Colon and Rectal Diseases
Colon and rectal diseases comprise a broad range of conditions and ailments, the severity of which can vary from mildly irritating to life threatening. Research has demonstrated that early screening and treatment of colon and rectal diseases can significantly improve treatment outcomes and survival rates, yet many patients delay or don't seek treatment because of lack of knowledge about their disease and its symptoms or the benefits of early treatment, or are too embarrassed to seek help.
Because the symptoms of different colon and rectal disease can closely resemble those of other such diseases, there is the potential for misdiagnosis and mistreatment. This is a crucial reason why these diseases should be treated by colon and rectal surgeons, experts in the surgical and nonsurgical treatment of colon and rectal problems.
Following is an overview of the major colon and rectal diseases and how they are treated:
Colorectal cancer incidence is increasing in India and other Asian Population.
High-risk factors include personal or family history of colorectal cancer, polyps (benign growths that may become cancerous), ulcerative colitis, or cancer of other organs.
Detection methods include a digital rectal exam (an exam of the rectum by a physician with his or her finger) and a chemical test of the stool for blood. Colorectal cancer can be prevented if polyps are detected and removed through an outpatient colonoscopy (examination of the entire colon), or an endoscopy flexible sigmoidoscopy (examination of the lower large intestine).
If symptoms such as rectal bleeding and changes in bowel habits appear, a colon and rectal surgeon should be immediately consulted to determine if the patient has colon cancer or another bowel disease, and the patient should be promptly treated as appropriate.
Surgery is required in nearly all cases of colorectal cancer for a complete cure, which is sometimes accompanied by radiation and chemotherapy. Between 80-90 percent of colorectal cancer patients are restored to normal health if the cancer is detected and treated in the early stages, but the cure rate drops to 50 percent if treatment does not begin until later disease stages. The surgery is now performed with minimally invasive treatment like laparoscopy.
Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD) that results in inflammation of the inner lining of the colon and rectum. While UC can occur at any age and affects both sexes equally, the peak age at onset of symptoms is about 20 years, with a second smaller peak at about 60 years.
The cause of UC is unknown. There is evidence that genetic factors may play a role in determining susceptibility to the disease, hence the tendency towards familial aggregation and differing incidences in different races.
Ulcerative colitis usually begins with inflammation of the rectum, also known as "ulcerative proctitis." The disease process then tends to extend proximally into the colon (i.e., "colitis"). The hallmark clinical signs are diarrhea and bleeding. However, the severity of symptoms vary markedly, ranging from insidious changes in bowel habits with intermittent diarrhea to rapid onset of profuse bloody diarrhea, bleeding, abdominal pain and fever.
The diagnosis of ulcerative colitis can be made by flexible sigmoidoscopy, since the rectum is virtually always inflamed. The characteristic appearance should be confirmed with biopsies and microscopic examination. Colonoscopy (or barium enema) frequently provides useful information, not only helping to assess proximal extent of disease, but also to look for skip areas, polyps, or other features which would challenge or confirm the diagnosis.
What are the complications of ulcerative colitis?
Common intestinal complications are; acute attack (relapse) leading to increased bleeding an dfrequency. Rarely this may lead to gross colonic dilatation (megacolon)or perforation. This is a serious life threatening complication. With pan colitis & prolonged duration of disease, there is a small but definite risk of developing colon cancer.
Extra intestinal complications may lead to joint pain (arthritis), spine problem (ankylosing spondylitis) or affects skin, eye or bile duct.
The goal of the medical treatment of ulcerative colitis is to induce clinical remission while avoiding toxic medications. Medications such as 5-ASA products (e.g., Mesacol, Asacol®, Pentasa®, etc.) are often used to maintain remission. Whereas, the 5-ASA medications are safe, chronic corticosteroids and cyclosporine are not. Therefore, when clinical remissions are induced with corticosteroids and/or cyclosporine, additional medications must be added to facilitate weaning of these drugs. 5-ASA compounds or immunosuppressants such as azathioprine and 6-MP are recommended. It is probably wise to attempt weaning off azathioprine or 6-MP after 1 to 2 years of remission.
The medical treatment should be tailored to the severity of symptoms and extent of disease. Patients with proctitis and proctosigmoiditis are best treated with topical treatment such as 5-ASA enemas or suppositories. As the disease extends proximally to the left colon, oral or systemic treatment becomes necessary. The first line of treatment should be 5-ASA products. In patients with severe colitis or moderate colitis that is not responding to maximal doses of 5-ASA, corticosteroids are initiated. Most patients with severe colitis (more than six stools/day, blood in stool, fever, tachycardia, and anemia) require hospitalization with bowel rest, intravenous corticosteroids, and parenteral nutrition. Approximately 50% of patients admitted to the hospital for treatment of severe or fulminant disease will respond to bowel rest and corticosteroids and will not require urgent operation. The addition of intravenous cyclosporine results in improvement in another 20-30% of patients. Thus, about 50-80% of patients can be discharged home without urgent surgery. Despite this, the majority of patients requiring hospitalization for treatment of severe UC undergo colectomy within one year.
When is surgery needed for ulcerative colitis?
Patients who have severe disease not responding to medical treatment would eventually require surgery. Many patients who develop complications of steroid treatment are candidate for surgery.
Also patients sho develop complications due to the disease itself like stricture or perforation or excessive bleeding would require surgery.
The well-accepted colon cancer risk factors in patients with UC are extent of disease and duration of disease. The increased risk for cancer in patients with pancolitis begins 8 years after onset of disease, with an incidence of about 0.5-1.0%/yr thereafter.
