COLON DISORDERS

Irritable Bowel Syndrome/Spastic Colon

Irritable bowel syndrome (IBS) is a gastrointestinal syndrome characterized by chronic abdominal discomfort and altered bowel habits (diarrhea or constipation) in the absence of any organic cause. IBS commonly affects both men and women, young patients and the elderly. However, younger patients and women are more likely to be diagnosed with IBS.

The cause of IBS remains uncertain. Abnormal movement within the gastrointestinal tract, visceral hypersensitivity (the abnormal perception of abdominal gas or bloating), postinfection, psychological dysfunction such as depression or anxiety, and emotional stress may all play a role in this syndrome.

Clinically, patients present with a wide array of symptoms which include both gastrointestinal and extraintestinal complaints. Chronic abdominal discomfort and altered bowel habits remain the primary characteristics of IBS. Patients may experience a significant amount of bloating. The abdominal pain location can vary, the severity range from mildly annoying to debilitating. Emotional stress and eating may exacerbate the pain while having a bowel movement often provides some relief. Patients with IBS can have diarrhea, constipation, alternating diarrhea and constipation, or normal bowel habits alternating with diarrhea and/or constipation. Blood in the stool, weight loss, and nighttime symptoms are not commonly associated with IBS.

There are certain criteria your gastroenterologist may use to diagnose IBS. A careful history may identify dietary factors or medications that mimic or exacerbate symptoms of IBS. Routine laboratory tests including a basic blood count and chemistry panel are usually required. Flexible sigmoidoscopy or colonoscopy may be used to exclude inflammatory bowel disease or malignancy.

Though there is no known cure, the approach to therapy usually begins with patient education concerning the condition and its chronicity. A careful dietary history may reveal patterns of symptoms related to dairy and gas-producing foods which may need to be excluded from the diet. An increase in fiber is generally recommended, either through diet or the use of bulking supplements. Increase of water intake and regular exercise are encouraged.

Certain medications, over the counter and/or prescription, may be used. Common agents used for abdominal pain, gas, and bloating include dicyclomine (Bentyl) and hyoscyamine (Levsin). Medications for diarrhea-prone IBS patients include loperamide (Imodium) and diphenoxylate (Lomotil). Tegaserod (Zelnorm), is commonly prescribed for constipation predominant IBS. Antidepressant medications are sometimes prescribed for their pain relieving properties independent of their mood improving effects. Your gastroenterologist will help decide which medication is best suited for your symptoms.

Diverticuosis, Diverticulitis

Diverticula are small pouches that bulge out from weak areas in the wall of the large intestine (colon). Each pouch is called a diverticulum. The development of diverticula in the colon is called diverticulosis. The tendency to have this condition increases with age. About half of people in developed countries age 60-80 and nearly all people over age 80 have some degree of diverticulosis.

It is thought to occur from increased pressure generated in the colon. The increased pressure is generally thought to be a result of harder stools from a lack of adequate fiber in the diet. Many people with diverticulosis, however, have never complained of constipation and report normal or even loose stools.

For the large majority of patients, diverticulosis is painless and never causes symptoms. If diverticulosis is found, a doctor will recommend an increase in dietary fiber and/or a fiber supplement. The goal in patients with no symptoms is to 1) prevent the development of more diverticula that might increase the risk of a complication or 2) prevent diverticulitis, an inflammation or infection of a diverticulum that can be serious. The current daily recommendation of dietary fiber is 20 – 35 grams. This can be achieved by eating high fiber foods such as fruits, vegetables and whole grain products. If this can not be achieved by diet, supplementing the diet with fiber supplements is recommended.

The cause of diverticulitis is not known with certainty, but is generally believed to be a result of stool or bacteria becoming trapped within a diverticulum. This results in swelling of the diverticulum and inflammation (diverticulitis). Abdominal pain (especially on the left side) is the most common symptom. Other symptoms may include cramps, constipation, fever, chills, nausea and vomiting. Most patients will respond to antibiotics, pain relievers and bowel rest. Other diseases can cause similar symptoms, so it is best to see your doctor for evaluation and treatment.

Other complications of diverticulosis can occur. They include bleeding, abscess, perforation and fistula. Bleeding results when a vessel on the edge of a diverticulum ruptures, producing a moderate to large amount of red bloody stool. It is frequently painless. If this is suspected, you should see your doctor. Most of the time, the bleeding will stop by itself, but in some cases, surgery is required to remove the involved area. Colonoscopy is typically performed once the bleeding slows or stops to identify the cause and location of the bleeding.

If a diverticulum ruptures, it can result in the formation of a walled off pus collection called a diverticular abscess. Often, these are drained by an interventional radiologist. Once the infection is under control, surgery will be required to remove the diseased area of the colon. If the infection does not wall itself off after a perforation, a person may develop peritonitis. This is an inflammation that can spread throughout the abdomen and usually requires urgent or emergency surgical treatment.

Sometimes an inflamed diverticulum will burrow through the wall of a nearby organ such as the urinary bladder or the vagina. This abnormal connection is called a fistula and requires surgical repair in most cases.

Intestinal obstruction can also be caused by diverticular disease. This is a blockage of the large intestine as a result of narrowing from scar tissue, inflammation or a combination of both. If complete blockage occurs, surgery is required as an emergency. If only partial blockage is present, surgical intervention can be planned according to the degree and severity of the partial blockage.

Surgery may be necessary if a person has repeated episodes of diverticulitis. The diseased portion of the colon is removed electively to help prevent future attacks and complications of diverticulitis.

