Colorectal Surgery Review for Primary Care Providers

Abstract

Colon and rectal disorders can be functional and inflammatory. This is the second paper of a three-part series¹⁴ and will focus on the diagnosis and treatment of rectal prolapse, fecal incontinence and inflammatory bowel disease.

Rectal Prolapse

Rectal prolapse is a disorder of the pelvic floor that leads to severe dysfunction during defecation.¹ Patients complain of bleeding, mucous drainage, pelvic pressure, tenesmus, rectal bulge, constipation, and fecal incontinence. This may lead to isolation and depression due to these serious functional difficulties. Risk factors include advanced age, female gender, multi-parity, other pelvic organ prolapse, chronic bowel dysfunction including constipation, chronic straining, vaginal deliveries, chronic diarrhea, developmental delays, psychiatric comorbidities, cystic fibrosis, dementia and stroke.¹ Women are six times more likely to develop rectal prolapse than men. The peak incidence is in the seventh decade of life.

Diagnosis of rectal prolapse is through visual inspection with confirmation of a prolapsing rectum with circumferential rings. Severe hemorrhoidal prolapse may be misdiagnosed as rectal prolapse

The radial groves separating different hemorrhoid locations distinguish hemorrhoid prolapse from the circumferential “beehive” appearance of rectal prolapse.¹

Straining on the commode during office evaluation usually confirms the diagnosis. Patients may provide their own pictures of the reported prolapse, which can be helpful with intermittent prolapse. Further workup of can include defacography (helps identify other pathology or internal prolapse), colonoscopy (to exclude other pathology and “clear” the proximal colon prior to repair), urodynamic and gynecologic evaluation (to assess for additional pelvic abnormalities), and barium enema (colonoscopy frequently incomplete due to redundant colon).²

Severity of disease ranges from early internal prolapse (only seen on defecography) and mucosal prolapse, which does not involve complete external intussusception of the rectum, to full-thickness rectal intussusception.

Rectal prolapse will not resolve with medical treatment. However, dietary manipulation, fiber supplementation, laxatives, intermittent manual reduction and pelvic floor physical therapy serve an adjunct role.

There are many named operations for the treatment of rectal prolapse. The basic surgical decision depends on an assessment of the patient’s operative risk.³ High-risk patients generally undergo a trans perineal operative approach, either a Delorme (usually for mucosal prolapse only) or Altmeier perineal proctectomy.⁴ These operations can be done under spinal or general anesthesia. They carry low operative risk but a higher recurrence rate.

Low to moderate risk patients are candidates for trans-abdominal repairs. This involves fixation of the rectum to the sacrum with suture material or mesh. Sigmoid resection can be added, especially in patients with more significant constipation. The transabdominal operations can performed through an open, laparoscopic or robotic approach.⁵ Bowel resection carries additional risks but recurrence does not change recurrence rates.

Fecal Incontinence

Fecal incontinence is defined in a consensus conference report in 2001 as recurrent uncontrolled passage of fecal material for at least one month, in an individual with a developmental age of at least 4 years. Incontinence to flatus may cause substantial impairment of quality of life is in the spectrum of disease. Incidence is reported between 1.4 to 18%⁶. Higher rates in nursing home residents, parous women, elderly, patients with neurologic and cognitive impairments.

Anal sphincter injury during vaginal delivery is a common cause of fecal incontinence. Pelvic nerve injury related to a traction injury may also contribute. Risk factors include forceps delivery, occipitoposterior position, previous anorectal surgery, prolonged labor and episiotomy/ lacerations.⁷ Obstetrical injuries can be occult or under-reported.

A detailed history frequently elicits exacerbating factors such as gastrointestinal or neurologic disorders. Inspection of the perineum may show anal scarring or a patulous anus. Digital exam can help gauge splinter strength. The majority of patients will require colonoscopy to exclude associated colorectal disorders such as tumor or ileitis/colitis. Anorectal manometry (to quantify strength, tolerance to rectal stretch and anal reflexes), pudendal nerve testing (to assess for nerve injury/ function), anal sphincter ultrasound (to assess for injury) and defecography can be considered.⁸

Correcting loose or frequent stools resolves many incontinence episodes. Stool bulking agents and dietary manipulation can help with stool consistency. Antidiarrheal agents to decrease stool frequency and firm up the stool is necessary. Over the counter loperamide, in titrated doses aiming for one bowel movement daily or every other day, typically has excellent results. Fewer bowel movements with better control of solid stool will typically eliminate a need for a formal workup. Pelvic floor physical therapy can aid in strengthening the pelvic floor.

Operative intervention is reserved for life-style limiting incontinence refractory to non-operative measures and is not needed often. Overlapping sphincteroplasty, only an option if a sphincter defect is confirmed, is historically the procedure of choice but has fallen out of favor due to moderate rate of long-term recurrent incontinence and significant wound complications. However, it remains the procedure of choice for incontinence with concomitant rectovaginal fistula.⁷ Sacral nerve stimulator implantation is a promising newer treatment option. It is expensive and requires device maintenance. Long-term data is lacking but is currently the procedure of choice for refractory incontinence. These advanced procedures are not indicated unless the patient is highly motivated and has refractory incontinence despite an extensive trial of antidiarrheals and nonoperative intervention. Again, most patients will have good results with constipating medications and surgical intervention with implanted devices is not often a consideration.

