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What is an anal fissure? An anal fissure is a tear in the anoderm, that is the skin by your anus. This problem can be very painful and is often exacerbated by constipation/straining while defecating. Most anal fissures are located in the posterior midline, because the blood supply is poorest over that area. It is important to determine where exactly your fissure is at this could signal other types of disease. What should I do if I think I have an anal fissure/ how is it treated? You should see your doctor if you think you have a fissure, to determine its location and to ensure that your symptoms aren't from another disease. If you do, in fact, have a fissure- conservative management will first be attempted. This involves ensuring soft stools (high fiber + water diet- see hemorrhoid section; with or without a stool softener) and minimizing time spent in the rest room defecating (as sitting on the toilet can increase pressures over the site). Medical management can include either a calcium channel blocker cream or a nitrous compound. This causes relaxation of the site, which allows the anoderm (skin) to heal. The most common and problematic side effect from these creams is a headache. More advance management regimens include botox injections (again the end goal is to relax the site to allow the skin to heal), and if there is still persistent symptom- surgery. Surgery involves cutting one of the muscles in the region to allow the area to relax. Risks include pain, bleeding, and infection. There can also be some gas/stool incontinence- though this is rare.
Abscess and Fistulas
A Brief Overview
What are anal abscesses?A peri-anal/rectal abscess is an infection that is usually caused by an obstructed gland in your anal region. This allows for bacterial proliferation, which eventually results in an infection of the site.What are symptoms of anal abscess?Depending on its location, peri-anal/rectal abscesses may be palpable. Other symptoms include pain over the site, discharge, fevers, and chillsWhat should I do if I think I have an anal abscess/ how is it treated?You should see a doctor if you believe you have a peri-anal/rectal abscess. The main treatment for most abscesses is incision and drainage. This means that the abscess, which is a typically a contained infection, needs to be opened up and its contents removed. Antibiotics have poor penetration of abscess cavities, but could be added depending on the abscess' location and how bad the infection is.Incision and drainage of the region is painful, but necessary. It should be noted that depending on the literature you read 30-50% of abscesses can progress to fistulasWhat is a fistula?A fistula is an abnormal connection between two orifices. The inflammation from an abscess and/or its treatment, can cause this abnormal connection.What are some symptoms of a fistula?Fistula-in-ano can present has persistent discharge over the region, recurrent infections, and difficulty with hygiene.How are fistulas treated?Depending on the fistula's location, extent, and depth- fistulas can be managed conservatively to surgically. You should be aware that this can be a very frustrating problem to have. Some treatment modalities include seton placement (placing a straw-like device through the tract to better define it and eventually remove it), opening the fistula tract, and some more invasive surgeriesYour surgeon will discuss the treatment modalities, risks, and benefits more in depth during your consultation
A Brief Overview
Inflammatory Bowel Disease (IBD) is, as its name suggests, an inflammatory disease that affects anywhere from 2-20 people per 100,000 people yearly. IBD is subdivided into Ulcerative Colitis (UC) and Crohns Disease. Ulcerative colitis is an inflammation of the superficial layer (mucosa) which typically involves the distal colon/rectum. Crohns on the other hand, is full thickness inflammation that can affect any portion of the gastrointestinal tract.What are some presenting symptoms for inflammatory bowel disease?Presenting symptoms for IBD varies. It range from abdominal pain, bloody bowel movements, bloating, fatigue, change in bowel habits, to abnormal weight loss.You can also have "extra-intestinal" manifestations of IBD- that is, symptoms not related to your abdomen. This includes eye problems, skin lesions, arthritis, and liver problemsHow is IBD diagnosed?Your presenting symptoms, physical exam, and family history may clue in your physician to the diagnosis of IBD. If there is a concern/suspicion of IBD, your physician will likely recommend a colonoscopy (please see colonoscopy section for more information). A colonoscopy is useful for many things- for IBD specifically, it can help differentiate between Ulcerative Colitis and Crohns, which ultimately can affect what type of management is recommended. Your physician may also order other labs/imaging studies depending on your overall picture.How is IBD managed?A multi-disciplinary team will likely be employed should you be diagnosed with IBD. This includes some combination of gastroenterology, general/colorectal surgery, rheumatology, internal medicine, and nutrition.A slew of medications can be used to manage the abnormal inflammation that lies at heart of IBD. This ranges from steroids to medications that directly affect the inflammatory cascade in your body. Your gastroenterologist and/or rheumatologist will be able to better discuss the benefits and risks associated with these medications. These medications are the pillars of IBD managementsYou will also need screening/surveillance colonoscopies at a younger age as you are at an increased risk for colon cancerWhen does surgery get involved?There are several scenarios in which surgery could/should get involved. In both UC and Crohns, emergent/urgent surgery may be needed should you have severe bleeding, a dangerously enlarged colon, an obstruction, strictures (narrowing of your GI tract from constant inflammation +/- low oxygen in the area), a perforation (hole in your colon) a bad infection, or cancer.In ulcerative colitis- surgery could also be an option for cure as the disease is typically relegated to the distal colon/rectum.What types of surgery can I expect?Depending on the underlying reason part or all of your colon may be removed. A ileostomy/colostomy may also be necessary. These may or may not be reversed at a later date. The main risks with this surgery include pain, bleeding, and infection. The most serious complication associated with this surgery is a leak- that is breakdown of the connection made surgically. There are several reasons for a leak, some of which IBD puts you at a higher risk for (like poor nutrition, friable tissue, and use of medications that can impair healing). Your surgeon will talk to you more about the benefits and risks of surgery.
