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Hemorrhoids
Hemorrhoids are the swelling and inflammation of veins in the rectum and anus.

Prevalence
Hemorrhoids are very common. It is estimated that approximately half of all Americans have this condition by the age of 50. However, only a small number seek medical treatment. Annually, only about 500,000 people are medically treated for hemorrhoids, with 10 to 20% of them requiring surgeries.

Causes and risk factors

Some people are more prone to developing hemorrhoids due to inherent problems with their bodies' collagen and elastic fibers due to a genetic predisposition. This leads to weak rectal vein walls or week venous valves. These people may have other related defects such as 'flat feet', herniae. Others develop hemorrhoids due to problems in their intestinal tract. The causes of hemorrhoids include genetic predisposition (weak rectal vein walls and/or valves, excessive time (over 1 minute daily) and straining during bowel movements, and chronic bowel straining or pressure due to poor posture or muscle tone. Constipation, bouts of diarrhea, poor bathroom habits (reading on the toilet or multiple cleaning attempts), pregnancy, excessive coughing, constant sitting and fiber-deprived Western diet can all foster the conditions that cause hemorrhoids. Hemorrhoids is particularly common among pregnant women. The pressure of the fetus in the abdomen, as well as hormonal changes, cause the hemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, hemorrhoids caused by pregnancy are a temporary problem.

Types of hemorrhoids

Hemorrhoids can present as internal or external hemorrhoids or both. External hemorrhoids are those that occur outside of the anal opening. Internal hemorrhoids are those that occur inside the rectum.

Clinical Picture
External hemorrhoids External hemorrhoids are asymptomatic except when secondary thrombosis occurs. However, some patients with non-thrombosed hemorrhoids may complain of pruritus ani or itching, swelling, and burning sensation. In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms. Draining mucus may also cause itching. If the vein ruptures and a blood clot develops, the hemorrhoids become a thrombosed hemorrhoid. Thrombosis may result from defecatory straining or extreme physical activity, or it may be a random event. Patients often report feeling the sensation of sitting on a tender marble. Physical examination identifies the external thrombosis as a purple mass at the anal verge. If infected this can lead to inguinal lymph node enlargement. The inguinal lymph nodes are situated in the crease between the leg and pelvis (more on the outside of that crease, ie, laterally). They drain the penis, scrotum, vulva, vagina, perineum, gluteal region, lower abdominal wall, lower anal canal. Internal hemorrhoids As this area lack sensitive nerve endings, internal hemorrhoids are usually not painful and most people are not aware that they have them. Internal hemorrhoids, however, may bleed when irritated. The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids. Prolapsed hemorrhoid is an internal hemorrhoid that are so distended that it is pushed outside of the anus. If the anal sphincter muscle goes into spasm and trap the prolapsed hemorrhoid outside of the anal opening, the supply of blood is cut off, and the hemorrhoids become a strangulated hemorrhoid.

Differential Diagnosis
Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching (pruritus ani), have similar symptoms. The differential diagnosis of anal mass includes many benign diseases. hemorrhoids, rectal prolapse, perianal haematomas, anal tags, polyps, warts or condylomas, anal abscesses can all present as an anal mass. Non-proctological lumps can also be present from time to time. These include sebaceous cysts and lipomas. On the other hand, a palpable mass and/or bleeding is the presenting symptom in 50% of patients that are later found to have anal cancer. Other potential causes include inflammatory bowel disease or bowel infection.

Diagnosis
A thorough evaluation and proper diagnosis are important any time bleeding from the rectum or blood in the stool occurs. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer. Examination of the anus and rectum to includes inspection to look for swollen blood vessels that indicate hemorrhoids and a digital rectal exam with a gloved, lubricated finger to feel for abnormalities. Closer evaluation of the rectum for hemorrhoids requires an exam with an anoscope, a hollow, lighted tube useful for viewing internal hemorrhoids, or a proctoscope, useful for more completely examining the entire rectum. To rule out other causes of gastrointestinal bleeding, examination of the rectum and lower colon (sigmoid) with sigmoidoscopy or the entire colon with colonoscopy may be necessary. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve the use of lighted, flexible tubes inserted through the rectum.

Prevention
Prevention of hemorrhoids includes drinking more fluids, eating more fiber, exercising, practicing better posture, and reducing bowel movement strain and time. Hemorrhoid sufferers should avoid using laxatives and should strictly limit time straining at stool to well under 1 minute (ideally 10 seconds) daily.

Treatments

For many people, hemorrhoids are temporary conditions that are healed either serendipitously or by the same measures recommended for prevention. In these cases, warm sitz bath, cold compress, or topical analgesic (such as Preparation H), is sufficient to provide temporary relief. The first step is to eliminate the factors causing hemorrhoids. After eliminating the risk factors and possible causes the goal is to achieve symptomatic relief as well as shrinkage of the hemorrhoids. This can be accomplished by Sitz baths as well as pain meds. Treatment of chronic or complicated hemorrhoids Chronic hemorrhoids or those that flare up from time to time can be medically treated by:

dilation: stretching of the anal sphincter muscle. Although no longer popular, this treatment can be successfully applied to select cases of strangulated hemorrhoids. rubber band ligation: elastic bands are applied onto an internal hemorrhoid to cut off its blood supply. Within several weeks, withered hemorrhoid is sloughed off during normal bowel movement. sclerotherapy (injection therapy): sclerosant or hardening agent is injected into hemorrhoids. This causes the vein walls to collapse and the hemorrhoids to shrivel up. cryosurgery: a frozen tip of a cryoprobe is used to destroy hemorrhoidal tissues. laser, infared or BICAP coagulation: laser, infrared beam, or electricity is used to cauterize the affected tissues. hemorrhoidectomy: a true surgical procedure to excise and remove hemorrhoids.

For severe cases of hemorrhoids, such as prolapsed, thrombosed, or strangulated hemorrhoids, surgery may be the only treatment option. The pain in thrombosed external hemorrhoid, which is better known as a perianal haematoma, is usually severe and instantly relieved by incision and evacuation of the clot. General measures to decrease flare ups and aggravation are increase dietary fiber found in fruits, vegetables, grains and cereals. A fiber supplement may also be used. Increase water intake. These measure may soften the bowel movements and prevent straining and trauma.

Natural astringents and soothing agents, such as witch hazel, cranesbill and aloe vera, may also be used topically. Lastly, fiber-rich bulking agents such as plantain and psyllium can be used to help create soft stool that is easy to pass to lessen the irritation of existing hemorrhoids or to achieve the daily limit of well under 1 minute (ideally 10 seconds) straining at stool.

http://www.merckmanuals.com/professional/gastrointestinal_disorders/tumors_of_the_gi_tract/polyp s_of_the_colon_and_rectum.html

Polyps of the Colon and Rectum

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An intestinal polyp is any mass of tissue that arises from the bowel wall and protrudes into the lumen. Most are asymptomatic except for minor bleeding, which is usually occult. The main concern is malignant transformation; most colon cancers arise in a previously benign adenomatous polyp. Diagnosis is by endoscopy. Treatment is endoscopic removal. (See also the American College of Gastroenterology's practice guidelines for diagnosis, treatment, and surveillance for patients with colorectal polyps.) Polyps may be sessile or pedunculated and vary considerably in size. Incidence of polyps ranges from 7 to 50%; the higher figure includes very small polyps (usually hyperplastic polyps or adenomas) found at autopsy. Polyps, often multiple, occur most commonly in the rectum and sigmoid and decrease in frequency toward the cecum. Multiple polyps may represent familial adenomatous polyposis (see Tumors of the GI Tract: Familial Adenomatous Polyposis ). About 25% of patients with cancer of the large bowel also have satellite adenomatous polyps. Adenomatous (neoplastic) polyps are of greatest concern. Such lesions are classified histologically as tubular adenomas, tubulovillous adenomas (villoglandular polyps), or villous adenomas. The likelihood of cancer in an adenomatous polyp at the time of discovery is related to size, histologic type, and degree of dysplasia; a 1.5-cm tubular adenoma has a 2% risk of containing a cancer vs a 35% risk in 3-cm villous adenomas. Serrated adenomas, a somewhat more aggressive type of adenoma, may develop from hyperplastic polyps.
Sessile Polyp

Pedunculated Polyp

Tubulovillous Adenoma

Nonadenomatous (nonneoplastic) polyps include hyperplastic polyps, hamartomas, juvenile polyps, pseudopolyps, lipomas, leiomyomas, and other rarer tumors. Juvenile polyps occur in children, typically outgrow their blood supply, and autoamputate some time during or after puberty. Treatment is required only for uncontrollable bleeding or intussusception. Inflammatory polyps and pseudopolyps occur in chronic ulcerative colitis and in Crohn's disease of the colon. Multiple juvenile polyps (but not sporadic ones) convey an increased cancer risk. The specific number of polyps resulting in increased risk is not known.

