Bowel (Colon & Rectal) Cancer

Cancer is an abnormal growth of cells forming a lump, called a malignant tumour. When this process occurs in the large bowel it is called bowel cancer. It may sometimes be called colon cancer or rectal cancer depending on where it originates. Cancer cells may spread outside the bowel to lymph glands or other organs and these clusters of cells are called metastases.

How Common is Bowel Cancer?

In Australia and NZ bowel cancer is the second most common cancer for both men and women combined. The disease is increasing as the average age of the population rises. In 2013, 14,962 new cases of bowel cancer were diagnosed in Australia and this is estimated to increase to 16,682 in 2017.

The risk of being diagnosed by age 85 is 1 in 10 for men and 1 in 15 for women. Across all cases, the five-year survival rate for Australians diagnosed with bowel cancer is 69%.

What is the Cause of Bowel Cancer?

The underlying cause of bowel cancer is not known. It is known that cancer develop from polyps and therefore treating polyps reduces your risk. It is more common in developed countries and is thought to be due to the food we eat. Dietary factors therefore may be important as a causative factor. Genetic factors which you inherit from your parents are also important. 

What are my Risks of Developing Bowel Cancer?

Your risk is greater if you:

  • Are > 50 years – Your risk increases with age
  • Have inflammatory bowel disease
  • Have adenomatous polyps
  • Have a significant family history of bowel cancer or polyps.

Other risk factors include:

  • Excess body fat and physical inactivity
  • High intake of particular foods (such as processed meat and high energy foods)
  • High alcohol consumption
  • Smoking
  • Some genetic conditions.

It is therefore recommended that you attempt to reduce your risk by undertaking regular exercise, maintaining an ideal weight and eating a diet low in fat/sugar and high in fibre.

What are the Common Symptoms?

  • A change in bowel habit with diarrhoea, constipation or the feeling of incomplete emptying
  • Thin bowel movements
  • Bleeding from the back passage or mixed in the stools
  • Abdominal pain, bloating or cramping that persists
  • Anal or rectal pain
  • A lump in the anus or rectum
  • Weight loss
  • Fatigue
  • Unexplained anaemia

What tests are used to diagnose bowel cancer?

If Bowel Cancer is suspected, your doctor or surgeon will likely perform a;

  • Thorough history and examination including an internal examination of the back passage
  • Blood test
  • Colonoscopy to visualise and sample (Biopsy) any pathology found
  • CT Colonography if you are too unwell for a colonoscopy
  • A staging CT Scan of the Chest / Abdomen / Pelvis
  • Rectal MRI +/- Rectal Ultrasound - For rectal cnacers

After the results of these tests are available, your specialist would discuss a plan of management. It is best at this stage to be accompanied by a friend or relative to help you in understanding the explanation and treatment plan.

How is Bowel Cancer Best Treated?

The most effective treatment, with the aim of cure, is surgical excision of the involved bowel segment. This also involves removing the lymph nodes surrounding the bowel and is most often completed as a key hole (Laparoscopic) procedure. 

Chemotherapy and/or radiotherapy may be given either before or after surgery depending on the cancers location and stage. The aim of this radiotherapy can be to reduce the size of rectal cancers and its risk of recurring. Chemotherapy is commonly given after surgery and primarily used to reduce recurrence. 

On some occasions patients may not be fit enough to be offered curative treatment or the cancer may have spread too far for treatments to be beneficial. In this setting palliative treatments will be offered which aims to reduce the symptoms from the cancer and improve your quality of life. 

Will I need a Stoma Bag?

If you have rectal cancer, you may require a permanent colostomy if the cancer is very close to the back passage. Technology and training in colorectal surgery have significantly reduced the need for a permanent colostomy however you may still requires a temporary stoma for a number of months to reduce the complications of surgery.

What is the Recovery and Follow-Up After the Treatment?

Your hospital admission can vary anywhere from 2 days after your resection but would usually be around 3-4. This will be determined by how well you are tolerating a diet and mobilising around the ward. It would also be reliant on normal observations, minimal pain and reassuring blood tests. Your bowels working would be reassuring but not essential. Any little hiccup or complication can add a day here or there.

It is still best to rest at home following discharge. This doesn't mean lying in bed or day which would be detrimental to your recovery. It means don't expect to be doing all the 'normal' things you were doing prior to the operation. You may find you fatigue easily so gradually increase the amount you do each day until you return to normal function.

An early post-operative review will be arranged for you from the hospital. This is usually within two-to-four weeks of leaving hospital. Your surgeon will assess your immediate recovery and wounds. They will also discuss further the results of any pathology and the possible need for further treatments.

