Specialties
Cancer
Anal cancer
Anal cancer is relatively rare, but this malignancy is increasing in incidence from ~4600 cases in 2006 to the current estimate of 7210 cases per year in the US according to the American Cancer Society. Anal cancer exists as several different types, but squamous cell carcinoma, a type of skin cancer, is by far the most common.
Infection by the human papilloma virus (HPV), the virus that causes anal warts, has been shown to increase the risk of anal cell changes and anal cancer. Other risk factors for developing anal cancer are multiple sexual partners, a history of cancer of the cervix, vagina or vulva, HIV infection, compromised immunity, smoking, practice of anal receptive intercourse, being a woman.
About half of the persons diagnosed with anal cancer have a lesion that has not spread beyond the anus, and about a third of the patients have disease spread to lymph nodes in close proximity to the anus. Approximately one in 10 patients with anal cancer have spread of the disease to other organs by the time they are diagnosed.
Patients with the earliest stage of anal cancer have a very good prognosis with an over 80% chance of living 5 years after their diagnosis. This chance is decreased to about 60% if the lymph nodes close to the anus are involved. The patients whose anal cancer has also spread to distant organs within their body have an approximately 1 in 5 chance to survive for 5 years or longer.
Symptoms
Some patients have no symptoms from their anal cancer, but bleeding and/or itching is common. Many patients have noticed a “bump” near the anus or have had increasing pressure or pain from the anal area. Change in discharges or bowel habits can also be due to anal cancer.
Diagnosis of anal cancer
Anal cancer can usually be detected during a routine digital rectal examination in the clinic. Further assessments may include biopsies, CT scan and/or ultrasound.
Treatment of anal cancer
Therapy for anal cancer may include chemoradiation therapy and/or surgery. The treatment recommended will depend on several factors, including the size of the tumor as well as the exact location of it. You will discuss this with us prior to therapy start. Most people with anal cancer will not need a permanent ostomy.
Colon cancer
Cancer that forms in the tissues of the colon (the longest part of the large intestine). Most colon cancers are adenocarcinomas (they are originating from the lining of the colon).
Colon cancer is a disease in which malignant (cancer) cells form in the tissues of the colon.
The colon and the rectum make up the large intestine. The first 6 feet of the large intestine are called the large bowel or colon. The last 6 inches are the rectum and the anal canal. The anal canal ends at the anus (the opening of the large intestine to the outside of the body).
Age and health history can affect the risk of developing colon cancer.
- Age 50 or older.
- A family history of cancer of the colon or rectum.
- A personal history of cancer of the colon, rectum, ovary, endometrium, or breast.
- A history of polyps (small buds) in the colon.<
- A history of ulcerative colitis (ulcers in the lining of the large intestine) or Crohn’s disease.
- Certain hereditary conditions, such as familial adenomatous polyposis and hereditary nonpolyposis colon cancer (HNPCC; Lynch Syndrome).
Symptoms
The two most common symptoms of colon cancer are blood in the stool and changed bowel habits. These symptoms can however be due to other conditions as well, why it is important that you seek a consultation with your doctor if you notice these symptoms. Other symptoms from colon cancer may include diarrhea, constipation, or feeling that the bowel does not empty completely, stools that are narrower than usual, frequent gas pains, bloating, fullness, or cramps, weight loss for no known reason, nausea/vomiting.
Diagnosis of colon cancer
Colon cancer can be diagnosed with a clinical examination, but usually other tests are required to establish the diagnosis. The most common and reliable test is colonoscopy. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
An alternative to colonoscopy is a barium enema, where a series of x-rays of the lower gastrointestinal tract are taken. A liquid that contains barium is at the same time put into the rectum. The barium coats the lower gastrointestinal tract and x-rays are taken. This procedure is also called a lower GI series.
CT colonography uses a series of x-rays called computed tomography to make a series of pictures of the colon. A computer puts the pictures together to create detailed images that may show polyps and anything else that seems unusual on the inside surface of the colon. CT scans are used to stage the tumor and to study possible spread to other organ systems.
Treatment of colon cancer
Treatment of colon cancer usually entails surgical removal of the tumor. This can frequently be done using robotic or laparoscopic technique. The best treatment option depends on the stage and location of the tumor. The stage of the colon cancer describes “how far along” the cancer has grown and if it has spread to lymph nodes or other organs. Surgical treatment can frequently be done with laparoscopic or robotic technique.
Early stage cancers can often be treated by surgery alone whereas later stage tumors may need postoperative treatment with chemotherapy. Late stage tumors frequently require chemotherapy treatment after the surgical resection.
We usually discuss and define the best treatment options at our multidisciplinary conference, where all available data about the patient and the tumor is discussed with our colleagues in oncology, radiology and pathology.
