Colon Disease Treatment Options

The common signs and symptoms of diverticulitis

Patients often present with the BELOW symptoms:

1. Left sided abdominal pain mainly over the lower left side (also known as left lower quadrant pain).
2. Fever
3. An elevation of the white cell count (blood test).

Patients may also complain of nausea or diarrhoea; others may be constipated.

Other symptoms could include: vomiting, bloating, bleeding from your rectum, frequent urination, and difficulty or pain with urination.

Tests to prove whether you have diverticulitis

Patients with the above symptoms are commonly studied with a computed tomography, or CT scan.

Your doctor may also choose to obtain a barium enema. In this test, x-ray dye (barium) is injected through the rectum and pictures are taken to study the inside of the colon. While this test is sensitive for the diagnosis, it does not give information about the overall extent of the disease.

Your doctor should discuss the reasons for choosing one of these tests versus another.

What needs to be done if you have diverticulitis

Medical Management

A first-time episode of diverticulitis is usually treated with conservative medical management, including bowel rest (i.e., ranging from nothing by mouth to liquids only), intravenous fluid, and antibiotics. Depending on the severity of your attack, this treatment plan may or may not require hospital admission.

Once your pain begins to resolve, most patients will be placed on a low residue diet. This low-fiber diet gives the colon adequate time to heal without needing to be overworked. Later, patients are typically placed on a high fiber diet as there is some evidence this lowers the risk for second and third attacks, known as recurrence.

Patient suffering one-time attacks typically do not require surgery so long as the attack resolved with medical therapy. Recurring attacks or more severe first-time cases may require surgery, either immediately or on an elective basis (see below). The decision to perform surgery for diverticulitis is always handled on a patient by patient basis so you should discuss your specific case with your doctor.

Surgical Therapy

In some cases, surgery may be required to remove the area of the colon most affected by the disease. For example, if the involved segment is the sigmoid colon, the procedure is known as a sigmoid colectomy.

You should understand that segmental colectomy only involves removing the infected or thickened area. Surgeons routinely leave other areas of diverticulosis behind to avoid removing large amounts of your colon. Only a very small percentage of people who have surgery will have a repeat attack in the remaining bowel. However, repeat surgery is not usually warranted.

When is Surgery Indicated?

• Repeated attacks of diverticulitis.
• Diverticulitis causing partial or complete bowel blockage (obstruction).
• Infected diverticulum leading to perforation of bowel contents into abdominal cavity, (also known as peritonitis or abdominal sepsis).
• Communication (fistula) between the affected bowel and any surrounding organs such as bladder, uterus, skin.

SurgICAL OPTIONS

Elective Colectomy:

More typically, elective surgery for diverticulitis occurs. As discussed above, this is called segmental colectomy and can be performed either open or laparoscopically.

In open surgery, a large abdominal incision is made. Through this incision the surgeon is able to remove the diseased intestine. Once the diseased bowel is removed the remaining colon is reconnected. With this, the patient is able to have normal bowel movements, the same as before the surgery.

In laparoscopic surgery incisions are made in the abdominal wall through which instruments and a viewing tube (laparoscope) are inserted. A camera attached to the viewing tube sends images of the inside of the abdomen to a television screen. The surgeon looks at the screen to see what he or she is doing while using the instruments to perform the surgery.

Emergency Colectomy:

In more emergent cases, when there has been perforation to the intestine from diverticulitis, two operations are usually involved.

• The first operation takes care of the immediate problem by removing the infected bowel. Due to the local inflammation and infection in such situations, the bowel is usually not healthy enough to reattach and the patient is left with a colostomy. A colostomy is a temporary situation in which the end of the colon is brought up to the skin. Stool will pass through the colon through this hole or stoma into an attached bag. 
• The second operation entails putting the colon back together. This operation can be performed either open (through an incision) or laparoscopic (through multiple small incisions). This decision will be left to you and your surgeon.