From then on your surgeon will recommend a set programme of reviews. This may be individualised based on your current fitness or risk of further disease. These recommendations involve:

  • A clinical review at regular and frequent intervals for five years
  • Regular CEA blood tests
  • CT Scan as required based on your risk
  • Colonoscopy

It is recommended that a patient is "followed up" by their surgeon for as long as he/she remains fit to undergo further treatment should a new cancer develop. Below is a PDF print out of your likely schedule. You can bring this to each follow up appointment and will be a good guide for you to follow. Your schedule may vary with individual patient pathology, surgeon preference and treatment type.

It is important to establish good eating, drinking and exercise habits early after bowel surgery to maintain a healthy lifestyle. It is also recommended that you avoid smoking and tobacco related products.


Constipation describes the difficulty opening your bowels and is defined as the presence of at least 2 of the following;

  • Less than 3 bowel actions / week
  • Having excluded organic disease
  • Needing to strain or manually assist evacuation >25% of time
  • Passage of hard stools >25% of time
  • Sensation of abnormal evacuation >25% of time

Constipation is highly prevalent affecting 28% of the community. It is known that patients with constipation have disproportionately high levels of depression, health related anxiety / stress related symptoms and somatisation. Like other functional bowel disorders management is first aimed at excluding organic disease.

What are the causes?

There are several causes of constipation. They can include;

  • Whole gut slow transit - This has many causes such as Diabetes, neurological disorders such as Multiple Sclerosis and Parkinsons and hypothyroidism, hypocalcaemia and hypokalaemia. Drugs are a common cause with opioids being at the top of the list. Others include anticholinergics, iron supplements, antacids and NSAIDS.
  • Rectal evacuatory dysfunction - Difficulty opening bowels causing obstructive defaecation
  • Bowel Obstruction - A blockage from a growth or narrowing


Your surgeon will likely perform some investigations to exclude sinister pathology and to confirm potential causes. Each patient will be assessed and may or may not require the following;

  • CT Scan - exclude pathology within the abdomen
  • Colonoscopy - to exclude bowel cancer or other obstructing lesions
  • Colonic transit study - determines the speed of the large bowel
  • Defaecating proctogram - measures the structural and functional disturbance within the rectum
  • Anorectal manometry +/- nerve conduction studies - assesses sphincter muscle function


Maintaining a healthy lifestyle goes a long way to avoiding constipation. A diet high in fibre and fluid helps regulate bowel function and gut transit times. Your surgeon may also add a fibre supplement into your diet such as psyllium husk for added effect. Regular exercise is also important.

Specific management would be required for certain conditions causing constipation. The overuse of laxatives is discouraged but may be needed from time to time and in combination with lifestyle changes. Biofeedback therapy has been found to be effective with improved symptoms and quality of life with reduced laxative use. This is under the guidance of a pelvic floor physiotherapist "Gut retraining" and appropriate coordination is relearnt.


Surgery is reserved for symptomatic patients once all above has failed. Even then specialists still try to avoid operating as the condition can effect the whole bowel not only the colon. Surgical options may include;

  • Disimpaction for faecally loaded rectums
  • Total colectomy with or without an ileorectal anastomosis
    • Satisfaction varies from 39-100%
    • Complications are frequent with 1/3 requiring further surgery. 25% willl have persistent constipation and 25% will have diarrhoea.
  • Sacral Nerve Stimulation - Limited success
  • Malone procedure – Antegrade continence enema
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Crohn's Disease

Crohn's Disease (CD) is a chronic transmural inflammatory disorder affecting any part of the gastrointestinal tract from mouth to anus and may be associated with extra-intestinal manifestations. 

  • Global distribution with slightly increased rates in
    • Urban environments
    • Cooler climates
    • Improved hygiene
  • Slightly more common in females
  • Bimodal age distribution
    • 15-25’s
    • 60’s

What is the cause of Crohn's Disease?

CD results from a genetic predisposition to an abnormal interaction between environmental influences and the immune system.

  • Smoking doubles your risk and patients have a more aggressive disease with earlier relapses
  • 1st degree relatives have a 5-10% increased risk of CD and an increased risk of Ulcerative Colitis
  • Genetic analysis has identified multiple susceptibility loci (IBD1-9) causing CD confirming a genetic predisposition.

Pathological Distribution

  • 50% ileocaecal
  • 30-35% isolated small bowel
  • 30% isolated colonic
  • 10% anorectal disease (though rarely confined to this site)
  • 5% have upper GI disease (stomach and duodenum)

Clinical features


  • Insidious onset
  • Acute presentation in ~10% - Right lower abdominal pain, fever, tenderness or mass
  • Diarrhoea – 70-90%
  • Abdominal pain - 60%
  • Per rectal bleeding – 30% (50% of patients with colonic disease) / massive bleeding - 1-2%
  • Anal disease – 10% atypical or complicated fistulas and fissures

            Systemic Symptoms

  • Weight loss - 70%
  • Low blood albumin levels
  • Vitamin D and potassium deficiency 
  • Terminal ileal disease – B12 deficiency / malabsorption of bile salts and fats

