What We Do
Our expert surgeons are committed to providing state-of-the-art care to you and your family. We work cooperatively with your other providers to help with diagnosis and ultimately treatment, if necessary. We aim to understand your concerns and integrate those into the treatment plan, with a focus on curative therapy and your comfort.
Colon and Rectum
In the United States and other Western cultures, diverticular disease of the colon is primarily located in the left and sigmoid colon and increases in prevalence with age (found in 1/3 of people over 45 years of age and in 2/3 of those older than 85). Rarely (<5%) are patients younger than 40 years. These diverticula are actually false diverticula, because they do not involve the whole wall of the colon and are really an outpouching of the inner lining of the colon (mucosa) through the muscular layer of the colon (muscularis). Left-sided diverticuli are thought to result from inadequate dietary fiber intake. Most diverticuli are found incidentally on studies done for other reasons and therefore are asymptomatic. These need no other treatment than a high fiber diet.
The signs and symptoms of uncomplicated diverticulitis usually include fever, left lower abdominal pain and an elevated white blood cell count. Diagnosis can be made clinically or with the assistance of a CT scan. There may be a microscopic hole in the colon (perforation) but no collection of pus (abscess). Once the inflammation has resolved, additional studies that may be done to rule out other colon diseases are barium enema and colonoscopy. Treatment of simple diverticulitis involves oral antibiotics; sometimes a low-residue, low-fiber diet may be recommended temporarily until pain has resolved. Patients may be hospitalized if they have significant nausea, vomiting, worsened abdominal pain or persistent fever. The majority of patients will recover and never have another episode. About 25% will have a second occurrence; this incidence may be higher in patients who present younger than 40 years.
Complicated diverticulitis is present if other intra-abdominal problems develop as a result of the colon inflammation. These complications include abscess, fistula (connection between the colon and another hollow organ in the abdomen, most commonly the bladder), blockage of the bowel (obstruction), or a large hole in the colon (free perforation with contamination). Additional treatment is generally needed for these complications and range from CT-guided drain placement to resection of the diseased colon.
Colon resection may be recommended for complicated diverticulitis, uncomplicated diverticulitis in patients under 40 years or who are immunocompromised, and uncomplicated recurrent diverticulitis (second or more episode). Surgery can be accomplished in one or two stages – two stage surgery is reserved for patients who are extremely ill or malnourished, have severe infection and contamination within the abdomen, or whose bowel may have inadequate blood supply. Colon resection for diverticular disease may be done open or laparoscopically, depending on the circumstances. The benefits of laparoscopic or robotic surgery may include earlier return of bowel function, lower risk of wound infection, less postoperative pain and shorter hospital stay.
Diverticuli of the colon may also be associated with bleeding, but this usually does not occur in the setting of diverticulitis. Lower gastrointestinal bleeding is due to diverticuli in only 20% of cases; the majority of diverticular bleeding episodes stop spontaneously, but again about 25% of patients may have another episode. Most patients with diverticular bleeding are older than 60 years. Diagnosis can be made by CT scan, colonoscopy, nuclear medicine scan and arteriography. Surgery is not recommended without first attempting to pinpoint the location of bleeding. About 10-20% of patients will require a colon resection to control the bleeding.
Colon and Rectal Cancer
Everyone has areas just inside the anus with thicker tissue that has a very strong blood supply, called “anal cushions”. When those areas become inflamed or slide down, they are called hemorrhoids. Why do they become inflamed? The most common reason is irregular bowel habits with straining from constipation.
Internal – Internal hemorrhoids are inflamed anal cushions that are lined with the same tissue that lines our intestinal tract. They can sometimes slide out the anus after BM. The most common symptom is bright red, painless bleeding at the end of BM.
Treatment for internal hemorrhoids are typically office procedures like hemorrhoid banding or injection sclerosis . For more extensive hemorrhoids we offer much less painful alternatives to hemorrhoid excision. These include stapled hemorrhoidectomy and HET procedure.
External – External hemorrhoids are inflamed cushions that are covered with skin that starts around the anus and extends a short way up the anal canal, called “anoderm”. This is highly sensitive tissue that is more like the skin on other parts of our body. They can swell and cause pain that is persistent. External hemorrhoids can be felt outside the body, and are very tender when irritated. As the inflammation lingers, there can be itching, too. Most external hemorrhoids can be treated in our office, under local anesthetic.
