Conditions We Treat
An anal fissure is a tear in the skin of the anal canal. The most common symptom for an anal fissure is pain and usually when opening the bowels. There can be associated bleeding which can be seen either on the toilet paper or in the bowl.
It is thought that an anal fissure is caused by over straining on opening bowels or can be from recurrent diarrhoea.
Fissures can often be treated with conservative measures such as softening of stools with a laxatives and avoiding straining. Although chronic fissures are likely not to heal without medical help. This is due to the muscles around the anus go into spasm because of the pain and this will prevent the fissure from healing.
Ointment and creams can be prescribed to help heal the fissure however success rate is approximately 60% and yet the fissure can recur. Surgical intervention could be warranted if creams and ointments have failed.
In the past the most common procedure to heal a fissure is a sphincterotomy which is cutting the sphincter muscle to relax the muscle and spasm. This however can be associated with some incontinence. However recently there are newer interventions to heal the fissure without the need for cutting.
Anal fistula is an abnormal connection between the lining of the anus and the skin that is around the anus or the buttock. This is usually a result from an infection of the anus. It starts with an abscess that bursts into the tissue around the anus which is from a blocked gland within the anus.
You will first have a few days pain around the anus from and then the infection will grow further until it reaches the skin and will burst which will give usually an immediate relief of the pain and discomfort felt. However, there will often be a continuous small discharge from the skin, this will create the fistula due to the abscess healing the hole in the skin that it burst through which connects to the original gland in the anus where the infection was caused from.
A fistula will not heal on its own and if it becomes blocked again will produce once more another abscess. Unfortunately to get rid of the fistula it is recommended that a patient have surgery.
Unfortunately fistulas are regularly associated with Crohn’s disease. Fistula surgery is quite complex and specialised surgeons are required due to the fistula tunnel passes through the sphincter muscles which are the continence muscles of the anus.
Coeliac Disease (pronounce (seel-ee-ak) is an autoimmune disease, meaning that the body mistakenly produces antibodies that damage its own tissues. The immune system’s reaction to gluten causes small bowel inflammation and damage. It is a permanent intestinal intolerance to dietary gluten. Gluten is a protein found in wheat, barley, rye and oats.
Coeliac disease affects approximately 1 in 100 people in Australia but 75% people don’t know they have it. People are born with a genetic predisposition to develop coeliac disease. They inherit a particular genetic make-up (HLA type) with the genes DQ2 and DQ8 being identified as the “coeliac genes”. Gene testing is presently available through pathology laboratories. The gene test is useful for excluding coeliac disease. The presence of HLA DQ2 and HLA DQ8 is not helpful as a positive predictor of coeliac disease, as only 1 in 30 people (approximately) with these genes will have coeliac disease. The gene test cannot diagnose coeliac disease – only
In those with untreated coeliac disease the mucosa (lining) of the small bowel (intestine) is damaged: The tiny, finger-like projections which line the bowel (villi) become inflamed and flattened. The function of the cells on villi is to break down and absorb nutrients in food. Through a microscope, the lining of the small bowel normally looks rather like shag-pile carpet, the villi making up the “pile”. The entire surface area of a healthy small bowel is comparable in size to that of a tennis court.
The long term consequences of coeliac disease are related to poor nutrition and malabsorption of nutrients. Untreated coeliac disease can lead to chronic poor health, osteoporosis, infertility, miscarriage, depression and dental enamel defects. There is also a small, but real, increased risk of certain forms of cancer such as lymphoma of the small bowel. In children, undiagnosed coeliac disease can cause lack of proper development, short stature and behavioral problems.
People with coeliac disease remain sensitive to gluten throughout their life, so in this sense they are never cured. There is no correlation between symptoms and bowel damage, so even if asymptomatic (you have no symptoms), damage to the small bowel can still occur if gluten is ingested. Once gluten is removed from the diet, the small bowel lining steadily repairs and the absorption of nutrients from food returns to normal.
People with coeliac disease should remain otherwise healthy as long as they adhere to a diet free of gluten. Relapse occurs if gluten is reintroduced.
Colonic polyps are small growths originating from the lining of the large bowel. They start as small wart-like growths and can vary in number and size between individuals.