Rectal cancer
Rectal cancer is the same as a malignant tumor in the rectum. The cause of rectal cancer is usually unknown, but some possible risk factors have been identified. These include age more than 50 years old, certain hereditary conditions, such as familial adenomatous polyposis (FAP) and hereditary nonpolyposis colon cancer (HNPCC or Lynch syndrome), personal history of colorectal cancer, polyps, cancer of the ovary, endometrium, or breast, family history of colorectal cancer or polyps.
Symptoms
Common rectal cancer symptoms include a change in bowel habits or blood in the stool. These symptoms may however also be caused by other conditions, such as hemorrhoids. <therefore, it is recommended that you should seek a consultation if you experience change in bowel habits, rectal bleeding, feeling that the bowel does not empty completely, stools that are narrower or have a different shape than usual, or weight loss for no known reason.
Diagnosis of rectal cancer
Rectal tumors may be possible to palpate with a digital rectal exam (the doctor inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual). Proctoscopy visualizes abnormalities in the rectum. A proctoscope is a thin, tube-like instrument with a light and a lens for viewing. Colonoscopy: A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer. A colonoscope is a thin, tube-like instrument with a light and a lens for evaluation of the colon and the rectum. Biopsies for microscopic analysis are usually obtained at proctoscopy or colonoscopy.
Most patients with rectal cancer undergo further assessment with CT scan, MRI scan and/or rectal ultrasound. These modalities are helpful in staging the tumor, which is important in selecting the appropriate treatment modality (please see below).
Treatment of rectal cancer
The best treatment for rectal cancer depends on the rectal cancer stage, the location of the tumor and some other factors. The stage of the rectal cancer describes “how far along” the cancer has grown and if it has spread to lymph nodes or other organs. We use methods such as MRI (Magnetic Resonance Imaging), CT scan, ultrasound and certain blood tests to determine the stage of the tumor.
Early stage cancers can often be treated by surgery alone whereas later stage tumors may need to be “pre-treated” with chemotherapy, radiotherapy or both. It is proven that patients with later stage disease do better if they are “pre-treated” prior to surgery. Most patients with rectal cancer will not need to end up with a permanent colostomy. The prognosis (chance of recovery) and treatment options depend on the stage of the tumor, whether the tumor has spread into or through the bowel wall, were the tumor is located in the rectum, whether the bowel is blocked or has a hole in it, whether all of the tumor can be removed by surgery, the patient’s general health, etc.
Anorectal Disorders
Anal fissure
An anal fissure is a small tear in the lining of the rectal opening. A fissure can occur anytime, but many patients indicate that they have had an episode of constipation. A few patients indicate that they developed the fissure after having loose stools.
Fissures are usually superficial and sometimes they can even be difficult to detect for the doctor. Chronic fissures can be deeper and they can sometimes reach down to the sphincter muscle.
Many patients with a fissure have a tight anal canal and several of the treatments (please see below) are aimed at correcting this circumstance.
Symptoms
The main symptom of anal fissure is pain. This pain is usually worst with a bowel movement and the pain sometimes persists after the bowel movement. The pain thereafter gradually improves until the next bowel movement. Some patients with fissure have rectal bleeding from the tear at bowel movements. The bleeding is usually bright red. The fissure is sometimes associated with a skin tag at its most outer part. This tag can be felt as a slight swelling. A few patients also have problems with itching, which can be caused by discharge from the fissure when the fissure alternately heals and reopens.
Diagnosis of anal fissure
Fissures can be diagnosed with a clinical examination. Sometimes the fissure is small and located a bit on the inside. In patients with significant tenderness, it can therefore sometimes be difficult to diagnose the fissure. These patients can then need an examination under anesthesia in the operating room.
Chronic fissures may need to be biopsied to rule out other reasons for the symptoms. Sometimes endoanal ultrasound can be helpful, before embarking on surgical treatment of the fissure.
Treatment of anal fissure
Many fissures will heal spontaneously without any medical or surgical treatment. This spontaneous healing is more frequent if it is possible to avoid constipation through good diet with proper amount of fiber. Sometimes your doctor will recommend a commercially available fiber product or a mild laxative. Sometimes a warm bath can reduce the spasm and the pain from the fissure.
Treatments are otherwise aimed at relieving the spam in the sphincter muscle. There are several creams that can help with this and they are therefore considered to be the first line medical option. Some patients are treated with Botox injection in the rectal area, since this treatment can relax the sphincter musculature.
If the above mentioned treatment options are not successful, surgical treatment can be considered. Surgery is usually aimed at cutting/dividing a part of the sphincter musculature, which will then decrease the tone in the sphincter muscle. The advantage is that this treatment is permanent, but at the same time dividing sphincter muscled will carry some risk for postoperative continence problems (rectal leakage).
