Dr. Jiten Chowdhry

If you think fissure and fistula are the same, you are mistaken. While the term fissure refers to the tear of the skin, fistula refers to the abnormal tube-like passages or connections between organs. Fissures get cured with or without treatment in a few days to few weeks and do not lead to complications. On the contrary, fistulas, when left untreated, may lead to complications.

Constipation is referred to difficult or infrequent or dry bowel movements, the passage of hard and small amounts of stool. The common symptoms of constipation are feeling bloated, sluggish, and uncomfortable. It can be acute or chronic. Acute constipation can occur suddenly and is noticeable, whereas chronic constipation begins gradually and might persists for months and/or years. At one time or another, every individual might get constipated. The reason being poor diet and lack of exercise.

Causes:
Constipation is caused due to the formation of hard and dry stools that occurs as the colon absorbs too much water from the diet or if the muscles of colon contracts slowly or very sluggishly, causing stools to move very slowly. The causes of constipation are listed below:

• Low fiber diet, the most common cause of constipation.
• Not drinking enough water and other fluids
• Lack of exercise
• Some medications can cause constipation, such as painkillers, antacids, blood pressure medicines, iron supplements, anticonvulsants, etc.
• Irritable bowel syndrome
• Ignoring the urge to have a bowel movement
• Overuse of laxatives
• Several diseases might cause constipation, such as neurological disorders, metabolic and endocrine disorders, and systemic conditions affecting organ system.
• Problems with colon, rectum or with intestinal functions
• Warning signs of constipation include swollen abdomen, vomiting, weight loss, and blood in the stool. When one observes any or all of these, then they should immediately consult a doctor for medication.

Treatment:

• Constipation can be best treated with a combination of high fiber diet, exercise and adequate intake of liquids.
• Dietary changes that one should make to treat or prevent constipation is to consume fiber-rich diet. You should include fruits and vegetables in your diet plan. Eat whole cereals that contain bran. Start slowly and gradually increase the amount of fiber to avoid bloating and gas formation. Drink enough water and liquid.
• Apart from dietary changes, use of laxatives and enemas is also approached that are taken to treat constipation.
• Types of laxatives are bulking agents, stool softeners, osmotic agents, and stimulants.
• Bulking agents are bran, polycarbophil, psyllium, and methylcellulose. The side effects include bloating, flatulence, and poor iron and calcium absorption. The bulking agents, add bulk to the stools and absorbs water. Bulking agents acts slowly and thus are the safest way to promote regular bowel movements.
• Stool softeners act slowly to soften the stools and thus bowel movements is made easy. These slightly increase the bulk of stools and stimulate natural contractions of large intestines and thus makes evacuation of stools easy.
• Osmotic agents are those that pull a large amount of water into large intestines, and as a result, stools are softened and loose for easy evacuation. The excess fluid in large intestines stimulates contractions.
• Stimulant laxatives contain irritating substances that stimulate the walls of large intestines to contract and pass the stool.
• Enemas function is to mechanically flush the stool from the rectum and lower part of large intestine. Plain water (slightly warm) is considered as best fluid to be used as an enema.

Can constipation be serious or complicated?
Constipation can sometimes be serious and complicated. The complications are hemorrhoids or anal fissures. These conditions lead to rectal bleeding. Constipation may cause hard stools to pack the rectum and intestine tight enough that prevents normal pushing of the bowel. This condition is called fecal impaction. Diverticular disease is another complication.
People who are over concern with regular bowel movements may abuse their bowel movements with the use of laxatives, suppositories, and enemas. Thus, overuse of these can actually inhibit bowel’s natural and normal contractions and worsen constipation.

Thus, constipation is a serious issue to be looked upon.

Anal bleeding is one of the most painful diseases that occur in most of the individuals. Bleeding is the indication of the presence of the colon in the human body. It is a result of a cut or if there is a tear in the lining of Anus or it can even be in the Anal opening. The persons who are having this problem will suffer very seriously from the pain in Anal at the same time there will be huge amounts of bleeding. The person who is having disease gets terrified by seeing the situation. Hence, as a first step, the patient will visit a reputed proctologist to solve the problem and get relieved from the pain and bleeding.

