Colorectal Problems

Anal Fissure
An anal fissure is a vertical tear in the skin of the anal canal. Typical symptoms include bright red rectal bleeding and severe tearing pain on and after defecation. The tear usually extends from the anal opening upwards into the anal canal. Many acute anal fissures will heal spontaneously but some fissures become chronic and will not heal. The most common cause for this is spasm of the internal anal sphincter muscle. This spasm causes poor blood flow to the anal mucosa, hence producing a chronic open wound.  Anal fissures are common in women after childbirth, after difficult bowel movements and in infants following constipation.

Treatment is aimed at reducing the spasm in the anal sphincter. Medical treatment requires the application of topical 0.4% GTN ointment or 2% Diltiazem ointment to the internal anal canal twice daily for 3 months together with stool softeners. If such measures fail or the pain is too severe, an examination under anaesthetic and botox injection can be performed. This aims to temporarily paralyse the anal sphincter and improve the blood flow to allow healing. A lateral sphincterotomy can be considered and in persistent cases, a mucosal advancement flap may be appropriate.

Rectal prolapse
Rectal prolapse normally describes a medical condition where the walls of the rectum protrude through the anus and become visible outside the body.  Rectal prolapse is caused by the weakening of the ligaments and muscles that hold the rectum in place. Rectal prolapse commonly presents in older female patients.

Surgical treatment can be either via the abdomen or the perineum. Frail elderly patients often tolerate a perineal (via the bottom) approach such as a Delormes or Altemeier procedure although it has a higher risk of recurrence than an abdominal ventral mesh rectopexy.

Anal warts
Anal warts are small warts that occur in the rectum and initially appear as tiny blemishes that can be as small as the head of a pin or grow into larger cauliflower-like protuberances. They can be yellow, pink, or light brown in colour, and only rarely are painful or uncomfortable. Roughly 90% of all anal warts are caused by the human papilloma virus (HPV). 

Treatment options include electrical cautery, surgical removal, or both. Warts that appear inside the anal canal will almost always be treated with cauterization or surgical removal.

Anal tags
Anal tags are harmless, small, brown or flesh coloured flaps of skin or flesh found at the anal verge. Anal skin tags are an extremely common condition and are mostly harmless. The soft skin, which is usually flesh coloured, or sometimes darker than the surrounding skin area, hangs on the opening of the anus by a stalk or stem that supplies the blood from the skin to the tag.  Anal skin tags are sometimes associated with other anorectal problems and may come about as a result of an injury, a haemorrhoid or an anal fissure.

Treatment includes diathermy excision under anaesthetic.

Haemorrhoids
Haemorrhoids are enlarged veins in the anus/lower rectum. They often go unnoticed and usually clear up after a few days, but can cause long-lasting discomfort, itching, bleeding and can occasionally be excruciatingly painful.  Haemorrhoids (also called piles) can be divided into two kinds, internal and external. Internal haemorrhoids lie inside the anus or lower rectum, beneath the anal or rectal lining. External haemorrhoids lie outside the anal opening. They can be present at simultaneously.

Haemorrhoids are caused by increased pressure in the veins of the anus most commonly through straining repeatedly to pass hard faeces which may result in a diet that is too high in refined foods and too low in fibre.  Haemorrhoids are also common during pregnancy.

Rectal bleeding and discomfort on defaecation are the most common features. A complication of prolapse is thrombosis and strangulation which can cause extreme pain.

There are a number of management and treatment options ranging from drinking plenty of fluids and eating a high-fibre diet to rectal suppositories and creams and local anaesthetics.  More troublesome haemorrhoids may be treated by sclerotherapy (injection of an irritant liquid) or banding.  A haemorrhoidectomy (surgical removal) is generally required for prolapsing haemorrhoids and there are several options including haemorrhoidal artey ligation and mucopexy (HALO), stapled haemorrhoidopexy (PPH) or open haemorrhoidectomy.

