The Colon & Rectal Clinic of Ft. Lauderdale

Colon Disease & Treatments

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Common conditions treated and Surgical options


Hemorrhoids are part of each individual's normal anatomy and are made of specialized blood vessels and connective tissues. They are located in the anal canal (internal hemorrhoids) as well as the perianal area (external hemorrhoids). They contribute to continence to feces and gas: when the pressure in the abdomen and in the rectum increases, those blood vessels tend to engorge and therefore enlarge, serving as a barrier to involuntary passage of feces and gas. 

Issues with internal hemorrhoids are very common. When abdominal and rectal pressures are abnormally elevated for a prolonged period of time (as in constipation, diarrhea, irregular bowel movements, pregnancy, COPD, or simply by taking the habit of sitting on the toilet for a long time), the internal hemorrhoids become chronically enlarged and redundant and tend to prolapse outside of the anal canal. The hemorrhoid then becomes dry and starts bleeding (Grade 1), causing many other uncomfortable symptoms (itching, sense of pressure, pain). Most of the times, they go back into the anal canal spontaneously (Grade 2) or with gentle manual reduction (Grade 3). In most severe cases, the prolapsed internal hemorrhoids can get stuck outside of  the anal canal and this can cut off the blood supply to these structures (Grade 4). This last scenario prompts an emergent operation.

Treatment always starts with an attempt to identify the reasons causing the increased abdominal pressure, and consists initially in dietary changes (increased fiber intake, decreased meat and starches), fiber supplements, stool softeners and warm baths (they decrease swelling and relax pelvic floor muscles and sphincter complex). When the condition is chronic and the stretched and enlarged hemorrhoids tend to prolapse often, simple office procedures as hemorrhoidal banding can offer significant relief. In less than 10% of cases, a more involved surgical procedure is required, usually a same-day surgery under local anesthesia and sedation (excisional hemorrhoidectomy, stapled hemorrhoidopexy).

Issues with external hemorrhoids are usually caused by sudden increase in abdominal and rectal pressures due to irregular bowel movements (constipation, diarrhea, large and bulky stool), strenuous exercise, cough. This situation determines the rupture of the small external hemorrhoidal vessel with subsequent bleeding and clot formation (thrombosed external hemorrhoid). The clot rapidly stretches the perineal skin, which is extremely sensitive, causing a significant amount of pain. If the patient is evaluated between 3 to 5 days from the onset, the blood clot can be removed in the office under local anesthesia (excision of thrombosed external hemorrhoid), providing relief and a faster recovery. After 5 days, the clot is usually well on its way to be naturally absorbed by the body, like a bruise, and removing the clot does not add significant advantage. In these cases, conservative management as in internal hemorrhoids treatment is recommended, particularly warm baths, which can expedite the softening and the absorption of the clot.

For more information refer to the American Society of Colon and Rectal Surgeons website.

Anal fissure

An anal fissure is a tear of the anal canal skin. It is usually caused by a large and bulky bowel movement associated with constipation, or by prolonged diarrhea. Symptoms are consistent with intense anal pain, especially during and after defecation as well as bleeding, which can be significant. The intense pain causes severe spasm of the anal sphincter muscles, which increases the level of pain and can actually prevent the tear from healing properly because of decreased blood perfusion of the posterior quadrant of the anal canal, the most common site for an anal fissure. Typical anal fissures are more commonly located posteriorly or anteriorly. Less commonly fissure are located laterally; these atypical fissures can be associated with sexually transmitted diseases, Crohn's disease, HIV or other hematologic or infectious conditions and should be evaluated immediately by a specialized physician.
Anal fissure can be acute (recent onset of the symptoms, usually few weeks) or chronic (symptoms have been present for many months). Treatment of acute fissure is usually conservative, as only a minority of cases requires surgery. 

Conservative management is based on dietary changes, fiber supplementation, stool softeners, and warm baths. One of the strategies to relieve the pain and promote healing is to apply a compound ointment to and inside the anal canal, usually nitroglycerin, nifedipine or diltiazem, medications that tend to relax the sphincter muscle tension. Less commonly, Botulinum injections to the sphincter muscle can be performed for the same reasons. Conservative management might take many weeks (usually 6 to 10) to be effective.

