An Anal Abscess is a painful, infected cavity filled with pus located near the anus or rectum. If the abscess is large, a person may develop a fever, chills, or a general ill feeling.

An Anal Fistula is a small tunnel which starts inside the anus and usually exits at one or more places on the skin of the buttocks, outside the anus. A fistula is almost always a result of a prior abscess. Common symptoms of a fistula include irritation of the skin around the anus, itching, and drainage of mucus or stool.

An abscess is caused by an infection of a small gland just inside the anus. Bacteria or foreign matter enters the tissue through the gland. Certain conditions, such as colitis or other inflammation of the intestine, can sometimes make these infections more likely.

In order for an abscess to heal, the pus must be released from the cavity. This is usually done by making an opening through the skin near the anus to relieve pressure, allowing the pus to drain. If the abscess is small and near the surface of the skin, this usually can be accomplished in the doctor’s office using a local anesthetic. A very large or deep abscess may require a more extensive procedure with anesthesia. In those circumstances, the drainage procedure is performed in the hospital. Generally, antibiotics are unnecessary and are not an alternative to draining the abscess.

Symptom relief is rapid and dramatic, after the drainage procedure. The abscess may continue to drain for several weeks until the infection is gone, and the cavity which contained pus has a chance to completely heal.

An anal fissure is a small tear in the lining of the anus. It may cause pain, bleeding, or even itching. It sometimes is hard to tell what causes a fissure. Sometimes the cause is hard, dry bowel movements that tear the lining, or diarrhea that leads to frequent bowel movements.

About 50% of the time fissures will heal themselves. Sometimes healing is aided by medicated creams, stool softeners, and/or sitz baths. A persistent fissure should be re-examined to see whether a definite reason exists for lack of healing. Fissures that continue to cause problems can be corrected by surgery. Surgical correction is done in an outpatient setting, which means no overnight hospital stay is required.

After surgery, there is minimal discomfort for a few days. This can be easily controlled with mild pain medications. Many people are able to return to work after only a day or two. Complete healing usually occurs in a few weeks, with pain often disappearing after 2-4 days.

More than 95% of patients who require surgical repair for this problem have no further trouble from fissure.

Anal Fissure Treatment Guidelines

Our providers will discuss fiber use with you. They recommend using Konsyl, Citrucel, or Metamucil nightly. You will also be prescribed Nifedipine, (which is made at Bernie’s Pharmacy), and Lidocaine 5% ointment, (which can be purchased at any pharmacy). Sitz baths may be helpful. A sitz bath involves soaking the anal area in warm to hot water 10-15 minutes, 2-3 times a day. This conservative treatment usually lasts for 6-8 weeks. Most patients do well with conservative treatment. However, if you have not healed sufficiently in 6-8 weeks, a surgical consultation will be scheduled for you.

DIRECTIONS FOR FIBER

Konsyl:

Mix 1 teaspoon in a cup of juice, shake quickly, and drink rapidly.

Metamucil or Citrucel:

Mix 1 teaspoon in a cup of water, stir fast, and drink quickly.

DIRECTIONS FOR PRESCRIBED MEDICATIONS

Nifedipine ointment:

Apply ½-1 inch of the ointment three times daily to the anal area. Ointment is for the outer anal area only. When applying the ointment, only a small portion of the tip of your finger should come into the anus itself.

Nifedipine is found at Bernie’s Pharmacy.

Lidocaine 5 % ointment:

Apply 1 inch of the ointment 5-10 minutes before you have a bowel movement. It is okay to use this ointment up to 4 times daily.

This will help reduce the pain during the bowel movement.

If you wish to schedule a surgical consultation, or if your symptoms worsen, please call our office at (907) 222-1401.

What is anal intraepithelial neoplasia?

Anal intraepithelial neoplasia (AIN) is a dysplastic (or abnormal skin change) condition of the squamous tissues of the anus. AIN is caused by the human papilloma virus (HPV). There are low-risk (HPV 6/11) and high-risk subtypes (HPV 16/18). There are three types of AIN determined by biopsy: I, II, III. Type one is often referred to as low-grade squamous intraepithelial lesion (LSIL) on anal pap smear. Type II/III are often referred to as high-grade squamous intraepithelial lesions (HSIL) on anal pap smear.

How did I get AIN?

The HPV virus is transmitted via contact. The virus can reside unnoticed for months or years in the deep basal layer of the skin.

What are the risks of AIN?

It is not cancer but does have a risk of developing into anal cancer if untreated.

How is AIN diagnosed?

AIN can be diagnosed with screening using an anal pap smear, however this is not 100% accurate. Any abnormal pap smear should be confirmed with high resolution anoscopy (HRA) and biopsy. Any abnormal anal lesion should always be visualized and biopsied if suspicious.

What is HRA?

It involves the use of a magnifying scope and acetic acid and iodine staining to identify abnormal cells and tissue of the anus.

How is AIN treated?

Once AIN is identified with HRA, biopsy is initially performed. If the result is positive for AIN I, then only routine surveillance is needed. If AIN II/III is present, then the abnormally staining areas will require fulguration (burning) that can be performed in the office or operating room depending on severity. Routine surveillance is then needed with HRA; risk of recurrence is high with likely need for future treatment.

What is the recovery after treatment?

This depends on the individual. Most people are moderately uncomfortable for a few days after treatment, however there are no work/activity restrictions.

What are anal warts?

Anal warts (also called “condyloma acuminate”) are a relatively common and bothersome condition, which affects the area around the anus. They also may affect the skin of the genital area.

Where do these warts come from?

They are caused by a virus which usually is transmitted from person to person through sexual contact. However, they can also be acquired through other means.

Do these warts always need to be removed?

Yes. If this is not done, the warts generally grow larger and more numerous. There is evidence that these warts can become cancerous if untreated.

What treatments are available?

If the warts are very small and are located only on skin around the anus, they can be treated with certain caustic liquid medicines which must be applied directly to the surface of the warts. Though relatively simple in concept, this treatment must be carried out with great care and precision, or there is a chance of injuring the normal skin around the warts. This method usually takes several applications, which are performed over several weeks. When warts are larger, more numerous or located inside the anus, chemical therapy generally is ineffective. Another form of treatment involves rapid destruction of the warts through electric cautery, surgical removal, or a combination of the two. This gives immediate results, but requires anesthesia that varies from simple local injections to general anesthesia, depending on the number and location of the warts being treated.

Must I be hospitalized for surgical treatment?

No. The cautery and excision technique can be done as an outpatient procedure, and you can go home an hour or two after it is complete.

How much time will I lose from work after cautery treatment?

This depends upon the individual. Most people are moderately uncomfortable for a few days after the treatment. Some people return to work the next day, while some may be out for up to several days.

Will a single treatment cure the problem?

Even with the cautery and surgical treatment, almost all people develop more warts after treatment. The virus can live in normal-appearing tissue for up to six months before causing a wart to develop. If warts do recur, they are thought to be new warts developing from the virus which was already in the tissue. As new warts develop, they usually can be treated in the office, using either acid or the electric cautery. These treatments are performed about once a month, initially. As the new warts become less numerous and smaller, treatment decreases to every two months. Sometimes the new warts develop so rapidly that office treatments would be quite uncomfortable. In such situations, a second, and occasionally a third visit to day surgery is recommended. If this is necessary, the discomfort associated with recovery is typically milder than it is after the initial procedure.

How often is follow-up treatment necessary?

Follow-up visits are necessary at various intervals, until six months after the last wart is seen. This is to ensure that no more warts develop from the virus that is present in the healthy-appearing skin.

What can be done to avoid getting these warts again?

It is important to avoid re-infection by other individuals who may have this condition. Sexual partners should be examined by their physician.

The appendix is a small finger-like projection that comes off the cecum of the large intestine and has no apparent function humans. When the opening in the sac is blocked, it leads to an inflammation of the appendix called appendicitis. This condition occurs most commonly in the young, between childhood and young adulthood. Appendicitis is an emergency condition and requires urgent surgical removal of the appendix.

Tests:

Laboratory:

• White blood cell count: The white blood cells are cells that fight off infection in the blood stream. An increase in the white blood cells, particularly neutrophils, is indicative of an infection within the body.

• An analysis of the urine is helpful to rule out a urinary tract infection, which may give symptoms similar to appendicitis. However, a person can have blood present in the urine when the inflamed appendix is located adjacent to the ureter, the tube that runs from the kidney to the bladder. A urinary infection also shows additional chemical finding such as glucocyte estrace or nitrace which are not present with appendicitis.

X-ray tests:

• Flat plate (plain film) of the abdomen. An abdominal X-ray is rarely useful for diagnosing appendicitis. On rare occasion, a hardened piece of stool with calcification, called an appendicolith, may show up on a plain X-ray. The plain X-ray, however, may rule out other reasons for the abdominal pain, such as a dilated bowel with a bowel obstruction. If the appendix has ruptured there may be evidence of air in the abdomen.

• Occasionally an ultrasound of the abdomen (a picture if the inside of the abdomen using sound waves) may be useful when the appendix is dilated. In females, this test gives helpful information regarding the state of the uterus, tubes, ovaries, and pelvis.

• A CT (Computerized Tomography) scan of the abdomen has been increasingly used for the diagnosis of appendicitis.

• It can detect either a distended appendix or inflammation around the appendix, which can be indicative of appendicitis.