      Extra-intestinal manifestations

These are features of CD which are separate to the gastrointestinal system. They are more common in large bowel inflammation rather than small bowel disease. Features include;


  • Pyoderma gangrenosum - ulcerations which typically occur on the legs
  • Erythema nodosum - nodular eruption on the legs. They change from red to blue as they regress and may last 2 weeks
  • Aphthous ulceration - Shallow ulcers commonly in the mouth
  • Metastatic Crohn's Disease - Nodular ulcerating skin lesions at distant sites


  • Uveitis, iritis, keratoconjunctivitis


  • Sacroiliitis and ankylosing spondylitis
  • Large joint arthritis


  • NASH / cirrhosis
  • Active hepatitis
  • Primary sclerosing cholangitis (more common in Ulcerative Colitis)
  • Gallstones - secondary to ileal disease and malabsorption of bile salts


  • Renal calculi secondary to increased oxalate absorption
  • Bowel cancer – 3-5% risk complicating Crohn's colitis / strictured segments
  • Amyloidosis – intestinal mucosa and kidneys, may resolve with disease resection


If your doctor suspects CD they will organise a series of investigations to firstly confirm the diagnosis and secondly to determine the disease extent. These would include;

  • Blood tests
  • Stool cultures - to rule out infections 
  • Colonoscopy - to examine the large bowel and the terminal ileum - biopsies will be taken for confirmation
  • MRE - Magnetic Resonance Enterography - A detailed scan to assess for disease in the small and large bowel
  • CT Scan - used in acute presentations to assess for complications of CD

Medical Management

There is no cure for CD. Medications are commonly used to control the inflammation. These include 5-ASA, antibiotics, steroids, antimetabolytes and  Anti-TNFa monoclonal antibodies. It is also highly recommended that patients cease smoking as recurrence is higher. Diet modifications may be suggested such as low residue for strictures to help control symptoms. Elemental diets can be as effective at controlling inflammation as steroids.

Surgical Management

In the setting of complications from CD or persistent inflammation despite medical management surgery is recommended. At some stage 80-90% of patients will require some degree of surgery in their lifetime. Of these ~50% will develop a recurrence and may require a further resection.

  • Surgery is for complications
    • Abscess – collection of pus not amenable to draining with a needle - perianal or intra-abdominal
    • Obstruction from a Crohn's stricture
    • Failed medical therapy / side effects from medications / chronic ill health 
    • Fistula (abnormal connection from the bowel to another organ) – if symptomatic
    • Acute colitis or inflammation of the large bowel
    • Bleeding which doesn't stop
    • Treatment or prevention of bowel cancer

Surgeons would always plan to be conservative in the amount they resect as recurrence is common and repeated resections can lead to short gut syndrome.

Diverticular Disease

Diverticula are small protrusions of the inner lining (mucosa) of the colon or large bowel, predominately within the sigmoid colon. It is primarily a Western disease attributed to deficiency of fibre in the diet. Diverticulosis (asymptomatic diverticular) is common with 10% of 40 year olds and 80% of 80 year olds having the condition. They are symptomatic however in only 10-30%.


It is thought that given the loss of stool bulk and lack of fibre there is increased intraluminal pressure required to promote stool transit. The sigmoid colon has the narrowest diameter and thickest wall and therefore generates highest pressures within the colon. Concurrently, the aging process results in hyperalestosis and an altered collagen structure which weakens the colonic wall. Diverticula then form through vascular defects in the muscle wall. Infection or diverticulitis may then develop secondary to faecal obstruction of a diverticula.


The vast majority of patients with diverticular disease have no symptoms. Definite symptoms occur when there is inflammation in a diverticulum, known as diverticulitis. These patients present with pain, a temperature and generally feel unwell. The condition may be insidiously progressive forming a stricture (narrowing) of the colon or a fistula, discharging infection into the bladder or vagina. These are all indications for surgical resection of the diseased segment. Occasionally a major bleed from a diverticulum may occur but fortunately in most patients the bleeding stops without any intervention.


For patients without symptoms a high fibre diet is sufficient treatment. It would also be important to cease smoking.

With a mild episode of diverticulitis a short course of antibiotics will usually resolve the symptoms in a few days. A severe attack will need treatment in hospital with fluid resuscitation and intravenous antibiotics.

Surgical intervention is reserved for complicated diverticular disease;

  • Acute diverticulitis with abscess formation or free perforation
  • Diverticular stricture causing a large bowel obstruction
  • Diverticular bleed which doesn't settle spontaneously 
  • Fistulous connection between the colon and either the bladder, vagina or skin
  • Recurrent diverticulitis resulting in several admission and days off work

If an emergency operation is required it will usually involve removal of the affected part of the colon and sometimes a temporary colostomy. It is very rare for a patient to need a permanent colostomy.

