Download Mr David Sellu, MSc ChM FRCS

UNDERSTANDING DISEASES AND CONCEPTS
Patient Information Leaflet 2.
2. Understanding cancer
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
Hospital NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
Normal cells
The basic building block of the body is the cell. Each cell has broadly the same
components as all others, but cells in different parts of the body contain specialised
components that enable them to perform unique functions. There are several millions of
cells in the body. Cells of similar composition are grouped together to form what is
known as a tissue. For instance, the cells lining the outside of the body form a tissue
called the cuticle or the epidermis, from which hairs can grow depending on where the
skin is. Tissues of different types are grouped together to form an organ, performing a
single function or a group of related functions. For example, the stomach is made of
several types of tissues and one of its functions is to help digest the food.
How does cancer occur?
All cells are carefully controlled so that they grow and function in a highly disciplined
way. For reasons that are not always clear, one single cell or a small group of cells gets
out of control and begins to behave erratically. It grows out of control and divides
excessively, sometimes forming a lump. This cluster of abnormal cells is often referred to
as a tumour, or a lump. Many tumours are completely surrounded by a lining that keeps
them entirely contained at the site from which they arose, and are said to be benign. Most
benign tumours are simply a nuisance and do not necessarily need to be removed. The
tumours that have a tendency to spread into neighbouring tissues and organs, and to
distant organs, are said to be malignant and are often referred to as cancer. Cancer
produces its harmful effects not only on the local organs next to it, but also the distant
organs to which it spreads. Cancer is another name for a crab and it is not difficult to
imagine what a crab can do with its claws.
Different stages of cancer
A cancer that is still only confined to the cells from which it has arisen is known as an insitu cancer and is the earliest form of the disease. Once the cancer breaks into the
surrounding tissue, it is said to be invasive. A cancer that has broken off from its primary
site and settled and grown in another site is known as a secondary or metastatic cancer.
One of the many factors determining how harmful a cancer will be is the stage at which it
is first detected. In general the earlier the stage the better the outcome, but other factors
such as the type of treatment given, affect outcome.
What causes cancer?
Exactly why a normal cell turns into cancer is still not entirely clear. In some cases, it
may be due to a faulty genetic message in the cell, and the individual is either born with
this faulty message or acquires it after birth. For example, about 10% of people with
bowel cancer have a faulty gene or genes they have inherited from earlier generations.
Some chemicals, known as carcinogens, can act on the cell and cause it to become
cancerous. Cigarettes, for instance, contain carcinogens that are now well known to cause
lung cancer. The way or ways in which carcinogens acts is partially understood, but there
is still a lot that is not known about the interaction between the cell and a carcinogen.
There are over 200 different types of cancer. Some form lumps and others do not. For
instance, many cancers of the blood cells remain suspended in blood and do not form
lumps or swellings. The way in which cancer behaves varies from the type of cancer and
even from one individual to another. The spectrum of cancer behaviour is very wide
indeed, and hence it is often difficult to predict the outcome of cancer in a given
individual.
It is clear from the above description that cancer is a complex disease. It is one of the
most commonly studied afflictions of man, but a lot more work needs to be done to
unravel its many mysteries. One in three of us will develop cancer at some stage in our
lives. The commonest cancers in women in the UK have recently been announced to be
lung and breast cancer, followed by bowel cancer. In men, lung cancer is the commonest,
followed by bowel cancer.
Is cancer treatable and if so, how is it treated?
One of the main messages to cancer sufferers is that cancer is treatable in all instances. It
has first to be diagnosed and the way in which this is done depends on the type of cancer.
In all cases, the doctor will take a history from and examine the patient. Tests are
performed including, in many cases a biopsy, or examination of a piece of the cancer
removed.
There are several ways of treating cancer and these include a surgical operation to
remove most or all of the cancer, or to alleviate a complication produced by the cancer.
Another common form of treatment is chemotherapy, in which chemicals are given to
destroy cancer cells. A third form of cancer treatment is radiotherapy, involving the use
of x-rays or gamma rays shone directly at the cancer. One, two or all three of these forms
of treatment can be used for a given cancer in a given individual but several factors are
taken into account in reaching this decision. Treatment can be given to cure the cancer
(curative treatment) or it can be given to alleviate the harmful effects of the tumour
(palliative treatment), leaving some, or all, of the tumour still in the body.
Where to get more information
1.
2.
The Cancer Guide by Simon Compton. Published by Macmillan Cancer Relief.
Can be obtained free by phoning 0845 601 6161
Cancer of the colon and rectum or colorectal cancer. Information Leaflet 14.
Patient Information Leaflet 3.
3. Gallstones
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What are gallstones?
