What Is An Anal Abscess?

An abscess is a collection of pus in any localised space in the body. An anal abscess is one that develops in the tissues around the anus.

What Is The Cause Of An Anal Abscess?

A number of small glands are normally present between the inner and outer layers of the anal sphincter muscle. Bacteria may lodge in these glands, setting up an infection. An abscess develops from this infective process. This may extend to various areas around the anal canal to involve the anal sphincter muscle and surrounding structures. The abscess may enlarge and burst through the overlying skin or may be drained by surgical treatment.

What Are The Symptoms Of Abscess?

As the amount of pus in an abscess increases, the pressure within it rises. This produces constant throbbing pain which continues until the pus escapes. Other symptoms are fever and sweating.

How Is An Abscess Treated?

The pus is drained from the abscess cavity by making an opening through the overlying skin. This may be done under local anaesthesia in the doctor’s office. A large abscess may require wider drainage, under general anaesthesia. Hospital admission is needed for such a procedure. Antibiotics may be used to control the spread of infection, but antibiotics alone will not cure an abscess. Drainage of the pus is always necessary. 

What Is A Fistula?

An anal fistula is an abnormal track (“tunnel”) between the internal lining of the anus and the skin outside the anus. A fistula may develop after drainage of an anal abscess but may occur spontaneously. Discharge of pus may be constant or intermittent as the external opening on the skin may heal temporarily. 

Is A Fistula Related To Cancer?

No, a fistula is not related to cancer.

Is A Fistula Related To Other Diseases?

Most fistulae are the result of infections in an anal gland. However patients suffering from inflammatory bowel disease (Colitis and Crohn’s disease) are more likely to develop anal abscesses and fistulae.

How Is A Fistula Treated?

Surgery is needed to cure a fistula. The course of the track between the anus and the skin has to be identified and exposed. This track may be treated in one of three ways according to its complexity.

• Fistulotomy opens the length of the track to the skin’s surface allowing the open wound to heal slowly. Some sphincter muscle is divided. This is the most common treatment employed.
• A Seton is a loop of flexible material placed along the track to maintain drainage for a period of time.
• Fistula repair closes the internal opening of the track and preserves anal sphincter muscle. This is a more complex operation.

Examination under anaesthesia may be necessary to assess the process of healing. Most operations for fistulae are performed in hospital but small fistulae can be managed in Day Care Centres.

Anal fistula can be a difficult and frustrating condition for a patient, as healing rates are variable, and there is often the need for several surgeries in the situation of a complex anal fistula. As a patient, it is important that you receive a clear description of the likelihood of healing from your surgeon. Please discuss any concerns around this with your surgeon, in particular if the condition is affecting your mood and your ability to carry out your normal daily activities.

Anal Sphincter Control After Surgery

Fistulotomy divides a varying depth of anal sphincter and this may result in some weakness of the muscle. The effect on continence will depend on the anatomy of the fistula and the amount of intact sphincter remaining after surgical treatment.

History

Fistula: from Latin meaning pipe or read. Fistula surgery has been practised since ancient times and is mentioned in the Ebers Papyrus of 1550 B.C. from Egypt. Fistula instuments have been unearthed in the ruins of Pompeii. Hippocrates (460-356 B.C.) realised that an anal fistula required fistulotomy and also used the Seton technique. Henry V of England died of a fistula at the age of 35. Louis XIV of France had a fistula successfully treated in 1687 which did much to improve the lowly status of surgeons at that time.

What you need to know about a very common condition.

What Is A Fissure?

A fissure is a split in the skin of the anal canal. This split fails to heal and becomes established as a painful ulcer associated with spasm of the anal sphincter muscle.

Cause

Most anal fissures arise following trauma (injury) to the anus. The commonest trauma is that occasioned by the passage of a hard, constipated stool. However, anal fissures can occur following bouts of diarrhoea, childbirth etc. An anal fissure is a simple mechanical problem and does not "turn to cancer".

Symptoms

Pain is the major symptom of anal fissure. It comes on at the time of passage of a bowel motion and lasts for a variable period afterwards. Pain is due to tenderness of the fissure itself and to intense spasm of the internal anal sphincter muscle. Bleeding is a common symptom, especially when the fissure first develops. Sometimes a swollen skin tag or lump develops at the external end of the fissure.

Medical Treatment

Most fissures heal on their own but some don't, becoming long term (chronic) fissures. Management includes ensuring soft stools by maintaining high dietary fiber and fluid intake and careful anal hygiene to keep the fissure clean. Frequent warm baths and topical application of muscle relaxing ointments (0.2% GTN or 2% diltiazem) help relax the anal sphincter muscle to reduce pain and help the fissure heal. The fissure may recur months or years later.

Surgical Treatment

The surgical treatment of an anal fissure can usually be performed as a day procedure with minimal hospital stay. A cut in the sphincter muscle (sphincterotomy) is the “gold standard” of treatment, curing most fissures, however an injection of Botox® into the anal muscle is an alternative treatment offered by some surgeons. Botox® injection causes temporary relaxation of the sphincter and lasts 8-12 weeks giving time for the fissure to heal. A sphincterotomy involves a small cut near the anal opening, with the division of the lowest part of the internal anal sphincter muscle. The spasm is relieved, which helps the fissure to heal. Sometimes the fissure itself may be excised, together with any nearby haemorrhoids and any large or troublesome skin tags.

Results

Prompt relief from the pain is to be expected, even though healing of the fissure may take some weeks. Healing of the fissure is to be expected in 75% of those who have Botox® injection and 95% of those with sphincterotomy. Those with persisting symptoms may need a further procedure (Botox® injection or sphincterotomy).

Complications Of Surgery

These are very uncommon as the operation is relatively minor and safe. Rarely there may be post operative bleeding or infection of the sphincterotomy wound. In approximately 5% of patients the healing of the wounds may be delayed.

Anal Sphincter Function After Surgery

Both sphincterotomy and Botox® injection may occasionally result in some impairment of the control of “wind” in the rectum. With Botox® injection this resolves within 3 months but following sphincterotomy this may be longer lasting. Incontinence of faeces (loss of control of bowel movement) is a very rare complication.

What is Bowel Cancer?

Bowel Cancer is an abnormal growth of cells lining the bowel forming a lump, called a malignant tumour. The cancer cells may spread outside the bowel from the primary cancer to lymph glands or other organs and these clusters of cells are called metastases or secondary cancer. The vast majority of bowel cancers involve the large bowel (colon and rectum); the small bowel is rarely affected.

How Common is Bowel Cancer?

In Australia and NZ bowel cancer is the most common internal cancer for both sexes combined. The disease is increasing as the average age of the population rises. More than 10,000 new cases are diagnosed in Australia and almost 3,000 in NZ each year. Australia and NZ are among the top 10 high risk countries in the world.

What is the Cause of Bowel Cancer?

The underlying cause of bowel cancer is not known. It is more common in developed countries and is thought to be due to the food we eat slowing the transit of stools through the bowel. This increases the exposure to the lining of the bowel by cancer-producing substances called carcinogens. Dietary factors therefore may be important as a causative factor. Genetic factors which you inherit from your parents are also important and research in genetics and molecular biology are increasing our knowledge of these inherited factors.

Is There Any Difference in Bowel Cancer in Men and Women?

Bowel Cancer is more common in men, and they are more likely to develop rectal cancer and have an overall slightly worse outcome. In women, cancer is more common in the colon than rectum.

What are my Risks of Developing Bowel Cancer?