Anal warts and anal dysplasia
Anal warts, anal dysplasia and anal cancer are all caused by the human papilloma virus (HPV). HPV is a common virus that can be transmitted sexually. There are over 40 types of HPV that can infect the genital and/or anal area. Some HPV types can cause warts. Other HPV types can cause anal and cervical dysplasia and cancer.
Genital HPV infection is very common in the US and most infected individuals are unaware of being infected. In women, warts can appear on and around the genitals and inside the vagina, on the cervix, and/or around the anus. Men typically develop warts on the penis, the testicles and/or around the anus.
Anal dysplasia is a pre-cancerous condition, where the cells of the anal canal (lower rectum) undergo abnormal changes. Anal dysplasia can progress from low-grade (low risk) to high-grade (high risk) changes before it turns into cancer. Anal dysplasia can turn into anal cancer, which is therefore also caused by HPV. This tumor usually develop slowly over a period of years. Anal cancer usually starts in the anal canal (lower rectum) or in the skin just outside of the anal canal opening.
Symptoms of anal warts
Many patients have no symptoms from HPV or their warts. Patients with anal warts may notice one or many “bumps” around the anal opening or in the anal canal itself. Some patients see blood when they wipe or experience anal itching.
Diagnosis of anal warts and dysplasia
Warts can be seen at visual clinical examination and at anoscopy (a small instrument is used to hold the rectal opening open to facilitate inspection of the lower rectum).
At anal pap smear, cells are collected with a swab that is inserted into the anus. These cells are examined under a microscope for pre-cancerous (dysplastic) abnormalities. Anal pap smears are recommended for patients with anal warts or with risk factors for HPV infection (i.e. patients engaging in anal sex, HIV or immunosuppression of other reason, women with cervical dysplasia/cervical cancer).
Pap smear results can be either be normal or abnormal. Patients with normal pap smear are usually recommended to undergo renewed pap smear after one (HIV positive patients) or two (HIV negative patients) years. Patients with an abnormal pap smear can be referred for high resolution anoscopy (HRA).
High resolution anoscopy (HRA) is an advanced diagnostic tool with which your specially trained provider can get enhanced assessment of the anal area. This enables better diagnosis of precancerous or cancerous lesions that may be present. The HRA technique is available only in specialized centers, with specially trained providers, like BIDC. Biopsies at HRA can come back as normal, low grade, or high grade dysplasia. Low grade dysplasia biopsies/warts are low risk, while high grade dysplasia biopsies/warts have a higher risk of developing cancer.
Treatment
Treatment is individualized. Visible warts are in general treated. Further treatment is usually tailored according to findings at the assessment (above).
Low grade lesions are low risk and they don’t need further treatment, in general. They should however be watched, since they can progress to more advance and high grade lesions (see below). High grade lesions should be treated, in general.
Treatment will be tailored to the types of lesion and our provider will discuss alternatives and listen to your preferences. Applying trichloroacetic Acid (TCA) can eradicate the lesion(s). This treatment frequently needs several consecutive treatments over a few weeks or months time span. Electrocautery can destroy the lesions and this treatment will destroy all or most lesions in one treatment session. – Topical 5% Imiquimod cream can decrease the risk for recurrence. Side effects of the cream include skin irritation and burns, but most patients are able to complete the therapy.
Follow-up
Follow-up is very important, since anal warts and dysplasia are caused by a virues that cannot be eliminated. Therefore, warts and dysplasia can recur and close follow up and monitoring is very important!
The follow-up program is tailored to the findings. Patients will low grade lesions are in general recommended to undergo a renewed HRA in about one year’s time (or sooner if new lesions are suspected). Patients with high grade lesions need follow-up more frequently and they are in general recommended a renewed HRA in three to six months (or sooner if new lesions are suspected).
Hemorrhoids
We all have small cushions with blood vessels in our lower rectum close to the rectal opening. Sometimes these cushions get bigger and start giving symptoms. A contributing factor for this may be constipation.
Sometimes patients develop small blood clots in the hemorrhoids and they are “thrombosed”. These hemorrhoids are swollen and they are usually painful.
Symptoms
Normal hemorrhoids are usually not painful. Enlarged hemorrhoids can cause a bright red bleeding and sometimes larger hemorrhoids can cause them to slide out (prolapse) at bowel movements. Sometimes this prolapse is reduced spontaneously, sometimes the patient need to use their hand to push them in. As indicated above, hemorrhoids can be caused by constipation. At the same time, hemorrhoids themselves usually don’t cause constipation.
Thrombosed hemorrhoids usually occur suddenly and they usually present as a painful, firm lump at the rectal opening.
