Proctology Treatments

Altemeire’s Procedure (Perineal Rectosigmoidectomy) for Rectal Prolapse

This is an operation that is performed on the back passage to repair an external rectal prolapse. The operation performed involves operating on the back passage (anus) itself. There are other methods to repair an external rectal prolapse and the surgeon will discuss these with you.

What does the operation involve?

Strong laxatives, to clear the bowel, are taken at home the day before the operation. You will receive written instructions about when to take the laxatives and when to stop eating and drinking. The operation is carried out under a general anaesthetic but can be carried out under a spinal anaesthetic. The operation is performed through the back passage. During the operation, the prolapsing bowel is cut away, leaving two ends that are then re-joined using sutures. The operation takes around 60 minutes to complete.

What are the possible complications?

There are small risks associated with any operation. During the hospital admission patients wear stockings and are given regular tiny injections to prevent thrombosis (blood clots). Bleeding is very rare in this type of surgery; most patients will notice small amounts of blood on the stools when they open their bowels soon after the operation. This usually settles in the first week.

Rarely the join in the bowel may separate at the stitch line. If this happens antibiotics will be required and occasionally another operation will be necessary. If the patient has problems with bowel control often this will improve after the surgery, but if it doesn’t further tests, such as anorectal physiology and endo anal ultrasound scan or treatment may be required.

What happens after the operation?

An Altemeire’s procedure doesn’t usually cause much pain afterwards. Most patients will need only simple oral painkillers after the first 24 hours. A drip is normally in place for 24 hours after the operation. Patients are allowed to eat and drink as soon as they feel able after the operation (usually the same day). A catheter (tube passed into the bladder) if required during the procedure is usually removed the day after surgery. Hospital stay is usually 3-5 days. After the operation patients are given as regular stool softener to take for 4-6 weeks and are advised to avoid straining. Patients are encouraged to keep mobile after the procedure. They should avoid heavy lifting or increased physical activities for about 6 weeks. Patients can normally resume driving after about 2 weeks, but this may vary.

Abnormal anal Pap Smear, Dysplasia.

Abnormal anal pap smears, anal dysplasia and anal cancer are all caused by human papilloma virus (HPV).

What is human papilloma virus (HPV)?

HPV is a common virus which can be transmitted sexually. HPV infection may present differently: some HPV types cause warts while other HPV types cause anal and cervical cancer.

Risk factors for HPV:

• Women: history of cervical high grade dysplasia or cervical cancer
• Women and men: HIV infection
• Women and men: history of receptive anal sex.
• Women and men: other HPV related diseases such as warts.
• Women and men: immunosuppression from diseases or from medications.

HPV prevention:

HPV vaccines: they are highly effective in preventing both HPV warts and HPV related cancers when given before becoming sexually active. Practicing safe sex reduces the risk of getting HPV; condoms are partially

protective. Stopping cigarette smoking decreases HPV disease and risk of recurrence. Treating HIV with antiretroviral therapy may reduce the risk of getting anal dysplasia

What is anal dysplasia:

Anal dysplasia is a pre-cancerous condition which occurs when the cells of the lining of the anal canal undergo abnormal changes.  The anal canal is the last few inches of the intestine.  Anal dysplasia may progress from low-grade (low risk) changes to high-grade (high risk) changes before it turns into cancer.

What causes anal cancer?

90% of anal cancers are caused by the HPV. Anal cancer may develop slowly over a period of years.  Anal cancer may occur inside the anal canal where the anus meets the rectum. Or it may develop in the skin just outside of the anal canal opening.  

What are the symptoms of anal cancer?

Sometimes there are no specific symptoms of anal cancer until it is quite advanced. There may or may not be a visible or palpable growth. People may also have anal pain, bleeding and discomfort. These same symptoms can be caused by other benign conditions, like haemorrhoids or anal fissures. This is one of the reasons you should be seen and examined when you have those symptoms, so the correct diagnosis is made. At a minimum, you should have the following examinations:

Digital rectal exam: your provider places a gloved finger in the anal canal to feel for lumps

Routine anoscopy: a visual examination of the anal canal. A short instrument is placed in the anal opening to allow the provider to see the lining of the anal canal

Diagnosis of anal dysplasia

The diagnosis of anal dysplasia may be made by performing an anal pap smear. Just like a cervical Pap smear, cells are collected from a swab inserted into the anus.  Those cells are then examined by a pathologist looking for pre-cancerous or dysplastic changes.  Male/female patients with any of the following risk factors should have an anal pap smear:

• History of receptive anal sex
• HIV infection.
• History of cervical high grade dysplasia or cervical cancer.
• Other HPV related disease: genital warts.
• Immunosuppression from disease or medications.

Follow-up of anal dysplasia is based on the results of anal Pap smear Results of anal Pap smear may be normal or abnormal. Any description of abnormal anal Pap smear usually triggers a recommendation to perform high resolution anoscopy.

High resolution anoscopy (HRA) uses magnification to obtain a more detailed view of the anal canal. The provider inspects carefully the entire anorectal junction under high magnification. HRA offers the opportunity to both diagnose and treat anal dysplasia. Suspicious or atypical areas can be biopsied, and the lesions may be destroyed in the course the same procedure.