Anal fistula & abscesses
An anal fistula is an abnormal channel connecting the inside of the anal canal with the skin surrounding the anus and may be caused by an abscess that develops in the anal wall. Symptoms include constant throbbing pain and swelling in the rectal area. Pus is sometimes visible draining from the fistula opening on the skin.  Whilst many anal fistulae are idiopathic, some may be related to underlying Crohn’s disease or rectal cancer.

An anal fistula may require an MRI to assess its relationship with the anal sphincters. Surgical options include laying open of the fistula, use of a fistula plug and insertion of draining setons.

Colorectal cancer - commonly known as colon cancer, or bowel cancer is any cancer that affects the large bowel - the colon and rectum.

Colon cancer is caused by the abnormal growth of cells in the lining of the bowel. Usually small lumps called polyps begin to form. Commonly these lumps are referred to as tumours.  The growth of polyps can be harmless; these are known as benign tumours. However, these polyps can also be caused by the growth of cancer cells. These are called malignant tumours.

The type of treatment for colon cancer will depend on a number of factors. These include the size and location of the cancer, the stage of development of the cancer, whether this is a recurrence of the cancer and the overall health of the person.
Surgical resection, chemotherapy and radiotherapy are some of the treatment options.

Diverticulosis
Diverticulae are small pouches protruding from the side of the colon.
Diverticulosis can cause episodes of pain in the lower abdomen, as well as constipation or diarrhoea. Treatment is usually a high fibre diet, fibre supplements and antispasmodic drugs which relieve the symptoms.

Complications of diverticular disease
Complications of diverticular disease include acute diverticulitis, bleeding, perforation and peritonitis and fistulation into the bladder or vagina. Such complications may require surgical resection.

Ulcerative colitis causes the colon to become inflamed and in severe cases, ulcers may form on the lining of the colon. These ulcers can bleed and produce mucus and pus. Ulcerative colitis is an unpredictable condition. Symptoms can flare up and then go into remission for months or even years.  Ulcerative colitis may lead to anaemia due to blood loss.  Other complications include a toxic form of megacolon. There is also an increased risk of developing cancer of the colon after 10 years from diagnosis.

In most cases, medical treatment effectively controls the disease by relieving symptoms and preventing complications.  Aminosalicylates, steroids and immunosuppressant medication may be used to prevent relapses under the care of a gastroenterologist.

A colectomy (surgical removal of the colon) may be required for those with complications, medically resistant disease, a severe acute attack or to avoid colonic cancer in patients with dysplasia. 

Crohn's disease is a condition that causes inflammation of the gastrointestinal tract. The gut consists of the oesophagus, stomach, and small and large intestine to the anus.  Crohn's disease can affect any part of the gut. However, it commonly occurs at the lower end of the small intestine, known as the ileum.

Complications arising from Crohn's disease may occur, particularly if symptoms are frequent and severe. These may affect the intestine or may develop elsewhere in the body.  The thickening of the intestinal wall may narrow the inside of the intestine so that an obstruction occurs.  A fistula (abnormal passageway) may be developed and an abscess may occur around the anus or within the abdomen. People with Crohn's disease also have a slightly higher risk of developing bowel cancer compared with those who do not have the condition.

5-ASAs, steroids or biological agents are commonly used to treat Crohn's disease. Whilst surgery to remove damaged sections of the intestine is avoided whenever possible, patients may need surgery at some stage to treat problems including abscesses and blockage of the intestine.

IBS is one of the most common gastrointestinal conditions and causes abdominal pain, diarrhoea and constipation. There are different types of IBS, depending on the main symptom.

Although IBS poses no serious threat to health, it can have an adverse effect on a person's quality of life. The exact causes of IBS are unknown.

The symptoms can be controlled with lifestyle changes and medication.  IBS can be controlled through a change in diet and use of relaxation techniques.  Bulk forming agents, short courses of antidiarrhoeal and anti-spasmodic drugs may also be employed.  Hypnosis, psychotherapy and counselling have proved effective in some cases.