Symptoms and Signs

Most polyps are asymptomatic. Rectal bleeding, usually occult and rarely massive, is the most frequent complaint. Cramps, abdominal pain, or obstruction may occur with a large lesion. Rectal polyps may be palpable by digital examination. Occasionally, a polyp on a long pedicle may prolapse through the anus. Large villous adenomas may rarely cause watery diarrhea that may result in hypokalemia.

Diagnosis

Colonoscopy

Diagnosis is usually made by colonoscopy. Barium enema, particularly double-contrast examination, is effective, but colonoscopy is preferred because polyps also may be removed during that procedure. Because rectal polyps are often multiple and may coexist with cancer, complete colonoscopy to the cecum is mandatory even if a distal lesion is found by flexible sigmoidoscopy.

Treatment

Complete removal during colonoscopy Sometimes follow with surgical resection Follow-up surveillance colonoscopy

Polyps should be removed completely with a snare or electrosurgical biopsy forceps during total colonoscopy; complete excision is particularly important for large villous adenomas, which have a high potential for cancer. If colonoscopic removal is unsuccessful, laparotomy should be done. Subsequent treatment depends on the histology of the polyp. If dysplastic epithelium does not invade the muscularis mucosa, the line of resection in the polyp's stalk is clear, and the lesion is well differentiated, endoscopic excision and close endoscopic follow-up should suffice. Patients

with deeper invasion, an unclear resection line, or a poorly differentiated lesion should have segmental resection of the colon. Because invasion through the muscularis mucosa provides access to lymphatics and increases the potential for lymph node metastasis, such patients should have further evaluation (as in colon cancersee Tumors of the GI Tract: Colorectal Cancer). The scheduling of follow-up examinations after polypectomy is controversial. Most authorities recommend total colonoscopy annually for 2 yr (or barium enema if total colonoscopy is impossible), with removal of newly discovered lesions. If 2 annual examinations are negative for new lesions, colonoscopy is recommended every 2 to 3 yr.

Prevention
Aspirin

and COX-2 inhibitors may help prevent formation of new polyps in patients with polyps or colon cancer. (See also the Cochrane review abstracts: dietary fibre, calcium supplementation, and aspirin and
NSAIDs for the prevention of colorectal adenomas and carcinomas.)

FAMILIAL ADENOMATOUS POLYPOSIS Familial adenomatous polyposis (FAP) is a hereditary disorder causing numerous colonic polyps and resulting in colon carcinoma by age 40. Patients are usually asymptomatic but may have heme-positive stool. Diagnosis is by colonoscopy and genetic testing. Treatment is colectomy. FAP is an autosomal dominant disease in which 100 adenomatous polyps carpet the colon and rectum. The disorder occurs in 1 in 8,000 to 14,000 people. Polyps are present in 50% of patients by age 15, and 95% by 35. Cancer develops before age 40 in nearly all untreated patients. Patients also can develop various extracolonic manifestations (previously termed Gardner's syndrome), both benign and malignant. Benign manifestations include desmoid tumors, osteomas of the skull or mandible, sebaceous cysts, and adenomas in other parts of the GI tract. Patients are at increased risk of cancer in the duodenum (5 to 11%), pancreas (2%), thyroid (2%), brain (medulloblastoma in < 1%), and liver (hepatoblastoma in 0.7% of children <5).

Symptoms and Signs

Many patients are asymptomatic, but rectal bleeding, typically occult, occurs.

Diagnosis

Colonoscopy Genetic testing of patient and 1st-degree relatives Offspring screened for hepatoblastoma

Diagnosis is made by finding > 100 polyps on colonoscopy. Diagnosed patients should have genetic testing to identify the specific mutation, which should then be sought in 1st-degree relatives. If genetic testing is unavailable, relatives should be screened with annual sigmoidoscopy beginning at age 12, reducing frequency with each decade. If no polyps are evident by age 50, screening frequency is then the same as for average-risk patients. Children of parents with FAP should be screened for hepatoblastoma from birth to age 5 yr with annual serum fetoprotein levels and possibly liver ultrasound.

Treatment

Colectomy Endoscopic surveillance of remainder of GI tract Perhaps aspirin

or coxibs

Colectomy should be done at the time of diagnosis. Total proctocolectomy, either with ileostomy or mucosal proctectomy and ileoanal pouch, eliminates the risk of cancer. If subtotal colectomy (removal of most of the colon, leaving the rectum) with ileorectal anastomosis is done, the rectal remnant must be inspected every 3 to 6 mo; new polyps must be excised or fulgurated. Aspirin

or coxibs may inhibit new polyp formation. If new ones appear too rapidly or prolifically to remove, excision of the rectum and permanent ileostomy are needed. After colectomy, patients should have upper endoscopy every 6 mo to 4 yr, depending on the number of polyps (if any) in the stomach and duodenum. Annual physical examination of the thyroid, and possibly ultrasound, also is recommended. PEUTZ-JEGHERS SYNDROME

Peutz-Jeghers syndrome is an autosomal dominant disease with multiple hamartomatous polyps in the stomach, small bowel, and colon along with distinctive pigmented skin lesions. Patients are at a significantly increased risk of GI and non-GI cancers; possibly the genetic defect involves a tumor suppressor gene. GI cancers include those of the pancreas, small intestine, and colon. Non-GI cancers include those of the breast, lung, uterus, and ovaries. The skin lesions are melanotic macules of the skin and mucous membranes, especially of the perioral region, lips and gums, hands, and feet. All but the buccal lesions tend to fade by puberty. Polyps may bleed and often cause obstruction or intussusception. Diagnosis is suggested by the clinical picture. Genetic testing is not routinely available but should be considered. First-degree relatives should be evaluated and have routine surveillance for cancers, but there is no firm consensus on specific tests and intervals. Colonic polyps larger than 1 cm typically are removed.

http://www.merckmanuals.com/home/digestive_disorders/tumors_of_the_digestive_system/colorectal _polyps.html

Colorectal Polyps

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Some polyps are caused by hereditary conditions. Bleeding from the rectum is the most common symptom. A colonoscopy is performed to make the diagnosis. Surgical removal is the best form of treatment.

A polyp is a growth of tissue from the intestinal or rectal wall that protrudes into the intestine or rectum and may be noncancerous (benign) or cancerous (malignant). Polyps vary considerably in size, and the bigger the polyp, the greater the risk that it is cancerous or precancerous. Polyps may grow with or without a stalk. Those without a stalk are more likely to be cancerous than those with a stalk. Adenomatous polyps, which consist primarily of glandular cells that line the inside of the large intestine, are likely to become cancerous (that is, they are precancerous). Serrated adenomas are a particularly aggressive form of adenoma. Hereditary Conditions: Some polyps are the result of hereditary conditions, such as familial adenomatous polyposis and Peutz-Jeghers syndrome. In familial adenomatous polyposis, 100 or more precancerous polyps develop throughout the large intestine and rectum during childhood or adolescence. In nearly all untreated people, the polyps develop into cancer of the large intestine or rectum (colorectal cancer) before age 40. People with familial adenomatous polyposis can develop other complications (previously termed Gardner's syndrome), particularly various types of noncancerous tumors. These noncancerous tumors develop elsewhere in the body (for example, on the skin, skull, or jaw). In Peutz-Jeghers syndrome, people have many small polyps in the stomach, small intestine, large intestine, and rectum. They also have numerous bluish black spots on their face, inside their mouth, and on their hands and feet. The spots tend to fade by puberty except for those inside the mouth. People with Peutz-Jeghers syndrome have an increased risk of developing cancer in many organs, particularly the pancreas, small intestine, colon, breast, lung, ovary, and uterus.

Did You Know...

There is an inherited disorder that causes people to develop hundreds of

polyps in their colon. Without treatment, nearly all of these people develop cancer by age 40.