Symptoms of Anal Bleeding
The first and the foremost symptoms of anal bleeding is the severe pain in the anal, which is unbearable by most of the individuals. At the same time individual also gets bleeding in the Anal which causes more tension that even leads to the depression. These are the most common symptoms that help in recognizing the disease.

Reasons for the Anal Bleeding
Anal bleeding is caused due to several reasons, and it may vary from one individual to the others. Though there are several reasons, some of them will be common in all the individuals. The most popular reasons for the Anal Bleeding are as mentioned below:

• Rectal fissures
• Intestinal infections
• Hemorrhoids
• Angiodysplasia
• Malignancy of the colon
• Colitis
• Intestinal Polyps
• Crohns disease
• Diverticulosis
• Worm infestation
• Endometriosis this is most commonly observed in the women
• Mesenteric vascular thrombosis

The entire above are the most common reasons, may not all be the reasons for the Anal bleeding but at least one from the list.

Indications of the anal bleeding through appearance?
Most of the individuals suffer from the Anal bleeding, but they feel shy to express it even at the Proctology specialist. The causes of Anal bleeding can be identified by the appearance of color in the blood. Below we mention about the nature of bleeding through its appearance:

• Scarlet color indicates Hemorrhoids or Anal fissure presence.
• Red color blood suggests a malignant tumor or polyps in the colon.
• Dark color blood clots mean Diverticulosis
• Black color bleeding indicates Gastric Pathologies and Duodenum.

Treatment of Anal bleeding by a proctologist
The best thing is to visit the proctologist so that they give the treatment depending upon the severity of the disease. The treatment can be from using of ointments in case of hemorrhoids or even laser treatments. Proctologists even suggest Hirudotherapy for some of the patients which depend on the condition of the individual. In some of the cases, even anti-inflammatory drugs will be suggested by the individuals to treat the disease. In case of Intestinal polyps, Diverticulitis treatment is used so as to remove benign tumors from the rectum, so as to prevent malignant tumor in the individuals. In any condition, the most important thing is to visit a proctologist and take correct treatment, before it leads to worst situations.

There are many kinds of conditions and symptoms that require different kinds of surgery for treatment as well as diagnostic management. One such procedure is called a laparoscopy or the laparoscopic surgery.

This is a surgical diagnostic management procedure that is known to be a low risk process with minimal invasion and suitable for various types of ailments. Read on to know everything about laparoscopic surgeries.

• Definition: A laparoscopic surgery is one where small incisions are made and an instrument called a laparoscope is used in order to take a look at the organs in the abdominal region. This tool is a long tube shaped one that comes with its own high intensity light and a high resolution camera that can easily move along the walls of the organs while the camera sends back imagery that will be displayed on a video screen in front of the doctor. This avoids the need for an open surgery and helps the doctors in getting samplesfor a biopsy on an outpatient basis.
• Need for Laparoscopy: This procedure is performed when the patient complains of persistent pain that is also sharp and shooting, in the abdomen region and surrounding areas like the pelvic cavity. This non-invasive method helps in diagnosis where other imaging methods like an ultrasound and CT or MRI scans would have failed to give a conclusive reason for the pain and suffering of the patient. When these tests do not supply enough reason for proper diagnosis, then the doctors usually resort to this kind of procedure.
• The Organs it can be used for: The laparoscopic surgery can be used for many organs including the appendix as well as the gall bladder, the pelvic region and the reproductive organs, the small and large intestines, the spleen, the stomach, the liver and the pancreas.
• What all can it Detect: The laparoscopic surgery can help in detecting a number of issues including any abnormal growth or mass that may be a tumour. It can also point at the presence of any disease in the liver, as well as the proper functioning of certain treatments. Also, it can show the amount of fluid that may or may not be present in the abdominal cavity and the extent of cancer's progression in the body.
• Risks: There are a few side effects or risks of this method including fever, chills, swelling, bleeding or redness of the site where the incision was made for the surgery, and shortness of breath. All these symptoms must be reported to the doctor immediately as they may point at the presence of an infection. Also, there is a risk of organ damage in this procedure.

