Colorectal Conditions

Anal fissure

This is an often painful split in the anal canal. It is usually associated with constipation and anal spasm but is occasionally a feature of Crohn’s disease. Treatment is aimed at softening the stool and relaxation of the anal sphincter if in spasm. Topically applied ointment (glycerine trinitrate or diltiazem) is the first line treatment which induces smooth muscle relaxation and subsequent healing after 6 weeks. Injection of botulinum toxin (Botox®) or surgery is reserved for resistant cases.

Bowel cancer

Bowel cancer is common and can be successfully treated in over 90% of cases, if it is diagnosed at an early stage, before it has had a chance to grow and spread.

The early symptoms for bowel cancer are very similar to other, much less serious problems with the bowel, such as haemorrhoids (piles), so it is very important to recognise any unusual changes and act quickly to get them investigated. The sooner bowel cancer is diagnosed the better the outlook.

Any of the following symptoms should be investigated urgently:

• Rectal bleeding and change in bowel habit age>40
• Rectal bleeding without anal symptoms age>60
• Persistent change in bowel habit (more than 6 weeks) age >60
• Iron deficient anaemia without obvious cause-this can cause tiredness, lethargy and shortness of breath.
• Palpable abdominal mass
• Unexplained weight loss

Symptoms are investigated by colonoscopy, barium enema or by CT colonography. A biopsy would be necessary to confirm the diagnosis and further scans (CT and/or MRI) to determine the tumour stage and plan treatment.

The earliest stage of bowel cancer is a malignant polyp that can be treated at colonoscopy. Most colorectal cancers do however require surgery. The site of the tumour determining the exact operation performed but generally involves resection of a part of the bowel which is then joined (anastomosed) to restore continuity.

The surgery can often be performed by a minimally invasive approach (laparoscopic surgery) which is an area of expertise of the Vale Healthcare colorectal team.

Diverticular disease

This is a common condition in which pouches (called diverticulae) of the bowel lining balloon out through weak areas in the bowel wall. These diverticulae develop over many years and cause few, if any symptoms, in the majority of people.

More commonly seen where diets tend to be low in fibre, this increases in incidence as we get older. Once formed, the pouches are permanent. The aim is to keep the pouches from causing complications and to reduce more pouches from forming.

Symptoms
Uncomplicated diverticular disease generally causes few symptoms which may include mild cramping pains, generally on the left side of the abdomen.

Complications
The diverticulae can become infected (Diverticulitis) which can cause severe pain, bleeding, fever and alteration in bowel habits. Other complications include bleeding, thickening and narrowing of the affected part of the bowel and rarely perforation of the bowel and other serious conditions.

Treatment
Diverticular disease can usually be controlled by dietary manipulation and occasionally medications to help control pain, cramps and changes in bowel habits may be needed.

Basic advice
Gradually add fibre to your diet (high fibre foods include fruits, green beans, vegetables, whole grain cereals, breads, rice)
Drink plenty of fluids
Eat regular meals & exercise daily
Respond right away to the urge to move your bowels
Avoid straining and avoid laxatives if possible

Is surgery a possibility?
Surgery is reserved for recurrent episodes of diverticulitis, complications or severe attacks when there is little or no response to medication. Should surgery be required, complete recovery can usually be expected. Normal bowel function usually resumes in about six weeks.

Experienced colorectal surgeons at the Vale Healthcare colorectal clinic will carry out this surgery using laparoscopic (key-hole) techniques in the majority of cases to facilitate quick recovery following surgery.

External rectal prolapse

Complete rectal prolapse is when the lower part of the intestine (the rectum) comes through the anus, presenting as a lump. It is more common in women than men and can be associated with prolapse of the bladder and womb associated with pelvic floor failure.

The lump from the anus initially occurs during straining at defaecation and resolves spontaneously, but in later stages requires manual replacement or becomes permanently prolapsed. Symptoms other than the lump include mucous discharge, bleeding, difficulty with defaecation and faecal incontinence.

After investigations your surgeon will determine the best operative approach to treat your prolapse. Options include abdominal surgery, which can often be performed using a laparoscopic (keyhole) method to ‘hitch up’ the rectum prevent the prolapse occurring. On occasion a direct approach to the prolapse itself via the anus is indicated.

Fistula in ano

Is an opening between the anus and rectum. Anal fistula usually occurs as a result of an infection or an abscess (collection of pus) in the anus. It can also be caused by conditions that affect the bowel such as inflammatory bowel disease.

The fistula can produce a persistent discharge of pus or can have cycles of healing, pus accumulation with pain and subsequent discharge. The fistula passes through the anal sphincter to a variable extent and it is how much muscle that is involved that determines the treatment of a fistula.

Approaches include placement of a permanent drainage stitch (referred to as a Seton), division of a portion of the sphincter muscle, or occasionally closure of the internal defect with a tissue flap.

