Tag: hemorrhoids

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Had Your Butt Checked Out Lately?

There are more jokes and humorous videos on the internet about colonoscopy than about mammography or cervical cancer screening. The reason is quite obvious. Most people do not like the idea of people inserting long tubes and cameras in the rear end of our anatomy. That is where the problem lies. Out of fear and embarrassment, we ignore that area and by the time we pick up cancer it is too late.

Alberta Cancer Board, Canadian Cancer Society and Alberta Health Services have been very aggressive in promoting the Alberta Colorectal Cancer Screening Program. You must have read about it in the newspapers, heard about it on the radio and seen the news on TV. The question is: what have you done about it? Are you ready for it?

The program aims to save lives by improving the prevention and early detection of colorectal cancer in Albertans between the ages of 50 and 74. The sad part is only 10 to 20 per cent of Canadians come forward to have some kind of screening test done for their colon. More women would go for mammography and cervical cancer screening than colorectal screening. And men are worse when it comes to screening for colorectal and prostate cancer.

Men and women are almost equally at risk of getting colorectal cancer. There is a less than three minutes video on YouTube (http://www.youtube.com/realmenscreen) titled: “Had your butt checked out lately? – The Canadian Cancer Society asked men this question.” It is humorous and educational. Check it out!

Colorectal cancer is the fourth most common cancer. The average lifetime risk of developing colorectal cancer is six per cent. It is the second leading cause of cancer death in Canada. It is expected that colorectal cancer screening will decrease both, incidence and mortality.

Most people are scared as soon as they hear the word colonoscopy. It is important to remember that colonoscopy is not the only test for screening although it is the best test and is considered as gold standard against which other screening tests are compared. In certain circumstances (high risk patients) you do not have a choice but go through a colonoscopy for diagnosis, prevention and treatment of certain conditions.

You are at a high risk of getting colorectal cancer if you have a family history of colorectal cancer or polyps, have a personal history of ulcerative colitis or Crohn’s colitis
and have had polyps or previous history of colorectal cancer.

If you have symptoms like rectal bleeding then you don’t have a choice – you need a test. Depending on your age, the test may be a flexible sigmoidoscopy in the office or colonoscopy at the hospital. For example, six per cent of the patients who say they are bleeding from hemorrhoids have colon or rectal cancer.

Every individual is at risk of developing colorectal cancer. If you have no symptoms, have no family history of colorectal cancer and you are 50 years or older then you do not have to go through colonoscopy. You have a choice of doing stool tests for occult blood yearly or bi-annually, flexible sigmoidoscopy in an office every five years or combine stool test and flexible sigmoidoscopy every five years.

Every test for screening has advantages and disadvantages. None of them are full proof. And they vary from very invasive (colonoscopy) to least invasive (stool test). If you fall into high risk category then colonoscopy is the way to go. If you are asymptomatic person with an average risk then you have a choice of tests mentioned earlier.

So don’t be scared, talk to your doctor and have your butt checked out!

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Anal Fistula Can Be Difficult To Treat

This model illustrates various pathology of the rectum. (iStockphoto/Thinkstock)
This model illustrates various pathology of the rectum. (iStockphoto/Thinkstock)

Last week, I was in San Francisco, California to attend the Clinical Congress (convention) organized by the American College of Surgeons. It is one of the largest surgical conventions in the world. The convention lasts five days (Sunday to Thursday). By Wednesday afternoon, total registration for the convention was 14,397: 8916 were physicians and the rest were exhibitors, guests, spouses and convention personnel.

Not everybody is in one auditorium or room at the same time. Each room has its own list of speakers and topics for discussion. So you head yourself to a room which offers discussion on a topic which interests you the most. The conference was held at the Moscone Convention Center. It is the largest convention and exhibition complex in

San Francisco. It comprises three main halls with total of 84,000 square meters of space (900,000 square feet).

One of the symposiums I attended was on surgical problems of anus and rectum: cancer, fistula, fissure and hemorrhoids. Today, I will review the subject of anal fistula (fistula-in-ano).

What is a fistula? A fistula is an abnormal tunnel connecting two body cavities (such as the rectum and the vagina) or a body cavity to the skin (like the rectum to the outside of the body). Fistulas are usually the result of infection, injury or surgery. With an anal fistula there is a tunnel between the anus (and/or rectum) to the skin. A peri-anal abscess has a 50 per cent risk of turning into a fistula.

Anal fistulas do not generally harm the body. They are mainly a nuisance with some pain or discomfort and irritating intermittent discharge of blood, pus or stool. They can form recurrent abscesses which may require drainage under local anaesthetic.

