Colon and rectal cancer (commonly known as colorectal cancer) is a commonly diagnosed cancer. About 5% of Americans will develop colorectal cancer in their lifetime. The colon compromises the first 4-5 feet of the large intestine starting from the small intestine to the rectum, while the rectum is the last 5 inches of the large intestine leading to the anus. Colorectal cancer is highly curable when diagnosed in early stages.
Colorectal cancer generally arises from the inner lining of the intestine then progresses deeper into the wall muscle, and eventually to the associated lymph nodes. Most colorectal cancers start as colon polyps that progress over time to become cancerous. Detection of these polyps early and removal reduces the risk of colorectal cancer.
Risk factors for colorectal cancer include older age, specifically as patients age over 50, family history of colorectal cancer (such as having parents or siblings with colon or rectal cancer), history of colorectal polyps, or prolonged history of Crohn’s colitis or Ulcerative colitis.
Symptoms of colorectal cancer include changes in bowel habits such as constipation, diarrhea, narrow stools, rectal bleeding, abdominal pain or cramps, fatigue, weight loss, or anemia. Some patients maybe diagnosed with colorectal cancer with a screening colonoscopy prior to the development of symptoms.
Patient with newly diagnosed colorectal cancer usually require evaluation with a physical exam, blood work, a complete colonoscopy, a CT scan to evaluate for tumor spread. Other tests that may be needed include a rectal ultrasound, a liver or pelvic MRI, and a PET CT.
Surgery to remove the portion of colon or rectum with the tumor in it continues to be important for cure. For colon cancer, surgery is usually the first step of treatment and requires removal of the part of the colon with the cancer, the lymph nodes associated with it, and a small portion of healthy colon, and reconnection of the intestine. The stage of the cancer then determines whether treatment with chemotherapy is needed. Radiation is usually not needed for colon cancer treatment.
Rectal cancer treatment depends on the stage. The tumor stage is determined with either an ultrasound or an MRI. Depending on the stage, treatment with radiation and chemo maybe needed before surgery to shrink the tumor and reduce the chance of the tumor recurring.
Diverticulosis refers to little outpouchings in the colon wall. Although diverticulosis can exist in other parts of the colon, most of the issues with diverticulosis occur in the sigmoid colon. Diverticulosis is thought to develop because of a diet low in fiber and high in red meats.
Diverticulitis is inflammation of the colon wall caused of perforation of one of the diverticula. Symptoms of diverticulitis include lower abdominal pain and fevers. Other symptoms can include abdominal bloating, nausea, rectal bleeding, and diarrhea. Most attacks of diverticulitis are now diagnosed with a CT scan. The majority of episodes of diverticulitis can be treated with antibiotics.
Diverticulitis can also have complications. The most common complications of diverticulitis include an abscess, a fistula, a stricture, or free perforation.
- Abscess: A pocket of pus that forms in the abdomen. It is the body’s way to wall off infection within the abdomen. An abscess that is large will require drainage usually through a catheter placed by interventional radiology as well as antibiotics.
- A fistula: a fistula is an abnormal connection between two organs. With diverticulitis, this most commonly occurs between the colon and the bladder, although it can also connect to other organs such as the vagina, uterus, skin, and other portions of the intestine. Symptoms of a fistula of the bladder consist of gas, blood, and stool in the urine as well as recurrent urinary tract infections.
- A stricture is a narrowing in the colon wall. This usually occurs after attacks of diverticulitis causing the colon wall to become scarred. This causes a partial blockage, which leads to narrower stools, trouble with bowel movements, and abdominal pain. Rarely, patient may have a complete blockage requiring more urgent surgery.
- Diffuse peritonitis: this occurs when there is a perforation in the colon leading to spread of pus or stool inside the abdomen. This can lead to peritonitis, significant abdominal pain, fevers, chills, and bloating. This can also cause sepsis and usually requires an emergency operation.
Surgery is usually not required for acute attacks of diverticulitis with no complications. Such attacks can usually be treated with hospitalization and antibiotics, or oral antibiotics at home. Elective surgery maybe required after multiple attacks. There is no set number of attacks that require surgery, however, as you develop more attacks, the likelihood of having more attacks in the future increases. The decision to undergo surgery for recurrent attacks can be made along with your surgeon to prevent future attacks.