Hemorrhoids are either internal or external. An internalhemorrhoid is present deep inside the rectum and anus, whereas external hemorrhoids are located at the base of the skin surrounding the anus. These are lower than the internal hemorrhoids. When they swell, they can be felt at the anus, as they are present outside. They might cause itching, pain, or bleeding during passing stools.

Externalhemorrhoid can protrude outside the anus and this can be seen and felt as a hard painful lump. They usually behave differently as they are covered by regular skin and when swollen they are painful, resulting in the formation of skin tags that can be felt. This skin tags can cause difficulties while passing bowel movements which can further lead to secondary skin infections. If the pain is too much and unbearable, the doctor might suggest removal of the blood clot from the thrombosed hemorrhoid that will stop the pain. Although, hemorrhoids are helpful in controlling bowel movements, only when they develop lumps and swelling they are considered as abnormal and painful.

Causes of Haemorrhoids:
Basically,hemorrhoids are caused by swelling in anal or rectal veins. This swelling can occur due to many factors, such as obesity, pregnancy, straining or pushing while passing a bowel movement, standing and sitting for long period of time (especially on the hard or concrete floor), chronic constipation or acute or chronic diarrhea, colon cancer, rectal surgery, etc. One important causes of the development of haemorrhoidsis diet low in fiber, as this can cause constipation and this can contribute in causing haemorrhoids in two ways: it will lead to straining or pushing in the toilet, and it will aggravate the development of haemorrhoids by producing hard stools and lead to irritation and swollen veins.

Symptoms of External Haemorrhoids:
External hemorrhoids can be felt as a bulged lump at the anus. They cause a problem only when there is blood filled inside them, which is known as thrombosis. The thrombosed external hemorrhoid is very painful, tender, and it often requires medical attention.

Diagnosis and Treatment:
Most individuals discover the presence of hemorrhoids by feeling the lump at the anus while wiping themselves after using a toilet, they note bleeding on the toilet bowl or on toilet paper, or they feel protruded or prolapsed hemorrhoid at the anus after bowel movements.

• One can be relieved with mild pain, inflammation, and swelling with some of the home treatments, such as:
• Consume high fiber diet such as more fruits, vegetables, whole grains, oatmeal, dry fruits, etc. This will help in softening of stools and increases the bulk and thus will not cause trouble while passing stools.
• Use of topical treatments which one can buy over-the-counter hydrocortisone or hemorrhoid cream or suppository or use pads which contains witch hazel or any numbing agent.
• Warm sitz bath, soaking the anal part in warm water for 10 to 15 minutes twice or thrice a day can be really beneficial
• Maintain anal hygiene
• Avoid using dry toilet paper and soap to clean or wipe anal area.
• Apply a cold compress or ice packs
• One can take oral pain relievers, some of the medicine that people with hemorrhoids take care acetaminophen, aspirin, and ibuprofen. These provide temporary relief from discomfort.

Hemorrhoids or piles are diagnosed by swelling of veins in the lower part of anus and rectum. Due to swelling, the walls of rectum and anus are stretched and thus become irritated. Hemorrhoids are of two types: Internal and External hemorrhoids.

Internal Haemorrhoids: As the name suggests, the piles are not visible from outside. These are present deep inside the rectum, located above the pectinate line and these are covered with the cells that are present through the rest of intestines. Internal hemorrhoids are normally painless. The first sign of internal hemorrhoids is rectal bleeding. However, straining can push internalhemorrhoid and it protrudes through the anus and this can be painful.

Causes of Haemorrhoids
The swelling of hemorrhoid occurs only when the pressure in the small vessels of rectum and anus is increased and is engorged with blood. The size of the hemorrhoids is also increased. The increased pressure may be due to various factors:

• Consuming low fiber diet and pushing or straining while passing stools, thus blood vessel pressure is increased.
• Pregnancy also is a cause of swelling as there is the increased pressure of the uterus on rectum and anus.
• Sitting for long on toilet also increases pressure.
• Obesity is also a cause of hemorrhoids.
• People suffering from diarrhea, both acute and chronic.
• A person having colon cancer might have hemorrhoids.

