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Common colorectal and surgical conditions

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Anal Fissure

Anal Fissure

An anal fissure is a persistent tear in the lining of the anal canal that does not heal on its own and typically reaches to the border of the anus. It’s generally found inside the anal canal and cannot be felt by touching with the finger.

The most frequent indications of this condition are intense pain in the anal area and bleeding while having a bowel movement. These symptoms arise when the anal fissure is stretched as stools pass through. Occasionally, patients may detect a small extra piece of skin, called a Sentinel Skin Tag, located at the edge of the anus, which typically appears with an anal fissure. This skin tag is usually painless and can be removed during surgery for the anal fissure.

Most individuals with an Anal Fissure usually report an episode of passing hard stools that preceded the development of symptoms. It is postulated that the passage of hard stools may have caused an acute tear that subsequently develops into a chronic non-healing anal fissure.

The development of anal fissures usually occurs in a subset of susceptible patients, namely those with high resting anal muscle tone. This is however not a conscious nor voluntary action on the part of the individual. As a result of the high resting anal pressure, the anus will get overly stretched out during the passing of motion and hence leading to an acute tear. Due to a decreased blood supply from the high resting anal pressure, the tear does not heal and ends up as a chronic non-healing tear.

Treatments for Anal Fissure

There are two types of treatments available for anal fissures – pharmaceutical (using medication) and surgical. Typically, medication is the initial choice for patients and surgery is only recommended for those who do not respond to medication or experience recurring anal fissures.

There are two common medications prescribed to treat anal fissures that work by relaxing the anal muscle and promoting healing. The success rate for medication treatment is over 60%, although recurrence of the condition is common after completion of the treatment.

Surgery is considered as a secondary treatment option for anal fissures when patients do not respond to or experience adverse effects from medication. Additionally, surgery may be recommended for patients who experience recurrent anal fissures despite completing medication treatment. The specific type of surgery used for this condition is called Lateral Sphincterotomy, which involves cutting a portion of the anal sphincter muscle to disrupt the muscle ring and reduce the resting anal tone. During the same procedure, the skin tag can also be removed. It is worth noting that there is a small chance of flatus or gas, as well as occasional leakage of liquid stool from the anus following this surgery.

Anal Fistula

Anal Fistula

An Anal Fistula refers to an atypical tunnel or path that connects the anal canal (anus) to the skin of the buttocks. In healthy individuals, this tunnel does not exist, and fecal matter within the anal canal should be contained within it.

The primary symptom of an anal fistula is typically staining of underwear, with many patients seeking medical attention after noticing yellowish stains or a small amount of feces on their underwear. This is often misdiagnosed as fecal incontinence, but the age of the patient can serve as a giveaway, as fecal incontinence typically affects the elderly or those who have undergone previous anal surgery.

The second most common symptom is the presence of a small pimple-like lump near the anus or on the buttock, which may be minimally tender. Some patients may report having discharged yellowish fluid or feces from the lump.

An anal fistula often begins with an infection that originates from the anal glands in the anal canal and progresses towards the skin of the buttock. This infection can cause a swollen pocket of infected tissue and liquid called a perianal or ischiorectal abscess, which can either rupture spontaneously or require surgical drainage. In some cases, the initial channel remains open, resulting in the formation of a permanent abnormal channel that connects the anal canal and the skin.

Crohn’s Disease is an underlying condition that can cause anal fistulas in a small number of cases, and patients with this disease may experience multiple fistulas that do not heal.

Available Treatments for Anal Fistula

The most common and effective treatment for anal fistulas is an anal fistulotomy. This procedure involves opening up the fistula tract and cleaning it to promote healing. During the surgery, part of the anal sphincter muscle is divided in order to maintain fecal continence. However, if the surgery is performed carefully and the muscle is not divided too much, the risk of fecal incontinence is minimal.

The LIFT (Ligation of Inter-Sphincteric Fistula Tract) procedure is a technique developed by Prof Arun Rojansakul. here is minimal risk of faecal incontinence when dealing with complex fistulas or high fistulas.

The two-stage surgery approach with Seton is to insert a suture or rubber band through the fistula channel, anal canal, and external skin. This involves placing the seton in the first stage and performing either a fistulotomy or a LIFT procedure in the second stage. The goal of using a seton is to gradually reduce the channel by allowing the suture or rubber band to cut into it over time. This increases the likelihood of success and reduces the likelihood of complications in the second surgery.

This will require regular washing during baths and after passing motion. No particular dressing is required except for a pad to be placed over the underwear to soak up any discharge from the wound.

A LIFT procedure involves a much smaller wound with the same type of care as above. A seton does not require much care other than regular washing and to avoid tugging on the suture or rubber tie.