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Faecal Incontinence

Faecal Incontinence (FI) is the inability to control faeces or gas from the anus.  This condition is more common than you would think and worsens with age. Episodes can vary from major accidents in public to minor leakage with streaking or smearing of the underwear. Faecal urgency is the inability to 'hang on' and is a common feature in those with FI. Accidents may not happen but faecal urgency is disabling. FI or simply urgency can lead a patient to be house bound. Work, social and sex life can all be affected.

What causes FI?

There are many causes of FI. They include:

  • Childbirth injury to the muscles or nerves of the anal sphincter.  This is the commonest cause and usually presents later in life unless there is a major disruption to the sphincter muscle which would be immediate.
  • Rectal prolapse may be associated with FI.
  • Injury to the anal sphincter from an accident or surgery (fistula, fissure, haemorrhoids).
  • Diseases of the bowel such as IBS and IBD which increase frequency and looseness.
  • Other causes such as Diabetes, Multiple Sclerosis, spinal injury and dementia.


The diagnosis is established by the history and a rectal examination.  Investigations are used to confirm the diagnosis of sphincter injury and to exclude any diseases of the bowel.

  • Anal manometry - involves the insertion of a slender catheter into the anus.  This test measures the strength of the anal sphincter muscles.
  • Endoanal ultrasound - involves the insertion of an ultrasound probe into the anus. It gives an accurate picture of the anatomy of the anal sphincter muscles and whether there is any injury or defect.
  • Pudendal nerve studies - sometimes used to detect if a nerve injury is present.  This may influence management.
  • Colonoscopy - to exclude any proximal pathology within the bowel.


Symptoms of FI are commonly improved through

  • Diet manipulation - to avoid precipitants of diarrhoea which leads to FI
  • Fibre bulking of the faeces and
  • Pelvic floor exercises / biofeedback therapy.

FI has been historically a difficult condition to treat surgically, and this has not changed. There are various surgical options available that can be offered to repair, tighten or fill the anal sphincter muscle when this is damaged. Unfortunately all of these techniques have poor long term results. For selected patients with FI who haven't improved after conservative therapies implanting a nerve stimulator to facilitate muscle contraction (SNS) may help. Occasionally, a colostomy (stoma) will be recommended.

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Fissure in ano

A fissure is an ulcer or tear in the lining of the anus. It commonly occurs during episodes of constipation and if it persists beyond 6 weeks becomes a chronic fissure. They may be associated with an anal skin tag or lump at the opening of the anus called a sentinel tag.

What Causes A Fissure?

The exact cause is unknown and it is likely multifactorial. Trauma through passage of a large, hard stool leads to a tear in the anal canal. This tear is usually at the back of the canal where there seems to be a relatively reduced blood supply which impairs healing. Spasm of the exposed sphincter muscle not only causes pain but contributes to the impaired blood supply.

Contributing factors are therefore;

  • Constipation or
  • Diarrhoea or
  • Pregnancy
  • Rarely fissures are associated with other conditions like Crohn's Disease or sexually transmitted infections.


  • Pain & bleeding (usually on paper only) with defaecation – Pain lasts minutes to hours and can be excruciating
  • Skin tag (sentinel pile) overlying external edge of chronic fissure
  • Fibrotic ulcer seen at examination


Mild symptoms can frequently be relieved by increasing fibre and fluids in the diet and avoiding excessive straining. Initial treatment is usually with local ointments such as RECTOGESIC or NIFEDIPINE OINTMENT. These are effective in around 60-70% of cases and if effective usually give some relief to symptoms within a week or two. If symptoms persist beyond a month an injection of BOTOX may be considered. This is particularly useful in women to avoid surgery and the risk of incontinence. The duration of action is for 3 months and has success rates of 70-90%.


If simple treatments are not effective a surgical treatment may be recommended. The operation is called a LATERAL INTERNAL SPHINCTEROTOMY. The operation involves dividing the lower portion of the internal anal sphincter to relax the muscle spasm causing the pain and the fissure to persist. This is effective in curing fissure in over 90% of cases and results in symptom relief within a few days. It is performed under a general anaesthetic. 

In a small proportion of patients (less than 5%) the operation results in weakening of the anal sphincter to a degree that causes decreased bowel control or incontinence. This complication is however rare and will be discussed with you prior to consideration of any surgical intervention for a fissure.

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Haemorrhoids are abnormally engorged and symptomatic anal blood vessels. They are equally common in men and woman with a peak incidence in the 50's and 60's. 

As haemorrhoids enlarge they bulge into the anal canal and eventually may protrude at the edge of the anus. This may be associated with an anal tag. External skin tags usually represent the remnant of stretched skin arising from prolapsed internal haemorrhoids at the anal verge or a previous peri-anal haematoma. A perianal haematoma or clot is a painful, sensitive lump on the edge of the anus, often mistaken for a prolapsed internal haemorrhoid.