• A newer technique places X-ray contrast material up the rectum to fill the large bowel. It also normally fills the inside of the appendix. If the opening in the appendix is blocked, then no contrast fills the appendix. This is highly suggestive of acute appendicitis.

• A CAT scan is also useful for finding other diseases which may be causing abdominal pain.

• A barium-containing enema may be used in a manner similar to the CT scan with the rectal contrast. If the appendix fills with the contrast as seen on an X-ray of the abdomen then there is no appendicitis. This has largely been replaced by the CT scan with rectal contrast.

Indications and Contraindications for Surgery:

• Allowing the appendix to rupture greatly increases the complications and risk of death, therefore, a surgeon must proceed with removal of the appendix if a high suspicion for appendicitis exists.

• Therefore, it is better to remove a normal appendix than to allow an inflamed appendix go on to rupture.

• Approximately 20% of appendices are normal.

• The only contraindication to removing the appendix is a situation where perforation has occurred and the abdomen is so inflamed that the appendix is not recognizable. In this situation the infection needs to be drained out but the infection is not removed.

• In a situation where the diagnosis is in question, a laparoscopy may be carried out.

  • The laparoscope is a long tube containing fiber optics with a lens at one end and a small television camera at the other. It is placed through a small opening in the abdomen just below the umbilicus called a port.

  • With laparoscopy, the appendix can be seen. If disease other than acute appendicitis is causing the pain, this can be discovered, and if the appendix is found to be diseased, it can be removed.

  • If a normal appendix is found and there is no evidence of other abdominal disease, the appendix is still removed. This will prevent the patient from coming back with pain that could possibly be appendicitis in the future.

The procedure:

Using a Laparoscope:

• In addition to the port below the umbilicus, extra ports are placed in the abdomen to allow removal of the appendix using instruments placed through the small ports.

• This technique does take longer than a standard open appendectomy and costs slightly more because of the instruments required for surgery.

Open appendectomy remains the standard of care for appendicitis.

• An incision is made in the skin over the area of the appendix in the right lower abdomen,

• The muscles are spread and the abdomen is entered.

• The large bowel or cecum is located and followed to its end where the appendix is found.

• The appendix is pulled up through the incision.

• The mesoappendix us separated off of the appendix, clamped, and tied off.

• The appendix is then tied off at its base next to the cecum.

• The reamainder of the appendix is clamped, cut, and removed.

• Care is taken to prevent spillage of bacteria from the cut end.

• The muscle layers are then sutured back together over the stump of the appendix.

• If the appendix has ruptured, a drain is placed in the region of the appendix to allow bacteria to drain out and the skin is left open and packed with gauze. The gauze and drain are removed when the infection is cleared.

Complications:

• Wound infections

• Abdominal abscess due to spillage of bacteria after ruptured appendicitis

• Bowel obstruction

• Urinary tract infection

• Hemorrhage

• Injury to the large or small bowel, ovary, or other abdominal organs requiring removal.

Postoperative Care:

Unruptured appendix:

• The patient is started on a liquid diet the morning after the surgery and progressed to soft and then regular diet.

• Additional antibiotics are also given to prevent wound infection.

• Often the patient can leave the hospital in 1-2 days after the surgery.

Ruptured appendix:

• The hospital stay is usually at least 4 days and possible longer.

• If there was spilling of bacteria from the appendix, recurrent abdominal abscesses and infections may occur.

• The bowel frequently stops normal function (ileus), causing bowel fluid and gas to distend the bowel. This distention is relieved by placing a tube through the nose and into the stomach for approximately 2-3 days. Once there is evidence that the intestines are active again, such as the passing of gas or stool, the tube is removed.

• The patient is then started on a liquid diet which is advanced to a regular diet as tolerated.

• If the appendix has ruptured, a drain is placed in the region of the appendix to allow bacteria to drain out and the skin is left open and packed with gauze. The gauze and drain are removed when the infection is cleared.

• Antibiotics are continued for approximately one week after surgery. Initially, this will be through a vein while in the hospital and then typically by pill after being sent home.

Cholecystectomy is the operation for removal of the gallbladder. Traditionally, the surgery is carried out through an incision in the right side of the upper abdomen. More recently the surgery has been carried out through a laparoscope employing 3 or 4 small incisions.

Pathology:

Stones may form in the gall bladder, which block the flow of bile resulting in pain in the right upper abdomen. Gallstones can lodge in the terminal part of the common bile duct that opens into the small intestine. Here the stones can also block the flow of pancreatic juice from the pancreatic duct that joins the common bile duct. This may result n a severe inflammation of the pancreas called pancreatitis. The exact cause of gall bladder disease is unknown. Some studies suggest that gallstones may be related to how the body handles cholesterol and bile acids that are synthesized in the liver and stored in the gall bladder. While some people may have no symptoms even in the presence of gallstones, others may have gallbladder problems even in the absence of stones.

Procedure for Open Cholecystectomy:

• Removal of the gallbladder is classically carried out through and incision in the right upper abdomen. This procedure is called an open cholecystectomy.

• The gallbladder is directly exposed and dissected off the liver and surrounding structures and removed.

• If indicated, a dye study of the common bile duct can be performed to determine the presence of stones in the bile duct. When present, open exploration of the common bile duct can be performed.

• This operation is now employed in cases where it may be dangerous or difficult to perform a laparoscopic cholecystectomy, such as technical difficulties due to dense abdominal adhesions from previous surgery, highly inflamed and adherent gallbladder, or when the anatomy of the gallbladder is not clearly visible through a laparoscope.

• The recovery period and hospital stay is usually 4-5 days.

• In some cases, it may not be possible to remove the gallbladder through a laparoscope. In these cases, this operation is usually transformed into an open cholecystectomy. In some cases, gallstones that are lodged in the common bile duct causing obstruction may be removed by exploration of the common bile duct during open surgery.

Procedure for Laparoscopic Cholecystectomy:

• Today, the standard of care is usually a laparoscopic cholecystectomy.

• The laparoscope is a long tube with lenses at one end that are connected by fiber optics to a small television camera at the other. The fiber optics also carries light into the abdomen from a special light source. This system allows the surgeon to see and operate within the abdomen.

• The procedure is usually performed under general anesthesia.

• Antibiotics are given intravenously prior to the surgery to reduce the rate of infection.

• After anesthesia is begun, the skin is prepared with antiseptic solution and 3-4 small incisions (called port sites) are made on the abdominal wall.

• A special needle (Veress needle) is inserted into the abdomen to inflate the abdomen with carbon dioxide gas. This distends the abdomen and creates space to insert the instruments.

• The laparoscope and laparoscopic instruments with long handles are inserted through the incisions into the abdomen. The entire operation is then performed while viewing the organs magnified on a television screen.

• The gallbladder is dissected of the surrounding structures. The cystic duct that attaches the gallbladder to the common bile duct is dissected and divided between metal clips.

• In some cases, a tiny catheter may be inserted into the cystic duct to inject dye and take X-rays to visualize any stones that may be blocking the common bile duct. If common bile duct stones are present, they may be removed with laparoscopic common bile duct exploration, by opening up the abdomen and exploring the duct, or by ERCP (see below).

• After the cystic duct is divided, the gallbladder is further dissected off the liver bed and a tny artery that supplies blood to the gallbladder called the cystic artery is divided between metal clips. The gallbladder is then further dissected off the liver avoiding spillage of bile into the abdominal cavity.

• In some cases, the gallbladder is shrunk by suctioning out bile. The gallbladder is then removed through one of the ports in the abdominal wall and the tiny incisions in the abdominal wall are closed after removing any gas left in the abdominal cavity. When there is spillage of bile, the local abdominal cavity is thoroughly cleansed with saline solution, and a small drain may be left in place. This may be removed the same evening or the next day.

ERCP (not performed in Anchorage):

• ERCP (Endoscopic Retrograde Cholangio-Pancreatography) is a procedure usually performed by and endoscopist. This procedure is useful when a stone obstructs the common bile duct.

• The common bile duct is approached using a special endoscope inserted through the stomach and small intestine to the entrance of the common bile duct.

• An X-ray study of the common bile duct is performed using a dye. A papilotomy (cutting the muscle of the lowest portion of the common bile duct) is performed to enlarge the duct opening and facilitate stone removal.

• A small catheter and instruments may be passed into the duct to remove the stones.

• A small catheter will occasionally be left in the duct for temporary drainage.

Complications:

The incidence of complications after cholecystectomy is relatively low.

• Complications of general anesthesia

• Postoperative bleeding

• Injury to the bile ducts or right hepatic artery

• Biliary leak

• Wound infection

• Injury to other abdominal organs

• Pulmonary embolism

• Deep vein thrombosis

• Respiratory or urinary infections

After Surgery:

The patient usually has minimal pain that is well controlled with medication. Frequently, patients are discharged home on the same evening after laparoscopic cholecystectomy or the next morning with a prescription for pain medication. Patient eats a normal light diet on the day after surgery and may be able to return to light work in 3-4 days. It is preferable to avoid exertion and heavy work for several weeks, though one can take regular walks.

Surgery of the colon and rectum is done for various reasons including cancer, diverticulitis, inflammatory bowel disease, volvulus, and fistulae.

Pathology:

• Cancer of the colon and rectum is the most common cancer of the bowel.

• In men, it is the third most common lethal cancer next to cancer of the lung and prostate.

• In women, it is second only to lung and breast cancer as a cause of cancer related death.