Lifestyle issues may be important in reducing the risks. These include: regular exercise, maintaining ideal weight and eating a diet low in fat and high in fibre. Known factors that will increase your risk are:

• A close relative with bowel cancer (parents, children or siblings)
• Bowel polyps (abnormal growth of cells on the bowel wall that form a mushroom-like lump)
• Inflammatory bowel diseases such as Ulcerative Colitis and Crohn’s Disease
• Genetic conditions where there are multiple polyps (e.g. Familial Adenomatous Polyposis - FAP)

What are the Common Symptoms?

• Change in bowel habit i.e. a recent onset of diarrhoea or constipation
• Bleeding from the back passage or blood mixed in the stool
• Abdominal pain that persists
• A low blood count or anaemia

You should see your doctor if these symptoms persist and tests will be arranged.

What are the Tests?

If your doctor suspects you may have bowel cancer, internal examinations of the back passage and special tests will be organised. A referral to a Specialist Colorectal Surgeon may be arranged. Your doctor or specialist may perform:

• A digital (finger) examination of the back passage
• An endoscopic examination of the back passage, rectum and colon with either a rigid sigmoidoscopy (up to 20cms), flexible sigmoidoscopy (up to 60cms) or colonoscopy (all of the large bowel)
• A sample of tissue may be sent for pathology during these internal examinations
• An X-ray that outlines the colon (CT colonography).
• A scan of the abdomen i.e. CT scan
• An internal ultrasound examination - Endorectal ultrasound
• A scan of the pelvis and rectum i.e. an MRI scan.

After the results of these tests are available, your doctor or specialist would discuss a plan of management. It is best at this stage to be accompanied by a friend or relative to help you in understanding the explanation and treatment plan.

How is Bowel Cancer Treated?

The most effective treatment, with the aim of cure, is surgical excision of the involved bowel. This means removing 20 to 40 cms of the bowel, though longer lengths of the bowel may be removed. Chemotherapy and/or radiotherapy may be given either before or after surgery. The aims of this treatment are to reduce: the size of the cancer, the chance of spread and the chance of the cancer recurring. When used to prevent the spread of cancer, it is called adjuvant treatment. When cancer has already spread and cannot be completely removed, it is used to relieve symptoms and is called palliative treatment. 

Will I Have a Permanent Bag (Colostomy) or Temporary Bag (Loop Ileostomy)?

If you have rectal cancer, you may require a permanent colostomy if the cancer is very close to the back passage. Developments in medical technology, especially surgical staplers and specialists training in colorectal surgery, have significantly reduced the need for a permanent colostomy. The vast majority of patients with bowel cancer will not need a colostomy. When modern techniques are used and the bowel is joined to the back passage, a temporary bag (loop ileostomy) may be necessary to reduce the complications of surgery. The temporary bag is usually closed at three to six months after surgery, depending on the need for adjuvant treatment.

What are the Prospects of Cure After Treatment?

The outcome (prognosis) will depend on several factors including:

• The growth pattern of the primary bowel cancer
• The depth the cancer has spread through the bowel wall
• The presence of cancer cells in lymph glands and other organs
• Your general health and well-being

Two thirds of people with bowel cancer can be cured if the diagnosis is made early and treatment performed promptly. If cure is not possible, recent advances in treatment can significantly reduce symptoms, especially pain.

What is the Recovery and Follow- Up After the Treatment?

Tiredness, discomfort and some bowel irregularity are common complaints whilst the body repairs itself and readjusts to the new arrangement of the bowel. These feelings may last for several months. Those people in paid employment may be back at work within four weeks, but for some others it may be longer. If adjuvant treatment is necessary this can be arranged around work commitments. Your surgeon will arrange a schedule of follow-up that will extend for any years after treatment. At each follow-up appointment, internal examination of the bowel may be performed with some blood tests. Colonoscopy is usually performed initially at one to three years and then every three to five years after surgery. Can Screening Tests Detect Bowel Cancer? A screening test is a test applied on the general population to detect the presence of cancer. Because bowel cancer starts on the lining of the bowel the abnormal growth can cause a small amount of invisible bleeding into the stool. A chemical test can detect that small amount of blood in the stool and this is called Faecal Occult Blood testing (FOB). This test is performed on samples of stool you collect yourself. Studies have shown that populations that are screened with a FOB have a lower risk of dying from bowel cancer. Screening programs using FOB are being developed in Australia. Colonoscopy may also be used as a form of screening. All screening programs come at a cost to the community. Discuss your concerns with your doctor or specialist. Useful web sites for further information: The Gut Foundation.

What is bowel cancer?

Bowel cancer is cancer of any part of the large intestine (colon or rectum). It is also known as colorectal cancer and may be referred to as colon cancer (affecting the upstream part of the large intestine) or rectal cancer (affecting the last 15 cm of the large intestine).

It is one of the commonest cancers in Australia and New Zealand, affecting approximately 1 in 21 people over the course of their life.

While bowel cancer is curable in its early stages it is preferable to avoid it if possible. There are some risk factors that we cannot influence such as increased age and genetics, but it is estimated that at least 40-50% of bowel cancers are potentially preventable by modifying lifestyle and dietary factors.

Can I influence my risk of developing bowel cancer?

There are 6 main ways to decrease your risk of developing bowel cancer.

1. Limit your alcohol intake.

It is recommended that you limit alcohol intake to no more than 2 standard drinks per day for men and one standard drink per day for women in order to decrease the risk of developing bowel cancer. 

2. Exercise regularly and avoid being sedentary.

If you are not physically active on a regular basis you stand to have an increased risk of developing bowel cancer. Increasing your regular activity during the day by walking, standing and being mobile is useful to reduce your risk. In addition to this regular vigorous physical activity such as running, cycling, swimming or cross training for at least 30 minutes, three times a week is desirable in order to minimize your chances of developing bowel cancer. 

3. Keep your weight within a healthy range.

This should be achieved by a combination of exercise and limiting your energy and fat intake. Limiting the total energy intake to less than 10,000 kilojoules in men and 8,000 kilojoules in women per day has been shown to decrease your risk of developing bowel cancer.

4. Maintain a healthy diet.

In addition to limiting your energy intake, a diet high in fruit, vegetables, wholegrains and fibre and low in processed and red meat has been shown to be effective in reducing bowel cancer risk. Milk and calcium rich foods are also protective against bowel cancer.

5. Don’t smoke.

Regular smokers are more likely than non-smokers to develop and die from bowel cancer.

6. Get screened for bowel cancer.

Screening is testing for cancer, or precancerous lesions (polyps), before symptoms develop. The current Australian recommendations are for people aged between 50 to 75 to have stool tests looking for hidden blood (Faecal Occult Blood: FOB tests) every 2 years. This can be performed through your GP or using the kits that are sent out in the mail as part of the NBCSP (National Bowel Cancer Screening Program).

For some groups of people at higher risk of developing bowel cancer, therapy with aspirin may be useful as a preventative strategy. If you feel that you are at higher risk it may be worthwhile discussing this option with your doctor.

Questions to be asked after an operation to remove bowel cancer.

What can I expect after the operation?

You can expect to be in hospital for up to two weeks after conventional surgery and by the time you leave hospital you will able to eat and drink normally. The usual wound is long and it will take a further month, at least, before you are fully active and able to return to work. The recovery time however, is variable and it will take longer for some patients. Your surgeon will advise you about your diet and lifestyle for the future.

Will I be cured of the cancer?

