Colorectal Cancer

Symptoms: loose motions, rectal bleeding, abdominal pain, weight loss, anaemia, difficult evacuation

Investigations: blood tests, colonoscopy, CT colonography, CT scan

Basic facts:

  • bowel cancer is common, it affects around 42,000 patients / year in the UK
  • it commonly affects people over the age of 50 but it can affect younger people in around 10-20% of cases
  • there is often a family history
  • the disease is often latent for a long time
  • change in bowel habit or rectal bleeding requires investigation
  • early diagnosis is crucial to achieving long term survival
  • surgery is the mainstay of treatment
Family tree colorectal cancer
  • the majority of patients who have surgery for colorectal cancer do not require a permanent stoma ie  a ’bag’
  • most cases of bowel cancer can be treated with laparoscopic ‘keyhole’ surgery
  • chemotherapy may be used either before or after surgery for colon cancers
  • radiotherapy or chemotherapy and radiotherapy are typically used before surgery for rectal cancer
  • chemotherapy may be required after surgery for rectal cancer
  • follow up after potentially curative surgery includes examination, blood tests, CT scans and colonoscopy

Who Is At Increased Risk Of Colorectal Cancer?

Patients with inflammatory bowel disease:

  • patients with a longstanding history of ulcerative colitis
  • patients with a longstanding history of Crohn’s colitis

Patients with a family history of bowel cancer:

  • the highest risk is those who have a first degree relative who had bowel cancer when under 45-50 years of age
  • patients who have a first degree relative (of any age) affected by bowel cancer are at significantly increased risk

Polyposis syndromes

  • Certain families have very high risks of bowel cancer – these are due to polyposis syndromes eg Familial Polyposis Coli, Gardner’s syndrome, Lynch syndrome, Hyperplastic Polyposis syndrome. There are also other, more rare types of family cancer syndromes.

Religious groups

  • Patients from the Ashkenazi Jewish faith are at significantly increased risk of bowel cancer.

Crohn’s Disease

Symptoms include: loose stool, bleeding with bowel movements, abdominal pain, weight loss, mouth ulcers, pain or swelling near the bottom.
Investigations: blood tests, colonoscopy, small bowel X ray, video capsule, MRI scan
Basic facts:

  • Crohn’s Disease can affect any age
  • the exact cause is unclear
  • most cases are managed with drugs
  • surgery may be required for complications of Crohn’s Disease eg abscesses near the bowel, bowel perforation, narrowing of the bowel or bowel cancer
  • surgery for Crohn’s Disease is best performed by a colorectal surgeon
  • longstanding Crohn’s Disease of the colon may occasionally lead to bowel cancer
  • to reduce the chance of bowel cancer, good medical therapy is required, along with occasional colonoscopy

Ulcerative Colitis (UC)

Symptoms: loose motions, blood with bowel movements, mucous from the bottom, weight loss, need to rush to the toilet.
Diagnosis: blood tests, stool analysis to rule out infection, colonoscopy.
Basic facts:

  • UC can behave in a variety of ways from very occasional, very mild flare ups ranging through to severe disease which can occasionally require emergency surgery.
  • most cases can be managed with drugs. These drugs are given either as tablets, into the bottom,  or in more severe cases by injection.
  • UC generally requires long term follow up.
  • sometimes UC can be associated with other conditions eg skin, eye, joint or liver problems.
  • there is a small but definite risk of bowel cancer developing as a complication of UC. This risk increase with duration of the disease, the severity and extent of the inflammation and possible development of liver related disease (primary sclerosing cholangitis).
  • surgery is typically required if the disease fails to be controlled with drugs in either the short term or the long term, or if there is felt to be a real risk of bowel cancer developing.
  • surgery for UC is a major undertaking as it generally requires all the large bowel to removed. If such surgery is required, some patients are suitable for a pouch operation and some might be advised to have a permanent ileostomy.

