Columbia Surgical Specialists

Colon & Rectal Surgery

Colon and rectal diseases comprise a broad range of conditions and ailments, the severity of which can vary from mildly irritating to life threatening. Colon and rectal surgeons are experts in the surgical and non-surgical treatment of cancer of the colon, rectum and anus, as well as benign conditions like diverticular disease, inflammatory bowel disease including Crohn’s disease and ulcerative colitis, various causes of colonic obstruction, a multitude of anorectal conditions, fecal incontinence and pelvic floor disorders. They complete residencies in general surgery in additional to surgical training fellowships dedicated to colon and rectal surgery; board certification requires completion of intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery.

Our colorectal group of board certified surgeons serves as the tertiary referral center for Eastern Washington and the surrounding tri-state region for both emergent and nonemergent colorectal conditions. Patient care is closely coordinated with local and regional medical and radiation oncologists, radiologists, gastroenterologists and primary care physicians along with general surgeons, gynecologists, gynecology oncologists and urologists as patient conditions require. Alongside clinical duties, our colorectal surgeons participate in state and national quality improvement projects, clinical research and leadership at the national level within the American Society of Colon and Rectal Surgeons.

Patient care is provided at Providence Sacred Heart Medical Center and Holy Family Hospital as well as MultiCare’s Deaconess Hospital.

Appointments  (509) 747-6194

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Colon & Rectal Conditions Treated

Colon cancer (commonly referred to as colorectal cancer) is preventable and highly curable if detected in early stages. The colon is the first 4 to 5 feet of the large intestine. Colorectal cancer tumors grow in the colon’s inner lining. 

FACTS AND STATS

In 2017, nearly 136,000 new cases of colorectal cancer were expected to be diagnosed in the U.S. About 1 in 20 (5%) Americans will develop colorectal cancer during their lifetime. 
Colorectal polyps (benign abnormal growths) affect about 20% to 30% of American adults.

RISK FACTORS

The exact cause of colorectal cancer is unknown. Physicians often cannot explain why one person develops this disease and another does not. However, the understanding of certain genetic causes continues to increase. The following factors can increase one’s risk of colorectal cancer.

  • Age: More than 90% of people are diagnosed with colorectal cancer after age 50.
  • Family history of colorectal cancer (especially parents or siblings).
  • Personal history of Crohn’s disease or ulcerative colitis for eight years or longer.
  • Colorectal polyps.
  • Personal history of breast, uterine or ovarian cancer.

PREVENTION

Colorectal cancer is preventable. Nearly all cases of colorectal cancer develop from polyps. They start in the inner lining of the colon and most often affect the left side of the colon. Detection and removal of polyps through colonoscopy reduces the risk of colorectal cancer. Colorectal cancer screening recommendations are based on medical and family history. Screening typically starts at age 45* in patients with average risk. Those at higher risk are usually advised to receive their first screening at a younger age.

While it is not definitive, there is some evidence that diet may play a significant role in preventing colorectal cancer. A diet high in fiber (whole grains, fruits, vegetables and nuts) and low in fat is the only dietary measure that may help prevent colorectal 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. 

COLORECTAL CANCER SYMPTOMS

Colorectal cancer often causes no symptoms and is detected during routine screenings. It is important to note that other common health problems can cause some of the same symptoms. For example, hemorrhoids are a common cause of rectal bleeding, but do not cause colorectal cancer. Colorectal cancer symptoms include:

  • A change in bowel habits (e.g. constipation or diarrhea).
  • Narrow shaped stools.
  • Bright red or very dark blood in the stool.
  • Ongoing pelvic or lower abdominal pain (e.g., gas, bloating or pain).
  • Unexplained weight loss.
  • Nausea or vomiting.
  • Feeling tired all the time.

Abdominal pain and weight loss are typically late symptoms, indicating possible extensive disease. Anyone who experiences any of the above symptoms should see a physician as soon as possible.

DIAGNOSIS AND STAGING

  • Physical exam and medical history.
  • Blood tests.
  • Colonoscopy: Examination of the entire colon with a long, thin flexible tube with a camera and a light on the end (colonoscope).
  • Biopsy: Removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer.

The following tests may be used for staging:

  • Computed Tomography (CT) scan: A highly sensitive x-ray test that allows physicians to see “inside” the body to identify new or recurrent tumors. This test can accurately detect the presence of most cancer cells that have spread outside of the colon.
     
  • Positron emission tomography (PET) scan: An imaging test that uses a special dye that has radioactive tracers. This allows physicians to detect the presence of most cancer cells that have spread outside of the colon.
     
  • CEA assay: Carcinoembryonic antigen is a substance in the blood that may be elevated if cancer is present. Although not completely conclusive on its own, this test is often done with other diagnostic tests.
     