Perianal infection The classic symptoms of perianal infection, or perianal abscess, are progressive swelling and pain near the anus after a bout of diarrhea. There can be fever and flu-like symptoms, as well. It is important to have this checked because the infection can get worse and lead to a chronic opening, called a fistula (see below). If there is an abscess, it can typically be drained in the office under local anesthetic, but sometimes may require an operative procedure.
Fistula Some people form a chronic opening in the skin near the anus that periodically drains pus. Most commonly, this follows a perianal infection, but not always. This can cause intermittent pain and sometimes bleeding, but is coming from outside the anus. The treatment for fistula requires general anesthesia, in the operating room.
Fissure Some people can develop a chronic tear in the skin of the anus, which causes sharp pain and bleeding with bowel movement. The tear can occur during a large or hard bowel movement, but then persist for weeks to months. There are both medicines and operations to fix this problem.
Constipation The term “constipation” means different things for different people. It can refer to bowel action that is less frequent than expected, or less often than that person’s previous pattern of bowel action. It can also concern small, hard or difficult bowel action. The first two things to consider is water intake and fiber content of the diet, particularly if there is a change in intake of these elements of the diet. In general, we recommend:
- High fiber diet with lots of vegetables and fruits
- Water – 6-8 glasses per day
- Activity is better than resting
- Avoid straining
- Consider fiber supplement
- Try to avoid narcotic medications
Some of our patients find that consulting with a dietician is helpful, particularly regarding the high fiber diet. Monica Martines, RD is the dietician in our office who can help you.
Skin tags and other perianal lesions Some of our patient detect other tissue on the outside of the anus that are concerning to them. Extra skin around the anus, often from external hemorrhoids that are no longer swollen, can be difficult to clean well. This skin can be removed in an office procedure, under local anesthetic. There can be other findings, like yeast infection, anal warts and very uncommonly, cancerous lesions. These can be examined, sampled and treated if necessary, at a consultation visit.
Pilonidal “cyst”/sinus and infections A pilonidal sinus is a chronic infection in the buttocks cleft that drains. The hair follicles located in the cleft can become blocked, with formation of a small cavity that becomes infected and filled with hair. There can be one or more “pits” along the buttocks cleft that accumulate hair. The infection causes painful warm swelling just to the side of the cleft. Drainage of the infection can be done in the office, but definitive surgery to prevent the recurrent cycle of infection, pain and drainage is done in the operating room under general anesthesia.
Fecal incontinence The most common reason there is fecal incontinence is changes to the muscles and nerves of the anus related to prior anal surgery or childbirth. There can be incontinence to gas and liquid stool, which may be more of a leakage problem than true incontinence, and can respond to diet and other changes in bowel habits. In older people, rectal prolapse can be the underlying cause of incontinence (see below).
Rectal prolapse When the full thickness of the rectum protrudes from the anus, it is called rectal prolapse. It can be related to chronic constipation and the associated straining. There are a number of operative procedures to treat this, including a laparoscopic technique that is done under general anesthesia in the operating room.
Pruritis ani – itchy anal area Itching in the anal area can have many causes and during our visit, we try to sort through all the factors that can cause this. Often people try more and more interventions to treat the problem, and those can make things worse! Common problems include irritating foods in the diet, diarrhea, chronic moistness in the area, or the use of irritating solutions and excessive persistent washing with aggressive scratching/rubbing. This is typically solved during our office visit.
Anal Condylomata – anal warts A sexually-transmitted disease caused by the human papilloma virus (HPV), anal warts are contagious and irritating. They can be seen around the perineal area and anus. They can cause itching, bleeding and make the area difficult to clean. There are a number of medicines the surgeon can apply to the area to treat these in the office, though it is important to also treat sexual partners to avoid reinfection.
Tumors of the anus and rectum Fortunately, tumors in this area are not as common as the above mentioned condition, but many of the symptoms are similar. Signs of these are a steadily growing mass or ulcer, bleeding or change in bowel habits. Any concerning lesion in this area should be checked by a doctor. If you have been diagnosed with one of these type of tumors, our surgical oncology team have extensive, specialty experience in the treatment of these conditions.
Please Click on the link to view Hemorrhoid information.