Yes there will be a good chance of being cured of the cancer if it is detected at an early stage. Overall more than 50% of patients are cured by surgery. Some patients will be advised that they need extra treatment if the cancer has extended beyond the confines of the bowel wall.

Will I develop another cancer?

Experience has shown that a patient who has developed one cancer is at a slightly greater risk than the rest of the community of developing a second cancer and for that reason your surgeon will recommend a programme of "follow-up".

How often should I see my surgeon?

An early post-operative review will be arranged for you from the hospital. This is usually within two-to-four weeks of leaving hospital. From then on the surgeon will recommend a set programme of reviews according to the recommendations of the Colorectal Surgical Society of Australia. These recommendations involve:

• a review at regular and frequent intervals for five years.
• yearly review thereafter.

Will special tests be done?

Yes, for a rectal (low bowel) cancer, the surgeon will perform a sigmoidoscopy at each visit. At the end of the first year after surgery (it will be done earlier if one has not been performed before the surgery) the surgeon will arrange for a colonoscopy (total examination of the bowel) and if that examination is clear it will be recommended that the colonoscopy is repeated at appropriate intervals. Any pre-cancerous lesions (polyps) seen on that examination will be removed at the time of the examination and be tested. The colonoscopy will then be repeated one year later and if the bowel is clear at the next examination, a three-yearly programme is recommended. Some blood tests can provide useful information about the likelihood of the cancer returning and your surgeon may order these from time to time according to the particular circumstances of your case. If a patient has symptoms or signs which might indicate that the cancer is returning, the surgeon may order other tests such as an x-ray or ultrasound of the liver and other areas

For how long should I continue to be checked?

The Colorectal Surgical Society of Australia recommends that a patient should be "followed up" by the surgeon for as long as he/she remains fit to undergo further treatment should a new cancer develop. The following is a summary of the plan recommended by the Colorectal Surgical Society of Australia and New Zealand for "follow-up" of a patient after an operation to remove a cancer of the large bowel.

• Early post-operative colonoscopy, if colonoscopy or barium enema had not been performed before the operation.
• A review at regular and frequent intervals for five years. These visits to be associated with digital and sigmoidoscopic examination depending on the aspects of your case.
• Colonoscopy every three years.
• Other tests to detect cancer according to clinical indications.

This protocol may vary with individual patient pathology and surgical treatment.

What Is Colonoscopy?
Colonoscopy is a procedure for diagnosing and treating a variety of problems encountered in the colon (also called the large bowel or large intestine). It is performed using an instrument called a colonoscope which is a flexible tube that is about the thickness of a finger. It is inserted via the rectum into the colon and allows the doctor to carefully examine the lining of the bowel. Abnormalities suspected by x-rays can be confirmed and studied in detail. Abnormalities which are too small to be seen on x-ray may also be identified and colonoscopy is now considered to be a more accurate examination of the large bowel than barium enema x-ray. If the doctor sees a suspicious area or needs to evaluate an area of inflammation in greater detail, the doctor can pass an instrument through the colonoscope and take a piece of tissue (a biopsy) for examination in the laboratory. Biopsies are taken for many reasons and do not necessarily mean that a cancer is suspected.

What Is Polypectomy?
Sometimes colonoscopy is undertaken to locate or remove polyps. These are small growths on the lining of the bowel. They are usually benign but occasionally can contain a small area of cancer. Removal of a polyp is called polypectomy. This is achieved by passing a wire loop through the colonoscope and snaring the base of the polyp, which is then severed from its attachment to the bowel wall by means of an electric current. This current cannot be felt and causes no pain. Early detection and removal of polyps prevents them from becoming malignant, and is therefore an important means of protection from colon cancer, (one of the most common cancers in Australia). The ability to remove polyps with the colonoscope means that the patient can avoid a major operation. After colonoscopic polypectomy the patient is allowed to resume usual activities within a day or two, and can return to a normal diet almost immediately.

Is Any Special Preparation Necessary?
Yes. For a successful colonoscopy, it is essential that the bowel is thoroughly emptied. This will usually mean taking clear liquids as well as a special laxative before the colonoscopy. More specific preparation instructions will be given to you. Occasionally one or more enemas may also be required. This preparation can usually be done at home. Failure to carry out the full preparation may leave solid material in the colon and could prolong the procedure or necessitate a repeat examination at another time. Retrograde pre-colonoscopy preparation (e.g. rectal pulse or colonic irrigation) may be a safe and effective alternative to oral bowel preparation that may be recommended in some cases when available.

What Happens During Colonoscopy?
When you arrive for the colonoscopy you will be asked to change clothes and may be given a small enema. The examination may be performed with intravenous sedation or a light anaesthetic and your particular management will be explained to you. If you are being managed with sedation you will probably sleep during most of the procedure but you may be aware of changes in position, inflation of the colon with air (distension) and temporary abdominal discomfort. Examination of the large bowel lining is made as the instrument is being inserted, and again as it is withdrawn. The examination may take 60 minutes especially if polyps are to be removed.

What Happens After Colonoscopy?
You will be asked to rest for a hour or two until the effects of the sedatives have worn off, and you have passed much of the inflated air. Although most of the effects of the sedative/anaesthetic wear off quickly you should not drive yourself home after your colonoscopy. You should therefore arrange for a friend or relative to accompany you when you leave.

Are There Any Complications From Colonoscopy Or Polypectomy?
Colonoscopy and polypectomy are very safe procedures with a very low risk of complications, although these occur very occasionally. Localized irritation of the arm vein may occur at the site of injections of the sedatives. A lump may develop and remains for several weeks or even months, it will eventually disappear. Perforation of the colon rarely occurs during colonoscopy however this can require abdominal surgery to close the defect in the bowel wall. Great care is taken to avoid this complication.

History
The colonoscope was developed in Japan in the 1960's and was preceded by instruments used to examine the stomach. The first flexible instrument was the gastrocamera and later the gastroscope. The gastroscope was subsequently modified to examine the large bowel (colonoscope). Colonoscopy was first used in Australia in the early 1970's and many technical (and expensive) improvments have occurred since. The image of the bowel interior is now observed on a video screen which allows all members of the colonoscopy team to assist more appropriately. The technique of Colonoscopy is difficult to master and strict guidelines for training now exist to ensure expertise and safety.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) has developed a number of resources to support implementation of the Colonoscopy Clinical Care Standard including useful fact sheets for both consumers and clinicians and videos.

CONSUMER FACT SHEET - COLONOSCOPY CLINICAL CARE STANDARD

What is Constipation?

Almost everyone gets constipated sometime or other - it is a very common condition. Constipation means different things to different people - some regard it as the passage of hard stools whilst other the infrequent passage of normal or hard stool. Some people believe it is vital to have one bowel action every day. The normal range of bowel frequency varies from three bowel actions per day to one bowel action every three days.

When should I see my doctor?

Constipation becomes an abnormal symptom when:

• there is a persistent change in your normal bowel habit
• it is associated with bloating or crampy abdominal pain
• there is bleeding from the back passage
• you find yourself spending long periods of time straining on the toilet
• you need to use your fingers in the back passage, or even the front passage (in women) to get your bowels going
• you have the feeling that there is a "ball" blocking the passage of motion in the back passage
• there is absolute constipation when you do not pass any motion or wind over several days

If you have these symptoms, contact your family doctor who may order some tests or refer you to a Specialist Colorectal Surgeon.

What are the causes of Constipation?

