Perianal Disease: Not Everything down there is a Hemorrhoid (Cortez, 11/20/2024)

 A recording of this presentation is available HERE. 

Many thanks to Dr. Allen Cortez for an excellent presentation on perianal disease. I learned a lot and was really impressed by how much Dr. Cortez, a long-time local general surgeon, knows and cares about a region of the body that many people are pretty uncomfortable talking about. I recommend you watch his presentation, the link above. 

My notes:

Hemorrhoids are extremely common -- 5-10% of the population, >2.2 million people per year with over 2 million prescriptions per year that add up to over $43 million in healthcare costs. But many patients are being treated for hemorrhoids when there may be other things going on down there, including: fissures, fistula, abscess, pruritis, and rectal prolapse. 

Dr. Cortez reminded us to go back to the basics: 1) listen to the patient (e.g. hemorrhoids generally don't hurt, so if the patient is complaining of pain, broaden your ddx) and 2) examine the patient.

Fiber

Encourage fiber! All our patients need more fiber. And fiber isn't good for just the perianal region. Fiber decreases risk of cardiovascular disease, decreases risk for colon cancer. "The best fiber out there is the one you'll take". Really, the only downside is increased flatulence.

Fiber options abound, including: psyllium husk, benefiber (can sprinkle on yogurt), fiber capsules or gummies (e.g. Kirkland brand, 2-4 gummies 2x per day, with LOTS of water).

Once you start a fiber supplement, don't make any changes for 5 days.

Miralax is good too, but it shouldn't replace fiber. Use miralax PRN for constipation. 

Dr. Cortez reminded us that the increased pressure of diarrhea can also contribute to hemorrhoids. The goal is ONE nice big healthy bowel movement per day, no more than 4-5 minutes sitting on the pot. It is better to return 3 or more times than sit for prolonged period of time on the toilet.

When you are going to examine a patient for perianal complaints: put them in L lateral decubitus (better to see than lithotomy). Look externally for tags, fissures/openings, thickened skin, ulcerations, masses. If you see a fissure stop there (you can make it worse). Use anoscopy and a digital exam to check for tone, masses, blood, etc. 

Dr. Cortez is not a fan of donuts for any perianal condition. In his eloquent words: "Gravity tries to push your liver right out your butt"

Hemorrhoid Treatment 

1) Banding (in office), no prep, effective, can be done several times, no downtime, no severe pain

2) Hemorrhoidectomy (surgical) is always a last resort, very pain ful but most effective. Stapled hemorrhoidectomies are not superior.

Thrombosed hemorrhoids, which present as big purple extremely painful lumps should be unroofed in first 2-3 days for pain control (in ED or office). If it has been > 5 days, healing is equivalent and intervention is not indicated.

Fissures

Perianal fissures, which are tears in the anoderm exposing the sphincter muscles, are extremely painful. Patients may describe symptoms as "crapping out glass" or "jamming a knife in my butt". 73% present midline posteriorly. If you visualize a lateral fissure, that patient needs a work-up, including testing for Crohn's, HIV, syphillis, TB and more. 

Acute fissures (< 6 months) can be treated with fiber, fiber and fiber, as well as hydration and sitz baths. This takes time! Topicals can sooth and manage symptoms, including topical nitroglycerine. Dr. Cortez's preferred topical is compounded diltiazem/nifedipine cream (locally can get compounded at Dollar Drug). Can be rx'd TID.

Chronic fissures (>6 months) require treatment with chemo-denervation, including Botox, which is effective and stops spasm. Some people need surgical intervention: with sphincterotomy or anocutaneous flap.

Perianal abscess

Perianal abscesses can also be extremely painful. 30-70% of abscesses have an accompanying fistula. 40-50% will develop a fistula over time.

 Treatment of perianal abscess is I&D, and usual management with packing is not effective because the skin often heals over before the abscess heals. Instead make a BIG incision (this may require sedation-- need to happen in ED?) and may need an initial packing but then should probably not be packed . Perianal abscesses can occur in several locations: ischiorectal, intersphincteric, perianal and supralevator. No antibiotics are indicated once drainage (i.e. source control) is achieved. Many fistulas will heal themselves and not all perianal abscesses need CT imaging. But if you are concerned, send to surgeon for further assessment. 

Malignancy

Finally, malignancies can present in the perianal region and the only way to diagnose them is to look for them. These can include squamous cell carcinomas and melanomas. See images below for some examples. 

Vaping: Medicine or Menace (Ling, 11/13/2024)

 A recording of this presentation is available HERE.

