Areas of Expertise

The average lifetime risk for developing a colorectal cancer in a person who has no increased risk factors is about 6%. Nearly all of these cancers start as a polyp. A family history of precancerous polyps, colon or rectal cancer, and certain other cancers, may increase your risk. Only 5% of colon cancers come from genetic syndromes. This means that up to 95% of colorectal cancers are preventable.

Family history is important. The biggest risk factor comes from a first degree relative (parents, siblings, children) or multiple second degree relatives (cousins, aunts and uncles, nieces and nephews). Colorectal cancer may also occur in genetic syndromes - HNPCC or Lynch Syndrome and Familial Adenomatous Polyposis (FAP). Conditions such as Crohn's disease and ulcerative colitis also increase that risk.

The only way to prevent colon cancer is to find it as a polyp and remove it before it becomes a cancer. If a polyp is too large to be removed during colonoscopy or is found to contain or be a cancer, then surgery is typically necessary to remove the lesion.

When a colon cancer is present, the lymph nodes that drain that cancer need to be included in the portion removed. Fortunately, most surgery is done with tiny incisions (laparoscopy, robotics) which speeds recovery.

Rectal cancer is not always treated the same as colon cancer. Often, rectal cancer needs a combination of chemotherapy and radiation prior to surgery. This may help shrink the tumor, possibly sterilize lymph nodes, and helps in sphincter saving surgery so a permanent bag is unnecessary. Other rectal polyps and early cancers can be removed without any incisions at all by TEMS or Transanal Endoscopic Microsurgery. In order to determine if you are a candidate for TEMS, or in need of radiation and chemotherapy prior to surgery, the lesions need to be staged. Rectal cancer is staged with endorectal ultrasound, which is performed by the surgeon to see what treatment option is the best.

If a colorectal cancer grows too large, it can block the bowel (large bowel obstruction). Symptoms of obstruction will include progressive narrowing of the stool or ribbon-like stools. Nausea and vomiting may be present, as well as abdominal distention and abdominal pain. Oftentimes, when a person is obstructed, we can relieve that obstruction with a colonic stent to open the tumor similiar to how cardiologists open vessels with stents. This allows us to determine if surgery is needed for future cure, and plan minimally invasive surgeries, often without the need for colostomy bags.

To see an example of colonic stent placement please click the link below:
http://www.youtube.com/watch?v=UEFSElsMIpc

Another form of minimally invasive surgery on the abdomen uses a robot. At St. Mary we have the da Vinci Si, currently the most advanced operative robotic unit available. We are also the only colorectal surgeons performing this in Bucks County and one of only a few in the region.

The da Vinci benefits both the patient and the surgeon. For the patient, robotic surgery maintains all the benefits of laparoscopy. Additionally, the robot controls exactly how the laparoscopic ports move through the abdominal wall. This causes less trauma and, therefore, less pain. For the surgeon, the robot has two major benefits. The first is that the surgery is performed at an operating console that lets the surgeon see in three dimensions (3D). Laparoscopy is in 2D, equivalent to watching a flat screen TV, while 3D lets you see depth just as in real life. The second benefit is that the robot has three operating arms (as opposed to the surgeon who only has two). This allows additional maneuverability and better performance. Finally, the robotic arms have a range of motion better than that of the human hand. All of this means that the surgeon can do the most exacting operations with less pain, better visualization, and faster recovery.

Abdominal pain has many causes ranging from cramps related to the bowel contracting, to gallbladder pain, to diverticulitis, or gynecologic pain in women. Most abdominal pain is short-lived and is not in need of any specific workup. Chronic abdominal pain is often related to constipation, scar tissue from prior surgery, or is referred from another source but felt in the abdomen. Workup, when appropriate, includes a physical exam in our office, radiologic studies such as a CT scan or pain x-ray of the abdomen, and, sometimes, specialized testing done here in the office. Pelvic floor muscle spasm can cause pain in the abdomen. This is usually identified with Anorectal Manometry and superficial EMG (non-needle). Other pelvic pains may be related to conditions of the bladder or gynecologic organs, but may be felt in the abdomen. Referral to a specialist in these areas is often recommended. Abdominal pain related to constipation is usually improved with simple stool softeners or antispasmodics. A more comprehensive workup for chronic constipation may be needed. This may include specialized radiologic studies, physiologic testing in the office, or colonoscopy. We often see patients in our office with unexplained abdominal pain. A good history and physical exam is often all that is needed to make a diagnosis. When a cause related to colon and rectal surgery is found, we will explain what the problem is and how we can make it better.