Signs and Symptoms of Haemorrhoids:

• The most common symptoms of hemorrhoids are painless bleeding, itching in anal, swelling and feeling of the presence of lump at the anus.
• All these symptoms are associated with inflamed hemorrhoid.
• Inflamed internal hemorrhoid can cause swelling, but is painless as there are no fibers attached to veins above the pectinate line that cause pain. However, passing hard stools can scrape off the thin lining of hemorrhoid, which can cause the painless bleeding.
• Spasms of the rectum and anal muscles caused by these swollen hemorrhoidscause pain, especially when they are protruded through the anus.
• Internal hemorrhoids can form a clot or thrombose resulting in severe pain.
• The presence of has inflammation, stool,and constant moisture and these can lead to itching and burning sensation in the anus among patient of internal hemorrhoid.

Treatment of Haemorrhoids

• Diet: Haemorrhoids can be treated when individuals consume a fiber-rich diet in order to soften the stools and ease their bowel movements. Fiber-rich foods include fresh fruits, dry fruits, grains, vegetables, and cereals. About 20 to 30 grams per day of fibrous foods is recommended. Dietary fiber will help create bulk in the intestines which will help in softening of stools and ease bowel movement. Supplemental fiber available in the marketincludes psyllium husk, methylcellulose, and calcium polycarbophil. Other recommendations include increased intake of liquids and having stool softeners. Drinking enough water and liquids will prevent stool from hardening.
• Over-the-counter topical treatment: There are various products available to treat hemorrhoids, such as gels, hydrocortisone creams, ointments, foams, pads, and suppositories.
• Home remedies: Soaking anus in a warm sitz bath might also help in hemorrhoids for about 10 to 15 minutes per day. One should practice good hygiene and clean anus with warm water while showering. Avoid using soap and dry toilet paper. One can also use a cold compress on the anus.

Minimally Invasive Procedure for Hemorrhoids (MIPH)

Out of the various types of medical and surgical interventions available to treat Piles, Minimally Invasive Procedure for Hemorrhoids (MIPH) 0r painless stapler surgery is known to be very popular since it acts an alternative approach to surgical interventions made for piles.

MIPH is defined as a minimally invasive surgical technique in which a band of loose or prolapsed mucosa and sub mucosa in the rectum is excised, proximal to the piles and disrupted mucosa is fixed by ‘stapled end to end mucosal anastomosis.

This will ultimately occlude the blood supply to the superior hemorrhoidal artery above the hemorrhoidal tissue, resulting in the retraction of prolapsed mucosa back to its original anatomical position. A special circular stapler known as PPHO3 is used in the anastomosis and the whole maneuver will take around 30–45 minutes. In case you have a concern or query you can always consult an expert & get answers to your questions!

Anal fissures arereferred to as a small cut or a tear in the lining of the anus. The cut or crack on the skin is the main cause of the severe pain. The person might observe bright red bleeding during and after passing bowel movements. Sometimes, when the fissure goes deep it exposes the muscle tissue underneath of the anus. An anal fissure might occur due to labor, i.e. during childbirth, straining or pushing during bowel movements, constipation, diarrhea, or certain medical conditions such as inflammatory bowel disease, cancer, and infection.

Individuals of all ages can be affected by anal fissure, including infants and young children. The common cause being constipation. This condition is not a serious issue. The tear can be treated or it might get heal on its own within a month or so. However, if it persists above two months, then it is considered a chronic or long-term fissure.

The symptoms of an anal fissure include:

• Visible tear or cut in the skin around the anus
• A small lump of skin or skin tag present next to the cut
• Severe pain in the area during a bowel movement
• Streaks of blood on stools or spotting on the dry tissue paper after wiping
• Burning sensation or itching in the anal area

Causes

Mostly an anal fissure occurs while passing very hard or large stools. This could be due to chronic constipation or frequent diarrhoeal episodes that can lead to tearing of the skin around the anus. Other causes of occurrence of an anal fissure are Crohn’s disease or inflammatory bowel disease, straining during labor, over tight or spastic anal sphincter muscles, or decreased blood flow to the anorectal area.
A fissure might also occur due to anal cancer, HIV AIDS, tuberculosis, syphilis, and herpes.