Buttock Abscess

Buttock Abscess

An abscess in the buttock area is a buildup of pus that can occur either on the surface of the skin or deep within the buttock fat. There are three types of buttock abscesses: perianal abscess, ischiorectal abscess, and superficial skin abscess.

Perianal Abscess
A perianal abscess is located on the skin surface next to the anus and usually presents as a tender lump with pus discharge. It results from infected anal glands within the anal canal, and the infection tracks to the skin surface, forming a collection of pus.

Ischiorectal Abscess
An ischiorectal abscess is a deep abscess that arises within the fat tissue of the buttocks. It often causes deep-seated pain and fever without any discharge of pus. It is difficult to diagnose and may require a consultation with a general surgeon. It also arises from infected anal glands and tracks further from the anus to end up in the deep fatty tissues of the buttocks.

Superficial Skin Abscess
A superficial skin abscess can occur anywhere on the buttocks, and the patient can feel a tender skin lump that is often red and may have pus discharge. It is usually caused by a break in the skin, which allows bacteria to infiltrate. In diabetics, these abscesses can arise spontaneously without any obvious skin damage.

Pilonidal Abscess
A pilonidal abscess occurs exclusively at the region of the natal and buttock clefts. The natal cleft is the ‘valley’ between the buttocks overlying the ‘tail bone’ of the spine and the buttock cleft is the corresponding ‘valley’ between the fleshy parts of the buttocks. The patient will experience a tender and red skin lump on either side of the cleft region,corresponding to an abscess. Some patients may, however, experience a pimple-sized nodule with occasional discharge of small amounts of pus for weeks on end. The pilonidal abscess has a unique underlying cause. Most pilonidal abscesses occur in individuals with heavy hair growth at the buttock and cleft regions. The pilonidal abscess starts with ingrown hairat a depth ofof the ‘valley’ of the clefts that eventually form tiny hair pits. The hair pits can be identified during a specialist consult as it manifests as small pinpoint holes in the clefts. The infection then spreads from these pits to both sides of the clefts to form an abscess.

All buttock abscesses need urgent treatment to allow the pus to be drained completely. This is accomplished through a minor surgery under general anaesthesia. The surgeon makes an incision/cut on the abscess to allow the pus to drain out with subsequent packing of the open wound with a special dressing material. In severe cases, the surgeon will need to remove part of the unhealthy and dead skin overlying the abscess and this will result in a bigger wound.

It is vital for the wound to be left open and not stitched up. Stitching up the wound will re-create the abscess cavity and allow pus to re-accumulate. The wound needs to be allowed to heal from the bottom up and this healing process will take at least 2 weeks.

Superficial Skin Abscess
The superficial skin abscesses usually heal with no further recurrences, except for diabetics with poorly controlled sugar levels who may have recurring abscesses.

Perianal and Ishiocorectal Abscess
The perianal and ischiorectal abscesses arise from infected anal glands with subsequent tracking of the infection to distant areas. In up to 37% of patients with either of these conditions, the track may remain patent/open instead of closing up. As a result, there is a small communication/tract between the anal canal and the buttock skin, resulting in regular but small amounts of discharging pus from the skin and occasionally repeated development of abscesses.

Pilonidal Abscess
The initial operation to drain the pus from the abscess is the first step in the treatment of pilonidal disease. As mentioned above, the root of the problem lies in the hair pits located in the natal and buttock clefts. Removal of the hair pits is essential in ensuring a long-term cure.
The surgical techniques available include Fistulotomy with marsupialisation of skin edges, Karydakis flap procedure, Bascom procedure or a rhomboid or buttock rotation flap procedure.

Colon Cancer

Colon Cancer

In Singapore, treatment and surgery options are available for colon cancer, which is a type of cancer that develops in the colon. It should be distinguished from rectal cancer, which occurs in the rectum. Together, they are referred to as Colorectal Cancer. The colon is made up of different sections, including the ascending colon, transverse colon, descending colon, and sigmoid colon, and any cancerous growths in these areas are considered colon cancer.

Colon cancer is typically diagnosed through a colonoscopy, which is a procedure used to examine the colon for cancerous growths. Some patients may undergo a colonoscopy due to symptoms that suggest cancer, while others may have a screening colonoscopy even without symptoms. During the procedure, biopsies can be taken to confirm the diagnosis of colon cancer. In some cases, colon cancer may be found incidentally during a scan performed for another reason, and a colonoscopy may be recommended to confirm the diagnosis.

The treatment of colon cancer in Singapore involves two main components: Surgery, as well as Chemotherapy and/or Radiotherapy. If the cancer has not spread, surgery is the first-line treatment. This means that the cancer is still confined to the colon and the nearby lymph nodes. During surgery, the affected portion of the colon is removed and the two ends of the colon are joined together (anastomosis). This procedure eliminates the cancer while allowing the patient to have normal bowel movements.

