Introduction
The
perianal, anal and rectal region lend themselves to
early clinical diagnosis without the need to resort
to complex investigative processes.
Procedures
The
history followed by inspection, palpation, rectal
examination, proctoscopy and then sigmoidoscopy are
sufficient to clinically diagnose most conditions.
If a full local examination is not performed a delay
in diagnosis of conditions such as carcinoma of the
anal canal and rectum may occur. Inappropriate treatment
of other conditions such as pruritus ani, warts, haemorrhoids,
polyps, abscesses and fistulas may result.
Functional Unit of
Continence
The
anus, anal canal and rectum are a functional unit
responsible for the maintenance of continence of faeces
and flatus as well as the co-ordinated process of
defecation. Theories such as the valvular mechanism
of the anorectal angle have been postulated to explain
the process. Basic factors responsible for the maintenance
of continence are the:
- internal sphincter
- external sphincter
- anorectal angle (formed
by the puborectalis muscle)
This
is all controlled by a reflex interaction and integration
between the:
- sensory receptors in the
pelvis
- smooth muscle internal
sphincter supplied by the autonomic nervous system
and
- striated muscle of the
external sphincter – supplied by the somatic fibres
of the pudendal nerve. It is postulated at rest
with the faeces in the rectum that the anorectal
angle acts like a valve. As pressure increases the
valve is accentuated, maintaining continence. However
as the bulk increases further receptive relaxation
of the internal sphincter occurs. There is a sampling
of the faecal material by the sensitive epithelium
of the anal canal resulting in the desire to defecate
and the sensation of the need to pass flatus.This
is further controlled by the voluntary external
sphincter muscle
Defecation
With
straining the anorectal angle is reduced and straightened,
the internal and external sphincter muscles relax
and defecation occurs.
Pathological
Continence
may be interfered with as a result of localised or
generalised disease or following trauma or surgery.
Histological Features
The
perianal skin is stratified squamous epithelium with
keratinisation. Just above the anal verge the skin,
hair, sebaceous glands and sweat glands and there
is a transitional type of epithelium for a distance
of approximately 1 cm – to the pectinate line.
Above
the pectinate line the glands of Lieberkuhn’s and
goblet cell appear a muscularis mucosa and lamina
propria are found.
The
pectinate line (dentate line):
- is formed at the site
of the fusion of the embryonic proctodermal plate
and post-allantoic gut embryologically.
- is land mark not only
histologically but is also the site at which there
are major practical significant changes as is a
junctional zone between:
- the somatic sensory supply
to the skin, modified skin and the autonomic supply
to the mucosa above the pectinate line.
- the junction between the
haemorrhoidal arterial supply derived from the mesenteric
artery and the lower pudendal artery supply from
the iliac artery
- systematic circulation
below the dentate and portal venous system above.
- lymphatic drainage below
the dentaline is to the inguinal node above the
dentaline to the pelvic lymph nodes – there is some
overlap with this particularly in pathological states
- anal glands open at the
pectinate
History and Examination
Symptoms
indicate disease but a more detailed analysis then
indicated the diagnosis:
- bleeding
- pain
- protruding or prolapsing
lump
- discharge – starting
on the underwear or associated bowel action with
pus and mucous
- an irritation
- faecal incontinence
- unsatisfied defecation
- changes in bowel
habit and urgency with either diarrhoea or constipation
- “Haemorrhoids” –
often patients complain of “haemorrhoids”
The
diagnosis of haemorrhoids cannot be taken at face
value as patients often use this term for any anorectal
problem.
All
the above symptoms may be associated with:
- disease in the anorectal
region
- disease from higher
level in the bowel
- result of some generalised
problem
The
history and examination are directed at differentiating
these possible signs:
- the type of bleeding
is critical and needs further description, the blood
may be dark or bright, mixed with the stool, on
the paper or dripping in the bowl. The bleeding
may be associated with pain or painless.
- blood mixed with
the stool can suggest a cause of bleeding higher
up in the bowel.
- bright red blood
on the toilet paper suggests haemorrhoids.
- black stools may
indicate bleeding from higher in the stomach.
- a few drops of blood
associated with severe pain on and after defecation
could suggest a fissure.
- the presence of
pus or mucous might suggest an inflammatory condition.
- a sexual history
may be necessary to diagnose HIV or AIDS or gonococcal
disease. Infected proctitis can occur in either.
This needs to be differentiated from non-specific
proctitis.
These
inflammatory conditions can present with an abscess
or fistula, an atypical fissure, which is of an opportunistic
infection such as amoebiasis or cryptos porous.
The Examination
- A general inspection. The
general appearance of the patient may suggest a
cause of bleeding and its severity. It may be signs
of pallor with excessive bleeding due to anaemia
or jaundice for example where there are liver problems.
There even may be signs of cachexia.
- The examination of the
abdomen is carried out first to detect masses or
other features such as an enlarged liver e.g. the
liver of psoriasis may be associated with portal
hypertension and bleeding haemorrhoids.
- The left lateral position
may be used for the examination.