Symptoms and Diagnosis

Most polyps do not cause symptoms. When they do, the most common symptom is bleeding from the rectum. A large polyp may cause cramps, abdominal pain, or obstruction. Large polyps with tiny, fingerlike projections (villous adenomas) may excrete water and salts, causing profuse watery diarrhea that may result in low levels of potassium in the blood (hypokalemia). Rarely, a rectal polyp on a long stalk drops down and dangles through the anus. A doctor may be able to feel polyps by inserting a gloved finger into the rectum, but usually polyps are discovered during flexible sigmoidoscopy (examination of the lower portion of the large intestine with a viewing tube). If flexible sigmoidoscopy reveals a polyp, colonoscopy is performed to examine the entire large intestine. This more complete and reliable examination is performed because more than one polyp is usually present and any may be cancerous. Colonoscopy also allows a doctor to perform a biopsy (removal of a tissue sample for examination under a microscope) of any area that appears cancerous.
Colonoscopy: Obtaining a Biopsy Sample

Treatment
Doctors generally recommend removing all polyps from the large intestine and rectum because of their potential to become cancerous. Polyps are removed during a colonoscopy procedure using a cutting instrument or an electrified wire loop. If a polyp has no stalk or cannot be removed during colonoscopy, abdominal surgery may be needed. If a polyp is found to be cancerous, treatment depends on whether the cancer is likely to have spread. The risk of spread is determined by microscopic examination of the polyp. If the risk is low, no further treatment is necessary. If the risk is high, particularly if the cancer has invaded the polyp's stalk, the affected segment of the large intestine is removed surgically, and the cut ends of the intestine are rejoined. When a person has a polyp removed, the entire large intestine and rectum are examined by colonoscopy a year later and then at intervals determined by the doctor. If such an examination is impossible because of a narrowing of the large intestine, a barium enema may be used to view

the large intestine on x-ray. For people with familial adenomatous polyposis, complete removal of the large intestine and rectum eliminates the risk of cancer. Alternatively, the large intestine is removed and the rectum is joined to the small intestine. This procedure sometimes eliminates the rectal polyps and thus is preferred by many experts. The remaining part of the rectum is inspected by sigmoidoscopy every 3 to 6 months, so that new polyps can be removed. If new polyps appear too rapidly, however, the rectum must also be removed. If the rectum is removed, a surgical opening is created through the abdominal wall from the small intestine (ileostomy). Bodily wastes are eliminated through the ileostomy into a disposable bag. Some nonsteroidal anti-inflammatory drugs (NSAIDs) are being studied for their ability to reverse the growth of polyps in people with familial adenomatous polyposis. Their effects are temporary, however, and once these drugs are discontinued, the polyps begin to grow again.

http://www.netdoctor.co.uk/diseases/facts/colonpolyps.htm

Polyps in the colon (large bowel)

Written by Professor Jonathan Rhodea, consultant gastoenterologist

What is a colonic polyp?

A polyp is a benign (non-cancerous) growth of the lining of the colon (large bowel). It can be anything from 2mm up to 5cm or more in diameter. Commonly, the abnormal cells form a small ball (about the size of a pea) on the end of a stalk of normal cells. The type of cell that forms the polyp varies and is important in determining its potential for developing into a cancer.

Types of polyp
Metaplastic polyps versus adenomatous polyps
The most common sort of polyp is a metaplastic polyp (in which cells change from one normal type to another). These usually do not grow much more than 5mm in diameter and have almost no risk of becoming malignant (cancerous). These polyps can be very similar in appearance to adenomatous polyps, the next most common type, which do have the potential to become malignant. About 50 per cent of people aged 60 will have at least one adenomatous polyp of 1cm diameter or greater. Familial polyposis coli (familial adenomatous polyposis or FAP ) involves multiple adenomatous polyps, often in their hundreds. This condition carries a very high risk of colon cancer. Other rarer types of polyps include:

Juvenile polyps: these are usually solitary polyps called hamartomas that affect 1 to 2 per cent of older children or adolescents. A single polyp carries no significant cancer risk but when these polyps are inherited and usually multiple (about one third of patients), the colon cancer risk is about 10 per cent. In this case, regular surveillance after excision (cutting out) of all polyps is required. Peutz-Jeghers polyps: found in Peutz-Jeghers syndrome, in association with freckling of the lips, are also of the hamartomatous type. These usually present in early adult life and carry a low but definite risk of malignancy, probably around five per cent per polyp, so they need excision. The number of polyps per individual is very variable and ranges, from as few as one or two to as many as 20 or more. Peutz-Jeghers polyps can also occur in the small intestine and can then be difficult to diagnose because they are beyond the reach of conventional fibreoptic endoscopes (internal telescope instruments). Such polyps tend to present with symptoms of obstruction (bowel blockage) or abdominal pain. Diagnosis is usually made with barium X-

rays (taken after the patient swallows barium liquid to show up the inside of the intestine). Treatment will usually be an operation that opens up the abdomen. Inflammatory pseudopolyps: can occur as a complication of ulcerative colitis or Crohn's disease of the colon. They are completely harmless and carry no risk of cancer but they can be confused with adenomatous polyps on examination. Cronkhite-Canada syndrome: an exceptionally rare condition, involves multiple colon polyps, hyperpigmentation (darkening of the skin) and nail atrophy (wasting away). The syndrome is not inherited and affects middle-aged or older individuals. It is linked with malabsorption and has been reported to respond to vitamin E therapy.

What causes polyps?

Most polyps, with the exception of the inflammatory pseudopolyps, result from some form of genetic (DNA) mutation in one of the colon lining cells. Fortunately, several, probably at least five, mutations are needed in the same cell before cancer occurs and most benign polyps probably only have one gene mutated. DNA damage occurs surprisingly often. Even in a healthy adult's colon, about 10 per cent of the lining cells, on average, contain major abnormalities of the chromosomes (packages of DNA that contain many genes). Fortunately, almost all these cells seem to undergo a form of programmed death called apoptosis, and then fall off harmlessly into the bowel lumen (cavity). Adenomatous polyps, even those from individuals who do not have familial polyposis, commonly contain mutations that stop the gene working in both copies of the adenomatous polyposis coli (APC) gene, the gene that is mutated in familial polyposis coli.

What symptoms do polyps cause?

Polyps usually cause no symptoms until they grow to 2cm or more in diameter. Then the most common symptom is rectal bleeding. If a polyp is large enough, say 2cm in diameter, it can simulate faeces so the colon undergoes vigorous muscular movements (peristalsis) in a futile attempt to expel the polyp. This can lead to severe colicky pains. Occasionally, large polyps with a characteristic villous (frondy) appearance will cause profuse watery diarrhoea, which can then result in severe potassium deficiency causing muscle weakness.

How is the diagnosis made?

Polyps can be seen directly during colonoscopy (telescope examination of the whole large bowel starting at the rectum). An experienced doctor can often differentiate metaplastic polyps from the pre-malignant adenomatous polyp by appearance alone. Nevertheless, most doctors prefer not to take the risk of getting it wrong and either take biopsy samples (small bites of tissue) or cut out the entire polyp (polypectomy). In

this case, checking the polyp's cells under the microscope (histology) is not essential providing that the doctor is certain that the polyp has been completely removed. Symptomless polyps are often found at barium enema examination (an X-ray test done after barium liquid is poured into the rectum) in a patient with bowel symptoms that could be due to irritable bowel syndrome. They are also commonly found by chance when screening is performed using flexible sigmoidoscopy (examination of the lowest part of the bowel using a bendy telescope) or colonoscopy.

What is the treatment?

Polypectomy
Most polyps can be removed during colonoscopy while the patient is sedated. This is done by passing a wire snare down the colonoscope, looping and tightening the snare around the stalk of the polyp, then passing an electric current through the wire. This coagulates the blood vessels and then cuts through the stalk. The polyp is then usually sent to the pathology laboratory for microscopic examination. The polypectomy is painless because the colon nerves are only sensitive to stretching. Polypectomy is very safe but carries a risk of perforation (going through the bowel wall) in about one case in 300 and bleeding in one case per 100. Bleeding usually stops by itself and only rarely needs treatment with blood transfusion.

Surgery
Occasionally, a polyp is too large to be removed endoscopically, usually when the diameter is more than about 4cm and, particularly, if the base of the polyp is broad with no well-defined stalk. In these cases, endoscopic removal can carry an unacceptably high risk of bleeding or perforation. Such polyps are also more likely to already contain cancer and removal by surgery that opens up the abdomen can be the safest option to ensure cure. Large, rectal polyps can sometimes be removed through the anus under general anaesthetic without the need to cut open the abdomen.

What follow up is needed after polypectomy?

A polyp that has been completely cut out will not itself recur but some people have a tendency to form multiple polyps so new polyps can grow after polypectomy. If an individual has four or more polyps, or one polyp of more than 1cm diameter or a polyp with severely abnormal cells (dysplasia) seen under the microscope, the risk of polyp or cancer occurrence is sufficient to warrant regular surveillance with colonoscopy. This is usually repeated every five or six years.