The gallbladder is a small pouch lying in the top part of the right side of the abdominal
or tummy cavity under the liver. It comes off the common bile duct (CBD), the tube that
connects the liver with the bowel. It is a few inches long and is pear shaped. It holds an
ounce or two of bile (previously referred to as gall, hence the name gallbladder). Bile is
produced by the liver continuously and is passed into the gallbladder so it can be stored
and concentrated. Bile is needed for digesting fatty foods and after a fatty meal, the
gallbladder contracts and empties its contents through the common bile duct into the
upper part of the small bowel.
The gallbladder contains a number of chemicals including cholesterol and calcium.
Normally all of these substances are well dissolved in bile and are kept in solution by
another important component of bile known as bile salts. In the absence of disease, bile
is a liquid. For reasons that are not always clear, the amounts of one or more of the
chemicals increase and these chemicals can no longer be kept dissolved and become
solid. The process is known in chemistry as precipitation and is similar to what happens
when you add too much salt to water. Gallstones result when chemicals, notably
cholesterol and calcium, precipitate out of bile.
What harm do gallstones cause?
Gallstones are common and their frequency increases with age. Over a third of people
over the age of 70 years have gallstones. The majority of these stones are said to be
‘silent’, producing no problems at all and are found in people undergoing investigations
such as scans for entirely unrelated problems. I shall discuss the issue of what to do about
gallstones found by chance in such way.
Gallstones can cause a number of problems, discussed below.
 They can cause sudden or acute inflammation of the gall bladder, a condition known
as acute cholecystitis. This results in severe pain, often but not exclusively, in the
upper right side of the tummy. This may be accompanied by a feeling of wanting to
be sick and sometimes actual vomiting. The patient may have to be admitted to
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

hospital. Many surgeons will allow the inflammation to settle down and wait for some
weeks before carrying out an operation to remove the gallbladder.
Rather than the sudden pain described above, the pain may be dull and persistent, but
is not severe enough to warrant admission to hospital. Sometimes the pain comes on
after a fatty meal and the sufferer may belch a lot of wind. This results from lowgrade inflammation of the gallbladder or chronic cholecystitis.
Jaundice. If a stone falls into the CBD, it can block it and prevent bile from passing
into the bowel. This yellow bile accumulates in the body causing jaundice. Itching
and fever may accompany jaundice.
Inflammation of the pancreas. The outlets of the CBD and the pancreas usually join
together forming a small pouch that opens into the bowel. Blockage of the pancreatic
outlet can result in serious inflammation of the pancreas, a disease known as acute
pancreatitis. This causes severe abdominal pain and requires admission to hospital.
Fortunately, it is rare.
Some of the complications above are a nuisance but others such as acute pancreatitis can
threaten life. Treatment is recommended for gallstones that cause symptoms.
How are gallstones treated?
In one of three ways.
 Leaving them alone. If they are not causing symptoms and are discovered by chance
(silent gallstones), the doctor may advise that they are simply watched and not
treated. The person will be advised to avoid excessive fatty foods. In a relatively
young person with small stones, however, treatment is recommended because over
the course of that individual’s lifetime, there is a risk that complications will occur.
 Dissolving them. Drugs are now available to dissolve some, but not all gallstones.
The drugs are made of bile salts and enable cholesterol to dissolve back in bile, rather
like adding more water to a solution of salt and water when the salt has precipitated
out. Only a small proportion of gallstones can be dissolved this way, and tests can be
done to find out which ones can. The medication needs to be taken for up to 1 year
and has side effects such as diarrhoea. This form of treatment is rarely used and is
reserved for those unwilling or unfit to have an operation.
 Removing the gallbladder. If the gallstones cause symptoms such as pain, or have
caused jaundice or pancreatitis, the gallbladder must be removed by means of an
operation. The operation is now generally done using the laparoscope (the operation
is referred to as laparoscopic cholecystectomy – Information Leaflet 47) or
occasionally by the open method in which a cut is made in the upper part of the
abdomen. The whole gallbladder, which has by now been damaged, is removed.
Simply removing the stones will not cure the problem, as they will reform. X-rays are
sometimes taken at the time of the operation to make sure there are no stones in the
CBD. If there are CBD stones, they need to be removed either at the time of this
operation or later by ERCP (Information Leaflet 40). People who have had their
gallbladders removed seem to be perfectly well and have no problems digesting fats.
Where to get more information
ERCP (Endoscopic retrograde cholangio-pancreatography). Information Leaflet 40
Laparoscopic removal of the gall bladder. Information Leaflet 47.
Patient Information Leaflet 4.
4. Peptic ulcers
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What is a peptic ulcer?
The bowel is a muscular tube extending from the mouth to the anus. Cells that provide
complete protection to the tissues forming the wall of the bowel line its interior. Any
break in this lining is known as an ulcer. When ulcers occur in the gut, they are more
likely in two main places, in the stomach and in the duodenum (the part of the small
bowel immediately the stomach). An ulcer in the stomach is known as a gastric ulcer,
and one in the duodenum is referred to as a duodenal ulcer. For reasons discussed
below, gastric and duodenal ulcers are also called peptic ulcers.