Diagnosis of hemorrhoids
Hemorrhoids are usually diagnosed by your doctor with a clinical examination. Your doctor may use a small instrument, an anoscope, to visualize the hemorrhoids better. Frequently your doctor will also recommend an evaluation of your colon with a flexible sigmoidoscopy or colonoscopy, if you have not undergone one of these examinations recently.
Office treatment of hemorrhoids
Normal, non thrombosed, hemorrhoids usually respond to improved eating habits and treatment of constipation. In addition, patients seen in our clinic are usually treated with banding procedures or injection therapy.
At banding of hemorrhoids, a rubber band is placed around the hemorrhoid, causing it to wither and fall off after about one week. You may feel a mild to moderate pain/pressure for a few days. If needed, you can take an over-the-counter pain medication, for instance Tylenol® or Advil®. When the rubber band falls off, you may notice a small bleeding. In general, you need to repeat the treatment a few times and we usually treat patients about once a month.
Hemorrhoids can also be injected with an agent that shrinks them. This may stop the bleeding and prevent the hemorrhoids to protrude. Also with this treatment you may notice some discomfort and/or minor bleeding.
Thrombosed hemorrhoids can be treated with a small incision, to evacuate the blood clots. This will frequently result in some pain and sometimes also some bleeding. If needed, you can take an over-the-counter pain medication. If the thrombosed hemorrhoid is already improving, sometimes it is better not to incise them and let nature to heal and improve the condition spontaneously.
Surgical treatment of hemorrhoids in the operating room
Some hemorrhoids will require surgical treatment in the operating room and you doctor will counsel you about his/her recommendations.
Surgical excision of hemorrhoids is usually quite effective in elimination the hemorrhoid symptoms. The postoperative period is unfortunately quite painful for one or two weeks and it is important that you have pain medication at hand and that you see that you don’t get constipated.
Stapled hemorrhoidectomy and suture of hemorrhoids are two other effective treatment options in the operating room. These options are usually associated with less postoperative pain, but may have other limitations. Your doctor will discuss treatment options with you and you can then decide what option you want to proceed with.
Problems after treatment of hemorrhoids
Office treatment of hemorrhoids is usually associated with only minor pain, except for incision of thrombosed hemorrhoids when the pain may be moderate. If you experience excessive pain, unrelieved by pain medication, please contact our office immediately or go to the emergency room. The same accounts if you experience fever or chills, increasing pain after a few days, difficulties to urinate, constipation or severe bleeding or other alarming symptoms. Other risks with treatment of hemorrhoids will be discussed by your doctor before proceeding with treatment.
Perianal abscess
An abscess in the rectal region is caused by an infection, which may start in the rectum or in the skin. Irrespectively, the treatment of abscesses in this region is the same (drainage; please see below).
Abscesses that start in the skin will usually heal without any problems. A few of these abscesses will have a pilonidal cyst, which mat need to be removed at a later date.
Abscesses that start in the rectum may have an underlying fistula, which may need further subsequent treatment. The risk for an underlying fistula is approximately 50 percent the first time a patient has an abscess. If the abscess recurs several time in the same location, this risk may be even higher. It is therefore important to follow-up in the clinic after drainage of an abscess, to ensure that the abscess completely heals and there is nothing additional that will further attention.
Symptoms
The most common symptom is pain. The pain is continuous and not always related to having a bowel movement or not. Some patients may develop fever or a feeling of “being sick”. A few patients will notice a swollen area, sometimes with some discharge of pus or blood.
Diagnosis of perianal abscess
Most times a reliable diagnosis can be done by clinical examination only. Sometimes an endoanal ultrasound can be helpful and in a few patients a CT or MRI scan can be necessary.
Treatment of perianal abscess
Drainage of the abscess is the treatment of choice. This can usually be performed under local anesthesia in our clinic. The doctor will anesthetize the area with a local anesthetic to allow the drainage to be as painless as possible. Thereafter, an incision is made into the abscess to drain the pus. In addition to drainage, antibiotics are sometimes given to some patients, for instance immune compromised patients, patients with artificial implants or diabetes.
After the incision you will have mild to moderate pain when the local anesthesia weans off. If needed, you can take an over-the-counter pain medication, for instance Tylenol® or Advil® or a medication that your doctor will give you a prescription for. You may also notice some secretion or bleeding after the procedure. Please be careful not becoming constipated after the procedure, and we recommend that you take a mild laxative, for instance Miralax, if needed.
A few patients with more complicated abscesses may need examination and incision under general anesthesia in the operating room. If this is the case, your doctor will discuss this with you and see if you also need to be admitted to the hospital.
After treatment, you will need to follow-up in our clinic. As indicated above, some patients with a perianal abscess will have an underlying fistula that may need further subsequent treatment.