  • Magnetic Resonance imagin (MRI): An imaging test that uses a magnetic field and pulses of radio wave energy to create pictures of organs and structures inside the body. This helps determine if the tumor has spread through the wall of the rectum and invaded nearby structures.
     
  • Abdominal ultrasound: A procedure in which a transducer is moved along the skin over the abdomen. This test looks for tumors that may have spread to the liver, gallbladder, pancreas or elsewhere in the abdomen.

The extent of cancer (clinical stage) is linked to treatment decision making and post-treatment patient outcome. Staging is based on whether the tumor has invaded nearby tissues or lymph nodes, and/or cancer has spread to other parts of the body. The exact stage is often not determined until after surgery. 

SURGICAL TREATMENT

Surgery to remove the colorectal cancer is almost always required for a complete cure. The tumor and lymph nodes are removed, along with a small portion of normal colon on either side of the tumor. A colostomy is a surgically created opening that connects a part of the colon to the skin of the abdominal wall. This procedure is typically only done in a very small number of colorectal cancer patients.

Minimally invasive surgical techniques may be used by trained surgeons based on the individual case. Your surgeon will discuss this with you prior to surgery and decide on the most optimal approach. 

MEDICAL TREATMENT

Chemotherapy may be offered either before or after surgery, depending on the stage of the cancer. Unlike rectal cancer, radiation therapy is rarely used for colorectal cancer. 

POST-TREATMENT PROGNOSIS

Patient outcome is strongly associated with colorectal cancer stage at the time of diagnosis. Cancer confined to the lining of the colon is associated with the highest likelihood of success. This is one reason why early detection through screening methods like colonoscopy is crucial.

Follow-up care after treatment for colorectal cancer is important. Even when the cancer appears to have been completely removed or destroyed, the disease may recur. Undetected cancer cells can remain in the body after treatment. Your colon and rectal surgeon will monitor your recovery and check for cancer recurrence at specific intervals. Blood tests, clinical examinations and imaging tests may be performed based on the stage of the cancer.

WHAT IS A COLON AND RECTAL SURGEON?

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.

The rectum is the last 6 inches of the large intestine (colon). Rectal cancer arises from the lining of the rectum. In 2012, more than 40,000 people in the United States will be diagnosed with colorectal cancer, making it the third most common cancer in both men and women. About 5% of Americans will develop colorectal cancer during their lifetimes. Colorectal cancer is highly curable if detected in the early stages.

Diagram taken from existing ASCRS brochure “Polyps”

WHO IS AT RISK FOR RECTAL CANCER?

No one knows the exact causes of rectal cancer. Rectal cancer is more likely to occur as people get older, and more than 90% of people with this disease are diagnosed after age 50. Other risk factors include a family history of colorectal cancer (especially in close relatives), and a personal history of inflammatory bowel disease such as ulcerative colitis, colorectal polyps or cancers of other organs.

CAN RECTAL CANCER BE PREVENTED?

Rectal cancer is preventable. Nearly all rectal cancer develops from rectal polyps, which are benign growths on the rectal wall. Detection and removal of these polyps by colonoscopy reduces the risk of getting rectal cancer. Your doctor can provide exact recommendations for rectal cancer screening based on your medical and family history. Screening typically starts at age 45* in patients with average risk, or at younger ages in patients at higher risk for rectal cancer.

Though not definitely proven, there is some evidence that diet may play a significant role in preventing colorectal cancer. As far as we know, a diet high in fiber (whole grains, fruits, vegetables, nuts) and low in fat is the only dietary measure that might help prevent colorectal 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.

WHAT ARE THE SYMPTOMS OF RECTAL CANCER?

Many rectal cancers cause no symptoms at all and are detected during routine screening examinations. The most common symptoms of rectal cancer are a change in bowel habits, such as constipation or diarrhea, narrow shaped stools, or blood in your stool. You may also have pelvic or lower abdominal pain, unexplained weight loss, or feel tired all the time.  Other common health problems can cause the same symptoms. Hemorrhoids do not cause rectal cancer but can produce similar symptoms. Anyone with these symptoms should see a doctor to be diagnosed and treated as early as possible. Abdominal pain and weight loss are typically late symptoms, indicating possible extensive disease.

WHAT TESTS ARE PERFORMED TO DIAGNOSE RECTAL CANCER?

  • Physical exam and medical history
  • Digital rectal exam (DRE)
  • Proctoscopy: An office based exam of the rectum using a proctoscope, inserted into the rectum.
  • Colonoscopy: A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer.
  • Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer.

WHAT DETERMINES THE PROGNOSIS (OUTCOME) FOR RECTAL CANCER?

  • The stage of the cancer (how far advanced the cancer is).
  • Where the cancer is found in the rectum.
  • Whether the bowel is blocked or has a hole in it.
  • Whether all of the tumor can be removed by surgery.
  • The patient’s general health and ability to tolerate different treatment regimens.
  • Whether the cancer has just been diagnosed or has recurred (come back).