Surgical treatment is reserved to chronic fissure which have not responded to conservative management and consists in partially dividing the internal sphincter muscle. It is the most effective treatment to heal the fissure. It is a surgical procedure performed as a same-day surgery and carry a very low, but real, risk of incontinence, mostly to gas.   

For more information refer to the American Society of Colon and Rectal Surgeons website.

Rectal abscess/fistula-in-ano

A rectal abscess is an infected pocket of pus that develops around the anorectal area. The infection usually starts from one of the glands of the anal canal which gets plugged by stool and bacteria. The infection spreads from the gland through the tissue around the anal canal and rectum to form a rectal abscess. Symptoms are fever, sick-feeling, intense rectal pain, redness and swelling. Sometimes the abscess opens up spontaneously, causing a large amount of pus to drain out of the abscess, relieving the pain immediately.
If that doesn’t happen, the abscess needs to be drained surgically under local anesthesia in the office or in the operating room. 

In about 50% of cases, the "tunnel" connecting the infected anal canal gland and the abscess remains open resulting in a fistula-in-ano. Symptoms of an anal fistula are persistent anal discomfort, drainage and swelling even though the abscess cavity has healed. Treatment of a fistula-in-ano can be very complicated and usually involves a procedure under anesthesia. The surgical strategy strictly depends on how much sphincter muscle is involved above the fistula tract. If only a small amount of muscle is involved, the fistula tract can be simply opened to unroof the tunnel and allow the open wound to heal spontaneously from the bottom up (fistulotomy). The advantage of this surgery is that immediately cures this condition; the disadvantage is that part of the sphincter muscle is divided in the process, which put the patient at increased risk of incontinence, especially in females which have a smaller amount of sphincter muscle overall.

When the fistula tract involves too much sphincter muscle, the strategy changes and treating the fistula becomes a multi-step process. The first step is to isolate the tract under anesthesia and to place a Seton around the tract, which is a drain that stays in place for few weeks, allows the infected debris to drain spontaneously and allow the formation of scar tissue around the tunnel.
Once this step is achieved, there are many different procedures available to treat the fistula, from the less invasive (but usually less effective) techniques (Fibrin Glue injection of the fistula tract, Fistula plugs) to the more involved and effective procedures (but carrying higher risks) such as rectal mucosa advancement flap or Ligation of Intrasphincteric Fistula Tract procedure (LIFT).
Crohn's-related fistulas represent a complex clinical and surgical challenge, which is based on identification and drainage of the fistula tracts with Seton drains. Because of tissue inflammation and friability, no incisions are performed. Further plan is based on the response to medical management of Crohn's disease.     

For more information refer to the American Society of Colon and Rectal Surgeons website.

Anal warts

Anal warts, also called "condiloma acuminata", are fleshy growths that develop around the anus. The size and the extent of these warts are variable, from small few skin spots to multiple larger cauliflower-like nodules covering most of the skin around the anus. Symptoms are variable as well. When the disease is extensive, they can present with anal itching, discomfort and bleeding. Anal warts are caused by an infection with Human Papilloma Virus (HPV) and are one of the most common Sexually Transmitted Diseases (STDs). Anal intercourse is not necessary for infection though, as they can be transmitted by simple contact with infected skin. That's the reason why you can find them in areas other than around the anus, such as groin and genitalia.
Treatment consists in biopsy and destruction of these growths, which can be achieved either by the local application of medications (special acids that "burn" the warts or medications that stimulate the immune response of the body against them) or surgically, through a same-day procedure under local anesthesia and sedation.

The management of this condition is particularly complicated in immunosuppressed individuals (HIV positive, AIDS and transplant patients). Longstanding infections with specific strains of the HPV virus can be a risk factor for anal cancer. 

For more information refer to the American Society of Colon and Rectal Surgeons website.

Anal cancer

Anal cancer is uncommon, representing only 1 - 2% of the malignancies of the gastrointestinal tract. "Squamous Cell Carcinoma" is the most usual type of anal cancer that can arise either on the skin around the anus or in the anal canal. It can present as an anal ulceration and can cause anal pain, bleeding or changes in bowel habits. Risk factors are age, longstanding  infection with Human Papilloma Virus or other Sexually Transmitted Diseases, history of Radiation Therapy to the area, history of chronic and poorly controlled Inflammatory Bowel Disease to the anus and rectum (Crohn's disease, Ulcerative Colitis), anal sex, immunosuppression (HIV positive, AIDS and transplant patients), smoking, chronic infection (long-standing rectal abscesses, fistulas-in-ano, open wounds). 

