Cancers of the skin are extremely common in Australia due to harsher than average ultraviolet exposure and the classic Australian beach lifestyle.
Common cancers are squamous and basal cell cancers which occur from long term sun exposure. Melanomas and melanoma-like tumours are less common, as are tumours of the skin appendages.
The gold standard treatment for skin cancers is surgical excision to ensure a clear margin of tissue. Regular skin checks are required after treatment.
Haemorrhoids are a normal part of our anatomy and contribute to continence and control, particularly for wind.
Haemorrhoids become problematic when grossly enlarged, prolapsing or bleeding.
They are common during/after pregnancy or with long term straining when moving the bowels.
Prolapsed haemorrhoids are felt as lumps that fall out of the anus with defecation and either return at the end of the movement or need to be manually reduced.
Some haemorrhoids are constantly prolapsed, and some become thrombosed which causes pain. In the absence of thrombosis, haemorrhoids are painless.
A fissure is a small tear in the lining of the anus. This occurs after passing a very firm motion or spontaneously in crohns disease and in immunosuppressed patients.
Fissures cause intense pain and some bleeding. The pain is due to spasm of the muscles of the anus and occurs during a motion or immediately after it. This pain can last some time.
Acute fissures last only a few weeks. Most will settle without a procedure and require laxatives and medications to relax the muscles of the anus.
Chronic fissures are present beyond several weeks. They are unlikely to settle without treatment. Many will settle with relaxing medications. Some will require BOTOX injection or sphincterotomy to relieve the pain and allow healing.
Anal warts vary from small to immense, sometimes covering the whole anus and surrounding skin. Infection with the Human Papilloma Virus (HPV) causes anal warts. HPV may be sexually transmitted.
Many viral subtypes predispose to anal cancer. This risk is substantially increased with any immune disorder or by drugs that suppress the immune system. The combination of HPV infection and HIV causes a 144-fold increased risk of anal cancer.
The body’s immune system must clear the warts. Surgical excision can provide substantial relief in the interim.
All patients with anal warts should be vaccinated against HPV unless they are immunocompromised. Vaccination should ideally be with a quadrivalent vaccine.
Anal cancers arise from regions of normal skin harbouring mutations. These regions are known as Anal Intraepithelial Neoplasias (AIN) and range from low to high grade.
AIN is very common in the immunocompromised community, particularly patients with HIV.
Patients with AIN should be reviewed frequently by a specialist with an interest in anal conditions and any masses that develop biopsied.
AIN is associated with human papilloma virus infection. It can also be associated with chronic inflammatory conditions such as lichen sclerosis.
Cancer of the anus is uncommon – certainly when compared to cancer of the colon and rectum. Anal cancer arises from regions of pre-malignant change called Anal Intraepithelial Neoplasia (AIN). Cancer can occur in the anal canal itself or in the skin surrounding the anus.
Anal carcinoma is commonly treated with radiotherapy and chemotherapy. Local excision (surgical removal) is sometimes required. If initial treatment is unsuccessful then radical surgery may be the only way to achieve control and cure.
Prevention is always better than the cure. Patients with known Human Papilloma virus infection, especially those with any immune disorder including HIV/AIDS, should be checked for lesions. Patients with known pre-malignant lesions of the anus should be seen by a specialist regularly.
A pilonidal sinus is not an ingrown hair. It represents hair that has fallen from another location (such as the head) and become implanted in the natal cleft (between the buttocks), along the back or between fingers or toes.
An abscess is a collection of pus. Abscesses around the anus are common and painful. Symptoms include throbbing pain and swelling with discharge when the abscess bursts.
The abscess can recur if there is a fistula; this is a “false passage” from inside the anus out on to the skin of the buttock.
Abscesses are treated with surgical drainage. A further procedure may be required if a fistula is present. It may not be possible to safely explore the fistula during the drainage procedure.
Crohn’s disease is a long-term inflammatory condition affecting the gut from the mouth to the anus. The cause is a complicated series of problems within the body which allow ordinary gut content to create inflammation. There are many genes and many hormones involved in the disease.
Organs outside the gut can be affected including the skin, eyes and joints. Some of these problems get worse with flares of the Crohns disease and improve when the disease settles.
Many patients with Crohn’s disease suffer from perianal fistulae. These are false passages from the anus through to the skin of the buttock and sometimes the genitals. They are difficult to treat and sometimes require a combination of surgery and specialised immune modifying drugs.
Fistulae cause abscesses (collections pus under the skin) and create discomfort. Abscesses are treated by surgical drainage to relieve pain and settle infection.
Diverticula are pockets in the wall of the bowel. They can occur in any part of the gut. They are most common in the colon.
Most diverticula are asymptomatic but they can cause:
1. Bleeding
2. Perforation and diverticulitis
3. Stricture formation (narrowing of the colon)
4. Fistula (false passages) to the bladder or other bowel.
Diverticula are often seen on colonoscopy. No preventative surgery is required once found and most people never have any of the above problems.