Problems after treatment of perianal abscess
Treatment of fistula is usually associated with moderate pain. If you experience excessive pain, unrelieved by pain medication, please contact our office immediately or go to the emergency room. The same accounts if you experience fever or chills, increasing pain after a few days, difficulties to urinate, constipation or severe bleeding or other alarming symptoms. Other risks with abscess surgery will be discussed by your doctor before proceeding with surgical drainage of the abscess.
Perianal fistula
A perianal fistula, almost always the result of a previous abscess, is a small passage connecting the anal gland from which the abscess arose to the skin where the abscess was drained.
An abscess is formed when a small gland just inside the anus becomes infected from bacteria or stool trapped in the gland. You did nothing to cause this infection. Certain conditions – constipation, diarrhea, colitis, or other inflammation of the intestine, for example, may make these infections more likely.
After an abscess has been drained, a passage may remain between the anal gland and the skin, resulting in a fistula. If the gland does not heal, there will be persistent drainage through this passage. If the outside opening of the fistula heals first, a recurrent abscess may develop.
Symptoms
Typical symptoms of a perianal fistula include frequent drainage of pus or blood through an opening in the perianal region. Sometimes there may also be some discomfort in the area. Sometimes, patients with perianal fistula may develop a perianal abscess with typical symptoms of pain, possible fever or a feeling of “being sick”.
Diagnosis of perianal fistula
A perianal fistula is usually diagnosed with a clinical examination. Fistulas usually have a draining small opening in the perianal region. Sometimes there is also a small opening found in the lower rectum, at clinical examination.
Fistulas can involve different amounts of sphincter muscle and therefore an endoanal ultrasound, and sometimes a MRI in complicated cases, can be quite useful. This may help the surgeon to advise you which type of surgery is most appropriate for you.
Treatment of perianal fistula
Surgery is usually necessary to treat a perianal fistula. The surgery is usually tailored to the extent of the fistula and how much of sphincter muscle is involved.
If there is a limited amount of sphincter involved in the fistula, the surgeon may suggest a fistulotomy. This involves cutting a small portion of the anal sphincter muscle to open the fistula. This procedure has a high rate of success, but there is some risk for continence disturbances if the fistula involves significant amount of sphincter musculature. Your doctor will discuss this with you before the surgery.
Fistulas involving more significant amount of sphincter muscle are usually treated with a sphincter saving procedure. These procedures are aimed at preserving/protecting the sphincter muscle. There are a few alternatives to choose from, including the LIFT procedure, flap procedure, plug procedure, etc. Your doctor will review these options with you to discuss which procedure will be most appropriate for you. In general, these procedures have a lower risk for postoperative continence disturbances but at the same time their healing rate may be lower.
It is unclear how much sphincter muscle is involved in the fistula, your doctor may elect placing a rubber band, a “seton” in the fistula. The doctor will then recommend you to come back to our clinic for an endoanal ultrasound to better “map” the fistula. At the same time, after the ultrasound, the doctor will discuss appropriate treatment options for you.
After fistula surgery you will have mild to moderate pain. If needed, you can take an over-the-counter pain medication, for instance Tylenol® or Advil® or a medication that your doctor will give you a prescription for. You may also notice some secretion or bleeding after the procedure. Please be careful not becoming constipated after the procedure, and we recommend that you take a mild laxative, for instance Miralax, if needed.
Problems after treatment of perianal fistula
Treatment of fistula is usually associated with moderate pain. If you experience excessive pain, unrelieved by pain medication, please contact our office immediately or go to the emergency room. The same accounts if you experience fever or chills, increasing pain after a few days, difficulties to urinate, constipation or severe bleeding or other alarming symptoms. Other risks with fistula surgery will be discussed by your doctor before proceeding with surgical repair of the fistula.
Colonoscopy
At colonoscopy, the lining of the colon and the rectum is examined using a colonoscope. The colonoscope is inserted into the rectum and is usually advanced through the complete colon. The colonoscope is a long tube with a camera at the tip, providing an inspection of the examined parts of the bowel. At colonoscopy, your doctor is able to carefully examine the lining of the bowel, diagnose colon and rectal problems, perform biopsies, and remove polyps.
At colonoscopy, your doctor may take biopsies, which are tissue samples. These samples will then be sent to the pathology lab for further analysis.
If polyps are encountered at colonoscopy, they are usually removed (polypectomy). Polyps are abnormal growths of tissue and they can vary in size. Polyps can usually be removed during colonoscopy and this is not painful. Retrieved polyps are usually sent to the pathology lab for further analysis.