- The rectal examination
may be difficult in the apprehensive, sensitive,
overweight patient with severe pain. An examination
under anaesthesia is required in some circumstances:
- the anal verge is inspected.
- the anal skin has ridges
which irradiating peripherally. The anal orifice
is usually closed but a gaping sphincter may be
present.
- the surrounding area is
examined.
- there may be signs of
ulceration, irritation, excoriation, swelling or
the external opening of a sinus or fistula with
a discharge. Skin tags are often present and may
point to underlying haemorrhoids or fissures.
- scars from obstetric injuries
or trauma or previous surgery can be important in
the assessment – particularly of incontinence.
- a protruding lump may be
present. The commonest cause of this would be haemorrhoids.
Several
different types of polyps may be present – particularly
if the patient is asked to strain or they may be prolapsed
down from the rectum by the examining finger on rectal
examination.
- a pedunculated fibro epithelial
polyp
- a pedunculated tubular
adenoma
- a sessile villous tumour
- a myeloma or other connected
tissue tumour such as a lipoma
- Even a malignancy can be
protruding
- there may be skin lesions
such as rarely melanoma, but occasionally conditions
such as squamous cell carcinoma in situ.
Haemorrhoids, polyps or
a rectal prolapse may appear with straining.
Abnormal
laxity or descent of the perineum may occur in disorders
of the pelvic floor, which can be associated with
incontinence.
The
anal verge can then be gently parted to demonstrate
any protruding lesion or the presence of an anal fissure.
Parting the anal verge may be painful with an anal
fissure and the sphincter can be seen to contract
with the pain.
Rectal Examination
Rectal
examination is part of the routine examination for
any abdominal or rectal problem. The glove must be
well lubricated first. An explanation is given regarding
the examination and the patient reassured. Gentle
pressure is applied over the anus and this tends to
overcome spasm and resistance and allows the gloved
finger into the anal canal without pain. The finger
is introduced posteriorly along the anal canal and
the tone of the sphincter is assessed. The walls of
the anal canal are palpated. Four to five centimetres
into the anal canal is the upper level of the surgical
anal canal. The ridge of the anorectal ring can be
palpated. The finger then enters the rectum.
The
finger palpates the mucosa thoroughly and then two
specific structures are sought:
- Anterior
- the prostate in males. The cervix and uterus in
females
- Posteriorly
- the hollow of the sacrum and
- Laterally
- the lateral ligaments and pelvic lymph nodes
- The
tip of the finger palpates the Pouch of Douglas
looking for a mass - for example secondary deposits
or a pelvic abscess.
Palpation
of the mucosa may detect lesions such as:
- Benign polyps – pedunculated
tubular adenomas or sessile villous adenomas
- Malignant lesions such
as carcinoma of the anus or rectum – ulcerated or
nodular
- Anal papillae
- The internal opening of
a fistula
Haemorrhoids
may be palpated as a soft cushion but are not readily
palpable unless very large or thrombosed. If a painful
condition such as an abscess or fissure is present,
resistance to examination by the patient will be obvious
and should not be pursued. On withdrawal of the glove
this is inspected for the presence of blood or mucous
land the colour of the faecal material. The rectal
examination should be performed before any instrumentation.
Proctoscopy and Sigmoidoscopy
The
mucosa is visualised and this is particularly useful
in the diagnosis of haemorrhoids. The haemorrhoids
will bulge into the lumen of the proctoscope as it
is withdrawn and the patient is straining.
Procedures
such as injection of haemorrhoids or rubber band ligation
can be performed through a proctoscope.
Sigmoidoscopy
Sigmoidoscopy
can be performed in the left lateral position. It
is usually a little uncomfortable particularly when
the area is inflated but is usually readily tolerated.
The area is inflated to allow visualisation of the
mucosa or lumen or when attempting to negotiate the
rectosigmoid junction which is at the level of 15
– 18 cms.
It
may not be possible in about 50% of patients to pass
the rectosigmoid junction which is at about 15 cms
due to discomfort because of the angulation to the
site.
Sigmoidoscopy
shows mucosal changes – signs of inflammation, melanosis
coli (patchy dark pigmentation) attributable to excessive
uses of laxatives and lesions arising from the mucosa
such as polyps or malignancies. These may be biopsied
as necessary.
A
high percentage of bowel tumours occur within reach
of the sigmoidoscope. Sigmoidoscopy is one of the
most cost effective ways of detecting the presence
of any carcinoma. It should be used more frequently
especially as bowel cancer is the second most common
cancer in males and females.
Up
to 50% of polyps and carcinomas of the colon are within
reach of the sigmoidoscope.
Further
investigation of the region may include flexible sigmoidoscopy,
sigmoidoscopy and barium anaemia.
Management of Anorectal
Conditions
Some
of the conditions may be treated with conservative
or appropriate ointments or creams.
Many
of the conditions can be treated in the office – such
as haemorrhoids. Injection sclerotherapy and rubber
band ligation are effective ways of treating haemorrhoids.
