Piles, fissure, fistula, perianal abscess, digestive disorders, colorectal cancer… look before you leap
CONSTIPATION: Root cause of colorectal diseases
The root cause of all colorectal diseases is constipation. Piles, fissure, fistula, perianal abscess, irritable bowel syndrome, colorectal cancer and many other diseases are all caused by constipation. And constipation is a lifestyle-related disorder.
Often, people come to me believing they have piles, while actually they have one of these more serious diseases. There isn’t enough awareness on colorectal diseases and people attribute all symptoms to piles. So, when a person comes to me with ‘piles’, I counsel the person and investigate in depth. In many cases, the investigation shows up a fissure, fistula, perianal abscess, or even inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease. It may even turn out to be a case of colorectal cancer. Some people even have a skin disease which they believe is piles.
Unfortunately, people don’t immediately consult their doctor in colorectal diseases due to inhibitions. There are stigmas and taboos attached to these conditions. Thanks to these stigmas, many people suffer in silence. On an average, a female patient is known to suffer for as long as nine years before consulting a specialist while a male suffers for seven. These people consult the doctor only when it becomes unbearable.
What causes constipation?
In India, about 15 per cent of the population suffers from constipation. There are two types of constipation - medical constipation and surgical constipation. Medical constipation can be treated with medication and lifestyle modification. In case of surgical constipation, surgery is the only treatment.
Many people think they are constipated when they have an episode of hard stool. Initially, the stool is hard and the remaining stool is soft. There are many causes for hard stool - not drinking enough water; not eating enough fruits, vegetables and fiber; lack of sleep; inadequate physical activity; and long spells of sitting. This isn’t constipation. If a person does not move his bowels for three days, sits in the toilet for a long time - 30 minutes and spends 15 minutes passing very hard stool, and this happens for six weeks, it is constipation.
Surgical constipation happens when a person strains very hard all the time to move his bowels and consequently the rectum comes down. It is called rectal prolapse. This can even happen in advanced age. This constipation can even occur during childbirth. In normal delivery, if the baby is big and the woman does not have a broad pelvis, the pressure exerted while pushing the baby down leads to the rectum coming down. It is called a rectocele. After some cases of Cesarean section, the woman feels unfinished after passing stools. She feels some is left in the rectum. Invariably, in such cases, they press hard but don’t get relief. This is called obstructive defecation syndrome.
There could be another issue connected to childbirth. In normal deliver, when the baby is large, along with the rectum the bladder also comes down. In such cases, whenever the bladder is full, there is leakage of 1-2 drops of urine. This leakage can also happen when the woman coughs or sneezes. This condition, called pelvic floor descent, leads to repeated urinary tract infections.
In such case, often, the person goes back to the doctor who advises surgery. But, a few years later, the patient visits a colorectal surgeon and reports she has piles as a result of the previous surgery. The root cause of the piles, however, is not the previous surgery but constipation that was not treated effectively.
Surgical constipation – rectal prolapse
This is a rather common condition in both women and men in an advanced age. The rectum comes out of the anal canal. It has to be corrected surgically with a laparoscopic procedure.
FISSURE: Straining hard is the root cause
A fissure is a crack in the anal canal. The anal canal is a narrow passage. When a person strains excessively while passing stools due to constipation or passes hard stools, a crack can develop. These cracks generally appear in the front or at the back - anterior or posterior.
A fissure is very painful. There will be bleeding in the anal canal. It will be very difficult to pass stools. People suffering from a fissure will go through hell. Many mistake it to be piles because of the extreme pain.
There are two muscles in the anal canal - one is the internal anal sphincter and the other is the external anal sphincter. The internal anal sphincter is involuntary and can become very tight. When it becomes tight it cracks when the person passes hard stools. When it cracks, it bleeds, burns and itches. This keeps happening repeatedly if not treated properly. Then, over a period of time, the person develops a condition called sentinel piles or sentinel tags. So, when a person has a fissure, it should be treated immediately.
Causes and diagnosis
Mostly, a fissure is purely a lifestyle disease. However, there are some fissures that are not due to lifestyle. If the person has more than one fissure in the anal canal, in two or more different areas other than front and back, it is an indication of inflammatory bowel diseases. In such cases, a colonoscopy has to be done to check the large intestine, up to the cecum, for an underlying cause.
A patient once came with multiple fissures and sentinel piles. The colonoscopy revealed ulcerative colitis. Whenever ulcerative colitis or Crohn’s disease is diagnosed, a CT enterogram and CT scan of the abdomen and intestines is done. In this case, the CT scans revealed lymph nodes. A PET scan was therefore done and it revealed neuroendocrine tumour. So, as in this case, a small fissure can go on to the diagnosis of a major cancer.