The causes of constipation are many and varied and may be combined together.  Most causes of constipation relate to lifestyle issues:

• low fibre high fat diet
• low fluid intake
• sedentary lifestyle (little exercise)
• change in daily routine
• stress and anxiety

Other factors that can aggravate constipation are:

• pregnancy
• overuse of laxative
• side effects of medication especially strong pain killers

Causes of persisting constipation, often associated with other symptoms are:

• blockage in the bowel by a growth or narrowing (bowel obstruction)
• a muscle problem either that the large bowel muscle is sluggish (slow transit constipation) or the anal sphincter muscle (at the back passage) does not relax when you are having a bowel motion (obstructed defaecation)
• Non-specific or functional problem where no immediate cause is obvious

What tests may I need to have?

Your general practitioner may organise these tests or refer you to a Specialist Colorectal Surgeon.

1. Examining the back passage and the inside of the bowel. This is done to determine if there is a blockage and you may need to have:

• Internal examination of the anus with the doctors finger and a rigid telescope (sigmoidoscope)
• Internal examination of the whole large bowel with a flexible telescope - flexible sigmoidoscopy or colonoscopy
• X-ray examination of the large bowel - barium enema

2. Tests to determine if there is a muscle problem

• A whole gut transit time. This is performed either by you taking a tablet containing markers, then having a series of x-rays or having a nuclear medicine scan after taking combined liquid and solid meal (containing Radio Isotope) and scans are then taken. These tests require x-rays or scans over a period of 5-6 days.
• Muscle test on the back passsage (Ano-rectal manometry). A catheter is placed in the anus and measurements of your muscles made including a balloon test
• Electrical tests on the muscle (EMG). These tests may be uncomfortable but they are occasionally necessary.

How is Constipation treated?

Maintaining a healthy diet and lifestyle.

• low fat/high fibre diet
• regular fluid intake
• regular exercise

What is fibre?

Fibre is in the cell walls of plants and in the bowel remains undigested. It acts like a sponge soaking up water into the bowel adding bulk to the bowel content and increasing the passage of digested food through the bowel.

How much fibre do we need?

Most Australians eat about 20gms of fibre per day but the recommended daily intake to remain healthy and have a regular bowel habit is 30gms per day.

Which foods are high in fibre?

• Breads
• Cereals
• Fruit
• Vegetables
• Nuts, seeds, legumes (lentils/beans)
• Foods that are high fibre are generally low in fat. A high fibre low fat diet is ideal.

What else can I do to help my bowels?

Fluids - drink plenty of water (2 liters per day). This increases the sponge effect of the fibre. Fitness - have regular exercise, 20 minutes, three times per week - walking is best. This stimulates bowel function. Fibre supplement - many natural fibre products are available at your pharmacy to add extra fibre. A formula for fighting constipation - the 5 F's

• HighFibre
• LowFat diet
• Fluid
• Fitness
• Fibre Supplement

What may my doctor do to treat Constipation?

Blockage or bowel obstruction

Surgery may be required to remove the affected part of the bowel causing the blockage. Your Colorectal Surgeon will explain the details of these procedures.

Bowel Muscle Problem (Slow Transit Constipation)

Majority of patients can be treated by a combination of dietary manipulation and laxatives. Occasionally surgery may be required to remove the large bowel (the sluggish bowel) and join the small bowel to the rectum.  A stoma bag is very rarely required.

Sphincter Muscle Problem (Obstructed defecation)

Treatment is a combination of diet, laxatives and bio feedback - exercises involving pelvic floor rehabilitation (retraining the sphincters to relax), usually under the supervision of a physiotherapist.

Non-specific

Often despite all investigations performed no specific cause can be found for the constipation though the symptoms persist. This can be frustrating both for yourself and the doctor but usually a combination of change in lifestyle, diet and laxatives will improve the situation.

General Advice

Should you be concerned about any symptoms or the information contained in this brochure, please feel free to discuss this with your Specialist Colorectal Surgeon or your General Practitioner.

What Is Crohn's Disease?

Crohn's disease is a type of chronic inflammatory condition that usually involves the small and/or large bowel. The cause is unknown but many theories exist.

Incidence

A rare disease, Crohn's affects males and females equally at the rate of about 5 per 100,000 of the population. Occasionally more than one family member is affected. Children and adults of any age may suffer from Crohn's disease, but there are slightly increased peaks of incidence around 25 and 65 years of age. How Does Crohn's Disease Affect The Bowel The inflammation occurs in a patchy manner and can produce areas of ulceration and narrowing of the small and/or large bowel lining, resulting in localised and general symptoms. Bleeding can lead to anaemia and abscesses can form next to the involved bowel and sometimes burst into other organs causing fistulae (abnormal track). If the anus is involved, fissures, fistulae and watery discharge may be present. The bowel ulceration causes diarrhoea and occasionally malnutrition. Narrowed bowel causes pain and symptoms of intermittent incomplete blockage.

Can Other Organs Be Involved?

Rarely other organs can develop problems such as arthritis, skin conditions and inflammation of the eyes. Some of these conditions respond to medical treatment and others only to surgery.

Symptoms

Abdominal pain, diarrhoea, malaise and fever occur in a chronic manner with acute exacerbations. Bleeding may be present and mixed with the stool, but more often it is not obvious and leads to anaemia and iron deficiency. The abdominal pain may be localised to one point, particularly in the area over the appendix and an incorrect diagnosis of appendicitis is sometimes made. Painful mouth ulcers are common, as is weight loss and tiredness.

Diagnosis

This can sometimes be difficult as Crohn's disease can mimic many bowel disorders, particularly the irritable bowel syndrome. Large bowel Crohn's disease (colitis) is best diagnosed by endoscopy (colonoscopy or flexible sigmoidoscopy). Biopsy and barium enema x-rays are sometimes helpful. Small bowel Crohn's disease requires a small bowel barium x-ray series for diagnosis. Rarely an isotope labelled white cell nuclear scan can identify disease. Certain blood tests may be helpful in the assessment of the severity of the illness. It is sometimes impossible to distinguish between Crohn's disease and ulcerative colitis.

Treatment

There is no cure for Crohn's disease. Medication often controls the inflammation, the main drugs being anti-inflammatory, such as Prednisone and Salazopyrine, anti-diarrhoeals and anti-spasmodics, iron and nutritional supplements. Occasionally immune suppressants are used such as Azothiaprine. Where there is a localised complication of Crohn's disease or an area causing troublesome symptoms that don't respond to medication the treatment of choice is surgery. The likelihood of surgery being required is high.

What Operation Might I Have?

The surgical procedure is tailored to the specific problem. If short segments of small bowel are involved a widening operation called stricturoplasty is carried out. If a longer length is involved that section of the bowel is removed and the ends rejoined. A stoma of either the large bowel (colostomy) or small bowel (ileostomy) is sometimes necessary and this can be permanent if the anus has been removed; or temporary, if it has been made to allow the residual bowel inflammation to subside. Abscesses always require surgical drainage and occasionally other organs need surgical attention.

Who Should Do My Surgery?

A surgeon who has specifically trained in the management of inflammatory bowel disease who works closely with your physician and who is interested in your wellbeing and quality of life. The members of the Colorectal Surgical Society of Australia have this expertise.

Is More Than One Operation Likely?

About half the patients who require an operation have a second operation at some stage in the future, often years later, and of these another half will require further surgery. Surgery is used to relieve symptoms and complications of Crohn's disease, and to improve the quality of life.

What About The Future?

Most people with Crohn's disease lead relatively normal lives, working and raising families, playing sport and enjoy a good life expectancy. Pregnancy is not contra-indicated. Patients with chronic colitis should undergo long term surveillance because of a slight increase in the risk of developing colon cancer. Crohn's disease can "bum out" after many years but the clinical course of the condition is always unpredictable.