HOW IS RECTAL CANCER STAGED?

Distant Staging:

  • CT scan can accurately detect the presence of most cancer cells that have spread outside of the rectum.
  • PET scan
  • CEA assay

Local Staging:

  • MRI is one of the tests used for local staging. This will help determine if the tumor has spread through the wall of the rectum and if it has invaded nearby structures.
  • Endoscopic ultrasound (EUS): A procedure in which an endoscope or rigid probe is inserted into the body through the rectum.

HOW IS RECTAL CANCER TREATED?

For a complete cure, surgery to remove the rectal cancer is almost always required.  Depending on the location and stage, this may be performed through the anus (opening of the rectum) or through the abdomen. Rectal cancer surgery removes the cancer and lymph nodes, along with a small portion of the normal rectum on either side of the tumor. The creation of a colostomy (opening the intestine to a bag on the skin) is typically needed only in a very small number of patients. Trained surgeons may use minimally invasive surgical techniques depending on certain features of your cancer. Your surgeon will discuss these features with you prior to the operation. Additional treatment with chemotherapy or radiation therapy may be offered either before or after the surgery, depending on the stage of the cancer.

WHAT FACTORS INFLUENCE PROGNOSIS (OUTCOME)?

The outcome of patients with rectal cancer is most clearly related to the stage at the time of diagnosis, with cancer that is confined to the lining of colon having the best chance of success. This is one reason why early detection through screening methods like colonoscopy is crucial.

WHAT FOLLOW-UP IS NEEDED AFTER TREATMENT?

After treatment for rectal cancer, a blood test to measure amounts of CEA (a substance in the blood that may be increased when cancer is present) may be done to see if the cancer has come back. Routine CT scans, clinical examinations, and colonoscopy are also performed at intervals determined by the stage.

WHAT IS A COLON AND RECTAL SURGEON?

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.

WHY SHOULD THERE BE A POSTOPERATIVE FOLLOW-UP PROGRAM?

Surgery is the most effective treatment for colorectal cancer. Even when all visible cancer has been removed, it is possible for cancer cells to be present in other areas of the body. These cancer deposits, when very small, are undetectable at the time of surgery, but they can begin to grow at a later time. The chance of recurrence depends on the characteristics of the original cancer and the effectiveness of chemotherapy, if needed, or other follow up treatment. Patients with recurrent cancers – if diagnosed early – may benefit, or be cured, by further surgery or other treatment.

Another good reason for postoperative follow up is to look for new colon or rectal polyps. Approximately one in five patients who has had colon cancer will develop a new polyp at a later time in life. It is important to detect and remove these polyps before they become cancerous.

HOW LONG WILL MY FOLLOW-UP PROGRAM LAST?

Most recurrent cancers are detected within the first two years after surgery. Therefore, follow up is most frequent during this period of time. After five years, nearly all cancers that are going to recur will have done so. Follow up after five years is primarily to detect new polyps, and can, therefore, be less frequent but advisable for life.

WHAT MIGHT I EXPECT AT MY FOLLOW-UP VISIT?

Your doctor will examine you approximately every two or three months for the first two years, and discuss your progress. A CEA blood test can be done, as a method of trying to detect recurrence of cancer. Because this test is not totally reliable, other follow up examinations may be advised. These examinations may include flexible sigmoidoscopy (an examination of the rectum and lower colon with a flexible, lighted instrument), colonoscopy (examination of the entire colon with a long flexible instrument), chest x-rays, and sometimes CT scans or ultrasound tests.

WHAT ABOUT MY FAMILY?

Close relatives of patients with colon and rectal cancer (parents, brothers, sisters, children) are at increased risk for the disease. Because of this risk, periodic colonoscopy is advised to detect small polyps. Prompt detection and removal of polyps reduces the risk of developing cancer. Your colon and rectal surgeon can further advise you and your family members on colonoscopy. Other factors which increase the risk of developing polyps or cancer include cancer occurring at an early age, and a personal history of breast or female genital cancer. 

WHAT IS A COLON AND RECTAL SURGEON?

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.

THE RISK OF COLORECTAL CANCER?

Colorectal cancer is the fourth most common non-skin cancer, affecting all ethnic groups. 140,000 people will be diagnosed with colorectal cancer each year and more than 50,000 will die; the lifetime risk is 1 in 20 (5%).  An increased risk of developing colorectal cancer is present if there is a personal or family history of colorectal cancer.  A personal history of breast, uterine, or ovarian cancer also increases one’s risk of developing colorectal cancer.  A personal or family history of colonic polyps also increases that risk. Both Crohn’s Disease and ulcerative colitis may also make colorectal cancer more likely after having the disease for a number of years.

WHY SHOULD PEOPLE BE SCREENED?