Inflammatory Bowel Disease

Crohn’s disease and ulcerative colitis are the two most common inflammatory bowel diseases (IBD). IBD is characterized by periods of symptomatic relapse and remission. The cause of IBD is believed to be a combination of environmental, genetic, microbiologic, and immunologic factors. The immune response causes varying degrees and locations of inflammation with resulting symptoms.⁹ Medical treatment continues to improve with the introduction of biologic agents. Failure of medical management or concern for malignancy indicate benefit from surgical evaluation.

Crohn’s Disease

Crohn’s disease (CD) is a chronic inflammatory condition that can affect any area of the gastrointestinal tract from the mouth to the anus. The terminal ileum and colon are most commonly involved. The inflammation tends to be focal and transmural. Inflammation results in fistulae, perforation and strictures. Associated symptoms including pain, bleeding, obstruction, weight loss, diarrhea, and fever, among others. A multitude of extra-intestinal manifestations can affect the eyes, skin, mouth and joints.

Evaluation of CD frequently requires endoscopy with confirmatory histology, CT/MR enterography and laboratory analysis including hemogram and inflammatory markers such as CRP⁹ and fecal calprotectin. The medical treatment include various combinations of anti-inflammatories such as sulfasalazine preparations or steroids (systemic or topical such as suppositories), immunomodulators such as methotrexate or azathioprine, and biologic agents such as Humira.¹²

It is important to remember that no operation can “cure” CD and surgical intervention is reserved for the medically refractory complications of CD. These include hemorrhage, intestinal obstruction, perforation, malignancy and fistula. There is increasing understanding regarding the risk of malignancy in CD. Risk is directly related to the severity and duration of the inflammation-regardless of location. Therefore, severely inflamed bowel must be regularly surveyed endoscopically.

Emergent surgical intervention is rarely indicated unless fulminant peritonitis exists. Concerning exam findings may be absent or blunted by steroid or biologic therapy. TPN should be considered peri-operatively for the severely catabolic patient. At operation, sites of refractory disease are resected.¹⁰ Primary anastomosis or ostomy can created. Stricturoplasty can help preserve bowel length if addressing short foci of stricturing disease. Diffuse jejunoileal disease benefiting from stricturoplasty is rarely the case, with terminal ileocolic disease amenable only to resection being far more common. Intestinal stomas, temporary or permanent, are commonly used for distal colorectal disease or severe ileal disease when operating under austere circumstances like malnutrition. Crohn’s colitis frequently requires total colectomy, but if the rectum and anus are healthy, an ileorectal anastomosis can provide good function without the need for an ileostomy. Perianal CD can lead to severe pain, fissures, fistulae and abscesses. Perirectal abscesses require drainage. Fistulae are best treated initially with seton drainage.⁹ Systemic CD medication can improve anorectal disease but the patient with severe fistulizing perianal disease may require fecal diversion due to persistent infections, inflammation, poor bowel control, and a refractory poor quality of life.

Ulcerative Colitis

Ulcerative colitis (UC) is a chronic inflammatory condition resulting in ulceration of the rectal and colonic mucosa. It starts in the distal most rectum and progresses proximally. Common symptoms in UC are bloody bowel movements, diarrhea, urgency and tenesmus. Similar to Crohn’s, the etiology of UC is multifactorial.

Initial treatment of UC involves antiinflammatories, sometimes including steroids, immunomodulators, and biologic agents.¹¹ Monitoring for the development of dysplasia requires periodic colonoscopy with biopsies. Progression to malignancy is possible and also depends on severity and duration of inflammation.

Medically refractory disease requires operation. Dysplasia and malignancy are also indications for surgery. Contrary to Crohn’s, UC is cured with total proctocolectomy. Healthy patients without continence issues can be candidates for ileal-pouch anal anastomosis (IPAA or J-pouch) to prevent permanent ileostomy.

Increasingly, patients and gastroenterologists are delaying surgical evaluation due to the hope that more aggressive biologic therapy, which has its own risks and expense, will delay operation indefinitely. Unfortunately, these patients present for surgical evaluation in subtle extremis with profound malnutrition, severe colitis with occult sepsis, DVT, and a severely compromised immune system, which blunts their physical findings. They require up to three operations including upfront urgent subtotal colectomy and ileostomy.¹³ Once normal physiology is restored, completion proctectomy is performed with either end ileostomy or J-pouch creation. Many J-pouch patients require protective ileostomy that will eventually require a “reversal” operation. Early surgical consultation, many times to merely to establish a relationship, should be strongly considered.

Conclusion

Inflammatory and functional colorectal conditions are complex problems. This requires specialized evaluation and treatment. A high degree of suspicion with prompt referral to colorectal surgery could achieve a desirable result.

Figure 1.

Rectal Prolapse. Concentric folds of rectal prolapse on left, radial folds of prolapsed hemorrhoids, right.

Figure 2.

Crohn’s Disease of Small Bowel with Stricture

Figure 3.

Ulcerative Colitis with Pseudo Polyps