History

In 1932 at the Mt. Sinai Hospital in New York, Drs. Crohn, Ginzburg and Oppenheimer described 14 specimens of chronic inflammation of the small bowel which they named regional iletis. In 1960 Drs. Lockhart-Mummery and Morson from St. Mark's Hospital, London published a detailed account of the surgical pathology of this condition affecting the large bowel. The inflammation may affect any part of the gastrointestinal tract is now known as Crohn's disease.

The Crohn's & Colitis Australia website can be accessed HERE

What is diverticular disease?

Diverticular disease is a benign (non cancerous) condition of the colon (large intestine or ‘bowel’). It is also known as diverticulosis and consists of small pockets (diverticula) that bulge out of the colon, through its muscle wall. When the pockets or diverticula get inflamed the resulting condition is known as diverticulitis.

Incidence

Diverticular disease is rare before 30 years of age and increases with age. Approximately one third of the population over the age of 60 and half of those aged between 80 and 90 years have diverticulosis. Females are often more affected than males.

Diverticulitis

Most people with diverticular disease have no symptoms and it is diagnosed ‘incidentally’ with a colonoscopy or a CT scan. The diverticula, however, can become inflamed and this is called diverticulitis. People with diverticulitis often present with lower abdominal pain, fever and generally a change in bowel habit (either constipation or sometimes diarrhoea). The diagnosis of diverticulitis is made with a CT scan. A mild attack of diverticulitis can be treated as an outpatient but sometimes admission to hospital is required, with or without antibiotics depending on the condition of the patient. Severe cases of diverticulitis can result in peritonitis (that usually requires emergency surgery), an abscess (that usually requires drainage) or a fistula, which is an abnormal communication between the bowel and another structure such as the bladder (that usually requires surgery). Most diverticulitis that is not considered severe can be managed without surgery. Colonoscopy may be required about 6-8 weeks after the attack if there is confusion about the diagnosis.

Bleeding

Occasionally a diverticula can bleed. These bleeds tend to be rather dramatic but most often stop on their own accord. Often due to the large nature of these bleeds hospitalisation is needed. Blood products are given if required. If the bleeding doesn’t stop on its own either a colonoscopy, angiography with embolization (x-ray of the vessels with a ‘plug’ in the bleeding vessel) or surgery may be required

Prevention

While it appears difficult to prevent diverticular disease forming, a high fibre diet is recommended to decrease the risk of another attack for people that have had diverticulitis.

Endometriosis is a poorly understood systemic disease with a current definition as the presence of endometrial tissue outside the uterus. Multiple other abnormalities are present and the clinical picture can include a wide array of signs and symptoms. Pain, dyspareunia (painful intercourse), infertility and menstrual bleeding irregularities are common features. Bowel symptoms such as bloating, change in bowel habit, tenesmus (sensation of incomplete evacuation), rectal bleeding or difficulty evacuating can occur but usually with advanced pelvic disease.

From a surgical perspective, endometriosis may be present anywhere within the abdominal cavity but most commonly within the pelvis. Extra-pelvic sites can include deposits in the abdominal wall, scar, umbilical and inguinal (groin) region. Other sites can also include the chest wall lining and lung. The disorder has been identified in multiple other sites and rarely in men.

Treatment can include medical and surgical therapy. Surgery with removal of the deposits is most often recommended for the treatment of deeply invasive disease, patients unresponsive to medical treatment or patients desiring fertility. The disease has an inflammatory and adhesive quality and can impact multiple organ systems including the gastrointestinal and urinary system. Severe, high stage disease may require multi-specialty surgical management. In most instances a gynaecologist would be expected to excise the disease usually with laparoscopic or robotic approaches.

Colorectal involvement will largely depend both on the extent of disease and the experience of the gynaecologist involved in the surgery. Options include shaving, disc or segmental resection of the rectum or colon. The decision as to which option can be difficult at times and should largely be individualised. Segmental resection is the ideal approach and preferred over larger resection for colorectal disease. A conservative approach to resection is recommended. It is notable that stoma rates vary widely within the literature and may relate to experience, extent of disease, and previous surgeries, especially previous bowel resections.

The advent of robotic surgery creates a new paradigm in relation to this type of surgery. Experienced gynaecological surgeons who have previously operated in parallel together with a colorectal surgeon at laparoscopy will understand and be aware of the significant difficulties operating on patients with endometriosis, especially those who have had multiple surgeries for endometriosis. Thus, would include and seek the expertise of a colorectal surgeon colleague to operate collectively for the best outcome for the patient.

Prior to surgery patients will require to prepare and empty the bowel by ingesting a solution the day before whilst on a clear fluid diet for 24 hours. There are many different bowel preparations and the surgeon will have their own preference.

As with any operation, there is a risk of complications and the surgeons, both gynaecologist and colorectal surgeon, will discuss these with the patient prior to surgery. The colorectal surgeon will discuss the risk of complications such as a bowel perforation and anastomotic leak following bowel resection, bleeding, pelvic collection and abscess/infection, ureteric injury (the ureter connects the kidney to the bladder), bladder injury and urinary retention (difficulty passing urine). A colovaginal fistula (an abnormal connection from the bowel to the vagina) is a reported complication but it is rare.

As with cancer surgery the best results are likely to be in the hands of high-volume surgeons with significant experience dealing with this enigmatic condition.

Authors:

Peter Lee, Colorectal Surgeon
Michael Cooper, Gynaecologist.
Updated: May 2022

Faecal Incontinence is the inability to control the passage of faeces or flatus from the anus. This can be severe with major accidents or minor with streaking or smearing of the underwear. Incontinence may occur everyday or at irregular intervals. There may be difficulty with cleaning and sufferers may routinely have to wear a pad. Faecal urgency is the inability to wait or 'hang on' to go to the toilet to use the bowels. A sufferer has to get to the toilet as soon as they feel an urge to go. Accidents may not happen but faecal urgency is disabling. Faecal incontinence or urgency may lead a sufferer to be house bound or only go to places where they feel safe from or can cope with an accident. Work, social and sex life can all be affected.

Normal Continence: This is the ability to recognise the need to go to the toilet and to "hang on" until a socially appropriate time to go. It relies on a healthy bowel and healthy anal spincter. These are the muscles of the anus that we can contract or relax.

What causes Faecal Incontinence?

There are many causes of faecal incontinence:

1. Childbirth injury to the muscles or nerves of the anal sphincter. This is the commonest cause of faecal incontinence.
2. Chronic constipation with repeated straining to defaecate may cause injury to the nerves of the anal sphincter muscle.
3. Faecal impaction and rectal prolapse (protrusion of the lower bowel through the anus) may be associated with incontinence.
4. Injury to the anal sphincter from an accident or surgery (fistula, fissure, haemorrhoids).
5. Diseases of the bowel such as irritable bowel syndrome and inflammatory bowel disease.
6. Congenital causes where babies may be born with a problem of the bowel or anal sphincter such as imperforate anus.
7. Miscellaneous causes such as diabetes, multiple sclerosis, spinal injury and dementia.

How common is Faecal Incontinence?

It is estimated that in Australia up to 5% of the population suffer from faecal incontinence. It is more common in the elderly and people in nursing homes.

Diagnosis: The diagnosis is established by the history of the incontinence and a rectal examination. Tests on the bowel such as a colonoscopy or barium enema may be performed to exclude diseases of the bowel. Further tests on the anal sphincters will help establish the cause and how to manage the problem.