Fecal Incontinence is the inability to hold solid stool, liquid stool, or gas from the rectum. This may effect up to 10% of the general population and is especially common in senior citizens and people living in assisted-living and nursing homes.

Fecal Incontinence in patients who are younger women is usually caused by childbirth injury. Factors affecting the anal sphincter include multiple vaginal deliveries, vaginal injury, episiotomies, prolonged pushing, and children of larger size. These problems may not be immediately evident after delivery, but may show up decades later as part of a more significant pelvic floor problem. Other tramatic injuries to the anus such as anorectal surgery can be an underlying etiology.

The level of estrogen and progesterone diminish as women age. Once menopause sets in, they are essentially absent. Hormones build up the pelvic floor muscles and, after menopause, the muscles of the pelvic floor begin to thin out. Incontinence may show up much later in life despite its origins at the time of childbirth.

Rarely, conditions such as multiple sclerosis, spinal cord injury, and metastatic disease can present with incontinence. This may be the first presentation of any of these conditions and, therefore, requires a high index of suspicion.

The evaluation of Fecal Incontinence includes specialized testing of the pelvic floor that we perform in the office. This allows us to measure function of the muscles of the pelvic floor, the muscles of the anal canal, and the function of the nerves that stimulate these muscles. To evaluate if a sphincter defect is present, endoanal ultrasound may be added to your evaluation to identify a gap in the muscle that can readily be repaired surgically.

Another therapy for incontinence is sacral nerve stimulation (Medtronic Interstim). When the nerves to the sphincter do not function well, bypassing or directly stimulating the nerve, using something similar to a pacemaker, will improve function. There is a temporary test phase to see if you will benefit from this therapy. If so, the permanent device can be implanted.

These are all done as small outpatient procedures. Where appropriate, this will be discussed with your physician. Most Fecal Incontinence will not require surgery. The majority of patients can be managed with medications, appropriate bowel regimens, and physical therapy that strengthens the pelvic floor muscles and trains patients to use muscles not otherwise used for continence.

Do not be embarrassed or afraid to discuss Fecal Incontinence with your doctor. Be assured that this is a much more common problem than is generally known. Much time has been put into the diagnosis and treatment of Fecal Incontinence to improve the quality of life.

To learn more about Fecal Incontinence please click the link below:
http://www.fascrs.org/patients/conditions/bowel_incontinence

To learn more about Interstim for Fecal Incontinence please click the link below:
http://www.medtronic.com/patients/bowel-incontinence/index.htm

Hemorrhoids are normal anatomy. They are part of the continence mechanism. You are born with them and they are with you for life. However, they should not bleed, hurt, or pop out. When these symptoms occur, a surgeon should evaluate them.

Treatment options for hemorrhoids start with simple measures. The daily recommended amount of fiber is 30-35 grams. That is the equivalent of 6-7 bowls of a high fiber cereal. Taking a supplement is an easy way to get that amount of fiber. Fiber capsules typically have 1 gram of fiber, and most powders have 3 grams of fiber per teaspoon. We recommend Konsyl, which has 6 grams of fiber per teaspoon. Be sure to drink a glass of water after the fiber supplement as the fiber holds the water in the stool to keep it soft. When hemorrhoids become painful, they are often clotted. You will likely feel a lump. If seen early, we can often remove the clot, which will relieve the pain and let you heal faster.

When internal hemorrhoids are enlarged and bleed, office treatments may be all you need. The most common and effective procedure is rubber banding. This chokes off the hemorrhoid, allowing it to fall off with a bowel movement. We also offer sclerotherapy, which injects a substance that will scar the vessels that feed the hemorrhoids, making the bleeding stop. This is an office procedure that can be done safely while on anticoagulation (blood thinners).

When surgery is recommended, there are multiple options. Excisional hemorrhoidectomy removes the hemorrhoid entirely. The defect is then sewn closed with suture. When a significant external (outside) component is present, this may be necessary, but is quite uncomfortable post-operatively. Less discomfort is associated with procedures such as a stapled hemorrhoidopexy (PPH - Procedure for Prolapsing Hemorrhoids) and Transanal Hemorrhoidal Dearterialization (THD).

