Colon Disease Diseases & Treatment Options

Diseases of the colon

Several diseases can interfere with the normal functioning of the colon. These diseases can have various effects and are traditionally classified as benign (non-cancerous) or malignant (cancerous) and can cause various symptoms including bleeding, infection, and perforation.

In some cases, doctors treat the disease by removing a segment of the colon. Given that the average human has 8-10 feet of small bowel and 3-5 feet of colon, removal of a segment will generally not effect normal functioning of the colon.

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Crohn’s Disease and Ulcerative Colitis

Background: Inflammatory Bowel Disease (IBD) includes Crohn’s Disease and Ulcerative Colitis

Inflammatory bowel disease (IBD) is caused by chronic inflammation of the intestinal tract. There are two forms of inflammatory bowel disease: Crohn’s disease and ulcerative colitis (UC).
Crohn's disease and ulcerative colitis are similar — so similar that they're often mistaken for one another. Both disease cause inflammation of the lining of your digestive tract, and both may result in severe bouts of diarrhoea and abdominal pain.
Crohn's disease can occur anywhere in your digestive tract, often spreading deep into the layers of affected tissues. Ulcerative colitis, on the other hand, usually affects only the innermost lining of your large intestine (colon) and rectum.

Clinical Presentation: What are the common signs and symptoms of inflammatory bowel disease?

Patients with inflammatory bowel disease could present with any of the following:

abdominal pain
nausea, vomiting
diarrhoea, bloody stools
weight loss or weight gain
various associated complaints or diseases, often autoimmune disorders (arthritis, skin lesions, and liver and bile duct disorders).

In Crohn’s disease, inflammation causes cells in the affected areas of your intestine to secrete large amounts of water and salt. Because the colon can't absorb this excess fluid, you develop diarrhoea. Altered intestinal contractions also can contribute to loose stools. Diarrhoea can range from mild to severe.

Diarrhoea can also be a symptom of ulcerative colitis. However, patients with ulcerative colitis tend to experience bloody diarrhoea and also something called tenesmus. Tenesmus is the sensation of having to move ones’ bowels.

Food moving through your digestive tract can cause inflamed tissue to bleed, and your bowel may also bleed on its own. You might notice bright red blood in the toilet bowl or darker blood mixed with your stool. Should this occur, you must notify your physician.

Treatment: What needs to be done if I have inflammatory bowel disease?

Medical Therapy:

Usually, treatment of inflammatory bowel disease begins with medical therapy. Most commonly, treatment of inflammatory bowel disease requires mesalamine or Asacol^® (mesalazine), which in part also acts as an anti-inflammatory agent.
Depending on the level of severity, inflammatory bowel disease may require immunosuppression to control the symptoms. Immunosuppression refers to using medications to depress the body’s ability to generate an inflammatory response. Such medications often used include azathioprine, methotrexate, or 6-mercaptopurine. If initial treatment is unsuccessful, a combination of the aforementioned immunosuppression drugs may or may not be administered, depending on the patient.
During times of acute exacerbation of inflammatory bowel disease, steroids are often used to control disease flares. Remicade^® (infliximab), another type of anti-inflammatory, has been used for many years in Crohn’s disease and more recently also in patients with ulcerative colitis.
Severe cases may require surgery, such as bowel resection of the diseased portion of intestines, and/or temporary or permanent colostomy or ileostomy.

Surgical Therapy: Crohn’s Disease

Surgery for Crohn’s disease is recommended in carefully selected cases because the disease can recur in any remaining portion of the gastrointestinal tract.
Surgery is recommended when Crohn’s related complications occur. This includes infection (abscess), perforation, blockage or obstruction and possible fistula (connection between bowel and other structures).

