Transcription:
Diagnosis and Management of Common Colorectal Problems

Caitlin Whyte: Colorectal problems can affect people in a range of ways. And today, we are going to talk about some of the most common issues and how to treat them with Dr. Iyare Esemuede, a general and colorectal surgeon at Montefiore St. Luke's Cornwall.

This is Doc Talk presented by Montefiore St. Luke's Cornwall. And I'm your host, Caitlin Whyte. To kick us off, doctor, what are some of the most common colorectal problems you see?

Iyare Esemuede, MD: So some of the most common problems that we see, there's kind of, you know, sort of benign as well as a malignant conditions we see. Probably the most common problem we see as colorectal surgeons is hemorrhoids. Hemorrhoids, it's a little bit of a misnomer because hemorrhoids are normal. We all have hemorrhoids. They're essentially a collection of blood vessels in the rectum that kind of end in these essentially sinusoids that we call hemorrhoids.

But some people, they become symptomatic. A lot of people have hemorrhoids. The incidence is hard to estimate because, you know, a lot of people may have issues, but they don't really come to their doctor. It's estimated that there are about 3 million office visits a year for this. And most commonly, the symptoms we see are bleeding. If you have a thrombosed external hemorrhoids, you have pain. You're going to have prolapse of the hemorrhoids as well as a perianal itching and hygiene issues from the rectal mucosa prolapsing out of the anus.

To kind of take a step back, we have two types of hemorrhoids, internal and external. Internal hemorrhoids are essentially, you know, in the rectum, you can't see them from the outside. And external hemorrhoids are on the outside. And as I previously mentioned, the symptomatology is a little bit different. Internal hemorrhoids generally do not cause pain because they do not have a somatic innervation. External hemorrhoids can cause pain.

But in terms of the etiology of hemorrhoids, usually you get them from sitting on the toilet too long, straining with bowel movements, basically anything that increases intraabdominal pressure as well as the intraabdominal vascular pressure. Patients with liver failure are at increased risk for hemorrhoids. Patients with benign prostatic hyperplasia who have to strain with urination, those patients can also have hemorrhoids and it's okay to speak patients with colon cancer can also have an increased risk for hemorrhoids.

In terms of diagnosing them, usually physical exam is adequate to diagnose hemorrhoids. You don't really need any imaging to diagnose this condition. And another thing that's useful is what we call an anoscopy, which I do in the office. It's a minor procedure. You basically just put a little scope inside the anus and take a look around, the size or the number of hemorrhoids.

The treatment of hemorrhoids is usually what we do first and that entails things like increasing the amount of fiber in the diet. Generally, it's recommended to take about 30 to 35 grams of fiber in the diet every day. And that's difficult to do, just in light of our diets in general in the Western societies are pretty low in fiber and high in processed food. To supplement the amout a fiber that you should get take in every day, we usually recommend people take things like Metamucil or Citrucel, any over-the-counter fiber formulation.

Also, you want to be very well-hydrated. So I drink about eight cups of water a day. Some of other things we could do if they become symptomatic are things called sitz baths, these are little warm water baths that you sit in. It allows the rectal muscles to relax and it helps decrease the swelling of the hemorrhoids. Stool softeners also help in terms of decreasing the amount of strain you have to do in the bathroom.

When these different things do not work, then usually I'll recommend other treatments based on what type of hemorrhoids the patient has as well as their desire to be more aggressive or less aggressive with treatments. The most common procedure we do for internal hemorrhoids is a hemorrhoid banding and we basically just put a rubber band around the internal hemorrhoid, which helps cut off the blood flow to the hemorrhoid and it eventually sloughs off. It's a painless procedure. You can go back to work the next day, and it's highly effective and very well tolerated. There are other treatments like coagulation, cryotherapy, but those are much less effective.

In terms of surgical treatments, the mainstay of therapy is what we call a hemorrhoidectomy, which is essentially taking out the hemorrhoid. It's the most effective method for getting rid of hemorrhoids, but it's also the most painful. So basically, what we do is it's an outpatient procedure. You get put to sleep by anesthesia and we essentially cut out the hemorrhoid and sew up the tissue afterwards. It's a relatively simple procedure, but just the healing of that area and the fact that, you know, you still have to use, you know, the rectum to have bowel movements that causes people to have a lot of pain afterwards. You know, we usually do that in patients who are very symptomatic or desire more definitive treatment for hemorrhoids. But again, it is the most effective.

Another disease process we see very commonly, us as well as primary care physicians and general surgeons, is diverticulitis. Again, this is another disease process that is by virtue of our diets. We allow low fiber food that causes the stools to be hard. And as the colon contracts, it creates little outpouchings of the colonic wall, which we call a diverticuli. And two things that could happen with these diverticuli, they can either bleed or they can become inflamed and cause an intraabdominal infection.

So I'm really just going to talk about the inflammation and the infection, which is called diverticulitis. This is most common in people over the age of 50 and it increases with age. We see diverticulosis commonly when we do screening colonoscopies and things like that. So it's very common, but it's not really initially all that symptomatic. Maybe like 20 to 30% of patients actually have symptoms from diverticulosis, particularly diverticulitis. There are almost two million office visits per year for this, and more than 300,000 emergency room visits with about two-thirds of those patients being admitted to the hospital.