PPH removes a ring of tissue that includes the blood vessels that feed the hemorrhoids. This also pulls up the tissues that prolapse out during a bowel movement. A staple line is left where the tissue is put back together. THD uses suture to tie off the vessels that feed the hemorrhoids, and the prolapsed portion is sewn back inside. No tissue is removed unless pre-planned with your surgeon.

We now off the HET Bipolar Forceps Hemorrhoidal Ligation Procedure. This technology will slowly burn the blood vessels that feed the hemorrhoids without burning any tissue except the hemorrhoid itself. It is essentially painless (some pressure may be noted) but does require some mild sedation. It is a same day procedure, with most people going back to work within a few days. It can be combined with other anorectal procedures, although those may have different risks and recovery. The HET system is one of the few procedure we can perform while on anticoagulation (blood thinners). Some bleeding may still occur, but not enough to warrant stopping the blood thinners or needing to reverse them. Please feel free to inquire at you visit if this is the right procedure for you.

More information can be found at the following websites:

http://www.fascrs.org/patients/conditions/hemorrhoids/
http://www.ethiconendosurgery.com/Clinician/Product/stapling/pph
http://www.thdamerica.com

A fistula is a tract (like a tube) that connects the inside of the anus to the skin around the anus. It usually starts as an abscess (infection) of one of the anal glands that then tunnels its way to the outside world.

Initial treatment usually is antibiotics. If the fistula closes, we simply watch to see if it comes back. More commonly, the tract persists and will need surgical treatment.

The standard treatment is Fistulotomy or cutting open the tract. This will destroy the duct that caused it and will heal up from the inside out. When there is very little sphincter muscle involved, this is a safe procedure.

When too much muscle is involved, cutting that tissue may make it more difficult to hold your bowels (incontinence). When we believe that the risk of incontinence is too high, we may place a Seton (a drain) to make sure no infection comes back and to keep the tract open and draining. We then will do a different procedure for the fistula down the road. This may be a Cutting Seton where we repeatedly tighten the drain to cut through the tissue slowly, like a wire through a block of ice.

This seton often creates scar tissue which when cut is less likely to lead to incontinence. This is called a Second Stage Fistulotomy.

Other procedures for a fistula after seton placement include an Anal Fistula Plug (actually plugs the holes and lets normal tissue grow into the tract), a Rectal Advancement Flap, (brings the rectal lining down over the hole on the inside), or a Ligation of Intersphincteric Tract (LIFT procedure) which actually divides the tract as it travels between the sphincter muscles.

We will explain all of these issues at the time of your visit and subsequent follow-up. Please bring a list of questions that you might have with you, and we will take the time to make sure you understand your treatment options.

An anal fissure is a tear in the lining of the anus. It is in one of the most sensitive areas of the body and causes pain, sometimes severe. The pain is usually worse during and after a bowel movement. It is also associated with rectal bleeding.

The best time to treat a fissure is immediately after it occurs. When the tear is present, the internal anal sphincter is exposed and goes into spasm. This also causes pain but, once in spasm, it holds the edges of the tear apart so they won't come together and heal like a regular cut on the skin.

If treated early using topical muscle relaxants, stool softeners, and warm tub soaks, the fissure is likely to heal without surgery. The muscle relaxants include compounds like Nitroglycerine and Diltizem ointments. These are not readily available and likely have to be compounded by a specialty pharmacy.

Once a fissure becomes chronic or if medical and conservative therapy fails, surgery may be indicated. The most common surgery is a Sphincterotomy where a cut is made in the sphincter to release the muscle allowing the skin edges to come together and heal. It is the most effective treatment but does carry a low risk of having trouble holding your bowels (incontinence). When that risk is too high, Botulinum Toxin (Botox) can be used to relax the muscle allowing the fissure to heal. While not actually "temporary", the muscles that are effected by Botox have new nerve growth fairly rapidly so there are little long-term issues that a permanent cut in the muscle might have.