Colonic polyps become more common with ageing and are more common in people with a personal or family history of polyps or bowel cancer. While most polyps do not turn into bowel cancer, most bowel cancers were once a colonic polyp, which slowly grew and changed into a bowel cancer.
When colonic polyps are detected before turning into bowel cancer they can be easily removed during a colonoscopy. Biopsies taken from the polyp can then be used to advise you on how to best prevent bowel cancer into the future. If you have a history of colonic polyps or bowel cancer affecting you or someone in your family, talk to your doctor about which bowel cancer screening strategies would be best for you.
Bowel cancer is a cancer that usually starts from a colonic polyp, which changes into cancer over time. Bowel cancer is the second most common cause of cancer affecting Australians. 1 in 20 Australians will get bowel cancer. Most people with bowel cancer have no symptoms in the early stages, whilst the cancer is at its most curable. What is not commonly known is that most bowel cancer is preventable.
The most common causes of bowel cancer in Australia is age, with 90% of bowel cancer affecting people over the age of 50, the incidence of bowel cancer increases rapidly in our 70’s and 80’s. 80% of people with bowel cancer do not have a family history of bowel cancer. For people with a family history of bowel cancer, the closeness of the relative, the total number of relatives affected and the age at which they were diagnosed all play a part in determining the risk of an individual. Other factors such as an unhealthy diet, lack of exercise, alcohol use and smoking also affect a persons risk.
The treatment of bowel cancer usually involves surgery, sometimes chemotherapy if suggested too or radiotherapy if the rectum is affected. If detected early, the outcomes of bowel cancer treatment can be very good, making prevention and early detection vital.
It is important that all Australians, age 50 and older take part in an appropriate form of bowel cancer screening. A healthy diet and regular exercise are not adequate for bowel cancer prevention alone. For people with a personal or family history of colonic polyps or bowel cancer, screening may need to be initiated at a younger age. Depending on your personal and family history, your doctor will be able to advise you on which test to use, the age at which to start screening and how often you should repeat the test.
Crohn’s disease is a type of severe inflammatory condition that will usually involves the small and/or large bowel. The cause of Crohn’s disease is still unknown.
Crohn’s disease affects females and males equally and occasionally more than one family member is affected with the disease.
The inflammation will occur in patches in the bowel and can produce areas of ulceration (which will occasionally cause diarrhoea) and narrowing of the small and/or large bowel lining. This will result in localised and general symptoms. Bleeding can lead to anaemia and sometimes abscesses can form next to the involved part of the bowel and will often burst into other organs and cause abnormal tracks. If the anus is involved fissures, fistulaes and a discharge will possibly be present. It is possible to develop problems such as arthritis, skin conditions and inflammation of the eyes.
Symptoms that may occur severely are abdominal pain, diarrhoea, malaise and fever. However there may be blood present or mixed with the stool, this can sometimes lead to anaemia and iron deficiency.
It is difficult to diagnose Crohn’s disease and is best diagnosed by a colonoscopy or flexible sigmoidoscopy if it is large bowel Crohn’s disease. To diagnose small bowel Crohn’s disease a small bowel barium x-ray series can be performed. Blood tests can help with assessing the severity of the illness.
Medication can usually control the inflammation such as an anti-inflammatory (Prednisone and Salazopyrine) Anti-diarrhoeals, anti-spasmodics, iron and nutritional supplements may be helpful also with controlling the illness. Unfortunately there is no cure for Crohn’s disease. However where there are areas causing worrying symptoms and does not respond to medication the next line of treatment will be surgery.
Surgical procedures will depend on the specific issue and your surgeon will discuss these further with you at time of consultation.
Diverticulitis is the result of abnormal formation of pouches in the bowel wall that become inflamed. This is a very common digestive disease. The formation of these pouches can occur within the large intestine, colon and rarely in the small intestine.
The common symptoms of diverticulitis is abdominal pain. The most common sign is tenderness around the left side of the lower abdomen. If infection is the cause, then nausea, vomiting, fever, cramping, and constipation may occur as well. Depending of the extent of the infection and complications will determine the severity of the symptoms. Diverticulitis may worsen throughout the first day of infection. It can start as a small pain and/or diarrhoea and may slowly proceed into vomiting and sharp pains.