1. Anal manometry involves the insertion of a slender catheter into the anus. This test measures the strength of the anal sphincter muscles.
2. Anal ultrasound involves the insertion of a probe into the anus. It is simply performed and not painful. It gives an accurate picture of the anatomy of the anal sphincter muscles. Injuries that are suitable for repair may be detected.
3. Nerve tests are used to detect if a nerve injury is present. This may influence management.

Treatment: Symptoms of faecal incontinence are readily improved. Alteration of diet, thickening of the faeces (medication and bulking agents), pelvic floor exercises and physiotherapy are often helpful in regaining control. Surgery can be offered to repair or tighten the anal sphincter muscle when this is damaged. For selected conditions causing incontinence, newer procedures are available to enhance sphincter closing by injecting inert materials into the muscle or by implanting a nerve stimulator to facilitate muscle contraction. Where this is not possible, a new anal sphincter can be created. These procedures are complex and may not be suited for every patient.

A plastic artificial anus can be used. Alternatively a muscle from the leg can be shifted to wrap around the anus and recreated the muscle of the anal sphincter. Occasionally, a colostomy will be recommended. Modern appliances make this an attractive option which may be preferable to continued soiling or accidents. The major reason for not seeking medical attention for continuing faecal incontinence is embarrassment. If you suffer or know someone who suffers from faecal incontinence talk to your doctor. A colorectal surgeon can give specific advice on the cause and potential remedies for the problem.

Faecal incontinence is a difficult and frustrating condition for a patient, and it can have a significant impact on your mood and your ability to carry out your normal daily activities. Please discuss any concerns around this with your surgeon. Treatment outcomes are variable, and there may be the need for several surgeries in complex situations. As a patient, it is important that you receive a clear description of the likelihood of treatment success from your surgeon.

Haemorrhoids are often described as “varicose veins” of the anal canal. In fact they consist of various swollen blood vessels covered by the lining of the anal canal. Most haemorrhoids commence as internal haemorrhoids and cannot be seen but as a haemorrhoid enlarges it bulges into the anal canal and eventually it may protrude through the opening of the anus (prolapse). This can sometimes cause an anal skin tag by stretching the skin.

What causes haemorrhoids?

Internal haemorrhoids are due to a weakening of the supportive connective tissues within the anal canal allowing the lower rectal lining to bulge. Contributing factors cause veins within the haemorrhoids to enlarge. Contributing factors might include:

• ageing
• chronic constipation or diarrhoea
• pregnancy
• faulty bowel habit
• straining at bowel action
• long periods on the toilet

What are the symptoms?

Bleeding

This is the most common symptom of haemorrhoids, usually seen on the toilet paper. Often the blood may drip or spray into the toilet bowl. It is unwise to assume that bleeding is always due to haemorrhoids without appropriate investigation.

Lumps

External lumps from haemmorhoids (prolapse) may occur during a bowel action or at other times. Usually this is reducible. Acute prolapse is less common, painful and requires a surgical opinion.

Discomfort - Pain

Moderate discomfort is common but severe pain may indicate a complication of the haemorrhoids (e.g. perianal thrombosis, acute prolapse) or the presence of an anal fissure (split).

Itch 

This common symptom is due to mucous discharge.

Do haemorrhoids lead to cancer?

No. There is no relationship known between haemorrhoids and cancer. However the symptoms of haemorrhoids may be very similar to those of bowel cancer. It is important that all symptoms, especially bleeding, are investigated by a surgeon specially trained in treating diseases of the colon and rectum.

How are haemorrhoids treated?

You should not rely on self medication. A consultation with your general practitioner and subsequent referral to a colorectal surgeon will ensure that your symptoms are properly evaluated and effective treatment is prescribed. Elimination of rectal bleeding is important. Elimination of rectal bleeding is important.

Mild symptoms can frequently be relieved by increasing fibre and fluids in the diet and avoiding excessive straining. Local ointments are of limited value but may give some relief. A perianal thrombosis (blood clot) may need excision under local anaesthetic. This procedure should provide rapid relief.

Injection

Injection with a chemical - phenol (in oil) can stop bleeding if the haemorrhoids are small.

Rubber band ligation

Rubber bands can be applied to internal haemorrhoids to decrease their size and rate of bleeding. This procedure can be performed in combination with injection and both can be performed as a day procedure or in rooms.

Haemorrhoidectomy

Surgical excision is sometimes necessary to treat large or complicated haemorrhoids. The procedure is performed under general anaesthesia. The operation may be conducted in hospital or in a day care centre.

Stapled Haemorrhoidectomy

This is a form of surgery that removes a circular disc of tissue lining the upper portion of the haemorrhoids so as to 'hitch up' prolapsing haemorrhoids.

THD (Transanal Haemorrhoidal De-arterialisation)

This procedure involves identifying the arteries to the haemorrhoids using an ultrasound device and suturing the arteries and haemorrhoid blood vessels. The aim of this procedure is to assist the haemorrhoids to 'shrink up' without removing them.

History

Haemorrhoid is derived from the Greek Haema (blood) and Rhoos (flowing). Pile comes from Latin Pila (a ball). Haemorrhoid disease, one of the oldest afflictions of mankind, was probably treated as early as 2250 b.c. in Babylon. Hippocrates (460 b.c.) advised ligation, cautery and excision. Galen (a.d. 131-201) reqarded bleeding as therapeutic "blood letting". John of Arderne (a.d. 1306-1390) used the term "piles" in his writing. In 1869 injection treatment was used by Morgan (Dublin). Rubber banding treatment was introduced by Barron (Detroit) in 1963.

The irritable bowel syndrome (IBS) sometimes called the "spastic colon" is common in our community. Many people have recurring gastrointestinal symptoms that can be attributable to IBS. Your bowels are intimately related to what happens in your life and changes in the stress levels, travel and diet often lead to an alteration of bowel function. Typical symptoms include abdominal bloating, colicky pain, diarrhoea or constipation and intermittent mucous discharge. Spasm of the pelvic floor muscles causing rectal pain often occurs in patients with IBS. Many patients are concerned about more serious causes of their symptoms such as bowel cancer and reassurance from their doctor and an explanation often alleviates some of the symptoms of IBS. Often there is a family history or a history of four or five varying symptoms which have occurred over many years alerting the doctor to the diagnosis. Bleeding from the bowel is never caused by IBS and must always be checked by your doctor.

Possible causes of IBS

IBS is most likely due to a diffuse disorder of the smooth muscle of the bowel causing both over and under activity leading to the varying combination of constipation or diarrhoea symptoms. This dysfunction has been attributed to previous infectious diarrhoeal illnesses, dietary allergies and psychogenic causes. None of these theories has been proven which makes treatment difficult and unpredictable.

Investigations

Clinical judgement is necessary to decide which investigations are necessary before an accurate diagnosis of IBS can be made. Because many of the symptoms are non specific, your doctor will decide after consultation whether there is a risk of more serious problems. IBS is a diagnosis after exclusion of other conditions such as bowel cancer, inflammatory bowel disease, infections and food allergies.