Most patients with rectal bleeding are referred to us for "hemorrhoids". This may be the case or there may be any number of other causes of bleeding. Our job is to figure out what the cause is and fix it. This could be a fissure, an abscess or fistula, pruritis ani, Crohn's Disease, ulcerative colitis, or other more worrisome problems that will need a further work-up.

Rectal bleeding is never normal. Simply assuming it is hemorrhoids can be a big mistake and delay the diagnosis of more serious conditions. If a colonoscopy is indicated, we will get you scheduled expediently. We use the most sophisticated equipment to diagnose and treat all conditions related to the colon, rectum and anus. Our goal is to provide exceptional care without discomfort or embarrassment. Please have a list of questions prepared and know that we will give you all the time you need to understand what your problems are and how we will treat them.

Most patients referred for pain in the anus and rectum are told they have "hemorrhoids", however, only thrombosed hemorrhoids hurt. Other diseases such as anal fissure, anal abscess, anal fistula, pruritis ani, and functional pain (muscle spasm) can be the underlying cause. Our job at CCRH is to figure out what is causing the pain and then treat it.

We understand that you may be embarrassed to see a proctologist, but this is what we do every day. We chose this profession to fix your problems. These are very common issues that affect people all over the world every day. In addition, there are times when what is thought to be a simple hemorrhoid is actually a much more complex problem. We use the most sophisticated equipment to diagnose and treat all disorders of the colon, rectum, and anus.

We will make you as comfortable as possible and take the time to answer all of your questions. Your exam will be as gentle as we can make it and, oftentimes, we can treat the problem immediately in the office.

Colorectal cancer is perhaps the most easily prevented cancer. This is because it almost always begins as a benign polyp that slowly turns cancerous over a period of many years. Polyps can be easily removed before that happens. Patients who are appropriately screened for colonic polyps and cancers rarely ever need surgery to remove these lesions and, therefore, can live healthier lives.

Normal screening for colorectal cancer begins at age 50 in a low-risk individual. This means that if you have no family members with colorectal cancer or certain other cancers, and you have no symptoms, such as rectal bleeding or a change in bowel habits, you should not need a colonoscopy before age 50. If you are concerned that you have an elevated risk for colorectal cancer, ask your primary care physician about screening or come in for a consultation visit.

You begin the colonoscopy process by cleaning out your colon at home prior to the procedure. There are a variety of oral solutions and pills available to accomplish this process. Enemas are generally not necessary. We will work with your particular needs to find a means of preparing your colon that will be acceptable to you.

Colonoscopy is a painless procedure with very little risk of any complications. On the day of your procedure, you will meet with an anesthesiologist who will supervise the sedation for the colonoscopy. You are not awake and you should not feel any discomfort during the procedure. The entire colon is inspected, and if anything abnormal is found, a biopsy (taking a piece of tissue) or a polypectomy (removing the entire polyp) will be performed through the colonoscope.

Colonscopy is the only screening procedure that can be therapeutic as well as diagnostic. This means that if a polyp is found, it can be taken care of right then and there. Other procedures, such as Barium Enema and Virtual Colonoscopy (CT Scan Colonography), are less accurate in detecting polyps and a polyp cannot be removed or a biopsy performed at this time. You would then still have to have a full colonoscopy at a later date to remove or biopsy the lesion.

At CCRH, we pride ourselves on being able to remove large polyps that are often otherwise referred for surgery. Studies have shown that Colon and Rectal Surgeons are more able to remove these polyps than other providers, as we are able to deal with any situation surgically should issues arise. If we are uncertain, we may, with your consent, perform your colonoscopy in an operating room in case we find that surgery is, in fact, needed. Most of our Colonoscopy procedures are performed at The Endoscopy Center at St. Mary.

The human papilloma virus (HPV) has over 80 different varieties. It can cause everything from plantar or palmar warts (feet and hands) to cervical and anal cancer.

The biggest impediment to treatment is usually the patient. We realize that anal warts can be very embarrassing, and many patients will not seek treatment early for fear of being embarrassed or judged. Rest assured, we take great care in making certain you feel comfortable. We make sure you understand the treatment options and will see you frequently to minimize recurrence.

The majority of anal warts come from benign HPV strains and can be treated either in the office or in the operating room when severe. There are medications that can treat HPV infections and even vaccines to prevent them from ever occurring. However, once you have them, they need treatment.