Colorectal cancer rarely causes symptoms in its early stages. Colon cancer usually starts out as a benign polyp. Colon polyps can be both pre-cancerous and non-pre-cancerous.  Polyps can be detected by screening tests and can be removed, thus preventing colorectal cancer. Early cancers can be cured in up to 90% of cases. Once colorectal cancer causes bleeding, change in bowel habits, or abdominal pain, it has usually progressed to a more advanced stage where less than 50% of patients are cured.

WHAT SCREENING TESTS ARE AVAILABLE?

Fecal occult blood testing checks several stool samples for invisible amounts of blood from a colorectal polyp or cancer. If it is positive, a colonoscopy (see below) is needed.

Colonoscopy uses a long, flexible instrument to evaluate the lining of the colon and rectum; abnormal areas may be sampled or removed and sent to the lab for testing. Safe and effective, colonoscopy is the most commonly recommended screening test, as the whole colon is seen and pre-cancerous polyps can be removed, preventing colon cancer.  Colonoscopy is the “gold standard” for colorectal cancer screening.

Flexible sigmoidoscopy allows a physician to look at the lower third of the colon, where about half of all polyps and cancers are found. If an abnormality is found, a colonoscopy is then needed. Fecal occult blood testing and flexible sigmoidoscopy are often combined for colorectal cancer screening.  However, colonoscopy, is considered the optimal method of screening when the test is available and there is no medical contraindication.

An air-contrast barium enema is an x-ray test in which the colon is filled with air and dye to make the lining visible. It is mostly used only if a complete colonoscopy cannot be done.

Virtual colonoscopy combines CT scan images of the air-filled colon into pictures that look like a colonoscopy.  If abnormalities are found, colonoscopy is then necessary. It is also useful in patients who have an incomplete colonoscopy.  However, most insurance plans as well as Medicare may not cover this procedure.

WHAT ARE SCREENING RECOMMENDATIONS?

For people with no risk factors, screening starts at age 45.* Having a colonoscopy every 10 years is considered the gold standard. Flexible sigmoidoscopy every 5 years with yearly stool occult blood testing is an acceptable alternative when a colonoscopy is not feasible.

People with a close relative (parent or sibling) with colorectal cancer or polyps will start screening at age 40, or 10 years before the youngest age at which a relative was diagnosed. These patients will often undergo screening every 5 years, even if their test is normal.

Less common types of inherited colon cancer (hereditary non-polyposis colon cancer and familial adenomatous polyposis) may require much more frequent screening, beginning at a much earlier age. 

*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. 

WHAT ARE SURVEILLANCE RECOMMENDATIONS?

People who have precancerous polyps completely removed should have a colonoscopy every 3 to 5 years, depending on the size, type and number of polyps found. The exam interval will usually depend upon the pathology of the growth removed.  If a polyp is not completely removed by colonoscopy or surgery, another colonoscopy should be done in 3 to 6 months.

Most colorectal cancer patients should have a colonoscopy within 1 year of its initial removal. If the whole colon could not be examined prior to surgery, then colonoscopy should be done within 3 to 6 months. If this first surveillance is normal, then colonoscopy should be done every 3 to 5 years.

Patients with ulcerative colitis or Crohn’s Disease for 8 or more years should have a colonoscopy with multiple biopsies every 1 to 2 years.

WHAT IS A COLON AND RECTAL SURGEON?

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. 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.

THE ROLE OF GENETICS

Genes are inherited from each parent. They determine various physical features and may predispose people to certain diseases. All cancers, but especially colon and rectal cancers, commonly referred to as colorectal cancer (CRC), have hereditary factors that potentially increase one’s risk. Genes are the underlying reason why many diseases such as CRC affect some families more often. For this reason, it is important to provide physicians with a detailed family history of cancer.

COLORECTAL CANCER CLASSIFICATIONS 

There are three broad classifications of CRC, two of which have a genetic component. The data below show the respective percentages for each type.

  • Sporadic Colorectal Cancer: 50% to 60%.
  • Familial Colorectal Cancer: 30% to 40%.
  • Hereditary Colorectal Cancers: 4% to 6%.

SPORADIC COLORECTAL CANCER

Sporadic colorectal cancer is the most common type, with 90% of people diagnosed at age 50 or older. It is not directly related to genetics or a family history. About 1 in 20 Americans develop this type of CRC. When a person is the first family member to be diagnosed with CRC, they should inform close relatives. People with a family history are advised to receive screenings at a younger age.

FAMILIAL COLON CANCER

Some families are predisposed to CRC. If a family has more than one relative with CRC, especially if it occurred before age 50, there is reason for concern. The risk for family members doubles when a first degree relative (parent, sibling or child) has it.

People with a close relative with CRC or colorectal polyps should receive their first screening at age 40, or 10 years before the youngest age at which the relative was diagnosed. These screenings should be done every five years, even if the test was normal.