Perianal haematomas may be incised or excised under
Local Anaesthetic. A small perianal abscess can be
drained. Skin tags can be removed.
Experienced
Surgeons may treat the more complex conditions in
the office. Anal fissures can be treated with sphincterotomy
under Local Anaesthetic. A variety of degrees of haemorrhoids
may be excised under Local Anaesthetic in the office
as appropriate.
Even
polyps may be pulled down and ligated.
The
same techniques can be used in hospital with the addition
of light sedation. Many cases can be treated as a
day case.
Thus after a comprehensive examination of the history
and examination which includes the abdomen, inspection
of the perianal region, palpation of the perianal
region, rectal examination, proctoscopy and sigmoidoscopy,
a plan of action can be carried out.
This may involves further investigative procedures
or surgery in hospital. However in many cases a definitive
diagnosis can be made and a treatment carried out
at that time or arranged for the near future.
Other
serious problems must not be overlooked and must be
taken into account before instituting a plan of action.
It
must be remembered when treating the anorectal region
the patients are apprehensive, may fear the presence
of a possible cancer and may find the examination
embarrassing and uncomfortable. This needs to be assessed
thoroughly before attempting any procedures. There
must be some explanation of the possibility of pain
in the post-operative period.
Of
course it is part of a risk management plan. The advantages
and disadvantages of having a procedure are discussed
and the alternative methods of treatment available
also discussed.
The
option may be to do nothing or to wait and see. A
further review may be judicious.
It
is however helpful to have literature available for
the patient to read which will explain their condition
in detail.
Rubber Band Ligation
for Haemorrhoids
This
is a simpler office or room’s treatment for haemorrhoids
as opposed to surgery, which usually takes place in
hospital. No anaesthetic is required and you are able
to go home almost immediately.
With
surgery hospitalisation and anaesthesia are required
and the post-operative course is often painful.
Banding
has many advantages over the haemorrhoid operation.
However not all haemorrhoids are suitable for rubber
band ligation.
Haemorrhoids
are formed just within the anus. They have a rich
blood supply and have been compared with protruding
varicose veins.
They
bleed or prolapse as a result of straining, which
occurs with the lack of fibre in the modern diet.
Haemorrhoids
may:
Stage 1 Bleed, particularly at the toilet – the blood
may drip or splash into the bowl or colour the toilet
paper.
Stage 2 Prolapse – usually with straining of the bowels.
They either return inside spontaneously or need to
be pushed back inside.
Stage 3 Thrombose and prolapse – this is very painful
and the haemorrhoid cannot be returned inside – not
suitable for banding and surgery may be required.
Treatment
for haemorrhoids depends on their severity (stage
or degree) and the main measures consist of:
- High fibre diet and use
of local shrinking and soothing applications such
as Rectinol or Cortisone containing creams.
- Injection sclerotherapy.
- Rubber band ligation.
- Radical operative haemorrhoidectomy.
This is performed less frequently now although it
is the most effective method of treating large thrombosed
haemorrhoids. However, surgery does involve hospitalisation
for two to five days and up to two to three weeks
of discomfort and time off work.
Rubber Band Ligation
This
is done in the office or occasionally together with
colonoscopy under anaesthetic. A latex rubber band
is placed around the neck of the haemorrhoid, via
a small instrument called a proctoscope. In some patients
because of other problems this instrument cannot be
inserted readily and the banding cannot be carried
out. Surgery may then be an alternative.
This strangulates its blood supply and the haemorrhoid
drops off within a few days. Because internal haemorrhoids
do not have sensitive pain nerve fibres of the skin,
the technique is usually not painful. However, the
external skin is painful and for this reason banding
is not suitable for those haemorrhoids, which are,
thrombosed and which have large skin tags.
Procedure
At
the first visit a rectal examination with a glove
is performed. Then the bowel above the haemorrhoids
is examined with an instrument called a sigmoidoscope
to exclude other causes of bleeding from the bowel.
In patients over 45 a colonoscopy may need to be arranged
to ensure no other cause for the bleeding is present.
A
suitable time to carry out the rubber band ligation
is then arranged. It is preferable for you to be driven,
as occasionally patients can feel faint after the
procedure.
Advantages
of Rubber Band Ligation
- No hospitalisation.
- No anaesthetic.
- Minimal pain.
- Minimal time off work.
Possible
Dissadvantages
- May require more than one
course of treatment.
- Does not deal with external
skin tags and loose skin of haemorrhoids.
- There is a small risk of
complications such as aggravation of other haemorrhoids,
bleeding, pain or infection. The pain is difficult
to predict and is usually not severe. There is a
bearing down sensation sometimes and Panadeine taken
after the procedure is helpful.
After
the Procedure
You
will be asked to rest in the office to ensure all
is okay for 15 minutes or so. It is best to be driven
home.
- Try not to use your bowels
the same day; the rubber band may fall off with
the straining. Occasionally you will note the band.
On most occasions over all you will not even notice
the rubber band.
- Avoid getting constipated
or straining. Two to three teaspoons of bran a day
or Coloxyl or Agarol may help.