Colonoscopy is usually done in an outpatient setting; you come and leave the same day. You have to take an oral preparation to cleanse the bowel before the procedure. During the procedure, your doctor usually will administer medicines to make you relax and decrease the discomfort.
The colonoscopy usually takes less than one hour. You usually rest for 1-2 hours before you can return home. Since you have received medications, you are not allowed to drive home by yourself. You can usually resume normal activities the following day.
Benefits and risks of colonoscopy
At colonoscopy, your doctor is able to carefully examine the lining of the bowel, diagnose colon and rectal problems, perform biopsies, and remove polyps. Polyps can then be removed before they turn into cancer and tumors can be identified and hopefully early, when the chance of cure is better.
Colonoscopy, biopsies and polypectomy are associated with very low risk of complications when performed by doctors with special training and experience doing these procedures. There is a very small risk for perforation, a tear through the bowel wall. This usually necessitates hospitalization and frequently surgery. Another risk is bleeding, for instance after biopsy or polyp removal.
Important considerations at scheduling a colonoscopy
Please let us know if you:
- have bleeding tendencies
- are on blood thinners or aspirin-containing products
- need to take antibiotics at dental visits
- have any heart or kidney problems
- are diabetic
Important considerations before and after a colonoscopy
- You will be on a clear-liquid diet and drinking laxatives the day before your colonoscopy. This may necessitate arranging your work/activity schedule.
- You will need someone to drive you home after the procedure. You cannot drive, take a taxi or bus alone after the procedure.
- We recommend that you have a responsible adult with you for 12 hours following your procedure.
Constipation
Patients with constipation (difficult defecation) have too few bowel movements and/or difficult rectal emptying. Some patients experience a sense of not emptying their bowel completely and may need to use enemas.
Normal bowel habits vary greatly in the population and normal frequency of bowel movements ranges from three times a day to three times a week. Normal bowel movements are usually not associated with discomfort/pain or excessive straining.
Mild or transient constipation is frequent and is usually relived by improved diet and/or increased fiber intake. Some patients, however, have more long-lasting severe symptoms that require them to seek medical attention.
Occasional constipation can be caused by a variety of factors, including poor eating habits or diet, stress, travel, lack of exercise or medications. Constipating medications include pain medications, psychiatric medications, iron and calcium supplements.
Chronic and/or severe constipation
If your constipation symptoms are more chronic or severe, it is wise to consult with a physician. You can then get good advice about life style and living habits and the doctor will discuss with you about a colonoscopy to exclude any tumors or other problems that may cause your symptoms.
The doctor will also review if you have any medical condition that may cause constipation symptoms, including Parkinson’s disease, diabetes, thyroid disease, back problems, etc. Symptoms may then improve with treatment of the underlying disease.
Your doctor may also suggest to further evaluate your symptoms with specialized tests. The transit test (Sitzmarks test) is used to evaluate the function of your bowels, manometry can rule out pelvic floor problems, EMG can identify muscle problems in the pelvic floor and defecography can visualize pelvic floor function and abnormalities in your pelvic floor.
Treatment of constipation
As indicated above, it is important to identify factor in your life style and habits that can contribute to your constipation problems. Some patients are helped by laxatives and there is a variety of different types available. Your doctor will identify a type that may be appropriate for you.
A common cause for constipation and rectal emptying difficulties is a failure to relax the pelvic floor muscles appropriately when trying to pass stool. This results in difficulties to empty the rectum and sometimes bowel movements can be even painful. Biofeedback can be helpful to help these muscles function better.
A small number of patients may benefit from surgical therapy. Some patients with rectocele can benefit from repair of the rectocele. Patients with pelvic floor laxity or prolapse can sometimes improve from surgical therapy. A very limited number of patients may also be a candidate for colectomy, which is a last resort for a few patients with severely handicapping constipation.
Crohn’s Disease
Crohn’s disease is an inflammatory bowel disease, which can engage the digestive system. The disease affect any area of the gastrointestinal tract and the most commonly affected part is the lower part of the small intestine; the ileum. The disease can also affect the colon and the rectum. Sometimes the upper gastrointestinal system can also be engaged. The disease is most common in young adults, but it can affect all age groups. Crohn’s disease seems to run in some families.
Symptoms
Common symptoms are pain in the abdomen and loose stools. Other symptoms may be weight loss and/or bleeding from the rectum. Fever, skin problems and joint pain may also occur. Some patients develop malnutrition, fistulas or bowel obstruction.
Diagnosis of Crohn’s disease
Diagnosis of Crohn’s disease depends on the affected portion of the gastrointestinal tract. CT or MRI scans are helpful to diagnose intestinal problems and colonoscopy can visualize the mucosa (the lining) of the bowel. If the rectum is engaged, this can be visualized at clinical examination. Sometimes, biopsies are needed to establish the diagnosis.
