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DIVERTICULAR DISEASE


Diverticulosis of the colon is a common condition that afflicts about 50 percent of Americans by age 60 and nearly all by age 80. Only a small percentage of those with diverticulosis have symptoms, and even fewer will ever require surgery.

What is Diverticulosis/ Diverticulitis?

Diverticula are pockets that develop in the colon wall, usually in the sigmoid or left colon, but may involve the entire colon. Diverticulosis describes the presence of these pockets. Diverticulitis describes inflammation or complications of these pockets.

What are the symptoms of diverticular disease?

Uncomplicated diverticular disease is usually not associated with symptoms. Symptoms are related to complications of diverticular disease including diverticulits and bleeding. Diverticular disease is a common cause of significant bleeding from the colon.

Diverticulitis - an infection of the diverticula - may cause one or more of the following symptoms: pain in the abdomen, chills, fever and change in bowel habits. More intense symptoms are associated with serious complications such as perforation (rupture), abscess or fistula formation (an abnormal connection between the colon and another organ or the skin).

What is the cause of diverticular disease?

The cause of diverticulosis and diverticulitis is not precisely known, but it is more common for people with a low fiber diet. It is thought that a low-fiber diet over the years creates increased colon pressure and results in pockets or diverticula.

How is diverticular disease treated?

Increasing the amount of dietary fiber (grains, legumes, vegetables, etc.) and sometimes restricting certain foods reduces the pressure in the colon and may decrease the risk of complications due to diverticular disease.

Diverticulitis requires different management. Mild cases may be managed with oral antibiotics, dietary restrictions and possibly stool softeners. More severe cases require hospitalization with intravenous antibiotics and dietary restraints. Most acute attacks can be relieved with such methods.

When is surgery necessary?

Surgery is reserved for patients with recurrent episodes of diverticulitis, complications or severe attacks when there's little or no response to medication. Surgery may also be required in individuals with a single episode of severe bleeding from diverticulosis or with recurrent episodes of bleeding.

Surgical treatment for diverticulitis removes the diseased part of the colon, most commonly, the left or sigmoid colon. Often the colon is hooked up or "anastomosed" again to the rectum. Complete recovery can be expected. Normal bowel function usually resumes in about three weeks. In emergency surgeries, patients may require a temporary colostomy bag. Patients are encouraged to seek medical attention for abdominal symptoms early to help avoid complications.

BOWEL INCONTINENCE


What is incontinence?

Incontinence is the impaired ability to control gas or stool. Its severity ranges from mild difficulty with gas control to severe loss of control over liquid and formed stools. Incontinence to stool is a common problem, but often it is not discussed due to embarrassment.

What causes incontinence?

There are many causes of incontinence. Injury during childbirth is one of the most common causes. These injuries may cause a tear in the anal muscles. The nerves supplying the anal muscles may also be injured. While some injuries may be recognized immediately following childbirth, many others may go unnoticed and not become a problem until later in life. In these ¬situations, a prior childbirth may not be recognized as the cause of incontinence.
Anal operations or traumatic injury to the tissue surrounding the anal region similarly can damage the anal muscles and hinder bowel control. Some individuals experience loss of strength in the anal muscles as they age. As a result, a minor control problem in a younger person may become more significant later in life.

Diarrhea may be associated with a feeling of urgency or stool leakage due to the frequent ¬liquid stools passing through the anal opening. If bleeding accompanies lack of bowel control, ¬consult your physician. These symptoms may indicate inflammation within the colon (colitis), a rectal tumor, or rectal prolapse - all conditions that require prompt evaluation by a physician.

How is the cause of incontinence determined?

An initial discussion of the problem with your physician will help establish the degree of control difficulty and its impact on your lifestyle. Many clues to the origin of incontinence may be found in patient histories. For example, a woman's history of past childbirths is very important. Multiple pregnancies, large weight babies, forceps deliveries, or episiotomies may contribute to muscle or nerve injury at the time of childbirth. In some cases, medical illnesses and medications play a role in problems with control.
A physical exam of the anal region should be performed. It may readily identify an obvious injury to the anal muscles. In addition, an ultrasound probe can be used within the anal area to provide a picture of the muscles and show areas in which the anal muscles have been injured.

Frequently, additional studies are required to define the anal area more completely. In a test called anal manometry, a small catheter is placed into the anus to record pressure as patients relax and tighten the anal muscles. This test can demonstrate how weak or strong the muscle really is. A separate test may also be conducted to determine if the nerves that go to the anal muscles are functioning properly.

What can be done to correct the problem?

Treatment of incontinence may include:

  • Dietary changes
  • Constipating medications
  • Muscle strengthening exercises
  • Biofeedback
  • Surgical muscle repair
  • Artificial anal sphincter

After a careful history, physical examination and testing to determine the cause and severity of the problem, treatment can be addressed. Mild problems may be treated very simply with dietary changes and the use of some constipating medications. Diseases which cause inflammation in the rectum, such as colitis, may contribute to anal control problems. Treating these diseases also may eliminate or improve symptoms of incontinence. Sometimes a change in prescribed medications may help. Your physician also may recommend simple home exercises that may strengthen the anal muscles to help in mild cases. A type of physical therapy called biofeedback can be used to help patients sense when stool is ready to be evacuated and help strengthen the muscles.