HEREDITARY COLORECTAL CANCERS

Hereditary colorectal cancers are associated with a specific inherited genetic abnormality. As genetic researchers continue to define certain syndromes, more genes that predispose one to CRC will likely be identified. Currently, some of the syndromes include:

  • Hereditary Non-Polyposis Colon Cancer, Lynch Syndrome (HNPCC).
  • Familial Adenomatous Polyposis (FAP).
  • Attenuated Familial Adenomatous Polyposis (AFAP).
  • APCI 1307K.
  • Peutz-Jehger’s Syndrome.
  • MYH Associated Polyposis (MAP).
  • Juvenile Polyposis.
  • Hereditary Polyposis.

IMPORTANCE OF FAMILY MEDICAL HISTORY

Family history information enables your colon and rectal surgeon to assess your risk of CRC and formulate the best plan for prevention and treatment. It is important to share the following:

  • A list of all family members diagnosed with colorectal polyps or cancer, with estimated age(s) at time of diagnosis.
  • Family history of breast, ovarian or uterine cancer.

Additional patient evaluations can help detect and identify family cancer syndromes. These may include genetic counseling, formal genetic testing, colonoscopy, regular follow-up exams and possible referral to other medical specialists.

WHAT IS A COLON AND RECTAL SURGEON?

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.

COLORECTAL POLYPS

Colorectal polyps are commonly found during standard screening exams of the colon (large intestine) and rectum (the bottom section of your colon). They affect about 20% to 30% of American adults. Polyps are abnormal growths that start in the inner lining of the colon or rectum. Some polyps are flat while others have a stalk.

 

 

Colorectal polyps can grow in any part of the colon. Most often, they grow in the left side of the colon and in the rectum. While the majority of polyps will not become cancer, certain types may be precancerous. Having polyps removed reduces a person’s future risk for colorectal cancer.

SYMPTOMS

Most colorectal polyps do not cause any symptoms unless they are large. That is why screening for polyps and cancer is so important. While uncommon, polyps can cause these symptoms:

  • Blood in the stool
  • Excess mucus
  • A change in bowel habits (such as frequency)
  • Abdominal pain

DIAGNOSIS

The most common test used to detect colorectal polyps is a colonoscopy. During this outpatient test, your colon and rectal surgeon will examine your colon using a long, thin flexible tube with a camera and a light on the end. If polyps are found, they are removed at the same time.

CT colonography (called virtual colonoscopy) may be used to examine the colon indirectly. However, If polyps or a tumor are found during this test, follow-up colonoscopy may be needed to remove or biopsy them. Other tests used to detect polyps include a digital rectal exam, fecal occult blood testing (this tests for microscopic or invisible blood in the stool), barium enema, and sigmoidoscopy, which uses a flexible tube to inspect the sigmoid colon.

TREATMENT

Removal of colorectal polyps is advised because there is no test to determine if one will turn into cancer. Nearly all polyps can be removed or eliminated during a colonoscopy. Large polyps may require more than one treatment. Rarely, some patients may require surgery for complete removal.

PROGNOSIS AFTER TREATMENT

Once a colorectal polyp is completely removed, it rarely comes back. However, at least 30% of patients will develop new polyps after removal. For this reason, your physician will advise follow-up testing to look for new polyps. This is usually done 3 to 5 years after polyp removal. Taking a daily aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs) may reduce the risk of new polyps forming. If you had polyps removed, ask your physician if you should take this medication to help prevent them from coming back.

WHAT IS A COLON AND RECTAL SURGEON?

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.

CONSTIPATION

Constipation, a common complaint, is usually simple to prevent and easy to treat when it occurs. However, constipation may reflect a more serious problem that will require the help of your medical provider to suggest tests, medical intervention and, rarely, surgery. 

WHAT IS NORMAL BOWEL FUNCTION?

The colon and rectum (i.e., large intestine) serve to remove water and certain electrolytes and store fecal material prior to elimination. The range of “normal” is quite wide, but in general, bowel movements should occur at least every third day and no more than three per day; stool should pass easily and not require excessive straining; and lastly, one should experience a sense of completeness of elimination. The belief that one should have a bowel movement every day simply is not accurate and can lead to unnecessary concern and even abuse of laxatives. 

WHAT IS CONSTIPATION? 

Given the range of normal, constipation may mean different things to different people. For some, constipation may mean infrequent bowel movements. To others, it is a hard, difficult-to-pass stool that requires excessive straining and causes pain as it passes. And to others still, constipation may mean a bowel movement which does not completely evacuate and leaves the person with a sense of dissatisfaction as if they “still need to go.” Constipation is often associated with a bloating sensation, mild nausea and mild cramping pain, all of which are generally relieved by bowel movements.

WHAT CAUSES CONSTIPATION?