How do ulcers form in the stomach and the duodenum?
The stomach produces hydrochloric acid and an enzyme called pepsin, and the two begin
the process of digestion of food. These substances are so powerful that they can easily
digest the lining and wall of the stomach, but the reason they do not is because there are
equally powerful defence mechanisms that protect the lining of the bowel. Ulcers occur
when the defences of the bowel lining are overcome by acid and pepsin, and the lining is
eaten away to leave a raw patch. These ulcers are named ‘peptic’ because pepsin is one of
the corroding substances. Ulcers do not form if there is no acid, but people with ulcers do
not necessarily produce more acid in their stomachs than people without ulcers. In those
with ulcers, however, reducing acid production increases the chances of the ulcers
healing.
A germ or bug called Helicobacter pylori (or H. pylori) has now been identified as an
important cause of peptic ulcers (see Information Leaflet 4). Nearly all patients with
duodenal ulcer have it, and 80% of those with gastric ulcer have this bug.
Who gets peptic ulcers?
Anyone can get peptic ulcers, but they are more common in younger adults. Men get
ulcers more than women. Factors that increase the risk of ulcers include:
 Cigarette smoking

The use of medicines known as non-steroidal anti-inflammatory drugs, for treating
arthritis and rheumatism
 The use of steroids, also for treating certain forms of rheumatism and arthritis
 Excessive alcohol
 Stress by itself does not produce ulcers but aggravates them if they already exist.
There is no evidence that eating spicy foods causes ulcers.
What should make me suspect I may have a peptic ulcer?
If you have pain in the tummy that fits into one or more of the following categories:
 Usually felt in the upper part of the middle of the tummy
 Sometimes goes straight through into the back
 Is burning in character and wakes you up in the middle of the night
 Sometimes occurs when you are hungry and is better after you drink milk
 Some types of peptic ulcers are made worse by food
 May be accompanied by nausea and occasionally vomiting
 If you develop complications such as vomiting blood
What tests are done to diagnose peptic ulcer?
The two main ones are barium meal (Information Leaflet 38) and gastroscopy
(Information Leaflet 29). Gastroscopy is preferred nowadays as it enables tissue samples
to be taken to rule out cancer and to determine whether H. pylori is present.
How are peptic ulcers treated?
There are a number of ways of treating ulcers but always make sure that treatment is
recommended and supervised by your doctor:
 Avoiding altogether or reducing the things that caused them or those making them
worse, eg excessive alcohol, smoking, steroids and non-steroidal anti-inflammatory
drugs and stress
 Avoiding foods that aggravate them and eating small and frequent meals to neutralise
stomach acid. It is not necessary to eat just bland foods.
 Reducing stomach acid. This involves the use of simple antacids or medicines that
specifically block the cells that produce acid. There are a number of these on the
market, some obtainable over the counter.
 Eradicating H. pylori if present. Your doctor will recommend a combination of
antibiotics and an acid suppressing medication for a week or two.
 Using medications that strengthen the lining of the stomach and prevent its damage
What about an operation?
Fortunately with all the medicines now available, it is uncommon for surgeons to operate
on peptic ulcers. Operations were done to cut the nerves supplying the acid producing
cells or removing a portion of the stomach. Operations are still necessary when
complications such as bleeding or perforation of the stomach occur.
Where to get more information
Helicobacter pylori. Information Leaflet 5.
Barium meal. Information Leaflet 38.
Gastroscopy. Information Leaflet 29
Patient Information Leaflet 5.
5. I have been told I have Helicobacter pylori.
What does this mean?
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
What is Helicobacter pylori?
The words Helicobacter pylori are sometimes abbreviated to H. pylori. H. pylori is a
germ or bug and lives in the sticky fluid or mucus that coats the lining of the human
stomach and duodenum. It may live in this location throughout the individual’s life and in
most people causes no problems whatsoever. However, in some people it causes
inflammation of the lining, leading to an ulcer. An ulcer is a sore or a break in the lining
of the organ. The two types of ulcer are gastric ulcer (in the stomach) and duodenal ulcer
(in the duodenum).
How does H. pylori infection occur?
It is not entirely certain how this infection passes from one individual’s stomach to
another but it is believed that it may be transmitted through infected vomit or stool. These
materials come in contact with a person’s hand and are then swallowed into the stomach
where a new infection occurs. Good hygiene is important in reducing the risk of this and
other infections.
The layer of mucus lining the stomach acts as a barrier between the contents of the
stomach, which are rich in acid, and the cells of the stomach. In the case of the
duodenum, the mucus protects against the juice inside, which is rich in alkali. This germ
may lie dormant for very many years in the mucus coating of the stomach and duodenum
without causing any infection.
