CONDITIONS TREATED
Lower Gastrointestinal
Appendicitis
The appendix is a small tube of tissue that is attached to part of the large intestine or colon. It sits in the lower right part of your abdomen and is about 5 to 10 centimetres long (that's about 2 to 4 inches).
Appendicitis means the appendix is inflamed. The causes are unclear but it is thought appendicitis occurs when the appendix gets blocked. Fluids, hard bits of stool or swollen lymph glands can get trapped in the appendix, and when this happens, the appendix becomes inflamed or infected. This leads to the painful symptoms of appendicitis. If the appendix is inflamed and it is not removed, the consequences can be fatal.
SymptomsThe symptoms of appendicitis begin with pain on the right-hand side of the lower abdomen. A lack of appetite and wanting to vomit are often experienced. In addition a patient might also experience the following:
- cramp-like pain
- a slight temperature
- constipation, or more rarely, diarrhoea
- pain that gets worse with movement or coughing
- a need to go to the lavatory
- it may be more comfortable bending over or lying with your knees drawn up.
Not everybody gets all of these symptoms, particularly those who are:
- very young or very old
- pregnant;
or:
- have an appendix which is not in the usual place
- have other medical problems such as diabetes or cancer
The only treatment for appendicitis is surgery to remove the appendix.
If appendicitis isn't treated, the appendix can burst causing a serious infection inside the body. The Surgeon can either operate using the open surgery or keyhole surgical techniques.
Constipation
Constipation in adults is common, often causing pain in the lower abdomen and more trips to the lavatory than normal.
The causes include the following:
- Eating too little fibre. Most people do not eat enough food containing fibre such as fruit, vegetables, and cereals
- Drinking too little
- Low fibre slimming diets
- Some medicines can cause constipation, including pain killers containing codeine, some antacids, and iron tablets
- Some medical conditions including: underactive thyroid, I.B.S. (irritable bowel syndrome)
- Pregnancy
- Emotional upset
- Unknown causes, known as "idiopathic", most common in women.
The treatment of constipation is simple and dietary changes are frequently advised.
No tests are required unless symptoms such as bleeding, weight loss, bouts of diarrhoea or symptoms are severe and recurring.
Crohn's disease
Crohn's disease is an inflammatory disease that can affect any part of the alimentary canal between the mouth and the rectum. Symptoms depend on where the inflammation is present. Whilst all of the gut can be affected the commonest areas for problems to occur are in the lower small intestine (the ileum), the colon and the rectum where infections may occur.
Patients with Crohn's disease will often feel unwell in a non specific way to begin with. This may involve loss of weight and appetite in addition to the abdominal symptoms. More specific intestinal symptoms are as follows.
Ileal Crohn's disease. Symptoms usually include lower abdominal pains often more to the right side. This is often worse after eating with abdominal swelling followed by diarrhoea.
Colonic Crohn's disease. This will cause symptoms very similar to ulcerative colitis with diarrhoea cramps and bleeding
Perianal crohns disease. This causes boils and abscesses in the perianal area. Some patients may develop a fistula where there is a discharge of mucous or blood to the skin
Crohn's disease of the stomach. This is much rarer and may present as an atypical form of indigestion.
This condition, in common with colitis, appears to be an abnormal reaction from the body's immune system against the gut. Whilst there may be a contribution from our genes to this, the exact triggers for the condition are not known. The condition is more common in some families which raises the possibility of a genetic link.
Investigations and Diagnosis
A series of blood and stool tests will be needed in order to exclude other conditions that can give rise to similar symptoms.
The most important test, especially when rectal bleeding and diarrhoea is involved is an endoscopic examination of the colon. During the endoscopy a biopsy can be taken of the small intestine. Crohn's disease can also involve X-ray investigation. Ultrasound, MRI, and CT scans can aid diagnosis too.
Treatment
Treatment options will depend on the symptoms and where the gut is affected. If the inflammation is limited to the lower part of the colon this could be treated with suppositories or enemas. Usually patients will need medication which not only treats the inflammation but reduces the risk of recurrence.
For more serious symptoms patients will require a short course of steroid tablets which can have fast results. Side effects such as loss of bone density which can occur with long term use are reduced by keeping courses short, and giving supplements of calcium and vitamin D.
Steroids are not used as a long term treatment. For patients who have a good response but whose symptoms return when the steroids are stopped there are other medications that are effective. The main treatment is with azathioprine. This has been used for many years and much is known about its safety and side effects.
Antibiotics are used where there is active inflammation and infection. These are usually used for short periods.