What causes Haemorrhoids?

Internal haemorrhoids form due to a weakening of the supportive connective tissues within the anal canal due to straining allowing the lower rectal lining with its vessels to become engorged. Contributing factors include;

  • Defaecation in the squatting position → prolapse
  • Constipation and straining
  • Straining due to the sensation of incomplete emptying
  • Raised intra-abdominal pressure / Obesity
  • Pregnancy – progesterone weakens smooth muscle and elastic tissue 


  • Bleeding - Most common and usually bright red. It often drips or sprays into the toilet and is painless.
  • Pain - Discomfort is common but severe pain may indicate ulceration or a thrombosed haemorrhoid
  • Mass / Swelling - Prolapsing haemorrhoids
  • Discharge & pruritis – Mucous discharge from prolapsed haemorrhoid
  • Soiling – Blood, Mucous or Faecal leakage 


All patients whether intervention is required or not should increase the fibre and fluids in their diet and avoid excessive straining. This may be all that is required in patients with mild symptoms. Local ointments will not make the problem go away but may give some relief to symptoms.

  • Rubber band ligation

This is a treatment which is appropriate for small haemorrhoids. No anaesthetic is required as the bands are applied to a part of the bowel that has no feeling. It is commonly performed at the time of a colonoscopy to investigate for bleeding. The rubber bands obstruct the blood supply. There may be some minor discomfort and a feeling of needing to empty your bowels for a few hours after having the bands applied. There may also be a small amount of blood in the motion about 10 days later. It may be necessary to repeat the procedure on 2 or 3 occasions before treatment is completed.   

  • Haemorrhoidopexy

This is a procedure using a series of sutures or ties to reduce the blood supply to the haemorrhoid complex in addition to fixing the haemorrhoids up into the anal canal and lower rectum. This may have less pain than excising the haemorrhoid and benefits in those which are prolapsing.

  • Haemorrhoidectomy

Surgical excision is sometimes necessary to treat large or complicated haemorrhoids. The procedure is performed under anaesthesia. Although this is a more painful procedure most patients still go home on the same day with pain killers and stool softeners.

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Irritable Bowel Syndrome (IBS)

Irritable Bowel Syndrome (IBS) is a collection of non-life threatening symptoms specifically related to functional abdominal pain with altered stool consistency or frequency.

IBS is highly prevalent affecting 22% of the population. Patients have disproportionately high levels of

  • Depression
  • Health related anxiety / stress related symptoms
  • Somatisation and 
  • Show a high placebo response of 30-80%

The aims of managing patients with IBS is to firstly exclude organic disease then concentrate efforts on reassuring patients, alteration of lifestyle and avoiding surgery.


Your surgeon may organise investigation to exclude organic disease. These could include;

  • Endoscopy – to exclude coeliac disease and other food intolerances
  • Colonoscopy – to exclude bowel cancer or diverticular disease
  • CT Scan - to exclude pathology within the abdomen


The first line of management is aimed at empathic reassurance of the patients symptoms, that there is no sinister pathology. Treatment is then focussed to;

  • Lifestyle Modification

Diet modification is important in IBS treatment and central to this is a Dietitian's input. Researchers from Monash University have identified compounds found in certain foods that increase the risk of IBS symptoms. These are called FODMAPS. It was found that avoiding these foods can improve symptoms. Attached below is a list for a low FODMAP diet and for further information the following link can be followed to the Monash University Low FODMAP diet webpage.

  • Medical

There are a variety of medications tried with varying success. Fibre is a common supplement to regulate bowel function. In the setting of diarrhoea and urgency Gastrostop may need to be used. There is no evidence that antispasmodics are better than placebo medications in reducing the symptoms of IBS. Although there is no harm from using probiotics, there is unlikely to be any improvement in symptoms. Occasionly antidepressants are used to help treat depression and anxiety which in turn helps the symptoms of IBS.

  • Psychological 

Interestingly, cognitive behavioural therapy directed towards the gut and hypnotherapy have shown positive results in the past.

  • Surgical

Although IBS patients are more likely to undergo surgery than the general population there is no role for it to improve the symptoms associated with IBS.

Perianal Abscess / Fistula

An abscess is a collection of pus in any localised space in the body. A perianal abscess is one that develops in the tissues around the anus.

What are the Causes?

A number of small glands are normally present between the inner and outer layers of the anal sphincter muscle.  These glands may become blocked setting up an infection. This is known as the cryptoglandular theory. An abscess develops from this infective process and may extend to various areas around the anal canal to involve the anal sphincter muscle and surrounding structures.  The abscess may enlarge and burst through the overlying skin or may be drained by surgical treatment. If this opening persists, it becomes a Fistula.