Haemorrhoids (piles)

Commonly known as piles, are swellings that develop in the anus and lower rectum (back passage). The small veins (blood vessels) in the lining of the anus and lower rectum sometimes become enlarged and engorged with more blood than usual. These engorged veins and the overlying tissue may then form into one or more small swellings called haemorrhoids.

There are 4 grades of severity. In many cases, haemorrhoids are small and symptoms settle down without treatment. The commonest symptom is bleeding when opening the bowel. Larger haemorrhoids may cause itchiness, pain and a mucus discharge, which may cause irritation.

Treatment varies according to the severity but principally involves changes in diet, possibly with medication, to avoid constipation; topical application of cream or ointment, or use of suppositories to relieve symptoms.

Inflammatory bowel disease (IBD)

This is a long-term (chronic) inflammatory condition affecting the intestine. The two broad types are ulcerative colitis (UC) or Crohn's Disease.

Ulcerative Colitis affects the rectum and colon whereas Crohn’s can affect any part of the intestine, commonly the end of the small intestine (ileitis) and colon (colitis). Symptoms of colitis are blood stained diarrhoea and urgency.

Small bowel Crohn’s disease causes abdominal pain and diarrhoea. Loss of energy and weight loss are associated symptoms.

Diagnosis is made at colonoscopy and biopsy (colitis) or with barium studies or CT scan (ileitis). Treatment options include medical therapy, aimed at immunosuppression, and surgery.

Patients with inflammatory bowel disease are often managed jointly by a gastroenterologist and a surgeon with an expressed interest in this challenging condition. Vale Healthcare consultants have a wealth of experience in the management of IBD and joint consultations can be arranged.
 

Internal rectal prolapse

This is a condition where the rectum descends below its normal position during defaecation. It is considered that progression can occur resulting in an external rectal prolapse. Symptoms are of obstructive defaecation and a need to strain at stool. Treatment is tailored to symptoms and extent and varies from simple advice to bowel retraining (biofeedback) and surgery in the form of laparoscopic ventral rectopexy.

Irritable bowel syndrome

Irritable bowel syndrome, or ‘IBS’ is a functional condition of the bowel characterised by pain, bloating and a chronic alteration in bowel habit towards either constipation or diarrhoea. It is thought to be due to an imbalance in the neural and local hormonal pathways controlling bowel sensitivity. It does not cause rectal bleeding or weight loss. Exclusion of physical bowel disorders may be required and appropriate treatment provided based on the predominant symptom.

Obstructive defaecation

This term is used to describe the feeling of a blockage in the bottom making defaecation more difficult. Associated symptoms are straining at stool and incomplete emptying, and an anal or vaginal lump. Causes can be structural (rectocoele, internal rectal prolapse) or functional. The Vale Clinic can offer a thorough assessment of the causes of obstructive defaecation and a tailored approach to its management.

Pilonidal sinus

A small hole or sinus in the cleft between the buttocks (natal cleft). The sinus is usually associated with a collection of hairs under the skin. Abcesses can form if the sinus seals. A variety of operations are used to treat this, ranging from simple excision to complex rotational flaps. Your colorectal surgeon will determine the most suitable procedure.

Polyps

These are abnormal growths of tissue from the lining of the colon or rectum. These can be on a stalk (pedunculated) or flat (sessile). With time polyps grow in size and become cancerous (malignant). Removal of polyps can prevent the development of cancer at that particular site. Some polyps, particularly if multiple, can arise because of a familial or genetic trait, and there may be a family history of polyp formation.

Polyps are not associated with symptoms in the earliest stages, but can cause bleeding and change in bowel habit as they progress. Polyps can be removed using a colonoscope in early stages (polypectomy), but with increasing size surgery may be required, often laparoscopically.

Rectocoele

This is a bulge of the rectum into the vagina causing the patient to experience a lump at the back of the vagina or difficulty in defaecation requiring vaginal support. They are thought to develop through childbirth trauma but can occur in chronic straining. Most rectocoeles do not require treatment unless they cause specific symptoms. Surgical repair can be performed through the anus, the perineum (between the anus and vagina) or the vagina, although a ventral rectopexy is indicated for associated symptoms.

Rectovaginal fistula

A communication between the rectum and vagina. Symptoms include discomfort or the passage of flatus or faeces through the vagina. Common causes include perianal infection/abcess or Crohn’s disease. Investigations are needed to establish if the anal sphincter is intact before treatment which can include medical treatment but usually surgical repair.

Stoma care (colostomy/ ileostomy)

Stomas are used to divert the faecal stream away from diseased area of bowel or when the rectum/anus has been removed. Colorectal conditions that can require stoma formation include cancer, inflammatory bowel disease or incontinence, and can be temporary or permanent.
Stomas can develop complications such as herniation, prolapse or retraction which require corrective surgery.