In terms of the symptoms, generally diverticulitis causes pain on the left side because it most commonly affects the sigmoid colon, which is on the left side. As it progresses, it could cause an intraabdominal infection, something we call an abscess. You could actually have perforation of the colon as well. Over time, it can actually cause the colon to get harder and to get more narrow or it can actually cause an abnormal connection between the colon and either the bladder or the uterus, which we call a fistula.

In terms of etiology, mostly dietary. There are some things that sometimes patients say it precipitate it like seeds and nuts. Some people say tomatoes with the small seeds also precipitate it. But usually, there's that one food that really precipitates the attacks. It's kind of patient-dependent, but generally raw fruits and vegetables or large pieces of meat can spur on attacks.

In terms of diagnosis, usually if a patient comes in with pain of the left side, we get a CT scan, which shows the inflammation of the sigmoid colon and we diagnose diverticulitis. You can also get inflammation of the right colon, but those are less common. You also sometimes see the diverticuli, as I mentioned before, on colonoscopy, you know, screening colonoscopies as I had mentioned, or a colonoscopy for another reason such as bleeding.

So when a patient has an attack of diverticulitis, usually we try medical therapy first. And there are kind of two options. You could do either outpatient oral antibiotics or the patient may have to be admitted to the hospital. So in terms of the outpatient therapy, it's usually a fluoroquinolone plus a medication called Flagyl. This helps fight the bacterial infection and usually patients are on this for about seven to 14 days. And after the acute attack is resolved, then we encourage increased fiber in the diet, again increased green leafy vegetables, or sometimes you can have over-the-counter fiber supplementation, again 30 to 35 grams. But in the acute phase, you know, you try to eat soft foods and things like that to allow the inflammation to resolve. When patients are admitted to the hospital, usually we don't let them have anything to eat or drink. We give IV antibiotics as well as IV fluids. And with the bowel arrest and the antibiotics, generally, this resolves the acute attack in a few days, and then the patient could go home.

And, you know, one attack of diverticulitis does not necessarily require surgery. Multiple attacks can or the severity of the attack can require a surgery. Typically, after one attack, we recommend a colonoscopy in six weeks because in up to 10% of patients, you can find if they have complicated disease, which is an abscess or a stricture or a perforation. You can find actually cancer in up to 10% of those patients. If it was just a regular attack of diverticulitis, then usually, the incidence of cancer is only about 1%. In addition, with a colonoscopy, you can find other pathologies such as inflammatory bowel disease or hemorrhoids so on and so forth in the colon. Colonoscopy is, you know, recommended to follow up.

Now, in terms of the severity of the attack, sometimes you have an attack that's very severe that will not resolve with just the antibiotics. Most commonly in terms of complicated diverticulitis, you see what's called an abscess, which is just a collection of bacteria that basically sits in the abdomen, usually around the sigmoid colon. But this can be treated non-surgically with what we call a percutaneous drainage. In this instance, an interventional radiologist will place a needle through the abdominal wall or through the back into the abscess and drain it. And the patient will stay on antibiotics, so that will resolve the issue.

And as I mentioned before, you can also have a colonic perforation. There's a hole in the colon that's big and causing a lot of infection. Then in that case, the patient needs a surgery to take out that part of the colon. In that case, the patient will need what's called a colostomy, which is the colon coming up to the abdominal wall. In some cases, you can actually put the colon back together. But when there's perforation, there's a risk of that not a healing. So sometimes we'll do what's called an ileostomy in those instances, which is a small intestinal ostomy.

In terms of those particular operations, emergency surgery has been decreasing over time as antibiotics have improved and technology has improved. So we don't do emergency surgery as often for diverticulitis, which decreases the need for a colostomy.

In general, when we treat diverticulitis, we like to allow the acute phase to resolve. And when it's fully resolved, and then we speak with the patient about whether or not they want elective surgery. Now, the elective surgery can be done laparoscopically, which I do; robotically, which I do; or open, but this is less commonly done. And it's kind of a discussion with a patient, how much the diverticulitis is affecting them, what kind of symptoms in the long term they're having. And also you want to look at their medical history and diagnoses to make sure they're well enough to tolerate the operation. I only offer it obviously to those who can. In the past, we used to operate on most patients with diverticulitis, but now we try to individualize the care. And in my colorectal surgery fellowship, I saw a wide variety of presentations. And so, I see that there's not really just one answer in terms of surgery for diverticulitis. You really have to talk to the patients and kind of determine what is best for them.

And finally, we see colon cancer patients as our specialty deals with the colon primarily as well as the rectum. We see a lot of those patients. So in terms of colon cancer, it's most common in patients over the age of 60. Sixties and seventies are usually when patients are diagnosed with colon cancer. It's the second most common cause of cancer death based on recent data and the fourth most common cancer diagnosis in the United States. Most people have 5% to 6% lifetime risk of colon cancer. And I'm always speaking of colon cancer, that's the most common type of cancer of the colon. There's also rectal cancer, but that's slightly different.