• Cancer of the colon is common in patients over 50 and steadily rises after that. Americans have about a 5% chance of developing colorectal cancer if they live to 70 years of age.

• The onset of familial and hereditary forms of colorectal cancer occurs at a much earlier age.

• Diverticulosis is a condition that is common in western society. It increases with age and is present in approximately 75% of Americans over the age of 80.

  • It is associated with diverticula, which are protrusions of the innermost lining of the colon through the muscular outer layers of the colon wall.

  • The diverticula can become inflamed, a condition called diverticulitis, which can cause perforation of the bowel, abscess, bleeding, obstruction of the bowel or fistulae of the colon (a communicating hole between the colon and other organs such as the small bowel, urinary bladder, vagina or skin).

• There may also be inflammatory bowel disease (called Crohn’s disease), ulcerative colitis or ischemic (decreased blood supply) colitis. These conditions result in inflammation of the colon that can involve the entire thickness of the colon wall (Crohn’s disease, ischemic colitis) or only the mucosa, the innermost lining of the colon (ulcerative colitis).

Indications:

• Colectomy (removal of the colon) can be carried out for various diseases including:

  • Cancer: Removal of the colon and rectum is the mainstay of treatment for cancer. It can be curative or palliative at which time the surgery is performed to relieve symptoms. Colon surgery for cancer may be combined with other forms of treatment including radiotherapy and chemotherapy.

  • Polyps: Removal of the colon is performed for a condition called Familial Adenomatous Polyposis that is associated with numerous polyps in the colon at a young age. It carries a very high incidence of colon cancer and hence requires the removal of the entire colon to prevent malignancy.

  • Colitis: Colon resection may be performed in patients with inflammatory bowel disease (ulcerative colitis or Crohn’s disease) with persistent, intractable pain and failure of medical treatment, intestinal obstruction, fistulae, bleeding, perforation, and marked dilation of the colon.

  • Diverticular disease: Colon surgery is performed in patients with diverticulitis (acute inflammation of the diverticuli) with or without abscess formation, persistent profuse bleeding, pr perforation of the bowel wall.

• Other conditions that may necessitate removal of the colon include:

  • Intestinal obstructions

  • Perforation of the colon wall

  • Volvulus in which the bowel is twisted on itself causing obstruction

  • Ischemic colon (lack of blood supply to the colon)

  • Toxic megacolon (massive dilation of the colon)

  • Fistulae between the colon and other organs such as the bladder or vagina

• Removal of the colon may be carried out as a scheduled procedure or as an emergency in life saving situations such as severe bleeding or perforation of the colon.

• The extent of removal of the colon varies depending on the site of the disease. In the removal of the colon for cancer, all the lymph nodes that drain the tumor are also removed.

Adjuvant Therapy (Complimentary Therapy):

• Clinical trials are underway to determine the role of neoadjuvant therapy in treatment of carcinoma of the rectum.

• Neoadjuvant therapy for rectal tumors usually consists of external beam irradiation (X-ray radiation therapy) to the affected area plus administrations of chemosensitizing agents (medication that enhances the effect of radiation).

• Neoadjuvant therapy appears to result in a lower local recurrence rate following surgery. This downstages the tumor (shrinks the tumor mass) and more often allows preservation of the anal sphincters (muscles) in lower rectal tumors avoiding permanent colostomy.

• Neoadjuvant theapy appears to improve survival. A standard of care for these rectal lesions that includes neoadjuvant therapy should be forthcoming in the next few years.

Surgical Procedure:

• Before surgery, the bowel must be prepared to decrease the incidence of infection. Preparation begins a few days prior to colon surgery. The patient is placed on a low residue diet for 2-3 days prior to surgery and on liquids the day before surgery, which complete fasting from the midnight before surgery.

• The patient is usually admitted to the hospital on the day before surgery and is given some purgatives to cleanse the large bowel along with antibiotics.

• Intravenous fluids are given on the night before surgery to avoid dehydration resulting fromt the diarrhea due to the cleansing action of the purgatives.

• Intravenous antibiotics are usually administered just before surgery to reduce the incidence of infections. They may be continued after surgery.

• The procedure is usually done to under general anesthesia.

• An incision is made in the abdomen, The incision is carried through the wall of the abdomen to expose the bowel.

• The diseased portion of the colon is identified and that part of the colon and its blood supply is divided and removed. The ends of the bowel are sutured together by hand with individual sutures. Care is taken to identify the ureters, small intestine, and other organs so as to avoid injury to these organs.

• In the last ten years, special instrumentation has greatly simplified the procedure. A stapler placed across the colon seals the colon on each side of the stapler and then cuts the colon between the staples. Likewise, a different type of stapler staples the anastomosis together.

• After surgery, the abdominal wound is usually closed although in cases with colon perforation, the wound may be left open and closed at a later date.

• Sometimes, an emergency operation may need to be performed to remove the colon in cases with perforation of the colon, bleeding, or diverticulitis.

  • In such cases, a colostomy is usually performed where the colon is brought out through a separate incision in the abdominal wall and sutured to the skin.

  • Feces are then excreted into a bag attached to the skin.

  • This may be temporary or permanent.

• Tumors or lesions in the ascending colon can be treated by an operation to remove the last part of the small bowel, the ascending colon, hepatic flexure, and a small part of the transverse colon (right hemi-colectomy).

• In a similar fashion, lesions of the descending colon and sigmoid are dealt with by left hemi-colectomy (removal of descending colon, and adjoining parts of the sigmoid colon, splenic flexure, and part of the transverse colon) and sigmoid colectomy, respectively.

• After removal of a segment of colon, the two ends of the bowel are joined together (called an anastomosis). Tumors in the upper part of the rectum and lower part of the sigmoid colon are dealt with by an operation called an anterior resection, wherein the rectum and sigmoid colon are removed and the lower end of the rectum is joined to the colon.

• Removing the entire rectum and part of the sigmoid colon (abdomino-perineal resection) is used as the treatment of tumors low in the rectum.

  • The end of the remaining colon is brought out as a colostomy.

  • Polyps or tumors that are very low in the anal canal can sometimes be resected from below, through the anus (transanal resection of the tumor).

Complications:

In addition to the routine complications of any general anesthetic, there can be complications as a result of the colon surgery. These include:

• Postoperative bleeding

• Dehiscence or breakdown of the anastomosis

• Recurrence of tumor

• Wound infection

• Urinary or respiratory infections

• Deep vein thrombosis with or without pulmonary embolism

• Urinary retention

• Adhesions with bowel obstruction

• Injury to the ureter

• Obstruction at anastomosis site

After Surgery:

• The recovery period after colon surgery is widely variable. It usually involves a stay in the hospital from 3-10 days in uncomplicated cases.

• The patient will have a catheter in the urinary bladder for a few days and will be given adequate pain relief, intravenous, antibiotics, etc.

• For patients who do not have any oral intake for several days, nutrition may be provided intravenously or through a tube in the stomach or bowel.

• The function of the bowel is monitored closely to await the passage of gas or stool after surgery.

• The patient then gradually begins to take liquids by mouth and solid food later on, following which they will be discharged home.

Treatment Plan: ______________________________________________________________________________________________________________________________________________________

What is a polyp?

A polyp is a small growth on the lining of the intestine. Sometimes there is only one polyp, but there can be several present at the same time. There also are rare conditions in which the colon (large intestine) contains a very large number of polyps. Polyps may be either benign (non-cancerous) or malignant (cancerous).

Why are polyps removed?

Removal is recommended for two reasons. First, in order to determine whether a polyp is benign or malignant, it is usually necessary for a pathologist to examine the tissue under a microscope. Second, most polyps, even though benign, have the potential to grow larger and become malignant if left in place. Removal of these polyps prevents them from becoming cancerous.

What are the alternatives to removing a polyp?

Repeated evaluation of a polyp with X-rays or by looking at it directly with either a sigmoidoscope or a long, flexible colonoscope are the only other ways to determine whether the polyp is changing or growing larger. Unfortunately, because cancer develops at the microscopic level, these evaluations cannot reliably predict if a polyp is becoming malignant.

How are polyps removed?

The tiniest polyps are removed by burning or cauterizing them. Larger polyps can usually be removed using a specially designed snare, which cuts the stalk of a polyp and cauterizes it at the same time, so that it does not bleed. The snare is passed through a channel in the colonoscope, when this technique is used.

Is surgery ever necessary to remove polyps?

Occasionally this may be necessary. This may be because the stalk (or neck) of the polyp is too broad to permit safe removal by snare, or because the colon is positioned in such a way that the colonoscope will not reach the polyp area safely. The great majority of polyps can be removed without surgery.

Most of the gastrointestinal (G.I.) tract from the mouth to the anus can be examined by endoscopy (endo, inside; scope, see; to see inside the body). The endoscope is a long and flexible tube that contains a light source, a lens system for focusing, and fiber optics to conduct light into the bowel. A picture of the bowel wall is sent back to a video camera and displayed on a monitor. The tube also contains a working channel through which small instruments can be passed for various uses. Colonoscopy enables the physician to examine the lining of the colon (large bowel), and is done by inserting the flexible endoscope (called a colonoscope) into the rectum and then into the entire colon.

Pathology:

• Cancer of the colon and rectum is common in patients over age 50 and steadily rises thereafter. Americans have about a five percent chance of developing colorectal cancer if they live to 70 years of age.

• Polyps are thought to progress to cancer.