For more information about diverticular disease you may want to consult a medical textbook or the internet or ask your doctor. The internet address for the National Digestive Disease Information Clearinghouse is www.digestive.niddk.nih.gov.

Ischemic Colitis

Ischemic colitis is a condition characterized by poor blood flow to the colon. Most of the time no obvious large blood vessel occlusion is noted, but we think the very small arteries to the colon may be blocked by fatty atherosclerosis, blood clots, or even emboli (small clots or fatty deposits) which lodge in the blood vessels. Spasm of the arteries may also cause this condition. Risk factors for ischemic colitis include diabetes, hypertension, smoking, and possibly high cholesterol.

The usual symptoms are crampy abdominal pain, usually of the left side, associated with bloody, sometimes loose stool. Ninety percent (90%) of patients that get ischemic colitis are older than 60 years of age. Most of the time all that is needed is supportive care, such as intravenous fluids and antibiotics, but some patients may need surgery if the occlusion is severe and part of the bowel wall becomes gangrenous.

Microscopic Colitis

Microscopic colitis is a general term used to describe a disorder of the colon that causes chronic diarrhea, and in severe cases significant abdominal pain and weight loss. There are two subtypes of microscopic colitis, collagenous and lymphocytic colitis. The diarrhea can be explosive and unpredictable but is usually non-bloody. The cause is unknown and the colon looks normal during colonoscopy but biopsies show the microscopic inflammatory changes that are felt to cause malabsorption leading to the described symptoms. This is a benign condition that does not require surveillance colonoscopy (differing from ulcerative colitis and chrohn’s colitis) as it does not cause an increased risk of colon cancer. Several treatments are available ranging from anti-diarrheal medications such as immodium or pepto bismol to anti inflammatory medications such as asacol or steroids in more severe cases. There is no known cure for this disorder. The symptoms of microscopic colitis tend to come and go in an unpredictable and often frustrating fashion.

Colon Polyps and Cancer

Over 130,000 new cases of colon cancer are diagnosed yearly in the United States. Colon cancer is the second most common cause of cancer-related death. Cancer cells do not develop from normal cells in the colon in most cases, rather normal cells develop abnormal changes in them and become "adenomas." Adenomas are small growths called polyps in the colon. If these are detected early and removed, colon cancer does not develop. Once a polyp (adenoma) develops, it may take up to 10 years for it to grow and finally degenerate into a cancer, so there is sufficient time for polyps to be detected and removed. This is why it is so important to have: 1) yearly check of the stools for occult blood (blood which cannot be seen with the naked eye yet), and 2) a sigmoidoscopy (viewing with a small tube up into the colon) every three years once one is beyond the age of 50. Unfortunately, if colon cancer is not detected in the early stages, it spreads beyond the colon and adequate treatment is not effective to provide a cure. If a person is beyond the age of 50, he should see his doctor to have a sigmoidoscopic examination and his stool checked yearly for occult blood. If one has a family history of colon cancer, he should inform his doctor of this and screening should start earlier. A complete evaluation of the colon should be done. Symptoms, which occur in association with colon cancer can be abdominal pain, distention, constipation, diarrhea, rectal bleeding, and anemia (usually associated with fatigue and weakness).

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	How Your Colon Works The Colon, also known as the large intestine or bowel, is a muscular tube approximately 5-6 feet long. Its job is to remove water from food and expel solid waste or stool through the rectum.
What Are Colon Polyps? Polyps are an overgrowth of tissue lining the inner wall of the colon. These may be mushroom shaped (pendunculated) or flat (sessile). Small polyps are usually harmless but may contain abnormal cells that have the potential to grow and become cancerous. The larger the polyp the greater the risk of malignancy (Cancer).
What Causes Colon Polyps? Since the cause of Colon Polyps is probably multiple, it is difficult to know how to prevent them. The following individuals are at a greater risk to develop polyps. Age 40 and Over First degree relative (mother, father, sister, brother, child) with history of colon polyps or colorectal cancer. Colorectal Cancer Colorectal cancer is the second most deadly cancer and kills more people yearly than breast or prostate cancer. The good news - with proper screening, this disease can be prevented.
Key to Prevention - Removal of Polyps Most polyps can be removed safely by colonoscopy before they become cancers. This exam can detect up to 97% of all polyps and cancers. After thorough cleansing of the colon, an outpatient exam is preformed with medication to make you sleepy and ease abdominal discomfort.
	A flexible, lighted tube (endoscope) with a camera allows the physician to view the colon on a video screen. Polyps may be removed by a wire snare placed tightly around the base. Cautery is used as the polyp is cut off to prevent bleeding. All tissue retrieved is sent to the lab, for examination and to determine proper follow-up.
Colonoscopy Risks Complications are rare but include: Possible reaction to medication Bleeding Perforation (a tear or hole which requires surgery to repair) Alternative Screening Exams Though colonoscopy is considered the "Gold Standard" in diagnosis of colorectal cancer, some insurances may not cover this exam without symptoms (example - rectal bleeding). The American Cancer Society recommends the following screening options if colonoscopy is not an option. At Age 50: Fecal Occult Blood Test Yearly with Sigmoidoscopy every 5 years (views approximately 1/3 of colon) or double Contrast Barium Enema every 5-10 years. If polyps are found by sigmoidoscopy or x-ray colonoscopy must be performed to remove them. Colon Cancer Prevention Screening is the best method to prevent colorectal cancer. In addition the following lifestyle changes are encouraged: Eat more fiber Eat less fat Exercise regularly Quit Smoking Maintain a healthy weight Alcohol in moderation Please see your physician regarding any questions from this brochure. [Back to Top]

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