Colorectal Surgery

A patient who feels ill and complains of chills, fever and pain in the rectum or anus could be suffering from an anal abscess or fistula. These medical terms describe common ailments about which many people know little.

What is an anal abscess?

An anal abscess is an infected cavity filled with pus found near the anus or rectum.

What is an anal fistula?

An anal fistula, almost always the result of a previous abscess, is a small tunnel connecting the anal gland from which the abscess arose to the skin of the buttocks outside the anus.

What causes an abscess?

An abscess results from an acute infection of a small gland just inside the anus, when bacteria or foreign matter enters the tissue through the gland. Certain conditions - colitis or other inflammation of the intestine, for example - can sometimes make these infections more likely.

What causes a fistula?

After an abscess has been drained, a tunnel may persist connecting the anal gland from which the abscess arose to the skin. If this occurs, continuous drainage from the outside opening may indicate the persistence of this tunnel. If the outside opening of the tunnel heals, recurrent abscess may develop.

What are the symptoms of an abscess or fistula?

Symptoms of both ailments include constant pain, sometimes accompanied by swelling, that is not necessarily related to bowel movements. Other symptoms include irritation of skin around the anus, drainage of pus (which often relieves the pain), fever, and feeling poorly in general.

Does an abscess always become a fistula?

No. A fistula develops in about 50 percent of all abscess cases, and there is really no way to predict if this will occur.

How is an abscess treated?

An abscess is treated by draining the pus from the infected cavity, making an opening in the skin near the anus to relieve the pressure. Often, this can be done in the doctor's office using a local anesthetic. A large or deep abscess may require hospitalization and use of a different anesthetic method. Hospitalization may also be necessary for patients prone to more serious infections, such as diabetics or people with decreased immunity. Antibiotics are not usually an alternative to draining the pus, because antibiotics are carried by the blood stream and do not penetrate the fluid within an abscess.

What about treatment for a fistula?

Surgery is necessary to cure an anal fistula. Although fistula surgery is usually relatively straightforward, the potential for complication exists, and is preferably performed by a specialist in colon and rectal surgery. It may be performed at the same time as the abscess surgery, although fistulae often develop four to six weeks after an abscess is drained sometimes even months or years later. Fistula surgery usually involves cutting a small portion of the anal sphincter muscle to open the tunnel, joining the external and internal opening and converting the tunnel into a groove that will then heal from within outward. Most of the time, fistula surgery can be performed on an outpatient basis - or with a short hospital stay.

How long does it take before patients feel better?

Discomfort after fistula surgery can be mild to moderate for the first week and can be controlled with pain pills. The amount of time lost from work or school is usually minimal.

Treatment of an abscess or fistula is followed by a period of time at home, when soaking the affected area in warm water (sitz bath) is recommended three or four times a day. Stool softeners may also be recommended. It may be necessary to wear a gauze pad or mini-pad to prevent the drainage from soiling clothes. Bowel movements will not affect healing.

What are the chances of a recurrence of an abscess or fistula?

If properly healed, the problem will usually not return. However, it is important to follow the directions of a colon and rectal surgeon to prevent recurrence.

What is anal cancer?

Anal cancer arises from the cells around the anal opening (verge) or within the anal canal (1-2 inches long) up to its junction with the rectum. Most anal cancers arise from skin cells and are called squamous cell carcinomas. Some arise from the special mucosal cells lining the upper anal canal and are called cloacogenic carcinomas. Although several other types of cancer may occur in this area, these two are the most common. They behave similarly and are treated in the same fashion. Cells that are becoming malignant but have not invaded below the surface are "pre-cancerous" (carcinoma-in-situ). This condition is called Bowen's disease.

How common is anal cancer?

Anal cancer is fairly uncommon. It accounts for about 1-2% of gastrointestinal cancers. About 3,400 new cases of anal cancer are diagnosed each year in the U.S.A., and about 500 people will die of the disease each year. This may be compared to 140,000 new cases of colorectal cancer with 50,000 deaths per year.

Who is at risk?