Can polyps be prevented?

Dietary changes have not so far proved very effective at preventing polyps but regular use of medication called cyclo-oxygenase inhibitors, such as the anti-inflammatory

medicine sulindac (Clinoril), can reduce polyp development. In general, however this only reduces the number of polyps that recur. It does not completely prevent their recurrence and it is not sufficiently effective to remove the need for regular colonoscopic surveillance

What is the prognosis (outlook)?

Metaplastic polyps have no significant potential to cause cancer and are very unlikely to lead to any significant problem even if not removed. The only exception is rare cases of multiple metaplastic polyps (50 or more), which probably increases the risk of colon cancer somewhat. Adenomatous polyps can all potentially become cancerous but the actual risk per polyp is very small even if they are not removed. Some 50 per cent of people aged 60 or over have one or more adenomatous polyps yet only 6 per cent of people develop bowel cancer. As long as the whole polyp is removed, there is no risk of recurrence or cancerous change of that polyp even when cancerous cells have invaded the stalk of the polyp. Further polyps can develop however. The risk of recurrence is greater if any of the initial polyps was over 1cm diameter, if the original polyps were multiple (four or more) or if any of the polyps show severe dysplastic (pre-cancerous) change under the microscope. In these cases, colonoscopic surveillance is usually recommended every five or six years. Familial adenomatous polyposis is likely when 100 or more adenomatous polyps are found. This condition carries a high risk of cancer development unless treated, usually by colectomy (surgical removal of the whole colon). Juvenile polyps that are single and have been completely excised carry no significant increased risk of malignancy. Multiple juvenile polyps can be a sign of the familial juvenile polyposis syndrome. This has a significant risk (approximately 10 per cent) of subsequent colon cancer and also a possible increased risk of cancers of the stomach and duodenum (first part of the small intestine). Further surveillance is then indicated, usually with both faeces testing for occult (non-visible) blood every year and flexible sigmoidoscopy every three to five years. Peutz-Jeghers polyposis is associated with an increased risk of malignancy in the colon and small intestine. Reports differ over the size of this risk but it could be nearly 50 per cent of patients that develop cancer without careful surveillance. Hopefully, with modern surveillance using colonoscopy and other endoscopic techniques, much of this cancer risk should now be preventable. References Lal G, Gallinger S. Familial adenomatous polyposis. Semin Surg Oncol 2000 Jun; 18(4): 31423. Giardiello FM, Offerhaus JG. Phenotype and cancer risk of various polyposis syndromes. Eur J Cancer 1995 Jul-Aug; 31A(7-8): 1085-87. [Review] Desai DC, Neale KF, Talbot IC, Hodgson SV, Phillips RK. Juvenile polyposis. Br J Surg 1995 Jan; 82(1): 14-17.

McGarrity TJ, Kulin HE, Zaino RJ. Peutz-Jeghers syndrome. Am J Gastroenterol 2000 Mar; 95(3): 596-604.

http://www.fascrs.org

Polyps of the Colon and Rectum

Polyps are abnormal growths rising from the lining of the large intestine (colon or rectum) and protruding into the intestinal canal (lumen). Some polyps are flat; others have a stalk. Polyps are one of the most common conditions affecting the colon and rectum, occurring in 15 to 20 percent of the adult population. Although most polyps are benign, the relationship of certain polyps to cancer is well established. Polyps can occur throughout the large intestine or rectum, but are more commonly found in the left colon, sigmoid colon, or rectum.

What are the symptoms of polyps? Most polyps produce no symptoms and often are found incidentally during endoscopy or x-ray of the bowel. Some polyps, however, can produce bleeding, mucous discharge, alteration in bowel function, or in rare cases, abdominal pain. How are polyps diagnosed?

Polyps are diagnosed either by looking at the colon lining directly (colonoscopy) or by xray study (barium enema). There are three types of colorectal endoscopy: (1) rigid sigmoidoscopy, (2) flexible sigmoidoscopy and (3) colonoscopy. Rigid sigmoidoscopy permits examination of the lower six to eight inches of the large intestine. In flexible sigmoidoscopy, the lower onefourth to one-third of the colon is examined. Neither rigid nor flexible sigmoidoscopy requires medication and can be performed in the doctor's office. Colonoscopy uses a longer flexible instrument and usually permits inspection of the entire colon. Bowel preparation is required, and sedation is often used. The colon can also be indirectly examined using the barium enema x-ray technique. This examination uses a barium solution to coat the colon lining. X-rays are taken, and unsuspected polyps are frequently found. Although checking the stool for microscopic blood is an important test for colon and rectal disorders, a negative test does NOT rule out the presence of polyps. The discovery of one polyp necessitates a complete colon inspection, since at least 30 percent of these patients will have additional polyps. Do polyps need to be treated? Since there is no fool-proof way of predicting whether or not a polyp is or will become malignant, total removal of all polyps is advised. The vast majority of polyps can be removed by snaring them with a wire loop passed through the instrument. Small polyps can be destroyed simply by touching them with a coagulating electrical current. Most colon examinations using the flexible colonoscope, including polyp removal, can be performed on an outpatient basis with minimal discomfort. Large polyps may require more than one treatment for complete removal. Some polyps cannot be removed by instruments because of their size or position; surgery is then required. Can polyps recur? Once a polyp is completely removed, its recurrence is very unusual. However, the same factors that caused the polyp to form are still present. New polyps will develop in at least 30 percent of people who have previously had polyps. Patients should have regular exams by a physician specially trained to treat diseases of the colon and rectum.

Anal Warts
What are anal warts? Anal warts (also called "condyloma acuminata") are a condition that affects the area around and inside the anus. They may also affect the skin of the genital area. They first appear as tiny spots or growths, perhaps as small as the head of a pin, and may grow larger than the size of a pea. Usually, they do not cause pain or discomfort to afflicted individuals. As a result, patients may be unaware that the warts are present. Some patients will experience symptoms such as itching, bleeding, mucus discharge and/or a feeling of a lump or mass in the anal area.

Anal warts, thought to be caused by the human papilloma virus, can grow larger and spread if not removed. What causes these warts?

They are thought to be caused by the human papilloma virus (HPV) which is transmitted from person to person by direct contact. HPV is considered a sexually transmitted disease. You do not have to have anal intercourse to develop anal condyloma. Do these warts always need to be removed? Yes. If they are not removed, the warts usually grow larger and multiply. If left untreated, the warts may lead to an increased risk of cancer in the affected area. What treatments are available? If warts are very small and are located only on the skin around the anus, they may be treated with a topical medication. They may also be treated by a physician by freezing the warts with liquid nitrogen. Warts may also be removed surgically. Surgery provides immediate results but must be performed using either a local anesthetic - such as novocaine - or a general or spinal anesthetic, depending on the number and exact location of warts being treated. Warts inside the anal canal usually are not suitable for treatment by medications, and in most cases need to be treated surgically. Must I be hospitalized for surgical treatment? No. Surgical treatment of anal warts is usually performed as outpatient surgery. How much time will I lose from work after surgical treatment? Most people are moderately uncomfortable for a few days after treatment, and pain medication may be prescribed. Depending on the extent of the disease, some people return to work the next day, while others may remain out of work for several days. Will a single treatment cure the problem? Recurrent warts are common. The virus that causes the warts can live concealed in tissues that appear normal for several months before another wart develops. As new warts develop, they usually can be treated in the physician's office. Sometimes new warts develop so rapidly that office treatment would be quite uncomfortable. In these situations, a second and occasionally third outpatient surgical visit may be recommended. How long is treatment usually continued? Follow-up visits are necessary at frequent intervals for several months after the last wart is observed to be certain that no new warts occur.

What can be done to avoid getting these warts again? In some cases, warts may recur repeatedly after successful removal, since the virus that causes the warts often persists in a dormant state in body tissues. Discuss with you physician how often you should be evaluated for recurrent warts. Abstain from sexual contact with individuals who have anal (or genital) warts. Since many individuals may be unaware that they suffer from this condition, sexual abstinence, condom protection or limiting sexual contact to single partner will reduce your potential exposure to the contagious virus that causes these warts. As a precaution, sexual partners ought to be checked, even if they have no symptoms.

Hemorrhoids
Did you know...

