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Diagnosis Information:
Colon and Rectal Diagnosis Information
Inflammatory Bowel Disease
Inflammatory bowel disease effects many individuals. There are two main types of inflammatory bowel disease: Ulcerative colitis and Crohn's disease.
Ulcerative Colitis
Ulcerative colitis effects only the rectum and colon. It is a disease of the lining of the large intestine and does not effect deeper layers of the bowel or the small intestine. Most of the time, ulcerative colitis can be successfully treated with medical therapies. When these medical therapies fail, however, surgery can be offered. The surgery for ulcerative colitis involves removing the entire colon and the entire rectum. In most cases, however, the anus can be preserved and a reconstruction operation called an ileoanal pullthrough can be performed. This surgery is usually done in two stages. At the first operation, the diseased colon and rectum are removed and then a portion of the small intestine is used to make a "neorectum" and this is then connected to the anus. A temporary ileostomy bag is then created. After approximately 8-12 weeks, this temporary bag can be taken away and then the patient can then evacuate in a normal fashion.
Crohn's Disease
Surgery for Crohn's disease is also performed when medical therapies fail. Sometimes patients with Crohn's disease will get a narrowing of their intestines called a "stricture". When this occurs, and it is unable to be treated with medications, surgery is then used to either remove or, in some cases, widen the bowel. Particularly with Crohn's disease of the small intestine, bowel preserving surgery is emphasized. Other areas of the gastrointestinal tract that are involved with Crohn's disease include the colon, rectum and anus. Anorectal problems are often initially treated surgically to drain infection. Once the infection is cleared, medical treatments are then started. In particular with Crohn's disease, we work in close conjunction with our medical colleagues since oftentimes a combination of surgical and medical procedures are needed in order to maximize a patient's therapy.
Diverticular Disease
The formation of colonic diverticulum, or small pockets in the bowel wall, is felt to be acquired from many years of consuming a low fiber diet. They occur most often in the left side of the colon in a segment termed the sigmoid colon. Patients whose colons contain these pockets are diagnosed with a condition called diverticulosis. In the United States the presence of diverticulosis is a common condition with its incidence increasing with the age of the individual. Fortunately only a small percentage of people with diverticulosis go on to develop problems related to their diverticulum. The main problems that occur are lower gastrointestinal bleeding and inflammation of the diverticulum, called diverticulitis. Patients with diverticulitis usually experience abdominal pain, fever, diarrhea or constipation.
The treatment of diverticular disease depends on the specific nature of the problem. Patients with diverticulosis are encouraged to follow a high fiber diet to prevent complications of their diverticulum. Patients with lower GI bleeding can be treated conservatively or may require an emergent operation to stop the bleeding. Patients with uncomplicated diverticulitis can usually be initially managed with bowel rest and antibiotics, although patients with two or more episodes are usually advised to undergo an elective bowel resection to avoid further and potentially more complicated episodes. Patients with complicated episodes of diverticulitis, such as intraabdominal abscess formation, fistulae formation or free perforation of the bowel usually undergo surgery, often emergently to treat their problems. Most patients recover completely with resumption of normal bowel habits.
Rectal Prolapse
Rectal prolapse is a condition where the rectum turns itself inside out and protrudes out through the anal opening. Other problems, such a s prolapsing hemorrhoids can sometimes be confused with true rectal prolapse. Although, no specific cause of rectal prolapse is known, it is associated with a variety of anatomical abnormalities and can be associated with faulty bowel habits or aging. Most patients are advised to have their prolapse corrected in order to alleviate the discomfort as well as any associated constipation or fecal incontinence they may have. The definitive treatment options are all surgical.
The operations available to treat rectal prolapse can be divided into two general approaches. Patients who are healthy enough to withstand major surgery are usually advised to have an abdominal operation such as a rectopexy since the recurrence rate of prolapse treated in this manner is very low. Patients who are considered higher surgical risk are often advised to have an operation through the anal opening directly. Although the recurrence rate of the prolapse using this approach is significantly higher, the stress of the operation is far less.