- If there is excessive
bleeding, lie down with your bottom up in the air.
Gravity usually stops the bleeding. However, if
it persists notify the office. Anusol or Rectinol
ointments may help minor bleeding.
- A burning or irritating
sensation may be present. Stop all coffee, alcohol
and spices and the use of Anusol or Rectinol suppositories.
- For pain use Panadol,
Panadeine, Digesic, Codral Forte or anti- inflammatories
such as Neurofen or Neurofen Plus as discussed.
- If another haemorrhoid
becomes inflamed, try to push it back inside and
use a suppository.
- For painful external swelling:
· Warm baths are helpful,
· Ice packs help the haemorrhoids shrink,
· Rest,
· Try to avoid straining at the toilet.
The
situation may be reassessed in about three weeks to
determine how successful the procedure has been. An
examination is not usually carried out until then,
because there is a wound inside where the haemorrhoid
has dropped off. This wound can bleed severely about
10 days after the procedure – rarely. For this reason
it is advisable not to have the banding done if you
are going away on holidays or traveling during that
time.
If
you have other specific medical problems such as being
on Warfarin or Aspirin these will need to be considered
and probably stopped. Also if you have a heart valve
problem or cardiac murmur an antibiotic cover may
be required.
Subcutaneous Lateral
Sphincterotomy:
An
office treatment
Sphincterotomy
is a way of treating anal fissures with minimal pain.
The procedure can often be carried out in the office
with only Local Anaesthetic infiltration thus avoiding
hospitalisation and a General Anaesthetic. The surgery
itself only takes a few minutes. It consists of making
a small cut in the skin near the anal canal and grasping
what is termed “the internal sphincter” and dividing
it. This sphincter often in spasm when a patient has
an anal fissure and dividing the sphincter relieves
this spasm.
Development
of an anal fissure:
Following
constipation or a change in bowel habits, a tear can
occur in the lining of the anal canal. As a result
of this tear, patients experience pain, burning and
some slight blood loss with their bowel action. This
condition may become chronic as repeated tearing occurs
and the underlying muscle goes into spasm.
The applications proprietary are applying creams or
ointments such as Rectinol or prescription medication
such as Proctosedyl have a Local Anaesthetic agent
and Cortisone which decreased the pain, swelling and
sensitivity. More recently there have been two new
additions non-surgical ways of treating a fissure.
These are the tablet Rectogesic and Botox. Both were
developed originally for other purposes.
Rectogesic consists of an agent, which dilates the
blood vessels promotes the blood supply to the area
and thus theoretically helps the fissure to heal.
The basic component was originally used for people
who had angina due to blocked arteries in the heart.
The idea being that these would help dilate the arteries
and promote the blood flow.
One of the side effects of Rectogesic, which needs
to be taken for two or three weeks, is a headache,
which may occur and often stops patients taking it.
The other newer agent is Botox, which is used in cosmetic
surgery to relax muscle sphincters. It is important
in diagnosing an anal fissure that the examining doctor
takes this into account because routine rectal examination
can be extremely painful.
The first clue that a doctor would have that you have
an anal fissure is the history you give of severe
pain with a bowel action and a drop of blood. When
you are examined, when the buttocks are parted with
a bad fissure this will cause pain. It may be also
a sentinel pile as mentioned. Often the fissure can
actually be seen as the buttocks are parted. However
there may be so much pain and spasm that the fissure
cannot be visualised. An attempt at rectal examination
then would be extremely painful. Thus a full examination
with a fissure at that time is not always possible.
Thus some patients are treated a little blind at first
and then re-examined later. However it is important
at that first visit to differentiate your pain from
that of a small abscess, which can also be very painful.
With an abscess there is usually some swelling – and
a painful lump.
Some chronic fissures are not quite as painful and
when a rectal examination is done with a glove the
rough fissure can be palpated confirming the diagnosis.
At that time a sigmoidoscopy may be carried out to
ascertain that there are no other problems. Fissures
are sometimes found in association with haemorrhoids.
It would be inadvisable to have haemorrhoids rubber
band ligated whilst the fissure is still active.
A certain number of patients with an anal fissure
do come to need surgery. This surgery is called a
subcutaneous lateral sphincterotomy. Years ago the
recommended treatments for a fissure were dilatation
of the anus under an anaesthetic. This broke down
the sphincters. However, this was found to cause some
leakage of faeces – incontinence, after the procedure
in a small number of patients and has been virtually
abandoned as a way of treatment.
With subcutaneous lateral sphincterotomy there is
a theoretical risk that the same problem could occur.
However in the experience of most Surgeons who specialise
in this area the incidence of this is extremely low.
However patients who have other conditions or who
are very elderly, consideration needs to be given
to this before the operation is carried out. It should
also be discussed with the patient by the doctor prior
to the procedure being carried out.
Sphincterotomy procedure:
The
patient is asked to lie on their side facing the wall.
Local Anaesthetic is then administered with a fine
needle and the area rapidly becomes anaesthetised.
