouts of delirium are more likely to have an extended hospital stay or even die. I'm wondering what the link is between delirium and these terrible outcomes?

Dr. Richard Barton: There have been associations in other studies, other situations, showing that delirium, which is really altered thought, almost like psychosis, that delirium is associated with not only poor immediate outcomes, but with actual decrease in mental function, if you will, over the long term. In other words, you don't want to be delirious for long periods of time. It literally seems to permanently alter brain function.

Interviewer: And is it the delirium that directly harms the individual, or is the delirium an indicator that something else is wrong?

Dr. Richard Barton: I think that's an excellent question, and I'm not sure that I know the answer.

Nick Lonardo: Do you know what? There is no answer. We don't know. We simply don't know. We know that the duration of delirium that we see in the ICU is strongly independently associated with increased six month mortality. But we do not know the mechanism of why that is so. The age old question is do you die with delirium or do you die because of it? And I do not believe anybody has been able to discern that.

Interviewer: So you've found that patients fared better with one sedative, Propofol, than with benzodiazepines.

Nick Lonardo: Propofol is a drug that has a very rapid onset, but a very short duration of action and so it is much more predictable in terms of its sedative effects. You can keep propofol on literally for days, and turn it off and your patient will awaken usually within an hour or so.

So we looked at data from 2003 through 2009 in the Project Impact Database that came out of 104 ICUs throughout the country. And when they met inclusion/exclusion criteria there were 13,692 patients. And when we did the statistics, we were able to see a decrease in mortality associated with the propofol group, decreased time on the ventilator, decreased time in the ICU, and increased ventilator associated pneumonias associated with the benzodiazepines. The most unexpected thing that we saw was a reduction in mortality, and that had not been shown before.

Interviewer: Are these changes that are taking place across the country, or is it kind of tricky to enforce these recommendations?

Nick Lonardo: That's a good question. I looked at some surveys, I think, as recently as 2006, but at that time there were still quite a few hospitals still using benzodiazepines. The 2013 guidelines have come out from the Society of Critical Care Medicine and they have now encouraged going away from benzodiazepines for sedation and are now recommending either propofol or dexmedetomidine. So the entire world, really, of critical care is becoming more aware of the potential dangers of sedatives in the ICU.

I think our paper is just one more of many that have really highlighted the dangers of benzodiazepines in particular, but I would also say oversedation in general. We now only lightly sedate our patients. The standard of practice is to wake them up once or twice a day, and to try to get the patient up and walking as soon as possible, and to avoid all these neuro-active drugs if at all possible.

Dr. Richard Barton: The only thing that I would have to say is that if you're still using benzodiazepines, don't. There are really better ways to sedate people, more safe ways to sedate people. You can still deliver all the sedation you need, but at the same time minimize some of the complications associated with sedation and with mechanical ventilation.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: February 26, 2019
originally published: August 29, 2014