In another case, a patient came with pain in the anal canal. It was found that he had a large tumour in the rectum. On conducting a biopsy, it was found to be a very rare cancerous tumour - angiosarcoma of the anal canal. This was the first case of angiosarcoma of the anal canal reported in India, and it was found at Smiles.
Prevention and treatment
Fissure can be prevented by the right lifestyle. Drink enough water; eat fruits and vegetables daily; ensure enough fibre in diet; get enough sleep and physical activity; and don’t strain hard while passing stools.
Fissure is treated with a laser procedure. It relieves the pain immediately. The next day, the patient is back to regular activities - all physical activity including exercising in the gym, driving etc.
Colorectal cancer: Early detection leads to complete cure
In India, colorectal cancers are not diagnosed early enough. This is the only cancer that is diagnosed late in the country. According to the Indian Council of Medical Research (ICMR), 78 per cent of colorectal cancers are diagnosed in a late stage - when you cannot operate
Causes of colorectal cancers
Unhealthy lifestyle, obesity, constipation, genetics, smoking and excessive consumption of alcohol and junk food are all causes of this cancer. According to the American College of Colon and Rectal Surgeons, there could be a 30 per cent increase in colorectal cancers in the 30-year age group by 2030. The incidence of colorectal cancers is increasing in younger age groups.
Symptoms
A simple bleed may be due to colorectal cancer. Bleeding, weight loss, loss of appetite, alternative constipation and diarrhea, are all symptoms of colorectal cancer. A young IT professional came to us with altered bowel habits. He was normal on a physical examination. However, we performed a colonoscopy and found a growth in the high rectum. We then did a biopsy. It was rectal cancer.
Colorectal cancers are very common these days. Any colorectal issue such as bleeding should not be taken for granted and treated as piles, fissure or fistula. We need to go deep into the patient, examine thoroughly and understand the disease, and then treat effectively.
The reason why one should go to a specialist early in case of any symptom is because Stage I and II can be cured completely. The only cancer that can be completely cured is colorectal cancer, if diagnosed early.
Treatment and prevention
Colorectal cancer is treated with radiotherapy, chemotherapy and surgery. After recovery, the patient can return to normal life. Millions of people are normal and leading a normal life now after being cured of colorectal cancer. If not treated early, this cancer can spread to lymphatics and other organs also.
The only way to prevent it is through healthy lifestyle. People with family history of colon cancer should get a colonoscopy done every year. There should be comprehensive screening of all family members every year. Unfortunately, there is no colorectal cancer screening in India as in the USA. Anybody above 40 years of age is screened for colorectal cancer there.
Lifestyle, genetics and environmental factors are the major reasons for the increasing incidence of colorectal cancer in India. Also, now these cancers are being detected early with better access to medical care and advanced diagnostics
Two cases that tell a story
Case I: Why a colonoscopy is advised
A young medical student, aged 21 years, came with a perianal abscess. Typically, for any perianal abscess, I don’t just perform incision and drainage - I follow a complete protocol, which includes a colonoscopy.
When I informed him about the need for a colonoscopy, he, being a medical student, began to argue, questioning its necessity. Despite providing a detailed explanation, he remained unconvinced. Consequently, I obtained his consent that he did not agree to the colonoscopy. I proceeded with an incision and drainage, performed a fistulotomy, and sent him home.
Two months later, he messaged me. “Sir, I have found another abscess in my anal canal and have internal assessments coming up. What should I do?” I advised him to complete his internal assessments and then come back to me. He developed another abscess around the anal canal and returned for a consultation. This time, I performed a colonoscopy.
Surprisingly, the colonoscopy revealed that he had full-blown ulcerative colitis. Further scans showed multiple fistula tracts, which we diagnosed thanks to the detailed work-up following the colonoscopy.
Case II: Thorough investigation is crucial
A patient from Andhra Pradesh came to me with a complaint of piles. On examination, I found he had Grade III internal hemorrhoids. He also brought a colonoscopy report, which was normal, despite his noticeable weight loss. Given the normal colonoscopy report, I proceeded to operate on him for piles.
One month later, he returned for a follow-up and was completely healed. However, after another month, he came back complaining of bleeding. On examining his anal canal, I found everything to be perfectly normal. I then suggested another colonoscopy, but the patient accused me of recommending it “only to make money”. To reassure him, I offered to do the colonoscopy free of cost.
The colonoscopy revealed a growth in the sigmoid colon. This case underscores the importance of thorough investigation in patients presenting with symptoms like piles, constipation, fissures and fistulas.