Following the injection there is no pain felt during
the procedure. A small cut is made in the loose skin
adjacent to the back passage. The muscle – sphincter
that is in spasm is identified, grasped and divided.
No suturing is required and the wound heals spontaneously.
A dressing pack is inserted and this is removed the
following day. A small pad may need to be worn for
a few days.
After care:
Bowels
can be used as desired. The first bowel action is
usually less painful. The skin wound usually heals
within a few days. The fissure may take a week or
two to heal and sometimes does not heal for a long
time. Pain however is relieved because the spasm is
gone. Sometimes associated with the fissure are the
skin tags, which may be removed. A skin tag may be
on the outside and there may also be a little polyp
at the base of the fissure internally. The edges of
the fissure may be trimmed to help it heal up.
The skin is then kept dry and a powder may be used.
Bruising of the area is of no consequence and resolves
rapidly. If necessary, mild painkillers may be taken
but in many instances these are not required. Heavy
constipating tablets should be avoided if possible.
The amount of time off varies and the rate of healing
and absence of pain caries.
As for all surgery the result cannot be guaranteed.
There are a small number of patients where the surgery
appears to be ineffective and a procedure may be required.
Other possible risks are that even after successful
surgery a fissure occurs from time to time at a later
date. There are occasional complications with the
wound of the operation such as some bleeding underneath
the wound or infection.
Some anal fissures can be a very painful problem for
patients and it is frustrating, as it is only just
a small thing but still disabling and irritating.
Treatment varies from just altering bowel habits and
use of local applications to the use of surgery. The
patient will usually indicate when they want surgery
because of their exasperation with the pain or chronicity
of the problem. This needs to be discussed in full
with the treating doctor.
Anal Abscess and Fistula
An
abscess is a collection of pus. Abscesses may occur
anywhere in the body after the early infection becomes
localised.
The
Cause of an Abscess
There
are a number of small glands just within the anal
canal, which communicate between the lining of the
anal canal and the muscular sphincters around the
anal canal. The bacteria accumulates in these glands
and when these conditions are ripe an infection occurs.
As this infection becomes localised an abscess develops.
The tissues around the anus are loose and the abscess
can spread deeper, involving the muscles and surrounding
tissues. The natural course of any abscess is to enlarge
and rupture through the overlying skin or inwards
into the anal canal and rectum.
Symptoms
As
the abscess enlarges the pressure within the abscess
increases and this causes severe pain. There may be
a throbbing pain and if it is a severe abscess then
there may be an elevated temperature and night sweats.
Treatment
of an Abscess
Initially
antibiotics are often given but once an abscess stays
these usually only contain the infection rather than
cure it. Thus surgical treatment and drainage is required.
For a small superficial abscess this can be done under
Local Anaesthetic in the Surgeon’s office. A larger
abscess may require hospitalisation and drainage under
General Anaesthesia. Antibiotics by themselves do
not cure an abscess. They may control some of the
fever and also the spread of infection into the general
circulation.
Fistula
Fistulas
may occur in many sites of the body. They are an abnormal
track between two surfaces. An anal fistula is track
between the lining of the anal canal and the skin
around the anus. A fistula forms usually after an
anal abscess has drained spontaneously or following
surgery. Because the track comes lined with chronic
infection it tends not to heal up by itself and there
is a persistent discharge of pus, which may settle
temporarily but then recurs. Fistulas can occur in
association with other conditions such as inflammatory
bowel disease e.g. Crohn’s disease or ulcerative colitis.
A fistula will not heal usually by itself and there
are a variety of ways of treating fistulas depending
on their size, length and how deep they are into the
anal canal. The more superficial fistulas are usually
readily treated surgically.
Fistulotomy
A
General Anaesthetic is usually required in hospital.
The track is completely opened up and allowed to heal
by what is termed second intention healing. This process
does take some time and cannot be hastened by sewing
up.
If
the fistula passes through the muscle this muscle
has to be divided and this makes the operation a little
tricky because there is a slight risk if too much
muscle is divided there can be a permanent leakage
of fluid. Thus particular care is required with this
procedure.
Setons
A
loop of flexible material is passed through the track
and ties over the skin.
Colonoscopy
These
days, in most patients over 45 years with bleeding,
a colonoscopy will be advised to exclude causes further
up the bowel such as polyps or even cancer. This is
recommended also if there is a family history of bowel
cancer.
Biopsies
may be taken, polyps if present can be removed and
sent for pathological examination.
The
procedure will be done at Masada Hospital as a day
case if you are insured. If not, other arrangements
will be made.
Colonoscopy
is a safe procedure. It involves taking a fluid the
day before the procedure to clean the bowel right
out. It is done under anaesthetic as a day case by
myself – a qualified Endoscopist, a specialist in
this field. There are extremely rare complications
to the procedure. This is perforation of the bowel
or severe bleeding and it may result in emergency
surgery. Removing polyps increases this risk slightly.
The incidence of complications may be 1 in 1000 or
2000.