Treatment
Mostly anal fissure does not require extensive treatment. Some of the home remedies can help treat anal fissure and relieve the discomfort caused. The home remedies used for treatment are:

• You can use over-the-counter stool softeners
• Drink more water or fluids
• Take fiber supplements
• Have high fiber diets by including fibrous foods, such as raw fruits and vegetables, dry fruits, cereals, etc.
• You can even take warm sitz bath to relax and relieve the pain in the anal muscles and it will also help to increase the blood flow to the anorectal area.
• You can apply an ointment containing nitroglycerin to the anus in order to promote blood flow, or
• Hydrocortisone cream to help with healing the inflammation.
• You can apply topical pain reliever, lidocaine to the anus to relieve yourself from discomfort.
• An ointment with calcium channel blocker can be used to relax the sphincter muscles and will help to heal anal fissure.
• Botox injections into anal sphincter can also heal anal fissure. Spasms in the anal area can be prevented through Botox injections. This injection temporarily paralyzes the muscle. Due to this, the anal fissure gets time to heal and prevent the formation of new fissures.
• If the fissure is not treated with home remedies, the doctor might recommend anal sphincterotomy. This surgery involves making a small incision in the anal sphincter to relax the muscle, thus healing the anal fissure.

Prevention
An anal fissure can be prevented by taking following preventive measures:

• Keep anal area dry
• Proper cleaning of the anal area with mild soap and warm water
• Drink plenty of water and fluids to prevent constipation
• Avoid consumption of sharp foods that are difficult to digest such as nuts, popcorn, etc.

Anal herpes and anal warts are sexually transmitted diseases. These both diseases affect the genitals. As these are sexually transmitted diseases, these are transmitted through sexual contact.

Anal Herpes:

• It is an infection caused by herpes virus, which is caused by the sore or blisters formed around the anus. This infection is caused by the herpes simplex virus (HSV) type 1 or 2 viruses.
• The symptoms of anal herpes include red bumps or white blisters, itching and pain around the anal area, development of ulcer at the site of blisters, a coating that covers the ulcers ruptures or is bleeding, any change in the bowel habit.

Treatment

• Antiviral therapy is one of the primary treatment for anal herpes. The virus responsible mainly for herpes is herpes simplex virus type II. Antiviral medications are given to patients, these medicines fight the virus. The symptoms of herpes are reduced with this therapy.
• Regular use of antiviral medication is referred to as suppressive therapy. As the name suggests, people on suppressive therapy, reduce the risk of passing the infection to their sexual partner.
• In severe anal herpes, the doctor might give intravenous antiviral therapy to control the infection.However, the herpes virus cannot be cured as it is considered a lifelong infection. The virus stays in the nerve cells for lifelong and is inactive for long periods of time. It only outbreaks when it is triggered by an externalfactor such as illness, stress, or sun exposure.

Prevention
As anal herpes is transmitted through sexual contact, one can lower the risk of this disease. Safety measures can be used are:

• Wear a condom or use barrier protection during every sexual intercourse, including anal or oral sex.
• Reduce the number of sexual partners.
• If one maintains monogamy, the risk is minimal for transmitting anal herpes.
• One should abstain from sex altogether, if possible.

Anal Warts:
Anal warts are small warts that occur around the anus. Another name for anal wart is condyloma acuminate. In many cases, anal warts don’t cause any pain or discomfort. But, they cause irritation when they grow in size and might be itchy and/or bleed. However, if there are no symptoms seen, people suffering from anal wart might not even know that they have warts. Anal warts might occur only at a spot or even spread to different parts of the genitals such as buttocks, anus, and inner thighs over a period of time.

Symptoms
The anal warts are small bumps initially, a size of the head of a pin, which is not even noticed. However, as they grow, they can develop to a size of a cauliflower-likean appearance, when several warts are clustered together to form a huge lump. These warts are peach colored and the color may vary from yellow, light brown, or pink and it might even blend with the skin color. Usually the anal warts are without any pain or discomfort, however, other rare occurring symptoms are itching, discharge from the anus, or bleeding. Anal warts in women might appear on vagina, vulva, or at the cervix, whereas in men it can develop on penis, scrotum, groin area, or thighs.