Diagnosis is made at physical examination and biopsy of the suspected area. Treatment consists in either local excision of the cancer, chemotherapy and radiation treatment to area, or complete removal of the rectum and anus with permanent colostomy (Abdomino-Perineal Resection, or APR), according to the type, location and extension of the cancer. 

For more information refer to the American Society of Colon and Rectal Surgeons website.

Pilonidal disease

Pilonidal disease indicates a particular skin infection that develop in the area between the buttocks (buttock cleft). The source of this condition is thought to be ingrowth hairs that can determine the infection of the follicle. The disease ranges from the mere presence of "pilonidal pits" (pinpoint holes at the buttock cleft) with no signs of infection, to more complex pilonidal abscesses that can extend to the surrounding skin of the buttocks or the anus. The diagnosis is pretty straight-forward at physical exam. 

In case of a pilonidal abscess, the treatment consists in the surgical opening of the abscess cavity and the drainage of the purulent material. The remaining skin infection is treated with antibiotics and the affected area is finally excised surgically once the acute inflammation has subsided. This strategy allows the surgeon to remove a smaller area of skin and subcutaneous tissue. The open wound is managed in different ways: if the defect is small, it can be left open to heal from the bottom-up like an open sore with daily packings. In case of bigger wound, special Vacuum Assisted Closure (V.A.C.) dressing changes might be indicated. Multiple surgical techniques to "flap" healthy tissue around the open wound to fill the cavity are available as well.

For more information refer to the American Society of Colon and Rectal Surgeons website.

Pelvic Floor Disorders

Pelvic Floor Disorder is a term that includes a wide range of problems related to the muscles and the ligaments that form the pelvic floor. The three main clinical conditions are urinary incontinence, fecal incontinence and organ prolapse. Less frequently, Pelvic Floor Disorder presents as chronic pain syndrome (vulvodynia, levator spasm syndrome), sexual dysfunction or disorders of evacuation such Obstructed Defecation Syndrome, which is characterized by symptoms of chronic constipation related to paradoxical contraction of the pelvic floor muscle at time of defecation (when they normally relax to allow the stool to pass) or by the presence of the rectum bulging into the vagina, entrapping the stool at the time of defecation (rectocele).
These issues are more commonly identified in women as they usually have a broader pelvis and thinner muscles. Pregnancy is a significant risk factor for pelvic floor disorder because of the strain that the gravid uterus exert on the muscles, ligaments, tendons and nerves of the pelvis. Hysterectomy is a risk factor as well, because the uterus contributes to the mechanical support of the pelvic floor.

While urinary incontinence is an issue commonly evaluated and treated by Urologist or Uro-Gynecologist specialists, the Board-certified Colorectal surgeon has a special expertise in the diagnosis and treatment of fecal incontinence (see below) and organ prolapse, most commonly rectal prolapse.

Rectal prolapse is a form of Pelvic Organ Prolapse that we commonly see in our Practice. It is usually associated to severe chronic constipation and advanced age and presents when the rectum “falls out” of the pelvis. This problem can be approached surgically in two ways: either through the perineum, removing the prolapsed rectum and reconnecting the two ends of the bowel, or through an abdominal operation, which consists in “lifting” the rectum in the pelvis and “tucking it” to the sacral bone. This last option is a major invasive operation with higher complication rates but better results. It is usually offered to younger, fit patients.

Another condition that we usually see and treat in our Practice is rectocele, which is determined by the rectum "bulging" through the posterior wall of the vagina. This bulging can become a sort of closed "pouch" where stool collects at the time of defecation, preventing the passage of the stool bolus and causing a physiologic obstruction (Obstructed Defecation Syndrome). Most of the patients respond to conservative management, including stool softeners, fiber supplementation or Biofeedback (physical therapy of the pelvic floor muscle). In a smaller percentage of cases, the bulge is so big that needs to be surgical removed and this can be obtained either operating through the perineum (transperineal rectocele repair) or with a stapled, minimally invasive procedure through the anus (Stapled TransAnal Rectal Resection or STARR procedure).  

We commonly cooperate with our Uro-Gynecologist colleagues in treating patients with complex organ prolapse conditions, which can present with prolapse of the bladder (cystocele) of the vagina (colpocele) associated with rectal prolapse. In those cases, we plan a join procedure to repair multiple conditions at the same time.