Surgery for colon cancer can be performed in two ways: Keyhole (laparoscopic) or open surgery. Both methods involve the same basic steps of removing the tumor and lymph nodes, and reconnecting the colon to restore fecal flow.

In Keyhole surgery, specialised instruments with long shafts and grasping jaws are used to replace the surgeon’s hands. Energy devices and staplers are also used during the procedure. Keyhole surgery is carried out through three to five small incisions on the abdomen, ranging in size from 5mm to 15mm. An additional incision of approximately 5cm is needed to remove the cancerous segment of the colon.

The procedure involves freeing the affected segment of the colon from its original position, sealing off the major blood vessel supplying the tumor, and cutting off the segment with a 5cm margin from the tumor. Since it is not possible to separate the tumor from the colon, a portion of the colon must be removed. After removing the affected segment, the two ends of the colon must be rejoined to restore normal fecal flow. This is achieved by either using specialized surgical staplers or stitching the two ends of the colon together by hand.

During the Hospitalisation phase, which lasts between 3-10 days, patients resume normal diets gradually over a period of 3-4 days. Patients may have a surgical drain leading out from the abdomen or a nasogastric tube for the first few days to allow drainage of fluids. All patients will have an intravenous cannula for administration of fluids and medications. After an average hospital stay of 4-5 days, patients will be discharged to recover at home.

It will take around 1-3 months for the patient to recuperate. During this time, patients may experience fluctuating bowel movements before establishing a regular pattern at around 6 months after surgery. Surgical wounds typically heal after two weeks, and bathing can usually resume the day after surgery. Patients may feel weaker after surgery but can expect to return to pre-surgery energy levels within 1-2 months.

Emergency surgery for colon cancer is typically performed in cases of tumour perforation or obstruction. Perforation can occur when the tumour erodes through the colon or causes the colon to tear. Emergency surgery is required in these situations because of the presence of faeces and pus in the abdomen. This surgery is usually open, and there is a high chance that a stoma will need to be created. Obstruction occurs when the tumour’s excessive growth causes a blockage in the colon, preventing the normal flow of faeces. There are two options available for treating obstruction: immediate emergency surgery or non-operative management with decompression tubes. Emergency surgery is typically open and may be required in urgent cases.

Colonic/Rectal Polyps

Colonoscopy

Polyps are growths that protrude from the internal lining of various organs, such as the nose, stomach, colon, and gallbladder. They resemble bumps or pimples on the skin and can be classified into different types. While some polyps are benign and do not increase the risk of developing into cancer, others are benign but have the potential to become cancerous. The mucosa, which is the internal lining of the colon and rectum, is where colonic and rectal polyps form. Both of these parts of the gastrointestinal tract share similar characteristics.

Polyps in the colon and rectum are growths that protrude from the inner lining of these organs. Polyps often emerge later in life as a result of damage caused by factors such as aging and diet. This damage leads to genetic mutations in the lining cells, which, in turn, causes polyps to form.

Colonoscopy can be done either for screening purposes or if someone shows concerning symptoms. Symptoms that may warrant a colonoscopy include rectal bleeding, persistent changes in bowel habits, unexplained abdominal pain, unintended weight loss, and the sensation of incomplete bowel movements. These symptoms may occur alone or in combination. For individuals aged 45 and older who don’t show symptoms, a colonoscopy may be performed as a screening test. Colonoscopy helps to identify polyps or cancerous tumors at an early stage, which increases the chances of a successful cure. The colonoscopy procedure is the same for both screening and symptomatic patients.

Small and flat polyps are typically removed using a biopsy forceps or snaring. A snare is also used to remove polyps with a stalk. Both these tools can be used with a cold cut technique or diathermy to minimise bleeding risk. Endoscopic Mucosal Resection (EMR) is a specialised technique used for removing larger flat polyps. Pedunculated polyps may require a clip to be placed across the stalk to prevent bleeding after snaring. With colonoscopy, polyps that are 2-3cm in size or smaller can be removed without the need for major surgery.

Colonoscopy is a safe procedure that requires bowel cleansing the day before. Bowel cleansing involves taking bowel laxatives and passing multiple stools, and it’s crucial to stay hydrated throughout the process. On the day of the colonoscopy, the patient is given sedation in the endoscopy room. The endoscopist inserts a scope through the anus and navigates it through the large intestine to the caecum. The scope is slowly withdrawn while the colon lining is carefully inspected for polyps or suspicious lesions, which will be removed or biopsied as necessary. It’s important to note that the inspection is performed during withdrawal, not insertion. Additionally, the procedure may include ligation of piles at the end if needed.