Treatment
Topical medication can be used to treat anal warts, such as imiquimod, podofilox, podophyllum, etc. Another treatment of anal wart that depends upon the location and severity of the condition:

• Cryotherapy
• Electrocautery
• Laser treatments

Surgery can be recommended for larger warts that do not respond to medications. In case you have a concern or query you can always consult an expert & get answers to your questions!

Crohn’s disease is a chronic inflammatory disorder of GI or digestive tract. Crohn’s disease is most commonly affects the mucosal lining due to ulcerations of small and large intestines, but it can affect the entire digestive system. Crohn’s disease is usually related to another chronic inflammatory condition namely ulcerative colitis, which involves mainly colon. Crohn’s disease and ulcerative colitis are together referred to as inflammatory bowel disease. The symptoms include vomiting, abdominal pain, diarrhea, bloody diarrhea, fever, weight loss, anal fistulae, and perirectal abscesses. But, the symptoms are mostly dependent on the location, extent,and severity of the inflammation.

Subtypes of Crohn’s disease are:

• Crohn’s colitis – Inflammation of the colon. The common symptoms are abdominal pain and bloody diarrhea. However, anal fistulae and perirectal abscesses can also occur.
• Crohn’s enteritis – Inflammation of small intestines. Mainly jejunum (second part) or ileum (third part). The common symptoms are abdominal pain and diarrhea. In this obstruction of small intestines can also occur.
• Crohn’s terminal ileitis – Inflammation of the part of the small intestine which is closest to the colon, i.e. ileum (third or terminal part of small intestine). Similar to colitis and enteritis, the common symptoms are abdominal pain and diarrhea.
• Crohn’s entero-colitis and ileocolitis – Inflammation involving both small intestine and colon. The symptoms include abdominal pain and bloody diarrhea. Obstruction of the small intestine can also occur.

Causes of Crohn’s Disease
The cause of the disease is still not known. However, the researchers report that it is due to the abnormal response of the immune system. The uncontrolled inflammation which is associated with Crohn’s disease may be caused by food or bacterial intestines or due to the lining of the bowel.

Diagnosis
There are various diagnostic procedures and laboratory tests by which Crohn’s disease can be distinguished from other GI tract disease such as ulcerative colitis. A gastroenterologist can perform a sigmoidoscopy or colonoscopy to get bowel tissue for analysis or upper endoscopy can be done to study esophagus, stomach,and duodenum (first part of small intestine). To study in detail of small intestine, capsule endoscopy can be done, which is done by using a small, pill-sized camera which is swallowed. Other tests that can be suggested by your doctor are:

• Blood tests can be done. High white blood cell indicates inflammation and low red blood cells indicates a sign of anemia due to blood loss.
• Stool examination can be done to rule out any infection that can occur due to diarrhea.
• Special x-rays, namely CT scan or MRI can be performed of both upper and lower GI tract in order to confirm the location of the inflammation.

Treatment
Although there is no cure for Crohn’s disease, however, one can lead normal lives. Crohn’s disease is normally treated with medications. These include:

• Anti-inflammatory drugs, namely, salicylates. Side effects of these drugs are gastrointestinal upset, nausea, rash, headache, or diarrhea.
• Corticosteroids, again type of anti-inflammatory drugs, but this is more powerful. The side effects are seen if these drugs are consumed for long periods of time, mainly, thinning of bone, muscle loss, skin problems, and increased risk of infections.
• Antibiotics can be given such as ciprofloxacin, metronidazole,and others. The side effects include nausea, tingling or numbness of feet and hands.
• Antidiarrheal drugs

Risks
Along with Crohn’s disease, you are likely to develop other health problems such as colon cancer, lymphoma, deep vein thrombosis or pulmonary embolism, or psoriatic arthritis.
Thus, with this information, you can with the help of your doctor can work out your plan to avoid problems and possible complications. In case you have a concern or query you can always consult an expert & get answers to your questions!