Treatment

Treatment is sometimes easy with the only reassurance that no serious underlying pathology exists. A good family doctor/patient relationship can be an important consideration. As the cause is unknown and the natural history is that of repeated episodes of intestinal symptoms, it is difficult to advise one particular treatment plan. Some treatments can help one manifestation of IBS but in so doing exacerbate another symptom. For example, fibre may improve constipation but may worsen or aggravate the feeling of being bloated. There seems little doubt that periods of emotional stress are likely to aggravate symptoms and an understanding doctor is often the most successful therapy. The use of or withdrawal of fibre supplements and dietary manipulations on an individual "trial and error" basis can also be tried. Probably long term treatments should be discouraged as the natural history of this condition is that of spontaneous remissions and exacerbations. Counselling and relaxation therapy by an experienced clinical psychologist may be helpful for some patients. Some patients may require testing for food allergies. Surgery has no role in the management of the irritable bowel syndrome.

What does a polyp look like?

Polyps vary in their shape, size and location within the large bowel. They may be single or multiple. A typical polyp has the appearance of a cherry with a short stalk or pedicle. Most polyps measure about one centimetre in diameter. Some have no stalk and are flat or carpet-like, spreading over the mucosal surface of the bowel.

Adenomatous polyps (adenoma)

There are different varieties of polyps but those which are associated with bowel cancer are termed adenomatous polyps or simply adenomas. This variety of polyp is important because there is strong evidence that some adenomas may undergo malignant change to produce bowel cancer. Patients who are found to have adenomas are considered at risk of developing bowel cancer. This risk is difficult to quantify. It varies from patient to patient and usually requires periodic surveillance by telescopic examination of all of the large bowel (colonoscopy).

Pre-cancer and cancer

Adenomas when pre-cancerous are composed of abnormal, rapidly dividing cells whose suspicious appearance and behaviour can only be accurately recognised by the pathologist when examined under the microscope. Therefore, when polyps are discovered they are best removed (polypectomy) so that they can be carefully examined and classified by a pathologist. It may take up to 12 years for a benign adenoma to become an invasive cancer. Large adenomas (greater than two centimetres in diameter) are always suspected of having developed a small focus of cancer until proven otherwise by the pathologist.

Symptoms

Although polyps are very common, they rarely produce symptoms and usually are discovered by chance at the time of colonoscopy. However, large adenomas occasionally may cause bleeding , usually as blood mixed in the stool.

Who is at risk?

People who have suspicious bowel symptoms (especially bleeding) and are approaching 40 years of age or older, may need a colonoscopic examination. Other people at risk include those with a significant family history of one or more first degree relatives (mother, father, sister, brother or child) who have had bowel cancer. Patients who have had a previous adenoma or cancer successfully treated, have a risk of developing polyps which continues through their life. Familial adenomatous polyposis (fap) is a rare, inherited disorder in which some members of the family will develop hundreds of polyps ultimately causing bowel cancer if not treated properly.

Treatment

Colonoscopy is the most accurate test to diagnose polyps. The purpose is to obtain a clear view of the whole length of the inner surface of the bowel, to search for and remove any polyps found, and have them examined under the microscope. Up to 90% of polyps can be safely and completely removed by colonoscopy.

Future checks

If adenomas are confirmed by a pathologist, it is recommended that the patient have regular "check-ups" by repeated colonoscopy. The frequency of examinations varies and this needs to be discussed with the doctor who performed the colonoscopy.

Definition

The word polyp refers to any visible structure which projects from the lining of the inner (mucosal) surface of the bowel wall. A polyp typically has the appearance of a small, warty outgrowth.

What is proctitis?

Proctitis is an inflammatory condition of the inner lining (mucosa) of the rectum (lowest part of the large intestine). Males and females tend to be equally affected and no age group is excluded.

What is the cause of proctitis?

The actual cause is unknown. Most cases of proctitis are part of the spectrum of chronic inflammatory bowel diseases of which ulcerative colitis and Crohn’s disease are examples. Others may be due to infectious agents, some of which may be sexually transmitted. Inflammation following radiotherapy to pelvic organs is also a cause of proctitis (radiation proctitis).

What are the effects of proctitis?

Non-specific proctitis involves the rectum above the anus and spreads for a variable distance upwards and is like a “burn” of the bowel lining. Crohn’s proctitis varies from small scattered ulcers through to deep, large, irregularly placed ulcers. Radiation proctitis tends to occur next to the organ that was irradiated. For example, the inflammation is close to the anus after prostate cancer irradiation and higher up after radiation for cervix cancer. The effects of radiotherapy vary from burn-like damage to discrete bleeding areas due to the development of multiple small fragile abnormal blood vessels.

What are the symptoms of proctitis?

The main symptoms are the need to pass a lot of stools (frequency) or the need to pass stools in a hurry (urgency), passage of blood and mucus, and looseness of stool, although some of these symptoms may be absent. Pain in either the lower abdomen or anus can sometimes occur. Because bleeding is a major symptom of proctitis, anaemia (low blood count) may result. Depending on the cause, the symptoms may last several days, weeks or years, continuously or intermittently.

Can other problems occur with proctitis?

It is very rare for other symptoms to occur with non-specific proctitis. Radiation proctitis may be associated with symptoms related to the original cancer if it recurs.

How is proctitis diagnosed?

The diagnosis is based on the clinical features and the appearance of the bowel lining at sigmoidoscopy. Colonoscopy is sometimes undertaken to exclude more extensive inflammation. There are no diagnostic blood tests. Biopsies may be helpful and bacteriology cultures may reveal the cause in infectious proctitis. Sigmoidoscopy is necessary to exclude other conditions which may mimic proctitis, such as rectal cancer or haemorrhoids.

How is proctitis treated?

The treatment is usually medical. It is only in rare circumstances that surgery is necessary. Non-specific proctitis is frequently treated with suppositories or rectal foam containing cortisone compounds. Occasionally cortisone enemas are used. Failure to respond to “local” treatment may require the use of tablets of salazopyrin or related compounds, and occasionally oral prednisone. Infective proctitis may resolve spontaneously (without treatment) but if a particular germ is isolated then a course of the appropriate antibiotic is indicated. Radiation proctitis is difficult to treat and troublesome bleeding can be improved with instillation of formalin-soaked packs in the rectum, or laser ablation of the bleeding points. Rarely surgical removal of part or all of the rectum is undertaken for intractable, severe bleeding due to radiation proctitis.

Who should look after my proctitis?

A specialist with an interest in inflammatory bowel disease and conditions involving the rectum is an appropriate person to look after you. The members of the Colorectal Surgical Society of Australia and New Zealand have this expertise.

What about the future?

Proctitis is usually a “nuisance” rather than a serious problem and frequently has no effect on your health. About 10% of patients with non-specific proctitis go on to develop more extensive ulcerative colitis, but mostly the condition runs a course over years with variable symptom-free periods punctuated with exacerbations of inflammation and usually the condition eventually “burns out”. Crohn’s proctitis may remain confined to the rectum. However, sometimes it is the first manifestation of a condition that can affect other parts of the large or small bowel, or anus. Radiation proctitis is frequent during or within the first few weeks of receiving pelvic radiotherapy and very often completely resolves. However damage following irradiation may appear years after receiving radiotherapy, and may be persistent.

What causes pruritus ani?

Many people develop pruritus ani (itchy anus) at sometime or other. The skin around the anus is sensitive and difficult to keep clean. Seepage of faeces and moisture are the commonest factors that cause this condition. Hair near the anus may aggravate the problem. The skin becomes irritated causing itchiness and the urge to scratch leads to skin damage, more irritation and a persistent cycle develops. Several common complaints such as allergies, diabetes and inflammatory bowel disease may involve the skin around the anus causing pruritus. Haemorrhoids with associated mucous discharge may also be associated with this problem. In children, threadworms may be the cause.