Treatment:

Visible warts are usually treated even if they are not pre-cancerous lesions. There are multiple treatment options. Some include:

• Lesion destruction with electrocautery (heat) or by infra-red coagulation (IRC- intense beam of light).
• Trichloroacetic acid (TCA): the lesion is treated by being touched with acid-soaked cotton.  

After treatment: surveillance

Anal dysplasia can be treated successfully with very close follow up and monitoring.  Individuals with low-grade lesions will generally have a repeat HRA in 1 year.  Individuals with high-grade lesions will have a repeat HRA every 3-6 months.  This will continue until there is no further evidence of high-grade dysplasia.

Anoscopy:

A tube called an anoscope is used to look at the inside of your anus and rectum. Doctors use anoscopy to diagnose haemorrhoids, anal fissures, and some cancers.

How do I prepare for the test?

Before the test, you might want to empty your bladder or have a bowel movement to make yourself more comfortable.

What happens when the test is performed?

This test is usually done in a doctor’s office. You need to remove your underwear. Depending on what the doctor prefers, you either lie on your side on top of an examining table, with your knees bent up to your chest, or bend forward over the table. The anoscope is 3 to 4 inches long and the width of an average-to-large bowel movement. The doctor coats the anoscope with a lubricant and then gently pushes it into your anus and rectum. By shining a light into this tube, your doctor has a clear view of the lining of your lower rectum and anus. When the test is finished, the anoscope then is pulled out slowly. You will feel pressure during the examination, and the anoscope will make you feel as if you are about to have a bowel movement. Do not be alarmed by this sensation; it is normal. Most patients who do not have pain with bowel movements do not feel pain from anoscopy.

What risks are there from the test?

There are no significant risks from anoscopy. Sometimes, especially if you have hemorrhoids, you may have a small amount of bleeding after the anoscope is pulled out.

Must I do anything special after the test is over?

You can return to your normal activities immediately.

How long is it before the result of the test is known?

Your doctor can tell you about your anoscopy exam right away. If a biopsy sample is taken during the test, results will take several days to return.

Barium Enema

The HEC Clinic offers a complete barium fluoroscopy service. Barium, a white powder, has long been used mixed with water, as a contrast medium to demonstrate the bowel on X-rays. Barium outlines the lining of the bowel allowing it to be visualized on X rays.

What is a Barium enema?

This is an X ray test to look at the large bowel (colon) and often part of the small bowel called the terminal ileum. Barium is mixed up with warm water to outline the large bowel and pictures (X rays) are taken to look for any abnormalities.

We often perform a barium enema for a number of reasons:

• Chronic diarrhoea.
• Chronic constipation.
• Blood in the stool.
• Irritable bowel symptoms
• Weight loss.
• Change in bowel habit.

Is there any preparation?

It is important to have a clean bowel. The radiology department will supply you with sachets of a laxative to be taken the day before the procedure and you should not eat or drink anything from midnight before the examination. You can take your normal medications.

What does the barium enema involve?

You will be asked to remove some of your clothes and wear a hospital gown. A small tube will be placed into your bottom in the X ray room and the warm barium ran in. A small injection is then given to relax the bowel and allow amounts of air to be instilled to distend the bowel and allow pictures to be taken. At the end of the examination you will spend a little time in the toilet before going home. You can eat and drink normally afterwards and ideally someone should drive you home.

Barium Meal and follow through

The HEC Clinic offers a complete barium fluoroscopy service. Barium, a white powder, has long been used mixed with water, as a contrast medium to demonstrate the bowel on X-rays. Barium outlines the lining of the bowel allowing it to be visualized on X rays.

What is a Barium meal & follow through?

This is an X ray test to look at the oesophagus (gullet), stomach, duodenum and small bowel. Barium is mixed with water to make a solution that you drink to allow us to see the bowel. As the barium flows through your bowel we take a number of X rays to show it. At the very end we may screen the last area to get more detailed pictures. We often perform this investigation for a number of reasons including heartburn, reflux, pain on eating, weight loss, irritable bowel and abdominal pain.

Is there any preparation?

It is important that you have an empty stomach to allow the barium to flow quickly into the small bowel. We ask that you do not eat or drink anything for 4-6 hours before the examination. You may take your normal medications.

What does the barium meal & follow through involve?

You will be asked to remove some of your clothes and wear a hospital gown. If the doctors are concerned about your gullet then pictures, X-rays, are taken as you drink the barium, however, more commonly you drink a few cups of barium and we take a picture every 15 minutes. It depends on how quick the barium flows through your bowel but if often takes two hours.

Abnormal anal Pap Smear, Dysplasia.

Abnormal anal pap smears, anal dysplasia and anal cancer are all caused by human papilloma virus (HPV).

What is human papilloma virus (HPV)?

HPV is a common virus which can be transmitted sexually. HPV infection may present differently: some HPV types cause warts while other HPV types cause anal and cervical cancer.

Risk factors for HPV:

• Women: history of cervical high grade dysplasia or cervical cancer
• Women and men: HIV infection
• Women and men: history of receptive anal sex.
• Women and men: other HPV related diseases such as warts.
• Women and men: immunosuppression from diseases or from medications.