Diverticulitis occurs when one of the diverticula on the colon ruptures, creating infection and inflammation on the outside of the bowel. These attacks occur randomly.
The inflammation causes pain and constipation. The patient may also have a fever. The attack is treated with antibiotics (usually) after careful diagnosis by your doctor; this may involve a CT scan to identify the affected region of the bowel. The scan will also show if an abscess (collection of pus) has developed alongside the bowel.
Severe attacks are treated in a hospital with intravenous antibiotics under the care of a surgeon. Abscesses are sometimes drained to settle the infection and relieve pain. An operation to clear away pus and infection may be required. Occasionally a bowel resection is needed to ensure a complete recovery.
After an attack of diverticulitis, a colonoscopy may be recommended to exclude other problems such as bowel cancer which may present in a similar fashion.
Diverticulitis can lead to a large abscess (collection of pus). If the abscess is next to the bladder a false passage (fistula) can develop between the bowel and the bladder.
This condition is common in older patients, particularly female patients who have had a hysterectomy. This is because the uterus usually separates the bladder and bowel.
Repeated urinary tract infections result from these fistulae. These will not resolve until the segment of bowel is removed and the defect in the bladder closed.
Up to 20% of the population has some degree of incontinence. Incontinence is more common in older age people. The most common cause is an injury to the anus from a difficult birth in female patients. Surgical procedures, radiotherapy, diabetes, inflammatory bowel disease, multiple sclerosis and rectal prolapse may all cause or contribute to incontinence.
Incontinence is due to failure of anal sensation, anal muscle function, problematic diarrhoea, loss of normal behavioural controls or all the above.
A complete assessment is always recommended when evaluating incontinence, including a history of the incontinence and careful examination. Assessment may involve endo-anal ultrasound to evaluate the muscle of the anus, anorectal physiology to assess the nerve supply to the anus and rectum, and examination under anaesthetic.
The treatment of incontinence is usually pelvic floor physiotherapy and retraining. Surgery is an option when these treatments do not work.
Rectal prolapse occurs when the rectum telescopes into the anus and passes through it; the rectum can then hang between the buttocks. The anus is stretched by this process and the patient remains incontinent while this continues.
Prolapse occurs in patients with a longterm history of straining on the toilet.
Numerous procedures have been developed to address this problem including laparoscopic ventral rectopexy, Delorme’s procedure and perineal rectosigmoidectomy (Altemeier procedure).
Patients with prolapse must address their issue with straining in the long term and be referred to a pelvic floor physiotherapist.
Adenocarcinoma of the rectum is the medical term for rectal cancer. These growths are common and affect both men and women. Rectal cancers can cause bleeding or block the bowel, preventing bowel function.
Rectal cancer begins as a polyp which progressively develops more abnormalities and mutations until it grows backward into the wall of the bowel. It can spread to the local lymph nodes (glands) or to the liver or lungs.
Rectal cancer can be prevented by regular colonoscopic screening, a diet low in meat and high in fibre and regular aspirin. However, the risks of taking regular aspirin outweigh the benefits unless it is needed for another medical condition such as heart disease or stroke.
There are many ways to treat cancer of the rectum but a surgeon should always be involved in the process. Most rectal cancers need to be surgically removed, and the majority of these operations can be done by keyhole surgery (laparoscopy). Treatment can involve radiation therapy and chemotherapy – sometimes before any operation can be performed.
Adenocarcinoma of the colon is the medical term for colon cancer. This affects the large bowel above the rectum. Symptoms, such as bleeding from the bowel are not always obvious and the cancer can be quite advanced before it is diagnosed.
Australia has a national bowel screening program to detect cancers early. Patients without symptoms are invited to test their stool for blood with a special kit. If the result is positive, then they are asked to have a colonoscopy.
Patients who have noticed symptoms such as bleeding, weight loss and change in bowel habits do not benefit from testing the stool for blood. They should proceed directly to colonoscopy.
Cancer of colon arises from a polyp which has become progressively more abnormal until it grows back into the wall of the bowel. It can then spread to surrounding lymph nodes (glands), to the liver and lungs.
Colon cancer is almost always treated with an operation. Keyhole (laparoscopic surgery) is often possible even if a patient has had previous surgery. Many different types of doctors and allied health staff will be needed to help with treatment and to provide support.
General and colorectal surgeons are specialists in the management of cancer of the colon and rectum.
Polyps are soft growths on the surface of the bowel that often look like a common wart. They are common and most will never progress to cancer.
Polyps range in size from 1-2mm to giant polyps which may cover large areas of the bowel wall. The larger the polyp, the more likely it is to contain a region of cancer within it.
Most polyps can be removed at the time of a colonoscopy and usually this is all the treatment they require. Polyps that contain regions of cancer require further treatment to ensure no cancer remains, either in the wall of the bowel near the polyp or in the lymph nodes (glands) along the bowel.
Sometimes people have multiple polyps and will be diagnosed with a polyposis syndrome. These syndromes have a significant cancer risk and frequent colonoscopy or complete removal of the colon are required to minimise this risk. Some polyposis syndromes are familial such as FAP (familial adenomatous polyposis) and Lynch syndrome.