For more information refer to the American Society of Colon and Rectal Surgeons website.

Fecal incontinence

Fecal incontinence is defined as involuntary loss of fecal material through the anus. Both continence and defecation are very complex functions, involving multiple systems to work together in a very sophisticated fashion. Fecal incontinence can be active, when the patient knows that she/he needs to move her/his bowel but cannot control it, or passive, when stool is lost without the patient knowing that this is happening. The most common causes of fecal incontinence are sphincter damage due to trauma, previous surgery or vaginal delivery, damage to the pudendal nerve (the nerve that controls the pelvic floor muscles and collect the sensation from the rectal area) from trauma, pregnancy or diabetes, or pelvic floor dysfunction.

This condition is evaluated with a thorough anorectal physiology work-up including:

In very old and debilitated patients, another option to treat fecal incontinence is the injection of a bulking agent underneath the mucosa of the anal canal. This procedure "fills up" the anal canal, promoting continence. The results of this technique have been proved, but the duration of the effect is very limited as the bulking agent is reabsorbed by the body within one to two years. The injection is performed in the office.

For more information refer to the American Society of Colon and Rectal Surgeons website.

Chronic constipation

Chronic constipation is a term that refers to unfrequent bowel movements, associated to the need for straining, sense of incomplete evacuation and need for chronic laxative products to be able to have a bowel movement. Most of the times, this issue is managed by increasing the fiber content in the diet, either increasing the amount of high fiber food in the daily diet (bran, whole-wheat bread and pasta for example) or taking over-the-counter fiber supplements. The recommended daily amount of fiber is between 25 to 35 grams, along with 60 to 80 ounces of water daily. Exercise is recommended as well to improve constipation. There are multiple medications that can cause constipation, such as some medications to treat high blood pressure as well as iron and calcium supplements.

In a small number of patients, constipation constitutes a problem since a very young age. In those cases, a more accurate work-up is necessary as the patient might be affected by a disorder that affects the motility of the bowel itself (atonic colon, Hirshsprung's disease).

A new onset constipation should always be evaluated promptly by a physician, because it might be caused by a narrowing of the colon determined by a growth, especially if rectal bleeding is associated to this picture.

For more information refer to the American Society of Colon and Rectal Surgeons website.

Pruritus ani

"Pruritus ani" is a Latin term that means anal itching. This problem can be very bothersome and significantly affect the quality of life. There are many conditions of the anus that can cause itching, including hemorrhoidal disease, fungal and viral infection of the perianal skin, Sexually Transmitted Diseases (STDs), rectal abscesses and fistulas-in-ano. Nonetheless, this term is usually related to a condition caused by excessive moisture of the anal area, which can be caused by excessive perspiration, small amount of residual stool in the area or excessive application of topical creams/ointments for a number of other reasons. In some individuals, anal itching is associated to the consumption of certain foods and alcoholic beverages that are though to affect the protective layer of the perianal skin when present in the stool. The initial step to assess this condition is always an accurate evaluation performed by a specialist in order to rule out a specific cause, as mentioned earlier. After that, the management consists in decreasing the presence of moisture in the perineal area, mostly keeping it dry and clean. Use of medicated products, creams or sprays, is contraindicated. Avoiding further trauma from scratching is very important as well.

For more information refer to the American Society of Colon and Rectal Surgeons website.

Inflammatory Bowel Diseases (IBDs)

Crohn's Disease (CD) and Ulcerative Colitis (UC) are called Inflammatory Bowel Diseases (IBDs) because are caused by chronic inflammatory conditions that affect the bowel. 

CD can affect any part of the gastrointestinal tract, from the mouth to the anus. Most commonly, it affects the last part of the small intestine (Crohn's ileitis) but can affect characteristically the anus and the rectum (proctitis, anorectal abscesses and fistulas). Initial symptoms can be abdominal pain, changes in bowel habits, weight loss, rectal bleeding, rectal pain and multiple atypical anal lesions, joint pain, skin lesions.