Colonoscopy is a safe procedure with a low risk of serious complications. The two most severe complications, perforation and bleeding, occur at a rate of 0.1% each. Colonoscopy is also the most accurate and dependable method for colon examination, with a miss rate for significant abnormalities of less than 5%.

Haemorrhoids

Haemorrhoids

Haemorrhoids, also known as piles, are swollen tissue cushions located in the anus caused by enlarged or congested blood vessels. They can be mistaken for skin tags but originate from inside the anus, while skin tags develop in the skin surrounding the anus. There are two types of haemorrhoids: internal and external. Internal haemorrhoids are situated in the lower rectum, while prolapsed internal haemorrhoids protrude from the rectum and extend outward from the anus. External haemorrhoids emerge beneath the skin around the anus and can be more painful because the skin covering them can become inflamed and wear away.

Haemorrhoids or piles can cause symptoms such as an itchy anus, the feeling of needing to go to the toilet even after passing stool, bright red blood after bowel movements, mucus in underwear or on toilet paper after wiping, and lumps or pain around the anus. Causes of haemorrhoids can include constipation, prolonged straining during bowel movements, heavy lifting, and pregnancy.

Haemorrhoids commonly cause bleeding during bowel movements, and it is important to seek medical attention if this symptom persists. It is especially crucial for individuals over 40 years of age to get an accurate diagnosis through a colonoscopy, as bleeding from colon or rectal tumors can be mistaken for haemorrhoidal bleeding. If symptoms persist for a week or more, it is recommended to consult a doctor. Medical attention should also be sought if additional symptoms are present, such as a high temperature, pus leakage from the haemorrhoids, continuous bleeding, large blood clots, or severe pain.

Haemorrhoids or Piles treatment in Singapore

Rubber band ligation is a quick and relatively painless clinic procedure for treating haemorrhoids in Singapore. It involves placing rubber bands around the haemorrhoids to cut off their blood supply, causing them to shrink and fall off within a few days to two weeks.

Stapled haemorrhoidectomy is a surgical procedure that uses a circular stapler to remove a 1cm ring of the anal lining containing the blood vessels supplying the haemorrhoids. The edges of the cut anal lining are then stapled together. Two common systems used for this procedure are the PROXIMATE® PPH system by Ethicon and EEA™ system by Medtronic.

THD (transanal haemorrhoidal dearterialisation) and HALO (haemorrhoid artery ligation operation) procedures use a specially designed ultrasound probe to locate the feeding vessels of the haemorrhoids. The vessels are then closed off with surgical stitching in the anus. These procedures are more suitable for patients with predominantly bleeding symptoms and minimal prolapse of haemorrhoids. The THD® Doppler Surgery system and the HALO™ system are commonly used in Singapore.

The Conventional haemorrhoidectomy is considered the standard against which all new hemorrhoidal surgery procedures are compared. This method has been used for over fifty years and is the only option available for large third-degree and fourth-degree hemorrhoids. The procedure involves surgically removing the haemorrhoids using diathermy, and the wound can be left to heal on its own (Milligan-Morgan method) or stitched up (Ferguson method), with each method having its own advantages and disadvantages.

Variants of the conventional haemorrhoidectomy method include the Harmonic or LigaSure Haemorrhoidectomy, which use the LigaSure™ surgical sealer or Harmonic® ultrasonic scalpel instead of electrical diathermy to reduce the risk of post-operative bleeding. It is important to discuss with a haemorrhoids surgeon to determine the best treatment option for an individual’s condition.

Gallstones

Gallstones

Gallstones are stones that form in the gallbladder and there are two main types: cholesterol stones and pigment stones.

Cholesterol stones are the most common type, accounting for over 90% of cases in Singapore. These stones develop when there is an excess of cholesterol in the bile, leading to the formation of cholesterol salts that eventually crystallise and create stones. Having high blood cholesterol levels does not necessarily increase the risk of developing gallstones. Both individuals with and without high cholesterol levels are equally likely to develop cholesterol stones, which typically occur in people over the age of 30.

Pigment stones are a less common type of gallstone and are caused by high levels of bilirubin in the bile. This happens due to the breakdown of red blood cells and is commonly seen in people with red blood cell disorders such as thalassemia, sickle cell anemia, and hereditary spherocytosis. Pigment stones tend to occur in younger people, typically in their 20s to early 30s.

The majority of people with gallstones do not experience any symptoms, and the condition is usually discovered during diagnostic imaging for other unrelated issues. However, those who do experience symptoms often report a range of discomforts that occur after eating, including mild discomfort, bloating, or severe pain. These symptoms typically occur in the upper central or right upper quadrant of the abdomen.