We do not know the exact cause of most anal cancers. But we do know that certain risk factors are linked to anal cancer. These include:

• Age – most people with anal cancer are over 50 years old.
• Anal warts – infection with the human papilloma virus (HPV) which causes condyloma (warts) may increase the chance of developing anal cancer.
• Anal sex – persons who participate in anal sex are at an increased risk.
• Smoking – harmful chemicals from smoking increase the risk of most cancers including anal cancer.
• Immunosuppression – people with weakened immune systems, such as transplant patients who must take drugs to suppress their immune systems and patients with HIV (human immunodeficiency virus) infection, are at a somewhat higher risk.
• Chronic local inflammation – people with long-standing anal fistulas or open wounds are at a slightly higher risk.
• Pelvic radiation – people who have had pelvic radiation therapy for rectal, prostate, bladder or cervical cancer are at an increased risk.

Can anal cancer be prevented?

Few cancers can be totally prevented but your risk may be decreased significantly by reducing your risk factors and by getting regular checkups. Avoid anal sex and infection with HPV and HIV. Use condoms whenever having any kind of intercourse. Although condoms do not eliminate the risk of infection, they do reduce it. Stopping smoking lowers the risk of many types of cancer, including anal cancer.

What are the symptoms of anal cancer?

Many cases of anal cancer can be found early. Anal cancers form in a part of the digestive tract that the doctor can see and reach easily. Anal cancers often cause symptoms such as:

• Bleeding from the rectum or anus
• The feeling of a lump or mass at the anal opening
• Pain in the anal area
• Persistent or recurrent itching
• Change in bowel habits (having more or fewer bowel movements) or increased straining during a bowel movement
• Narrowing of the stools
• Discharge (mucous or pus) from the anus
• Swollen lymph nodes (glands) in the anal or groin areas.

These symptoms can also be caused by less serious conditions such as hemorrhoids but you should never assume this. If you have any of these symptoms, see your doctor

How is anal cancer diagnosed?

Finding cancers early is the key to cure. Regular checkups with a digital (finger) exam of the rectum and anus will find many problems which are easy to treat when found early. Routine screening for colorectal and anal cancer in people without any symptoms includes a digital rectal exam and test for blood in the stool yearly and a flexible endoscopy exam (lighted probe) every 5-10 years starting at 50 years of age.

If anal cancer is suspected based on your doctor’s exam, a biopsy will be performed to confirm the diagnosis. If the diagnosis of cancer is confirmed, additional tests to determine the extent of the cancer may be recommended.

How are anal cancers treated?

Treatment for most cases of anal cancer is very effective. There are three basic types of treatment used for anal cancer:

• surgery to remove the cancer
• radiation therapy to kill cancer cells
• chemotherapy drugs to kill cancer cells

Combination therapy including radiation therapy and chemotherapy is now considered the standard treatment for most anal cancers. Occasionally a very small or early tumor may be removed surgically (local excision), with minimal damage to the anal sphincter muscles.

Will I need a colostomy?

The majority of patients treated for anal cancer will not need a colostomy. If the tumor does not respond completely to combination therapy, if it recurs after treatment, or if it is an unusual type, an abdominoperineal resection (APR) removal of the rectum and anus and creation of a colostomy may be necessary.

What happens after treatment for anal cancer?

Follow-up care to assess the results of treatment and to check for recurrence is very important. Most anal carcinomas are effectively treated. In addition, many tumors that recur may be successfully treated if they are caught early. A careful examination by an experienced physician at regular intervals is the most important method of follow-up. Additional studies may be recommended. You should report any symptoms or problems to your doctor right away.

Conclusion

Anal cancers are unusual tumors arising from the skin or mucosa of the anal canal. As with most cancers, early detection is associated with excellent survival. Most tumors are well treated with combination chemotherapy and radiation. Recurrences may often be treated successfully. Follow the recommended screening examinations for anal and colorectal cancer and consult your doctor early when any anorectal symptoms occur.

What is an anal fissure?

An anal fissure is a small tear or cut in the skin lining the anus which can cause pain and/or bleeding. Read more.

What are anal warts?

Anal warts (also called "condyloma acuminata") are a relatively common and bothersome condition that affects the area around the anus. They may also affect the skin of the genital area. They first appear as tiny blemishes, perhaps as small as the head of a pin, and may grow larger than the size of a pea. Usually, they do not cause pain or discomfort to afflicted individuals. As a result, patients may be unaware that the warts are present. Read more.

What is incontinence?

Incontinence is the impaired ability to control gas or stool. Its severity ranges from mild difficulty with gas control to severe loss of control over liquid and formed stools. Incontinence to stool is a common problem, but often it is not discussed due to embarrassment. Both bladder and bowel incontinence are problems that tend to increase with age. Read more.