Most often, constipation is due to any combination of three factors: a low fiber diet, poor fluid intake, or a lack of physical activity or exercise. However, there are other causes that must be considered. First, specific medical conditions can cause constipation, including diabetes, low thyroid hormone (hypothyroidism), depression or other less common diseases. Medications may contribute to constipation, including those commonly prescribed for pain relief, high blood pressure, antidepressants, psychiatric drugs and antacids.

Unfortunately, there are serious causes of constipation that are more mechanical in nature. Diseases that cause inflammation, such as diverticulitis or Crohn’s disease, can cause excessive scarring and narrowing. In addition, tumors or growths in the colon can physically block the bowel. Although less likely to be the cause, these more serious causes should be evaluated and ruled out by your physician. 

HOW IS CONSTIPATION AVOIDED OR TREATED?

Generally, constipation is avoided by following the basics of good intestinal health: healthy diet, proper fluid intake and physical activity. Twenty-five to thirty-five grams of fiber per day is the recommended daily amount of dietary fiber. Eating a diet rich in whole grain breads, cereals and fiber bars, in addition to fresh fruits and vegetables, often will improve bowel habits by adding bulk to the stool.

Drinking six to eight glasses of water per day will help keep the stool from being hard and make it easier to pass the stool. Lastly, regular exercise, which can be as simple as taking a brisk walk for 30 minutes per day, will likely improve bowel movements.

There are many different laxatives available over the counter in grocery stores and pharmacies. The way in which laxatives work varies by laxative but they can be very effective for acute relief of constipation. Although it may be necessary to take laxatives on a regular basis, you should only do so after consultation with your medical provider.

WHEN SHOULD I SEEK HELP FROM MY MEDICAL PROVIDER?

Medical attention should be sought if:

  • There is a new onset of persistent constipation.
  • Longstanding constipation becomes progressive either in frequency or severity, and it is not manageable with the simple measures described above.
  • Constipation is associated with a change in bowel habits from the normal pattern (narrow stools or loose stools), excess weight loss or bleeding.

WHAT IS A COLON AND RECTAL SURGEON?

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.

Diverticular disease is the general name for a common condition that causes small bulges (diverticula) or sacs to form in the wall of the large intestine (colon). Although these sacs can form anywhere in the colon, they are most common in the sigmoid colon (part of the large intestine closest to the rectum).

  • Diverticulosis: The presence of diverticula without associated complications or problems. The condition can lead to more serious issues including diverticulitis, perforation (the formation of holes), stricture (a narrowing of the colon that does not easily let stool pass), fistulas, and bleeding.
  • Diverticulitis: An inflammatory condition of the colon thought to be caused by perforation of one of the sacs. Several secondary complications can result from a diverticulitis attack. When this occurs, it is called complicated diverticulitis.

Diverticulitis Complications

  • Abscess formation and perforation of the colon with peritonitis. An abscess is a pocket of pus walled off by the body. Peritonitis is a potentially life-threatening infection that spreads freely within the abdomen, causing patients to become quite ill.
  • Rectal bleeding
  • Formation of a narrowing of the colon that prevents easy passage of stool (called a stricture)
  • Formation of a tract or tunnel to another organ or the skin (called a fistula). When a fistula forms, it most commonly connects the colon to the bladder. It may also connect the colon to the skin, uterus, vagina, or another part of the bowel.

CAUSES

The most commonly accepted theory ties diverticulosis to high pressure within the colon. This pressure causes weak areas of the colon wall to bulge out and form sacs. A diet low in fiber and high in red meat may also play a role. Currently, it is not well understood how these sacs become inflamed and cause diverticulitis.

SYMPTOMS

Most patients with diverticulosis have no symptoms or complications. Some patients with diverticulitis experience lower abdominal pain and a fever or they may have rectal bleeding.

DIAGNOSIS

Diverticulosis often causes no symptoms. It may be diagnosed during screening tests such as a colonoscopy. A CT scan of the abdomen and pelvis may be used to confirm the diagnosis of diverticulitis.

TREATMENT

Most people with diverticulosis have no symptoms. However, as a preventative measure, it is advised to eat a diet high in fiber, fruits, and vegetables, and to limit red meat.

Most cases of diverticulitis can be treated with antibiotics in pill form or intravenously (IV). Diverticulitis with an abscess may be treated with antibiotics with a drain placed under X-ray guidance.

Surgery for diverticular disease is indicated for the following:

  • A rupture in the colon that causes pus or stool to leak into the abdominal cavity, resulting in peritonitis, which often requires emergency surgery.
  • An abscess than cannot be effectively drained.
  • Severe cases that do not respond to maximum medical therapy including IV antibiotics and hospitalization.
  • Patients with immune system problems (e.g. related to an organ transplant or chemotherapy).
  • A colonic stricture or fistula.
  • A history of multiple attacks may result in a patient deciding to undergo surgery to prevent future attacks.