Some individuals with non-symptomatic gallstones will go on to develop pain or complications in their lifetime. This occurs at a greater percentage in the first five years after the discovery of the gallstones.

Cholecystectomy, or gallbladder removal surgery, is mostly done using laparoscopic techniques, which involve making small incisions in the abdomen. This method has several advantages, including smaller wounds, less stress on the body, shorter hospital stays, less post-operative pain, and lower wound infection rates. During the procedure, four small incisions are made, with the largest one at the belly button and the others ranging from 5-8mm in length. The entire gallbladder, along with any gallstones, is removed through these incisions. The cystic duct, which connects the gallbladder to the common bile duct, is closed off with surgical clips, and the gallbladder does not regrow after the surgery.

Irritable Bowel Syndrome

Irritable Bowel Syndrome

IBS is a functional disorder of the gastrointestinal tract (intestines) whereby the sufferer experiences various degrees of abdominal pain and change in bowel motion habits. The term ‘functional’ refers to the fact that there are no abnormalities found on either various types of scans or endoscopy.

There is a wide spectrum in the symptoms of IBS. In addition, as many of these symptoms are fairly vague and non-specific, many patients with IBS may have been labelled as ‘tummy colic’ or ‘non-specific pain’ or even as ‘psychological pain’.

Generally, the symptoms of IBS can be divided into two categories, namely that of abdominal pain and a change in motion habits and stool consistency.

Abdominal Pain
The symptoms of abdominal pain can range from the milder symptoms such as occasional abdominal discomfort to intermediate symptoms such as abdominal bloatedness with a visible increase in tummy size to severe symptoms such as bad abdominal cramps that affect work and lifestyle. The abdominal pain is often related to the passing of motion, whereby some suffers experience pain relief after passing motion while others have increased pain after motion. Abdominal bloatedness is often associated with belching or passing wind from the bottom.

Change in Motion Habits and Stool Consistency
The symptoms of change in motion habits and stool consistency can, in turn, be subdivided into sufferers with diarrhoea symptoms or constipation symptoms. Sufferers with diarrhoea may experience multiple episodes of loose bowel movements, usually of small amounts each time. This contrasts with the diarrhoea associated with food poisoning whereby there are large amounts of stools. Suffers with constipation will often pass small, hard, and often pellet-like stools. Also, they may pass motion only once every few days to once a week. Common to both subgroups are the symptoms of passing mucus (clear discharge) with stools and the sensation of incomplete passing of motion and a burning sensation in the bottom after passing of motion.

The proposed main causes of IBS include abnormal movements and contractions of the gastrointestinal tract, increased sensitivity to pain and gaseous distension, silent inflammation in the gastrointestinal tract, changes in the composition of gut bacteria, dietary factors such as sensitivity to certain food groups, and psychological factors.

Research has identified various potential causes of IBS. One proposed factor is abnormal contractions and movements of the gastrointestinal tract, which can be prolonged and frequent in individuals with IBS. Another factor is changes in gut bacteria composition, which can result from factors such as food poisoning, and may be improved with probiotic supplements. Psychological factors, such as high levels of stress, anxiety, or depression, may also contribute to IBS symptoms, as certain hormones secreted during these states can impact the gastrointestinal tract.

IBS treatment involves lifestyle changes and medication, which is tailored to the individual patient due to the variable underlying causes and symptoms of the condition. Surgical intervention is not necessary for IBS. Stress reduction measures and avoiding certain foods, such as high FODMAP, lactose, and gluten-containing foods, can also be helpful. Medical treatment differs for constipation and diarrhea subtypes, with laxatives and stool softeners used for constipation, and anti-diarrheal medication for diarrhea. However, finding the right combination of medications may require trial-and-error.

Hernia

Hernia

A hernia is when an internal organ pushes through a weakened area in a muscular wall, causing it to protrude. They are common in areas such as the abdomen, hips, and chest. There are various types of hernias, including inguinal, epigastric, incisional, hiatal, and umbilical hernias, which are frequently found in Singaporeans.

  1. Inguinal hernia – An inguinal hernia happens when an internal organ protrudes through a weakened area in the muscular wall, resulting in a bulge.
  2. Epigastric hernia – An epigastric hernia occurs when a portion of the intestine protrudes through a weak spot in the stomach or abdominal muscles, causing a bulge or lump in the affected area.
  3. Incisional hernia – An incisional hernia occurs when a surgical wound, typically from an abdominal surgery, does not heal properly and leads to a weakness or hole in the abdominal wall. This can cause tissues, such as the intestine or organ, to protrude through the weakened area and result in a hernia.
  4. Hiatal hernia – An hiatal hernia occurs when a portion of the stomach protrudes through the diaphragm and into the chest cavity.
  5. Umbilical hernia – An umbilical hernia occurs when a section of the intestine protrudes through a weak spot or a gap in the abdominal muscles around the navel or belly button, causing a bulge or swelling.