***

This was a mind-blowing and practice-changing Grand Rounds this week -- so much to learn and understand about vaping (aka e-cigarettes) as primary care providers. The speaker, Dr. Pamela Ling, is the Director of the UCSF Center for Tobacco Research and Education, and she shared so much valuable data and on-the-ground information about the current state of vaping. The title of her talk was Vaping: Medicine or Menace?

Here's what I learned:

First off, the vaping industry is rapidly evolving. Unfortunately, the science, while forthcoming, lags behind an agile and sneaky industry. The first e-cigarettes came on the market in 2009 and looked like little "fake cigarettes" (they even featured a puff of smoke). Now, vapes come in a shapes and sizes and with increasingly concentrated (and flavored) solutions and changing delivery devices. 

E-cigarettes create an aerosol by using a battery to heat up liquid that usually contains nicotine, flavoring, and other additives. Users inhale this aerosol into their lungs. E-cigs can also be used to deliver cannabinoids, such as marijuana and other drugs. 

OMG check this out! These are vaping products confiscated from high schools in California and North Carolina (1000 products from 25 high schools) from an MMWR publication.

While cigarette smoking levels are down in California (and SoCO), vaping is on the rise, and the youngest have the highest rates.

In fact, SoCo teens seem to have higher rates of vaping than California teens overall.

And, unsurprisingly for those of us who care for marginalized populations, more vulnerable kids (based on gender identity, race, etc) have even higher rates of e-cigarette use

Note that while Sonoma County average of e-cigarette use is 12%, certain groups have MUCH higher rates, namely: SoCo gender questioning kids and kids who identify as black/African American, and Native American.

In addition to vaping nicotine, cannabis is increasingly popular; almost as many people use cannabis as tobacco now in the US. And while smoking is still the most common way to consume cannabis, edibles and vaping are both increasing.

Of note, older generation vapes contained far LESS nicotine. Newer vapes include chemicals that make higher concentrations more palatable and more appealing. As you can see in the image below, whereas older versions (The JUUL) contained the equivalent of about 1 pack of cigarettes, newer versions (e.g. Flum pebble) now contain up to 30 packs of cigarettes. This leads to increased nicotine consumption and dependence. And because of price controls and taxation cigarettes, vaping can save money, which certainly also influence habits and behaviors. Whereas a carton of cigarettes may cost upward of $50-85, a single vape (the equivalent of 3 cartons) costs less than $20 online. 

The same is true for rising THC concentrations in cannabis vapes. 

Do E-cigarettes help people quit smoking?

It is important to understand that there is SOME evidence of the use of e-cigarettes to promote smoking cessation, though the evidence is weak at best. E cigarettes are not approved by the FDA for smoking cessation, though they are recommended by the UK NHS due to this evidence. Under RCT conditions, earlier generations of vape products have been shown to be more effective than nicotine replacement therapy. You can see this data below summarized in the Cochrane review below. 

This has not borne out in population level observational studies-- in other words, when used as a consumer product, e-cigarettes do not help with cessation. Also important to note that the e-cig market is evolving extremely rapidly and the products are increasingly appealing to young people (this is not a coincidence).

Isn't vaping better for us than smoking?

Stella Tomassi and colleagues published a study of young adult vapers who never smoked compared to smokers using quantitative PCR to detect DNA damage (as a marker for future cancer).  They found a dose-dependent formation of DNA damage in oral cells of vapers who had never smoked tobacco cigarettes as well as exclusive cigarette smokers. They also found more damage seen in heavier users, users of pod vapes and sweet flavors) independent of nicotine levels.  

Recent studies of the epigenetic effects of tobacco smoking and e-cigarette use found similar changes in DNA methylation among people using cigarettes and people using e-cigarettes, changes that were associated with lung carcinogenesis.

While we do not have direct human data on vaping and lung cancer outcomes, these newer biomarkers of DNA damage and epigenetic changes are likely to be informative for lung cancer risk.

When people switch completely from cigarettes to e-cigs, there is definitely a decline in those biomarkers. So maybe vaping IS better than cigarette smoking. Unfortunately, many people try to convert to vaping but then continue intermittently also smoking cigarettes. Interestingly, the evidence shows that these "dual users" do not reduce their exposures to carcinogens.  

In terms of cardiovascular disease: a recent study published in NEJM 2024 found that CV disease risk from vaping was NO different than CV disease risk from smoking. So for CV risk the answer is NO.

But here's perhaps one of the most important take home points: dual use (using BOTH vapes and cigarettes) is definitely the worst for patients. Check out this summary table below showing the risk of disease appears higher for dual users. . .