When none of these treatments give good control of symptoms, some of the newer ‘biologic treatments' are used. These are antibodies that are used to target specific sites in the immune system that are active in Crohn's disease. They can be very effective and have made a very significant difference to treating more complicated Crohn's disease. They are new treatments and all new treatments are undergoing a continuing process of evaluation regarding their safety, side effects and situations where they are best used.
Some patients with severe conditions may require hospital admission and treatment with intravenous steroids. Sometimes this and more potent drugs don't bring the condition under control and surgery may be necessary
The Risk of Bowel Cancer
This is relevant to patients who have predominantly inflammation in the colon. The long term increase in risk is related to the extent of inflammation, the amount of time that the condition has been present (decades) and the adequacy of control of inflammation. Patients who have very limited inflammation of just the lower part of the colon are not at a significantly increased risk. When the inflammation has involved the entire colon, the disease has been active for more than 10 years and the inflammation has been difficult to control, then the risk of developing pre cancerous changes is increased.
Good control of symptoms is very important. There is increasing evidence that taking regular asacol can not only reduce the frequency of relapses but also reduces the risk of precancerous changes. If you have extensive colitis your specialist may recommend 2 yearly colonoscopy after the condition has been present for 8 -10 years.
Fertility and Crohn's Disease
If well controlled the condition should not affect fertility and pregnancy. Most of the medications that are necessary to control this condition can continue to be used in pregnancy if your specialist feels this is necessary. Some medications may need to be discontinued. Men should not take azathioprine when trying to conceive.
Ulcerative colitis
Ulcerative colitis is a condition that causes inflammation of the colon. It begins in the lower part of the colon and can spread all the way around the large bowel to the point where the large and small intestine joins. Symptoms include blood and diarrhoea with cramp pain.
The condition usually develops in both men and women and in patients between 20 and 40 years of age. There is usually no apparent reason why the condition develops when it does.
The most important test will be a direct examination of the colon. This will involve a colonoscopy or perhaps initially a colonoscopy (see link to endoscopic procedures). This not only allows the exclusion of other diseases but confirmation of the presence of colitis with biopsy.
Diagnosis
The tests for ulcerative colitis will involve blood tests and a stool examination for infection in order to exclude other conditions that could give similar symptoms.
Colitis appears to be a condition caused by the immune system which targets its inflammatory cells against the colon. The reason for this is unknown but theories include an abnormal response to the bacteria in the colon. Diet is not a factor in causing this condition.
Treatment
The type and level of treatment will depend on the symptoms and how much of the colon is inflamed. If the inflammation is limited to the lower part of the colon this could be treated with suppositories or enemas. Usually patients will need a medicine which not only treats the inflammation but reduces the risk of recurrence.
Patients with more serious symptoms are given a short course of steroid tablets which usually have a fast result. There can be side effects such as a loss of bone density but the risk is reduced by keeping courses short, supplementing calcium and vitamin D and using other medications when necessary that allow the steroids to be stopped.
It is possible to heal all the changes caused by colitis and return the lining of the colon to normal. Symptoms can also settle completely. Unfortunately there is no absolute medical cure so a return of symptoms and inflammation may occur at any time. The use of medication on a long term basis can reduce the frequency and severity of relapse in patients with colitis. The type of medication and the duration of treatment will depend on the severity of the initial problems.
In severe cases, some patients may need to be admitted to hospital and treated with intravenous steroids. Sometimes this and more potent drugs don’t bring the condition under control and surgery is necessary. This provides a cure for the condition. Whilst this cures the condition this does mean that a stoma is necessary for a period of months. Following this an artificial colon reservoir which is called a pouch can often be constructed restoring normal anatomy.
There is some risk of developing bowel cancer if a patient has severe symptoms over many years. But patients who have very limited inflammation of just the lower part of the colon are not at a significantly increased risk. When the inflammation has been involved the entire colon, the disease has been active for more than 10 years and the inflammation has been difficult to control, then the risk of developing pre cancerous changes is increased. Good control of symptoms is very important. There is increasing evidence that taking preventative medicines can not only reduce the frequency of relapses but will also reduce the risk of precancerous changes. If you have extensive colitis your specialist may recommend 2 yearly colonoscopy after the condition has been present for 8 -10 years.
There is a small chance that children may also develop the condition but this is low at about 6%.
Potential Affects on Fertility
If well controlled the condition should not affect fertility and pregnancy. Most of the medications that are necessary to control this condition can continue to be used in pregnancy if your specialist feels this is necessary. Some medications may need to be discontinued. Men should not take azathioprine when trying to conceive.