Foods such as seeds, nuts and corns were thought in the past to be the possible aggravation of diverticulitis. Recently studies have shown no evidence that suggests the avoidance of nuts and seeds prevents the progression of diverticulosis to a acute case of diverticulitis. Not only has this research shown that they do not appear to be aggravating the diverticulitis, but it appears that a higher in take of nuts and corn could in fact help to avoid diverticulosis in adult males.
Diverticulitis is often a medical emergency, requiring immediate medical attention and, frequently, admission to hospital. Mild attacks can be treated at home, but should always be assessed promptly. Treatment may include:
- No eating or drinking – intravenous fluids are given to rest the bowel
- Pain-killing medications
- Surgery – if the weakened sections of bowel wall have ruptured or become obstructed, or if the attack of infection fails to settle
- Colostomy – if it isn’t possible to rejoin the healthy sections of bowel, a colostomy bag will be fitted. This is more common if the surgery is performed as an emergency. The use of a colostomy is generally temporary and the bowel can be rejoined after six to 12 months, if health permits
- The long-term use of a mild antibiotic – this is often necessary to prevent further attacks.
Peptic (stomach and duodenal) ulcers are defects in the protective lining of the stomach or duodenum. People with peptic ulcers can have abdominal pain, discomfort before or after meals, nausea and vomiting. The more serious but less common symptoms include anaemia, vomiting blood, passing altered blood and perforation (rupture) of the ulcer requiring an operation.
Most ulcers are caused by a bacteria called Helicobacter pylori or medications such as aspirin, pain medications (non-steriodal anti-inflammatory drugs such as ibuprofen and COX-2 inhibitors) and blood thinning medications such as clopidogrel. The risk increases with prolonged use, when more than one of these drugs is used concurrently, especially in people over the age of 75 and those who also have Helicobacter pylori infection.
Peptic ulcers are diagnosed by looking in the stomach and duodenum with an endoscopic camera (gastroscopy). If the ulcer is bleeding, the bleeding can be stopped using special techniques, by the doctor performing the gastroscopy. Depending on the severity of the ulcer, treatment may involve treating any underlying infection with antibiotics, stopping medications contributing to the ulcer and using a medication to help heal the ulcer.
Haemorrhoids or otherwise know as piles are the swelling of the blood vessels within the anus. These blood vessels are a part of everyone’s anatomy, however they are called haemorrhoids when these blood vessels bleed, become itch or prolapse from the anus.
Haemorrhoids are quite a common problem and can be caused from issues such as constipation, straining, diarrhoea or a family history of haemorrhoids.
In most cases symptoms of haemorrhoids will settle on their own accord, conservative measures can help with the symptoms settling such as laxatives.
Unfortunately not all haemorrhoids will settle down or may frequently recur therefore further treatment is required. There are few treatments that our doctors recommend for treatment such as injection, haemorrhoidectomy, haemorrhoid banding and haemorrhoidal artery ligation (which is a less invasive procedure and does not require any cutting or dressings).
Incontinence of Faeces
Incontinence of faeces is the lack of control of passage of faeces or flatus from the anus. This could lead to accidents or minor or streaking or smearing on underwear. Incontinence can occur on a daily basis or at irregular periods. Some sufferers will use a pad in severe cases. It has been estimated that approximately 5% of the Australian population suffer from incontinence of faeces and more common in elderly people.
Normal continence is the ability to be familiar when the need to go to the toilet and to be able “hold on” until there is an appropriate time to go. This is achieved by a health bowel habit and healthy anal sphincters.
There are many cause for incontinence of faeces:
- Childbirth – the injury of the anal sphincter muscles or nerves.
- Severe constipation – from constant straining at defecation which also causes injury of the anal sphincter.
- Faecal impaction and rectal prolapse.
- An accident or surgery that injures the anal sphincter.
- Disease such as irritable bowel syndrome or inflammatory bowel disease.
- Congenital causes in which you are born with a problem of the bowel or anal sphincter.
- Diabetes, multiple sclerosis, spinal injury and dementia are a variety of causes also.