Hernias can affect both children and adults in Singapore, caused by weakened muscles present since birth or weakened due to trauma, pregnancy, or obesity. The increased pressure can create a gap and cause an organ to bulge out through the muscular wall, which may disappear or be pushed back in certain positions. However, hernias should be treated immediately as they can be life-threatening. Hiatal hernias, which occur internally, do not show external signs. Possible causes of hernias include repeated strain on abdominal muscles, age-related muscle weakening, trauma, and heavy smoking.

Hernias are a common condition in Singapore, and older adults and males have a higher risk of developing them. Children as young as 0 to 5 years old can also have hernias. Smoking can weaken the abdominal wall and increase the risk of hernias, as well as make surgery and healing more difficult. It is important to be aware of any symptoms and seek medical attention promptly to prevent complications.

Hernias can be treated with open or laparoscopic surgery, both of which aim to repair the abdominal wall and place the organ back into its correct position. Open surgery involves making a cut in the affected area and using stitches or synthetic mesh to strengthen the abdominal wall. Laparoscopic surgery is a minimally-invasive surgery that uses a laparoscope to access the area through a small incision at the belly button. This procedure is less painful and has a shorter recovery time compared to open surgery.

Hernias cannot be treated with medications alone and may lead to complications if left untreated. Additionally, hernias can cause discomfort and limit physical activities, such as lifting heavy objects, exercising, and traveling. Surgical intervention is often necessary to repair the hernia and prevent further complications.

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a condition where stomach acid constantly flows back into the esophagus. The acid reflux can cause irritation to the lining of the esophagus. GERD is a common condition and can be managed with lifestyle changes, medications, and, in some cases, surgery. If an individual experiences persistent symptoms of GERD, it is important to seek medical help as soon as possible, as this can lead to complications such as esophageal ulcers, strictures, and even cancer.

Some of the common symptoms of GERD include a burning sensation in the chest (also known as heartburn) after eating, having the sensation of acid or food coming back up into the throat or mouth, acid reflux (or regurgitation) after eating, difficulty swallowing, or feeling like there is a lump in the throat.

Factors that may increase the risk of getting GERD are ageing, pregnancy, obesity, over-eating, or taking medications which may irritate the gut. These include ibuprofen, naproxen, iron salts, aspirin and potassium chloride. Eating too quickly or very close to bedtime, or eating foods high in fat, garlic and onion might cause the condition too.

Individuals who experience chest pain, persistent cough, difficulty swallowing, vomiting, or constant regurgitation of food and stomach acid, should seek medical attention. The healthcare provider can diagnose the condition through a series of tests, such as upper endoscopy, or x-ray of the upper digestive system. Medications such as antacids and alginates can help to neutralise stomach acid and protect the gut from gastric acid. If medicaiton does not help to improve the condition, the doctor might recommend surgery.

Gastritis

Gastritis

Gastritis occurs when the lining of the stomach is eroded or inflamed, causing discomfort or pain in the upper abdomen.

Some of the common symptoms of gastritis include upper abdominal pain, nausea and/or vomiting, bloating, heartburn or acid reflux, indigestion, dark or tarry stools.

Gastritis could be caused by the Helicobacter pylori (H. pylori) bacteria which infects the stomach lining. Other causes could be the regular use of nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen and naproxen. Autoimmune disorders in which the immune system attacks the cells of the stomach lining, could be a cause of gastritis too.

Gastritis can be treated with antibiotics and antacids. Some lifestyle changes such as avoiding smoking and excessive drinking of alcohol can also reduce the risks of gastritis. It is important to seek the advice of a Specialist if the symptoms are severe and persistent.

Anorectal Prolapse

An anorectal prolapse (rectal prolapse) is a condition that occurs due to the weakening of muscles and ligaments around the rectum—the last part of your large intestine, causing the rectum to protrude out of your annual opening.

Anorectal prolapse can cause symptoms such as incontrollable bowel movement, constipation or loose stools, a pressured feeling or bulge in your anus, blood or mucus leakage, anal pain or itching.

Although the symptoms of anorectal prolapse and haemorrhoids can be similar, anorectal prolapse involves the entire segment of the bowel, which is chronic and progressive. Causes of anorectal prolapse include constant strain during bowel movements, pregnancy or ageing.

Anorectal prolapse can be treated with open or laparoscopic or surgery. In open surgery, an incision is made in the affected region, and stitches or synthetic mesh are employed to reinforce the abdominal wall. Laparoscopic surgery, a minimally invasive procedure, utilises a laparoscope to access the region through a small incision located at the belly button. This method is associated with reduced pain and a quicker recovery period in comparison to open surgery.