Dr. Ling's closing advice to clinicians:

• Ask about vaping to engage in a cessation conversation
• Ask about both nicotine and cannabis vaping
• Encourage to treat nicotine vapes like any tobacco product
• Encourage complete switching not dual use
• Longer term transition off vaping products (using nicotine-replacement)

Ariel Thomas-Urlik, MPH from the Sonoma County Department of Public Health, who helped make this presentation possible, also shared some local information about local laws aimed at preventing widespread sales of nicotine products to children and adults.  

Did you know that SoCo has a minimum price of $10/pack for cigarettes? No coupons or discounts are allowed to be applied. 

Also California law currently prevents flavored tobacco products from being sold in physical retail stores, and a new law going into effect this week prohibits County of Sonoma do NOT ALL e-cigarette sales in physical retailers that sell tobacco (cannabis dispensary do not apply). While retailers continue to sell, DPH is using volunteer decoys to catch retailers who are violating this law. There is less access in SoCo, and we know that when access goes down, people become more interested in quitting. 

A new state law CA AB3218 which goes into effect on January 1, 2025 makes online purchase of vapes illegal in the state of California!

Methadone in Hospitalized Patients (Bowen & Aguilar 11/6/2025)

 A recording of this presentation is available HERE. 

Deep gratitude for our two Addiction Medicine Fellows, Drs. Bianka Aguilar and Anna Bowen, for an important and concrete presentation this week on Methadone in Hospitalized patients. They will be back in the spring with another Addiction Medicine presentation!

Here are my favorite pearls:

1) Starting methadone in the hospital decreases self-directed (AMA) discharges (30% vs. 59.6%), reduces all-cause readmission rates (27% vs. 41%), and decreases risk of endocarditis, osteomyelitis, and septic arthritis. I was taught that we should be "cautious" in the hospital about starting methadone if there wasn't a long-term plan for follow-up, but this is no longer true. If a patient is motivated to start methadone and it is indicated, we should do it. There are many new algorithms that can cross taper people easily from methadone to buprenorphine IF they are unable to get methadone through an outpatient treatment center.

2) Fentanyl in our drug supply has changed the treatment of opioid use disorder (OUD).  Recent studies are showing the methadone may be superior to buprenorphine in terms of treating OUD in fentanyl users. Methadone for OUD also appears to have higher retention rates. 

3) Traditional methadone induction involved weeks of up titrating doses until methadone was at therapeutic levels; newer studies, particularly in the fentanyl era, have found that quick starts--  higher starting doses, 30-40mg on D#1, and quicker up-titrating, increasing by 10-15mg, per day is safe and effective.

4) While methadone is known to lengthen the QT interval, not everyone on methadone needs serial or even baseline EKG monitoring. Most guidelines recommend an EKG at initiation of methadone only for patients with other cardiac risk factors (e.g. known prolonged QT, CAD, CHF, etc.)  AND once methadone doses near 100mg daily. This is a dose response side effect. We should remember to look at other medications that can also prolong QTc to see if those can be altered/discontinued. A QTc of >500 is not an absolute contraindication to treating with methadone, but the clinical scenario merits review (e.g. medication review)

4) Some people are "rapid metabolizers", meaning that single daily dose of methadone may be insufficient to help with cravings and treat their opiate use disorder. This is known to be true in pregnancy, but can also occur in some patients. Rapid metabolizing most often manifest as someone who appears appropriately treated by a certain methadone dose by 2-4 hours after their dose (maybe even a little sedated), but then 12 hours later is experiencing s/sx of withdrawal or cravings. We can potentially help their case to receive methadone BID by checking "peak" (2-4 hours after the dose) and "trough" (right BEFORE their dose) serum level of methadone.

Practical tips for methadone in hospitalized patients:

• Consult the addiction medicine fellows (on call schedule on Epic)
• Document a 1 year history of OUD
• Use the COWS score to monitor s/sx of withdrawal
• We have 2 Methadone clinics in Santa Rosa: DAAC and SRTP. When initiating methadone, contact one of these clinics ASAP to arrange intake.
• There is a federal 3 day exception for patients being discharged from the hospital, to whom we can prescribe methadone. Current local help is available via Creekside Pharmacy vs. SSRRH ER.
• Offer all patients naloxone on discharge. 
• Use the California Bridge website for help, including guidelines and algorithms.
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• Keep your eye out for newer studies showing quick start algorithms

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  Toronto Perinatal Addiction Medicine Team