Polyps
Polyps are small growths that develop along the lining of the colon. They often look like small nubbins, similar in appearance to the bumps on the outside of a squash. Some have a stalk or pedicle, giving them a mushroom look. Others are flat, like a small patch of miniature shag carpet.
Polyps are important because it is now known that most colon cancers arise from benign (non-cancerous) polyps. If we can identify patients who have colon polyps without cancer, we can probably prevent those patients from getting cancer, by removing their polyps.
Most polyps can be removed without surgery. The procedure is called colonoscopy, and it involves passing a long flexible scope up into the colon through the anus. The polyps can be seen, snared with a wire loop through the scope, and removed for analysis. Some polyps may be too large or too flat (the “shag carpet” type) to be removed through the scope. Is such cases, surgery may be recommended to remove the polyp.
Diverticulosis
Diverticulosis is a disorder of the bowel, mostly of the colon, that generally affects people over 50 years of age. Diverticulosis involves the formation of pouches (diverticuli) along the wall of the colon.
Diverticulosis is very common in older people. Diverticulosis has for years been thought to be the result of a diet low in roughage (fruit and vegetable fibers). This has been based on the markedly low incidence diverticulosis and diverticulitis in Africa, as compared to North America. Presumably the typical US diet of processed foods, and comparatively low fiber content has been the culprit. But recent studies have questioned this explanation. In fact, one study found that a high fiber diet INCREASED the incidence of diverticulosis, and that a diet high in nuts, seeds, and popcorn DECREASED the incidence of the complications from diverticulitis. Go figure….
Although in many cases there are no symptoms, some patients may have occasional abdominal pain and rectal bleeding. A barium enema, sigmoidoscopy, or colonoscopy is used to reveal the presence of diverticuli.
Treatment recommendations for prevention of complications have included a high-fiber diet and plenty of liquids, about 6 to 8 glasses of water or juice per day, which increases the bulk and water content of the stool, which in turn reduces intestinal pressure. With the newer studies mentioned above, it’s uncertain what to recommend, but there are definitely other benefits for maintaining a diet high in fiber.
In some cases, the diverticuli cause massive (typically painless) bleeding from the rectum due to the presence of blood vessels alongside the diverticuli. Although such bleeding usually stops on its own, surgery may be necessary if the bleeding does not stop.
Diverticulitis
Diverticulitis is a common disease of the colon. Diverticulitis results if a diverticulum in the colon becomes inflamed. Bacteria may subsequently infect the outside of the colon if an inflamed diverticulum bursts open. If the infection spreads to the lining of the abdominal cavity, (peritoneum), this can cause a potentially fatal illness (peritonitis). Sometimes inflamed diverticuli can cause narrowing of the bowel, leading to an obstruction. Also, the affected part of the colon could adhere to the bladder or other organs in the pelvic area. In some cases, there can even be a rupture between the colon and the bladder or other organs, or through the skin. When this occurs, stool from the colon will actually flow through the perforation into the bladder, or vagina, or out through an opening to the skin. This sort of false passage is called a “fistula”. Diverticulitis most often affects middle-aged and elderly persons but can occur in young people as well.
It has been thought for decades that diet plays a major role in the development of diverticulosis and diverticulitis. It is interesting to note that diverticulitis rarely occurs in African countries but is quite common in North America, and other industrialized nations. If one compares dietary habits between these 2 different groups, there is much less fiber and “roughage” in the typical American diet. Now, with the more recent long-term followup studies described above, it seems we still have much to learn about how to prevent this disease.
The symptoms of diverticulitis include localized abdominal pain and tenderness, usually low on the left side, loose bowel movements or constipation, and fever. A blood test shows an increased number of white blood cells. Patients often have pain severe enough to go to the emergency room. A CAT scan is a frequent test done to confirm the diagnosis.
An acute attack of diverticulitis is usually treated with antibiotics, and diet modification, avoiding roughage, such as popcorn, nuts, and seeds. Fiber may also be limited in the initial treatment phase. When the infection has been controlled, patients ma resume their regular diet. Patients who have recurring acute attacks or complications, such as peritonitis, require surgical treatment. Milder cases can be treated without being hospitalized, with oral antibiotics. More severe cases may require a brief or sometimes more extended hospital stay. Most surgeons agree these days that surgery may not be necessary unless a patient has either 3 or 4 attacks, or if they have a particularly severe first episode, or if a secondary problem occurs, such as obstruction, or a fistula.
