Dr. Ghulam Fareed
Medical Gastroenterology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
Answered by
Medically reviewed by
Patient's Query
Hi doctor,
I have been experiencing problems with blood after defecation for the past four months. I saw a proctologist this year and was diagnosed with first-degree internal hemorrhoids, a tight sphincter, and an anal fissure. She performed an anal anoscope. She prescribed Diltiazem cream, ORS (oral rehydrating solution), Ziprax syrup (cefixime), and Tufpro suspension (bacillus clausii spores). I have been using these medicines, and there has been some improvement, but I still have stomach pain.
Hi,
Welcome to icliniq.
I do understand your concern.
I am reviewing your case history in detail and the attached files, and I will get back to you shortly with a detailed response.
Thank you for reaching out to me at icliniq.com.
I hope I was able to help you.
Wishing you better health.
Patient's Query
Hi doctor,
Thank you for the reply.
My first symptoms before bleeding started with a lot of scratching in the anal area. I only have pain at the beginning of a bowel movement, and then it does not hurt. Sometimes the stool is softer, and sometimes, it is harder, but it feels like when the stool is passing, the inside is tight, and that is why it hurts. I was just checking my reports from the proctologist, and in the diagnosis when I went the second time, she wrote that I also have a fistula, but she never mentioned it to me. I do not have anything on the outside that looks like a fistula, and the only time it hurts is when the stool is passing, but just at the beginning. I do not have pain in the stomach or pain while sitting or anything. Recently, in the last two years, I had a lot of stress in life. I am also diagnosed with vulvar lichen sclerosis, which can be causing fissures. I am an ex-professional athlete and still involved in sports, so exercise is something I do daily. Concerning everything I wrote and all the tests I did, do you think a colonoscopy is very necessary to do right now? In my family, I have no one diagnosed with colon cancer. Regarding the creams that you recommended, do I need a doctor to prescribe them?
Hi,
Welcome back to icliniq.com.
Regarding the fistula mentioned in your reports (attachment removed to protect the patient’s identity), if it is not causing you any significant external symptoms or discomfort, it might not be an urgent issue. However, discussing this with your proctologist is important to determine the need for further evaluation or treatment. As for the need for a colonoscopy, it can be considered if you continue to experience symptoms such as bleeding and pain, especially if they persist or worsen. It is a valuable diagnostic tool.
Looking forward to your response in order to help you.
Thank you.
Patient's Query
Hi doctor,
I wanted to provide some feedback and seek your advice regarding the treatment plan you suggested. Following your recommendation to use suppositories, I began incorporating them into my routine, typically once daily in the evening. I have observed a reduction in bleeding, with only two thin lines noticed after defecation. The level of pain has also decreased significantly, to the point where it is nearly nonexistent. In an attempt to gauge the effectiveness of the treatment, I experimented with minimizing my use of psyllium. Despite experiencing harder stools, the associated discomfort was considerably lessened. However, I still encounter occasional instances of bleeding, particularly when stools are firm. Comparing my current situation to last year, when I experienced between one to three days of bleeding per month, there has been an increase since the summer, following my consultation with the proctologist and initiation of diltiazem usage. Bleeding episodes now range between two to seven days per month. Although the suppositories have contributed to a reduction in bleeding, there are still occurrences, primarily when stools are hard. I maintain regular bowel movements, except on days when I am traveling, which amounts to approximately three to four days per month. Additionally, I have recently noticed a fissure at the six o'clock position following a bowel movement. Over the past week or two, there has been a recurrence of itching, albeit sporadic. I wanted to inquire about the recommended duration of suppository usage. Furthermore, it seems addressing bleeding and firm stools may require additional measures beyond suppositories and psyllium, as you previously mentioned. Could you provide insight into the frequency at which bleeding from hemorrhoids and fissures is considered normal?
Thank you once again for your valuable time and guidance.
Hi,
Welcome back to icliniq.com.
I read and understand your concern.
1) Your primary concern is constipation or hard stools.
2) Our focus is on softening stools to prevent pain or trauma at the anal verge, which can lead to bleeding. Prolonged constipation or straining during bowel movements can result in hemorrhoids, causing bleeding.
3) Therefore, the goal is not just to reduce the number of days with bleeding, but to eliminate pain and bleeding altogether.
4) Regarding treatment, glycerine suppositories are suitable, but should be used as needed rather than daily.
5) It's important to continue taking Psyllium husk, as it is a highly effective natural bulk-forming laxative that promotes soft and smooth stools, thus preventing straining and bleeding.
6) Given your profession, staying well-hydrated by drinking plenty of water is crucial.
7) Sodium picosulphate (Laxoberon) is a commonly used laxative that can be kept on hand. The aim is to achieve soft stools; it's not necessary to use all these remedies simultaneously.
8) It's positive that your pain has subsided, likely due to the healing of an anal fissure. However, there's a risk of recurrence if stools become hard or straining persists.
9) In summary, maintain hydration, incorporate Psyllium husk regularly, use suppositories as needed for hard stools, and consider using laxatives like sodium picosulphate (Laxoberon) when constipation or hard stools are severe. Wishing you continued good health.
Looking forward to your response in order to help you.
Thank you.
Patient's Query
Hi doctor,
Thank you for the reply.
I am feeling anxious about whether there might be something more serious than just hemorrhoids and a fissure. Apologies for my concern, but considering all the symptoms and your experience, do you believe there could be an underlying issue beyond hemorrhoids and fissures? Additionally, given the ongoing symptoms, do you still recommend a colonoscopy? I understand it may take weeks or even months for symptoms to completely disappear after having them for over a year. I am apprehensive about undergoing the check-up, as I am not particularly fond of visiting doctors unless absolutely necessary.
Thank you once again for your time and understanding.
Hi,
Welcome back to icliniq.com.
I read and understand your concern.
Based on your symptoms, there does not seem to be any cause for alarm. It is important to adhere to the medical recommendations I have already provided. These medications should alleviate your symptoms. However, if bleeding persists despite addressing constipation or hard stools, further evaluation may be necessary. In the meantime, prioritizing the prevention of constipation and hard stools will significantly aid in managing your condition.
Looking forward to your response in order to help you.
Thank you.
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Medical Gastroenterology
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