However, the method of surgery is dependent on one’s age, physical condition, extent of prolapse and the result of tests.

Anus Skin Tags

Typically found at the edge of the anus, skin tags are referred to the excess skin and lumps protruding from the anus. Skin tags may occasionally be mistaken for haemorrhoids, as they may cause pain or discomfort and bleed occasionally.

Anal skin tags are often the result of stretched or damaged skin in the perianal region, which can occur due to factors such as chronic straining, haemorrhoids, anal fissures (small tears in the lining of the anus), inflammatory bowel disease, and childbirth. They can also develop due to the healing process after certain surgical procedures.

Although anus skin tags are not harmful, excessive they can still cause symptoms such as pain, itch and discomfort. Over time, the excessive skin may grow due to repeated trauma or irritation.

If the anal skin tag is small and does not cause any disturbance or irritation, it can be left alone. Although skin tags are not harmful, it is not advisable to remove them at home as this may cause further complications such as infection and pain.

Where required, the excessive skin can be surgically removed easily. This is usually performed as a day case procedure.

Pernianal Abscess

A perianal abscess is a boil-like lump that contains pus, located near the anus, perianal region, or rectum.

Pus and discharge from a boil-like lump (akin to a pimple) near the anus is a common presenting symptom. Other symptoms include pain, bleeding and itch.

A perianal abscess often occurs when bacteria or stool particles become trapped in a blocked gland located in the anus, leading to an infection of the gland.

A sizeable or large perianal abscess is best treated with formal surgical drainage, and removal of any unhealthy and non-viable tissue in the area. Antibiotics may be required to treat the infection appropriately.

Piles during pregnancy

Piles, also known as Haemorrhoids, is a common condition during pregnancy, particularly during the third trimester and up to a month after childbirth. The tissue cushions in the anus become swollen due to enlarged and congested blood vessels.

Increased pressure of the foetus on the pelvic area, and constipation due to hormonal changes during pregnancy can cause the enlarged and congested blood vessels in the anal tissue cushions to swell and bleed.

Besides anal swelling, bleeding may be observed in the toilet bowl or on toilet paper after wiping. Other common symptoms may include persistent itch and discharge. In serious cases, large painful irreducible prolapsed piles may lead to further complications such as infection or ulceration.

Although piles during pregnancy are common, medical attention should be sought if the symptoms, such as bleeding, persist and/or worsen.

To ease the symptoms caused by piles during pregnancy, avoid prolonged standing or straining. Fibre and water intake can help with regular bowel movement. Certain cases may benefit from consultation with a specialist colorectal surgeon for individualised treatment.

Diverticular Disease

Diverticulosis of the colon: It is a precursor of diverticular disease and a common condition that is characterized by focal mucosal outpouchings (small pouches or sacs known as diverticula) from the colon.

While most patients with colonic diverticulosis are asymptomatic, some may experience symptoms due to complications such as infection, bleeding, and obstruction.

Diverticular disease encompasses a spectrum of conditions, including diverticulitis. Diverticulitis is a condition the focal mucosal outpouching(s) become infected or inflamed. Severe diverticulitis may result in abscess formation and/or perforation.

The symptoms of diverticular disease depends on the type and severity of complications arising from this condition.

Mild diverticulitis may present with mild to moderate abdominal pain, localized to the affected part of the colon, and fever. Severe or perforated diverticulitis is characterized by severe and/or generalized abdominal pain, and sepsis. Other symptoms include fatigue, nausea and vomiting.

Bleeding arising from colonic diverticular disease can range from small and self-limiting episodes to large volume bleeding with blood clots which will require urgent medical attention.

Other symptoms of colonic diverticular disease include bloating and change in bowel habit and/or stool calibre, which may warrant further investigations such as a computed tomography (CT) scan and/or colonoscopy.

Further complications of diverticular disease and diverticulitis include abscess formation, fistulation into adjacent organs such as bladder or small intestine, perforation, bleeding and intestinal obstruction.

Uncomplicated colonic diverticulosis does not require any treatment.

The treatment for diverticulitis may include the administration of antibiotics and a period of bowel rest. Localised abscesses may be amenable to percutaneous drainage under appropriate radiological guidance. Severe cases with sepsis may require surgery to resect the affected diseased segment of colon.

Functional Disorders including Bowel Incontinence

Bowel incontinence, also known as faecal incontinence, is the inability to control bowel movements, causing involuntary leakages. These leakages range from an occasional stool leakage when passing gas to a complete loss of control over liquid or solid stools.