Colon cancer and repeated or severe infections of the small outpouchings of the colon called diverticula (diverticulitis) require the removal of the affected portion of the colon. Additionally, there are inflammatory conditions that may require removal of part or all of the colon.

Preoperative Evaluation

Except in emergencies, all patients undergo a barium enema or colonoscopy to evaluate the colon. In some cases a CAT scan and/or blood tests are used to evaluate other organs in the abdomen. Additionally, a bowel prep is taken before surgery to clean out the colon.

Procedure

The affected portion of the colon is removed and the intestine is then sewn back together. In some situations, as discussed with the patient before surgery, the intestine cannot be sewn back together and instead a temporary or permanent colostomy is created.

Length of Stay

Variable depending upon overall patient health. However, the average stay is about five days.

Recovery

Four to six weeks with no driving for two weeks and no lifting more than 10 pounds for six weeks.

Colorectal cancer is the second most common cancer in the United States, striking 140,000 people annually.. and causing 60,000 deaths. That's a staggering figure when you consider the disease is potentially curable if diagnosed in the early stages.

Who is at risk?

Though colorectal cancer may occur at any age, more than 90% of the patients are over age 40, at which point the risk doubles every ten years. In addition to age, other high risk factors include a FAMILY history of colorectal cancer and polyps and a PERSONAL history of ulcerative colitis, colon polyps or cancer of other organs, especially of the breast or uterus.

How does it start?

It is generally agreed that nearly all colon and rectal cancer begins in benign polyps. These pre-malignant growths occur on the bowel wall and may eventually increase in size and become cancer. Removal of benign polyps is one aspect of preventive medicine that really works!

What are the symptoms?

The most common symptoms are rectal bleeding and changes in bowel habits, such as constipation or diarrhea. (These symptoms are also common in other diseases so it is important you receive a thorough examination should you experience them.) Abdominal pain and weight loss are usually late symptoms indicating possible extensive disease.

Unfortunately, many polyps and early cancers fail to produce symptoms. Therefore, it is important that your routine physical includes colorectal cancer detection procedures once you reach age 40. Those detection methods are a digital rectal exam and a chemical test of stool for blood. A sigmoidoscopy - the inspection of the lower bowel with a lighted tubular instrument - should be part of routine physical check-ups.

How is colorectal cancer treated?

Colorectal cancer requires surgery in nearly all cases for complete cure. Radiation and chemotherapy are sometimes used in addition to surgery. Between 80-90% are restored to normal health if the cancer is detected and treated in the earliest stages. The cure rate drops to 50% or less when diagnosed in the later stages. Thanks to modern technology, less than 5% of all colorectal cancer patients require a colostomy, the surgical construction of an artificial excretory opening from the colon.

Can colon cancer be prevented?

There are steps that reduce the risk of contracting the disease. One way is having benign polyps removed by an outpatient procedure called colonoscopy. In addition to removing the polyps, the long flexible tubular instrument used in the procedure provides a more thorough bowel examination.

Though not definitely proven, there is some evidence that diet may play a significant role in preventing colorectal cancer. As far as we know, a high fiber, low fat diet is the only dietary measure that might help prevent colorectal cancer.

Finally, you must be aware of changes in your bowel habits and make sure bowel examinations are included in routine physicals once you fall under the "high risk" category.

Can hemorrhoids lead to colon cancer?

No, but hemorrhoids may produce symptoms similar to colon polyps or cancer. Should you experience these symptoms, you should have them examined and evaluated by a physician, preferably by a colon and rectal surgeon.

Crohn's disease is a chronic inflammatory process primarily involving the intestinal tract. Although it may involve any part of the digestive tract from the mouth to the anus, it most commonly affects the last part of the small intestine (ileum) and/or the large intestine (colon and rectum).

Crohn's disease is a chronic condition and may recur at various times over a lifetime. Some people have long periods of remission, sometimes for years, when they are free of symptoms. There is no way to predict when a remission may occur or when symptoms will return.

What are the symptoms of Crohn's disease?

Because Crohn's disease can affect any part of the intestine, symptoms may vary greatly from patient to patient. Common symptoms include cramping, abdominal pain, diarrhea, fever, weight loss, and bloating. Not all patients experience all of these symptoms, and some may experience none of them. Other symptoms may include anal pain or drainage, skin lesions, rectal abscess, fissure, and joint pain (arthritis).

Who does it affect?