Other less common causes include;

  • Inflammatory Bowel Disease
  • Malignancy
  • Hidradenitis
  • Iatrogenic
  • Fissure
  • Radiation

What are the Signs and Symptoms?


  • Pain - Increasing as the pus increases and improves once drained
  • Tender mass
  • Fevers and sweating


  • Offensive discharge
  • Bleeding
  • Itch
  • Often painless

Treatment of an Abscess

A short operation is usually required to allow the pus to be drained from the abscess cavity. This is done by making an opening through the overlying skin.  A hospital admission is required and is commonly overnight is needed.  Antibiotics may be used to control the spread of the infection, but antibiotics alone will not cure an abscess.  Drainage of the pus is always needed.


What is a Fistula-In-Ano?

An anal fistula is an abnormal track (Connection) between the internal lining of the anus and the skin on the outside.  A fistula usually develops after drainage of an anal abscess but may occur spontaneously.  Discharge of pus may be constant or intermittent as the external opening on the skin may heal temporarily.

Most fistulae are the result of infection in an anal gland. Fistulas do not cause cancer however cancer in the anus or rectum could present as a fistula. Patients suffering from inflammatory bowel disease are more likely to develop anal abscesses and fistulae.

Treatment of a Fistula?

Surgery is usually needed to treat a fistula.  The course of the track between the anus and the skin has to be identified and exposed.  This tract may be treated in one of three ways according to its complexity.

  1. Fistulotomy - Opening the entire length of the track to the skin’s surface allowing the open wound to heal slowly.  Some sphincter muscle is usually divided.  This is the most frequent treatment employed and has the lowest recurrence rate.
  2. Seton Drain - Is a loop of flexible material placed along the track to maintain drainage. This is used if too much sphincter muscle restricts a fistulotomy and there is too much infection for a definitive repair.
  3. Definitive Fistula repair - A more complex operation to close the internal opening of the track and preserve the anal sphincter muscle.
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Polyps are abnormal and exaggerated growths of the gut lining (mucosa). They can occur anywhere in the gastrointestinal tract but are most common in the colon. They vary in their shape, size and location within the bowel. Most polyps are smaller than one centimetre in diameter. Some have a stalk and others are flat or carpet-like, spreading over the surface of the bowel. There are several types of polyps however the most significant are adenomatous polyps and serrated adenomas.

Adenomatous Polyps

When polyps are discovered during colonoscopy they should be removed (polypectomy). They are then examined and classified by a pathologist which indicates the risk for further polyp development. This dictates when you should have a further colonoscopy. Removal of adenomas is important because there is strong evidence that indicates some adenomas undergo malignant change to produce bowel cancer. This process is usually slow but can be accelerated in a small number of patients. 

What are the Symptoms of Polyps?

Polyps are small and rarely produce symptoms and are usually discovered at the time of colonoscopy. A patient with no symptoms may be suggested to undergo investigations for the following findings;

  • Positive FOBT
  • Iron Deficiency Anaemia
  • Family History

However, large adenomas occasionally may cause

  • Bleeding
  • Mucous Discharge / Diarrhoea or Incontinence for rectal adenomas
  • Prolapse for rectal adenomas
  • Tenesmus

These symptoms should be investigated further with endoscopic evaluation to exclude sinister pathology.

Who is at Risk?

Advancing age is the most significant risk. People who have the above symptoms (especially bleeding) and are approaching 40 years of age or older, may need a colonoscopic examination. Other people at risk include those with a significant family history and patients who have had a previous adenoma or cancer successfully treated. 


Colonoscopy is the most accurate test to diagnose polyps. The purpose is to obtain a clear view of the whole length of the inner surface of the bowel, to search for and remove any polyps found, and have them examined under the microscope. Up to 90% of polyps can be safely and completely removed by colonoscopy.


If adenomas are confirmed by a pathologist, it is recommended that the patient have regular "check-ups" by repeated colonoscopy.  Other types of polyps may not require any specific follow up. Attached below is a PDF of the National Guidelines which recommend intervals of surveillance colonoscopy based on previous polyp detection.

Pruritus Ani (Anal Itch)

Advice to reduce symptoms;


A high fibre diet will change a loose stool into a formed one and reduce perianal irritation. Reducing the consumption of foods that decrease the time taken for food to pass through the body, such as hot and spicy foods, may be of help for some patients.


Cleansing after every bowel movement may have to be adopted as a lifelong strategy to prevent itch. Both neglecting and overdoing hygiene can be damaging.  Cleanse the perianal area after every bowel action, and not only when the area becomes itchy. Avoid harsh toilet paper. Baby wipes are a good alternative to toilet paper, particularly when the itch is at its worst.  Dry the area by dabbing (not rubbing). Drying the area with a hair dryer can be a good method. Avoid liquid and bar soaps.


