Inflammatory Bowel Diseases

  • Crohn’s disease
  • Ulcerative colitis

Crohn’s disease

This type of inflammatory bowel disease can affect any part of the Gastrointestinal tract (GIT). It most commonly affects younger individuals and involves the terminal part of small intestine and the large intestine. The disease can however present in the elderly population.

Clinical features include both intestinal and extra-intestinal manifestations. It most commonly presents with oral cavity ulcers, vomiting, rectal bleeding, passage of mucous per anum, abdominal pain, diarrhoea or loose stools, malabsorption and weight loss. The disease can be associated with intestinal ulcers, fistula or narrowing (strictures).

Macroscopic features of the intestine

  • Skip areas (affected segments of intestine followed by unaffected areas)
  • Stiff walled segment (narrowing of intestines)
  • Fat wrapping (increased swelling, thickening of intestine wall with fat wrapping around it)
  • Intestinal ulcers
  • Cobblestone appearance of the inside of the intestine forming polyps which are inflammatory in nature
  • Narrowing of intestine, Fistula and abscess (collection of pus)

Crohn’s disease can be diagnosed using colonoscopy or imaging such as CT scan of the abdomen and pelvis. Management is usually with medications. Removal of affected intestine may sometimes be required depending on affected bowel and associated complications.

Ulcerative colitis

This type of inflammatory bowel disease can affect only the large bowel or the colon. It is often a disease of the younger individuals. Clinical features include both intestinal and extra-intestinal manifestations. Common symptoms include loose stools or diarrhoea, passage of mucus discharge per anum, per rectal bleeding, weight loss. Extraintestinal manifestations include conditions that may or may not associated with disease activity (oral cavity ulcers, kidney stones, gallstones, liver cirrhosis, pyoderma, erythema nodosum, large joint arthritis).

It can affect various parts of the large bowel as follows:

  • Proctitis – disease limited to rectum
  • Distal colitis – disease extends to mid-sigmoid (approx 60cm from the anal canal)
  • Left sided colitis – disease extends to splenic flexure
  • Extensive colitis – disease extends beyond the splenic flexure
  • Pancolitis – disease extends to caecum

Diagnosis can usually be made by colonoscopy and histopathology (intestinal biopsy). Management is mainly with medications, but resection or removal of large intestine may sometimes be required depending on the disease complications and severity.

Anal Fissure

An anal fissure is a tear or crack in the skin lining in the anal canal. When you are seen in clinic Dr.Murugesan will take a full history and carry out a clinical examination. If you have had any bleeding or change in bowel habit, Dr.Murugesan may recommend endoscopic examination of the bowel either by flexible sigmoidoscopy or colonoscopy to ensure that it is otherwise healthy, alongside treating the fissure. Most fissures can be treated without the need for surgery. With small, shallow anal fissures, patients are advised to keep their stools soft and to avoid straining. This can be helped by taking a high fibre diet with plenty of fluids. Fissures that do not respond to the simple measures above can be treated with creams that are specifically designed to relax the anal muscle and improve blood flow to allow healing. Fissures that don’t respond to topical creams, are treated with Botulinum Toxin injection, failing which surgery may be required.

Constipation

The western diet is often low in fibre (which is found in foods such as cereals, vegetables, fruits and whole grain foods). Fibre passes through the body as waste and helps food pass more quickly. It is recommended that people eat at least 25/30 grams of fibre and drink 2 litres of water every day. If there is an acute change in bowel habit that persists (goes on for some time) and does not respond to simple lifestyle changes, you will need to consult your doctor. A common evaluation would include colonoscopy or flexible sigmoidoscopy, tests to work out if the colon or bowel itself is sluggish or slow (colonic transit study) or if the problem arises from a difficulty in emptying the faeces from the back passage, often known as an "evacuatory" problem (defecating proctogram or MR proctogram). Dr.Murugesan will discuss with you the various treatment options.