The inflammation related to Crohn's disease usually goes full-thickness through the bowel wall, and that can complicate the course of the disease with narrowing of the bowel or creating fistulas (communicating tracts) with other organs such as skin, colon, bladder, vagina. Diagnosis is made through an accurate physical examination and other tests like colonoscopy, small bowel contrast X-rays, CT scan of the abdomen and pelvis. Treatment is initially medical, based on "cooling off" the inflammation with steroids, progressively transitioning to medications that "turn down" the immune system in order to decrease the chances of recurrence. This is necessary to avoid the severe side-effects of prolonged steroid treatment such as diabetes, muscle waisting, impaired wound healing, susceptibility to infection, osteoporosis, to mention few. The surgeon becomes involved in the care of these patients whenever the disease creates a severe narrowing of the affect bowel or an enteric fistula as mentioned above. A colorectal surgeon expertise is particularly valuable in the management of anal Crohn's disease, which is mostly based on draining the areas of infection and allow the medical management to treat the inflammation before definitive care. 
UC affects the rectum initially, extending progressively to the colon.

The inflammation is limited to the inner layer of the bowel and for this reason narrowing and fistulas are not part of the disease. Symptoms are rectal bleeding, abdominal pain, changes in bowel habits and weight loss. As for Crohn's disease, the initial management is medical and based on steroids in the acute settings, subsequently tailored to other medications that "turn down" the immune system to decrease the chances of recurrence and avoid the side-effects of chronic steroid use. Because this condition affects only the colon and the rectum, surgery offers the only curative option in patients in which the disease is not controlled on medications. The operation consists in the complete removal of these organs (total proctocolectomy). When the patient is acutely ill (toxic megacolon, refractory colitis), the treatment consists in removing most of the colon through an abdominal operation, leaving the rectum behind and connecting the ileum to the abdominal wall to collect the waste products (total abdominal colectomy with end ileostomy). Further steps are taken after 2 to 3 months, when the patient's general conditions are improved. At that point, a second operation is entertained to remove the rectum (proctectomy) and reconnect the small bowel, folded in a special pouch, to the anus (ileal-pouch anal anastomosis or IPAA). Because the connection between the small bowel and the anus is very delicate, a loop ileostomy is left in place to protect it to prevent stool from passing though the new connection. The ileostomy is finally closed after 2 to 3 months (3-stage process). In specific cases, such as in very young individuals, a total abdominal colectomy with connection of the small bowel to the rectum (ileo-rectal anastomosis or IRA) can be considered, as the proctectomy carries a significant risk of infertility and sexual disfunction.

The disease in the rectum is usually treated then with steroid or anti-inflammatory medication enemas, sparing the patient from the side-effects of systemic treatment. Proctectomy can be considered a later time.

Both CD-related colitis and UC carry an increased risk of developing colorectal cancer, directly associated to the duration and the extent of the inflammation of the colon. It is very important to establish a cancer screening protocol through regular colonoscopies.

For more information refer to the American Society of Colon and Rectal Surgeons website.

Colorectal Cancer Screening / Risk assessment

To screen for colorectal cancer means to look for it in patients that have no symptoms of it. Early detection of cancer impacts significantly the patient's survival, as opposed to diagnosing the cancer when it has already spread to lymph nodes or other organs (metastatic disease). This can be achieved through physical examination (i.e. digital rectal exam), fecal occult blood test (FOBT), endoscopy (flexible sigmoidoscopy, colonoscopy) and special X-rays that use contrast injected into the rectum to evaluate the internal lining of both colon and rectum for any abnormalities (narrowing, polyps or cancer). Any abnormality at FOBT or radiologic imaging needs to be evaluated with a complete colonoscopy, that provides direct visualization and the capability to remove the polyp or perform a biopsy.

In an average-risk individuals, which means in patients with no symptoms, no rectal bleeding, no family history of colorectal cancer or other cancers in close relatives diagnosed at early age, no history of genetic predisposition for cancer or history of Inflammatory Bowel Diseases, screening should start at age 50 with either 1) high-sensitivity FOBT; 2) flexible sigmoidoscopy every 5 years combined with FOBT every 3 years; 3) colonoscopy every 10 years. Obviously, in patients at higher-risk for colorectal cancer, as indicated above, the cancer screening needs to be started at earlier age and at different intervals.

For more information refer to the American Society of Colon and Rectal Surgeons website.