Increasing the ventilation in the perianal area reduces the moistness that can lead to the skin becoming soft and more easily damaged.   Wear cotton underwear only.  Avoid tight clothing and pantihose.  Avoid sitting for long periods of time on vinyl seats.  If you are overweight losing weight can make a big difference.

Protective Preparations

Should be avoided if possible. If night itch is a problem, mild protective applications (such as Zinc cream or Calmoseptine ointment) can be useful for night-time protection. Avoid perfumed talcum powders.

As the condition improves

Gradually reduce the strictness of the regimen described above. Stick with principles however of keeping the area clean and dry and avoid damaging it with excessive rubbing or medication. If the condition recurs, as it may from time to time, start the routine again.

Remember that pruritus ani is not progressive, but rather a temporary nuisance from time to time that can be controlled and that it is not associated with bowel cancer or any other serious conditions of the bowel.

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Rectal Prolapse

A rectal prolapse is a protrusion of some part of the bowel through and outside the anus. It may occur in childhood or in the elderly. There are three types of prolapse:

  1. Mucosal or incomplete prolapse involving only the inner lining of the rectum.
  2. Internal prolapse - The rectum is not yet protruding through the anus.
  3. External prolapse of the rectum.

What causes prolapse?

The exact cause is not known. Possible explanations are excessive straining at the toilet, a weak and aging pelvic floor, or a lack of fixation of the rectum to adjacent pelvic structures. Rectal prolapse is six times more common in women than in men. It is more commonly seen in people with;

  • Increased BMI
  • Redundant sigmoid colon
  • Nerve injuries and a weak pelvic floor
    • Pregnancy
    • Diabetes
  • Laxative abuse / chronic constipation
  • Psychiatric disorders - particularly anorexia
  • Spinal cord injuries
  • Connective Tissue Disorders
    • Marfan Syndrome
    • Ehlers-Danlos Syndrome


Protrusion of the bowel through the anus occurs during defaecation (opening your bowels) which at first goes back in by itself. Later it needs to be reduced by hand. There may be discomfort, bleeding and the passage of mucous. Incontinence or poor control of the bowel is a very common complaint. A feeling of constipation or incomplete emptying of the rectum may be an associated symptom. Symptoms become more severe as the prolapse increases in size and eventually it may not be able to go back in.


Inspection by the doctor is often all that is required after asking the patient to strain. Sometimes it is necessary for the patient to sit on the toilet and strain to produce a prolapse. If a prolapse is suspected but the patient cannot induce it, a special x-ray called a proctogram may be required. This is a dynamic test which can not only confirm the diagnosis but differentiate the degree of full thickness rectal prolapse from mucosal prolpase. It may also reveal associated conditions such as a rectocoele. If incontinence has been a problem there are tests of sphincter muscle function which can be performed.


The treatment of mucosal prolapse or incomplete prolapse remains controversial and is treated either by conservative options or surgery depending on the patients symptoms. If a complete prolapse of the rectum occurs then surgery is usually required. There are several operations available which may be performed either via the abdomen or the anus (perineum).

Abdominal operations involve securing the bowel to the lower spine (sacrum) and may include removal of part of the bowel if constipation is a special feature. This is usually performed as a laparoscopic operation. 

Perineal operations have a lower success and less significant complication rate than abdominal approaches and are therefore reserved for the frail and unfit patient under a spinal anaesthetic.


The choice of which procedure is best needs to be decided on an individual basis. Success rates for surgery are very good but vary for each type of operation. Some alteration in bowel habit after operation may occur. This is variable, usually not severe and improves with time.

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A rectocoele is a hernia of anterior rectal wall through the rectovaginal septum (thin layer between the rectum and vagina). It is seen ballooning out into the vagina when you push down to have a bowel movement. It is thought to arise following muscle and nerve damage after childbirth, menopause, chronic constipation or abnormal contraction of pelvic floor muscles and leads to a thinning of the rectovaginal septum.

What are the symptoms of a rectocoele?

Many women have rectocoeles but only a small percentage of woman have any symptoms related to the rectocoele. 

Vaginal symptoms include;

  • Vaginal bulging
  • The sensation of a mass in the vagina
  • Painful intercourse
  • Vaginal bleeding is occasionally seen

Rectal symptoms include;

  • Constipation, particularly difficulty evacuating with straining - this is know as obstructive defaecation
  • Bulging in the vagina when straining
  • Self digitation or pressing against the vagina helps to empty the rectum
  • Sensation of incomplete emptying - A rapid return of the urge to have a bowel movement after leaving the bathroom because stool that was trapped in the rectocoele may return to the rectum after standing up.
  • Feeling of pelvic pressure or discomfort is often present.

How is a rectocoele diagnosed and when should it be treated?