HPV prevention:

HPV vaccines: they are highly effective in preventing both HPV warts and HPV related cancers when given before becoming sexually active. Practicing safe sex reduces the risk of getting HPV; condoms are partially

protective. Stopping cigarette smoking decreases HPV disease and risk of recurrence. Treating HIV with antiretroviral therapy may reduce the risk of getting anal dysplasia

What is anal dysplasia:

Anal dysplasia is a pre-cancerous condition which occurs when the cells of the lining of the anal canal undergo abnormal changes.  The anal canal is the last few inches of the intestine.  Anal dysplasia may progress from low-grade (low risk) changes to high-grade (high risk) changes before it turns into cancer.

What causes anal cancer?

90% of anal cancers are caused by the HPV. Anal cancer may develop slowly over a period of years.  Anal cancer may occur inside the anal canal where the anus meets the rectum. Or it may develop in the skin just outside of the anal canal opening.  

What are the symptoms of anal cancer?

Sometimes there are no specific symptoms of anal cancer until it is quite advanced. There may or may not be a visible or palpable growth. People may also have anal pain, bleeding and discomfort. These same symptoms can be caused by other benign conditions, like haemorrhoids or anal fissures. This is one of the reasons you should be seen and examined when you have those symptoms, so the correct diagnosis is made. At a minimum, you should have the following examinations:

Digital rectal exam: your provider places a gloved finger in the anal canal to feel for lumps

Routine anoscopy: a visual examination of the anal canal. A short instrument is placed in the anal opening to allow the provider to see the lining of the anal canal.

Diagnosis of anal dysplasia

The diagnosis of anal dysplasia may be made by performing an anal pap smear. Just like a cervical Pap smear, cells are collected from a swab inserted into the anus.  Those cells are then examined by a pathologist looking for pre-cancerous or dysplastic changes.  Male/female patients with any of the following risk factors should have an anal pap smear:

• History of receptive anal sex
• HIV infection.
• History of cervical high grade dysplasia or cervical cancer.
• Other HPV related disease: genital warts.
• Immunosuppression from disease or medications.

Follow-up of anal dysplasia is based on the results of anal Pap smear Results of anal Pap smear may be normal or abnormal. Any description of abnormal anal Pap smear usually triggers a recommendation to perform high resolution anoscopy.

High resolution anoscopy (HRA) uses magnification to obtain a more detailed view of the anal canal. The provider inspects carefully the entire anorectal junction under high magnification. HRA offers the opportunity to both diagnose and treat anal dysplasia. Suspicious or atypical areas can be biopsied, and the lesions may be destroyed in the course the same procedure.

Treatment:

Visible warts are usually treated even if they are not pre-cancerous lesions. There are multiple treatment options. Some include:

• Lesion destruction with electrocautery (heat) or by infra-red coagulation (IRC- intense beam of light).
• Trichloroacetic acid (TCA): the lesion is treated by being touched with acid-soaked cotton.  

After treatment: surveillance

Anal dysplasia can be treated successfully with very close follow up and monitoring.  Individuals with low-grade lesions will generally have a repeat HRA in 1 year.  Individuals with high-grade lesions will have a repeat HRA every 3-6 months.  This will continue until there is no further evidence of high-grade dysplasia.

Screening and Surveillance for Colorectal Cancer:

Colorectal cancer is a common malignancy for both men and women.  Screening for colorectal cancer is the process of identifying apparently healthy people who may be at increased risk of developing this disease. Properly done, screening for colorectal cancer saves lives. Removing a pre-cancerous polyp prevents the development of colorectal cancer.  In addition, if found early, colorectal cancer may be cured in up to 90% of cases. Screening is for people without symptoms. Patients who experience rectal bleeding, changes in their bowel habits, abdominal pain, or unexplained weight loss should seek medical attention.

Patients who are considering screening for colorectal cancer need information.

What is the risk of colorectal cancer:

It is estimated that the lifetime risk of developing colorectal cancer is about 1 in 20. The risk is similar for men and women. Some people are at a slightly higher risk for colorectal cancer due to their personal or family characteristics. Patients who have had prior pre-cancerous polyps or a cancer are at an increased lifetime risk of developing more polyps or another cancer. Close relatives of patients with colorectal cancer OR polyps have a two- to three- fold increased risk of developing colorectal cancer or polyps. Familial Adenomatous Polyposis (FAP) is an uncommon inherited condition which typically causes hundreds of polyps in the colon. Patients with this condition have an almost 100% chance of developing colorectal cancer, usually before age 50. Hereditary Non-Polyposis Colon Cancer (HNPCC) is another uncommon inherited condition, characterized by colorectal cancers in multiple family members. Patients with inflammatory conditions of the colon, such as Crohn’s disease or ulcerative colitis, have an increased risk of colorectal cancer as well. 

What is the benefit of colorectal screening:

Like other serious, common medical problems such as high blood pressure colorectal cancer is considered to be a “silent disease” in its early stages. Up to 90% of these early cancers can be cured, but once symptoms develop, cure rates fall to less than 50%.Unfortunately, not everyone receives proper screening.

What screening tests are available?

Faecal occult blood testing (FOBT) detects very small amounts of blood in stool that may have been shed from a cancer or polyp. The advantages of FOBT are that it is inexpensive and non-invasive; bowel cleansing and sedation are not required. Positive tests require another procedure, typically a colonoscopy. Flexible sigmoidoscopy uses a thin, flexible tubular instrument to give magnified views of a patient’s large intestine.  It allows the doctor to examine the lower third of the colon and the rectum directly and to take samples of abnormal areas for testing in the lab. Flexible sigmoidoscopy has been shown to be highly effective in detecting polyps in the area viewed and is an effective method, especially when paired with FOBT, to reduce colorectal cancer mortality. The main advantages are its short duration, the ability to take samples, and the lack of significant discomfort. Colonoscopy is similar to flexible sigmoidoscopy, but the entire colon is examined. A colonoscope is a long, thin, flexible tubular instrument that provides magnified views of a patient’s large intestine.