PILES: Increasingly common across age groups
The root cause of piles is constipation. It happens due to excessive straining while passing stools. These days people sit in the toilet for a long time, busy on the mobile or newspaper. Reading a book, updating social media profile, answering email and checking WhatsApp…everything happens in the toilet, unmindful of time. When a person sits in the toilet for a long time, because of gravity, there is increased pressure on the anal canal. The blood vessels in the anal cushions tend to bulge in size, and the person develops piles.
What is piles?
It is the bulging of blood vessels in the anal canal caused by straining; hard stools; inadequate consumption of water, fruits, vegetables; lack of fibre in diet; inadequate sleep and physical activity; and sitting for long periods at work. Any job that involves long spells of being seated predisposes one to piles.
These days people in lower age groups are developing piles as many youngsters are addicted to junk food, don’t drink enough water, and don’t eat fruits. Many parents have this complaint. So, even children are developing piles.
Piles in children
A major reason for children developing piles is their lifestyle. For example, the school bus comes at 7.30 am. The child then wakes up at 6.30 am and has to use the toilet before getting ready for school. The child does not get enough time in the toilet as the mother keeps asking it to come out quickly so as not to miss the bus. The child then comes out without passing stools completely. Often, the child does not use the toilet in the school and withholds the urge to move bowels through the day. On returning home, the child rushes to the toilet and passes hardened stools. When this happens repeatedly, fissures occur and then piles develop
Seniors can be affected too
In advanced years, the elasticity of tissues is lost and they become weak. That’s why some people develop piles in an advanced age. I have operated on people in their 80s and even 90s. I have operated on over 100 patients who were over 95 years old. Recently, I operated on a 98-year-old man.
People ask ‘why is surgery needed at this age?’ A senior citizen should not be neglected because of his age. With piles the person won’t be able to sit or pass stools without a lot of pain. In such cases, we perform a laser procedure and ensure their quality of life improves.
Can piles be prevented?
With the right lifestyle, piles can certainly be prevented. Drink enough water; eat fruits and vegetables daily; ensure enough fibre in diet; get enough sleep and physical activity; don’t strain hard while passing stools and don’t spend too much time sitting in the toilet; and don’t sit for long spells in the office – take a break every hour. With this lifestyle, apart from piles, around 90 per cent of diseases can be prevented.
Can there be a relapse in piles?
Yes, if the root cause - constipation or obstruction – is not treated, the patient will get piles again.
How common is piles in India?
Around 36 per cent of India’s population suffer from some kind of colorectal disease at any given point in time. At least 50 per cent suffer once in their lifetime from one colorectal disease.
Piles is a very common problem not addressed by any government so far. There are no awareness programmes on colorectal diseases. We don’t have enough awareness programmes for digestive disorders, colorectal diseases and cancers.
Consult a qualified specialist only
An unfortunate challenge we face is many don’t consult a qualified specialist and end up with more complications. They visit unqualified, unscrupulous people, often in ‘clinics’ around bus terminals and bylanes of commercial hubs, promising ‘cure without surgery’. They promise instant relief and quick end to all symptoms. Those who fall prey to such elements come to us in an advanced stage of the disease. If it happens to be cancer, the delay will mostly be fatal. I have had patients come to me in late stages of cancer after spending valuable time on one such self-appointed ‘doctor’. Patients have come with serious conditions such as gangrene of the scrotum due to the unhygienic conditions in which these ‘doctors’ performed ‘procedures’.
Even in this day and age, we see these elements fleecing people and killing a good many too. It is high time the government acts against this unscrupulous and dangerous trade.
FISTULA: An infected track in anal canal
Anorectal fistula is effectively a ‘communication’ from the anal canal to the exterior in the form of an infected track. It happens because of a perineal abscess. Around 90 per cent of perineal abscesses are due to bacteria, and 10 per cent are due to tuberculosis, ulcerative colitis, Crohn’s disease, climatic infections and many other causes.
An abscess leads to a fistula. A perineal abscess is very painful. It is accompanied by swelling and fever. Most people go to a doctor who prescribes antibiotics. This treatment will open up the abscess and all the pus will come out. This brings down the pain. But, this isn’t the end of it. After some days, there will be discharge of pus again. These patients go on to develop fistula.
Unfortunately, around 40 per cent of abscesses develop into fistula. It can be prevented by draining out the pus properly. Therefore, a surgeon who operates on an abscess should be well-trained. Even though it looks simple, actually it is a very complex surgery. If the surgeon does not drain the pus effectively, the sphincter muscles can be damaged and this develops into a complex fistula. A complex fistula is very difficult to operate.