• Diverticulitis is a condition that is common in western society. It increases with age and is present in approximately 75% of Americans over the age of 80. It is associated with diverticula, which are protrusions of the innermost lining of the colon through the muscular outer layers of the colon wall. The diverticula can become inflamed, a condition called diverticulitis, which can cause perforation of the bowel with abscess, bleeding, obstruction of the bowel, or fistulae of the colon (a communicating hole between the colon and other organs such as the small bowel, urinary bladder, vagina, or skin).

• There may also be inflammatory bowel disease, namely Crohn’s disease, ulcerative colitis, or ischemic (decreased blood supply) colitis. These conditions result in inflammation of the colon that can involve the entire thickness of the colon wall (Crohn’s disease, ischemic colitis) or only the mucosa, the innermost lining of the colon (ulcerative colitis).

Indications:

Indications for colonoscopy are:

• Blood in the stool

• Preventative colonoscopy – periodic colonoscopy is desirable over age 50 to detect polyps

• Polyp found on X-ray studies

• Persistent diarrhea or constipation

• Imaging studies (barium enema, CT scan, MRI) suggestive of an abnormality

Procedure:

• The colon must be completely cleaned for the procedure to be accurate and complete. In general, preparation consists of being on a liquid diet the day before the test and taking laxatives to clean the bowel.

• Most medications may be taken as usual but some medications may interfere with the preparation or examination. Therefore, the physician should be told of the medications that the patient is taking as well as any allergies to medications. Aspirin products, arthritis medications, anticoagulants (blood thinners, i.e. Coumadin, Plavix), insulin, and iodine products are examples of such medications. The patient should also alert the physician if they require any antibiotics prior to the procedure.

• Colonoscopy is usually done under sedation. It is common for patients to sleep during the procedure. Some discomfort, such as a feeling of pressure, bloating or cramping, or pain may be encountered at all times.

• The patient lies on the left side, or sometimes on the back during the procedure.

• The colonoscope is slowly inserted into the rectum and slowly advanced through the colon while the physician removes any residual material missed by preparation and observes the wall of the bowel. As the colonoscope is slowly withdrawn, the lining is again carefully examined. In some cases, passage of the colonoscope through the entire colon to its junction with the small intestine cannot be achieved.

• The procedure takes between 15-30 minutes. If the examination is not complete, the physician will decide if other examinations are necessary.

• If an area of the bowel wall needs to be evaluated in greater detail, a forceps instrument is passed through the colonoscope to obtain a biopsy. The specimen is submitted to the pathology lab for analysis.

• If sites of bleeding or a potential bleeding site is found, the bleeding may be controlled by injecting certain medications or by coagulation with electricity, heat or laser.

• Polyps are removed.

  • Polyps are an abnormal growth from the lining of the colon which vary in size from 2-3 millimeters to several centimeters.

  • The majority of the polyps are benign (non-cancerous), but the examining physician cannot always tell a benign from a malignant (cancerous) polyp by its appearance alone. For this reason, removed polyps are sent for tissue analysis. Most colon polyps are completely removed.

  • Removal of colon polyps is an important means of preventing colon cancer.

  • Tiny polyps may be totally destroyed by fulguration (burning), but larger polyps are removed by a technique called snare polypectomy. The doctor passes a wire loop (snare) through the colonoscope and severs the attachment of the polyp from the intestinal wall by means of an electrical current.

  • There is a small risk that removing a polyp will cause bleeding or result in a burn to the wall of the colon, which could require emergency surgery.

Complications:

• Perforation or tear through the bowel wall that may require surgery.

• Bleeding may occur from the site of biopsy or polypectomy. It is usually minor and stops on its own or can be controlled through the colonoscope. Rarely, blood transfusions or surgery may be required.

Other potential risks include:

• Reaction to the sedatives.

• Complications from associated heart or lung disease.

• Localized irritation of the vein where medication was injected. Applying hot packs or hot moist towels may relieve discomfort.

Although complications after colonoscopy are uncommon, it is important for the patient to recognize early signs of any possible complication. The patient should contact the physician if any of the following symptoms are being observed:

• Severe abdominal pain

• Fever or chills

• Rectal bleeding of more than one-half cup. Bleeding can occur several days after polyp removal.

After Care:

• After the test, patients are monitored in the recovery room for 30-45 minutes until the effects of sedation have worn off. They will need to make arrangements for somebody to drive them home (not a taxi) and to stay with them for the remainder of the day because sedation affects judgment and reflexes for the rest of the day. No driving or working is allowed until the next day. It is advised to have somebody stay with the patient for the rest of the day.

• There may be some cramping or bloating because of the air introduced into the colon during the examination. This disappears with the passage of flatus (gas).

• Generally the patient should be able to eat after the endoscopy, but the physician may restrict the diet or activities, especially after extensive endoscopic work (i.e. large polypectomy, control of bleeding, etc.).

• The doctor will discuss with the patient or designated companion any further instructions or need for follow-up.

COLORECTAL CANCER

PREVENTION AND SCREENING

Colorectal cancer is the second leading cause of cancer death for both men and women in the United States. This year, more than 150,000 people in the U.S. will be diagnosed with colorectal cancer; more than 50,000 will die from their disease.

Colorectal cancer is one of only three cancers which can actually be prevented by regular screening examinations (the other two cancers which can be prevented are cervical cancer and skin cancer). Therefore, it is important for patient’s to understand A) that colorectal cancer is preventable; B) the methods by which colorectal cancer can be prevented; and C) how and when these methods should be used based on risk factors such as age, family history, personal history of other cancers and history of other related disease.

Nearly all colon and rectal cancers come from "polyps", which are small, benign (non-cancerous) growths on the lining of the colon and rectum which often progress to cancer. Approximately 20% of all people will develop polyps. When they are small, polyps almost never cause symptoms and most people are unaware that they have them. While not every polyp will turn into a cancer, many polyps will become cancerous if not removed. If polyps are present and found early, before they can become cancerous, it is possible to remove these, preventing their development into cancer.

Screening is designed to detect polyps and to eliminate them before cancer develops. Prevention of cancer is the #1 goal, but even if cancer should already be present, early detection, before cancer has had a chance to spread, is also an important factor in leading to a cure and saving lives.

How does a person get screened?

The American Cancer Society recommends colonoscopy as the best method for screening.

When should I be screened?

The timing and frequency of colonoscopy is based on risk of developing this kind of cancer and is usually categorized As: Average, Moderate, or High risk.

KNOW YOUR RISK LEVEL

Average Risk

The average risk of developing colorectal cancer for both men and women over the age of 50 is approximately 1 in 20 if no screening is done. For those at average risk, the American Cancer Society recommends colonoscopy every 10 years beginning at age 50.

Moderate Risk

People are at moderate risk for colorectal cancer if they have either:

• A personal history of polyps or colorectal cancer themselves;

• a family history (sister, brother, parents or children) of colorectal cancer or polyps;

• a personal history of breast, ovarian or endometrial cancer, or

• a personal history of inflammatory bowel disease, such as ulcerative colitis.

The risk of developing colorectal cancer in this group is three times greater than for average risk, or 1 person in 6, if no screening is done. Most patients in the moderate risk category should have colonoscopy every 3 to 5 years beginning at age 40. For those with inflammatory bowel disease involving the colon, specific recommendations for screening vary widely and should be discussed with your physician.

High Risk

People at high risk for colorectal cancer include those that have either:

• a family history of "familial adenomatosis polyposis" (a genetic disorder causing cancer to develop at an early age in 100% of those), or

• a family history of "hereditary nonpolyposis colon cancer" (HNPCC) (a genetic disorder with several other family members, especially under the age of 50, having colorectal cancer). Those in either of these risk groups should have colonoscopy every 1 to 2 years beginning no later than age 21.

These recommendations are based on guidelines published by the American Cancer Society, the American Society of Colon and Rectal Surgeons, the American College of Gastroenterology and other interested groups. Your doctor may offer you other options for screening and surveillance based on your state of health and risk factors.

NOW, ABOUT THAT COLONOSCOPY…

A colonoscopy is an examination of the entire colon and rectum using a lighted flexible instrument. This test requires clearing the bowels with laxatives on the day before the test.

Colonoscopy has the advantage of viewing the complete lining of the colon and is very accurate in detecting polyps. Polyps can be removed without discomfort at the time of the examination. Colonoscopy can be performed either by a gastroenterologist, or by a colon and rectal surgeon, (those trained in the diagnosis, as well as medical and surgical treatment, of disorders of the colon, rectum and anus).

IN SUMMARY…

Know your risks, talk to your doctor, and follow the recommended timelines for screening.

IT COULD SAVE YOUR LIFE!

Risk group Start at age Interval

Average 50 Every 10 years

Moderate 40 Every 3 to 5 years

High 21 Every year

What is constipation?

Constipation may mean hard, dry bowel movements, difficulty eliminating bowel movements, and/or infrequent bowel movements, sometimes preceded by cramping or bloating

What causes constipation?

Many factors can contribute to constipation. Painful conditions of the anus can discourage regular bowel movements, which can result in a large, hard and painful bowel. Inadequate amounts of liquid or fiber in the diet can be partly responsible. Some medications may be constipating. Poor habits, such as waiting to long to respond to the urge to move one’s bowels, can be a factor. In other cases, poor muscle function of the intestine, resulting in slow movement of intestinal contents, is a factor. Abnormal function of the anal muscles may also contribute to these conditions. Anatomic changes in the intestine such as tumors, cancers and other problems can account for a change in the bowel habits. And in many cases, no definite cause can be found.