Colon and Rectal Polyps

Polyps are areas of abnormal growth of the internal lining (mucosa) of the colon and rectum. They can be of different size or shape (flat or with a stalk). They can be completely asymptomatic or cause rectal bleeding when they grow to a significant size. Polyps are usually found during a colonoscopy performed in an asymptomatic individual (screening colonoscopy, see above for further details) or performed to investigate specific symptoms (diagnostic colonoscopy) such as rectal bleeding, changes in bowel habits or anemia.
Removal and destruction of colorectal polyps is recommended because polyps, even though benign, are considered precursors of cancer. It usually takes 5 to 10 years for a polyp to become cancerous. Polyps are usually removed at the time of colonoscopy, but larger polyps or polyps that carry malignant cells need to be removed surgically, which means to remove the segment of colon in which they are located (segmental colectomy). In case of large rectal polyp, removal of the rectum (proctectomy) might be necessary to avoid risk of recurrence or progression to cancer.

For more information refer to the American Society of Colon and Rectal Surgeons website.

Colon and Rectal Cancer

Colorectal cancer is the second most common cancer in the United States, with about 150,000 patients diagnosed annually. It can strike at any age, but the vast majority of patients are diagnosed after age 40. Colorectal cancer usually develops from colorectal polyps that, undiagnosed, tend to grow in size and become malignant. That's why screening for colorectal cancer has been effective in the past 20 years in decreasing the number of cancer cases. Colorectal cancer is a PREVENTABLE disease. 

Symptoms of colorectal cancer can be very subtle, like change in bowel habits, minor rectal bleeding or abdominal discomfort, but they tend to become more dramatic when the cancer grows. In particular, a cancer can grow in size so much to create a blockage in the affected segment of the colon or the rectum, or cause a perforation, which are both surgical emergencies. These events impact the prognosis negatively, increasing the chances of recurrence and decreasing the long-term survival. The bigger the tumor, the higher the chances that the cancer has spread to the local lymph nodes or to other organs (metastatic disease).

After the diagnosis is confirmed on colonoscopy, multiple other tests are performed to "stage" the disease to assess whether the cancer is still localized to the colon or has spread. If the cancer is deemed "operable", surgery offers the best chances of cure. Chemotherapy and radiation therapy are sometimes involved in the treatment plan.

For more information refer to the American Society of Colon and Rectal Surgeons website.

Genetic testing for Hereditary Colorectal Cancer Syndromes

The vast majority of colorectal cancer are "sporadic", which means that occur in individuals with no risk factors. About 5% of colorectal cancer are determined by a specific genetic abnormality that is transmitted in the family, generation after generation. The two most common and important genetic syndromes are the Familial Adenomatous Polyposis (FAP) and the Hereditary Non-Polyposis Colorectal Cancer syndrome (HNPCC).

These two syndromes are characterized by a definite abnormality of one or more genes that regulate how the individual cells multiply and interact with each other. Patients affected by FAP start to develop multiple colorectal polyps (up to thousands) at a very young age and inevitably develop cancer by age 40. Treatment involves complete removal of the colon and rectum (total proctocolectomy) with the creation of an artificial pouch with the last part of the small bowel (ileal-pouch anal anastomosis). FAP patients are at high risk to develop cancer of the duodenum and other benign tumors (desmoid tumors). 
HNPCC patients have a very characteristic family tree, where a first-degree relative is diagnosed with colorectal cancer before age 50 and other relatives diagnosed with early colorectal cancer in consecutive generations. HNPCC is associated to other kind of cancer that are diagnosed at early age, especially gynecologic cancers (cancer of the uterus or ovary).

For more information refer to the American Society of Colon and Rectal Surgeons website.

Diverticular disease

Colonic diverticuli are small pouches made of colon inner layer that gets squeezed through the colonic muscular fibers. They can be found throughout the colon but are more frequently seen in the left colon. Diverticuli are very common, and the chance to have them increases with age. The causes are not completely clear but it is though that this condition is related to the Western diet, poor in fibers and rich in refined sugars. This diet determines harder and smaller stool, which tend to increase the pressure inside the colon and therefore facilitate the creation of diverticuli. 

The majority of patients do not develop symptoms. The term "diverticulosis" indicates the presence of colonic diverticuli. Older patients with diverticulosis might develop significant rectal bleeding, which, most of the times, is self-limited. 

