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Colorectal cancer is cancer of the colon and rectum that begins with the development of pre-cancerous polyps from the lining of the colon and rectum.
Polyps are mushroom-like growths that form when cells lining the colon grow, divide and reproduce in an unhealthy, disorderly way. Polyps can become cancerous over time, invading the colon wall and surrounding blood vessels, and spreading to other parts of the body.
The exact causes of colorectal cancer are unknown, but the disease appears to be caused by both inherited and lifestyle factors. Lifestyle factors - such as cigarette smoking, lack of physical exercise, and obesity - may increase the risk of developing the disease. Genetic factors may determine a person's susceptibility to the disease, whereas dietary and other lifestyle factors may determine which at-risk individuals actually go on to develop the disease. Most of the time no identifiable cause is found for the development of colorectal cancer in any given individual, and it is simply due to random genetic changes that have occurred in the cells lining the colon or rectum.
Colorectal cancer is the second leading cause of death from cancer in the United States, and the third most common cancer overall. This year, more than 56,000 Americans will die from colorectal cancer and more than 140,000 new cases will be diagnosed. In fact, more women over the age of 75 die from colorectal cancer than from breast cancer. Eighty to 90 million Americans (approximately 25 percent of the U.S. population) are considered at risk because of age or other factors. (American Cancer Society Website)
Men and women aged 50 or older are at almost equal risk of developing colorectal cancer. Those who have a personal or family history of colorectal cancer or polyps are at higher risk of developing the disease. Anyone who has a long-term personal history of inflammatory bowel disease (Ulcerative Colitis or Crohns Disease) also is at higher risk.
See your doctor for yearly screenings if you are aged 45* or older. Be sure to maintain a diet low in animal fat and high in fruits, vegetables and fiber. Get regular exercise and avoid cigarette smoking. Keep alcohol consumption in moderation. Colon Cancer screening tests can identify and allow removal of pre-cancerous polyps and prevent the development of cancer.
*In 2018, secondary to new data on the increased risks of colon cancer in those under 50, the American Society of Colon and Rectal Surgery changed recommendations to consider starting screening at age 45.
Screening tests are the best way to find and remove polyps before they become cancerous, or to find an early cancer, when treatment can be most effective.
Several screening options exist. These include the fecal occult blood test (FOBT), flexible sigmoidoscopy, double contrast barium enema, and colonoscopy. Patients should talk to their colorectal surgeon or other healthcare provider to find out which screening method is right for them.
It is important to note that all people have hemorrhoidal tissue as part of their normal anatomy. Only in a minority of people do hemorrhoids become enlarged or otherwise symptomatic. Hemorrhoidal tissue lies within the anal canal and perianal area and consists of blood vessels, connective tissue, and a small amount of muscle.
There are two main types of hemorrhoids: internal and external. Internal hemorrhoids are covered with a lining called mucosa that is not sensitive to touch, pain, stretch, or temperature, while external hemorrhoids are covered by skin that is very sensitive. When problems develop, these two types of hemorrhoids can have very different symptoms and treatments.
Answer the following questions to see if you are at risk for developing colorectal cancer:
If you answered "yes" to any of these questions, you could be at risk of developing this disease. Talk to your colorectal surgeon or other healthcare provider about getting screened for colorectal cancer (screening means getting tested for a disease even if you don't have symptoms).
Screening can prevent colorectal cancer and healthy lifestyle choices can help. There are some things you can do to lower your risk of developing colorectal cancer.
Enhanced recovery after surgery, known as ERAS is a multimodal approach to surgical care that has been shown to improve recovery after surgery, especially in patients undergoing colorectal surgical bowel resections. Patients typically experience less pain, faster recovery and a shorter hospital stay with ERAS. This approach requires a very good cooperation between Surgeons, the Anesthesiologists, Nurses and the entire surgical team.
ERAS for colorectal resection surgery usually starts with a high carbohydrate drink 90 to 120 minutes prior to surgery. This helps to keep the bowels functioning during and after surgery. Medication given prior to surgery has also been found to improve the comfort level after surgery. Intravenous fluids are carefully monitored during surgery to decrease the possibility of fluid over load and edema or swelling of the intestines. Injections of long lasting anesthetics into the abdominal wall or spine may also reduce post operative pain and aid recovery.
After surgery patients are encouraged to get out of bed and walk early in their hospital stay. Food intake is started early and patients may eat regular foods as they are able to tolerate them.