Hemorrhoids are one of the most common ailments known. More than half the population will develop hemorrhoids, usually after age 30. Millions of Americans currently suffer from hemorrhoids. The average person suffers in silence for a long period before seeking medical care. Today's treatment methods make some types of hemorrhoid removal much less painful. What are hemorrhoids? Often described as "varicose veins of the anus and rectum", hemorrhoids are enlarged, bulging blood vessels in and about the anus and lower rectum. There are two types of hemorrhoids: external and internal, which refer to their location. External (outside) hemorrhoids develop near the anus and are covered by very sensitive skin. These are usually painless. However, if a blood clot (thrombosis) develops in an external hemorrhoid, it becomes a painful, hard lump. The external hemorrhoid may bleed if it ruptures. Internal (inside) hemorrhoids develop within the anus beneath the lining. Painless bleeding and protrusion during bowel movements are the most common symptom. However, an internal hemorrhoid can cause severe pain if it is completely "prolapsed" - protrudes from the anal opening and cannot be pushed back inside. What causes hemorrhoids? An exact cause is unknown; however, the upright posture of humans alone forces a great deal of pressure on the rectal veins, which sometimes causes them to bulge.

Other contributing factors include: Aging Chronic constipation or diarrhea Pregnancy Heredity Straining during bowel movements Faulty bowel function due to overuse of laxatives or enemas Spending long periods of time (e.g., reading) on the toilet Whatever the cause, the tissues supporting the vessels stretch. As a result, the vessels dilate; their walls become thin and bleed. If the stretching and pressure continue, the weakened vessels protrude. What are the symptoms? If you notice any of the following, you could have hemorrhoids: Bleeding during bowel movements Protrusion during bowel movements Itching in the anal area Pain Sensitive lump(s) How are hemorrhoids treated? Mild symptoms can be relieved frequently by increasing the amount of fiber (e.g., fruits, vegetables, breads and cereals) and fluids in the diet. Eliminating excessive straining reduces the pressure on hemorrhoids and helps prevent them from protruding. A sitz bath - sitting in plain warm water for about 10 minutes - can also provide some relief . With these measures, the pain and swelling of most symptomatic hemorrhoids will decrease in two to seven days, and the firm lump should recede within four to six weeks. In cases of severe or persistent pain from a thrombosed hemorrhoid, your physician may elect to remove the hemorrhoid containing the clot with a small incision. Performed under local anesthesia as an outpatient, this procedure generally provides relief.

Severe hemorrhoids may require special treatment, much of which can be performed on an outpatient basis. Ligation the rubber band treatment - works effectively on internal hemorrhoids that protrude with bowel movements. A small rubber band is placed over the hemorrhoid, cutting off its blood supply. The hemorrhoid and the band fall off in a few days and the wound usually heals in a week or two. This procedure sometimes produces mild discomfort and bleeding and may need to be repeated for a full effect. Injection and Coagulation can also be used on bleeding hemorrhoids that do not protrude. Both methods are relatively painless and cause the hemorrhoid to shrivel up. Hemorrhoid stapling this is a technique that uses a special device to internally staple and excise internal hemorrhoidal tissue. The stapling method may lead to shrinkage of but does not remove external hemorrhoids. This procedure is generally more painful that rubber band ligation and less painful than hemorroidectomy. Hemorrhoidectomy surgery to remove the hemorrhoids - is the most complete method for removal of internal and external hemorrhoids. It is necessary when (1) clots repeatedly form in external hemorrhoids; (2) ligation fails to treat internal hemorrhoids; (3) the protruding hemorrhoid cannot be reduced; or (4) there is persistent bleeding. A hemorrhoidectomy removes excessive tissue that causes the bleeding and protrusion. It is done under anesthesia using either sutures or staplers, and may, depending upon circumstances, require hospitalization and a period of inactivity. Laser hemorrhoidectomies do not offer any advantage over standard operative techniques. They are also quite expensive, and contrary to popular belief, are no less painful.

Rubber Band Ligation of Internal Hemorrhoids: A. Bulging, bleeding, internal hemorrhoid B. Rubber band applied at the base of the hemorrhoid C. About 7 days later, the banded hemorrhoid has fallen off leaving a small scar at its base (arrow) Do hemorrhoids lead to cancer? No. There is no relationship between hemorrhoids and cancer. However, the symptoms of hemorrhoids, particularly bleeding, are similar to those of colorectal cancer and other diseases of the digestive system. Therefore, it is important that all symptoms are investigated by a physician specially trained in treating diseases of the colon and rectum and that everyone 50 years or older undergo screening tests for colorectal cancer. Do not rely on over-the-counter medications or other self-treatments. See a colorectal surgeon first so your symptoms can be properly evaluated and effective treatment prescribed.

Hemorrhoids: Expanded Version

What are hemorrhoids? It is important to note that all people have hemorrhoidal tissue as part of their normal anatomy. Only in a minority of people do hemorrhoids become enlarged or otherwise symptomatic. Hemorrhoidal tissue lies within the anal canal and perianal area and consists of blood vessels, connective tissue, and a small amount of muscle. There are two main types of hemorrhoids: internal and external. Internal hemorrhoids are covered with a lining called mucosa that is not sensitive to touch, pain, stretch, and temperature, while external hemorrhoids are covered by skin that is very sensitive. When problems develop, these two types of hemorrhoids can have very different symptoms and treatments. Symptoms

Roughly 5% of people will develop symptoms attributable to their hemorrhoids and only a small fraction of those patients will require surgical treatment. Patients may experience symptoms caused by either internal or external hemorrhoids or both. The majority of patients with anal symptoms seen in a colon and rectal surgeons office complain of their hemorrhoids but a careful history and examination by an experienced physician is necessary to make a correct diagnosis. Some patients will have long-standing complaints that are not attributable to hemorrhoidal disease. Other serious diseases such as anal and colorectal cancer should be ruled out by a consultation with physicians knowledgeable in evaluating the anal and rectal area. Internal Hemorrhoids Painless rectal bleeding or prolapse of anal tissue is often associated with symptomatic internal hemorrhoids. Prolapse is hemorrhoidal tissue coming from the inside that can often be felt on the outside of the anus when wiping or having a bowel movement. This tissue often goes back inside spontaneously or can be pushed back internally by the patient. The symptoms tend to progress slowly over a long time and are often intermittent. Internal hemorrhoids are classified by their degree of prolapse, which helps determine management: Grade One: Grade Two: Grade Four: No prolapse Prolapse that goes back in on its own Prolapse that cannot be pushed back in by the patient (often very painful)

Grade Three: Prolapse that must be pushed back in by the patient

Bleeding attributed to internal hemorrhoids is usually bright red and can be quite brisk. It may be found on the wipe, dripping into the toilet bowl, or streaked on the BM itself. Not all patients with symptomatic internal hemorrhoids will have significant bleeding. Instead, prolapse may be the main or only symptom. Prolapsing tissue may result in significant irritation and itching around the anus. Patients may also complain of mucus discharge, difficulty with cleaning themselves after a BM, or a sense that their stool is stuck at the anus with BMs. Patients without significant symptoms from internal hemorrhoids do not require treatment based on their appearance alone.

External Hemorrhoids Symptomatic external hemorrhoids often present as a bluishcolored painful lump just outside the anus and they tend to occur spontaneously and may have been preceded by an unusual amount of straining. The skin overlying the outside of the anus is usually firmly attached to the underlying tissues. If a blood clot or thrombosis develops in this tightly held area, the pressure goes up rapidly in these tissues often causing pain. The pain is usually constant and can be severe. Occasionally the elevated pressure in the thrombosed external hemorrhoid results in breakdown of the overlying skin and the clotted blood begins leaking out. Patients may also complain of intermittent swelling, pressure and discomfort, related to external hemorrhoids which are not thrombosed. Anal Skin Tags Patients often complain of painless, soft tissue felt on the outside of the anus. These can be the residual effect of a previous problem with an external hemorrhoid. The blood clot stretches out the overlying skin and remains stretched out after the blood clot is absorbed by the body, thereby leaving a skin tag. Other times, patients will have skin tags without an obvious preceding event. Skin tags will occasionally bother patients by interfering with their ability to clean the anus following a BM, while others just dont like the way they look. Usually, nothing is done to treat them beyond reassurance. However, surgical removal is occasionally considered. What Causes Symptomatic Hemorrhoids? The majority of factors thought to produce symptomatic hemorrhoids are associated with an increased pressure within the abdomen that gets transmitted to the anal region. Some of these factors include: staining at stool, constipation, diarrhea, pregnancy, and irregular bowel patterns. It seems that, over time, these factors may contribute to the prolapse of internal hemorrhoidal tissue or thrombosis of external hemorrhoidal tissue. EXAMINATION After obtaining a careful history regarding your symptoms and your personal and family medical history, your doctor will need to perform an examination in the office. This usually consists of careful inspection of the outside of the anus, placement of a finger through the anus into the rectum (digital examination), and placement of a finger-sized instrument through the anus to