Faecal Incontinence

Anal or faecal incontinence is the inability to control bowel movements, leading to faeces unexpectedly leaking from the rectum. Anal incontinence affects more women than men. Women can be particularly affected by anal incontinence after complicated childbirth. In the elderly, anal incontinence can develop when muscles become weak and the supporting structures in the pelvis become loose. Two main forms of anal incontinence include Urge incontinence and passive soiling. At review in the clinic, Dr.Murugesan will take a full history and carry out a clinical examination. Further testing would include a colonoscopy to ensure that it is otherwise healthy. Anorectal physiological testing with an endoanal ultrasound scan, anorectal manometry and pudendal nerve testing will be performed as an outpatient in the rooms (please refer to the section on anorectal physiology). Occasionally, if there are any symptoms of rectal prolapse, defecating proctogram may be required.

Treatment options include:

  • Conservative therapy
  • Sacral nerve stimulation (also known as sacral neuromodulation or SNS) is a procedure where the sacral nerve at the base of the spine is stimulated by a mild electrical current from a small device.
  • Sphincter repair - damaged sphincter muscles are overlapped and stitched back together.
  • Ileostomy or Colostomy - this is only recommended when other surgical treatments have been unsuccessful.

Haemorrhoids

Haemorrhoids are swollen blood vessels in the anus and rectum. The commonest cause is constipation and excess straining at stools that results in normal veins becoming enlarged and forced downwards to become haemorrhoids. Other causes include pregnancy and childbirth. Most common symptoms include bleeding during bowel movements, prolapse during bowel movements and anal itch. When you are seen in the clinic, Dr.Murugesan will take a full history and carry out a clinical examination. Further testing would include a flexible sigmoidoscopy or colonoscopy to ensure that it is otherwise healthy, before treating any haemorrhoids.

Treatment options include:

  • Rubber Band Ligation
  • Injection sclerotherapy
  • Haemorrhoidal artery ligation operation and rectoanal repair
  • Stapled haemorrhoidectomy
  • Laser Procedure
Dr.Murugesan will advise you of the most appropriate treatment for your haemorrhoids, at review.

Hernia

A hernia is an abnormal protrusion through the abdominal wall.  The protrusion contains a sac (hernial sac) which can be empty or more often filled with abdominal contents such as fat or bowel. Hernias become more prominent with increase in intra-abdominal pressure, for example when straining (coughing, heavy lifting), as this forces intra-abdominal contents into the sac. Most common presentation includes a bulge that enlarges with standing or coughing, a dragging sensation and sometimes pain (uncommon unless something is stuck in the sac). There is a risk that bowel can get ‘stuck’ in the sac and not return to the abdomen which can result in loss of blood supply to bowel, resulting in strangulation or bowel obstruction.

Various types of hernia include:

  • Inguinal hernia
  • Umbilical hernia
  • Incisional hernia – a surgical scar becoming weak and resulting in a hernia
  • Femoral hernia
  • Parastomal hernia – hernia around a stoma

Dr.Murugesan will take a detailed history and perform a clinical examination at review. Usually, an ultrasound scan is performed to confirm the findings. For large abdominal wall hernias a CT scan is particularly useful for planning the most appropriate technique of repair. Dr.Murugesan specializes in hernia repairs and offers minimally invasive techniques (robotic and laparoscopic surgery) and open repairs. Robotic surgery is a newer most significant revolution in minimally invasive technique for hernia and bowel surgery. Like laparoscopic surgery, robotic surgery uses keyhole, and is performed in the same way (small incisions, a small camera, insufflation of the abdomen, and projecting the inside of the abdomen onto television screens). In robotic surgery, the surgeon is seated at a console in the operating room and handles the surgical instruments from the console and this allows the surgeon to work with increased accuracy, dexterity and precision in confined spaces. While robotic surgery can be used for hernias, it can also be used to reconstruct the abdominal wall. The difference is that the patch or graft is inserted in a very safe plane, away from the bowel, between the abdominal wall and the fascia. Studies of robotic hernia repairs show evidence that there's a low risk of recurrence, complications, shorter hospitalization time and less need for narcotic analgesia. Dr.Murugesan will be operating in the robotic suite at Campbelltown Private Hospital. He introduced robotic eTEP (extended view Totally extra peritoneal) and robotic TAPP (trans abdominal pre peritoneal) techniques in Macarthur area health service to treat complex hernia in a minimally invasive manner, providing his patients with the best possible care. He also uses the robot for bowel surgery including colonic and rectal surgery.