Emergency surgery is usually required for diffuse peritonitis. This usually requires resection of the disease portion of the colon. A colostomy or an ileostomy maybe required in this case depending on the extent of the contamination and how ill the patient is from the diverticulitis. Rarely, emergency surgery may also be required for a blockage related to diverticulitis.
Patients with complicated diverticulitis will benefit from elective surgery. This usually requires resection of the sigmoid colon and reconnection of the colon to the rectum. This is usually performed in minimally invasive fashion. This will help in resolving the symptoms from the complication as well as preventing future attacks.
An anal fissure is a small tear or cut in the anal canal lining. Symptoms of anal fissure include severe sharp cutting pain. Pain usually starts with the bowel movement and lasts for minutes to hours. Other symptoms include small amounts for bright blood and a skin tag near the anus. A fissure is caused by trauma to the anal canal, usually from hard stool and constipation or severe diarrhea. Treatment usually includes non-surgical options such as improvement of bowel movements with fiber supplementation, taking stool softeners, increasing water intake, sitzs baths, prescription creams to help with pain as well as help heal the fissure. If your fissure does not heal, then surgery is recommend. The options include Botox injections into the anal sphincter to relax the muscle or division of the inner part of the sphincter muscle to allow it to heal.
Anal abscess and Anal fistula
An anal abscess is an infection near the anus or distal rectum. It usually consists of a pocket with purulence in it. A fistula is an abnormal tunnel that develops from the inside of the anal canal or distal rectum to the outside skin near the anus. An abscess is usually an acute issue, and 40-50% of patients who develop an abscess may progress to develop a fistula. Symptoms of an abscess include sever pain in the anal area, associated with swelling and redness. Patients with an abscess can also have fever or feel ill. Fistula symptoms usually include some discomfort and constant or recurrence drainage from an opening near the anal area. Certain patients are more prone to developing abscesses and fistulas such as patients with Crohn’s disease.
Treatment of an abscess usually requires drainage. This can be performed in your surgeon’s office under local anesthesia or may require drainage in the operating room. Fistula treatment is usually surgical and can include a variety of procedure, such as a seton placement (a small drain left in the fistula tract), a fistulotomy which is cutting the fistula tract, and other procedures to repair the fistula. The type of fistula procedure required depends on how much of anal sphincter muscle is involved with the fistula.
Hemorrhoids are a normal part of everyone’s anatomy. Hemorrhoids consist of blood vessels, connective tissue, and small amount of muscle that lie in the distal rectum and anal canal. There are two types of hemorrhoids, internal and external hemorrhoids depending on the location.
Hemorrhoids can become symptomatic as a result of many factors, including constipation, diarrhea, aging, pregnancy, and certain defecation habits such as prolonged straining and sitting on the toilet bowel.
- Internal hemorrhoids are located inside the rectum. Symptoms of internal hemorrhoids include bleeding. Bleeding tends to be bright, painless, and occur with bowel movements.
- Internal hemorrhoids can also prolapse. Prolapse can usually occur after bowel movement, prolonged standing, or activity. Prolapsed internal hemorrhoids can vary in severity from ones that reduce spontaneously, to requiring them to be pushed back in, to ones that are not reducible.
- Treatment of internal hemorrhoids depends on severity and ranges from medical therapies, to office-based procedures such as rubber band ligation, or surgical options such as trans-anal hemorrhoidal de-arterialization (THD) or hemorrhoidectomy.
- External hemorrhoids are located outside the rectum and covered by skin. Symptoms of external hemorrhoids are usually caused by an episode of severe straining. Thrombosed external hemorrhoids will cause severe pain with a lump about grape size that tends to be blue and can be felt near the anal canal. The clot inside the hemorrhoid can cause pressure and burst through the external hemorrhoid skin causing bleeding. Treatment of thrombosed external hemorrhoids usually involves incision and excision of the clot.
Rectal prolapse is a condition that results from protrusion or telescoping of the rectum from the anal canal. Rectal prolapse can be either partial a full-thickness. Symptoms of prolapse usually consist of tissue that comes out form the anus, as well as possible mucous seepage and fecal incontinence. The definitive treatment of rectal prolapse is surgical either through an abdominal or perineal approach, depending on multiple factors. You should have a discussion with your surgeon about the best approach. Abdominal repair is usually performed in minimally invasive fashion, either robotic or laparoscopic.