Abnormal areas can be sampled or removed completely, depending on their size. Colonoscopy is often considered the “gold-standard” screening test, as it allows for both detection and removal (or sampling) of polyps and cancers. The advantages of colonoscopy are the ability to examine the whole colon and to sample or remove abnormal tissue. Barium enema is an x-ray test that allows examination of the lining of the colon. Computed tomographic colonography uses a CT scan to make images of the lining of the colon that appear similar to views seen during standard colonoscopy. This test usually requires the same type of thorough bowel cleansing needed for colonoscopy.

What are the recommended starting ages and frequency for screening tests?

For average risk individuals, screening should start at age 50.Of the screening methods discussed above, FOBT should be done yearly, along with a flexible sigmoidoscopy every 5 years. Screening should begin earlier in people with a family history of colorectal cancer or polyps.

Surveillance:

Surveillance refers to the process of evaluating patients with a personal history of polyps or cancer.  People who have precancerous polyps completely removed should have a colonoscopy every 3-5 years. Every effort should be made to remove polyps, as there is a significant risk that over time they can progress to an invasive cancer. If a polyp cannot be removed with colonoscopy, surgery to remove that portion of the colon is often needed. Most patients who have a colorectal cancer removed surgically should have a colonoscopy within one year. Patients with ulcerative or Crohn’s colitis for eight or more years should have a colonoscopy with multiple biopsies every 1-2 years.

CT Colonography (CTC)

What is CT Imaging?

CT or Computer Tomography is a special X-ray machine that produces an image of a cross-section, or slice, of the body. The scanner consists of a ‘doughnut’ shaped structure, or gantry, about two feet thick, through which you pass on a couch. The information passes to a computer that then produces a picture of the internal structure of the body. They produce in excess of 600 images of the body, which can be used to show internal structures in 2D and 3D planes. In CTC we use the 3D packages to get a view of the colon as if we were travelling through it.

Is there any preparation needed beforehand?

As CTC is a very specialized examination of the colon the radiology department will supply you with two sachets of a laxative (usually picolax) to be taken the day before the procedure. You should not eat or drink anything from midnight before the examination. You can take your normal medications. It is important you have a clean colon.

What does a CT Scan involve?

You will be asked to remove some of your clothes and wear a hospital gown. A small cannula will be placed into a vein to allow the administration of a “dye”, known as contrast, to be given. This improves the quality of the scan and demonstrates accurately all the organs and blood vessels in your abdomen. A CT Colonography (CTC) is similar to a barium enema in a way. You will have been given a laxative the day before the CT to clean the colon. A a small tube will be placed into your bottom in the X ray room to allow air to be instilled. A small injection is then given to relax the bowel (buscopan) and contrast is administered via the cannula prior to the pictures being taken. After the examination you may eat and drink normally.

Delorme’s Procedure

This is an operation that is performed on the back passage to repair an external rectal prolapse.  The operation performed in our Clinic involves operating through the back passage (anus) itself. There are other methods to repair an external rectal prolapse and the surgeon will discuss these with you.

What does the operation involve?

An enema is usually given an hour or so before the operation to clear the lower part of the bowel. The operation is performed under a general anaesthetic but can be carried out under a spinal anaesthetic. During the operation itself the lining (mucosa) is stripped off the prolapse to expose the muscle of the bowel wall. When all the lining has been stripped, the muscle is bunched up with stitches to get rid of the prolapse. The excess lining (mucosa) is then trimmed and stitched back to cover the repair. The operation takes around 60 minutes to complete.

What are the risks?

There are small risks associated with any operation. Pre-operative assessments are made of any heart or lung conditions, as well as any co-existing medical condition. During the hospital admission patients wear stockings and are given regular tiny injections to prevent thrombosis (blood clots). Bleeding is very rare in this type of surgery; most patients will notice small amounts of blood on the stools when they open their bowels soon after the operation. This usually settles in the first week. Occasionally the lining of the bowel may separate at the stitch line. This rarely causes a problem, but patients may notice that they continue to pass a little blood for longer than normal after the procedure.

If the patient has problems with bowel control and often this will improve after the surgery but if it doesn’t further tests, such as anorectal physiology and endo anal ultrasound scan or treatment may be required.

What happens after the operation?

A Delorme’s procedure doesn’t usually cause much pain afterwards. Most patients will need only simple oral painkillers after the first 24 hours. A drip is normally in place for 24 hours after the operation. Patients are allowed to eat and drink as soon as they feel able after the operation (usually the same day). A catheter (tube passed into the bladder) if required during the procedure is usually removed the day after surgery.

Hospital stay is usually 3-5 days. After the operation patients are given as regular stool softener to take for 4-6 weeks and are advised to avoid straining. Patients are encouraged to keep mobile after the procedure. They should avoid heavy lifting or increased physical activities for about 6 weeks. Patients can normally resume driving after about 2 weeks, but this may vary.