A diagnosis is formed by the history of the incontinence and a rectal examination. Tests can be performed such as a colonoscopy or barium enema that can exclude diseases of the bowel. Further tests can be performed on the anal sphincter to determine the diagnosis such as an anal manometry which tests the strength of the anal muscles, an anal ultrasound this gives a picture of the anatomy of the anal sphincter muscles or a nerve test to determine whether there is a nerve injury.
Symptoms of incontinence can be improved by simple interventions such as alteration of diet, bulking of the stool with medications, pelvic floor exercises and physiotherapy can also help. Surgery is a possibility to repair or tighten the anal sphincter muscle when this is damaged.
For some conditions of incontinence there are modern procedures that are available that will enhance the sphincter closing with injections into the muscle or implant of a nerve stimulator.
However where these interventions are not possible a new anal sphincter can be created. This can be very complex and may not be suited to everyone and on some occasions, a colostomy is recommended.
Inflammatory Bowel Disease (IBD): Crohn’s Disease and Ulcerative Colitis
Inflammatory bowel disease is the name of a group of disorders that cause the intestines to become inflamed (red and swollen). The inflammation lasts a long time and usually comes back over and over again.
If you have inflammatory bowel disease, you may have abdominal cramps and pain, diarrhoea, weight loss and bleeding from your intestines. Two kinds of inflammatory bowel disease are Crohn’s disease and ulcerative colitis. Crohn’s disease usually causes ulcers (open sores) along the length of the small and large intestines. Ulcerative colitis causes ulcers in the large intestine, often starting at the rectum.
Based on your symptoms, your doctor may suspect that you have Crohn’s disease or ulcerative colitis. Your bowel movements may be tested for germs and the presence of blood. Your doctor will probably look inside your intestines with a sigmoidoscope or a colonoscope. In these procedures, the doctor uses a narrow flexible tube to look directly inside your intestines. Special x-rays may be helpful in diagnosing this illness.
The best thing you can do is take good care of yourself. It’s important to eat a healthy diet. Depending on your symptoms, your doctor may ask you to cut down on the amount of fibre in your diet. In addition to eating well, you need to get enough rest. It’s also important that you learn to manage the stress in your life. When you become overly upset by things that happen at home or at work, your intestinal problems can get worse.
You will most likely be treated by a team of doctors. This team may include your general practiotioner, a gastroenterologist and, possibly, a surgeon.
The goal of treatment is to get rid of the inflammation. Many types of medicine can reduce inflammation, including 5ASA drugs such as sulfasalazine, corticosteroids such as prednisone, and immune system suppressors such as azathioprine, mercaptopurine and methotrexate. An antibiotic, such as metronidazole, may also be helpful for killing germs in the intestines, especially if you have Crohn’s disease.
It is important to talk to your doctor before taking any over the counter medicine on your own. Your body may not be able to handle the effects of medicine. If you have severe symptoms, such as diarrhoea, fever or vomiting, you may need to go to the hospital to be treated with special fluids and medicines that must be given intravenously (in your veins).
If your ulcerative colitis becomes so severe that it can’t be helped by medicines, it may be necessary to remove part of your small or large intestines surgically.
Irritable Bowel Syndrome
Irritable Bowel Syndrome (IBS) is a “syndrome,” meaning a group of symptoms. IBS commonly causes abdominal pain or discomfort often reported as cramping, bloating, gas associated with diarrhoea, and/or constipation. IBS affects the colon, or large bowel, which is the part of the digestive tract that stores stool.
IBS is not a disease. It’s a functional disorder, meaning that the bowel doesn’t work, or function, correctly but there are no signs of diseases such as imflammation or tumours. Doctors are not sure what causes IBS. The nerves and muscles in the bowel appear to be extra sensitive in people with IBS. Muscles may contract too much when you eat. These contractions can cause cramping and diarrhea during or shortly after a meal. Or the nerves may react when the bowel stretches, causing cramping or pain. IBS does not cause permanent harm to the intestines, and it does not lead to a serious disease, such as cancer.
The main symptoms of IBS are abdominal pain or discomfort in the abdomen, often relieved by or associated with a bowel movement. It also causes chronic diarrhoea, constipation, or a combination of both. Other symptoms are whitish mucous in the stool, a swollen or bloated abdomen and the feeling that you have not finished a bowel movement. Women with IBS often have more symptoms during their menstrual periods.