Every fistula is different. An MRI fistulogram by a very good radiologist is needed before treating it. Apart from analysing what sort of fistula it is, the surgeon has to check how many muscles it is crossing and where, and how deep the crossing is. The surgery is a combination of procedures. Only such hybrid procedures yield a complete cure of fistula. The patient then will not develop a fistula again and will not lose control over stools.
A fistula should never be ignored as it can be dangerous. Around two per cent of fistulas, if not treated for a long time, will develop into cancer - squamous cell carcinoma. We have reported seven cancers in fistulas at our institute.
Risk factors and prevention
People with constipation, those who strain hard while passing stools, pass hard stools, sit for long spells, travel frequently and use public toilet commodes carry the risk of perineal abscesses.
Preventive measures include using clean toilets, clean commodes, drinking adequate water, consuming fruits daily, consuming vegetables with adequate fibre, and not straining while passing stools. Around 10 per cent of the population is suffering from fistula.
Never ignore a fistula
Never take it for granted. A medical student who came to us with a fistula refused a colonoscopy. After a month he reported a second fistula. This time he agreed to a colonoscopy and we discovered that he had Crohn’s disease. A colonoscopy is a must in case of fistula. A colonoscopy is needed because in 10 per cent of cases, the fistula is due to causes other than bacteria. It could be due to ulcerative colitis or Crohn’s disease. So, in case of fistula or perianal abscess, a complete evaluation of the GI system should be done. The anal canal is a window to the GI system. Through the anal canal, many diseases can be seen and diagnosed.
Digestion: Your gut is your ‘second brain’
Around 56 per cent of India’s population suffers from some kind of digestive disease. It could be H pylori infection, dyspepsia, gastritis, duodenitis, ulcerative colitis or irritable bowel syndrome. Mostly, these digestive disorders are due to unhealthy lifestyle, poor eating habits, excessive consumption of junk foods, unhealthy foods such as pizza and burger, inadequate consumption of water, lack of fibre in diet, not enough sleep daily, inadequate physical activity and consumption of contaminated food are the leading causes of digestive diseases. We come across these disorders daily.
Treatment
First, we have to diagnose the disorder. Then, it is treated depending on the diagnosis. It is important to treat digestive disorders early. Ulcers in the digestive system can lead to cancer. Gastric ulcers can lead to gastric cancers. Ulcerative colitis can lead to cancer of the intestines.
A good lifestyle, early diagnosis of an ulcer and treatment is how you prevent an ulcer from turning into cancerStrengthening your digestive system healine.
How strong a person’s digestive system is depends on the gut microbiota. The gut microbiota is the main precursor of all diseases of the digestive system. It is also the precursor of other diseases such as cardiac diabetes, mental health issues, Parkinson’s disease and dementia. All these are linked to digestive health. The brain is the ‘first brain’ and the gut is called the ‘second brain’. That’s why it’s called ‘gut feeling’ when a person has a hunch.
A healthy lifestyle and good eating habits are what it takes for a strong gut microbiota.
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SMILES puts your smile back
SMILES Hospital is a specialist centre of excellence for all colorectal diseases. It is equipped with the state-of-the-art technology. The hospital upgrades its equipment constantly to stay on par with the latest and best in the world. The treatment here is most effective and advanced with the use of tools such as artificial intelligence (AI) and Internet of Things (IOT). SMILES Hospital uses a combination of technology and experienced specialists to get the best clinical outcomes for every patient.
A key aspect of SMILES Hospital is accessibility and affordability. The hospital has patients across all income groups coming with its affordable treatment that is of global standard.
Legend behind SMILES Hospital
The renowned colorectal surgeon, Dr C M Parameshwara, is the moving spirit behind this institution. It is said it takes five years to become an expert and 20 years to grow into a legend. With 24 years of experience behind him, Dr Parameshwara is truly a legend. The hand-picked team of Dr Parameshwara, state-of-the-art technology at SMILES Hospital, and indepth knowledge, combine to ensure accurate diagnosis, appropriate and effective treatment, and optimum outcome for patients.
His advice to all is simple - eat healthy, drink adequate amount of water daily, cultivate only clean habits, ensure physical activity, sleep well, and engage in activities such as meditation or yoga as exercise for the brain.
For all colorectal issues:
For all colorectal issues:
SMILES Hospital
1st Main Road, 1st Stage, 423, 60 ft Road, Near SBI Bank, Gokula
1st Stage, Gokula Extn., Mathikere, Bengaluru,
Karnataka - 560054 | Call: 8010540540
Mandya: S D Jayaram Hospital, 3rd Cross,
Ashok Nagar. Call: 9448359977
Email: wecare@smileshospitals.com
Website: gastroenterology.smileshospitals.com