Flexible Sigmoidoscopy:

What is a flexible sigmoidoscopy?

Flexible sigmoidoscopy is an examination of the inside of the rectum and the lower part of the colon. A flexible, lighted tube called a sigmoidoscope is inserted into the rectum and advanced into the colon, allowing the doctor to examine the lining of the lower 30 inches of the colon.

Why should I have flexible sigmoidoscopy?

Flexible sigmoidoscopy is done for several reasons. One is to evaluate symptoms, such as rectal bleeding, abdominal pain, or change in bowel habits. Another reason is to detect colon polyps or colon cancer. Most colon cancer begins in polyps (benign growths in the lining of the colon). Studies show that up to 70% of all polyps occur in the lower portion of the colon. If polyps are detected, they are removed in a later procedure, which helps prevent cancer.

What happens during flexible sigmoidoscopy?

You will be lying on your left side with your knees slightly drawn up. The doctor will first do a digital exam by inserting a gloved finger into the rectum. The sigmoidoscope is then inserted into the rectum and advanced into the colon so the doctor can see the lining of the colon. It is necessary to inflate the colon with air to visualize the entire lining, which may result in some cramping. A biopsy or culture may be taken to diagnose abnormal areas or growths. The entire procedure should take no more than 10 minutes. You will be able to drive yourself home. Most people find that they can go about their normal daily activities.

How do I prepare for flexible sigmoidoscopy?

You need to use two Fleet enemas.  On the day of your exam, take one enema two hours before and another an hour before your exam. You may have regular meals and all the fluid you want. Please tell your doctor ahead of time if you have bleeding tendencies, are taking anticoagulant medications (blood thinners).

When can I get the results from the exam?

Immediately following your exam, your doctor will explain the results. Any biopsies or cultures taken during the exam will be sent to a laboratory where a pathological study of the specimen will be done. Accurate results often take 48 hours or more. You will be notified of the results of these tests.

Are there complications?

Sigmoidoscopy is a safe procedure with very low risk when performed by doctors who are trained and experienced. However, there are rare complications, such as bleeding and perforation. Notify your doctor if you have any of the following:

• Severe pain
• Vomiting
• Temperature greater than 39 degrees
• Bright, red blood greater than 2 tablespoons

Banding of Haemorrhoids:

Piles or haemorrhoids are a common condition. The common symptoms are bleeding, irritation and tender lumps around the anus. Piles cause problems when the lining of the lower rectum slips down and is liable to damage when passing a motion. Leakage of mucus from the prolapsed piles causes irritation in the sensitive skin around the anus. Most patients with symptomatic piles can be treated without needing an operation. One method of treatment is to apply rubber bands to the lining of the rectum and anus just above the pile. This shrinks the pile down and returns it back into the anus where is it less likely to cause trouble.  The band may fall off as soon as 48 hours after the banding. There are usually three banding sessions required at two week intervals. The procedure is relatively painless, since the banding of the area involved does not have the type of nerves that sense sharp pain. You may experience a feeling of fullness or pressure in the rectum for the first 24 hours. Occasionally, more bleeding than usual can occur after the banding procedure. This is often from the untreated haemorrhoids rather that the treated one. If bleeding does not stop within a few minutes or you feel feint call your doctor and either come to his/her office or head to the nearest Hospital emergency room.

Your Haemorrhoid Treatment:

Your first office visit will include a consultation, sigmoidoscopy/anoscopy, and initial treatment of your condition. The procedure is relatively painless, and we employ topical lidocaine to ensure the procedure goes quickly and smoothly. You can even drive yourself and return to normal activities the same day; no special preparation is needed and you may eat normally. For regular haemorrhoid treatment we recommend three banding sessions at two week intervals with a final check-up a few weeks later.

Advantages:

• No hospitalisation
• No Anaesthetic.
• Minimal pains.
• Minimal time off work.
• Cost effective.
• Easily repeatable.

Post-Banding Instructions:

• Following the procedure, rest at home in the evening and resume full activity the next day. Avoid air travel and exercise for 24 hours. You may experience a feeling of fullness or pressure in the rectum for the first 24 hours, but over-the-counter pain medication may be taken if needed.
• Do not spend more than a few minutes on the toilet bearing down if you cannot empty your bowel instead re-visit the toilet at a later time.
• A sitz bath (soaking in a warm tub) is useful for cleansing the area after every bowel movement until the area heals.
• Avoid constipation: take any over the counter fiber supplement with 7-8 glasses of water.
• Unless prescribed a rectal medication, do not put anything inside your rectum for two weeks: No suppositories, enemas, fingers or other devices.
• Do not stay seated for more than 2-3 hours. Tighten your buttock muscles 10-15 times every two hours and take 10-15 deep breaths every 1-2 hours.
• Problems are not common. However, if there is a substantial amount of bleeding, severe pain, chills, fever or difficulty passing urine, you should call your doctor’s office or report to    the nearest Hospital Emergency Room

Coagulation of haemorrhoids:

Infrared photocoagulation (also called coagulation therapy) is a medical procedure used to treat small- and medium-sized haemorrhoids. This treatment is only for internal haemorrhoids. During the procedure, the doctor uses a device that creates an intense beam of infrared light. Heat created by the infrared light causes scar tissue, which cuts off the blood supply to the haemorrhoid. The haemorrhoid dies, and a scar forms on the wall of the anal canal. The scar tissue holds nearby veins in place so they don’t bulge into the anal canal. Only one haemorrhoid can be treated at a time. Other haemorrhoids may be treated at 10- to 14-day intervals. This medical procedure may be done with other devices, such as a laser or electrical current, that also cut off a haemorrhoid’s blood supply. Infrared photocoagulation is done in a doctor’s office. You may feel heat and some pain during the procedure.

