Procedures

Colon cancer is very common, and if caught early, treatment can be quite successful.

Symptoms can range from bleeding from the bowel, to a change in your bowel pattern, to anaemia on blood tests or abdominal pains. The mainstay of diagnosis is colonoscopy. Bowel cancers can be picked up on CT scans, but these are not as reliable as colonoscopy.

If a colon cancer is found at colonoscopy we would next order a CT scan of your lungs and abdomen looking at the other major organs. For bowel cancers in the rectum which is the last part of the bowel we would also order an MRI. In this area we sometimes treat the cancer with radiotherapy first before surgery.

If your scans are clear, then we start to plan surgery. How the surgery is performed depends upon where the cancer is in the bowel, if you have had previous surgery, if you are slim or overweight. Most people are in Hospital around a week, and spend another 4-6 weeks at home recovering.

Surgery removes a whole piece of the colon, and this is examined in the laboratory after the surgery. The report takes nearly a week to arrive, and depending upon what the pathologists have seen you may need chemotherapy afterwards.

Every patient undergoing bowel cancer treatment is different, and may need different treatments. Its best if we go through the process with you and your family in person as there are exceptions to every rule.

Colonoscopy is a very common procedure, passing the camera through the anus around the entire large bowel to the appendix, and sometimes the end of the small bowel (called the terminal ileum). This is often combined with a gastroscopy looking at the stomach if the patient has symptoms of reflux or a stomach ulcer. The large bowel needs to be almost completely empty to allow the camera to pass through, and to see the bowel lining well. For most people the process of emptying the bowel is the worst part of the procedure. The day before only clear fluids may be drunk (water, lemonade, apple juice, black tea or coffee, jelly and chicken broth). The evening prior typically Picoprep is drunk to flush out the bowel creating diarrhoea, and it is very important to keep up with fluid intake at this point. It is best if the fluids contain sugars and salts- avoid tap or bottled water.

In the Hospital the anaesthetist will place an IV line and then we will soon be underway.

The procedure takes between 20-30 minutes. One of the most important things we are looking for are bowel polyps. These are growths on the bowel lining which have the potential to become cancerous. For this reason when we see them we almost always remove them at the same time (unless they are too big, or a difficult shape- in which case surgery will be needed afterwards). Likely the polyp will be retrieved and sent to the laboratory to see what type of polyp it was as this can help us decide when another colonoscopy should be done. Polyps are very common aged 50-70 years, about 1 in 6 people will have them. Once polyps have been found and removed, there is a chance of more polyps growing in the future, and this is why we would recommend further colonoscopies. Whenever we are removing polyps, particularly a larger polyp, there is a small risk of causing a hole in the bowel (1 in 1000), and this may require surgery to fix.

Haemorrhoids are also very common, and if we are doing the colonoscopy to investigate bleeding we may use the camera to treat them at the same time. The most common treatment is to place elastic loops on the haemorrhoids which strangle the blood vessels feeding the haemorrhoids and cause them to shrink over 2-3 days. Patients may notice a bright green loop in the toilet afterwards, not to worry- it will have done its job by then. For the first 1-2 days after banding most patients have the feeling of needing to defecate despite the fact their bowel is mostly empty. This is the pressure from the haemorrhoid banding. Try not to sit on the toilet for long periods of time.

After the procedure you should be given a copy of the colonoscopy report- your GP will get the same report. On it will be what was found during the colonoscopy, and any instructions afterwards.

Everyone is invited to participate in the Government Bowel Cancer Screening Programme, every two years between the ages of 50-74 years. Sample of bowel motion are submitted testing for microscopic traces of blood. If you are seeing blood while going to the toilet it is much more likely to have a positive test. If you are taking powerful blood thinners such as Warfarin, Plavix, Pradaxa or Eliquis again it is more likely to have a positive test.

If you have a positive test we normally recommend undergoing colonoscopy. While three quarters of people have no cause found, about a quarter will have a polyp, and 1% a cancer. We just don’t know which group you are in without doing a colonoscopy.

If you have had a colonoscopy within the last 12 months, are very elderly, or have a number of medical problems you may not need to do the screening test. Speak to your GP if unsure.

Everybody has haemorrhoids if we look carefully enough. Only those causing problems- most commonly bleeding when defecating -do we need to treat them. The commonest treatment is banding often combined with a colonoscopy to ensure haemorrhoids are the cause of the bleeding.

During the colonoscopy we place elastic loops on the haemorrhoids which strangle the blood vessels feeding the haemorrhoids and cause them to shrink over 2-3 days. Patients may notice a bright green loop in the toilet afterwards, not to worry- it will have done its job by then. For the first 1-2 days after banding most patients have the feeling of needing to defecate despite the fact their bowel is mostly empty. This is the pressure from the haemorrhoid banding. Try not to sit on the toilet for long periods of time.

Some haemorrhoids particularly if they are mostly external or on the outside of your anus require surgery. This is very effective for treating haemorrhoids, but is not often performed as it is incredibly painful afterwards for 2-3 weeks. Most patients once they have recovered are pleased they had the surgery, but would never go through it again.

Sometimes often without any reason your haemorrhoids will swell on the outside of your anus and become very painful. When this happens your haemorrhoids are external and thrombosed. Because it is very painful most people see their GP or present to ED in the Hospitals hoping for a speedy treatment. Once upon a time we used to incise the haemorrhoids under local anaesthetic to drain them, but this has fallen out of favour as it is itself quite painful afterwards. The best thing to is be very gentle wiping after going to the toilet. Don’t try and push them “back in” as once they are swollen they won’t go. Apply ice packs for short periods and soak in a warm salt water bath. Use plenty of pain killers and rest. Once the swelling has gone down, we can start to think about what treatment you might need.

Anal fissures which are a tear in the lining of your bottom are also quite common. Sometimes a bout of constipation can trigger them, but just as often there is no cause. They cause extreme pain going to the toilet with a little blood on the toilet paper. Treatment is quite different from haemorrhoids. There are 2 ointments specifically for fissures, (Rectogesic 0.2% available over the counter, and Diltiazem 2% which needs a prescription) haemorrhoid creams will not get rid of a fissure. Until the fissure has healed you should take Movicol or Metamucil daily. If after 3-4 weeks the fissure ointments have not helped, we would plan for a colonoscopy at this point.

If you have had pain in your groin, your GP may book an ultrasound test to see why. These commonly find tiny hernias (3-5mm in size) which usually don’t need surgery. Unless the hernia is visible with an obvious asymmetrical swelling when you stand, or can be felt when you cough it likely won’t need surgery. These hernias which can only be seen on ultrasound usually don’t progress to needing surgery in the future, and without the ultrasound we wouldn’t know you have it. If your pain has persisted for some weeks, you may have a groin strain. These can be painful for months, and can be troublesome.

If your hernia is visible, or can be felt when you cough you may well need surgery. Come in so we can assess the situation and discuss surgery. In essence we almost always place finely woven nylon mesh between the muscle layers to strengthen them, and reduce the chance of the hernia coming back (to around 5%). It takes four weeks for the mesh to fully adhere to the muscles and over this time it is important not to lift heavy weights. If you are in physical work, you may need the full four weeks off while you recover.