Emotional stress does not cause IBS. But people with IBS may have their bowels react more to stress. So, if you already have IBS, stress can make your symptoms worse.
IBS is diagnosed frequently from the symptoms you report using the ‘Rome criteria’. Medical tests may also be done to make sure you don’t have any other health problems that cause the same or silmilar symptoms. These may include blood tests, ultrasound scans, CT scans or Endoscopic procedures such as Gastroscopy or Colonoscopy.
IBS has no cure, but you can do things to relieve symptoms. Treatment may involve diet changes, medicines and stress relief. You may have to try a few things to see what works best for you. Your doctor can help you find the right treatment plan.
To understand pancreatitis, one has to appreciate that it is a long gland behind and below the stomach. The majority of its cells produce most of the body’s digestive enzymes which are secreted down a duct into the intestine to digest food. A minority of cells produce insulin.
Under certain circumstances, the digestive enzymes act on their own tissue, causing inflammation of the pancreas which we call pancreatitis. This causes severe pain, often with vomiting and in a minority of cases it can be fatal. Attacks last days at a time and require rest in hospital, fasting and intravenous fluids.
If the condition does not resolve, or if it keeps recurring, it leads to scarring and permanent loss of cells. This manifests itself as malnutrition (from lack of digestive enzymes) and diabetes (from lack of insulin).
The commonest causes of pancreatitis are gall stone disease and alcohol excess. Rarely, it is due to inherited disease, to parasites, drug allergies or other metabolic conditions.
Pilonidal sinus is a cyst or abscess that is located at the bottom of the spine just above the anus. Pilonidal means nest of hair and is derived from the Latin words for hair which is pilo and nest is nidus. Therefore a pilonidal sinus is the track leading to the nest of hairs under the skin. This cyst or abscess will often contain hair and skin and can be often very painful for the patient however some patients with a pilonidal sinus will be asymptomatic.
Usually a pilonidal sinus is caused by an ingrown hair although there is still many theories on how the hairs become embedded under the skin.
Treatments for pilonidal sinus can be antibiotic treatments and hot compresses or for more severe cases or a recurring pilonidal sinus is surgical intervention. The most common surgical intervention is excision with healing by packing and dressing of the wound. This surgery method requires daily dressing the healing process can take up to 12 weeks and still with a high recurrence rate.
There is a more modern surgical intervention for a pilonidal sinus which will give the wound primary healing with an approximate 95% healing rate in the first two weeks. It has been noted that the recurrence rate with this surgery is approximately 2%. This surgery is a very complex and needs to be performed by a highly specialised doctor with experience to achieve a good result.
Obviously the sighting rectal bleeding will be quite an alarming issue for most patients due to the concern of having bowel cancer. Luckily in most cases rectal bleeding has been the cause from other conditions such as a fissure or haemorrhoid/s present and can be treated with non-invasive methods. However the risk of having bowel cancer increases with your age and especially with a family history of bowel cancer. If you do have bleeding that persists you should see your doctor and discuss whether a colonoscopy is warranted.
Rectal prolapse is a condition where some part of the bowel protrudes from the normal anatomical position through to the outside of the anus. This may occur whilst straining at defecation which may need to be need to be reduced by hand or at rest. There may be symptoms such as discomfort, bleeding, incontinence or poor control and mucous.
There are 3 types of rectal prolapses:
- Incomplete prolapse (it is has not protruded through the anus)
- Mucosal prolapse (the inner lining rectum is only involved)
- Complete prolapse (the prolapse of the rectum)
Possible causes for a rectal prolapse are excessive straining at defecation, weak pelvic floor and anal sphincter muscles or a lack of fixation of the rectum to the adjacent pelvic structures. Rectal prolapses have been noted to be six times more common in women than men and has not been related to childbirth.
A called a proctogram can be organised if a prolapse cannot be produced at time of consultation with your doctor. This will confirm the prolapse.
A mucosal prolapse can be treated with either rubber banding or by surgery. If a complete prolapse is diagnosed surgery will be required however if the patient an incomplete prolapse this can be treated with laxatives to reduce straining.
There are different types of surgeries that can be suited and will be discussed with you at time of consultation due to each patient being different.