Any age group may be affected, but the majority of patients are young adults between 16 and 40 years old. Crohn's disease occurs most commonly in people living in northern climates. It affects men and women equally and appears to be common in some families. About 20 percent of people with Crohn's disease have a relative, most often a brother or sister, and sometimes a parent or child, with some form of inflammatory bowel disease.

Crohn's disease and a similar condition called ulcerative colitis are often grouped together as inflammatory bowel disease. The two diseases afflict an estimated two million individuals in the U.S.

What causes Crohn's disease?

The exact cause is not known. However, current theories center on an immunologic (the body's defense system) and/or bacterial cause. Crohn's disease is not contagious, but it does have a slight genetic (inherited) tendency. An x-ray study of the small intestine may be used to diagnose Crohn's disease.

How is Crohn's disease treated?

Initial treatment is almost always with medication. There is no "cure" for Crohn's disease, but medical therapy with one or more drugs provides a means to treat early Crohn's disease and relieve its symptoms. The most common drugs prescribed are corticosteroids, such as prednisone and methylprednisolone, and various anti-inflammatory agents.

Other drugs occasionally used include 6-mercaptopurine and azathioprine, which are immunosuppressive. Metronidazole, an antibiotic with immune system effects, is frequently helpful in patients with anal disease.

In more advanced or complicated cases of Crohn's disease, surgery may be recommended. Emergency surgery is sometimes necessary when complications, such as a perforation of the intestine, obstruction (blockage) of the bowel, or significant bleeding occur with Crohn's disease. Other less urgent indications for surgery may include abscess formation, fistulas (abnormal communications from the intestine), severe anal disease or persistence of the disease despite appropriate drug treatment.

Not all patients with these or other complications require surgery. This decision is best reached through consultation with your gastroenterologist and your colon and rectal surgeon.

Surgery is not "curative," although many patients never require additional operations. A conservative approach is frequently taken, with a limited resection of intestine (removal of the diseased portion of the bowel) being the most common procedure.

Surgery often provides effective long-term relief of symptoms and frequently limits or eliminates the need for ongoing use of prescribed medications. Surgical therapy is best conducted by a physician skilled and experienced in the management of Crohn's disease.

What is diverticulitis?

Diverticulosis of the colon is a common condition that afflicts about 50 percent of Americans by age 60 and nearly all by age 80. Only a small percentage of those with diverticulosis have symptoms, and even fewer will ever require surgery. Read more.

What are hemorrhoids?

Often described as "varicose veins of the anus and rectum", hemorrhoids are enlarged, bulging blood vessels in and about the anus and lower rectum. There are two types of hemorrhoids: external and internal, which refer to their location. Read more.

What is pilonidal disease and what causes it?

Pilonidal disease is a chronic infection of the skin in the region of the buttock crease. The condition results from a reaction to hairs embedded in the skin, commonly occurring in the cleft between the buttocks. The disease is more common in men than women and frequently occurs between puberty and age 40. It is also common in obese people and those with thick, stiff body hair. Read more.

What is rectal prolapse?

Rectal prolapse is a condition in which the rectum (the lower end of the colon, located just above the anus) turns itself inside out. In the earliest phases of this condition, the rectum does not stick out of the body, but as the condition worsens, it may protrude. Weakness of the anal sphincter muscle is often associated with rectal prolapse at this stage and may result in leakage of stool or mucus. The condition occurs in both sexes, although it is more common in women than men. Read more.

What is a rectocele?

A rectocele is a bulge of the front wall of the rectum into the vagina. The rectal wall may become thinned and weak, and it may balloon out into the vagina when you push down to have a bowel movement. Most rectoceles occur in women where the front wall of the rectum is up against the back wall of the vagina. This area is called the rectovaginal septum and may be a weak area in the female anatomy. Other structures may also push into the vagina. The bladder bulging into the vagina is called a cystocele. The rectum bulging into the vagina is termed a rectocele. And the small intestines pushing down on the vagina from above may form an enterocele. Although uncommon, men may also develop a rectocele. Read more.

What is ulcerative colitis?

Ulcerative colitis is an inflammation of the lining of the large bowel (colon). Symptoms include rectal bleeding, diarrhea, abdominal cramps, weight loss, and fevers. In addition, patients who have had extensive ulcerative colitis for many years are at an increased risk to develop large bowel cancer. The cause of ulcerative colitis remains unknown. Read more.