What To Expect After Treatment

Bleeding from the anus occurs 7 to 10 days after the procedure, when the haemorrhoid falls off. Bleeding is usually slight and stops by itself.        

Why It Is Done

Doctors recommend coagulation therapy in cases where small internal haemorrhoids continue to cause symptoms after home treatment.

How Well It Works

Infrared photocoagulation works for about 7 to 10 out of 10 people who have it. But improvements may not last. And 2 out of 10 people may need surgery.

What To Think About

The success of coagulation therapy depends largely on the doctor’s expertise and your ability to make changes in daily bowel habits that will make passing stools easier. Not all doctors have the experience or the equipment needed to do coagulation therapy. Lasers have not been proved to be more effective than other forms of treatment. Procedures using lasers take longer, and may damage surrounding tissue and cause more scarring.

Haemorrhoidectomy

Haemorrhoids are a common problem. Many patients can manage their symptoms with attention to diet or a topical treatment when symptoms are minor. For small internal haemorrhoids rubber band ligation can be an effective treatment. When haemorrhoids are large, prolapse (drop down) and particularly when they are associated with large external tags, surgical removal (haemorrhoidectomy) may be recommended.

 What does the procedure involve?

An enema is usually given an hour or so before the operation to clear the lower part of the bowel. The operation is performed under local or general anaesthetic. During the operation the haemorrhoids and tags are removed using an electrical cutting device (diathermy). Usually the wounds are left open. The operation takes around 45 minutes to complete.

What are the risks?

There are small risks associated with any operation. Pre-operative assessments are made of any heart or lung conditions, as well as any coexisting medical condition. During the hospital admission patients wear stockings to prevent thrombosis (blood clots). Bleeding can occur after haemorrhoid surgery; most patients will notice small amounts of blood, particularly when they open their bowels. Usually this is a small amount but rarely it can be quite a lot, if that occurs patients must seek medical advice. Infection is very rare; if patients develop increasing pain, fevers or flu-like symptoms they should seek medical advice.

Longer-term complications are rare but include:

• Stenosis; narrowing of the back passage as a result of surgical scarring
• Damage to sphincter muscles resulting in leakage problems after surgery

What happens after the operation?

A haemorrhoid surgery can be uncomfortable afterwards. You will have some local anaesthetic injected into the area; this will numb the pain for a few hours. If the surgeon has placed a dressing pack in the anus this will be removed before discharge. Patients are allowed to eat and drink as soon as they feel able. Patients will normally be able to go home on the same day as the operation. You will be given painkillers to take by mouth; you should take these regularly to prevent pain coming on. You will also receive an antibiotic, Metronidazole (Flagyl) to take for 7 days after the operation; this has been shown to help with the discomfort. It will be uncomfortable when you first open your bowels after the operation, it is important that you do not avoid going to the lavatory. The discomfort will get better. Patients are given a regular stool softener to take for 4-6 weeks and are advised to avoid straining.

Injection Therapy for Treating Haemorrhoids

People who suffer from haemorrhoids are usually willing to try just about anything to alleviate their discomfort. Surgery is sometimes necessary in advanced cases of haemorrhoids. For mild cases, though, injection therapy – or sclerotherapy – is a popular option.

What Is Sclerotherapy?

Sclerotherapy – or injection therapy – is a procedure that is used to help eliminate a haemorrhoids. This process is most frequently used to treat bleeding internal haemorrhoids.

During the procedure, a solution is injected into the base of the offending haemorrhoids. Chemicals in the solution work to harden the haemorrhoid, causing its vein tissue to harden, scar and shrivel away. Injection therapy for haemorrhoids is an outpatient procedure. Patients usually have it done at their doctor’s office.  Multiple haemorrhoids can be treated at same time.

Drawbacks to Injection Therapy

As with any type of medical procedure, there are some drawbacks to sclerotherapy. The biggest and most obvious of these drawbacks is the fact that injection therapy does not cure haemorrhoids. The same haemorrhoids can with time.  Another pitfall to sclerotherapy is that it is not usually successful for larger haemorrhoids. These patients usually need a more intensive procedure, such as rubber band ligation.

Possible Complications

There are a few possible side effects associated with injection therapy. The most common is bleeding after the procedure. This is usually caused when an artery is accidentally nicked by the needle. It is not generally serious but does occur on occasion. Additionally, sometimes the injection is accidentally made in the wrong location. Finally, while a bit of aching and discomfort is common following injection therapy, actual pain is not. In general, injection therapy can be a great option for people with small to mid-sized internal haemorrhoids. While they do not provide an actual cure for haemorrhoids, they do offer long term relief. People who wish to avoid actual surgery are likely to find this a preferable alternative. 