allow visual inspection of the hemorrhoidal tissue (anoscopy). Although it may not occur during the initial visit, your doctor may want to look even further upstream into the colon to rule out polyps, cancers, and other causes of bleeding. A flexible sigmoidoscopy can visualize approximately half of your colon, while a colonoscopy usually allows for visualization of the entire colon. If this is not discussed with you at your initial visit, you are encouraged to discuss this with your physician. Laboratory tests are not usually needed. NON-SURGICAL TREATMENT OF INTERNAL HEMORRHOIDS There are a wide variety of treatment options available for symptomatic internal hemorrhoids depending upon their grade (see above discussion) and the severity of your symptoms. Often, adherence to the dietary/lifestyle changes detailed below will relieve your symptoms. However, if you fail to respond to these changes alone, or if your symptoms are severe enough at the outset, there are a number of office-based and surgical procedures available to alleviate your symptoms. Dietary/Lifestyle Changes The cornerstone of therapy, regardless of whether surgery is needed or not, is dietary and lifestyle change. The main changes consist of increasing your dietary fiber, taking a fiber supplement, getting plenty of fluids by mouth, and exercising. This is all designed to regulate, not necessarily soften, your bowel movements. The goal is to avoid both very hard stools and diarrhea, while achieving a soft, bulky, easily cleaned type of stool. This type of stool seems to be the best kind to prevent anal problems of almost all kinds. It is usually recommended to achieve 20-35 grams of fiber per day in the diet, including plenty of fruits and vegetables. Most people can benefit from taking a fiber supplement one to two times daily. These supplements are available in powder, chewable, and capsule/tablet forms your pharmacist can help decide which may be best for you. Also important is adequate fluid (preferably water) consumption, often considered 8-10 glasses daily. Caffeinated drinks and alcohol tend to be dehydrating and therefore do not count toward this total. Office-Based Therapies For Internal Hemorrhoids

The most commonly used office procedures are rubber band ligation, infrared coagulation, and sclerotherapy. These treatment options are for internal hemorrhoids only and do not apply to external hemorrhoids. Rubber Band Ligation Rubber band ligation can be used for Grades 1, 2, and some Grade 3 internal hemorrhoids. At the time your doctor performs the examination described above (anoscopy), he or she can place a device through the anoscope, which can pull up the redundant internal hemorrhoidal tissue and place a rubber band at its base. The band acts to cut off the hemorrhoids blood supply and it falls off (with the band) at roughly 5-7 days, at which time you may notice a small amount of bleeding. If you are taking blood thinners such as Coumadin, Heparin, or Plavix you may not be a candidate for this procedure. Your doctor may place anywhere from one to three rubber bands per visit and this may require several short visits to achieve relief of your symptoms, but is not associated with any significant recovery time for most people. Rubber band can be associated with a dull ache or feeling of pressure lasting 1-3 days that is usually well-treated with Ibuprofen or Tylenol. Upon completion of your banding session(s), you likely will not need further treatment, provided you continue the previously described dietary and lifestyle changes. If your symptoms return, repeat banding certainly can be considered. Hemorrhoidectomy is always an option if significant progress is not made with banding. Complications are very uncommon, but may include bleeding, pain and infection, among others. Infrared Photocoagulation Infrared coagulation (IRC) is another office-base procedure, for Grades 1 and 2 and occasional Grade 3 internal hemorrhoids, which can be performed during anoscopy. IRC utilizes infrared radiation generated by a small light that is applied to the hemorrhoidal tissue. This energy is converted to heat and causes the hemorrhoidal tissue to become inflamed, slough off, and scar down, thereby eliminating this excess tissue. This procedure is usually quick, painless, has few complications, but may take several short sessions to achieve relief of symptoms. Sclerotherapy Sclerotherapy is another office-based treatment for Grades 1 and 2 internal hemorrhoids. It involves the injection of chemical irritants into the hemorrhoids, resulting in scarring and

shrinkage by reducing the blood vessels present in the hemorrhoidal tissues. Sclerotherapy is similarly quick, often painless, has few complications, and may take several short sessions to achieve relief of symptoms. This has the potential to be used in patients taking blood thinners such as Coumadin, Heparin, or Plavix, but would need to be discussed with your physician. OFFICE TREATMENT OF EXTERNAL HEMORRHOIDS This involves the injection of a local anesthetic (numbing medicine) and excising the hemorrhoidal tissue. The pain associated with a symptomatic, thrombosed external hemorrhoid (see description above) often peaks about 48-72 hours after its onset and is largely resolving after roughly four-five days. Pain is the indication to treat thrombosed external hemorrhoids and, therefore, the treatment will depend upon where you are at in the natural history of the problem. If you are improving significantly and your doctor is able to touch/pinch the involved external hemorrhoid without significant discomfort to you, then non-operative measures are used (warm baths, pain-relieving creams and pills, and fiber therapy described above). If you present to your doctors office in severe pain, an office-based surgical procedure may be offered. This involves the injection of local anesthesia (numbing medicine) and excising the hemorrhoidal tissue. It is important to note that the entire hemorrhoid must be removed and not lanced, as that can be associated with the hemorrhoidal skin sealing over and a recurrent thrombosis (blood clot) developing. External hemorrhoids, which are not thrombosed, are generally managed symptomatically, with dietary management and topical agents. Only occasionally are they removed surgically.

Operative Treatment of Hemorrhoids Fewer than 10% of all patients evaluated with symptomatic hemorrhoids will require surgical management. Most patients respond to non-operative treatment and do not require a surgical procedure. Hemorrhoidectomy, or surgical removal of the hemorrhoidal tissue, may be considered if a patient presents with symptomatic large external hemorrhoids, combined internal and external hemorrhoids, and/or grade 3-4 prolapse. Hemorrhoidectomy is highly effective in achieving relief of symptoms and it is uncommon to have any significant recurrence. However, it also causes much more pain and disability than office procedures and has somewhat more complications.

Hemorrhoidectomy may be done using a variety of different techniques and instruments to remove the hemorrhoids and the particular technique is usually chosen based on a particular surgeons preference. In basic terms, the excess hemorrhoidal tissue is removed and the resultant wound may be closed or left open. Hemorrhoidectomy is performed in an operating room and may be done while youre completely asleep (general anesthesia), under a spinal block (analogous to an epidural injection during childbirth), or with a combination of intravenous relaxing medications and local anesthesia injected around your anus after youre relaxed. In an attempt to avoid some of the postoperative pain associated with hemorrhoidectomy, a more recently developed option has emerged, called a stapled hemorrhoidopexy (sometimes inaccurately referred to as stapled hemorrhoidectomy). The procedure involves a circular stapling device which removes some of the tissue located upstream from the hemorrhoids, thereby pulling the hemorrhoids upward, returning the problematic hemorrhoidal tissue to its normal position, and staples this tissue up into place. Most or all of the staples later fall out over time. Studies comparing stapled hemorrhoidectomy to standard hemorrhoidectomy have found it to be equally safe and associated with a shorter time to full recovery. Long term recurrence rates appear to be higher than with hemorrhoidectomy, and this operation is not effective for treating large external hemorrhoids. All operative procedures for hemorrhoidal disease carry their own set of risks and benefits and the ultimate choice of procedure must be made between you and your surgeon.

POSTOPERATIVE INSTRUCTIONS You can expect to have pain following hemorrhoid surgery. The goal is to make it manageable, but it may be up to 2-4 weeks before youre able to resume your full level of activities. You likely will be given a variety of medications that have been specifically chosen for their ability to work together and address your pain in different ways. Sitting in a bath (sitz bath) 23 times daily for 10-15 minutes per time in warm water up to your lower abdomen may make you more comfortable. Occasionally, patients will have difficulty urinating after anorectal surgery. If you are unable to void, try urinating in the tub during a sitz bath. If that does not work, proceed to an emergency department for placement of a catheter in your bladder. Failure to do so can result in permanent bladder damage from over-stretching.