Is constipation unhealthy?

While most people have bowel movements somewhere between three times daily and every three days, some may go a week or two between bowel movements without harmful effects. However, if pain, cramping, or other discomfort develops, evaluation is needed.

How can the cause or causes of constipation be determined?

Since constipation may have one or more causes, it is important to identify the reason(s) for the constipation in order to correct the problem as simply, and specifically, as possible. Several tests of intestinal and anal function are available to help determine the cause or causes in each individual case. Examination of the anorectal area is usually the first step. Examination of the intestine, either with a flexible lighted instrument or with barium x-ray study, may also be important. A “marker study,” during which small markers, given by mouth, are followed for several days with repeated x-rays, can give clues to disorders of muscle function of the intestine itself. Testing of the function of the anus and rectum during the act of elimination can be helpful in determining malfunction of the anorectal muscles, or internal disorders of the rectum such as rectocele ( a pocket forming just above the anal muscle) or rectal prolapse (a portion of the rectal wall sliding down to, or beyond the anus). Such tests may include “video-defecography” (an x-ray of the function of the anorectum) or “anorectal manometry” (which tests nerves and muscles of the anorectum).

What can be done about constipation?

If there is an anatomic cause for the problem, such as a polyp or a narrow area, treatment should generally be directed to correction of the abnormality. If no anatomic cause can be found, constipation is considered to be a disorder of the function of the intestine. If specific functional causes are found, they can often be treated with drugs or other measures. If no definite cause is identified, constipation is said to be nonspecific, and treatment is begun with fiber therapy. Dietary fiber, or “bran,” consists of nondigestible plant products which should be part of a healthy diet. The amount of dietary fiber can be readily increased by use of a fiber supplement such as Metamucil. Though often referred to as “bulk laxatives,” fiber supplements are not laxatives at all, and are neither harmful nor habit forming. Fiber has many beneficial effects in addition to the relief of constipation; it may help lower cholesterol, diminish the chance of polyps or cancer of the colon, and diminish the frequency and severity of symptoms in individuals with divertiular disease, irritable bowel syndrome, or hemorrhoids. In the absence of a specific anatomic abnormality, virtually all constipation can be effectively treated by increasing consumption of dietary fiber and fluid, and use of a fiber supplement. Fiber therapy may, however, take several weeks, or sometimes even months, to become maximally effective. It may cause mild bloating or abdominal discomfort until the intestine becomes used to the increased bulk, after which symptoms rapidly improve. It is important to take the same dose of fiber supplements and fluids at the same time everyday, in order to retrain the colon and small intestine. It takes about a month of regular use to evaluate the effectiveness of a given dose of fiber. If, after a month normal bowel movements have not been restored, a telephone conference with the doctor or medical assistant will be helpful; adjustments often need to be made.

Are laxatives harmful or habit forming?

There are several types of true laxatives including osmotic laxatives (Milk of Magnesia), lubricants (mineral oil), and stimulant laxatives (cascara or Ducolax). Prolonged, regular daily use of stimulant laxatives (usually over the course of several years) may be damaging to the muscles of the intestine itself. Other types of laxatives are generally safe and not habit forming. Short term use, as directed, should not cause any significant problem.

How long will it take to fix the constipation problem?

While many people considerably improved after a month, for others, the process may take up to six months or more. There is usually no way to predict in advance how quickly a particular individual will respond to such a program.

How long will I have to take fiber?

Fiber supplements can be taken on a daily basis with no ill effects at all. In fact, the “typical American diet” would be made substantially healthier with the addition of more dietary fiber. Ultimately, the goal should be consumption of adequate fiber in your daily diet to prevent constipation; the fiber supplements are just an easy and effective way to do this.

What is diverticulosis?

“Diverticulosis” is a term that refers to having “pockets” in the colon, and it is a common condition in North America. These pockets form in the colon as patients get older. More than 50% of Americans have this condition by age 65, and almost all Americans have it by age 80. These pockets, or diverticula, cannot turn into cancer and do not cause problems in the majority of patients who have them.

What are the symptoms of diverticulosis?

In most patients, diverticulosis causes no symptoms. The major cause of diverticulosis is increased pressure in the colon, which results when there is not enough fiber in the diet. This can cause the colon muscle to cramp or spasm, which pushes out the pockets. These muscle spasms may cause cramping pain in the left lower abdomen in some patients.

In a small percentage of patients, complications of diverticulosis can occur. Complications of diverticulosis include diverticulitis and gastrointestinal bleeding. For these patients, hospitalization and/or surgery may be necessary.

What is diverticulitis?

“Diverticulitis” is a potential complication of diverticulosis, and refers to inflammation or infection of one of the “pockets.” This occurs when a small hole develops in a pocket, releasing a small amount of infection into the surrounding tissues. The cause of this is not known. Patients with diverticulitis usually feel ill, along with serious abdominal pain and fever. Mild cases can usually be treated with bowel rest and antibiotics. Severe cases can cause abscesses to develop in the abdomen, which often need to be drained. Very sick patients may even require urgent surgery.

Complications of diverticulitis can include complete colon perforations, fistulas (tunnels to the bladder or vagina), and narrowing or blockage of the intestine. Surgery is almost always required in these serious cases.

Bleeding typically does not occur with diverticulitis, but can occur from one of the noninflamed pockets (diverticulosis). Most bleeding from diverticulosis stops on its own, but blood transfusions and surgery are sometimes required.

Diverticulosis/Diverticulitis Continued…

If I have been diagnosed with diverticulosis, do I need a specific diet?

In the past, patients with colon pockets were placed on a special diet in the mistaken belief that this would help prevent complications of the pockets. We now know that it is okay to eat seeds, nuts, tomatoes, strawberries, popcorn, etc.., and that this will not increase the likelihood of developing complications of diverticulosis. This is true even in patients who have had a previous episode of diverticulitis or bleeding.

Colon pockets are caused by increased pressure in the colon due to low dietary fiber. A diet high in fiber will help reduce this pressure, which means pockets will be less likely to form and complications will be less likely to occur. Dietary fiber is found in unprocessed grains such as bran, and is not found in sufficient quantities in vegetables such as peas and carrots. Therefore, your doctor will likely recommend starting a fiber supplement such as Metamucil, Citrucel, or Fibercon (calcium polycarbophil).

Is there anything I can do to help prevent future problems with my diverticulosis?

Once pockets have developed in the colon there is no guaranteed way to prevent future complications. However, increasing dietary fiber and taking a fiber supplement is the best way to help reduce the likelihood of future problems. In those patients who are having repeated cases of diverticulitis or bleeding, surgery to remove the affected part of the colon is usually recommended.

Soluble Fiber:

Absorbs water and bulks the stool to allow less straining with elimination of stool. Promotes intestinal health by increasing bowel motility and transit with less contraction and spasm of the colon. There is research suggesting that increased dietary soluble fiber can decrease the incidence of colon cancer, lower cholesterol, improve diabetes, and aid weight control.

Sources: Psyllium, Oatmeal and oat bran, legumes (beans, peas, lentils), fruits and vegetables (prunes) Other uses: treatment of constipation, hemorrhoids, diverticulosis, irritable bowel syndrome.

Insoluble Fiber:

Minimal water absorption and less effective as a stool bulking agent. Although less effective than soluble fiber , it remains an important part of the diet for improving transit time necessary to move stool through the colon.

Sources: Whole grains (wheat bran, whole grain breads), fruits and vegetables with edible skins and seeds (apples, pears, strawberries, tomatoes)

DAILY RECOMMENDED FIBER ALLOWANCE

The National Cancer Institute recommends 25-35 grams per day, the equivalent of 9-13 apples per day or 12 bowls of raisin bran or 12-16 slices of whole wheat bread. Most Americans eat only 10-15 grams of fiber per day. Therefore, fiber supplementation is an excellent way to add additional fiber to the diet, especially with psyllium.

PSYLLIUM:

Natural grain with a husk that is a rich source of natural soluble fiber.

Take daily, 1-3 times per day per container instructions.

Possible side effects: bloating, flatulence (gas), abdominal cramping that will generally resolve with daily use over 1-2 weeks as the body adjusts to the increased fiber.

Foods That May Affect Bowel Function

Foods Effects

Beans May increase output

Beer May increase output

Caffeinated beverages May increase output

Chocolate May increase output

Leafy green vegetables May increase output

Nutmeg May increase output

Raw fruits and vegetables May increase output

Sorbitol May increase output

Spicy Foods May increase output

Foods Effects

Apples May thicken stool

Applesauce May thicken stool

Bananas May thicken stool

Beef May thicken stool

Boiled rice May thicken stool

Cheese (creamy) May thicken stool

Dried beans May thicken stool

Figs May thicken stool

Pasta May thicken stool

Peanut butter May thicken stool

Pork May thicken stool

Potatoes May thicken stool

Tapioca May thicken stool

Wheat May thicken stool

Foods Effects

Beer May cause gas

Bran May cause gas

Carbonated beverages May cause gas

Dried beans and peas May cause gas

Figs May cause gas

Milk and milk products May cause gas

Onions May cause gas

Rye May cause gas

Vegetables in the cabbage family May cause gas

(e.g. cabbage, brussel sprouts, broccoli)

Foods Effects

Asparagus May cause odor

Eggs May cause odor

Fish May cause odor

Garlic May cause odor

Onions May cause odor

Foods Effects

Buttermilk May reduce odor

Parsley May reduce odor

Yogurt May reduce odor

What are Hemorrhoids?