Symptoms

Itch, a raw feeling and occasional bleeding (caused by scratching) are the common symptoms. The urge to scratch is sometimes uncontrollable. Stress, a change of living circumstances or a change in diet may make the condition worse. Diarrhoea necessitating frequent cleaning of the anus will irritate pruritus.

Diagnosis

Don’t be embarrassed about seeing a doctor. This condition is very common. Your doctor will want to examine your anus and an “internal” as well as an “external” examination will be necessary. Swabs or scrapings of the skin near the anus are sometimes taken for pathology examination. More complex bowel tests are usually not necessary.

Treatment

Surgery is not necessary. The important thing to do is keep the anal skin clean and dry with good anal hygiene. A medication that reduces the itch and has sedative side effects may be prescribed by the doctor. The condition has a tendency to recur. The ten golden rules of treatment are:

1. After a bowel action use only the softest toilet tissue to clean the anus. It is better to use a dabbing technique rather than rubbing across the anus as most people do. You may prefer to use small moistened cotton wool pads rather than toilet paper.
2. To remove any small particles of motion, the area can be kept thoroughly clean by washing with warm water (e.g. after each bowel action and/or before retiring at night).
3. Avoid rubbing with soap or applying antiseptics as this may increase irritation.
4. Ensure the skin around the anus is dry by gently dabbing with soft tissues, towel or cotton wool or using a hair dryer.
5. If an ointment is not being used, a drying powder or baby powder can be applied but avoid perfumed talcum powder etc.
6. Do not use ointment unless prescribed by your doctor. Note that ointments containing cortisone should be used in small amounts and not for prolonged periods.
7. Choose sensible clothing (e.g. cotton underwear rather than nylon briefs) and generally avoid tight fitting garments.
8. Keep your bowels regular with a high fibre diet or fibre supplement.
9. Improvement follows diligence. If it recurs be patient and continue with the above measures.
10. If these measures do not solve the problem you may need to see a skin specialist after consultation with your family doctor.

What is a prolapse?

A prolapse is a protrusion of some part of the bowel through and outside the anus. It may occur in childhood or in the elderly. There are three types of prolapse:

1. Incomplete (internal) prolapse: the rectum is not yet protruding through the anus.
2. Mucosal prolapse involving only the inner lining of the rectum.
3. Complete (external) prolapse of the rectum.

What causes prolapse?

The exact cause is not known. Possible explanations are excessive straining at defaecation, a weak pelvic floor and anal sphincter muscles, or a lack of fixation of the lower bowel (rectum) to adjacent pelvic structures. Rectal prolapse is six times more common in women than in men, but is not related to childbirth. It is common in early childhood and usually resolves without surgery in this age group.

Symptoms

Protrusion of the bowel occurs during defaecation which at first goes back by itself. Later it needs to be reduced by hand. There may be discomfort, bleeding and the passage of mucus. Incontinence or poor control of the bowel is a very common complaint. This becomes more severe as the prolapse increases in size. A feeling of constipation or incomplete emptying of the rectum may be an associated symptom.

Diagnosis

Inspection by the doctor is often all that is required after asking the patient to strain. Sometimes it is necessary for the patient to sit on the toilet and strain to produce a prolapse. If a prolapse is suspected but the patient cannot induce it, a special x-ray called a proctogram may be required. If incontinence has been a problem there are tests of sphincter muscle function which can be performed.

Treatment

In children treatment of constipation is usually all that is necessary to correct the prolapse. In adults mucosal prolapse is treated either by rubber banding or by surgery. An incomplete prolapse of the rectum in adults may be treated with bulk laxatives in an attempt to reduce straining with defaecation. If a complete prolapse of the rectum occurs then surgery is usually required. There are several operations available which may be performed either via the abdomen or the anus. Abdominal operations involve securing the bowel to the lower spine (sacrum) and may include removal of a part of the bowel if constipation is a special feature. Laparoscopic (key hole) surgery is currently being evaluated to treat this condition. If the results prove to be as successful as those achieved by major surgery this may become the preferred operation for this condition.

Results

The choice of which procedure is best needs to be decided on an individual basis. Success rates for surgery are very good but vary for each type of operation. Some alteration in bowel habit after operation may occur. This is variable, usually not severe and improves with time.

What is ulcerative colitis?

Ulcerative colitis is a rare disease affecting about 5 per 100,000 of population. Males and females are equally affected and may present at any age, particularly between the second and fourth decades.

What is the cause of ulcerative colitis?

The cause is unknown, but many theories exist. It does not appear to be contagious or hereditary, but rarely more than one family member can have the condition. It is not caused by any dietary factors. It may follow an acute diarrhoeal illness.

How is the bowel affected by ulcerative colitis?

Only the large bowel is involved, with the inflammation starting in the rectum and extending for a variable distance towards the beginning of the large bowel (caecum). If the caecum is involved it is called pancolitis, whereas if the rectum alone is involved it is called proctitis. Ulcerative colitis is comparable to a "bum" of the inner lining of the bowel (mucosa) resulting in inflammation and shallow ulceration which causes diarrhoea, bleeding and mucus. With time the patient may become anaemic, protein and salt depleted.

Can other problems occur with ulcerative colitis?

Occasionally liver disease can occur (sclerosing cholangitis), as can eye inflammation (iritis), arthritis and skin lesions (pyoderma gangrenosum). Ulcerative colitis is also a premalignant disease and the incidence of colon cancer progressively increases with the duration of the disease.

What are the symptoms?

Episodic or continuous diarrhoea with blood and mucus are the main symptoms. There may be urgency to defaecate, with crampy lower abdominal pains. The symptoms can be very mild or so severe that up to 30 bowel actions a day occur. Patients can feel completely normal or become very ill with a life threatening episode. The illness may run a continuous or relapsing course. Occasionally it can "burn out" after a number of years.

How is it diagnosed?

Diagnosis is based on the clinical picture and the appearance of the large bowel mucosa at colonoscopy. Biopsies are taken. In the earliest stages of the disease it is sometimes confused with other conditions. There are no diagnostic blood tests.

When is surgery needed?

Surgery is indicated when medical treatment can no longer control the symptoms that prevent a patient from leading a reasonable lifestyle. Surgery may be indicated in the presence of, or to prevent such complications as haemorrhage, acute toxic colitis and cancer.

What operation might I have?

The aim is to remove all of the large bowel and this can be done in one or more stages. There are two options following total colectomy. The first is to have a permanent ileostomy (bag at the end of the small bowel) and the second is to preserve the anal sphincter muscles to maintain continence, and construct a "new rectum" using small bowel and connecting it to the anus. This removes the need for a permanent ileostomy. This operation, which is called "pouch" surgery or ileoanal reservoir is not suitable for all patients and is more complex surgery than a permanent ileostomy. It results in a variable number of loose but well-controlled bowel actions in a 24 hour period. If cancer has complicated ulcerative colitis the surgical treatment may be modified.

Who should do my surgery?

The decision to operate is always made by the patient's physician and surgeon in consultation, but it is very important that the surgeon is familiar with all aspects of ulcerative colitis and is skilled in the full range of available surgical techniques. Members of the Colorectal Surgical Society of Australia and New Zealand have these skills, and they are trained in the long term support and follow-up of patients who have had surgery for colitis.

What can I expect after surgery?

Removal of the diseased bowel implies cure without the need for drugs, and removes the risk of cancer. Life expectancy should be normal. With an ileostomy usual occupations and most sports can be resumed. A normal sex life and pregnancy should be possible. Pouch surgery allows defaecation through the anus, however functional results are variable.