A GP quizzes an expert to take a medical issue beyond the textbook
Linden Ruckert is a GP in central London
is professor of gastrointestinal surgery at the Chelsea and Westminster Hospital, London
GP Dr Linden Ruckert in conversation with Timothy Allen-Mersch, professor of gastrointestinal surgery
Practical points l
New treatments for problematic haemorrhoids
Best treatment of
Pitfalls in surgery for pilonoidal sinuses
Advances in CT scanning may reduce need for colonoscopy
Adjuvent therapy in
Are there any new treatments for difficult haemorrhoids?
We see a lot of haemorrhoids in general practice and I wonder if we manage them optimally. What is the most effective management? We don't generally do proctoscopy should we?
The term haemorrhoid refers to veins within the anal canal, but the common use of the word haemorrhoids implies symptomatic haemorrhoids. Therefore, when referring the most relevant thing is the patient's symptoms rather than carrying out a proctoscopy to visualise haemorrhoids.
Often an episode of anal pain or bleeding on to the toilet paper will settle spontaneously and require no further treatment. Where symptoms persist then a stool softener such as Normacol granules one sachet daily maybe sufficient to allow symptoms to resolve.
Sclerotherapy (phenol injections) is controversial and some studies comparing it with stool softeners have shown no difference in outcome. There is also the issue of technical skill; injection in the wrong place can result in a prostatitis or autonomic nerve damage.
In my experience it does work for patients with uncomfortable second-degree haemorrhoids and I find it a useful treatment. Rubber-banding treatment provides a quicker resolution in patients with larger secondary haemorrhoids, but this can be an uncomfortable treatment.
The conventional operation for prolapsing haemorrhoids is the open haemorrhoidectomy. This produces good long-term results but is notoriously painful in the short-term.
A more recent development is the stapled haemorrhoidopexy which restores the prolapsing haemorrhoids into the anal canal, by excising a circular cuff of anal canal, and fixes them to prevent further prolapse. This is less painful often dramatically less painful so my threshold for undertaking the stapled haemorrhoidopexy is less than I had for the open procedure.
Again, it does require skill an inexperienced operator could, for example, staple a cuff of vagina and create a rectovaginal fissure.
Treatments for anal fissure and developments in IBS management
Do you have any advice on assessment of anal fissure? Why is my local provider using topical diltiazem?
Anal fissure usually occurs as a small split in the posterior midline of the anal canal and sometimes, particularly in women, can occur as a similar split in the anterior midline. Simple anal fissure does not occur away from the midline of the
anal canal; if an eccentrically placed fissure is seen an alternative diagnosis should be considered.
Acute fissure looks like a cut or abrasion, whereas a chronic fissure can resemble a shallow ulcer with thickened edges. Often there is an associated skin tag hanging down from the anal verge, the so-called sentinel pile. First-line treatment should be a preparation inserted into the anal canal to relax the anal sphincter. The most frequently used treatment is 0.2 per cent GTN, inserted twice daily into the anal canal for six weeks. If treatment is not continued for six weeks, the probability of the fissure resolving is reduced.
Six weeks' treatment produces healing in about 60 per cent of patients. GTN tends to produce a transient headache, so another smooth muscle relaxant (diltiazem) has also been advocated. Results are similar to use of GTN.
In those with persistent symptoms, anal sphincterotomy is usually advocated. This has a high probability of resolution of the fissure but there is a 5 per cent chance of detectable minor faecal incontinence. Because of this risk, attempts have been made to transiently paralyse the external anal sphincter with botulinum (Botox) in the hope that a transient paralysis would let the sphincter heal without impairing the external anal sphincter. This seems promising but is still experimental.
The older procedure of anal stretch has now been abandoned because of the unacceptable risk of incontinence.
Although it is classified as a medical condition you must see a lot of IBS too. Have there been any recent developments in its management?
Irritable bowel syndrome is a poorly understood condition. It is a constellation of symptoms including abdominal bloating, pain and fluctuating bowel habit. It seems to have a variety of triggers including stress, gastrointestinal infection, and perhaps gastrointestinal procedures.
There is no clear understanding of the cause of the symptoms and treatment is still at the rudimentary level of antispasmodic drugs.
Some recent studies have focused on the cerebral representation of pain experienced in IBS. These suggest specific areas of the brain are more active in those with IBS. Hypnosis appears to block the representation of this pain in the cerebral cortex but not in preventing increased activity from pain centres in lower areas of the brain.
In addition, immunological studies in the gut have shown a small but
significant proportion of IBS sufferers may have immunological or allergic-type reactions similar to those that are seen in coeliac disease.
Pitfalls in surgery for pilonoidal sinuses
Some patients now have pilonoidal sinus treated with primary closure, although these seem to break down post-operatively. I thought it was best treated by opening the tract and leaving it to granulate. Many abscesses seem to recur in a low-grade way is it unsatisfactory to treat?
Pilonoidal sinus disease can be relatively simple to treat but there is a significant minority of patients in whom symptoms are troublesome and persistent. These patients usually have deep natal clefts and are hirsute.