Colonoscopy
is the passage of a long flexible instrument to allow
the lining of the large bowel to be examined. It is
capable of detecting polyps, tumours or inflammation
of the large bowel or even the end part of the small
bowel. Biopsies may be taken and polyps removed. These
specimens are always sent for pathology to be examined
under the microscope.
Colonoscopy
is usually carried out when there are symptoms related
to the bowel such as abdominal pain, bleeding or anaemia,
that is a low count from bleeding. Family history
of polyps or tumours is another indication for colonoscopy.
Preparation
for Colonoscopy
The
bowel must be completely empty and cleaned. This is
done by taking the appropriate medication the day
before the procedure as directed by our staff and
instruction sheet. A variety of preparations to suit
individual needs, these include Picolax and Glycoprep.
Medication
You
should take your medication the day of examination.
Aspirin medication is stopped for 4 – 5 days before
the procedure, as is iron medication.
For women, the oral contraceptive pill may become
ineffective because of the bowel prep, so alternative
contraceptive should be used for 10 days.
Any
patients on blood thinning tablets such as Warfarin
require separate advice. Diabetics also need specific
advice.
Risks
of Colonoscopy
There
is a small risk, possibly 1 in 1500 or 1 in 2000 of
bleeding or damage or perforation of the bowel wall
by the instrument. Should this occur complicated surgery
might be required. Another possible problem is severe
bleeding. This can occur after biopsies or the removal
of a polyp. This bleeding usually settles down, but
surgery can also be required. Fortunately these events
are rare.
After
the Procedure
You
would always be seen by myself after you have had
the procedure and you are awake. You may not always
remember the discussions. You will be given something
in writing. Usually a letter will be sent to you advising
about further follow-up and the need to repeat the
colonoscopy at a later date. This is particularly
the case with patients who have polyps or a family
history of bowel cancer.
Your
referring doctor will be sent a written report and
a copy of the pathology report.
If
you are unclear about any of the reports or the need
for follow up please contact our office.
Bowel Cancer Screening
Program
Bowel
cancer is now the commonest cause of cancer-related
death in Australia. Every year about 12,600 new cases
of bowel cancer are diagnosed and about 4,700 people
die from the disease.
Studies
carried out overseas and here in Australia have suggested
that this mortality rate will be reduced by up to
33% by population-wide screening.
The
screening program will utilize the faecal occult blood
test (FOBT) kit, which detects the presence of microscopic
amounts of blood in faecal material. benign and cancerous
tumours in the bowel tend to bleed, and this blood
is detected by the FOBT. A positive FOBT result means
that blood has been detected, a negative result means
that there is no evidence of blood present.
The
results from research studies suggest that a person
with a positive result has a 45% chance of having
an adenoma (a benign, but potentially pre-cancerous,
tumour) and a 5% chance of having an actual cancer.
Other benign conditions, such as haemorrhoids, account
for the remaining 50%.
Diverticular Disease
of the Colon
This
disease usually affects the sigmoid colon, which is
in the lower left side of the abdomen. It can affect
the rest of the bowel occasionally also.
It is an extremely common condition in western society
and is associated with the western style diet i.e.
a low fibre diet.
Features
- Small
pockets protrude through the wall of the bowel.
The pocket consists of the inner lining and outer
covering of the bowel wall, which have penetrated
between the muscles. The opening of the pocket or
diverticulum is called the mouth.
- The
muscle wall of the bowel becomes very thick through
the bowel, and the bowel becomes narrow.
Causes
As
the pressure within the bowel increases because the
bowel becomes narrower, the pressure causes these
pockets to protrude between the muscle bowel walls.
The Diverticular disease is extremely common and many
people have these pockets without experiencing any
problems whatsoever. However, they then may develop
cramping, left lower abdominal discomfort, diarrhoea
and some urgency of motion. Even watery diarrhoea
can occur. The condition affects both men and women
and in western society it is occurring at an earlier
age.
Thus
in summary Diverticular disease consists of pockets
in the bowel as a result of increased pressure associated
with spasm and hypertrophy of the muscle and firm
stools.
When
these diverticular become inflamed the condition is
called Diverticulitis.
The discomfort can be quite disabling for patients.
Worse however is that when complications develop.
These complications may be:
- An abscess, this can cause
severe pain in the central or lower left side of
the abdomen. There may be an elevated temperature
with either constipation or diarrhoea. Less commonly
this abscess can burst resulting in generalised
inflammation of the abdominal cavity – peritonitis
or local peritonitis. Here surgery may be required
in an emergency situation.
- Haemorrhoids. Inflammation
may damage arteries near the mouth of the pocket
causing bleeding. This bleeding can be quite heavy
and require hospitalisation. The bleeding needs
to be differentiated from other causes of bleeding
from the bowel, such as bowel cancer.
Other
Complications
The
inflammation causes organs within the abdomen to stick
together leading to bowel obstruction or even a fistula
– this is an abnormal communication between the bowel
and such organs as the bladder or vagina. A fistula
is an abnormal communication between two structures.