So in terms of colon cancer, when it is symptomatic, usually a patient will have bleeding. They may have obstruction. They may have abdominal pain. And when it's more advanced, they may have weight loss as well. In terms of causes, the most highly associated thing in terms of causes of colon cancer is again diet. And I'm sure you can see a theme here where diet affects the colon a lot. A lot of it is, again, low fiber as we postulated to increase the risk of colon cancer. Colon cancer is formed from a variety of genetic changes that occur in the colon cells over time. And we know that most colon cancer are seen in patients over 60, which is why in the past, so we used to recommend colon cancer screening at 50, because we know that, if you're seeing the cancers in the 60s, colon cancer is usually a slow-growing cancer. So when you screen patients, you want to catch it early. And they form generally from what we call polyps in the colon, which are kind of the first step in terms of the progression from normal colonic epithelium to cancer. So they recently changed the guidelines in terms of screening colonoscopies in a patient who has no family history of colon cancer and no symptoms to 45. It used to be 50, but now it's 45. And that's because the incidence of colon cancer has been rising in patients younger than the age of 50. So we're trying to screen them a little bit earlier. And with a colonoscopy, you can take out the polyps prior to them becoming cancers. And colonoscopy is the most common way we diagnose colon cancers. In terms of physical exam in the office, you can't really feel a colon cancer unless it's very large. Sometimes you diagnose them with a CAT scan as well. But again, we usually only do that when they're very large.

In terms of the treatments for colon cancer, surgery is the mainstay of therapy for colon cancer. Most colon cancers are very responsive to surgery as long as they are localized. In terms of the workup for colon cancer, you should do a CT chest, abdomen, pelvis as part of the staging workup prior to operation. And then that will help determine where your next steps should be. There are different stages of colon cancer from stage I to stage IV. Stages I and II are usually localized to the colon, but have different depths of invasion into the colonic wall. Stage III colon cancers have lymph node metastasis. And then stage IVs have metastasis to other organs. In the past, we used to feel that stage IV patients did not need surgery because we felt their too low. But this day and age, with increased chemotherapy and advancements in surgical techniques, we can even operate on patients who have stage IV, as long as they have isolated organ metastasis. For example, a single liver lesion and the right colon cancer, you could do a full section as well as a liver resection in addition to chemotherapy. And those patients can have very good five-year survivals.

But in general, as said, colon cancer is very responsive to surgery. We can do surgery again laparoscopically or robotically, which is generally what I do. It kind of depends on the body habitus of the patient and so on and so forth. Whether I do them laparoscopically or robotically, they have essentially equivalent outcomes. So basically, I can take out the colon, with a very small incision in the abdominal wall. So after the colon is taken out, we send it to a pathologist to look at it under the microscope, and then they can see whether or not there are lymph nodes involved or there are particular characteristics of it for which further therapy will be needed. If there are lymph nodes involved, those patients generally need chemotherapy. Even if there are not lymph node involved, sometimes if there are very large tumors and they penetrate through the wall of the colon, those patients may need chemotherapy. And of course, if they're stage IV, they need chemotherapy. It's unusual to need radiation therapy for colon cancers. But sometimes, it does happen.

In terms of followup, after you have colon cancer surgery, you should get a colonoscopy in a year and then the next three years, and then every three to five years after that. We measure different biochemical markers and those can be measured every three to six months to check for recurrence. You want to do a CT of the abdomen pelvis as well as chest yearly.

Caitlin Whyte: Well, that really covers all of my questions, doctor. As we close out here today, when it comes to these issues, what does life look like with them and how can patients manage to live a so-called normal life?

Iyare Esemuede, MD: Yeah, the main thing is, you know, make sure you live a healthy lifestyle, eat well, vegetables, drink a lot of fluids, avoid high fat diets and low fiber diets. And if you are having colorectal issues, it's important to let your doctor know. And, you know, if they're happening over a long time you can actually request that you see a colorectal surgeon or a gastroenterologist so that you can get a colonoscopy because one of the most common misdiagnoses in patients with colon cancer with bleeding is hemorrhoids. I've seen patients who have hemorrhoids where they have bleeding and people assume that's the cause of their bleeding. Then you do a screening colonoscopy on them and then you see a big cancer.

So it's important that if you have persistent symptoms, not just bleeding, but constipation, abdominal pain, you know, talk to your physician about getting further testing. And in particular, if you have a lot of rectal symptoms, to be considered for a colonoscopy. And in particular, if you're over the age of 50. Younger patients, it's not as necessary to get a colonoscopy for those symptoms, but definitely people over 50, the incidence of colon cancer is high enough that, you know, those patients routinely have a colonoscopy, especially if they have bleeding.

Caitlin Whyte: Well, thank you so much for joining us today. That was Dr. Iyare Esemuede, a general and colorectal surgeon at Montefiore St. Luke's Cornwall. Visit montefioreslc.org for more information. And if you found this podcast helpful, please share it on your social channels and be sure to check out all of our other Doc Talk episodes. This has been Doc Talk, the podcast for Montefiore St. Luke's Cornwall Hospital. I'm Caitlin Whyte. Stay well.