Many patient's don't know if they have been exposed to HPV, but may be at an elevated risk (women with positive pap smears, men and women who have practiced anal intercourse, HIV positive patients, and other patients with immune system compromise for any reason - steroids, chemotherapy, medications or diseases that knock down your immune system like Remicade, Humira, and certain autoimmune diseases). Unlike screening for cervical cancer, where pap smears are performed to look for abnormal cells, for anal HPV we typically first do DNA testing (a simple swab) to see if HPV is present. If the test is positive for HPV, we may recommend High Resolution Anoscopy with biopsies so we can assess if the strain of HPV is one of the ones at risk for anal cancer, or the more benign types like anal warts.

The treatment starts with an exam in the office. Where appropriate, we may treat them right away with topical solutions, freezing, or burning them. Disease on the inside of the anus will likely need treatment in the operating room. When in the OR, we use High Resolution Anoscopy (a highly magnified view with special solutions to highlight any abnormal lesions). All visible and suspicious lesions are treated at that time. As with any virus, there is a risk of recurrence (how many times have you had the common cold or the flu?), but many recurrences are treated in the office painlessly.

When in the operating room, specimens will be sent to identify which subtype of the virus caused the lesions. If we identify the types that are known to cause cancer, we will be much more aggressive in treatment and surveillance.

Having a list of questions ahead of time may make your visit easier. We will give you as much time as you need to feel comfortable with the treatment of this disease.

Having "normal" bowel movements is defined as moving your bowels from three times a day to three times per week. More than three bowel movements daily may be considered diarrhea. Less than three bowel movements per week is considered constipation.

Constipation refers to the slow transit of stool through your colon. It often is confused with the need to strain or assist in evacuation, which is really outlet obstruction, or the inability to get stool out.

Most constipation related to slow transit is remedied by adding both fiber and water daily. Fiber without additional water may actually firm up the stool more. The daily recommended fiber a person needs is between 30 and 35 grams. To give an example, a high fiber cereal may have 5 grams of fiber, so you would have to eat 6 to 7 bowls of cereal to get that much fiber. We typically recommend a supplement such as Konsyl, which is over the counter, and has 6 grams of fiber per teaspoon. Other products like Metamucil and Citrucel typically have 3 grams per dose.

Medications can often cause constipation. You should look at the side effect profiles of any medications you are taking. Rarely, however, constipation can be indicative of underlying conditions such as polyps and cancers and therefore, where appropriate, colonoscopy is recommended.

Refractory constipation often can be treated with stronger medications like Miralax, an over-the-counter stool softener, which is a powder similar to that used in bowel preparations.

True laxatives are to be avoided as these irritate the bowel to force the colon to move stool forward and out. These are medications that your colon can become addicted to, requiring higher and higher doses in order to get the same effect. If you regularly take laxatives, we recommend that you slowly wean off of these as you add stool softeners to your daily regimen.

There is a disease termed "Colonic Inertia" or "Slow Transit Constipation". This is a condition where the colon cannot actually propel stool forward due to a decrease in the number of nerve endings between the muscle layers of the bowel wall. Unfortunately, true Colonic Inertia can only be helped with a major operation. This can be done laparoscopically, but is rarely offered unless all other options have been exhausted. A simple radiologic study can be performed that will accurately diagnose this condition.

Trouble with evacuation (obstructed defecation) is a much more complex problem. This usually is a problem related to the rectum itself or the muscles and nerves of the pelvic floor. When simple remedies fail, outlet obstruction requires specialized testing in order to determine the underlying cause. Oftentimes, significant straining to evacuate is a simple disorder of the muscles of the pelvic floor where coordination of these muscles is abnormal and, therefore, getting stool out is difficult.

A rectocele is a pouching of the rectum into the vagina. This is best diagnosed if aiding evacuation by supporting the rectocele is noted. This includes pressing the rectocele back into the rectum through the vagina during evacuation or pressing between the rectum and the vagina in order to aid evacuation. When a rectocele alone is the problem, it can be fixed quite easily with surgery. Many times, however, a rectocele is a symptom of something bigger. When stool cannot make it out, it gets trapped and pushes forward toward the vagina, stretching out the tissue, creating that pouch.