What
the Patient Notices
Prominent
symptoms are – pain and alteration of bowel habit.
There are various combinations together with bleeding.
Other
conditions, which need to be excluded, are bowel polyp
and cancers.
When
the patient presents to the doctor, abdominal examination
and a rectal examination with a glove, then a sigmoidoscopy
are all helpful steps in the investigations. X-rays
may be required particularly if there is bowel obstruction
or evidence of perforation.
In
the less acute case a barium enema – particularly
where colonoscopy is not available, can be helpful
and has a typical appearance.
Treatment
of Diverticulitis can be:
- Dietary – in a non-acute
attack as a long-term treatment. A high fibre diet
and a bulking agent reduce the pressure. Examples
of the type of food are wholemeal bread, wholegrain
cereal, peas and beans etc. This matter of diet
is a complex matter and requires consultation with
a General Practitioner or a dietary expert. A type
of bulking agent is Metamucil (Psyllium).
- Anti-spasmodic – Colofac
or Buscopan are commonly used and the diarrhoea
can be treated symptomatically by such agents as
Lomotil.
Irritable Bowel Syndrome
Irritable
bowel syndrome (IBS) is a very common condition which
affects the function of the bowel. It is generally
a chronic condition although the symptoms and severity
may vary from person to person.
Definitions
Bowel=intestine
(in irritable bowel syndrome, this refers to the large
intestine)
Syndrome= a group of symptoms
Causes
of irritable bowel syndrome
No
one knows the exact cause of irritable bowel syndrome.
One possible reason one gets IBS is that there is
an imbalance between the activity of the nerves and
muscle contractions in the bowel wall. For instance,
the bowel wall may contract more strongly and food
is rushed thorough the intestines more quickly resulting
in diarrhea, bloating, flatulence and abdominal pain.
In another instance, the opposite may occur and the
bowel contracts more slowly leading to constipation.
The
presence of food in the bowel may also affect the
sensitivity of the nerves hence some people may find
that certain food (e.g. fatty food, alcohol, caffeine)
can trigger an attack of abdominal pain.
Symptoms
or complaints
The
symptoms which varies from person to person include:
1. Abdominal pain or cramping usually relived by going
to the toilet
2. Alteration in bowel habit/diarrhoea/constipation
(usually painful)
3. Bloating or flatulence
4. Mucus in the stool
5. The feeling that one has not finished a bowel movement
You
should always see a doctor if you have any of the
above symptoms because these symptoms are also often
found in other diseases affecting the colon such as
bowel cancer, diverticular disease and inflammatory
bowel disease.
Differential
diagnoses to consider - What other conditions can
mimic symptoms of irritable bowel syndrome?
1. Diverticular disease
2. Bowel cancer
3. Inflammatory bowel disease
4. Coeliac disease
Management
History
and Examination
If
you have any of the above symptoms, you should see
your doctor. You may need to be referred to a specialist
for further assessment.
A
thorough careful history and examination needs to
be taken in particular to exclude conditions such
as bowel cancer.
The
examination would consist of an abdominal examination
including a rectal examination. A rigid sigmoidoscopy
should also performed
Investigations
A
colonoscopy may be indicated especially if there is
a change in bowel action as this can be a symptom
of bowel cancer as well. Unlike other colon conditions,
there is no pathology to find in irritable bowel syndrome
e.g. no inflammation of bowel or polyps.
Other
tests including blood tests may be necessary.
Treatment
General
measures
- Diet changes – A high-fibre
diet and fibre supplements such as Metamucil (psyllium)
or Fybogel (ispaghula husks) may help especially
for those with constipation. Eating regular meals
may also help.
- Avoidance of trigger factors
(these may vary from person to person)
· Caffeine (e.g. from coffee)
· Chocolate
· Fatty foods like chips
· Milk products
· Alcohol
· Carbonated drinks like Coke
· High-gas food like beans and artichokes
- Stress relief – Stress
can make the symptoms worse. Counseling and regular
exercise may help.
Medications
These
should only be used in consultation with your doctor.
They include;
- Antidiarrhoeal medications
(e.g. loperamide or cholestyramine) for diarrhoea
- Laxatives for constipation
- Antidepressants (e.g. fluoxetine,
amitriptyline) – these medications affect the neurotransmitter
levels in the nerves in the bowel
- Antispasmodics can be used
for pain relief (e.g. Mebeverine, hyoscine and peppermint
oil)
- Medications directly affecting
the nerve receptors in the bowel e.g. Alosetron(an
antagonist of serotonin receptors in the bowel)
and tegaserod (an agonist of serotonin receptors)
(The latter medication has been shown to be effective
for short-term use in women but it is expensive)
Other
analgesics are generally ineffective and codeine-containing
drugs should be avoided.
Other
therapy
Counseling,
relaxation exercises, deep breathing techniques, cognitive
behaviour therapy, biofeedback, hypnotherapy all may
help. Complementary therapy such as acupuncture or
probiotics may help some people.