Just what triggers off infection and ulcers in some people is unknown. The use of
medications such as aspirin and other anti-inflammatory drugs, and cigarette smoking are
well known to damage the delicate lining of the stomach and duodenum and may trigger
infection. Some people may inherit the genes that make them prone to infection by H.
pylori. Infection initially causes widespread inflammation of the lining of the stomach
and duodenum. In some patients, an inflamed area may turn into an ulcer or ulcers.
How do I know I have an infection with H. pylori?

As mentioned above, most people with H. pylori infection have no symptoms. There
are tests (see below) for diagnosing people who carry H. pylori. However, if such
individuals do not have any symptoms, there is nothing to be gained from putting
them through this test, as there is no evidence that treating them, when they do not
have ulcers or inflammation, makes any difference to them in the long term.
 Symptoms of H. pylori infection include indigestion, vomiting blood and
occasionally, severe pain in the tummy when an ulcer in the stomach or duodenum
has burst.
If your doctor suspects that you have H. pylori infection, he or she will arrange certain
tests for you. You may not need all of these tests and the doctor will decide which one is
appropriate for you.
 Antibody test: People infected with H. pylori produce antibodies to the bug. The level
of this antibody can be measured in the blood by using a small sample of blood
obtained by a pin prick or a larger sample.
 Testing a sample from the stomach: The doctor can have a look in the stomach by
means of a test called gastroscopy and take tiny samples (biopsy). The pathologist
will search for the bug in this sample by using a microscope. Alternatively, the doctor
doing the gastroscopy can do a rapid analysis of the sample looking for evidence of
this bug.
 A breath test, which is described in Information Leaflet 30.
What is the treatment for H. pylori infection?
There are several treatment options for H. pylori but the principle is the same for all of
them, and this is: giving antibiotics to clear the bug and giving a medication to reduce
acid secretion by the stomach. Usually two antibiotics are given and the length of the
treatment is from 7 to 14 days. Most treatments are for 7 days and you must do your best
to complete the treatment.
The treatment may produce side effects, including a bad taste in the mouth, nausea and
diarrhoea. If these are present, they will clear after the treatment has been completed.
Follow carefully the instructions you are given with these medicines, and in particular the
need to avoid alcohol if the course includes a medicine called metronidazole or Flagyl.
This last mentioned does not go down well with alcohol and makes you feel sick if you
take the two together.
If an ulcer is present, it usually heals when this treatment is taken. Inflammation of the
stomach will also subside when H. pylori is cleared from the stomach. Most doctors will
not do repeat tests to find out if this bug has been cleared if your symptoms subside.
Occasionally, your doctor will recommend that you have one of the tests above to see if
the infection has been cured.
Where to get more information
I suffer from indigestion and/or heartburn. What should I do?– Information Leaflet 24
Gastroscopy - Information Leaflet 29.
13
C-Urea breath test - Information Leaflet 30
Patient Information Leaflet 6.
6. Hiatus hernia and gastro-oesophageal reflux
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What is a hiatus hernia?
Hiatus hernia is a condition in which the upper part of the stomach is pushed up into the
lower part of the chest through a weakness in the diaphragm. The diaphragm is a strong,
dome-shaped sheet of muscle that separates the chest from the abdominal cavity. The
oesophagus or gullet passes through the diaphragm on its way to join the stomach, which
lies immediately on its underside. In some people, the opening through which the
oesophagus passes becomes slack and allows the top part of the stomach to rise into the
chest.
What problems does a hiatus hernia cause?
Many people have hiatus hernias that do not cause any symptoms and are discovered
entirely by chance during x-rays or endoscopy examinations of this area. No action needs
to be taken for such a hernia. Symptoms caused by hiatus hernia are due to the juices
from the stomach working their way upwards and eroding the lining of the gullet. This is
referred to as gastro-oesophageal reflux. The lining of the gullet was not designed to
come in contact with gastric juices. The lining is inflamed and eroded (reflux
oesophagitis), resulting in heartburn (Information Leaflet 24). The symptoms are made
worse if the individual is overweight, wears tight clothing such as abdominal corsets, or
bends down often or lies flat in bed. These symptoms also occur in pregnant women but
often clear after the baby is born.
A more serious problem due to the constant irritation of the lining of the gullet is the
formation of scar tissue in the gullet leading to narrowing of the gullet. If this is not
relieved the individual will have difficulty in swallowing and this can itself lead to many
complications.
How is hiatus hernia diagnosed?
The pain of hiatus hernia can sometimes mimic heart disease and so it is important to
establish the diagnosis with certainty. Your doctor, on listening to your history and
examining you will decide on the tests to perform to make a diagnosis. These will include
doing a heart tracing or ECG, a barium meal and/or oesophago-gastro-duodenoscopy.