Surgery for diverticular disease usually involves removal of the affected part of the colon. It may or may not involve a colostomy or ileostomy (intestine brought out through the abdominal wall to drain into a bag). A decision regarding the type of operation is made on a case-by-case basis.

WHAT IS A COLON AND RECTAL SURGEON?

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.

An ostomy, or stoma, is a surgically created opening between the intestines and the abdominal wall. The most common types of ostomy connect either the small intestines (ileostomy or jejunostomy) or the large intestine (colostomy) to the abdominal wall. Ostomies can be temporary or permanent. 

REASONS FOR AN OSTOMY

  • Cancer
  • Trauma
  • Inflammatory bowel disease (IBD) such as Crohn’s disease or ulcerative colitis.
  • Bowel obstruction
  • Infection
  • Fecal incontinence (inability to control bowel movements)
  • Diverticular disease (small bulges or sacs that form in the wall of the large intestine)

OSTOMY TYPES

Ask your surgeon if you do not know what type of ostomy you have.

  • Ileostomy: Connects the last part of the small intestines (ileum) to the abdominal wall.
  • Colostomy: Connects a part of the colon (large intestine) to the abdominal wall.
  • Temporary ostomy: This is an ostomy that can be removed surgically at a later time.  It is generally made from the small intestines (ileostomy).  It prevents the passage of stool through the intestines below the stoma. A temporary ostomy is created to allow the intestines to heal after surgery or from a disease such as diverticular disease or Crohn’s disease. 
  • Permanent ostomy: This is an ostomy that is used when parts of the rectum, anus and colon have been removed due to disease or treatment of a disease.  It is generally made from the large intestines (colostomy). It may also be done when the muscles that control elimination are removed or no longer function properly. A permanent ostomy may be removed under some circumstances.  

Figure 1: An ostomy connects either the small or the large intestine to the abdominal wall.

THE OSTOMY BAG

After an ostomy is created, bowel movements occur through the opening in the abdominal wall or stoma. The ostomy appliance consists of a wafer and bag. The wafer sticks to the abdominal wall with adhesive and is made of plastic.  The bag catches and holds the stool. The bag is disposable and emptied or replaced as needed. This system is secure, odor-free and accidents are uncommon.

OSTOMY PLACEMENT

Prior to surgery, your surgeon or Wound, Ostomy and Continence (WOC) nurse will examine your abdomen to find a suitable place on your abdominal wall for the opening or stoma. An ostomy is best placed on a flat portion of the front of your abdomen that is easy to see. A colostomy is usually placed to the left of the navel and an ileostomy to the right.  

 

Figure 2: An ostomy appliance is a plastic pouch. It is held to the body with an adhesive skin barrier that provides secure and odor-free control of bowel movements.

POSTSURGICAL CARE

  • You will be taught how to use the ostomy bag by a WOC nurse or enterostomal therapist and your colon and rectal surgeon. The doctors and nurses will work with you on any necessary changes to your diet.
  • The frequency and volume of bowel movements vary from person to person. Your bowel movements will depend on how often you went to the bathroom prior to surgery, the type of ostomy that was placed, the type of surgery that was done and your dietary habits.

An ostomy appliance is a plastic pouch. It is held to the body with an adhesive skin barrier. It provides secure and odor-free control of bowel movements.

DIETARY RESTRICTIONS

Depending on the type of ostomy, you may need to change what you eat to control the number of and consistency of bowel movements. You will learn to monitor the effect of food on ostomy function. After a period of time, many patients are able to slowly introduce foods back into their diets. It helps to chew food well, drink plenty of fluids and avoid certain high roughage foods, such as green leafy vegetables. After recovering from surgery, most patients do not have dietary limitations.

PHYSICAL RESTRICTIONS

All activities including recreational sports and activities may be resumed once healing from surgery is complete. Public figures, famous entertainers and even professional athletes have ostomies that do not limit their activities.

Most patients with ostomies are able to resume their usual sexual activity. Some patients worry that their sexual partner will not find them attractive due to the ostomy bag. This change in body image can be overcome. A strong relationship, time, patience and support groups all help address these problems.

WILL PEOPLE KNOW I HAVE AN OSTOMY?

Unless you tell someone, they won’t know that you have an ostomy. An ostomy is easily hidden by most clothing. You have probably met people with an ostomy and did not realize it.

POST-OSTOMY PROGNOSIS

An ostomy can have complications. In the beginning, it may take some time to adjust to the way the appliance fits and empties. During this time, accidents, or leakage from the bag, may happen. Once you are used to the stoma wafer and bag, most common problems, such as local skin irritation, are easily treated. Major changes in weight loss or gain can affect how the ostomy sits on your abdomen. Some people develop a hernia (weakening of the abdominal wall around the ostomy) or prolapse (a protrusion of the bowel). These problems require surgery only if they cause major symptoms.