A Brief Overview
Colonic diverticulosis is an abnormal outpouching of the colon, typically caused by high intracolonic pressure. This higher pressure is caused by a multitude of factors that include diet (low fiber/high fat), smoking, and chronic constipation. Diverticulosis, in and of itself, is fairly common: 40-60% of the population will have diverticulosis at 60 years old. Diverticulosis is asymptomatic. The issue arises when these outpouchings (think of them as pockets), get infected. This causes the diverticulosis to become diverticulitis.What are symptoms of diverticulitis?Abdominal pain (can be severe) and rectal bleeding are the most common presenting symptoms of diverticulitis. Other symptoms include fevers, chills, fatigue, and overall sense of malaise. Diverticulitis is a spectrum of disease that can range from a mild infection to a very bad infection/perforation of your colon. How is diverticulitis managed?If you are diagnosed with diverticulitis, you will likely be admitted to the hospital. Labs will be drawn, and imaging may be obtained. You will likely not be allowed to eat or drink anything to let your bowel rest. You will be given antibiotics, and your fluids/electrolytes will be repleted. Your other symptoms will also be monitored and managed. After your diverticulitis resolves, you will be put on a high fiber/ high water diet, to help prevent future episodes. However, even with the best preventative measures, there is no guaranteeing that you wont have episodes in the futureA colonoscopy approximately 6 weeks after your diverticulitis episode resolves will also be highly recommended to make sure that there are no other causes for your symptoms/ no cancer.When do I need surgery?The decision/ need to go to surgery depends on a couple of factors.There are instances where emergent/urgent surgery is needed. This includes perforation, obstruction, severe bleeding, or a severe infection.Elective surgery, that is undergoing surgery in a more controlled/planned setting, can be undertaken if there is a fistula found (abnormal connection between two orifices), chronic diverticulitis (persistent/non remitting pain), and repeat episodesSurgery can mean many things in diverticular disease. It can range from removing part of the colon, removing all the whole colon, and bringing up an ileostomy/colostomy. Your surgeon will discuss your options, benefits, and risks in a more in depth manner with you.
Colonoscopy is an terrific imaging and therapeutic modality that has "changed the game" for the better in terms of one's health. Take for example colon cancer- the third most common cancer in the United States, with more than 140,000 new cases diagnosed yearly. Unfortunately, it is this disease kills more than 50,000 people yearly. Thankfully, colonoscopy allows for both diagnosing and if caught early enough- immediate treatment of this problem. Colonoscopies are useful for more than just colon cancer- they are key for a whole bunch of colorectal issues. It allows for visualization and several interventions (dealing with bleeding, biopsies, removing polyps, etc).We recommend colonoscopies to everyone over the age of 50 years old. There are certain conditions, and/or details in your family history that may prompt your doctor to recommend a colonoscopy sooner.A colonoscopic procedure typically involves two phases: the prep phase and the procedure itself. The prep is perhaps THE MOST IMPORTANT PART of a colonoscopy. A good prep can be the difference between seeing a cancerous polyp, and missing it. For more instructions on getting a good prep, please see the "colon health tools" section. The procedure portion involves being consciously sedated and a scope being driven throughout your entire colon. Conscious sedation means that you won’t feel or remember your procedure, but you will be awake during it. You will need someone to be with you the day of your procedure. After your procedure, you may experience some mild bloating, abdominal discomfort, and have some rectal bleeding (if a biopsy was performed/polyp was removed) after your procedure, but it should not be severe. If this were the case (that it is severe), or if you have new symptoms (chest pain, trouble breathing, severe pain, bloody bowel movements) please go to your nearest ER or call 911.If your colonoscopy was completely normal, you're next one will most likely be in 10 years. If there were findings- your doctor will inform you of what the next steps should be.Colonoscopies have saved thousands of lives since its inception. It truly is a great tool for both the doctor and the physician. Be sure that you are up to date on your colonoscopy!
Enhanced Recovery After Surgery
What is ERAS?ERAS stands for Enhanced Recovery After Surgery, and are a set of proven procedures/medications/techniques/protocols to help achieve good surgical outcomes. These evidence backed protocols minimize surgical trauma, improve pain, lower complications, and decrease hospital stay. It's main goal is to ensure a healthy and happy patient.ERAS starts before surgery and continues until some time after surgery. Though the surgical team will play a role in ERAS, the biggest key to success, is you. Though there are no guarantees in life, following the ERAS protocol will certainly give you the best shot at getting good results.Please refer to the "health tools" for a patient check list for your upcoming surgery
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