Hemorrhoids are enlarged veins in the anal area covered with the lining of the rectum or skin. They are similar to varicose veins in the leg. They may be located inside the anus (internal hemorrhoids) or outside the anus (External hemorrhoids). It is fairly common for people to have both internal and external hemorrhoids at the same time. There are usually three internal and three external hemorrhoids.

Why do people get hemorrhoids?

There is no easy answer to this question. While everyone has veins in this area, not everyone develops hemorrhoid problems. The enlargement of the veins may be due to constipation, prostate trouble in men, or chronic cough - all of which cause straining and increased pressure in the abdomen. They may be related in part to a diet without bulk fiber and roughage (such as bran, fresh fruit, and fresh vegetables). There may be a hereditary factor in some cases, or there may be no specific explanation at all. Some people develop hemorrhoids for as yet undiscovered reasons.

Are hemorrhoids caused by heavy lifting, prolonged sitting, or other work-related activities?

While these activities can sometimes make hemorrhoids more bothersome or noticeable, these activities do not cause hemorrhoids.

How do hemorrhoids bother people?

Hemorrhoids can be troublesome in several ways. Internal hemorrhoids may cause bleeding, and/or may fall out of the anal canal, requiring a person to push them back up inside after bowel movements. External hemorrhoids may become swollen and painful. While these are not usually serious or life-threatening problems, some require careful evaluation. Bleeding, in particular, can be caused by a hemorrhoid or from another problem, higher up, such as inflammation of the bowel, a polyp, or cancer.

Should hemorrhoids always be treated?

Not necessarily. If symptoms are mild or infrequent, often no treatment is required. For more severe symptoms, the goals are relief of pain, and the restoration of normal function. Bleeding, whether painful or not, should always be evaluated and usually should be treated. A change in bowel habits should likewise be evaluated, because of the possibility of bowel disease or cancer.

What types of treatment are used?

This depends on the severity and location of the hemorrhoids. For mild or intermittent symptoms, sitz baths (soaking the affected area in warm water, with no additives, for 20 minutes, 2-4 times daily) and a special cream are usually all that is necessary. For external hemorrhoids, which develop painful clots (called “thrombosis”); removal of the external hemorrhoid in the office, using a Novocain-type anesthetic usually brings dramatic relief. Removal of the external hemorrhoid prevents the problem from recurring in the same place.

For people with internal hemorrhoids only, tiny rubber bands can be placed around the base of the hemorrhoids, causing them to shrink and fall off. This procedure is done in the office, and usually causes minimal discomfort. For those persons with larger, more severe hemorrhoids (usually external and internal hemorrhoids together), surgical removal of the hemorrhoids may be the simplest permanent solution. This is an outpatient procedure and does not require an overnight stay in the hospital.

What about other types of treatment for hemorrhoids?

Other therapies for hemorrhoids gain popularity for time to time, such as cautery (burning), cryotherapy (freezing), laser therapy and stretching the anus. These techniques have not had nearly the permanent long-term relief of hemorrhoids which rubber-banding or surgery offer, are often actually more painful, and are more complicated than necessary for simple hemorrhoid problems.

Will hemorrhoids come back after treatment?

For the external hemorrhoid removal and rubber band methods, recurrences occasionally happen, usually after several years, but can often be treated again with similar conservative techniques. After surgical removal of hemorrhoids, it is rare for hemorrhoids to ever come back.

Hernia Repair

A hernia is a protrusion of a loop of bowel or a tissue through an opening in the wall of the abdominal cavity in which the bowel lies. Hernias are one of the most common conditions requiring surgery. Hernias can occur in men and women of all ages, and children. Hernias can develop around the navel, in the groin, or any place where you may have had a surgical incision. Some hernias are present at birth, while others develop slowly over a period of months or years, or they may come on suddenly.

Pathology:

• Hernias commonly develop in an area of weakness. These areas include natural spaces and thing tissue, such as the internal inguinal ring and the floor of the inguinal canal. Hernias may develop at these sites or other areas due to aging, injury, an old incision, or a weakness present at birth.

• Another important factor in the development of hernias is an increase in the intraabdominal pressure. This could be secondary to chronic constipation and prolonged straining, chronic persistent coughing, or lifting heavy objects.

• Types of hernia:

  • Inguinal hernias are in the groin area. They are most common in men, primarily because of the unsupported space left in the groin after the testicles descend into the scrotum. Inguinal hernias can be indirect, where the hernia sac exits through the internal inguinal ring and takes an oblique path; or direct, where the hernia sac exits through the external inguinal ring directly.

  • Femoral hernia occurs at the top of the thigh in the space through which the femoral artery, vein and nerve pass into the thigh. These hernias occur most often in women and commonly result from pregnancy and childbirth.

  • Umbilical hernias occur in the umbilicus (belly button) and occur most often in infants.

  • Incisional hernias occur at the site of previous abdominal surgery.

Indications for Surgery:

• There are two reasons for hernia repair:

  • Correction or prevention of a dangerous strangulated hernia.

  • Elimination of pain that may be interfering with normal activity.

• In general, all hernias should be repaired unless there are other conditions in the patient that preclude a safe outcome.

• Trusses and surgical belts are helpful in the management of small hernias when surgery is contraindicated.

Surgical Repair:

• A hernia repair is usually done on an outpatient basis. Typically, the procedure takes less than an hour to complete. Most patients are fully ambulatory and able to go home after about 2-4 hours.

• Inguinal hernia

  • An inguinal hernia is repaired by first making an incision just above the crease where the abdomen meets the thigh.

  • The inguinal canal is opened; the hernia sac is separated from the spermatic cord, lifted and opened. Intestine or other tissue is then placed back into the abdominal cavity. The excess sac is tied off and removed. The opening at the internal ring may be tightened and the abdominal wall reinforced using sutures to bring together the neighboring tissues without tension.

  • A synthetic mesh and/or plug may be used to repair the hernia. The tapered shape of the plug eases insertion into the defect and fills the ‘hole’ much like a cork in a bottle. A second piece of flat mesh may be placed over the plug to prevent future hernias at the same site.

  • The wound is closed with sutures.

  • Another method for hernia repair is through the laparoscope. The laparoscope is introduced through a small incision at the navel. Two or three small incisions are made and the hernia is repaired from the inside of the abdominal cavity.

  • A flat mesh is placed over the internal inguinal ring to prevent tissues or organs from protruding through the opening.

  • Postoperatively, the patient may experience local wound pain, scrotal swelling, retention of urine, or bruising. These are temporary problems and will resolve eventually.

• Femoral hernia

  • The skin incision for a femoral hernia is similar to that of an inguinal hernia. The hernia sac is lifted and opened. Intestine or other tissue is then placed back into the abdominal cavity. The excess sac is tied off and removed.

  • The femoral canal (a space near the femoral vein that carries blood from the leg) is closed with sutures or reinforced with synthetic mesh. The skin incision may be sutured or stapled.

• Incisional hernia

  • The incision from the earlier surgery is reopened at the site of the hernia. The hernia sac is carefully dissected and opened. The intestine or other tissue is placed back into the abdominal cavity.

  • The defect is repaired or reinforced either with synthetic mesh or by pulling together and stapling the abdominal muscle tissue. The skin incision may be sutured or stapled.

• Umbilical hernia

  • A semicircular incision is made near the navel. After the navel is raised, the intestine or tissue in the hernia is placed back into the abdominal cavity. The umbilical weakness is tightened with sutures or reinforced with synthetic mesh and the navel is returned to its normal position.

  • The skin incision is closed with sutures or staples.

Complications:

• Chronic pain may result from surgical handling of the sensory nerve in the groin area during surgery, or after surgery from constricting scar tissue.

• Infection

• Hemorrhage

• Ischemic orchitis due to thrombosis of the spermatic cord and venous congestion produces pain and swelling

• Recurrence of the hernia due to excessive tension during repair, inadequate tissue, inadequate repair, and overlooked hernias. Recurrence rates are 1-4 %.

Post-operative and After Care:

• Following surgery you may be given medication to relieve pain in the area of your incision. It is normal to see some swelling and discoloration around your incision. This will disappear with time.

• After surgery, if you must lift something, lift only light objects that you can manage easily. Keep your back straight, and allow your legs to do most of the work.

• Driving may strain your incision. Ask your physician when you can drive. Do not drive while taking your pain medication.

• To avoid constipation that could cause you to strain against your incision, eat a high fiber diet and drink lots of fluids. If necessary ask your doctor about using a stool softener.

• Your doctor will be able to let you know when it is okay to work again. If you have a desk job, you may be able to return to work in a week or two. If your job requires more physical activity, you may have to wait longer.

• Your doctor may schedule a follow-up visit in about a week. During the visit, your doctor will remove stitches or staples if necessary, and check the progress of your healing.

What is Levator Syndrome?

Levator Syndrome is a condition caused by spasms of the levator muscles, which are large muscles in the lower pelvis which surround the rectum, urethra and vagina. These muscles help form the pelvic floor and support and encircle the lower pelvic organs. Levator Syndrome includes other named conditions such as proctalgia fugax, anismus, non-relaxing puborectalis, and chronic pelvic pain syndrome.

What are the symptoms of Levator Syndrome?