Living with an ostomy requires a period of learning and adjustment. Your colon and rectal surgeon and WOC nurse will provide necessary assistance and support. With a little time, you will discover ways to live an active and full life with an ostomy.

WHAT IS A COLON AND RECTAL SURGEON?

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.

Ulcerative colitis (UC) is an inflammatory disease potentially affecting the entire large bowel (colon and rectum). The inflammation is confined to the innermost layer of the intestinal wall (mucosa). UC can go into remission and recur. Medical management is typically the first option for treatment. If surgery is needed for UC, it is usually curative.

RISK FACTORS

Men and women are affected equally and people of all ages can develop UC. A family history of UC slightly increases the risk of the disease.

CAUSES

The exact cause of UC is unknown, but it is not contagious. Potential causes include immune system abnormalities and bacterial infection.

SYMPTOMS

Most patients develop symptoms in their 40s. A smaller number experience symptoms for the first time later in life (ages 60 to 70). The symptoms of UC are similar to Crohn’s disease, when the latter only affects the colon and rectum. The most common symptoms of UC include:

  • Abdominal cramping.
  • Pain.
  • Diarrhea.
  • Bleeding with bowel movements.
  • Fever.
  • Fatigue.
  • Weight loss.

DIAGNOSIS

The first step is to undergo a thorough medical history and physical exam. Following this, additional testing may be needed. This may include blood tests, a complete colonoscopy of the rectum, colon and terminal ileum (the end of the small intestine that intersects with the large intestine), as well as x-rays. This evaluation helps determine the extent and severity of UC, rules out other diseases such as Crohn’s disease, and guides management. 

MEDICAL TREATMENT

Medical treatment is always the first choice unless emergency surgery is required. The goal of medical therapy is to improve a patient’s quality of life. Initially, the most common therapy is corticosteroids (steroid hormones) combined with anti-inflammatory agents. Based on the extent of the disease, these are taken orally or as a rectal suppository.

SURGICAL TREATMENT

Surgery is considered for patients when medical management is no longer effective.  Other reasons that a patient may require surgery include cancer or precancerous lesions that are found during a colonoscopy.  Sometimes surgery needs to be performed when a complication of the disease occurs such as a perforated bowel (hole in the bowel), severe bleeding or serious infection (toxic colitis).

Since UC involves only the colon and rectum, complete removal of both may be done in some cases. This treatment option is curative, but requires an ileostomy. Some patients may be candidates for a J-pouch. This procedure involves the removal of the entire colon and all of the rectum with the exception of the last section where the sphincter muscles are located.  The small bowel is then used to create a “new” rectum (the pouch) which is attached just above the sphincter muscles. The patient will have a temporary ileostomy during the healing period however ultimately this will be taken down and the patient will be able to pass stool through their anus again.   

Elective and emergency surgeries can be performed through traditional “open” procedures or minimally invasive (laparoscopic) approaches depending on the circumstances. The safest, most effective approach is determined on an individual basis.

 

EMERGENCY SURGERY

Because emergency surgery is done for potentially life threatening conditions, it is most often done as an open procedure. During emergency surgery, the large bowel (colon) is removed. The rectum and anus are left in place temporarily. The end of the small bowel (ileum) is brought out through the abdominal wall to the skin level. An ileostomy is created through which fecal matter is allowed to empty into a bag attached to the skin. 

After recovery, a second procedure can be performed. During this surgery, the diseased rectum is removed. A new rectum (ileal pouch) is created using the small bowel. The new rectum is connected to the anal opening. A loop ileostomy is created to protect the area until it has healed. 

When healing is complete, a third procedure is done to close the ileostomy. This three-stage UC procedure ultimately results in patients being able to live without an ileostomy.

ELECTIVE SURGERY

In elective surgery, the first and second stages described above are combined. This is the two-stage surgery for UC, done through a minimally invasive or open procedure. Both the colon and rectum are removed. A new rectum or J-pouch is made from the small intestine and connected to the anal opening. A diverting ileostomy is often made to protect the area until it heals. After the patient recovers, a second procedure is performed to close the ileostomy and reconnect the small bowel. In select cases, some surgeons choose not to create a diverting ileostomy, which results in a one-stage procedure.

 

POSTSURGICAL PROGNOSIS

After surgery, five to six bowel movements a day and one at night can be expected. Infection may develop in the pouch. This is usually treated effectively with antibiotics. Due to complications, about 10% of pouches must be removed and an ileostomy created.

 

LONG TERM FOLLOW-UP

Regular follow-up medical appointments are scheduled. During these periodic visits, your physician will evaluate the function and health of the pouch.

 

WHAT IS A COLON AND RECTAL SURGEON?

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.

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