The standard procedure for treatment of UC is Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis. This procedure can now be very well performed laparoscopically.
Crohn's disease is a chronic inflammatory condition primarily involving the intestinal tract that predominantly affects young adults between 16 and 40 years. About 20 percent of the people with Crohn's have a family member with the disease.
Crohn's is diagnosed through a physical examination, review of symptoms and family history. In addition, testing may include barium x-rays of the upper and lower intestinal tract, a sigmoidoscopy or colonoscopy, which allow a direct examination of the colon with a lighted tube inserted through the anus, and intestinal biopsies. The cause and how to prevent Crohn's is unknown.
Medical treatment with anti-inflammatory or immunosuppressive medication to control symptoms is the preferred initial form of therapy. However, surgery to remove the diseased segment of the bowel and join the healthy bowel ends together, called resection and anastamosis, is recommended in more advanced or complicated cases.
Surgery is eventually required in up to three-fourths of all Crohn's patients and is best conducted by a colon and rectal surgeon, who is skilled and experienced in Crohn's disease management. Surgery often provides long-term relief from symptoms and limits or eliminates the need for medication.
Irritable Bowel Syndrome (IBS)
Irritable bowel syndrome is a common intestinal muscle functioning disorder involving constipation, diarrhea, or a combination, accompanied by pain, bloating and cramps, that affects up to 30 percent of population at some point during their lives.
To diagnose, a flexible sigmoidoscopic examination or colonoscopy (allowing visualization of the colon and intestine), a hemmocult test to detect hidden blood in the stool, an x-ray of the lower intestines and/or a psychological evaluation are used to rule out other diseases or conditions, such as cancer, diverticulitis, inflammation of the intestines, or depression.
Because the symptoms of IBS so closely resemble those of other, sometimes life-threatening diseases, such as colon cancer, Crohn's disease or ulcerative colitis, it is imperative to seek medical attention so that these disorders may be ruled out.
In some IBS patients, mental health counseling and stress reduction can help relieve symptoms. In others, increasing the amount of liquids and bulk-forming foods in the diet to soften stools may provide relief. If dietary change isn't sufficient, the physician may prescribe medications that help intestinal muscle contractions return to normal.
Diverticulosis, which afflicts about 50 percent of patients by age 60 and nearly all by age 80, is the presence of pockets (called diverticula) in the colon wall. Diverticulitis is inflammation or infection of these pockets.
With routine colon and rectal examinations, diverticula can be detected and diverticular disease may be prevented. A colon and rectal surgeon can best differentiate the disease from other bowel diseases and determine an individual's treatment plan.
Diverticulosis and diverticular disease are usually treated with a high-fiber, low-fat diet and occasionally by medications to control pain, cramps and changes in bowel habits. Diverticulitis treatment requires antibiotics, dietary restrictions and possibly stool softeners. Some patients need to be hospitalized to adequately treat acute diverticulitis.
Surgery to remove part of the colon is used only with recurrent episodes, complications or severe attacks with little response to medication. Complete recovery from surgery can be expected, with normal bowel function resuming soon after surgery.
Hemorrhoids are one of the most common colorectal ailments, with millions of Indians currently suffering from them. More than half the population will develop hemorrhoids, usually after the age of 30.
External hemorrhoids, which develop near the anus, are distinguished as a hard, sensitive lump, which will painfully swell if a blood clot develops. Internal hemorrhoids, which develop within the anus beneath the lining, are distinguished by painless bleeding and protrusion during bowel movements.
Factors that may contribute to and be considered in the prevention of hemorrhoids are: faulty bowel function due to overuse of laxatives or enemas, straining during bowel movements, spending long periods of time on the toilet, chronic constipation or diarrhea, pregnancy and heredity.
Mild symptoms are usually controlled by increasing the amount of fiber and liquids in the diet to eliminate difficult bowel movements and straining. For severe cases, a physician may remove the hemorrhoid by ligation, ('cutting it off' with a rubber band); injection and coagulation, which cause it to shrivel up; or a hemorrhoidectomy to surgically remove it.
Now a day’s Staplers are used to do surgery which leads to bloodless surgery and faster healing and recovery
An anal fissure is a small tear in the lining of the anus caused by a hard, dry bowel movement, diarrhea or inflammation of the anorectal area. It's a common problem that affects a majority of the population at some point and is normally diagnosed upon examination following pain, bleeding and/or itching of the outer anus area.
Up to 90% of all fissures heal by themselves with non-operative treatment, using stool softeners, avoidance of constipation and/or soaking in warm water (sitz bath).
If a fissure doesn't heal due to scarring or muscle spasm of the internal anal sphincter muscle, surgery to reduce the pressure in the anal canal may be needed. In the case of surgery, pain often disappears after a few days and complete healing takes a few weeks, with more than 90 percent of patients never experiencing the problem again.
Bowel incontinence is the impaired ability to control gas or stool release due to a severed or weakened anal muscle caused by childbirth, old age or other nerve or muscle injury.
Diagnosis of the extent of impairment is done through examination of the affected area, frequently followed by a test to record pressure as a patient tightens the anal muscles (manometry), and an ultrasound probe to visualize muscle injury.
Mild incontinence can be addressed by dietary changes, the use of constipation medicine and simple home exercises to strengthen muscles. In other cases, biofeedback may be used to help patients sense when stool is ready to be evacuated and to strengthen weak muscles, or anal muscles may be repaired with surgery. Finally, the recent introduction of an artificial anal sphincter muscle is providing new help to patients with this problem.