Treatment of Crohn’s disease
Most patients are treated with medications, which limit or resolve the inflammation in the bowel. Medical treatment can curb a flair of the disease, while it other times can prolong the periods of remission, when patients may be free of symptoms. Some patients will need surgical interventions, which may include bowel resection or surgical management of rectal problems. Nutrition supplements may be helpful for some patients.
Additional support
The local chapter of the Crohn’s and Colitis Foundation of America (CCFA) is an excellent resource. The local chapter can be reached at 847-827-0404. The national organization can be reached at 800-932-2423, email [email protected] or website www.ccfa.org.
Diverticulosis and Diverticulitis
Diverticulosis is the presence of pockets (diverticulae) that develop in the colon wall and they are most common on the left side of the colon. Diverticulosis usually affects middle/aged or older patients, but increasingly young patients are also diagnosed with this condition. Diverticulosis is quite common and it is estimated that more than half of the population have diverticulae at age 60.
Diverticulosis develops gradually over time and the development of diverticulae may be due to excessive pressure or spasms in the bowel. Diet lacking fiber and fluid may increase the risk for development of diverticulae.
Diverticulitis is an inflammation/infection in a diverticulum. This infection can lead a localized infection and symptoms may include abdominal pain (usually left side) and fever. Patients may also develop bowel perforation, abscess, bleeding, or spread of the infection to other organs.
Symptoms
A majority of people with diverticulosis have no symptoms. Some patients may have left lower abdominal pain, loose stools, and change in bowel habits. Patients with diverticulosis can develop rectal bleeding, which sometimes can be severe.
Diverticulitis usually presents as abdominal pain, on the left side or diffusely and patients frequently have fever. Patients with more severe diverticulitis can become quite sick, and may have high fever and sometimes develop sepsis. Patients with fistula can develop symptoms from the vagina, bladder or the skin.
Diagnosis of diverticulosis and diverticulitis
Diverticulosis can be seen at colonoscopy, CT scans or contrast x/rays of the bowel. The first line assessment of patients with diverticulitis includes labs (inflammation parameters) and a CT scan.
Treatment of diverticulosis and diverticulitis
Diverticulosis can be prophylactically prevented with adequate intake of fluid and fibers. A daily intake 25 grams fibers combined with adequate fluid intake (8-10 glasses daily) is recommended.
Mild diverticulitis can usually be managed at home with oral antibiotics and a modified diet. Severe cases require hospitalization with iv fluids, iv antibiotics, and avoidance of food. In cases with severe inflammation, which may include perforation or fistula, surgical intervention may be needed. Emergence surgery usually removes the diseased part of the bowel and sometimes a temporary colostomy or ileostomy is needed.
Patients with several repeated attacks of diverticulitis can sometimes benefit from an elective resection of the affected bowel segment. The bowel can then usually be reconnected.
Ulcerative Colitis
Ulcerative colitis is an inflammatory bowel disease, which can engage the colon and the rectum. The inflammation is characterized by inflammation and sometimes ulcerations of the mucosa (the lining) of the colon and/or rectum (the rectum is the last six inches of the large intestine). The cause of ulcerative colitis is unknown.
Symptoms
Ulcerative colitis usually presents with loose stools/diarrhea that can be mixed with blood. Patients may also have mucus discharge, rectal pain, and sometimes fecal incontinence (because of loose stools). The bleeding from ulcerative colitis is usually limited, but sometimes it can be significant.
Diagnosis of ulcerative colitis
Visual examination of the lining of the colon & rectum is usually diagnostic. This can be achieved with colonoscopy or sometimes flexible sigmoidoscopy. At the endoscopy your doctor may take biopsies. Sometimes radiographs and/or CT or MRI scans may be helpful.
Treatment of ulcerative colitis
The treatment of ulcerative colitis depends on the extent of the inflammation and the number of flare-ups you have had. Most patients receive medical treatment, which may include enemas, suppositories, oral and/or intravenous medications.
Regular examinations are important for monitoring the disease and most patients are managed by a gastroenterologist. If the disease activity becomes more intense/severe, you may need surgical treatment.
Surgical treatment can involve removal of the colon & rectum, which cures the disease in the bowel. Most patients who undergo removal of the colon, can subsequently undergo a restorative pouch procedure which enables patients to have bowel movement in the normal way and avoids the need for an ileostomy.
Additional support
The local chapter of the Crohn’s and Colitis Foundation of America (CCFA) is an excellent resource. The local chapter can be reached at 847-827-0404. The national organization can be reached at 800-932-2423, email [email protected] or website www.ccfa.org.