Injuries to the anal muscles may be repaired with surgery. Some individuals may benefit from a technique that delivers electrical energy to the skin and muscles surrounding the anus which results in firming and thickening of this area to help with continence.

In certain individuals that have nerve damage or anal muscles that are damaged beyond repair, an artificial sphincter may be implanted. The artificial sphincter is a plastic, fluid filled doughnut that is surgically implanted around the damaged anal sphincter. This artificial sphincter keeps the anal canal closed. When an individual wants to have a bowel movement, the fluid can be pumped out of the doughnut to allow the anal canal to open.

In extreme cases, patients may find that a colostomy is the best option for improving their quality of life.

CONSTIPATION


What is constipation?

Constipation is a symptom that has different meanings to different individuals. Most commonly, it refers to infrequent bowel movements, but it may also refer to a decrease in the volume or weight of stool, the need to strain to have a movement, a sense of incomplete evacuation, or the need for enemas, suppositories or laxatives in order to maintain regularity.

For most people, it is normal for bowel movements to occur from three times a day to three times a week; other people may go a week or more without experiencing discomfort or harmful effects. Normal bowel habits are affected by diet. The average American diet includes 12 to 15 grams of fiber per day, although 25 to 30 grams of fiber and about 60 to 80 ounces of fluid daily are recommended for proper bowel function. Exercise is also beneficial to proper function of the colon.

About 80 percent of people suffer from ¬constipation at some time during their lives, and brief periods of constipation are normal. Constipation may be diagnosed if bowel movements occur fewer than three times weekly on an ongoing basis. Widespread beliefs, such as the assumption that everyone should have a movement at least once each day, have led to overuse and abuse of laxatives.

Eating foods high in fiber, including bran, shredded wheat, whole grain breads and certain fruits and vegetables will help provide the 25 to 30 grams of fiber per day recommended for proper bowel function.

What Causes Constipation?

There may be several, possibly simultaneous, causes for constipation, including inadequate fiber and fluid intake, a sedentary lifestyle, and environmental changes. Constipation may be aggravated by travel, pregnancy or change in diet. In some people, it may result from repeatedly ignoring the urge to have a bowel movement.

More serious causes of constipation include growths or areas of narrowing in the colon, so it is wise to seek the advice of a colon and rectal surgeon when constipation persists. Individuals with spinal cord injuries frequently experience problems with constipation. Constipation may be a symptom of diabetes. Constipation may also be associated with scleroderma, or disorders of the nervous or endocrine systems, including thyroid disease, multiple sclerosis, or Parkinson's disease.

Can Medication Cause Constipation?

Yes, many medications, including pain killers, antidepressants, tranquilizers, and other psychiatric medications, blood pressure medication, diuretics, iron ¬supplements, calcium supplements, and -aluminum containing antacids can slow the movement of the colon and worsen constipation.

When Should I See a Doctor About Constiptation?

Any persistent change in bowel habit, increase or decrease in frequency or size of stool or an increased difficulty in evacuating warrants evaluation. Whenever constipation symptoms persist for more than three weeks, you should consult your physician. If blood appears in the stool, consult your physician right away.

How can the cause of constipation be determined?

Constipation may have many causes, and it is important to identify them so that treatment can be as simple and specific as possible. Your doctor will want to check for any anatomic causes, such as growths or areas of narrowing in the colon.

Digital examination of the anorectal area is usually the first step, since it is relatively simple and may provide clues to the underlying causes of the problem. Examination of the intestine with either a flexible lighted instrument or barium x-ray study may help pinpoint the problem and exclude serious conditions known to cause constipation, such as polyps, tumors, or diverticular disease. If an anatomic problem is identified, treatment can be directed toward correcting the abnormality.

Other tests may identify specific functional ¬causes to help direct treatment. For example, "marker studies," in which the patient swallows a capsule containing markers that show up on ¬x-rays taken repeatedly over several days, may ¬provide clues to disorders in muscle function within the intestine. Other physiologic tests ¬evaluate the function of the anus and rectum. These tests may involve evaluating the reflexes of anal muscles that control bowel movements using a small plastic catheter, or x-ray testing to evaluate function of the anus and rectum ¬during defecation.

In many cases, no specific anatomic or functional causes are identified and the cause of constipation is said to be nonspecific.

How is constipation treated?

The vast majority of patients with constipation are successfully treated by adding high fiber foods like bran, shredded wheat, whole grain breads and certain fruits and vegetables to the diet, along with increased fluids. Your physician may also recommend lifestyle changes. Fiber supplements containing indigestible vegetable fiber, such as bran, are often recommended and may provide many benefits in addition to relief of ¬constipation. They may help to lower cholesterol levels, reduce the risk of developing colon polyps and cancer, and help prevent symptomatic hemorrhoids.

Fiber supplements may take several weeks, possibly months, to reach full effectiveness, but they are neither harmful nor habit forming, as some stimulant laxatives may become with overuse or abuse. Other types of laxatives, enemas or suppositories should be used only when recommended and monitored by your colon and rectal surgeon.

Designating a specific time each day to have a bowel movement also may be very helpful to some patients. In some cases, bio-feedback may help to retrain poorly functioning anal sphincter muscles. Only in rare circumstances are surgical procedures necessary to treat constipation. Your colon and rectal ¬surgeon can discuss these options with you in greater detail to determine the best treatment for you.