Patients usually experience either dull, aching pain, particularly after prolonged sitting, or sudden sharp pains. Others have the sensation of having a ball or object stuck in their rectum. Patients may have dull, mild constant pain or brief, sharp pains lasting only a few seconds (proctalgia fugax). These pains can occur suddenly and awaken one from sleep. For unknown reasons, the pain is often felt more on the left side of the body. In some patients the abnormal sensations may involve the genital organs as well. In some cases, patients may have little pain but have significant problems in passing stool because their outlet muscles don’t relax during defecation.

Why do people get Levator Syndrome?

The causes of Levator Syndrome are not well understood. Tension and stress are often important underlying factors. Sleep deprivation and night shift work may also contribute. Poor posture and lack of exercise are also contributors in some cases. In most patients, the exact cause is unknown.

How is Levator Syndrome diagnosed?

Levator syndrome is often a diagnosis of exclusion, meaning that other causes of pelvic pain are ruled out first. The symptoms described above are usually highly predictive of this condition and, most importantly, the muscle is tender and tense when examined by a doctor. The tenderness on examination is usually in the tailbone area and/or on either side of the rectum. Palpation of these muscles often reproduces the patients’ pain. In Levator Syndrome, unlike other painful anorectal conditions, bowel movements often make the pain better.

What can be done to treat this condition?

The first step in treatment of levator syndrome is making a correct diagnosis. This involves a thorough history and physical exam and ruling out other painful anorectal conditions. Establishing a correct diagnosis of levator syndrome is very important as it provides the patient an explanation for their symptoms, and helps to break the vicious cycle of worry, stress, muscle spasm, and increasing pain. Levator syndrome is benign and ultimately cannot harm a patient. It is bothersome and painful but not dangerous.

What treatments are available?

Any treatment which relieves stress and muscle spasm can be effective. Stretching, exercise, stress relief, hot baths, and normalization of sleep routine all tend to be helpful. In persistent cases, referral to outpatient physical therapy is usually recommended. Other potentially helpful treatments include biofeedback and acupuncture. If no relief is obtained from the treatments mentioned above, another alternative is to massage the muscle very vigorously in the operating room, using a brief anesthetic. This is sometimes combined with injection of botulinum toxin, which is sometimes effective in paralyzing the levator muscle for up to six months, allowing relief of pain. Patients leave the hospital an hour or two after completing this treatment, and do not need to stay overnight in the hospital. This treatment is necessary only in the most difficult cases, and is often successful in eliminating the aching. Medications are rarely helpful. The so-called “muscle relaxants” do not, in fact, relax the muscles, but only give temporary relief from anxiety; they are not useful in achieving a long-term solution to this problem. Opiate pain medicines are usually harmful and detrimental in this condition as they produce constipation, drug tolerance, and potential addiction issues while not treating the underlying causes of the muscle spasm and discomfort.

Once my symptoms improve, will they come back?

As Levator Syndrome is often a manifestation of increased life stress, (similar to conditions such as migraine headaches) there is a tendency for this condition to re-occur at various times throughout life. However, once a patient has the correct diagnosis of Levator Syndrome, and knows strategies to deal with the problem, symptoms will often improve and decrease with age.

InterStim™ II and InterStim™ Micro Allow Patients to Choose a Lifestyle-Friendly Sacral Neuromodulation Therapy for Overactive Bladder and Bowel Incontinence

What is sacral neuromodulation?

Sacral neuromodulation (SNM) is a proven treatment option for managing the symptoms of overactive bladder (OAB), non-obstructive urinary retention or fecal incontinence (FI) for people who have not found success with more conservative treatments.

SNM stimulates the sacral nerves, which control the bladder and bowel and muscles related to urinary and bowel function. If the brain and sacral nerves do not communicate correctly, the nerves will not tell the bladder or bowel to function properly, which can cause bladder or bowel control problems. SNM targets this communication problem by stimulating the nerves with mild electrical pulses.

How common are overactive bladder and fecal incontinence in the United States?

OAB affects approximately 37 million adults – almost one in six – and FI affects 18 million – about one in 12 – in the U.S.i,ii,iii,iv Many sufferers limit their lives socially, professionally, and personally.v However, as many as 45% who suffer from symptoms do not seek treatment and as many as seven in 10 stop using medications within six months due to intolerable side effects or unsatisfying results.vi,vii,viii

What is InterStim™ II?

The recharge-free InterStim™ II system gives patients freedom from a recharging routine, the hassle of recharging components, and a reminder they have a disease. InterStim™ II is simple, convenient, low maintenance. InterStim II now allows full-body 1.5 and 3 Tesla MRI conditional scans with SureScanTM MRI technology.

What is InterStim™ Micro?

The U.S. Food and Drug Administration recently approved the InterStim™ Micro neurostimulator, the market’s smallest and fastest rechargeable device to deliver sacral neuromodulation (SNM) therapy. It offers a smaller size compared to InterStim II and a longer battery life. InterStim Micro also allows fullbody 1.5 and 3 Tesla MRI conditional scans with SureScanTM MRI technology.

What are the benefits of the new InterStim™ systems for patients with OAB or FI?

Medtronic is the only company to offer patients the freedom to choose between a rechargeable or recharge-free sacral neuromodulation device to best match their preferences, lifestyle and treatment goals. Both InterStim™ Micro and InterStim™ II are full body MRI conditional, and deliver the same therapy and long-term relief.

The recharge-free InterStim II system is simple and convenient with lower maintenance and time commitments. This specific system gives patients the freedom from a recharging routine, the hassle of recharging components, and a reminder they have a disease.

The InterStim Micro rechargeable system is the smallest device on the market with the fastest rechargeability and is stronger than other manufacturers’ batteries. It features proprietary Overdrive™ battery technology — a battery with virtually no loss in capacity over time.ix The new battery technology allows patients to choose how and when they want to charge their device — from as often as once a week, or as infrequent as once per month, depending on the patient’s preference and device settings. There is no battery fade at 15 years* and patients can restart their therapy after extended breaks in time.

How does InterStim ™ Micro compare in size to other neurostimulators?

The InterStim™ Micro neurostimulator is about half the size of the other rechargeable device on the market.

The most common adverse events include pain at implant sites, new pain, lead migration, infection, technical or device problems, adverse change in bowel or voiding function, and undesirable stimulation or sensations. Any of these may require additional surgery or cause return of symptoms. See full safety information.

Visit Medtronic.com to learn more.

*Under standard patient therapy settings.

i Stewart WF, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003 May;20(6):327-336.

ii United Nations, Department of Economic and Social Affairs, Population Division (2011). World Population Prospects: The 2010 Revision, CD-ROM Edition.

iii Whitehead WE, Borrud L, Goode PS, et al. Pelvic floor disorders network. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology. 2009;137: 512-517.

iv United States Quick Facts. United States Census Bureau Web site. Available at: https://www.census.gov/quickfacts/table/ PST045215/00. Accessed July 19, 2016.

v Dmochowski RR, Newman DK. Impact of overactive bladder on women in the United States: results of a national survey. Current Medical Research and Opinion. 2007;23:65-76.

vi Leede Research, "Views on OAB: A Study for the National Association of Continence." December 16, 2015.

vii Yu YF, Nichol MB, Yu AP, et al. Persistence and adherence of medications for chronic overactive bladder/urinary incontinence in the California Medicaid Program. Value in Health. 2005;8(4)495-505.

viii Yeaw J, Benner JS, Walt JG, Sian S, Smith DB, et al. J Manag Care Pharm. 2009;15(9):728-740.

ix Medtronic data on file. UC202105394 EN

What is a “pilonidal cyst?”

A “pilonidal cyst” is a lump under the skin, located in the crease between the buttocks. It may cause an infection or “abscess” under the skin, near or above the tailbone, and may cause pain and swelling in the area. Sometimes, like a large pimple, the infection either bursts through the skin by itself, or may need to be lanced or drained to let the infected fluid out. A pilonidal cyst may become infected only once, or may come back in the same place repeatedly.

What causes pilonidal cysts?

Some people are born with a small abnormal area under the skin, which later can develop into a pilonidal cyst. In other cases, the cyst may develop from ingrown hairs between the buttocks. In most people, there is no definite way to tell whether the cyst has been present from birth or has developed from ingrown hairs.

What can be done about pilonidal cysts?

If an “abscess” is present, containing infected material or pus, it is important to release the fluid by making a small opening in the cyst. This is done after first making the area numb using Novocain-type local anesthesia. Once fluid is released, the pain rapidly disappears. Antibiotics are usually unnecessary after the fluid is drained.

In many cases, this small procedure completely alleviates symptoms and the problem does not recur. If the cyst becomes infected repeatedly, and does not go away on its own, surgery may be recommended to remove the cyst itself. Such surgery must be done in an operating room, but can usually be done as “outpatient surgery,” allowing the patient to return home an hour or two after the procedure is completed. There is usually little postoperative pain, and most people can return to work within the next couple of days.

What are the results of treatment?

Most people are free of further problems with pilonidal cysts after these procedures. However, in some cases, the cyst can recur. The reasons for this are not known. It is possible for a new cyst to form from an ingrown hair, or it is possible to have another congenital cyst flare up at a later time. When this happens, surgery can again be done, with the specifications of the procedure being dictated by the nature of the recurrence.

What is a pruritus ani?

Itching around the anal area, called pruritus ani, is a common condition. This condition results in an irresistible urge to scratch one’s bottom. This is usually most noticeable and bothersome at night, or after bowel movements.

