A review of common colo-rectal conditions Ian H K Scott 13 April 2016

Haemorrhoids Anatomy: Mucosal excess/prolapse in anal canal Symptoms: Sub-mucosal space filled with multiple arterio-venous fistulae Symptoms: Bleeding – bright red, at and after defaecation periodic Prolapse – covert overt Strangulation

Fissure –in-ano Symptoms: Anal pain at and after defaecation for variable period Bleeding Discharge which may be associated with a very low fistula Examination: Very high anal tone (in most cases, but some may be normal) Fissure may be visible Sentinel tag

Fissure-in-ano Treatment: In general, avoid cathartics. A bulky soft stool is best, so consider Fybogel or other bulking agent Diltiazem 2% cream - two x one month courses Sphincterotomy Low tone fissure presents considerable problem Conservative management as long as possible Operation to: 1. Close fissure with sutures 2. Cover defect by advancement flap

Rectal Prolapse Anatomy: May be simple mucosal prolapse, when symptoms may be mainly related to mucus discharge Full thickness prolapse, which is a herniation of the Pouch of Douglas through the anal sphincters Treatment Simple mucosal prolapse – sclerotherapy or banding Full thickness prolapse – Delorme’s procedure or Per-anal proctectomy (Altmeier’s procedure)

Diverticular Disease Incidence: Symptoms: It is said to be present in 80% of 80 year olds Can occur in much younger patients Symptoms: Only c.10% have significant symptoms Variable bowel habit Lower abdominal pain relieved by passage of flatus or stool Abdominal distension Urgency, occasionally leading to incontinence

Diverticular Disease Treatment: Increase fluid intake and add a bulking agent Antispasmodic Operation for unresponsive symptoms Complications: Acute diverticulitis Peri-colic abscess Bleeding Fistulation to bladder, vagina, abdominal wall, uterus, ureter

Colo-rectal Carcinoma Presents in many ways, from silent anaemia to disabling symptoms, and as unheralded acute obstruction Bleeding on its own is an uncommon presentation Persistent change in bowel habit to loose stools Tenesmus and mucus discharge in rectal cancer Be suspicious if woken early in the morning to empty bowels Be suspicious of symptoms that disturb sleep Treatment: Resectional operation aiming for 65% laparoscopic Rectal cancer often has multi modal treatment