Coagulation of haemorrhoids:

Infrared photocoagulation (also called coagulation therapy) is a medical procedure used to treat small- and medium-sized haemorrhoids. This treatment is only for internal haemorrhoids. During the procedure, the doctor uses a device that creates an intense beam of infrared light. Heat created by the infrared light causes scar tissue, which cuts off the blood supply to the haemorrhoid. The haemorrhoid dies, and a scar forms on the wall of the anal canal. The scar tissue holds nearby veins in place, so they don’t bulge into the anal canal. Only one haemorrhoid can be treated at a time. Other haemorrhoids may be treated at 10- to 14-day intervals. This medical procedure may be done with other devices, such as a laser or electrical current, that also cut off a haemorrhoid’s blood supply. Infrared photocoagulation is done in a doctor’s office. You may feel heat and some pain during the procedure.

What to Expect After Treatment

Bleeding from the anus occurs 7 to 10 days after the procedure, when the haemorrhoid falls off. Bleeding is usually slight and stops by itself.        

Why It Is Done

Doctors recommend coagulation therapy in cases where small internal haemorrhoids continue to cause symptoms after home treatment.

How Well It Works

Infrared photocoagulation works for about 7 to 10 out of 10 people who have it. But improvements may not last. And 2 out of 10 people may need surgery.

What To Think About

The success of coagulation therapy depends largely on the doctor’s expertise and your ability to make changes in daily bowel habits that will make passing stools easier. Not all doctors have the experience, or the equipment needed to do coagulation therapy. Lasers have not been proved to be more effective than other forms of treatment. Procedures using lasers take longer and may damage surrounding tissue and cause more scarring.

Coagulation of haemorrhoids:

Infrared photocoagulation (also called coagulation therapy) is a medical procedure used to treat small- and medium-sized haemorrhoids. This treatment is only for internal haemorrhoids. During the procedure, the doctor uses a device that creates an intense beam of infrared light. Heat created by the infrared light causes scar tissue, which cuts off the blood supply to the haemorrhoid. The haemorrhoid dies, and a scar forms on the wall of the anal canal. The scar tissue holds nearby veins in place, so they don’t bulge into the anal canal. Only one haemorrhoid can be treated at a time. Other haemorrhoids may be treated at 10- to 14-day intervals. This medical procedure may be done with other devices, such as a laser or electrical current, that also cut off a haemorrhoid’s blood supply. Infrared photocoagulation is done in a doctor’s office. You may feel heat and some pain during the procedure.

What to Expect After Treatment

Bleeding from the anus occurs 7 to 10 days after the procedure, when the haemorrhoid falls off. Bleeding is usually slight and stops by itself.        

Why It Is Done

Doctors recommend coagulation therapy in cases where small internal haemorrhoids continue to cause symptoms after home treatment.

How Well It Works

Infrared photocoagulation works for about 7 to 10 out of 10 people who have it. But improvements may not last. And 2 out of 10 people may need surgery.

What To Think About

The success of coagulation therapy depends largely on the doctor’s expertise and your ability to make changes in daily bowel habits that will make passing stools easier. Not all doctors have the experience, or the equipment needed to do coagulation therapy. Lasers have not been proved to be more effective than other forms of treatment. Procedures using lasers take longer and may damage surrounding tissue and cause more scarring.

Procedure for prolapse and haemorrhoids (PPH)

This operation is also known as stapled anopexy. A specially designed circular stapling instrument is inserted through the anus (back passage) into the rectum. The operation pulls the swollen and prolapsing blood vessels of the haemorrhoids (piles) back into their normal position by removing a circumferential section (complete ring) of the internal rectal lining. The wound is inside the rectum causing little pain.

Why PPH?

Several studies have shown that the PPH operation is as effective as surgical removal of piles (haemorrhoidectomy) with the additional benefits of being associated with:

• Less post-operative pain, A faster recovery time, Shorter hospital stay
• Early return to normal activities and improved patient satisfaction

Do I need bowel preparation?

Yes. You are may be required to have an enema or be given suppositories to insert in your back passage to help empty your rectum before surgery.

Will I need to stay in hospital?

The PPH operation is usually performed as a day case procedure allowing you to return home the same day. Either a general or regional (epidural, spinal) anaesthesia is used.

Your surgeon and anaesthetist will discuss these choices with you.

Are there any complications with this operation?

There are risks as with all operations. Approximately, 1 in 15 (5-8%) patients may have further piles in the future. The complications after PPH include:

• Pain, Bleeding, A persistent urgent need to go to the toilet with some leakage, Narrowing of the back passage (stricture), Rarely severe pelvic infection, and In females, fistula formation (false channel) between the rectum and vagina

High resolution anoscopy:

What is High Resolution Anoscopy?

High Resolution Anoscopy, or HRA, is a procedure that allows for examination and evaluation of the anal canal. Using a small thin round tube called an anoscope, the anal canal is examined with a high resolution magnifying instrument called a colposcope. Application of a mild acidic liquid onto the anal canal facilitates evaluation of abnormal tissue such as anal dysplasia. If indicated, a biopsy can be obtained. A digital rectal examination is also done at the time of the procedure. The procedure is performed in the office and generally lasts about 15 minutes. It is usually very well tolerated with mild if any discomfort. Significant risks such as bleeding or infection are extremely rare. Note should be taken that HRA is very different from colonoscopy or flexible sigmoidoscopy, neither of which can adequately examine the anal canal for the problems being detected by HRA. No bowel prep is needed for this examination.

Who needs a High Resolution Anoscopy?