What causes this to happen?

Several factors can be at fault. Moisture around the anus from excessive sweating, or from moist, sticky stools is one factor. In some people, a high intake of liquids can cause a loose, irritating stool. Other possible causes or contributing factors include pinworms, psoriasis, eczema, dermatitis, hemorrhoids, anal fissures and anal infections.

Does this come from not keeping my anal area clean enough?

This is almost never a factor. However, the natural tendency is to wash the area vigorously and frequently with soap and a washcloth. These activities almost always make the problem worse, not better, by damaging the skin and washing away protective oils.

How can a doctor determine what is causing the itching in my case?

A careful examination may show a definite cause for the itching, in which case a treatment can be directed specifically to eliminate the problem.

What can be done to make this itching go away?

There are 4 parts to a good treatment plan.

1. AVOID FURTHER TRAUMA.

   1. Do not use soap of any kind on the anal area.

   2. Do not scrub the anal area with anything (even toilet paper), and avoid rubbing.

   3. For hygiene, use wet toilet paper and blot the area clean, do not rub.

   4. Try not to scratch the itchy area. This can lead to more damage, which may make the itching worse.

2. USE 2.5 % HYDROCORTISONE CREAM as prescribed. Apply this cream sparingly to skin around the anal area three times daily using the finger tip.

3. AVOID MOISTURE in the anal area.

   1. Use either a few wisps of cotton, or some corn starch to keep the area dry.

   2. Avoid all medicated, perfumed, and deodorant powders.

4. AVOID EXCESSIVE FLUID IN THE DIET. A maximum of six glasses of fluid daily is reasonable. There normally is no health benefit to drinking more fluid than this in the course of a day.

How long does this treatment usually take?

Most people experience improvement within a week, when they follow the instructions outlined above. Although these symptoms almost always disappear within 3-4 weeks, some patients may need treatment for a longer period of time. You may find that you need to repeat these steps from time to time for recurrent symptoms.

What is a “rectal prolapse?”

Rectal prolapse is a condition in which the rectum loses its internal support and protrudes or falls out of the anus. In the earliest phase, the rectal prolapse may be internal. As the condition progresses, the rectum can also be seen or felt outside of the body. When this occurs, it is called a complete rectal prolapse. Weakness of the anal sphincter muscle often is an associated problem at this stage, and may result in leakage of stool or mucus at unwanted times. This condition occurs in both sexes, but is more common in women.

Why does it occur?

Rectal prolapse seems to be part of the aging process. It is due in part to weakening of supporting structures within the pelvis, as well as loss of anal sphincter muscle tone. Several things may contribute to the development of rectal prolapse. A lifelong habit of straining to have bowel movements may contribute. It also may occur as a late result of the stresses involved in childbirth. There may be a hereditary factor in some families. In most cases, however, there is no single cause which can be identified; it just happens.

Is rectal prolapse the same as hemorrhoids?

No. Rectal prolapse involves a part of the rectum which is higher than the level of hemorrhoids. Some of the symptoms, however, may be the same. There may be bleeding and/or tissue which protrude from the rectum in both conditions. Rectal prolapse is not typically associated with pain.

How is rectal prolapse diagnosed?

Diagnosis is usually made after taking a careful history and performing a complete anorectal examination. The prolapse can be identified by asking the patient to strain, as if they are having a bowel movement, or by having the patient sit on the commode and strain prior to examination. At times the prolapse may be hidden or internal. An x-ray examination called a videodefecogram may be helpful for diagnosis in this case. This examination takes pictures during a simulated bowel movement and may help to determine the appropriate type of surgery. Anorectal manometry also may be helpful. This test measures muscle function, and can diagnose nerve disorders which may affect the sphincter muscles.

How is rectal prolapse treated?

Although constipation and straining may be possible causes of rectal prolapse, correction of these conditions may not improve the actual prolapse. There are several surgical methods used to correct rectal prolapse. Your doctor can help you decide which method likely will give the best result, given your individual situation.

The simplest method involves implanting a band of elastic material under the skin around the outside of the anal muscle. This is called the Thiersch procedure. This keeps the anus from stretching to allow the rectum to fall out. This procedure does require the use of an operating room and an anesthetic, but usually can be done without requiring an overnight stay in the hospital. Unfortunately, in nearly half of the cases, the elastic material is rejected by the body, necessitating its removal. Despite this, there may be enough scar tissue formed to improve control of the anus and to delay the return of the prolapse for months or years after removal of the elastic material.

Another approach involves operating through the anus and removing the extra tissue from the rectum. This approach is used to perform a Delorme’s procedure, or an Altemeier procedure. These operations usually require a brief hospital stay, but are typically followed by a swift recovery. There is relatively minor pain during recovery after these procedures, due to a lack of surgical incisions in the skin. Rectal prolapse may recur in 1 out of 10 patients after a variable period of time, but the correction is permanent in 9 out of 10.

The most complicated approach involves operating through the abdomen and correcting the rectal prolapse from inside. This approach often involves removing a segment of the colon or rectum which is too long, as well as re-supporting the rectum from inside. This procedure involves a few days stay in the hospital after surgery, but it is the most permanent and effective operation for advanced cases.

How successful is this treatment?

Success depends on a number of factors, including the status of the anal sphincter muscles before surgery, whether the prolapse is internal or external, the overall condition of the patient and the surgical method used. If the anal muscle has been weakened due to the prolapse, this will often, but not always, improve after correction of the rectal prolapse. In situations where the anal sphincter muscle remains weak and incontinence or seepage is continued, the Thiersch procedure is sometimes helpful after full recovery from the original procedure. The great majority of patients is completely and permanently relieved of symptoms, or is significantly improved by the appropriate procedure.

What is a rectocele?

A rectocele is forward bulging or displacement of the rectum into the vagina. This creates a pouch in which stool can accumulate and become “trapped,” often making it difficult to initiate or complete a bowel movement. Patients with this condition often describe having to push or “splint” inside or near their vagina in order to complete a bowel movement.

What causes a rectocele?

A rectocele is caused by a weakening of the tissue between the rectum and vagina. This allows the wall of the rectum to push forward against the back wall of the vagina. Weakening of this rectovaginal wall occurs due to a combination of aging and pelvic floor stretching from childbirth. Rectoceles may be seen in younger women after difficult or multiple deliveries.

Do all rectoceles need to be repaired?

Many women will have small or even larger rectoceles that do not cause any symptoms. As long as bowel movements are occurring normally, a rectocele does not have to be repaired. In women who are having difficulty with bowel movements, correction of diarrhea or constipation with bulk fiber laxatives often helps considerably.

In those women who continue to have difficulty, surgical repair of the rectocele is often beneficial. Rectocele surgery involves strengthening the weakened wall between the rectum and vagina. Depending on a variety of factors, your surgeon may recommend a repair of the rectocele through the rectum, or through the vagina. Both of these repairs are done as an outpatient procedure, which means no overnight hospital stay is required.

Many women with rectoceles also have associated bulging of their bladders (cystocele) or small intestines (enterocele) into their vagina. Before surgery is planned, a test called videodefecography is usually performed to determine if these other conditions need to be repaired as well. In this test, a barium paste is placed in the rectum and video x-rays are taken of the rectum at rest, and during passage of the barium paste. Often, an oral contrast dye is also given during the test in order to detect associated prolapse of the small intestine.

Sitz Bath

Why:

Sitz baths (soaks) are highly recommended because the warm water helps soothe and relax the anal sphincter and pelvic muscles.

The warm water greatly reduces the spasm, thus reducing your post-operative pain.

This will also help alleviate pressure, itching, and will keep the area clean.

It is a very important part of your pain management regimen.

Please complete as recommended.

How:

Bath Tub

If you’re taking a sitz bath in the bathtub, make sure that the bath tub is clean.

• Fill the tub with so the water comes up to your waist (WATER ONLY). The water should be as warm as tolerated, not too hot.

• Sit inside the tub and soak your perineum for 15 to 20 minutes.

• After getting out of the bathtub, dry the area with a hair dryer on cool setting, or pat dry the area. Don’t rub or scrub the perineum, as this may cause pain and irritation.

• Replace the dressing as needed.

Plastic Kit

A plastic sitz bath kit is a basin that fits over the toilet. They can be purchased at Walgreens.

Rinse the bath kit with clean water before using it

• Add warm (but not hot) water. WATER ONLY, nothing added.

• Place the sitz bath into the open toilet. Test it by trying to move it side-to-side to ensure it will stay in place and will not shift. You can pour warm water in before you sit down, or you can use the plastic bag and tubing to fill the tub with water after you have sat down. The water should be deep enough so that it covers your perineum. Soak for 15 to 20 minutes.

• If you used the plastic bag, you can add warm water as the original water cools. Most sitz baths have a vent that prevents water from overflowing. The water conveniently overflows into the toilet and can be flushed.

• When you are finished, stand up and dry the area with a hairdryer on the cool setting, or pat the area dry with a clean cotton towel. Avoid rubbing or scrubbing.

• Give the basin a proper cleaning after every use. Repeat 3 times a day at minimum. It’s suggested that you do a soak before and after a bowel movement.

IMPORTANT ADVICE:

• Make sure you measure your toilet seat size before buying the item in order to achieve the right fit. If you have a standard oval or round shaped toilet you should be able to make it fit.

• Do NOT add anything to the water.

• Sit for 15-20 minutes each time