Inflammatory
bowel disease (IBD) refers to a group of conditions
where the bowel becomes inflamed. These conditions
include ulcerative colitis and Crohn’s disease. In
10% of cases there may be features of both ulcerative
colitis and Crohn’s disease and these cases are termed
indeterminate colitis.
The
cause of these conditions is not yet fully understood,
but is thought to relate to the bacteria living in
the bowel and the immune response. Genetic factors
have also been implicated.
Ulcerative
Colitis
Ulcerative
colitis is characterized by recurring episodes of
inflammation limited to the inner lining of the colon.
It generally involves the rectum and can extend in
a continuous fashion to involve other portions of
the colon. Inflammation can occasionally extend to
involve the end portion of the small bowel.
Ulcerative
colitis can be classified according to the extent
of involvement:
Ulcerative
proctitis - limited to the rectum.
Proctosigmoiditis
- affecting the rectum and the end portion of the
colon (sigmoid colon).
Left-sided
ulcerative colitis – affecting the colon on the left
hand side of the body
Pancolitis
– involvement extending beyond the colon on the left
hand side of the body.
Crohn’s Disease
Crohn’s
disease may involve the entire gastrointestinal tract
from mouth to perianal area and there can be areas
of involved bowel separated by normal bowel, known
as skip lesions. The full thickness of the bowel wall
can be involved, and this can result in scarring and
narrowing of the bowel and tracts communicating between
the bowel and other areas (fistulae and perforations).
The
majority of patients with Crohn’s have small bowel
involvement, usually in the end part of the small
bowel known as the terminal ileum. One third of patients
have inflammation limited to this area, 50 percent
of patients have involvement of both the ileum and
colon, and 20 percent have disease limited to the
colon.
A
small percentage of patients have predominant involvement
of the mouth, oesophagus, stomach or upper small bowel
(duodenum). Crohn’s disease affects the area around
the anus in one third of patients.
Letter to Editor
It
is well known that the world population is aging rapidly.
In this sense, Turkey can be categorized as an aging
society, considering the demographic allocation of
those over 65 years of age. Even more, when statistical
figures are analyzed, Turkey is predicted to be an
elder society in the near future(1). With the elderly
population increasing rapidly, demand for service
for the elderly rises proportionally. As a result,
there is a significant necessity for services benefiting
the elderly, to increase on a similar scale.
Currently
in Turkey, facilities for the necessities of the geriatric
population are being rapidly developed and Izmir Narlidere
Geriatric Care Center and Residential Home is the
largest of those organizations serving the elderly
since 2001. The above-mentioned nursing home has a
capacity of 1100 elderly, and has currently 850 geriatric
residents; 670 of those capable of self-care, and
180 incapable of self care. The elderly residents
are able to benefit from health and social services
with a small amount of individual payment, due to
the fact that their health expenditures are paid by
the public and private health insurances.
Health
services are handled effectively by full-time primary
care physicians. Additionally, sufficient number of
nurses, health aides, physiotherapists, social workers,
clinical psychologists, radiology technicians and
assistant personnel are also present to ensure the
well-being of the residents. Main blocks accommodate
those capable of self-care while those incapable of
self-care are made comfortable in the geriatric care
center. The majority of those incapable of self-care
suffer from dementia and similar chronic diseases
and are bed ridden. They are cared for in rooms accommodating
mostly two people. Close care is initiated by nurses
attending in-service education programs on a regular
basis. This facility also provides numerous job opportunities
for health aides who are required to follow similar
continuous in-service education programs.
Izmir
Narlidere Geriatric Care Center and Residential Home
is affiliated with the closest university hospital
in the region. The facility is able to initiate radiological
procedures and the university hospital assists in
procedures involving laboratory work and complicated
procedures and conditions.
Izmir
Narlidere Geriatric Care Center and Residential Home
is widely preferred by European nursing instructors
and students who study in Turkish universities with
regard to European Exchange programs such as Erasmus,
Leonardo da Vinci. Furthermore, the facility is also
an integral part of medical students’ internship and
practice. It is undeniable that the nursing home is
an important ground of practice of geriatrics for
family medicine physicians. It is quite possible that
the nursing home can be a special training area for
family medicine residents in the near future.
Izmir
Narlidere Geriatric Care Center and Residential Home
is located in a decent part of the city, by the coast,
close to pine forests; and facilities are convenient
and safe for elderly residents, including hobby areas,
swimming pool and physiotherapy units. The rooms for
housing are either for one or two persons. Also, apart
from interior sections, an amphitheater, a large sera
and a small private forest are also operational for
the benefit of the facility(2).
Though
organized as a modern and capable facility, Izmir
Narlidere Geriatric Care Center and Residential Home
still is in need of additional units. Some of these
necessities are setting up a laboratory, organizing
support from professional geriatrists, inclusion of
more physiotherapists, social workers and psychologists
and the presence of occupational therapists replacing
medical instructors.
Consequently,
though there is still room for facilitative improvement.
Izmir Narlidere Geriatric Care Center and Residential
Home resembles an emerging role model in a developing
and aging country and successfully serves the Turkish
elderly.
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