Moving your bowels after hemorrhoid surgery is always a concern for patients. Most colon and rectal surgeons recommend having a BM within the first 48 hours after surgery. You should already be taking a diet high in fiber, a fiber supplement, and increased liquid intake. If this does not produce a BM, you may need to take laxatives to achieve this. Your doctor should make recommendations as to the best medications to use in this situation, given your particular medical issues. Expect to have some bleeding with BMs for several weeks after surgery. Call your surgeon if you are experiencing bleeding that doesnt seem to stop after the BM.

http://www.mdguidelines.com

Colorectal Polyps
Definition

Reed Group
Rectal polyps are well-defined projections that grow from the mucous membrane that lines the wall of the lower colon (rectum). Polyps may grow singly or in groups, and they may grow on stalks (pedunculated) or they can have a broad, flat base (sessile). They range in size from 1 to 2 millimeters to greater than 10 centimeters. Rectal polyps are classified according to their tissue-type (histology). There are three major groups:adenomas (67%), hyperplastic polyps (11%), and a miscellaneous group (22%) that includes mucosal polyps (made of normal mucosa), inflammatory polyps, juvenile polyps, hamartomas, and a variety of nonmucosal lesions. Adenomas are unique among polyps in that only they are known to be direct precursors of cancer (carcinoma). Lifestyle choices, including a high fat and calorie, low-fiber diet; obesity; cigarette smoking; and alcohol consumption, increase the risk of developing rectal polyps. Those with cirrhosis of the liver, or chronic inflammatory bowel disease(ulcerative colitis, Crohn's disease) also are at increased risk. Rectal polyps are also associated with two inherited conditions, familial adenomatous polyposis and Gardner's syndrome. In both these conditions, hundreds of small adenomas begin to develop during the teen years, and colon cancer usually develops before age 40.

Risk: Chance of developing rectal polyps increases with age. They are uncommon
before age 40 (Beers). White males are at greater risk than black males for developing rectal cancer (and thus adenomatous polyps), but the risk for women of both races is the same, and slightly lower than for men.

Incidence and Prevalence: Adenomas occur in up to 30% to 40% of individuals over

age 60 in the US (Russell 742). In 2000, there were 36,400 new cases of reported rectal

cancer in the US (Hassan). Incidence of rectal polyps worldwide follows the incidence of colon cancer, being higher in North America and northern Europe, Australia, and New Zealand; lower in Japan, and southern Europe; and almost non-existent in most parts of Africa and Asia (Goldman 742; Hassan).

Source: Medical Disability Advisor

Diagnosis
History: Individuals will occasionally complain of abdominal pain, diarrhea, or rectal
bleeding. More commonly, there are no signs or symptoms, and rectal polyps are detected during routine screening for rectal cancer.

Physical exam: The exam is usually normal. A gloved finger inserted into the rectum
(digital rectal examination) may reveal rectal polyps, but cannot confirm the diagnosis.

Tests: Tests include examination of the inside of the rectum using a flexible, fiberoptic
viewing instrument (colonoscopy). Also, small samples of polyp tissue (biopsy) may be taken during colonoscopy for microscopic examination. If necessary, the rectum may be evaluated further with proctosigmoidoscopy or anoscopy. X-rays of the colon can be taken following instillation of a contrast medium into the bowel (barium enema) in order to further visualize the polyps. Blood in the stool can be identified using a fecal occult blood test (FOBT), which may be used as a screening test for rectal polyps or cancer.

Source: Medical Disability Advisor

Treatment
The preferred treatment for rectal polyps is to remove them during colonoscopy (colonoscopic polypectomy) or sigmoidoscopy. The specific technique for polyp removal during colonoscopy (hot biopsy technique, snare excision with electrocautery, piecemeal snare excision) depends upon polyp size and configuration, experience and expertise of the physician, and the equipment that is available for the procedure. Surgical removal (excision) of polyps by cutting out a section (resection) of the rectum is recommended for individuals with polyps that cannot be removed completely during colonoscopy. Depending upon the extent of the surgical resection, the individual may require an artificial opening (stoma) through the abdominal wall for the purpose of fecal elimination (colostomy).

Source: Medical Disability Advisor

ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*

* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines

Prognosis
Most rectal polyps are removed without incident and serious complications occur in less than 0.2% of sigmoidoscopyprocedures. Following removal, rectal polyps will recur 40% of the time. Individuals with adenomas have a 1% to 15% chance of developing rectal cancer within 15 years of diagnosis. Approximately one-third of polyps that are removed from the rectum will be cancerous, although less than 5% of small polyps (1 cm tubular adenomas) will be cancerous (Townsend 1448-1449). Surgical cure is possible in 70% of individuals with adenomas (Beers).

Source: Medical Disability Advisor

Rehabilitation
Adequate fluid intake, a high fiber diet, and a regular exercise routine may be useful in reducing the risk of recurrence of rectal polyps. Aerobic exercise such as walking, jogging, or swimming (30 to 45 minutes per session) is usually beneficial.

Source: Medical Disability Advisor

Complications
If not removed, rectal polyps may develop into cancer and/or grow to block the colon.

Source: Medical Disability Advisor

Return to Work (Restrictions / Accommodations)

No workplace restrictions should be necessary for individuals who are treated using colonoscopy for rectal polyps. If surgery was used as a treatment, heavy physical labor may have to be restricted until recovery is complete. Workplace accommodations should include easy access to restroom facilities if the individual has a colostomy.

Source: Medical Disability Advisor

Failure to Recover
If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

Has diagnosis of rectal polyps been confirmed? If diagnosis was uncertain, was a colonoscopy exam used to confirm the diagnosis and rule out other conditions with similar symptoms? Were x-rays of the colon taken to further visualize the polyps? Was biopsy of polyp tissue used to determine the type of polyp? Did a fecal occult blood test (FOBT) reveal unseen blood in the stool?

Regarding treatment:

Were polyps removed during colonoscopy? If not, will the individual need to undergo a resection in order to remove them? Did the individual require a colostomy during the surgery? What is the anticipated recovery time after surgery? Because psychological issues can be associated with a colostomy, would individual benefit from counseling?

Regarding prognosis:

Were the polyps removed successfully? Was the polyp cancerous? Did postsurgical complications occur, such as severe bleeding or infection?

Were complications effectively treated? What is the expected outcome after treatment? If colostomy was necessary, have psychological issues been resolved through counseling? Because polyps recur about 40% of the time, has individual been instructed in lifestyle modifications which may reduce the risk of polyps? Has individual complied with recommendations to lower fat and calories and increase fiber in the diet? Would individual benefit from consultation with a nutritionist? If individual has not been able to reduce weight, would he or she benefit from enrollment in a community weight loss program? Has individual been able to abstain from alcohol and tobacco use? Would individual benefit from enrollment in community programs or support group?

Hemorrhoids
Definition
Hemorrhoids are swollen, inflamed veins or vascular cushions (arteriovenous plexuses) in and around the anus and lower portion of the rectum. Internal hemorrhoids are cushions of subepithelial connective tissue located near the beginning of the anal canal, about 1 inch inside the rectum, and are a normal part of the anorectum known to be present in the developing fetus and in healthy individuals. These cushions are made up of vascular tissue (arterioles, venules, and arteriolar-venular connections), connective tissue, and smooth muscle and are covered with a mucous membrane. When the cushions become enlarged, inflamed, thrombosed or prolapsed, they produce symptoms and are then referred to as hemorrhoids. Internal hemorrhoids are not innervated by cutaneous nerves and therefore do not produce pain and can remain asymptomatic. External hemorrhoids are tiny veins located under the skin surrounding the anal opening. They are covered with epithelial layers and receive sensory impulses from the rectal nerve, making them subject to pain. Internal and external hemorrhoids can occur at the same time or separately. Internal hemorrhoids can also become enlarged and protrude from the anus (prolapsed), becoming external hemorrhoids. Symptomatic hemorrhoids can be acute or chronic; recurrence is common. The degree of acuity of hemorrhoids determines how they are classified. First-degree hemorrhoids bleed but do not prolapse through the anus/rectum. Second-degree hemorrhoids prolapse during bowel movements but then withdraw back up into the rectum (anal canal). Third-degree hemorrhoids remain prolapsed unless pushed gently back into the anal canal, while fourth-degree hemorrhoids cannot be pushed back into the anal canal. Hemorrhoids are caused by increased pressure on the vascular tissue and tiny veins of the rectum and anus. The most common cause of this increased pressure is excessive straining at bowel movements, due either to constipation or to small-caliber stools occurring as a result of a low-fiber diet. Other causes of increased pressure in the veins of the rectum and anus include prolonged sitting on the toilet, pregnancy and the strain of childbirth, and obesity. Other factors that contribute to hemorrhoid development include anal infection, diarrhea, delaying the urge to empty the bowels, prolonged sitting, a family history of hemorrhoids, and liver disease.