Risks of laparoscopic colectomy for diverticulitis

The risks of any surgery must be weighed against the risks associated with disease state requiring the intervention. In the case of recurrent complicated diverticulitis, the risks of ongoing inflammation and infection are greater than the risks described below and surgery is thus indicated.

Major risks of laparoscopic colectomy for diverticulitis can include but are not limited to:

• Wound infection possibly requiring opening of wound, drainage, antibiotics and prolonged wound care.
• Abdominal cavity infection possibly requiring antibiotics, drainage of the infection via a catheter or reoperation to drain the infection.
• Leakage from the re-connection points (anastomotic leak) resulting in infection and possibly drainage of the infection via a catheter or re-operation to drain the infection. Re-operation may also require creation of a temporary colostomy to allow the body time to heal the infection. This can typically be reversed 4-6 months later.
• Bleeding from surgical sites requiring observation, blood transfusion or re-operation.
• Recurrence of diverticulitis in adjacent or remote areas of the colon requiring additional medical or surgical therapy

Signs and symptoms of colon polyps / colorectal cancer

Polyps rarely cause symptoms by themselves. On occasion, polyps may bleed and this will typically manifest as dark or tarry stool. Such a finding should prompt a phone call to your physician.

There are often no symptoms of colorectal cancer during its early stages. When symptoms do occur, they will vary according to the location and size of the cancer.

Symptoms may include:

• Prolonged changes in your normal bowel habits, including diarrhea or constipation.
• Changes in size or shape of bowel movements (i.e., narrow, pencil thin stools).
• Persistent abdominal pain or distention.
• Rectal bleeding or blood in your stool – either bright red or dark depending on where to cancer is located.
• Unexplained weight loss or change in appetite.

Risk Factors

Some factors that increase your risk of colon cancer include¹:

• Age: your chance of having colorectal cancer goes up over the age of 50.
• Family history, inherited genetic risk.
• History of colonic polyps: certain polyps increase the risk of cancer, especially if they are large or come in large numbers.
• Inflammatory bowel disease: long standing history of ulcerative colitis or Crohn’s disease is associated with increased risk.
• Diabetes: people with diabetes have a 40% increased risk of colon cancer.
• Diet: a diet high in red meat, especially processed meat.
• Smoking / alcohol: may increase your risk.
• Being overweight or obese.
• Physical inactivity.

Screening and diagnosis

Most colon cancers develop from adenomatous polyps, so early and routine screening is very important for detecting colon cancers. Common screen procedures include:

• Screening: Faecal occult blood test (FOBT) is a non-invasive test for blood in the faeces that can be done at home, is recommended for Singaporeans aged 50 and above​.¹ 
• Faecal occult blood test: This test checks your stool sample for hidden blood. Very small amounts of blood can be in the stool when polyps or cancers start to form. It can either be done in the doctor’s office or by yourself at home using a special kit. If the results are positive for blood, further test are needed to find the exact cause of bleeding.
• Digital rectal exam: This is done in the office and is usually painless. A doctor uses a gloved finger to examine the last few inches of your rectum. This exam cannot detect polyps or abnormalities higher in your colon/ rectum.
• Flexible sigmoidoscopy: This test is typically done in the office. Your doctor uses a slender lighted tube attached to a video camera so that he/she can examine your rectum and sigmoid colon. If a polyp or abnormality is found, you will be recommended to undergo a formal colonoscopy to examine the entire colon and rectum, and to remove or biopsy any polyps detected.
• Colonoscopy: This is the most comprehensive and sensitive test for colon cancer. The instrument is a longer version of the flexible sigmoidoscopy and allows the entire length of the colon and rectum to be examined. The day before, you will be asked to undergo a bowel prep to clean out your colon. And during the procedure, you will receive a mild sedative to make the procedure more comfortable. Most patients go home the same day.

Treatment for Colorectal Cancer

There are four main types of treatment for colorectal cancer:

• Surgery
• Radiation therapy
• Chemotherapy
• Targeted Drug Therapy

The treatment or combination of treatments depends on the stage or extent of cancer present: location of the cancer, how far the cancer has penetrated the wall of the bowel, and whether the cancer has spread to the lymph nodes and other parts of your body.