During the last tests, biopsies can be taken to determine the extent of inflammation of the
oesophagus. These tests will also determine the degree of narrowing of the oesophagus.
What is the treatment of hiatus hernia causing symptoms?
The treatment in most people is by simple means, supplemented by medications.
 Having small but frequent meals. Have drinks at different times to meals.
 Avoid foods which may cause problems, mainly spicy, fatty or fried foods, strong
coffee, fizzy drinks, lots of caffeine, alcohol, very hot or very cold drinks
 Adopt better posture. Avoid bending, lifting and lying down for 2 hours after food.
Cut down on or give up smoking.
 Tight fitting clothes and underwear can sometimes aggravate the problem.
 If you suffer badly at night, try sleeping with extra pillows; alternatively, you can
prop up the bed a few inches at the head end.
 Milk and yoghurt may help to relieve the symptoms.
 If you are overweight, it is important to lose weight, as this may alleviate most of
your symptoms.
 Your doctor will prescribe medications that help to neutralise the acid coming up into
the gullet, to reduce acid production and to help the gullet to empty the acid that
comes into it more quickly. A number of these medications are now available on the
market and some can be bought over the counter at chemists. It is important not to
treat yourself but to follow treatment prescribed by the doctor.
Why operate?
In most people, symptoms are controlled by the measures above. An operation is
considered in the minority of patients in the following categories: those in whom
symptoms control is ineffective by these means; those who have dangerous bleeding from
the gullet due to the damage by the acid; those who have narrowing of the gullet and have
difficulty swallowing.
How is the operation done?
The aim of the operation is to get the stomach back into the abdominal cavity, to reduce
the size of the hole in the diaphragm so the stomach cannot slip back upwards, and to
restore the valve mechanism to stop acid going up into the gullet. Several operations have
been tried and many abandoned as they were not very effective or were deemed
dangerous. They all involved cutting through the abdominal wall to reach the gullet, and
then performing the repair.
The new way is to use the laparoscope or the key-hole technique, and the operation is
called laparoscopic fundoplication. The stomach is brought down and a part of it
wrapped around the lower gullet to achieve the aims above. Recovery is quick and in
good hands the results are very promising.
If the gullet has become narrowed, it can now be easily stretched or dilated using a
gastroscope. This stretching, often a day case procedure, needs to be repeated several
times under sedation. Rarely, it may be necessary to leave a tube permanently in the
gullet to keep it open but this is very rarely done for this particular problem.
Where to get more information
Hiatus hernia and gastro-oesophageal reflux – Information Leaflet 6.
Patient Information Leaflet 7.
7. Irritable bowel syndrome (IBS)
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
Introduction
One of the many functions of the bowel is to propel the food eaten and its digested
products from the top part of the gut towards the anus to be evacuated as stool or waste
matter. The food being digested is divided into a series of small portions, and as each
portion passes, the bowel above it contracts and the bowel below relaxes, enabling the
food to glide through smoothly.
What is the irritable bowel syndrome (IBS)?
This is a condition in which the bowel muscle is extra sensitive to the normal stimuli in
and around it. The bowel contracts more forcefully than normal and the normal waves of
contraction become erratic. Parts of bowel that should relax sometimes contract and vice
versa; bowels may be either sluggish or over-active, and wind often gets trapped in it.
Some people have severe symptoms at times of stress and it is believed that the nerves
supplying the bowel get overstimulated. Similarly, certain foods can produce the
symptoms, but this condition is not due to food allergy.
IBS is extremely common: about a third of the population has it at some point in their
lives. While in many the symptoms are mild, in a small proportion, they can be severe.
Women seek more medical help for IBS though it occurs equally in both sexes. It is
commonest between the ages of 15 and 45 years.
What causes the irritable bowel syndrome?
Although we understand how the bowel behaves in IBS, we do not yet know the cause.
Several things may make the symptoms worse, but they are not necessarily the cause. As
mentioned above, stress and diet are common aggravating factors. One type of food may
make symptoms worse in one person and yet be completely harmless in others. Foods
more commonly known to worsen symptoms include alcohol, coffee, tea and animal
milk, and smoking.
What are the symptoms of the irritable bowel syndrome?
The symptoms are mild in some and severe in others. They vary a great deal from one
person to the next, and even in the same person at different times, but include one or
more of the following:
Abdominal pain: This is a colicky or griping tummy pain making the sufferer double up.
Sometimes passing wind makes it better. Women sometimes notice that the pain is worse
at certain times in the menstrual cycle.
Bloating and fullness: Trapped wind makes the tummy bloat and clothes sometimes feel
tight and uncomfortable. The tummy may rumble as the wind moves about and often a lot
of wind is passed from the anus.