Intestinal Failure

The inability of the gut to absorb adequate nutrition and / or water. This may be temporary or permanent.
Causes may include: extensive prior intestinal surgery, complications of intestinal surgery, side effects of drugs, radiation, widespread small bowel disease.
Management is often complex and usually is dealt with by a multi-disciplinary approach. It may involve supportive care with either intravenous feeding (‘Parenteral Nutrition’) or intra-luminal feeding into the gut (‘Enteral Nutrition’), drugs to slow bowel transit, control of any co-existent infection, possibly later reconstructive surgery.

Diverticular Disease

Symptoms: often none ie it is often a condition that is discovered incidentally during other tests (eg CT scan or colonoscopy). If diverticular disease causes symptoms, these might include lower abdominal pain and fever. Occasionally repeated episodes of diverticulitis can lead to bowel obstruction, peritonitis or abscess formation within the pelvis.
Cause: often thought to be related to the ‘Western Diet’ that lacks fibre ie roughage. It may be due to other reasons though.
Treatment:

  • dietary advice
  • fluid intake advice
  • sometimes antibiotics are indicated for diverticulitis.
  • small abscesses might require antibiotics, whereas larger abscesses might require drainage under X ray guidance or even surgery to remove the diseased bowel.
  • severe peritonitis requires abdominal surgery

Irritable Bowel Syndrome (IBS)

Symptoms: IBS can cause a variety of symptoms including abdominal cramps, bloating, constipation, loose motions, urgent need to pass stool, shooting pains in the bottom. Some or all of these symptoms may relate to a previous episode of gastroenteritis and then be made worse by subsequent stress.
Diagnosis: some cases are very typical and can be treated as IBS with an expectation of improvement. Failure to improve or unusual features may require certain tests to act as supporting evidence that there is no other more serious problem going on. IBS is sometimes regarded as ‘a diagnosis of exclusion’ ie there needs to confidence that other conditions have been excluded.
Investigations: may include blood tests including screening for coeliac disease, a stool sample to rule out infection, a stool test to assess for inflammation in the bowel, an endoscopic test, and /or a scan (ultrasound or CT) depending on the symptoms.
Basic facts:

  • slightly more common in females than males
  • can affect any age group though most often younger and middle-aged patients
  • certain symptoms can be affected by diet
  • treatment comprises appropriate investigation if necessary. Dietary change may be required. A variety of drugs may be tried depending on the dominant symptoms.
  • if patients continue to experience symptoms, further investigation may be required or alternative drug / treatment strategies.

Incisional Hernias

Symptoms: a swelling in the region of a previous abdominal surgical scar. Pain can indicate a risk of bowel or fat becoming trapped within the hernia.

Basic facts:

  • these are unfortunately quite common after major abdominal surgery
  • not all such hernias necessarily require repair
  • repair can be straightforward or really very complicated and involved depending on the size of the hernia, the number of previous attempts at repair and the general health of the patient.
  • large or multiply recurrent hernias are generally best treated with abdominal wall reconstruction using a technique called ‘Component Separation Repair’
  • the outcome of this technique is generally very successful (80% +) though it is a major undertaking and patients require careful counselling prior to surgery.
  • weight loss and stopping smoking may be required before abdominal wall reconstruction.

Umbilical / Paraumbilical Hernias

Symptoms: painful or painless swelling in or near the umbilicus (‘navel’)

Diagnosis: clinical examination

Basic facts:

  • such hernias can occasionally entrap fat from within the abdomen or even a piece of bowel
  • these hernias are normally easy to repair
  • sometimes a mesh is required to reinforce the repair
  • most surgery is done as a day case procedure

Groin Hernias

Symptoms: pain in the groin or a swelling in the groin, occasionally blockage of the bowel
Basic facts:

  • groin hernias are common
  • there are two common types: inguinal and femoral
  • femoral hernias should always be repaired
  • inguinal hernias that cause pain or limit mobility should be repaired
  • operations are usually performed with laparoscopic (‘keyhole’) surgery
  • most operations are performed as a day-case
  • most operations successfully prevent hernia recurrence
laparoscopic equipment

Anal Fistula

Symptoms: a small discharging opening near the bottom. There may have been a preceding abscess near the bottom that has required surgical drainage. Some pain prior to discharge is common.