Common Anorectal Problems
Patients with common anorectal problems are seen by the members of the Section of Colon and Rectal Surgery and by other colleagues in the Division of General and GI Surgery. The two most common problems seen in our office are patients with hemorrhoids and patients with anal fissures. It is important to realize, however, that common anorectal problems such as hemorrhoids and fissures are oftentimes associated with other problems of the colon and rectum. Besides evaluating the anus and distal rectum in the office, we often recommend followup flexible sigmoidoscopy or colonoscopy, particularly if an anorectal problem is associated with rectal bleeding.
One of the mainstays of therapy of many anorectal problems is a change in diet. Many patients do not take enough fiber in their diet. Fiber supplementation with products such as Metamucil, Citrucel, Konsyl, or Fibercon are recommended. High fiber breakfast cereals such as All Bran or Bran Flakes are also recommended if a patient has difficulty taking fiber supplementation on a regular basis. Fiber supplementation only works well if an individual patient takes enough water and fluids. Therefore, emphasis for the treatment of common anorectal problems will include increasing fluids over the course of a 24-hour period.
Two other common anorectal problems include pruritis ani (anal itching) and anorectal abscesses and fistulae. Anal itching is usually related to problems with diet and certain other maneuvers can be recommended to help this condition. If the condition persists after modification of the patient’s diet, then biopsy of the anal area is sometimes necessary. Anorectal abscesses and fistulae oftentimes develop suddenly and require drainage. Usually this infection can be drained during a small office procedure, although on occasion the patient must go to the operating room. Many anorectal infections result in a small fistula, or tunnel. Ultimate treatment of the fistula requires either one or two surgeries. Further workup with either a flexible sigmoidoscopy or a colonoscopy is sometimes recommended. On rare occasions, inflammatory conditions of the colon and rectum will be associated with an anorectal infection.
Fecal Incontinence
Fecal incontinence or the inability to defer bowel movements to the proper time and place is a devastating and often embarrassing problem for patients. Because of this, fecal incontinence is often underreported to physicians. The symptoms can range from occasional seepage of stool to loss of control of full bowel movements. If an initial evaluation of this change in bowel habits is unrevealing, patients are often referred to a colon and rectal surgeon for further evaluation. This evaluation includes a careful history and physical examination. Further, more sophisticated testing includes a radiologic examination of the anal sphincters as well as an anorectal manometry, which measures pressure generated by the anal sphincters and potential injuries to the nerves that supply these sphincters. After this evaluation patients may be recommended to undergo changes in diet, medications, biofeedback exercises or a surgical repair of their anal sphincter. For those unfortunate few patients who do not respond to the above measure newer more aggressive treatments are being performed at a few centers in the United States, including the Brigham and Women's Hospital.
Constipation
Constipation is defined as infrequent bowel movements, excessive straining at bowel movements or particularly hard stools. Although most people experience the symptoms of constipation at one time or another most people respond to simple dietary or behavioral manipulations to correct the problem. Persistent constipation should be brought to the attention of a physician and be evaluated, as any change in bowel habits would be. A small percentage of patients who have no anatomical explanation for their constipation and do not respond to the above measures are diagnosed with functional constipation. A very small subset of these patients can be evaluated for a potential surgical approach to their symptoms. The evaluation usually includes radiologic studies to evaluate the transit time of the larger intestine and/or internal abnormalities within the anorectal area. Anorectal manometry, a pressure study of the anus and rectum, is also used to rule out potential functional problems. If patients are diagnosed with a significant functional problem and fail all attempts at medical management, they may respond to surgical attempts to correct these problems.
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Patients with severe constipation from "colonic inertia" will benefit from a total colectomy and anastomosis or "hookup" of the small intestine to the rectum. In properly selected patients, constipation is cured. However, this procedure is only reserved for patients with well documented and diagnosed colonic inertia for disorders of the colon.
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