In some patients, the first attack is more severe. Sometimes the infection breaks through the wall of the colon, causing a perforation. If this happens, the abdominal cavity can become infected fairly quickly. This is called peritonitis. In patients who have peritonitis, there is usually much more pain and tenderness. In these cases, patients more often require emergency surgery, and a colostomy may be necessary in order to get the problem corrected. If a colostomy is necessary, it usually can be “reversed” at a second operation either several weeks or months later.
If the first episode is not so severe as to require surgery, patients can usually get back to a fairly regular routine not long after the antibiotic treatment is completed. In some cases, there may be reasons to consider a planned surgical removal of the involved colon even after the first episode. But in the majority of cases, one could just continue treatment with careful attention to diet and bowel habits (avoiding constipation and straining while on the toilet). If more episodes occur, surgery is usually considered in these cases. The surgery can usually be planned in advance. This is called “elective surgery”. In these cases, colostomy is not usually necessary. The affected part of the colon can be removed, and the two ends can be sewn (or “stapled”) back together.
If elective surgery as planned, it would be important to have had a fairly recent colonoscopy, in which a flexible lighted scope is passed upward through the anus to visualize all of the linings of the colon. This will ensure that there are no other problems inside the colon, such as polyps, cancer, or some inflammatory disease.
The surgery is done either using laparoscopic techniques or through a lower abdominal incision, usually running about from the naval down to the pubic bone. In most cases, the portion of the colon involved with diverticulitis is what’s called the “sigmoid colon”. This is the part of the colon just above the rectum, which is the part of the large intestines in the pelvis. The hospital stay can range anywhere from 3-to 7 days, and if any of complications occur, the hospital stay could be longer. In some cases, the procedure can be done with “laparoscopy”, in which smaller incisions are used, but the hospital stay is still typically about the same.
Crohn’s Disease
Crohn’s disease, known medically as regional ileitis or regional enteritis, is a chronic, inflammatory condition of the intestine. There is no known cause, although it may be hereditary. It is usually confined to the lower end of the small intestine (ileum), but may involve the large intestine (colon) and may occur anywhere in the GI tract. The symptoms include intermittent attacks of diarrhea and abdominal pain, weight loss, and fever. Rarely, the intestine may become blocked or ulcerate into adjacent areas via fistulas. Treatment involves a nutritious diet, painkilling drugs, antibiotics, and sometimes corticosteroids. If complications occur, the physician may recommend surgery to remove the diseased section of intestine, though the inflammation has a tendency to recur.
Ulcerative Colitis
Ulcerative colitis is a disorder of the large intestine, in which the colon becomes inflamed and ulcerated. It usually occurs in persons between 15 and 35 years old. The underlying cause is not known.
What are the symptoms of ulcerative colitis?
The most common symptom is a series of attacks and bloody diarrhea that vary in severity and duration from one person to another and from one attack to another. They may start suddenly or gradually and may occur as frequently as 10 or 15 times in 24 hours. The attacks are often accompanied by pain and spasms around the anus (tenesmus). Attacks may also cause fever, loss of appetite, and weight loss.
With mild attacks, the symptoms are less alarming. The patient may feel tired, but usually, there are no signs of generalized illness.
The symptoms usually disappear between attacks, although some patients may suffer from mild chronic diarrhea.
Can ulcerative colitis cause complications?
Yes. The most serious complications are associated with a sudden attack of bloody diarrhea, perforation of the intestine, peritonitis, and intestinal bleeding.
Persons with ulcerative colitis may also develop anemia, arthritis, inflammation of the eyes, or tender nodules under the skin. If ulcerative colitis persists for longer than about 10 years, there is a greater than average chance of developing cancer of the colon.
How is ulcerative colitis diagnosed and treated?
A positive diagnosis may require an internal examination of the colon and a barium enema x-ray.
Mild attacks of ulcerative colitis are usually treated with antidiarrheal drugs, a low-fiber diet, and rest. Sulfonamide drugs may control the symptoms of a severe attack. Treatment with corticosteroids may also be necessary.
Persons who suffer an extremely severe attack may require hospital treatment. If complications develop, such as peritonitis or intestinal bleeding, emergency surgery may be necessary.
The outcome of ulcerative colitis is variable. However, most patients suffer repeated attacks over many years, and about 30 percent eventually require some form of surgery.
Patients with recurrent ulcerative colitis should have regular internal examinations of the colon to check for early signs of intestinal cancer. In most cases, it eventually is necessary to remove the colon (colectomy). The function of the anal sphincter can be preserved with a pouch procedure, and a permanent colostomy can usually be avoided.