Other conditions that can cause obstructed defecation or difficult evacuation include rectal prolapse, where the rectum comes all the way out of the anus, or internal rectal prolapse (internal intussusception). This is best treated either laparoscopically by suspending the rectum back into the pelvis or through the rectum where the excess bowel is excised from below. For internal intussusception, a STARR (Stapled Trans-Anal Rectal Resection) procedure excises the excess prolapsing tissue transanally, restoring both normal anatomy and normal function to the rectum. In some patients, it is also possible to re-suspend the rectum surgically as you would do for an external rectal prolapse. When a suspension procedure is done for rectal prolapse, it typically is done laparoscopically or robotically.

The workup for constipation includes colonoscopy, radiologic studies, and pelvic floor studies. Once an accurate diagnosis can be made, a treatment plan can be formulated that will improve the patient's bowel habits and, therefore, quality of life.

More information can be found at the following websites:

http://www.fascrs.org/patients/conditions/constipation/

http://www.fascrs.org/patients/conditions/rectocele/

Diverticulosis is a common condition that occurs as we age. Although it is not present in every patient, it is never an unexpected finding unless the patients are very young. Diverticula are pouches that form in the wall of the bowel. The most common region is called the sigmoid colon which is on the lower left side of the abdomen. It is the narrowest portion of the colon.

Most diverticula occur as hard stool passes through the colon. Since the sigmoid colon is narrower than other parts, as well as being more tortuous (looped), the colon has more trouble pushing hard stool through this narrowed area. Weak areas in the wall of the colon start to form the pouches which can become quite large. Although the sigmoid colon is the most commonly affected area, these can occur anywhere in the colon.

Some diverticula are congenital (you are born with them) and are more common on the right side of the colon and in the small bowel. The rest are acquired over time. Hard stool is what causes diverticulosis and also diverticulitis. It is not from seeds, nuts, popcorn, or any other specific foods that you might have heard. This has been well studied. Hard stool can get stuck in the pouch and erode through. This can lead to bleeding, perforation (diverticulitis), or both. Soft stool usually can drain from the pouch without difficulty.

Only 20% of patients with diverticula will have symptoms, and only a small proportion of these patients will need surgery for diverticulosis. The vast majority will remain asymptomatic for their lifetime. Up to 80% of the population will have diverticulosis by the age of 80 years.

Diverticular bleeding tends to be brisk and is worse if you are on blood thinners. Most bleeding stops without surgery. If you are on blood thinners, you may need blood products like platelets or plasma. If the bleeding does not stop, a radiology procedure or even surgery may be needed.

Diverticulitis is a perforation of the pouch. Mild perforations can be controlled with antibiotics. More severe perforations may need hospitalization and intravenous antibiotics. If an abscess develops, this may need draining by radiology or in surgery. Rarely, a really bad perforation needs emergency surgery and usually a temporary colostomy bag.

The best prevention of complications of diverticular disease is simply to take a stool softener. Fiber based products are excellent for asymptomatic disease. If constipation is also present, and fiber is not enough, stool softeners such as Colace or Miralax (both have generic forms) may be needed. There is no need to adjust your diet to treat or prevent complications of diverticulosis.

Diverticulosis is a common condition that occurs as we age. Although it is not present in every patient, it is never an unexpected finding unless the patients are very young. Diverticula are pouches that form in the wall of the bowel. The most common region is called the sigmoid colon which is on the lower left side of the abdomen. It is the narrowest portion of the colon.

Most diverticula occur as hard stool passes through the colon. Since the sigmoid colon is narrower than other parts, as well as being more tortuous (looped), the colon has more trouble pushing hard stool through this narrowed area. Weak areas in the wall of the colon start to form the pouches which can become quite large. Although the sigmoid colon is the most commonly affected area, these can occur anywhere in the colon.

Some diverticula are congenital (you are born with them) and are more common on the right side of the colon and in the small bowel. The rest are acquired over time. Hard stool is what causes diverticulosis and also diverticulitis. It is not from seeds, nuts, popcorn, or any other specific foods that you might have heard. This has been well studied. Hard stool can get stuck in the pouch and erode through. This can lead to bleeding, perforation (diverticulitis), or both. Soft stool usually can drain from the pouch without difficulty.