Surgical Therapy: Ulcerative Colitis

Of the two conditions, patients with ulcerative colitis are more likely to undergo surgery because removal of the colon and rectum will cure the disease.
Surgery for ulcerative colitis usually entails removing the entire colon. There are different ways to remove the colon as well as different ways to put the colon back together.
The surgery that was traditionally performed for ulcerative colitis was a proctocolectomy which removed the entire colon, rectum and anus. However, this operation required the creation of an ileostomy. This is an opening in the small intestine that is brought up to the skin where waste is expelled. This opening requires a bag to be worn over the opening in the skin to collect waste.
Another surgical option would be to create an ileostomy with an internal pouch that acts as a collecting system. This eliminates the need for a bag; however, the opening in the skin still exists. Defecation is maintained by the patient on a schedule.
A different surgical approach would be to only remove the large intestine (colon) leaving the rectum and anus. The small intestine (ileum) would then be connected to the rectum. This relieves the patient of having to live with a colostomy but leaves large intestine behind that may be susceptible to recurrent ulcerative colitis. Thus, frequent surveillance colonoscopy is required.
A newer and more appealing surgical procedure is called an Ileo-anal J pouch. This operation removes the large intestine and rectum but leaves the anus. The small intestine is then connected to the anus and fashioned into a pouch capable of storing faeces.
Most of these operations can be done either open or laparoscopically. Laparoscopic surgery for ulcerative colitis has shown similar long term outcomes when compared to open surgery. As with other types of minimally invasive surgery, laparoscopic surgery usually results in shorter hospital stays and shorter recoveries.
It is important to note that not all procedures can be done laparoscopically and the decision should always be discussed between patient and surgeon.

Risks of surgery for ulcerative colitis:

The risks of any surgery must be weighed against the risks associated with disease state requiring the intervention.

In the case of ulcerative colitis, the risks of ongoing inflammation, infection and subsequent colon cancer are sometimes greater than the risks described below and surgery is thus indicated.

Major risks of laparoscopic proctocolectomy with ileoanal J pouch for ulcerative colitis can include but are not limited to:

Wound infection (1-3%) possibly requiring opening of wound, drainage, antibiotics and prolonged wound care.
Abdominal cavity infection (1-3%) possibly requiring antibiotics, drainage of the infection via a catheter or re-operation to drain the infection.
Leakage from the re-connection points (anastomotic leak) (5-10%) 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 (1-3%) requiring observation, blood transfusion or re-operation.
Pouchitis or inflammation of the J pouch (25%) with subsequent diarrhea and possible leakage of mucous and stool from the anus.

Diverticulitis and Diverticulosis

What is diverticulitis ?

Diverticulitis is a common gastrointestinal disorder found mainly in the left side of the large intestine, primarily the sigmoid colon. Diverticulitis develops from a condition called diverticulosis, which involves the formation of outpouches of the colon wall. Diverticulolsis is quite common and tends to occur after the age of 50. Diverticulitis results if one or more of these pouches (or diverticula) becomes inflamed. While left sided involvement is the rule, some patients may have diverticulosis and subsequent diverticulitis on the right side of the colon.

Risk factors believed to be important for developing diverticulosis includes: aging, low fibre diet and possibly lack of exercise. There are no known factors that cause diverticulosis to become diverticulitis.

What are the common signs and symptoms of DIVERTICULITIS?

Patients often present with the classic triad of symptoms:

Left sided abdominal pain mainly over the lower left side (also known as left lower quadrant pain).
Fever
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.

Diagnosis: What tests may be done to prove that a patient has DIVERTICULITIS?

Patients with the above symptoms are commonly studied with a computed tomography, or CT scan. The CT scan is very sensitive (it will detect 98% of all patients with diverticulitis).

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 I have DIVERTICULITIS?

Medical Management

A first time episode of diverticulosis 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-fibre diet gives the colon adequate time to heal without needing to be overworked. Later, patients are typically placed on a high fibre 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 4% 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, (surgery usually advised after two to four attacks).
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.

Types of Surgeries:

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. This will typically be left in place for 4-6 months to allow the infection and inflammation on the inside to heal.
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.

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, 3-5 small 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.

Recent studies show that when laparoscopic colectomy is performed by an appropriately trained surgeon, the short- and long-term outcomes are better than with open surgery. This stems from shorter recovery time, reduced length of hospital stay and earlier return to daily activities. You should ask your surgeon about this approach and about his personal skill level and experience with laparoscopic colectomy.