A hernia is a bulging of the belly contents through the belly wall creating a visible lump under the skin. Hernias in the groin are usually inguinal hernias which appear as a lump to one side of the pubic bone and cause discomfort with straining or heavy lifting.
Inguinal hernias are common in men. The testicle communicates into the abdomen through a passage in the belly wall, creating a vulnerable area for these hernias to form.
Painful hernias should be repaired to reduce problems such as the bowel becoming stuck and damaged within the hernia.
There are now keyhole options for repair of groin hernias as well as the classical open surgery methods. Keyhole repair is preferred by patients as cuts are smaller and the return to work is faster. No matter how the hernia is repaired, heavy lifting and straining is prohibited for 4-6 weeks after the operation.
A hernia is a bulging of the belly contents through the belly wall that can be noticed just under the skin. Hernias can develop in old wounds in the belly, particularly those in the centre of the abdomen.
Unfortunately, these hernias can become “incarcerated” i.e. the belly contents get stuck outside the belly muscle wall. The content can be damaged in the process necessitating emergency surgery.
Symptomatic hernias should be repaired when possible. Both keyhole (laparoscopic) and classical surgical techniques are effective ways to repair hernias and prevent their return. Minimising body weight is important after surgery to prevent repeated hernia formation.
The gallbladder is an important structure which sits beneath the liver. It is responsible for storing and concentrating bile. Bile is made by the liver and helps to digest the fat in our diet, acting like a detergent by breaking fat into small globules for absorption.
Gallstones are soft, generally cholesterol-rich deposits which form inside the gallbladder. Most gallstones never cause problems but sometimes they block the gallbladder causing brief pain (biliary colic) or pain for hours to days (cholecystitis). Gallstones can pass down into the main pipe draining the liver and block it causing fever, pain and jaundice (cholangitis) or attacks of pancreatitis. Very rarely, gallstones can pass into the bowel through a false passage and cause a bowel blockage (gallstone ileus). These complications can be life threatening.
Once symptoms have developed, the only successful and safe treatment is removal of the gallbladder. This can almost always be done as a keyhole procedure (laparoscopy). After the gallbladder is removed, there is a temporary intolerance for fatty foods. This abates with time and patients can return to a normal diet.
The bowel is comprised of small and large bowel. The small bowel begins just after the stomach; it moves freely and is attached to the back wall of the belly by fatty tissue with many blood vessels and glands.
After major surgery, bad infections in the belly or radiotherapy, the small bowel can become stuck to the belly wall, the colon, the liver, the fatty apron that sits over the bowel or to other segments of small bowel. These adhesions can pull the bowel into positions that prevent food from passing through; this scenario is called an “adhesive small bowel obstruction”.
Cancers, benign growths, telescoping of the bowel inside itself (intussusception) or twisting of the small bowel (volvulus) can also cause small bowel obstruction.
Bowel obstruction is an emergency and cannot be treated without medical attention. Surgery is required roughly 50% of the time to relieve the blockage.
Tumours in the small bowel are far less common than tumours and polyps in the colon. However, they do occur and their diagnosis may be difficult.
Tumours can present with pain, bleeding (usually dark bleeding) or bowel obstruction but many will have no symptoms.
Carcinoid tumours are the most common and problematic tumour of the small bowel. These tumours are similar to colon cancers but have the capacity to make hormones. They often cause narrowing of the bowel and result in bowel obstruction when detected at a later stage.
This is an inflammatory condition limited to the colon and rectum. The lining of the colon becomes inflammed and tends to bleed. The region affected always extends from the rectum upwards. It can be either limited or extensive.
Ulcerative colitis is diagnosed on colonoscopy and is principally managed by medications which can be administered orally, rectally or intravenously.
Ulcerative colitis increases the risk of developing colorectal cancer and regular colonoscopy is essential to management of the disease.
Surgery is required to remove cancers, to treat disease that does not respond to medication, or to treat patients experiencing problems with the medications.
This in an inflammatory condition affecting any part of the gastrointestinal tract. Commonly the junction of small and large bowel is involved, which may result in narrowing and obstruction of the bowel.
Different patients will have different symptoms – largely dependent on the location and severity of their disease.
Common patterns include:
1) Disease around the anus (peri-anal Crohns disease)
2) Disease of the small bowel (Crohns ileitis/jejunitis)
3) Disease of the colon (Crohns colitis)
4) Combinations of the above
In addition, disease of the mouth and oesophagus may occur.
Both Crohns disease and Ulcerative colitis may be associated with other diseases affecting the spine, eyes, liver, joints and skin.
Sometimes it is unclear whether the condition affecting the large bowel is Ulcerative Colitis or Crohn’s Disease; in this scenario, we refer to the condition as indeterminate colitis.
Treatment for the condition is based on the more likely of the two diagnoses. This makes it challenging to manage. Advice about surgical options for treatment are harder to provide due to the uncertainty of the diagnosis. A cooperation between the surgeon and the managing gastroenterologist is essential.
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