Pain medication is diversified and individualized to include non-opioid pain medication which can inhibit the normal return of bowel function.
Using these techniques, hospital stay has been decreased and recovery has been shown to be improved.
Irritable bowel syndrome (IBS) is a common disorder affecting over 15 percent of the population. The following information has been prepared to help patients and their families understand IBS, including the symptoms, causes, evaluation, and treatment options.
IBS is one of a range of conditions known as functional gastrointestinal disorders. While no structural abnormalities exist and nothing abnormal is seen on tests, the bowel may function abnormally. IBS is sometimes referred to as spastic colon, spastic colitis, mucous colitis or nervous stomach . These are outdated terms. IBS should not be confused with Inflammatory Bowel Disease (commonly referred to as IBD) which is primarily made up of ulcerative colitis and Crohn’s disease. Importantly, treatment for IBS is medical, and surgery is not indicated for this problem.
HPV stands for human papillomavirus. HPV is a collection of 150 related viruses that can cause a variety of different problems of the genital and anal skin. It is the most common sexually transmitted infection (STI) and can cause genital and anal warts, a precancerous change called anal intraepithelial neoplasia (AIN), and anal cancer.
HPV is an STI that is passed from skin-to-skin contact through vaginal, anal or oral sex with someone who has the virus. HPV infection can also occur without sexual intercourse, as any direct contact with affected skin or bodily fluid from an infected person can cause HPV infection. HPV is very common and most people get infected with HPV at some point in their lives.
Rectal prolapse is a condition in which the rectum (the last part of the large intestine before it exits the anus) loses its normal attachments inside the body, allowing it to telescope out through the anus, thereby turning it “inside out”. While this may be uncomfortable, it rarely results in an emergent medical problem. However, it can be quite embarrassing and often has a significant negative impact on patients’ quality of life.
Overall, rectal prolapse affects relatively few people (2.5 cases/100,000 people). This condition affects mostly adults, and women over 50 years of age are six times as likely as men to develop rectal prolapse. Most women with rectal prolapse are in their 60’s, while the few men who develop prolapse are much younger, averaging 40 years of age or less. In these younger patients, there is higher rate of autism, developmental delay, and psychiatric problems requiring multiple medications.
Although an operation is not always needed, the definitive treatment of rectal prolapse requires surgery.
1. Thrombosed External Hemorrhoid
This is a blood clot that forms in an outer hemorrhoid in the anal skin. If the clots are large, they can cause pain when you walk, sit, or have a bowel movement. A painful anal mass may appear suddenly and get worse during the first 48 hours. The pain generally lessens over the next few days. You may notice bleeding if the skin on top opens. Nonsurgical treatment includes warm tub baths (sitz baths), pain medications, and stool softeners. Most experts recommend that the blood clots be removed surgically. This short surgery can be done in the surgeon’s office or at the hospital under local anesthesia.
2. Anal Fissure
The anal canal is a short tube surrounded by muscle at the end of your rectum. The rectum is the bottom section of your colon (large intestine). An anal fissure (also called fissure-in-ano) is a small rip or tear in the lining of the anal canal. Fissures are common, but are often confused with other anal conditions, such as hemorrhoids. The goal of all nonsurgical treatments is to make stools soft, formed, and bulky. Treatments include a high-fiber diet and over-the-counter fiber supplements (25-35 grams of fiber/day); over-the-counter stool softeners; warm tub baths (sitz baths) for 10 to 20 minutes, a few times per day; and several types of medication. Although most anal fissures do not require surgery, chronic ones are harder to treat and surgery may be the best option. The goal of surgery is to help the anal sphincter muscle relax, which reduces pain and spasms, allowing the fissure to heal.
3. Anal Abscess and Fistula
An abscess is an infected cavity filled with pus near the anus or rectum. In most cases, an abscess is treated by draining it surgically. A fistula is a tunnel that forms under the skin, connecting the clogged, infected glands to the abscess and out to the skin near the anus. Surgery is often needed to cure an anal fistula. Sometimes these surgeries are simple; however, more difficult cases may need multiple surgeries to take care of the problem.