Only 20% of patients with diverticula will have symptoms, and only a small proportion of these patients will need surgery for diverticulosis. The vast majority will remain asymptomatic for their lifetime. Up to 80% of the population will have diverticulosis by the age of 80 years.

Diverticular bleeding tends to be brisk and is worse if you are on blood thinners. Most bleeding stops without surgery. If you are on blood thinners, you may need blood products like platelets or plasma. If the bleeding does not stop, a radiology procedure or even surgery may be needed.

Diverticulitis is a perforation of the pouch. Mild perforations can be controlled with antibiotics. More severe perforations may need hospitalization and intravenous antibiotics. If an abscess develops, this may need draining by radiology or in surgery. Rarely, a really bad perforation needs emergency surgery and usually a temporary colostomy bag.

The best prevention of complications of diverticular disease is simply to take a stool softener. Fiber based products are excellent for asymptomatic disease. If constipation is also present, and fiber is not enough, stool softeners such as Colace or Miralax (both have generic forms) may be needed. There is no need to adjust your diet to treat or prevent complications of diverticulosis.

IBS is typically a medical disease. However, the latest classification system (ROME III criteria) does include many of the disease states that we have treated for decades under other names. Below are the criteria and descriptions of these disorders from the Rome Criteria website.
www.romecriteria.org
Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders
ASCRS education for Irritable Bowel Syndrome


F1. Functional Fecal Incontinence
Diagnostic criteria*
ei. Recurrent uncontrolled passage of fecal material in an individual with a developmental age of at least 3 years and one or more of the following:
a. Abnormal functioning of normally innervated and structurally intact muscles
b. Minor abnormalities of sphincter structure and/or innervation
c. Normal or disordered bowel habits, (i.e. fecal retention or diarrhea)
d. Psychological causes
AND
Exclusion of all the following:
a. Abnormal innervation caused by lesion(s) within the brain (e.g. dementia),
spinal cord, or sacral nerve roots, or mixed lesions (e.g. multiple sclerosis), or as part of a generalized peripheral or autonomic neuropathy (e.g. due to diabetes)
b. Anal sphincter abnormalities associated with a multisystem disease (e.g. scleroderma)
c. Structural or neurogenic abnormalities believed to be the major or primary cause of fecal incontinence
*Criteria fulfilled for the last 3 months

F2a. Chronic Proctalgia
Diagnostic criteria* must include all of the following:
1. Chronic or recurrent rectal pain or aching
2. Episodes last 20 minutes or longer
3. Exclusion of other causes of rectal pain such as ischemia, inflammatory bowel disease, cryptitis, intramuscular abscess, anal fissure, hemorrhoids, prostatitis, and coccygodynia
*Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis
Chronic proctalgia may be further characterized into levator ani syndrome or unspecified anorectal pain based on digital rectal examination.

F2a.1. Levator Ani Syndrome
Diagnostic criterion
Symptom criteria for chronic proctalgia and tenderness during posterior traction on the puborectalis

F2a.2. Unspecified Functional Anorectal Pain
Diagnostic criterion
Symptom criteria for chronic proctalgia but no tenderness during posterior traction on the puborectalis

F2b. Proctalgia Fugax
Diagnostic criteria must include all of the following:
1. Recurrent episodes of pain localized to the anus or lower rectum
2. Episodes last from seconds to minutes
3. There is no anorectal pain between episodes
For research purposes criteria must be fulfilled for 3 months; however, clinical diagnosis and evaluation may be made prior to 3 months.

F3. Functional Defecation Disorders
Diagnosis criteria*
1. The patient must satisfy diagnostic criteria for functional constipation**
2. During repeated attempts to defecate, must have at least two of the following:
a. Evidence of impaired evacuation based on balloon expulsion test or imaging
b. Inappropriate contraction of the pelvic floor muscles (i.e. anal sphincter or puborectalis) or less than 20% relaxation of basal resting sphincter pressure by manometry, imaging, or EMG
c. Inadequate propulsive forces assessed by manometry or imaging
*Criteria fulfilled for the last 3 months with symptom onset at least 3 months prior to diagnosis
**Diagnostic criteria for functional constipation:
1. Must include two or more of the following:
a. Straining during at least 25% of defecations
b. Lumpy or hard stools in at least 25% of defecations
c. Sensation of incomplete evacuation for at least 25% of defecations
d. Sensation of anorectal obstruction/blockage for at least 25% of defecations
e. Manual maneuvers to facilitate for at least 25% of defecations (e.g. digital evacuation, support of the pelvic floor
f. Fewer than three defecations per week
2. Loose stools are rarely present without the use of laxatives
3. Insufficient criteria for irritable bowel syndrome