Risk: Peak age range for developing hemorrhoids is between 45 and 65. A family
history of hemorrhoids can be a predictive factor. Pregnant women are at increased risk of developing hemorrhoids. Elderly individuals also have greater risk as anal support structures weaken and digestive disturbances change elimination patterns.

Incidence and Prevalence: Hemorrhoids are one of the most common problems of
the lower digestive tract. It is estimated that hemorrhoids affect about 4.4% of all individuals or over 10 million individuals in the US (Gurley). One-half of Americans over the age of 50 suffer from hemorrhoids although the exact prevalence is unknown due to the large number of asymptomatic hemorrhoids (Hemorrhoids; Thornton).

Source: Medical Disability Advisor

Diagnosis
History: A complete health history may be obtained, including dietary patterns and
family history of hemorrhoids. Individuals who suffer from both internal and external hemorrhoids may report rectal bleeding after bowel movements and/or bright red blood in the stool; however, individuals with external hemorrhoids will also report pain during bowel movements and anal itching. Individuals with internal hemorrhoids usually do not experience pain unless the hemorrhoids protrude through the anus (prolapse).

Physical exam: A digital (finger) rectal exam is usually sufficient to diagnose both
internal and external hemorrhoids. A complete physical may be done to assess nutritional and health status, including the presence of possible underlying illness.

Tests: A stool guaiac test may be performed to confirm the presence of blood in the
stool. Because rectal bleeding may be indicative of diseases more serious than hemorrhoids, anoscopy, proctoscopy, sigmoidoscopy, or colonoscopy may be performed to rule out any other source of bleeding and sometimes to confirm a diagnosis of internal hemorrhoids. A complete blood count (CBC) with hemoglobin and hematocrit is usually performed, as anemia can develop from even small bleeding that persists over long periods of time. Liver enzymes may be measured to rule out liver

disease.

Source: Medical Disability Advisor

Differential Diagnoses

Anal fissure Anogenital warts (condyloma acuminata) Anorectal abscess Anorectal fistula Diverticulosis Eczema Fistula Fungal infection Impaction Infections (sexually transmitted diseases - STDs) Levator syndrome Neoplasm Pruritus Rectal polyps Rectal prolapse Rectal trauma Viral infection

Treatment
Conservative treatment often is sufficient for mild hemorrhoids, especially those that occur during pregnancy, since they tend to disappear after delivery. General treatment measures include a high-fiber diet and adequate fluid intake to avoid constipation. Stool modifiers such as softeners or bulk formers may also be given, and cultivating regular bowel habits may help prevent chronic hemorrhoids. Irritation of the skin around the anus may be relieved by ointments or suppositories. Moisturized cleansing pads may be used after bowel movements to keep the anal area clean. Topical application of corticosteroid creams may help reduce pain, itching and swelling. Warm sitz baths for up to ten minutes several times a day may also relieve symptoms. Ice can be used to relieve thrombosed hemorrhoids. Treatment of internal hemorrhoids that do not respond to conservative measures may employ various non-operative methods, including rubber band ligation, sclerotherapy injection, infrared photocoagulation, laser ablation, and freezing. The presence of specific symptoms usually indicates the type of treatment needed. Laser ablation is used to accurately vaporize or remove hemorrhoids by sealing off nerves and tiny blood vessels with invisible light. This usually results in less discomfort, less medication, and faster healing than

conventional surgery, and a hospital stay is generally not required. Laser treatment can be used alone or in combination with other modalities. If bleeding is a problem with internal hemorrhoids, a substance can be injected into the vein to cause internal scarring (sclerosis), thus blocking the vein (sclerotherapy). The bleeding usually stops within days after the injection; however, it may recur. Since injection has little effect on prolapse, rubber band ligation may be indicated for significant vein prolapse. Alternatives include freezing the hemorrhoid (cryotherapy) and/or heating it (thermal coagulation). Acute clotting (thrombosis) or ulceration of internal hemorrhoids may also be treated conservatively. Bedrest is prescribed to minimize swelling and prevent further thrombosis. Analgesics and sedatives may be helpful. Warm sitz baths relieve pain and swelling, and help prevent infection. Suppositories or astringent compresses also may be used to relieve symptoms. Antibiotics are sometimes indicated. The acute pain subsides over a period of 1 to 2 weeks, with the thromboses gradually being reabsorbed over a 1 to 2 month period. After the acute attack, the hemorrhoids may be ligated or removed surgically (hemorrhoidectomy). Surgery is usually reserved for either reducible or non-reducible hemorrhoids that have severe symptoms or complications (third- and fourth-degree hemorrhoids). Surgical treatments include stapled hemorrhoidectomy and surgical resection, which are usually indicated for individuals for whom nonoperative methods did not provide relief. If thrombosis of hemorrhoidal tissue has occurred and the individual is seen within the first 48 hours, an acutely thrombosed external hemorrhoid may be relieved by removing the obstructing clot through a small incision. After that period, the clot cannot usually be removed, and is then treated conservatively; the pain usually subsides over several days.

Source: Medical Disability Advisor

ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*

* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines

Prognosis
The prognosis for both internal and external hemorrhoids is good. For mild hemorrhoids, conservative treatment is usually effective, but recurrences can occur if a high-fiber diet with adequate fluid intake is

not adopted. If surgery (hemorrhoidectomy, rubber band ligation, or sclerotherapy) becomes necessary, it is usually highly successful. After five years, there is a 15% to 20% recurrence rate of internal hemorrhoids treated with rubber band ligation (Baker).

Source: Medical Disability Advisor

Complications
Hemorrhoids can be the source of many uncomfortable, yet generally non-serious problems. Formation of a blood clot (thrombosis) may cause severe pain. External hemorrhoids can be extremely itchy and irritated, especially if the area is allowed to remain moist. The combination of moisture and inflammation creates an environment that may encourage bacterial infection. Both internal and external hemorrhoids can result in fresh red blood oozing. Iron deficiency anemiamay result from prolonged blood loss.

Source: Medical Disability Advisor

Return to Work (Restrictions / Accommodations)

The extent of disability may depend on whether the individual's job involves heavy lifting, or prolonged sitting or standing. This condition is particularly prevalent among and difficult for, long-haul truck drivers and operators of heavy equipment as it combines prolonged sitting and jouncing-type pressure on the rectum and anus. Temporary accommodations may be necessary.

Source: Medical Disability Advisor

Failure to Recover
If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

Did individual present with symptoms and a clinical presentation consistent with the diagnosis of hemorrhoids? Was diagnosis confirmed with a rectal exam? If diagnosis was uncertain, were other diagnostic tests (anoscopy, proctoscopy, sigmoidoscopy, colonoscopy) done to diagnose internal hemorrhoids or rule out conditions with similar symptoms?

Regarding treatment:

Were conservative measures successful? Was individual compliant with treatment recommendations? Did individual experience complications such as persistent bleeding or prolapsed or thrombosed hemorrhoids? Was laser ablation performed? Were hemorrhoids treated with more aggressive measures such as injection sclerotherapy, band ligation, cryotherapy, or thermal coagulation? Is surgical intervention (hemorrhoidectomy) indicated?

Regarding prognosis:

Did symptoms persist or worsen despite treatment? Was individual compliant with treatment recommendations? Would individual benefit from dietary counseling? Have hemorrhoids recurred, even after surgical treatment? Does individual have a coexisting condition that could impact ability to recover such as anorectal infections, fecal impaction, and rectal neoplasms? Would individual benefit from consultation with a specialist (gastroenterologist, general surgeon)?

Source: Medical Disability Advisor

References
Cited
"Hemorrhoids." National Digestive Diseases Information Clearinghouse. Nov. 2004. National Institute of Diabetes and Digestive and Kidney Diseases. 3 Mar. 2009 <http://digestive.niddk.nih.gov/ddiseases/pubs/hemorrhoids/index.htm>.

Baker, Howard. "Hemorrhoids." Health A to Z. 14 Aug. 2006. 3 Mar. 2009 <http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestU RI=/healthatoz/Atoz/ency/hemorrhoids.jsp>. Gurley, David, et al. "Hemorrhoids." eMedicine. Eds. William Gossman, et al. 20 Apr. 2006. Medscape. 3 Mar. 2009 <http://emedicine.medscape.com/article/775407-

overview>. Thornton, Scott. "Hemorrhoids." eMedicine. Eds. Brian James Daley, et al. 19 Aug. 2008. Medscape. 3 Mar. 2009 <http://emedicine.medscape.com/article/195401overview>.