Causes: most such cases are spontaneous. Rarely fistulae might be related to Crohn’s Disease, malignancy, radiotherapy, TB, hidradenitis suppurativa, or previous major pelvic surgery.

Investigation: examination under anaesthetic or an MRI scan or both.

Treatment: There are a variety of options (lay open the fistula track, loose or cutting setons, LIFT procedure, insertion of a fistula plug, formation of an advancement flap). Some of these options are very simple and some slightly more complicated. The exact procedure offered will take into account the complexity of the fistula, the sex of the patient, the bowel control of the patient and what previous attempts might have been undertaken. The goal of treatment is to prevent further abscess formation, preserve good bowel control and try to get the fistula to heal.

Haemorrhoids

Symptoms: bleeding, irritation around the anus, a lump near the anus, pain near the anus

Investigations: clinical examination, limited endoscopic ie ‘telescope’ examination of the lower part of the bowel

Basic facts:

  • haemorrhoids are common
  • they often produce symptoms due to a lack of fibre (ie roughage)or a lack of water in the diet
  • bleeding from the bottom should not always be assumed to be due to haemorrhoids
  • examination +/- tests are required to confirm that haemorrhoids are the cause of bleeding from the bottom
  • haemorrhoids may be treated by diet alone, injection of a chemical, banding, or by surgery
  • injection or banding of haemorrhoids are easily performed in the clinic
  • haemorrhoid surgery is performed as a day case operation

Anal Cancer

Symptoms: anal pain, swelling or ulceration near anus, irritation near the anus, bleeding

Diagnosis: examination and biopsy under anaesthetic

Staging: by CT scan and MRI plus PET scan

Basic facts:

  • anal cancer is uncommon
  • treatment is either by local removal of the tumour (if possible) or by a combination of chemotherapy and radiotherapy
  • most patients can avoid a colostomy, though a proportion will need either a temporary or a permanent colostomy
  • prognosis depends on extent of the disease, response to chemotherapy and radiotherapy and background health

Anal Fissure

Common causes: constipation, diarrhoea, trauma

Treatment algorithm

  • high fibre diet
  • increase water intake
  • stool softening laxatives
  • drugs to reduce anal sphincter spasm (GTN, diltiazem, Botox)

operation: Botox injection to the internal sphincter muscle

operation: lateral sphincterotomy (division of a small amount of the internal anal sphincter)

Anal Irritation

Symptoms: an intense desire to scratch or rub the skin near the bottom. This sensation is often worse at night and can be associated with mucous leaking onto the skin near the bottom.

Causes: haemorrhoids, fissures, fistulae, previous anal surgery or trauma, skin conditions. Occasionally anal cancer, Crohn’s Disease or radiotherapy damage can cause such symptoms.

Basic facts:

  • treatment is aimed at the underlying cause.
  • maintaining the skin appropriately dry or moistened as required tends to help.
  • avoidance of scratching is very important.
  • sometimes a change in diet is required.
  • barrier creams and topical steroid creams (in the short term) can help.
  • additional treatment from a dermatologist may be required.
  • severe cases may benefit from injection of a dye called methylene blue into the skin near the bottom.

Pilonidal Sinus

Condition: small skin defects in the cleft between the buttocks that can become infected, often but not always in relation to ingrowth of hair.

Affects:  mostly younger and middle –aged people, especially males.

Treatment:

  • stopping smoking is strongly recommended
  • weight reduction is sometimes advised
  • antibiotics alone rarely cure the condition
  • pilonidal abscess (‘collection of pus’): emergency drainage of the abscess, generally including removal of the tiny skin defects too. Typically peformed as a  day-case.
  • pilonidal sinus: planned removal of the affected skin in the cleft between the buttocks. Generally a ‘cleft lift procedure’ is the standard operation (success rate ~80-85%). Alternative or secondary operations may include procedures such as the Limberg flap or a Z plasty ie small ‘plastic surgery’ operations. Typically performed as a day-case.

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Ian Botterill holds practices as both Leeds Teaching Hospitals and Spire Healthcare. To book a consultation, please contact his secretary.