Changes in the bowel habit: Some people experience constipation, others diarrhoea, and
in some patients the bowels alternate between constipation and diarrhoea. The stools may
be hard or they may be liquid, and sometimes when the individual has to open their
bowels, they have to rush (some actually soil themselves if they do not go quickly).
Patients may suffer pain when passing stools and at times, there is a sensation that the
bowels are not emptying fully.
Passing mucus or slime in the stools: Mucus is the normal lubricant the bowel produces
to help stools glide easily through it. In IBS there may be an excess of mucus passed from
the back passage. Bleeding from the back passage is not a symptom of IBS. If it
occurs, it must be investigated.
Are tests needed to diagnose the irritable bowel syndrome?
In many young people the history is so typical that after a physical examination the
doctor may decide you do not need tests. In some, simple tests such as blood and stool
tests will suffice. In others combinations of scans of the tummy, barium enema, flexible
sigmoidoscopy or colonoscopy may be necessary. The reason that tests are sometimes
necessary is because some of the symptoms of IBS may be produced by other more
serious conditions such as cancer.
How is IBS treated?
Diet: For most people major changes in diet are unnecessary, but modest changes are
often beneficial. You need to try various things to see what suits you and disagrees with
you. The following often help to reduce symptoms: increasing and sometimes reducing
the amount of fibre helps; reducing fat intake; avoiding excesses of coffee, tea and animal
milk; and stopping smoking. Eat regular small meals and avoid large, infrequent meals.
Relaxation: Avoid stressful situations and try and relax as much as possible. Taking on a
hobby often helps. Knowing that your symptoms are not due to serious disease and that in
time they get better should help alleviate any anxieties you may have about the diagnosis.
Medicines: These are prescribed as a last resort and are claimed to help your bowels
relax. Some help to slow the bowel down and make the stools more solid. Do not treat
yourself , but follow the doctor’s advice.
Where to get more information from
Colonoscopy. Information Leaflet 33.
High fibre diet. Information Leaflet 28.
Patient Information Leaflet 8.
8. Appendicitis and appendicectomy
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What is the appendix?
The appendix is a small tube the width of a pencil and hangs down from the right side of
the colon. One end is closed and the other end opens into the caecum, the first part of the
large bowel. Contrary to popular belief, it is not a useless appendage. It contains
lymphatic tissue which helps fight infection in early life. Having said that, there are
plenty of other lymphatic organs in the body and removing the appendix does not result
in an increase in the risk of infections.
How does appendicitis occur?
How appendicitis occurs is not entirely understood. In some people, a piece of hardened
stool becomes lodged in the appendix and the muscular wall of the appendix cannot
dislodge the stool. So the appendix swells, becomes red and starts to cause symptoms. In
typical cases, pain is felt around the navel and then later settles on the right side at about
the belt line. Appendix pain can be very different, however and appendicitis can be very
difficult to diagnose.
As time goes by, the obstructed appendix fills with pus and may burst, spilling its
infected contents into the abdominal cavity, producing the potentially lethal complication
of peritonitis. The pain may be associated with a feeling of sickness and actual vomiting.
The bowels may either be constipated or in some the stools are loose. Fever occurs but
not in everybody with appendicitis.
The symptoms above can be caused by a wide variety of conditions, some serious, other
trivial; this is particularly the case in children and the elderly and in young women.
How is appendicitis diagnosed?
The doctor will take the history into account and will examine you. In typical cases the
area on the right side of the tummy just below the navel is very painful to touch. The
doctor may examine the back passage with a finger as sometimes, the appendix pops
down into the pelvic cavity and can be felt when the rectum is examined. X-rays are not
necessary to diagnose appendicitis unless certain other conditions such as kidney stones
cannot be ruled out. Blood tests may help the doctor but they must be interpreted
carefully and they can be misleading. In some instances, especially when there is doubt
about the diagnosis, an abdominal scan may be helpful as it may pick up other problems
such as cysts on the right ovary and infections in the pelvic cavity in women.
How is appendicitis treated?
We now know that some, probably many cases of appendicitis settle without an
operation. In early cases, or where there is doubt about the diagnosis, the doctor will
choose to treat you without an operation. You will be given painkillers, fluids into your
veins and paracetamol to bring your temperature down. Sometimes antibiotics are used.
If, despite the above measures your symptoms do not subside, the doctor will advise that
you have your appendix removed. The operation, referred to appendicectomy, is
performed under general anaesthetic and the cut is on the right side of the tummy.
Nowadays, many operations to remove the appendix are performed using the
laparoscopic or ‘keyhole’ technique.
After the operation
Most people recover quickly after an appendicectomy. Apart from soreness and stiffness
at the site of the operation, there are no major side effects if the inflammation is caught
early. Water is allowed the day after the operation and food within 48 hours.
If the appendix had burst and produced peritonitis, however, recovery takes much longer.