F3a. Dyssynergic Defecation
Diagnostic criterion
Inappropriate contraction of the pelvic floor or less than 20% relaxation of basal resting sphincter pressure with adequate propulsive forces during attempted defecation

F3b. Inadequate Defecatory Propulsion
Diagnostic criterion
Inadequate propulsive forces with or without inappropriate contraction or less than 20% relaxation of the anal sphincter during attempted defecation

Our Anorectal Physiology Lab allows us to accurately diagnose these disorders. The testing, including Anorectal Manometry, Surface EMG (non-needle), Balloon Sensory Testing, Pudendal Nerve Testing, Colonic Transit Time Studies, Defecography, and Endoanal Ultrasound, allows us to comprehensively evaluate the anorectum and come up with treatment plans that will improve quality of life and sometimes even cure these issues. At CCRH we understand that many of these issues have plagued you for years, if not decades. Our philosophy is that if something can be measured, it can be treated. Most IBS is based on symptoms.

Using small incisions on the abdomen, we can perform most of the operations that normally would require a large incision on the abdomen. Pain is less than a large incision, and your ability to get up and moving after surgery is much greater. Hospital stay is usually shorter, and patients are back to their normal lives faster using these techniques.

The abdomen is filled with a gas (carbon dioxide), and high definition cameras are used to visualize everything inside the abdomen. Specialized equipment lets us manipulate the bowel and transect blood vessels all through tiny holes that are about the size of a pencil eraser.

Sometimes, a special port is used that allows a hand to be inside the abdomen to feel and manipulate bowel, while the other instruments use the laparoscopic ports.

Regardless of technique, one incision has to be big enough to remove the specimen. This still leaves the patient with a largest incision usually around 3 inches long.

The only way to prevent colorectal cancer is to find it as a benign polyp and remove it before it can become a cancer. Colorectal cancer is also one of the most preventable cancers. At CCRH we specialize in the diagnosis and treatment of colon and rectal cancer. To understand your risk for developing polyps and cancers, a detailed family history and review of symptoms is performed. Where appropriate, we will schedule you for a colonoscopy. We follow national screening guidelines for colorectal cancer which are based on your particular risk factors. These include a first degree relative (parents, siblings, children) with colorectal cancer or certain types of precancerous polyps, a significant change in bowel habits, bleeding from the rectum, unexplained weight loss, or a low blood count found on a blood test.

Colonoscopy is a routine procedure performed by our doctors many times a day with very low risk. We have many types of bowel preparations that will accommodate your taste and ability to clean out the bowel. It is a normal screening examination just like a prostate check, mammogram, or pap smear.

The greatest impediment to screening colonoscopy is fear. Fear of the bowel prep, fear of what might be found, and fear of complications are what most patients report when asked about why they did not get their colonoscopy. Unfortunately, most patients who are reporting these fears are referred for a colorectal cancer found when they become symptomatic. This may be too late to offer a cure. Removing a polyp before it becomes a cancer is truly the only way to prevent colorectal cancer.

We are happy to spend as much time as you need to discuss the procedure, the prep, and the low risks that are inherent in this and any other invasive procedure. Having a list of questions prepared can be very helpful at the time of consultation. If you have any symptoms, please bring them up at the time of your visit.

Why a Colorectal Surgeon?

While a colonoscopy is a routine procedure, we cannot make the risk zero. Should there be a complication, as surgeons we can immediately fix the problems that do rarely occur. In addition, we can be more aggressive about polyp removal and retrieval. We are often referred patients for surgery because an endoscopist could not remove a polyp. Many of these patients will not need surgery if we can remove the polyp despite there being a higher risk than a standard colonoscopy. Should a complication occur, we are surgeons and can fix the problem surgically. In this way, many surgeries are avoided altogether.

  • Bowel Obstruction
  • Crohn's Disease
  • Hereditary Colon Cancer
  • Incisional Hernia
  • Pilonidal Cyst
  • Ulcerative Colitis