The term "diverticulitis" indicates inflammation of a specific segment of the colon that carries diverticuli, usually the left colon. It is caused by the plugging of the diverticulum mouth with stool or other debris. There is no scientific proof that this event is caused by ingestion of seeds, nuts or pop corns. Once the diverticulum is plugged, the bacteria trapped inside multiply until an infection develops, with subsequent micro-perforation of the diverticulum. Patients with acute diverticulitis presents with abdominal pain, fever and increased number of white blood cells in the bloodstream (leukocytosis). Diverticulitis ranges from a simple inflammatory process of the affected segment (acute non-complicated diverticulitis), which is treated with bowel rest and antibiotic treatment, to a much more complex situation where a colonic abscess develops or where a gross perforation of the bowel causes peritonitis and acute abdomen, requiring emergent operation (acute complicated diverticulitis). In some cases, the inflammatory process becomes chronic and the patients are at risk of developing narrowing of the affected segment of bowel or, in most severe cases, fistulas (communicating tracts) with other structures nearby, more commonly bladder (colovesical fistula) or vagina (colovaginal fistula). 

Patients that had previous attacks of mild diverticulitis that didn't require hospitalization can be treated with a high-fiber diet, fiber supplementation and stool softeners after the acute attack is completely treated with bowel rest and antibiotics.

In case of recurrent acute non-complicated diverticulitis requiring hospitalization or controlled chronic complicated diverticulitis, the resection of the sigmoid colon (the most frequently affected segment) can be planned electively after the acute attack has been treated with antibiotics and the acute inflammation cooled off. In these cases, the bowel can be safely reconnected without creating a diversion to the abdominal wall (ostomy). In case of acute diverticulitis with perforation and contamination of the abdominal cavity (diffuse peritonitis),  it is not safe to reconnect the bowel at the time of the first operation and an ostomy is created. A second operation is planned to reconnect the bowel after 2 to 3 months, in order to allow the inflammation to subside and the patient to recover.

The chronic inflammation and the deposition of scar tissue can become so significant that diverticulitis can be clinically confused with a perforated cancer, that's why is important to try to obtain a colonoscopy prior to the operation if feasible.

For more information refer to the American Society of Colon and Rectal Surgeons website.


An ostomy (stoma) is a connection between a segment of the bowel and the outside of the body through a hole surgically created in the abdominal wall. Stool is diverted through the stoma and collected in an ostomy bag. If the colon is used to create the stoma, we define it as "colostomy"; if it is small bowel, we usually define it "ileostomy". An ostomy can be temporary or permanent. It is very hard for the patients to adjust to the new body image, but ostomates (ostomy patients) can live a completely normal and fulfilling life. Specialized nurses (Ostomy Care Nurses) are available to teach the patients and guide them through the use of different appliances, as well as numerous support groups.

Problems with managing an ostomy are usually related to occasional leakage of stool around the appliance which can disrupt the patient's social life and self confidence, and skin irritation, especially in case of ileostomies that produce a higher volume, more acidic output. Another complication is represented by herniation of bowel through the abdominal wall defect (parastomal hernia), which can cause abdominal pain, bowel obstruction and difficulty in effectively placing the ostomy appliance because of the abdominal bulge. In most cases, symptoms of a parastomal hernia are mild and can be improved with some good advices from an experienced Ostomy Care Nurse; in other cases, an operation is needed to reduce the hernia and reinforce the abdominal wall defect to decrease the chances of recurrence. 

For more information refer to the American Society of Colon and Rectal Surgeons website.

Irritable Bowel Syndrome

Irritable Bowel Syndrome (IBS) is a very common disease affecting a large part of the population. It presents as intermittent changes in bowel habits (alternating diarrhea and constipation), crampy abdominal pain and sense of abdominal bloating and fecal urgency. This condition is defined as a "functional" disorder, because comprehensive work-up usually does not reveal anything wrong. The cause of this disorder is thought to be related to an unregulated contraction of the bowel muscles. The condition is sometimes exacerbated by stress, anxiety or specific foods. Treatment is usually conservative, including high-fiber diet, stress reduction and exclusion diet to isolate the specific foods that may cause exacerbation of the symptoms. Medications to decrease the symptoms are available as well for the appropriate patients. 

It is very important to thoroughly evaluate this condition, as it might mask a more serious problem like IBDs, cancer or other kind of colonic diseases, especially if fever, rectal bleeding, weight loss are identified, which are not part of the IBS symptoms.

For more information refer to the American Society of Colon and Rectal Surgeons website.

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