Rectal Prolapse

Rectal prolapse occurs when the normal supports of the rectum (the lower end of the colon just above the anus) become weakened and the rectum drops down outside the anus. This often happens because the anal sphincter muscle (the muscle of the anus) has become weak and there is difficulty in controlling the bowels with leakage of stool. Dr.Murugesan will take a careful history by asking you a series of questions and a complete anorectal examination. In some cases, an x-ray test called Defecating proctogram may be helpful. Anorectal Physiology studies are most often arranged to assess the anal sphincters. There are different ways to surgically treat rectal prolapse, one through the abdomen called a Rectopexy and the other through the anus called the “perineal” approach.

Diverticular Disease

A diverticulum is a protrusion of the inner lining of the bowel which form pockets in the bowel wall. Diverticulitis is an inflammation of these pockets. The etiology of diverticulae is not precisely known. However, lack of dietary fibre over a number of years causes the muscle of the bowel wall to work harder. This creates an increased pressure inside the bowel, resulting in diverticula formation. Diverticulitis generally requires treatment with antibiotics and in some cases this treatment needs to be in hospital. These attacks usually settle down quickly but some discomfort may persist for several weeks after. A CT Scan can be helpful in making the diagnosis and assessing the infection. Some patients who have frequent episodes of infection might be advised to have a planned operation to remove the affected part of the bowel. When an abscess or a collection of pus develops, a CT scan is usually required to make the diagnosis. Generally the abscess can be drained from the outside without an operation and antibiotics are given. Although rare, if peritonitis develops an emergency operation to remove the affected part of the bowel is usually required.

Bowel Cancer

Bowel cancer refers to cancer developing in the large bowel (colon and rectum). Bowel cancer often develops from a pre-cancerous growth called polyp. Polyps are usually non-cancerous but if untreated, some can develop into cancer.

The exact causes of bowel cancer are not known, but certain risk factors have been recognised to increase the risk of developing bowel cancer:
  • Family history of bowel, breast or ovarian cancers consisting of a first degree relative
  • Previous diagnosis of ovarian cancer or breast cancer or polyps in the colon or rectum
  • Previous diagnosis of inflammatory bowel disease (ulcerative colitis or Crohn’s disease)
  • A diet high in fat, red or processed meat and low in fruit and vegetables

As with most forms of cancer, early detection gives the best chances of cure and survival. Some symptoms of bowel cancer include altered bowel habits, per rectal bleeding, iron deficiency anaemia, incomplete emptying after a bowel movement, abdominal pain and discomfort, loss of appetite and unexplained weight loss.

Investigations would generally include a combination of the following:

  • Clinical examination of abdomen and back passage
  • Colonoscopy
  • CT scan abdomen and pelvis; MRI pelvis (rectal cancer)

A multidisciplinary approach is taken in managing bowel cancer (specialists including surgeons, radiologist, pathologist and oncologist will meet as a team and review the case and results of investigations to decide on the most appropriate management). Treatment is dependent on the stage of the cancer. The mainstay of treatment for bowel cancer is surgery, which usually involves removal of the affected part of the bowel and the surrounding lymph glands. However, surgery alone is not always successful in treating bowel cancer and often chemotherapy or radiotherapy is given before or after surgery, either to shrink the cancer prior to its removal or to decrease the risk of the cancer recurrence.