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 (1-3%) possibly requiring opening of wound, drainage, antibiotics and prolonged wound care.
Abdominal cavity infection (1-3%) possibly requiring antibiotics, drainage of the infection via a catheter or reoperation to drain the infection.
Leakage from the re-connection points (anastomotic leak) (1-2%) 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 (1-3%) requiring observation, blood transfusion or re-operation.
Recurrence of diverticulitis (10%) in adjacent or remote areas of the colon requiring additional medical or surgical therapy

Colon Polyps and Colorectal Cancer

What are polyps and how do they relate to colorectal cancer ?

Colorectal cancer is cancer of the large intestine (colon), the lower part of your digestive system. Rectal cancer is cancer of the last part of your colon. Together, colorectal cancer is the #2 cause of cancer-related deaths in the United States (second to lung cancer.)

In most cases of colon cancer, the process begins in the form of a polyp. These are benign (non-cancerous) clumps of cells that are often small, and produce few symptoms other than silent and slow bleeding (which may manifest as dark stool.)

Polyps are of 2 main types and may be hyperplastic or adenomatous.

Hyperplastic polyps are benign and have no potential to develop into cancer.
Adenomatous polyps come in different varieties all of which have the potential to develop into cancer.

It is not possible to distinguish adenomatous from hyperplastic polyps in the body so the current standard of care is to completely remove any colon polyps to permit complete analysis.

On occasion, it may be found that colon cancer has already developed in a removed polyp. In such cases, if the cancer has been completely removed, no further tissue removal is necessary. In cases where residual cancer is left, or if there is uncertainty if cancer cells remain, removal of the affected portion of the colon is indicated (see below.)

Screening tests, as well as simply lifestyle and diet changes, can greatly reduce your overall risk of developing colon cancer because most polyps can be found and removed before they turn into cancer.

What are the signs and symptoms of colon polyps and/or 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 diarrhoea 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:

There are many factors that may influence the development of colon cancer.

Some include:

Age: your chance of having colorectal cancer goes up over the age of 50.
Family history: your risk is higher if a close family member (sibling, parent) has colon cancer.
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 fats (especially animal fats) may increase your risk for colon cancer.
Cigarette smoking/ alcohol: may increase your risk.
Sedentary lifestyle.
Race: African Americans have the highest number of colorectal cancer cases in the United States and the reason is still unknown.

Screening and diagnosis:

Most colon cancers develop from adenomatous polyps, so early and routine screening is very important for detecting colon cancers.

Common screening procedures include the following:

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.
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.
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 4 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 into 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 colon cancer.

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.

Traditionally, surgery for colon cancer has been done through one large incision in the abdomen. More recently, several large scale studies have been done to prove that laparoscopic surgery can be used to safely remove colon cancer and reattach the ends.* This is known as a laparoscopic colectomy. In each of the studies, researchers have shown that colon cancer patients treated by laparoscopic colectomy have the same propensity for survival as those treated with open colectomy but receive all the benefit of the quicker recovery of a laparoscopic operation.

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 tumours 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 (1-3%) possibly requiring opening of wound, drainage, antibiotics and prolonged wound care.
Abdominal cavity infection (1-3%) possibly requiring antibiotics, drainage of the infection via a catheter or reoperation to drain the infection.
Leakage from the re-connection points (anastomotic leak) (5-10%) 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 (1-3%) 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 tumour before surgery.

There are two main types of radiation therapy, according to 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 tumour. 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, diarrhoea, 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.

Treatment for Colorectal Cancer: Targeted Drug Therapy

These drugs target the special defects that allow cancer cells to grow and proliferate. Currently, there are 3 drugs available to patients with advanced cancers and are still experimental.

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 third most common cancer in men and women. Each year there are more than 153,000 new colorectal cancer cases and more than 52,000 deaths related to colorectal cancer**.

References

* COST Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004;350:2050-2059.,Veldkamp R, Kuhry E, Hop WC, et al;

Colon Cancer Laparoscopic or Open Resection Study Group. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of randomised trail. Lancet Oncol. 2005;6:477-484., Guillou PG, Quirke P, Thorpe H, et al.

Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trail): mulicentre, randomised controlled trial. Lancet 2005;356:1718-1726.

** www.cancer.gov (National Cancer Institute)

Information on this site should not be used as a substitute for talking with your doctor. Always talk with your doctor about diagnosis and treatment information.