4. Fungal Infection or Sexually Transmitted Diseases
Patients with fungal infections or infections caused by sexually transmitted diseases (STDs) may have mild to severe anal or rectal pain. STDs include gonorrhea, chlamydia, herpes, syphilis, HPV, etc. The pain is not always tied to having bowel movements. Other signs may include minor anal bleeding, a discharge, or itching. Treatment includes topical or oral antibiotics and antifungal medications.
5. Skin Conditions
Skin disorders that affect other parts of the body (e.g. psoriasis, warts) may also affect skin around the anus. Anal itching, bleeding, and pain may come and go. In some cases, a skin biopsy is needed. Treatment is tied to the results of the skin biopsy and/or physical exam. Early diagnosis is key so treatment can begin as soon as possible.
6. Anal Cancer
While most cases of anal pain are not cancer, tumors can cause bleeding, a mass, and changes in bowel habits, as well as pain that gets worse over time. If you have pain or anal bleeding that does not go away or gets worse, see a colon and rectal surgeon as soon as possible. The first office visit includes a physical exam, exam of the anal canal with a small, lighted scope (anoscopy) to visualize any abnormal areas, and biopsy of the mass. If the pain is too bad for an exam in the office, your surgeon may need to perform an exam under anesthesia to make a proper diagnosis. Treatment of anal cancer or other anal tumors may involve chemotherapy, radiation and/or surgery.
Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board-certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.
Anal warts (also called "condyloma acuminata") are a condition that affects the area around and inside the anus. They may also affect the skin of the genital area. They first appear as tiny spots or growths, perhaps as small as the head of a pin, and may grow quite large and cover the entire anal area. They usually appear as a flesh or brownish color. Usually, they do not cause pain or discomfort and patients may be unaware that the warts are present. Some patients will experience symptoms such as itching, bleeding, mucus discharge and/or a feeling of a lump or mass in the anal area.
Warts are caused by the human papilloma virus (HPV), which is transmitted from person to person by direct contact. HPV is considered to be the most common sexually transmitted disease (STD). You may be upset when you are given this diagnosis and it is important to note that anal intercourse is not necessary to develop anal condylomata. Any contact exposure to the anal area (hand contact, secretions from a sexual partner) can result in HPV infection. Exposure to the virus could have occurred many years ago or from prior sexual partners, but you may have just recently developed the actual warts.
Obstructed Defecation: Obstructed defecation is difficulty getting bowel movements out of the body. Although the stool reaches the rectum, or bottom of the colon, the patient has difficulty emptying. This often makes patients feel that they need to go the bathroom more often, or that they cannot empty completely, as if stool remains in their rectum. Obstructed defecation may be caused by pelvic floor prolapse (discussed below), pain symptoms or muscles not functioning normally.
Rectocele: A rectocele is a bulge of the front wall of the rectum into the vagina. Normally, the rectum goes straight down to the anus (picture). When a patient with a rectocele strains, the stool may get caught in an abnormal pocket of the rectum which bulges into the vagina. This prevents the patient from emptying the rectum completely. Generally, rectoceles do not produce symptoms. As they grow larger, rectoceles may cause difficulty going to the bathroom, or cause leakage of stool after having a bowel movement. Rectoceles are more common in women who have given birth. Rectoceles are usually caused by thinning of the tissue between the rectum and vagina and weakening of the pelvic floor muscles.
Pelvic Floor Prolapse: The pelvic floor consists of the muscles and organs of the pelvis, such as the rectum, vagina, bladder. Stretching of the pelvic floor may occur with aging, collagen disorders or after childbirth. When the pelvic floor is stretched, the rectum, vagina, or bladder may protrude through the rectum or vagina, causing a bulge, which can be felt. In addition to a rectocele, patients may have rectal prolapse, a cystocele (prolapse of the bladder) or protrusion of the small bowel. Symptoms generally include difficulty in emptying during urination or defecation, incontinence or pressure in the pelvis.
Paradoxical Puborectalis Contraction: The puborectalis muscle is part of the control muscles that control bowel movements. The puborectalis wraps like a sling around the lower rectum. During a bowel movement, the puborectalis is supposed to relax to allow the bowel movement to pass. If the muscle does not relax or contracts during paradoxical contraction, it may feel like you are pushing against a closed door.
Levator Syndrome: Levator syndrome is abnormal spasms of the muscles of the pelvic floor. Spasms may occur after having bowel movements or without a known cause. Patients often have long periods of vague, dull or achy pressure high in the rectum. These symptoms may worsen when sitting or lying down. Levator spasm is more common in women than men.