Most of the time the diagnosis of fistula is made on the basis of classical clinical history and physical findings. Examination of the rectum may show an opening of the fistula onto the skin, the area may be painful on examination, there may be redness, a discharge may be seen or it may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula.

Treatment of the fistula depends on the presentation of the problem. If there is active infection or abscess then it needs to be treated with drainage of the pus and antibiotics. Once the infection is cleared the fistula can be treated surgically. If it is difficult to get rid of the infection then long term drainage can be established by inserting a seton – a length of suture material or thin rubber tubing is looped through the fistula which keeps it open and allows pus to drain out.

The treatment aim should be to prevent recurrence of fistula. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses.

There are several options. Doing nothing – a drainage seton can be left in place long-term to prevent problems. But this does not cure the fistula. Fistula can be layed open under anaesthetic. Once the fistula has been layed open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. Depending on the depth of the fistula, this option may affect continence if the fistula involves sphincter muscles. Most fistulas are superficial and can be layed open under local anaesthetic without much problem with continence.

Other methods of treating fistula are: using fibrin glue injection, using fistula plug, creating a flap to cover the internal fistula opening and using a seton to cut through the deep fistulous tract. Each method has advantages and disadvantages.

Some fistulas are very difficult to treat if they are caused by inflammatory bowel disease like Crohn’s disease. Any patient with recurrent fistula should be investigated for inflammatory bowel disease. Otherwise, most fistulas can be cured with patience and perseverance.

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Hemorrhoids

My doctor says I have hemorrhoids. Can you please tell me more about this subject? What is the treatment for hemorrhoids?

Answer: We all have hemorrhoids. Hemorrhoids are vascular cushions in the anal canal. External hemorrhoids are in the margins of the anal canal. Internal hemorrhoids are at the junction of the rectum and the anal canal. There are three internal hemorrhoidal cushions at three, seven and 11 o’clock.

It is important to remember that hemorrhoids are not always symptomatic and all problems in the rectal area are not due to hemorrhoids. It is difficult to estimate the true incidence of symptomatic hemorrhoids.

The earliest writings on the subject of symptomatic hemorrhoids occurred in 400 BC by Hippocrates. It was thought that the hemorrhoidal symptoms were due to infection of the veins in the rectum due to passage of stool. Red-hot iron was used to cauterize the hemorrhoids!

Napoleon was finally defeated by the British at the Battle of Waterloo in 1815. Several accounts by those who were close to him have indicated that the battle was lost because Napoleon was too busy treating his hemorrhoids. He routinely treated his hemorrhoids with three to four leeches!

There are two main reasons why people get symptomatic hemorrhoids: there is a history of straining while having a bowel movement and the aging process makes the supporting tissues in that area lax. Increased intra-abdominal pressure (for example in pregnancy) and increased congenital internal anal sphincter pressure can give rise to symptomatic hemorrhoids.

Internal hemorrhoids are classified by the degree of prolapse:
-First-degree hemorrhoids do not prolapse with straining, but can be associated with bleeding.
-Second degree hemorrhoids protrude during straining but will spontaneously retract.
-Third degree hemorrhoids protrude outside the anal canal with straining and require manual reduction.
-Fourth degree hemorrhoids remain prolapsed independent of straining and are irreducible.

Patients with hemorrhoids have no symptoms or present with variety of symptoms such as bleeding, prolapse, feeling of incomplete evacuation, soiling, irritation and itching. Severe pain in the rectal area is due to thrombosed hemorrhoid, fissure or cancer.

The diagnosis of symptomatic hemorrhoids is usually made with digital rectal examination and direct visualization with an instrument. If patient presents with rectal bleeding then other causes of bleeding should be ruled out by endoscopy.

Treatment of hemorrhoids includes dietary and lifestyle changes, rubber band ligation of hemorrhoids and surgery.

High fiber diet and fiber supplement reduces the bleeding and discomfort from hemorrhoids. Fiber causes bloating and flatulence so it should be increased gradually. Avoid straining at the time of defecation. Use hemorrhoidal ointment to lubricate the anal canal before and after bowel movement.

Hot baths help relax the internal sphincter and ease discomfort in the anal area. In 1963, Barron described rubber band ligation for second and third degree hemorrhoids. After the procedure the patient may experience a feeling of pressure or rectal fullness for a period of 24 to 48 hours. There are other complications but they are rare and occur in less than three to four per cent of people.

For fourth degree hemorrhoids, surgical excision is the best option for relief of symptoms. Likely post-operative complications are pain, bleeding and urinary retention. But these treatment options are better than using leeches or red-hot iron rod!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!