The patient will be put on a drip and a tube passed into the stomach to suck out its
contents and stop vomiting. Antibiotics and painkillers are given. Water and food are
withheld for longer while the operation site heals.
What are the complications of appendicectomy?




If there was a lot of infection in the tummy cavity, the bowels may become paralysed
for a few days. This complication is referred to as paralytic ileus and needs time to
clear. The bowels will be rested and this means no food or drinks and a tube down in
the stomach for some days.
There is a chance of the wound becoming infected especially if the appendix had
burst. In these cases some stitches may be removed to allow the infection to drain and
the wound packed with antiseptic dressings.
Bleeding can occur from the wound but this is uncommon.
On rare occasions, tight bands of scar tissue, known as adhesions, can occur and these
stick bowels together. It is rare to get adhesions in the few days after the operation but
they can occur. If they occur, adhesions are more common months or years later.
When they obstruct the bowels, an operation may be necessary to free them.
Patient Information Leaflet 10.
10. Anal fissure or fissure-in-ano
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What is an anal fissure?
Anal fissure is also sometimes referred to as a fissure-in-ano. It is a painful crack or cut in
the skin at the opening of the back passage or the anus. Sometimes, but not always, it is
caused by passing a hard stools which takes away the skin lining the anus. A fissure starts
as a small tear but is reopened each time you have a bowel movement. This tear can bleed
and cause painful spasm of the anal muscle.
How do I know I have an anal fissure?
The common symptoms mentioned above are pain and bleeding. The pain is felt at the
end of the back passage and is worse when the bowels open. It can last several hours after
the bowels are open. In severe cases, pain is felt all the time. The blood is red in colour
and is on the outside of the stools.
When the doctor examines you, he or she may be able to see the tear. Sometimes the tear
cannot be seen but a little tag of skin may be found around the anus. Any attempt by the
doctor to do an internal examination of your anus will cause excruciating pain and cannot
be tolerated. Other conditions that cause such pain are an abscess or a boil in the back
passage and occasionally bad piles.
What treatments are available for anal fissure?
Looking after the bowels and making sure the stools are not hard is a first step. This
involves eating a high fibre diet and drinking plenty of fluids. You may already have tried
creams containing local anaesthetics to soothe the back passage. Small fissures heal with
these simple measures but if the symptoms do not clear, you will need something more
definitive to heal the ulcer. There are three means now available to heal fissures. The first
two are ointments called glyceryl trinitrate and Diltiazem, and the third is an operation.
Glyceryl trinitrate (GTN) ointment and Diltiazem
This ointment is applied in and around the back passage and it works by relaxing the
muscles that surround the back passage. This relaxation increases the blood supply to the
fissure and promotes healing.
The cream is applied twice or three times daily for 4 weeks. One important side effect of
GT N is headaches. Even the small amount that is applied around the back passage can be
absorbed into your circulation and acts on the blood vessels on the scalp. If the headaches
are severe, then discontinue the medication and consult your consultant. This side effect
is not seen with Diltiazem which most doctors now prefer. About 60% of fissures heal
with creams.
Operation
In those in whom the cream does not heal the fissure or in those instances where the
doctor decides that a cream is not appropriate, the only choice left is an operation. The
operation involves cutting the lower part of the muscles that surround the back passage.
This operation is often done under general anaesthetic. As these muscles are designed to
keep the back passage shut except when the bowels are being open, there is a small risk
of incontinence. In the few in whom it happens, the person cannot control the passage of
wind and occasionally stools, leading to soiling of underclothes. Some people who suffer
this get better with time, but in a small minority, it may be permanent. It must be stressed
that this complication is rare but you must discuss it with the doctor doing the operation.
After the operation: A small pack may be left in the back passage after the operation to
stop the cut from bleeding. You may spend one night in hospital and the following day
the pack is removed. When you are discharged home you may be given opening
medicines, pain killing tablets and a local anaesthetic cream for a week.
The first stool after the operation is sometimes painful but the pain soon subsides. You
will get a bit of discharge from the back passage and some bleeding for a week or two
after the operation. These will subside as the fissure heals. Keep the back passage clean
by washing the area with warm water after every motion. Leave a sanitary pad around to
avoid soiling your underclothes.
The fissure and the operation cut heal fairly quickly within 2 weeks you will feel
considerably better.
A word about rectal bleeding. Do not assume that bleeding from the back passage is from
a fissure, even if you have the typical pain described above. Cancer of the anus, rectum
and large bowel also causes bleeding and it is important for the doctor to check you up to
make sure there is no such serious cause.
Where to get more information
I have seen blood from my back passage. What should I do? Information Leaflet 25.
Patient Information Leaflet 11.
11. Anal fistula or fistula-in-ano
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What is an anal fistula?
