Colorectal Disease: Conditions and Treatment Updates Mr. R. Kalbassi, Consultant Colorectal Surgeon

Rectal Bleeding - Painless/ Painful Anorectal/ altered Conditions: - Haemorrhoids Fissure in ano Diverticular Disease Inflammatory Bowel Disease Colorectal Cancer

Haemorrhoids Fresh Painless bleeding - On toilet paper/ splashing into the toilet - Internal / external Pruritis ani Treatment: Dietary advice, lifestyle changes, toilet training laxatives, local creams and suppositories - Left colonoscopy Vs full colonoscopy Banding Vs injection of Haemorrhoids - Surgery: Excision, HALO, Stapled haemorrhoidectomy

Haemorrhoids

Fissure in Ano - Break in an epithelium Painful fresh rectal bleeding Anal spasm “ Like passing glass” – sharp/stinging after Defaecation Often after episode of constipation/ passing hard stool Treatment: laxative, analgesia, dietary advice Topical Rectogesic/ Diltiazem ointment for 6-8 weeks twice Surgery: EUA + injection of Botox, EUA + lateral sphincterotomy

Fissure in Ano: Botulinum Toxin

Diverticular Disease/ bleed Sacs/outpouchings In the wall of the bowel Cause: high pressure in colon, diet low in fibre and high in red meat ” Diverticular bleed responsible for 17-40% of lower Gastrointestinal bleeds” Painless bleed, fresh Self-limiting Common in elderly on anticoagulation Treatment: Supportive, resuscitation, stopping anticoagulation, Transfusion, Tranexamic acid Left colonoscopy once stable/ CT angiogram/embolization Surgery: resection

Inflammatory Bowel Disease Fresh Rectal bleeding in colitis/proctitis Associated with Crohns and Ulcerative colitis Also in infective or ischemic colitis Multiple fissures in ano in Crohns Treatment: resuscitate, Tranexamic acid, Transfusion Colonoscopy and biopsy CT angiogram/embolization? Treatment of underlying cause Surgery: colonic resection

Colorectal Cancer 3rd most common cancer worldwide Increase in incidence in under 50 years of age Fresh rectal bleeding/ blood mixed with stool About 4% patient with rectal bleeding diagnosed with colorectal cancer in patients of 34 years and over Increasing age and association with other symptoms increase this risk to nearly 12% Over 30% of rectal cancer with bleeding PR palpable on DRE Treatment: Clinical assessment/ DRE, left colonoscopy/ Colonoscopy + biopsy, Radiological staging, MDT discussion, Chemo/radiotherapy Surgery: Robotic/ Laparoscopic/ open/ transanal (TEMS/TAMIS)

Rectal bleed - recommendations Detailed history, examination, digital rectal examination Low threshold for referral for left sided colonoscopy/colonoscopy Treat fissure in ano with laxatives and local Topical ointment early Caution as incidence of colorectal cancer increasing in young under 50 When in doubt refer or contact Colorectal surgeon for advice

Contact: Mr. R. Kalbassi Tel: 0872355657 01-2920565 Fax: 01-2920566 Email: reza.kalbassi@beaconhospital.ie rkalbassi.sec@beaconhospital.ie Address: Suite 4, Beacon Consultants Clinic, Beacon Court, Dublin 18