Other Conditions
Pilonidal cyst
A pilonidal cyst is a hair filled cavity underneath the skin over the tailbone. It is believed that this condition is usually acquired, resulting from impaction of hair under the skin in the midline in the gluteal region. The condition is more common in young people men, but it can also affect women.
Symptoms
Some people with a pilonidal cyst have no symptoms and treatment may not be necessary. Sometimes, the cyst gets infected and pus can accumulate forming an abscess. This causes pain, swelling, and possibly fever. In other patients, the infection may be low grade and these patients usually experience recurring episodes of milder pain and swelling.
Diagnosis of pilonidal cyst
The diagnosis of a pilonidal cyst is usually a typical history and findings at clinical examination. It is rare that further examinations would be needed.
Treatment of pilonidal cyst
Patients with an acute abscess usually need incision and drainage of the abscess. This can usually be performed under local anesthesia in our clinic. The doctor will anesthetize the area with a local anesthetic to allow the drainage to be as painless as possible. Thereafter, an incision is made into the abscess to drain the pus. In addition to drainage, antibiotics are sometimes given to some patients, for instance immune compromised patients, patients with artificial implants or diabetes.
Some patients may need prophylactic surgery, especially if there are several repeated infection episodes or continuing infection. Surgery for pilonidal disease is usually performed as an outpatient procedure at a hospital or a surgical center. The most common surgery is to open the cyst, clean out hair and debris and allow the cyst from inside out. The patient usually returns to our office every two to four weeks until the wound is completely healed.
After surgery, you will have mild to moderate pain. If needed, you can take an over-the-counter pain medication, for instance Tylenol® or Advil® or a medication that your doctor will give you a prescription for. Please be careful not becoming constipated after the procedure, and we recommend that you take a mild laxative, for instance Miralax, if needed. Careful cleansing and a gauze can prevent infection or premature closure of the skin, which can increase the risk for recurring/persisting symptoms.
After surgery, approximately ten percent of patients will have problems with healing or develop another cyst. The risk for this happening can be decreased by appropriate wound care, including keeping the area free from hair and clean the area carefully. A few patients with recurrent problems may need a more complex surgical procedure. This procedure may involve moving in new tissue in to wound area from the surroundings. Your doctor will discuss this option with you if he/she thinks that this could be beneficial for you.
Problems after treatment of pilonidal cyst
Treatment of pilonidal cyst is usually associated with only minor pain, except for incision of thrombosed hemorrhoids when the pain may be moderate. If you experience excessive pain, unrelieved by pain medication, please contact our office immediately or go to the emergency room. The same accounts if you experience fever or chills, increasing pain after a few days, difficulties to urinate, constipation or severe bleeding or other alarming symptoms. Other risks with treatment of hemorrhoids will be discussed by your doctor before proceeding with treatment.
Pruritus ani (rectal itching)
Pruritus ani is bothersome itching around the rectal opening. There are a variety of causes that can generate this problem, including diet, skin irritants, moisture, excessive or poor hygiene, etc.
Some foods are known to increase the risk for rectal itching. The most common irritant is caffeine and foods that contain caffeine will increase risk for symptoms, i.e. cola drinks, coffee, tea, and chocolate. Other foods that may cause rectal itching include citrus, tomatoes, nuts, beer, spicy foods, and dairy products.
Some hygiene articles, such as soaps, detergent or dyed or scented toilet paper can cause itching. Poor hygiene with stool left on the skin can cause itching, but at the same time excessive cleanliness may also be a problem causing increased itching. Vaginal or rectal discharge can cause itching (moisture), as moisture cause by tight clothing. Other potential causes of itching include skin conditions, fungal infections, pin worms, skin burns, etc.
Symptoms
Rectal itching is bothersome and symptoms sometimes include a burning sensation around the rectal opening. It can be difficult to avoid scratching, which sometimes will cause some bleeding. Symptoms are more common night time.
Diagnosis of pruritus ani
A clinical examination of the skin around the rectal opening usually determines the diagnosis. Mild pruritus may demonstrate redness of the skin, while more severe symptoms may result in thickening of the skin and sometimes open sores. Sometimes a skin biopsy is needed to exclude other diagnoses.
Treatment of pruritus ani
If it is possible to determine an underlying cause for the itching, this should be addressed. Otherwise it is recommended to gently clean the skin and make sure that the skin is dry. A hair dryer may be convenient. An ointment recommended by your doctor can be helpful. Sometimes a small rolled cotton ball placed between the cheeks can help with symptoms. Cotton loose (not tight) underwear is preferred, use plain toilet paper and wipe gently, use a mild soap or only water for cleaning, try to avoid foods mentioned above, normalize stool consistency (avoid loose stools), and take medications prescribed by your doctor. Try to avoid scratching or rubbing the area around the rectal opening and don’t use pads containing alcohol.