Two types of bowel incontinence that may occur are urge and passive incontinence. Urge bowel incontinence is when a patient feels a sudden urge to go to the toilet but cannot reach the bathroom in time.

Another type of bowel incontinence is called passive incontinence or passive soiling, whereby there is no sensation felt before soiling or slight soiling occurring when passing gas.

This condition can affect people of any age and may be caused by a multitude of different underlying conditions including weakened or damaged anal sphincter muscles, nerve damage that might be associated with ageing or childbirth, diabetes mellitus, congenital disorders, neurological disease, previous anal surgery and anorectal prolapse.

The treatment of bowel incontinence is individualised to the patient, underlying cause, and the severity of the condition. This may include dietary modification, medication, anorectal biofeedback (bowel training), neuromodulation and injectable anal bulking agents. Surgical intervention, such as sphincteroplasty, may be required in suitable cases.

Hereditary and Genetic Colorectal Conditions

The two most common hereditary syndromes linked to colorectal cancer are: familial adenomatous polyposis (FAP) and Lynch syndrome.

Familial adenomatous polyposis (FAP): FAP is an autosomal dominant genetic condition characterized by a mutation in the APC (adenomatous polyposis coli) gene, where an individual develops more than 100 adenomatous polyps usually at young adulthood between the ages of 20-35 years. If these polyps are left untreated, there is a very high likelihood of developing colorectal cancer.

Lynch Syndrome: Lynch syndrome is also known as hereditary non-polyposis colon cancer (HNPCC) due to a mutation in one of the DNA mismatch repair genes including MLH1, MSH2, MSH6 and PMS2. Patients with Lynch syndrome have an increased risk of developing colorectal cancers at a younger age and other cancers such as endometrial, ovarian, and stomach.

Young individuals with a strong family history of cancers, especially associated with a younger age at diagnosis, may be at risk of hereditary cancer syndromes. Symptoms such as blood in stools, abdominal cramps, unexplained weight loss, fatigue, nausea and vomiting, diarrhoea and irregular periods of constipation, may warrant further investigation.

The management of hereditary colorectal conditions is highly specialised and individualised, depending on factors such as the specific genetic mutation, age and health condition of the patient, and stage of disease. Surgery may be required to remove part or whole of the colon.

Inflammatory Bowel Disease (IBD)

Inflammatory Bowel Disease (IBD) is characterised by chronic inflammation of the digestive tract. This includes Crohn’s disease and ulcerative colitis (UC). Chronic bowel inflammation puts the patient at a higher risk of developing colorectal cancer.

Crohn’s disease

In Crohn’s disease, inflammation of the bowel involves all the layers of the digestive tract (transmural inflammation), and this can affect any part of the digestive tract, from the mouth to the anus. The most commonly affected area is the lower part of the small intestine (ileum). The perianal region may be affected in some cases as well.

Ulcerative colitis

Ulcerative colitis (UC) refers to inflammation involving only the innermost layer (mucosa), often affecting the rectum, colon, and occasionally, the ileum.

Symptoms of IBD vary depending on the severity of inflammation and part(s) of the bowel affected. These may include abdominal pain, rectal bleeding or bloody stools, persistent diarrhoea, weight loss and fatigue.

The exact cause of IBD is unknown. It may be contributed by an inappropriate immune response among genetically susceptible individuals resulting in chronic inflammation of the digestive tract. It is believed that the combination of environmental and genetic factors triggers the body’s immune system to react and to produce an inflammatory response in the digestive tract.

Environmental factors

Lifestyle and diet choices may contribute to the development of IBD, such as tobacco smoking, the presence of certain bacteria in the gut and excessive consumption of sugar, saturated fat and processed food.

Genetic factors

Both UC and Crohn’s disease have a genetic predisposition, which puts individuals at higher risk of developing IBD should there be a significant family history.

IBD requires a multi-modality management with a team including gastroenterologists, colorectal surgeons, dieticians, nurses, radiologists and pathologist. The treatment is highly individualised, depending on factors such as the severity and extent of inflammation and nutritional status of the patient.

Appendicitis

The appendix is a small, worm-like pouch that protrudes out from the caecum (first part of the large intestine). It measures between 4-10 cm in length.

Inflammation of the appendix can occur due to bacterial infection, or blockage of the inner lining of the appendix due to a faecolith (hard lump of stool). This results in swelling, inflammation or even perforation.

Abdominal pain (either at the middle of the abdomen near the belly button, or in the right lower quadrant), nausea, loss of appetite, fever and abdominal swelling and tenderness are common symptoms.

Acute appendicitis can be treated with antibiotics and surgery. Appendectomy is a surgical removal of the inflamed appendix, most commonly performed using the laparoscopic approach with keyhole (small) incisions.