The procedure is used in the treatment and surveillance of anal dysplasia and the prevention of anal cancer. It is performed on patients with an abnormal anal cytology or anal Pap test. Anal Pap tests are obtained on individuals who are at risk for genital or anal HPV (Human Papilloma Virus) infections, even in the absence of signs or symptoms of infection.

What is an MRI scan?

An MRI scan uses a large magnet, radio waves, and a computer to create a detailed cross-sectional image of the patient’s internal organs and structures. The scanner itself typically resembles a large tube with a table in the middle, allowing the patient to slide into the tunnel. An MRI scan differs from CT scans and X-rays because it does not use ionizing radiation that can be potentially harmful to a patient.

Uses of MRI scan:

The development of the MRI scan represents a huge milestone for the medical world, as doctors, are now able to examine the inside of the human body accurately using a non-invasive tool. The following are just some of the examples where an MRI scanner is used:

• Abnormalities of the brain and spinal cord
• Tumours, cysts, and other abnormalities in various parts of the body
• Injuries or abnormalities of the joints, such as back pain
• Certain types of heart problems
• Diseases of the liver and other abdominal organs
• Causes of pelvic pain in women (e.g. fibroids, endometriosis)
• Suspected uterine abnormalities in women undergoing evaluation for infertility

Preparation:

There is little to no preparation required for patients before an MRI scan. On arrival at the hospital, doctors may ask the patient to change into a gown. As magnets are used, it is critical that no metal objects are in the scanner, so the patient will be asked to remove any metal jewellery or accessories that may interfere with the machine. Sometimes, patients will be injected with intravenous (IV) contrast liquid to improve the appearance of a certain body tissue. Once the patient has entered the scanning room, they will be helped onto the scanner to lie down. Staff will ensure that they are as comfortable as possible by providing blankets or cushions. Earplugs or headphones will be provided to block out the loud noises of the scanner.

During an MRI scan:

Once in the MRI scanner, the MRI technician will speak via the intercom to ensure the patient is comfortable. During the scan, it is imperative to stay still. Any movement will disrupt the images created.

After an MRI scan:

After the scan, a radiologist will examine the images to check whether any further images are required. If the radiologist is satisfied, the patient can go home. The radiologist will prepare a short report for the doctor, who will make an appointment to discuss the results.

Proctoscopy

What is a proctoscopy?

This is an examination of the lowest part of the rectum and anal canal using a short telescope with a light called a proctoscope.

What do the tests involve?

You will be asked to lie on an examination couch on your left side with your knees bent. This does not involve blowing air into the bowel and is most usually carried out in the outpatients where it is most useful for examining haemorrhoids (piles). The proctoscope is also used when haemorrhoids or piles are treated by banding or injection.

Do I need any preparation before-hand?

You will not need any preparation before-hand.

Rigid Sigmoidoscopy:

What is a rigid sigmoidoscopy?

This is an examination using a short illuminating telescope.

What do the tests involve?

You will be asked to lie on an examination couch on your left side with your knees bent. The doctor introduces some air into the bowel at the same time, so that that the scope can be moved forwards. This procedure is frequently performed in the outpatient clinic. It gives good views of the rectum and if necessary biopsies can be taken (painless removal of a small piece of tissue).

Do I need any preparation before-hand?

You will not need any preparation before-hand

Transit Studies

This is a test to whether or not movement through the bowel is normal or slow (delayed transit). It is often used to investigate patients who have constipation and/ or have symptoms of obstructed defaecation where simple laxatives or stool softeners haven’t worked. It is often arranged alongside other tests of bowel function including videoproctograms and anorectal physiology and endoanal ultrasound scan.

Do I need any preparation before-hand?

You will receive written instructions about the test beforehand. You should stop taking your normal laxatives or stool softeners at least 1 week before the test.

What does the test involve?

You will be given three capsules. Each capsule contains different shapes. You will be asked to take a capsule each day for 3 days. On the 5^th day you will be asked to attend the x ray department where an x ray of your abdomen is taken.

What happens afterwards?

The x ray takes only a few minutes to complete. You will be able to go home straight afterwards and you can continue with all normal activities. The radiologist will analyse the x ray and count the different shapes. From this they can work out colonic transit. A full report will be sent to your doctor.

Ultrasound:

The Haemorrhoid Clinic can provide a complete state of the art diagnostic and interventional ultrasound service. We have access to modern ultrasound machines allowing high quality images to be obtained in all body areas.

What is ultrasound?

High frequency sound waves are used to produce an active picture of the inside of your body. Ultrasound does not use radiation (X rays) and is therefore extremely safe. Although ultrasound is very good at visualizing the solid organs (e.g. liver, kidneys, bladder, aorta) a doppler / duplex ultrasound can evaluate blood vessels. Ultrasound is also very good at directing needles and drains to areas if needed to gain a small sample (biopsy) or drain an abscess / collection (drainage).

Is there any preparation?

We generally ask that you do not eat any solids for 6 hrs and drink plenty of fluids so that you have a full bladder at the time of the scan.  Some ultrasound scans require no preparation at all. The radiology department will advise you prior to your appointment.

What does an Ultrasound involve?

You will be asked to remove some of your clothes and wear a hospital gown. A small ultrasound probe attached to an ultrasound machine is used to obtain the pictures (see picture). We use a small amount of clear jelly to gain the images, which will need to be cleaned off at the end of the procedure.