Coccygodynia: The coccyx, or tailbone, is located at the bottom of the spine. Coccygodynia is pain is of the tailbone. The pain is usually worsened with movement and may worsen after defecation. It is usually caused by a fall or trauma involving the coccyx, although in a third of patients no cause is noted.
Proctalgia Fugax: Proctalgia fugax is a sudden abnormal pain in the rectum that often awakens patients from sleep. This pain may last up to several minutes and goes away between episodes. Proctaliga fugax is thought to be caused by spasms of the rectum and/or the muscles of the pelvic floor.
Pudendal Neuralgia: The pudendal nerves are the main sensory nerves of the pelvis. Pudendal neuralgia is chronic pain in the pelvic floor involving the pudendal nerves. This pain may first occur after childbirth, but often comes and goes without reason.
Pruritis ani is a Latin term meaning “itchy anus” and is defined as an unpleasant sensation of the skin around the anus (i.e., rectal opening) that produces the desire to scratch. Pruritis ani is classified as primary or secondary. The primary form is the classic syndrome which may not have an identifiable cause (referred to as “idiopathic”) and the secondary form has an identifiable, and often specifically treatable, cause.
Minimal stimulation of the skin may cause itching. The subsequent scratching may cause injury to the skin which produces a larger area of irritated skin. Continued scratching causes the need to scratch more, making the problem worse.
An anal abscess is an infected cavity filled with pus near the anus or rectum.
An anal fistula (also called fistula-in-ano) is a small tunnel that tracks from an opening inside the anal canal to an outside opening in the skin near the anus. An anal fistula often results from a previous or current anal abscess. As many as 50% of people with an abscess get a fistula. However, a fistula can also occur without an abscess.
Anal cancer is an abnormal growth of cells in or around the anus or anal canal which is the short passage through which bowel movements pass. The most common type of cancer found in this location is believed to be related to a type of viral infection known as the human papilloma virus (or HPV) which has been linked to causing other types of cancers as well. Anal cancers are usually treated with radiation and chemotherapy. Surgery to remove the cancer is performed for very small or early anal cancers and when other therapy is not an option or has been unsuccessful in treating the anal cancer. Assessment for cancer spread and close follow up are necessary when treating anal cancer.
An anal fissure is a small tear in skin that lines the opening of the anus. Fissures typically cause severe pain and bleeding with bowel movements. Fissures are quite common in the general population, but are often confused with other causes of pain and bleeding, such as hemorrhoids.
Anal fissures can occur at any age and have equal gender distribution. 85-90% fissures occur in the posterior midline (back) of the anus with about 10-15% occurring in the anterior midline (front). A small number of patients may actually have fissures in both the front and the back locations. Fissures located elsewhere (off to the side) should raise suspicion for other diseases (see below) and will need to be examined further.
Fecal incontinence (also called anal or bowel incontinence) is the impaired ability to control the passage of gas or stool. This is a common problem, but often not discussed due to embarrassment. Failure to seek treatment can result in social isolation and a negative impact on quality of life.
There are many causes of fecal incontinence such as injury, disease and age.
After eating, food is transported through the small intestine, where it is broken down and the nutrients are absorbed. The remaining liquid waste then passes into the colon. The colon removes water and certain electrolytes, turning the liquid waste into a more solid form. It then passes into the rectum, where it is stored until it is time to have a bowel movement. Discussion of bowel function can be broken down into four main components:
Given the four main components of bowel function described above, constipation may mean different things to different persons. For some, constipation may mean infrequent bowel movements. To others, it is a hard stool which may be difficult to pass and requires excessive straining. Lastly, constipation may mean a bowel movement which does not completely evacuate and leaves the person with a sense that they still “need to go.” Some patients have combinations of these symptoms. As one can see based on the various combinations of symptoms, it can be somewhat difficult to specifically define what constipation is.
In an effort to better define constipation, specific criteria were established by the ROME Multinational Consensus in 2000, and subsequently updated last in 2016:
Pilonidal disease is a chronic skin infection in the crease of the buttocks near the coccyx (tailbone). It affects about 70,000 people in the US annually and is more common in men than women. Most often it occurs between puberty and age 40. People who are overweight and who have thick, stiff body hair are more likely to develop pilonidal disease.
A risk factor is something that increases a person’s chance of getting a disease or problem. There are many risk factors for diverticular disease including:
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