Most rectocoeles are diagnosed following an examination of the vagina and rectum in the rooms.  However, it may be difficult to assess the size and significance of the rectocoele.  A more accurate method of assessing the rectocoele is an x-ray study called a defaecating proctogram.  This is a dynamic study showing how large the rectocoele is and if it empties with evacuation. You should consider having your rectocoele treated when it causes significant symptoms.  It takes an experienced doctor to help you decide whether your symptoms are caused by a rectocoele.

What treatment is available for a rectocoele?

Rectocoeles that are not causing symptoms do not need to be treated.  In general, you should avoid constipation by eating a high fibre diet and drinking plenty of fluids.

Medical Treatment

This includes a diet high in fibre and increasing your fluid intake each day.  Fibre acts like a sponge.  It soaks up fluid so that less is removed as the stool travels around the colon.  The stools will be larger, softer and easier to pass.  You may wish to add a fibre supplement such as psyllium husk preparations to this regimen to improve stool consistency. Avoid straining.  If you cannot completely empty get up and return later.  Holding pressure with a finger to support the rectocoele and encourage the stool to go in the correct direction is often helpful.  This may be accomplished by pressing against the lower back wall of the vagina or along the posterior rim of the vagina.  Avoid placing a finger inside the anus to pull the stool out as this may cause harm.

Surgical Treatment

If symptoms persist even with medical therapy, then surgical repair may be indicated.  Surgical treatment is the last resort for those with severe symptoms.  There are several surgical techniques used to repair a rectocoele.  The best operation for you depends on what symptoms you have and the skills of the surgeon.  It should be noted that even in expert hands with carefully selected patients not all patients undergoing surgery have complete resolution of the symptoms of a rectocoele.  Most studies report success in around 60-70% of patients.


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Ulcerative Colitis

Ulcerative Colitic (UC) is a diffuse inflammatory condition of unknown aetiology affecting the internal lining of the colon and rectum. It commonly presents during the ages of 20-40, but can occur at any age, and affects males and females equally. 

What is the cause of UC?

The cause is unknown, but many theories exist. Having said this, UC is more common amongst Jewish families and families with a history of CD and UC. There doesn't seem to be any association with diet however there may be a link following infections of the large bowel.

Only the large bowel is involved, with the inflammation starting in the rectum and extending for a variable distance towards the beginning of the large bowel (caecum). 

Can other problems occur with ulcerative colitis?

As with CD, UC patients can also develop extra-intestinal conditions. These include


  • Pyoderma gangrenosum - ulcerations which typically occur on the legs
  • Erythema nodosum - nodular eruption on the legs. They change from red to blue as they regress and may last 2 weeks
  • Aphthous ulceration - shallow ulcers commonly in the mouth
  • Metastatic Crohn's disease - nodular ulcerating skin lesions at distant sites


  • Uveitis, iritis, keratoconjunctivitis


  • Sacroiliitis and ankylosing spondylitis
  • Large joint arthritis


  • NASH / cirrhosis
  • Active hepatitis
  • Primary Sclerosing Cholangitis
  • Gallstones - secondary to ileal disease and malabsorption of bile salts


  • Renal calculi secondary to increased oxalate absorption
  • Bowel cancer – 3-5% risk complicating Crohn's colitis / strictured segments
  • Amyloidosis – intestinal mucosa and kidneys, may resolve with disease resection

What are the symptoms?

Episodic or continuous diarrhoea with blood and mucous are the main symptoms. Crampy lower abdominal pains with urgency to defaecate is common given the rectal inflammation. The symptoms can vary from mild to so severe that patients require an acute admission to hospital and possible surgery. Occasionally it can "burn out" after a number of years.

How is it diagnosed?

Diagnosis is based on the clinical picture and the appearance of the large bowel mucosa at colonoscopy. Biopsies are diagnostic and can also establish the degree of inflammation. CT scans may be organised in a severe presentation where a complication is suspected.

When is surgery needed?

Surgery is indicated when medical treatment can no longer control the inflammation. Similarly to CD surgery may be indicated in the presence of complications

  • Abscess – collection of pus not amenable to draining with a needle - perianal or intra-abdominal
  • Failed medical therapy / side effects from medications / chronic ill health 
  • Acute colitis or inflammation of the large bowel with or without perforation
  • Bleeding which doesn't stop
  • Treatment or prevention of bowel cancer

The aim is to remove all of the large bowel and this can be done in one or more stages. There are two options following total colectomy. The first is to have a permanent ileostomy (Stoma bag) and the second is to form a pouch using small bowel and connecting it to the anus. This removes the need for a permanent ileostomy. This operation is not suitable for all patients and is more complex surgery than a permanent ileostomy. It results in a variable number of loose but well-controlled bowel motions per day.

What can I expect after surgery?

Removal of the diseased bowel implies cure without the need for drugs, and removes the risk of cancer. Life expectancy should be normal. With an ileostomy usual occupations and most sports can be resumed. A normal sex life and pregnancy should be possible. Pouch surgery allows defaecation through the anus, however functional results are variable.