Treatment for Colorectal Cancer: Surgery

Surgery is the main treatment option for early colon cancer. The most common surgery for cancer that begins in the colon is a colectomy. The type of colectomy performed will depend on whether all or part of the colon needs to be removed.¹

Segmental Colectomy is a surgical procedure that removes the part of your colon that contains the cancer, plus a margin of healthy colon on either side to make sure no cancer is left behind. The two ends of colon are typically then reconnected.

In laparoscopic colectomy, surgeons utilise special instruments and cameras that are inserted inside the body through multiple small incisions, rather than one large incision. Patients usually recover faster after this technique and leave the hospital earlier on average than patients who choose open surgery. The cosmetic benefits also apply. Not everyone is a candidate for laparoscopic colectomy. People who have large tumors or those who have had many abdominal surgeries in the past, may not be candidates for this technique. This should be discussed with your surgeon as the decision is always dependent on your unique situation and your surgeon's level of comfort.

Risks of laparoscopic colectomy for colon polyps or colon cancer

The risks of any surgery must be weighed against the risks associated with disease state requiring the intervention. In the case of polyps or cancer, the risks of developing or leaving known cancer in the body are greater than the risks described below and surgery is thus indicated.

Major risks of laparoscopic colectomy for colon polyps or cancer can include, but are not limited to:

• Wound infection possibly requiring opening of wound, drainage, antibiotics and prolonged wound care.
• Abdominal cavity infection possibly requiring antibiotics, drainage of the infection via a catheter or reoperation to drain the infection.
• Leakage from the re-connection points (anastomotic leak) resulting in infection and possibly drainage of the infection via a catheter or re-operation to drain the infection. Re-operation may also require creation of a temporary colostomy to allow the body time to heal the infection. This can typically be reversed 4-6 months later.
• Bleeding from surgical sites  requiring observation, blood transfusion or re-operation.

Treatment for Rectal Cancer: Radiation Therapy

Radiation is typically reserved for patients with rectal cancer only because it is dangerous to radiate the small bowel that comes in contact with the areas of the colon other than the rectum. Radiation therapy involves treatment with powerful energy rays that kill cancer cells.

If the cancer is large or if the cancer’s location makes surgical treatment difficult, radiation therapy may shrink the tumor before surgery.

There are two main types of radiation therapy, depending on the source of the high energy rays:

• External radiation therapy is used most commonly for people with colorectal cancer. Treatments are typically given 5 days a week for several weeks. Each treatment lasts only a few minutes.
• Internal radiation therapy involves placing small seeds of radioactive material directly into or near the cancer.

This allows high energy rays to focus directly onto the tumor. This technique is more frequently used with rectal cancer, prostate cancer, and in older or ill patients who would not be able to withstand surgery.

Radiation therapy causes several side effects: nausea, skin irritation, diarrhea, rectal or bladder irritation, or fatigue

Treatment for Colorectal Cancer: Chemotherapy

Also known as “chemo” and is the use of drugs that kill cancer cells. They may be given intravenously or taken by mouth. The drugs penetrate through the bloodstream, making them effective for cancers that have spread throughout the body.

Chemotherapy after surgery can increase the survival rate for some patients with invasive colorectal cancer. However, there are negative aspects to chemotherapy as well. While killing cancer cells, chemotherapy drugs can also damage normal, healthy cells too. This leads to side effects such as:

• Nausea, vomiting
• Fatigue
• Diarrhoea
• Hair loss
• Increased risk of infection
• Bleeding or bruising
• Mouth sores / ulcers

Most side effects (such a hair loss) will resolve when chemotherapy is completed.

DID YOU KNOW?

When caught early, colorectal cancer is one of the most preventable and curable cancers. Because so  many polyps are left untreated, colorectal cancer is now the most common cancer in men and second common cancer in women in Singapore.​