In patients with minor pilonoidal sinus disease, the Bascom's procedure, involving laying open the granuloma via a lateral incision with closure of the pilonoidal pit, is now the treatment of choice.
It is simple, can be done as a day case and produces reliable results, with healing usually taking place within a month.
However, those patients whose pilonoidal sinus appears likely to be more troublesome should be treated by an excision technique that flattens the natal cleft and achieves primary closure.
My practice is to use the Karadakis asymmetric primary closure, which produces healing within two months in virtually all cases, but similar results can be achieved using flap techniques and rhomboid flap techniques.
Patients with pilonoidal sinus should be treated in centres with appropriate expertise because the worst difficulties, involving prolonged periods of disability with open granulating and suppurating sacral wounds, usually result from treatment rather than the primary disease and are avoidable.
Is there anything you'd like to say in relation to inflammatory bowel disease?
Patients with known inflammatory bowel disease can develop exacerbations and de novo IBD can arise in patients with no previous history of symptoms.
GPs should be aware that any patient with colicky abdominal pain, swelling, and frequent diarrhoea needs careful assessment and review.
Although these symptoms might
arise from gastroenteritis there is a danger in leaving patients with these symptoms in the community for more than a few days.
I feel these patients should be assessed in hospital as delay, in a small group of patients, can lead to toxicity and overwhelming sepsis. Subsequent treatment then carries a significant mortality and morbidity.
Colon cancer: screening, prevention and treatment
Where are we with screening for colonic cancer?
Screening for colorectal cancer by faecal occult blood tests has been shown to reduce death rates by some 12-14 per cent. Despite this clear benefit, there have been difficulties in introducing a national screening programme, and these are being resolved in pilot studies. In addition, there is currently a large screening study of flexible sigmoidoscopy being analysed and due to be published.
It is not clear at present whether both of these strategies or only one and if so which one will be finally adopted as national screening policy. The most appropriate screening strategy for individuals who test positive has yet to be clarified.
Offering colonoscopy to all those who test positive may not be the most appropriate response, since colonoscopy carries a small but significant risk of colonic perforation.
Barium enema or CT colography may prove to be more appropriate, with colonoscopy being reserved for patients found to have polyps that require removal. Modern spiral CT scan of the abdomen and pelvis can be carried out quickly, within a few minutes.
Advances in CT scan software allow the mucosal lining of the colon to be inspected in some detail to identify where there might be polyps. This technology is rapidly developing and being assessed. It seems likely that within the next five to 10 years CT colography will be capable of providing equivalent definition of colonic mucosa to that currently achieved by colonoscopy.
A video capsule that can be swallowed and passes through the GI tract, allowing views of the mucosa, is being developed and may offer some opportunities, particularly in the small bowel for increased imaging of the mucosa.
Do we know how long it takes for colonic cancer to develop from the first changes?
Colorectal cancer develops by a series of genetic changes in the lining of the colon. It is thought the first step is an increase in the rate of proliferation of colonic cells resulting in the formation
Further genetic changes ensue with transformation of adenomatous polyps into invasive adneocarcinomas. Estimates of the time required are difficult to arrive at, but it seems most likely that the whole process takes, on average, 10 years.
Around this average there are likely to be considerable variations. In some cases invasive cancer can develop rapidly and some polyps might never be destined to develop into invasive cancer.
Is there any good evidence that diet or lifestyle can prevent colonic cancer?
There is limited evidence for the efficacy of preventive measures in colorectal cancer. This suggests a high-fibre diet is not preventive, although it is, for other reasons, healthy. Diet may be a factor. Those countries where the diet is high in meat have a higher incidence of colorectal cancer than vegetarian populations, but there is no evidence that avoiding meat reduces the incidence.
There is some evidence that increasing calcium supplementation taking one or two grams of calcium daily reduces proliferation in the cells lining the colon, and thus reduces the risk of colorectal cancer.
It has been shown those who take regular doses of aspirin have a lower rate of colorectal cancer and it has been suggested a small regular dose of aspirin might act as a preventive.
Obesity and lack of exercise are also associated with an increased risk of developing colorectal cancer.
What is the place of adjuvent chemotherapy and radiotherapy?
Polyps are usually treated by snare removal at colonoscopy, and if these are at the adenomatous stage, this is curative. Invasive cancer of the colon is treated by surgical excision. Recently this has been accompanied by chemotherapy and, in some cases, by radiotherapy. This may be administered before or after surgery and can improve the chance of cure.
The use of chemotherapy is conventionally limited to those whose lymph nodes are involved with cancer (Dukes C) where the benefit is roughly
5 per cent for colonic and 9 per cent for rectal cancer. But studies suggest there is also some benefit to be gained in those with node-negative cancer (Dukes B) and chemotherapy is increasingly being used in these patients, often because of high levels of patient anxiety about recurrence, despite the modest statistical advantages of adjuvant chemotherapy.
Metastatic cancer is now treated by liver resection where possible. In addition, treatments involving a combination of liver resection and ablation of metastases, by either radiofrequency or freezing, are being developed.
These can also be accompanied by chemotherapy. The combination seems capable of prolonging survival from an average of seven months without treatment to two or three years, and achieving a cure in roughly one in four of carefully selected patients.