This is a tunnel (or tunnels) leading from the anal canal to the skin on the outside. It
results from an infection starting in the wall of the rectum or anus. The infection breaks
through to the skin like any other boil, but in this case it leaves a track that often
continues to discharge pus. The symptoms of anal fistula are pus and or blood
discharging from the back passage area and staining your underclothes, pain around the
area and from time to time infections or boils. You must tell the doctor if your bowel
habit has changed, particularly if you have diarrhoea and see blood in your stools. If this
is so, you may also have inflammatory bowel disease, which may be the reason you have
developed the fistula.
What else can cause pus to discharge from the back passage?
Other conditions that cause pus to discharge from the back passage include an abscess
around or inside the back passage, inflammatory bowel disease and a condition known as
an anal sinus. Unlike a fistula, which has two openings, one in the back passage and one
on the outside, a sinus has only a single opening, usually on the outside. The distinction is
made between a fistula and a sinus using x-rays and scans, and when the anus area is
explored by the doctor, while you are under anaesthetic.
How is the diagnosis confirmed?
The doctor will take account of your history and he or she will examine the back passage
area. It may be possible to feel the track or tunnel leading inside the back passage and the
internal as well as the external opening. An x-ray can be performed in which contrast or
dye is injected into the external opening under gentle pressure and pictures taken to see
where the tunnel leads.
Ultrasound and MRI (magnetic resonance imaging) are occasionally used when the
fistula is complex but these investigations are only available in certain centres such as
Hammersmith Hospital and St Mark’s Hospital. A small probe the size of a pen is
inserted into your back passage and pictures taken. The doctor will also examine you
while you are asleep and could inject a blue dye and see whether it leaks into the back
passage and if so where.
How is anal fistula treated?
If there is evidence of infection the doctor will take a swab and start you on antibiotics.
An operation is necessary because these fistulae never heal by themselves and the long
term skin irritation and abscess formation are unpleasant for the sufferer.
The operation is carried out under a general anaesthetic. The doctor opens the skin outlet
and follows the tunnel into the back passage. If the tunnel opens inside without going
through the important muscles that control the back passage, the track is laid fully open
and dressing packs left on it. However, if the track goes through these muscles, it will be
dangerous to slice through these muscles, as this will make you incontinent of stools.
Instead, a special stitch often known as a seton stitch or suture is placed through the
muscle portion of the tunnel and tied loosely around the back passage. This means you
will have a wound on the outside and the stitch at the back passage opening. The aim of a
seton stitch is to slowly cut through the muscle but at such a slow rate that the muscle has
a chance to heal before it is permanently damaged. It also reduces the chance of infection
settling on the muscles.
After the operation
You will require dressings for the outside wound often under the supervision of the
district nurses once you leave hospital. Make sure the bowels work regularly and the
stools are kept soft by eating a high fibre diet. You need to keep this area meticulously
clean and this means washing the back passage after every stool. Dressings will continue
until the wound has healed, and this can take several weeks and sometimes even months,
so be patient. If you have a seton stitch in place, you will need to come back to hospital
and have it replaced or tightened under general anaesthetic. You may need several of
these operations over a period of many months, and sometimes it may even take a year or
two.
Are there any dangers from the operation?

Having a wound around the back passage and having to have regular dressings
around this area are unpleasant but you will adjust to these slowly. Once the wound is
clean and there is no infection, you do not feel much pain.
 As mentioned above, one of the main dangers is damage to the anal muscles, which
are important in making sure you do not leak stools. Such damage may lead to
incontinence. It is precisely to avoid this that a seton stitch is used.
Patient Information Leaflet 12.
12. Haemorrhoids or piles
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What are haemorrhoids?
Haemorrhoids or piles are enlarged tissue pads with blown up blood vessels in the anus
or the lower part of the back passage. It is not clear why people get piles but there is some
evidence that they occur because our diet is low in fibre. Low fibre diets produce stools
that are hard in consistency and small in volume, and their passage requires the
individuals to strain.
Doctors subdivide haemorrhoids into internal (those that are not seen) and external (those
that show). Often both are present. Internal piles are also graded depending on whether
they remain inside when the individual strains (Grade 1 or first degree); those that come
out but pop back up of their own accord or can be pushed back up with a finger are Grade
2 or second degree; and those internal piles that are permanently on the outside are Grade
3 or third degree. As you will see below, these subdivisions are useful because the type of
treatment given depends on the grade of the piles.
How do I know I have piles?
Bleeding from the back passage is the earliest symptom of piles. The blood is red in
colour and is seen either on the toilet paper or on the outside of the stool as a smear.
Bleeding can sometimes be severe and some people describe blood dripping into the
toilet bowl like a tap. Other symptoms include itching at the back passage, an ache or
sometimes a pain and seepage on to the underclothes. If the external piles are large and if
the internal piles pop out, the sufferer will notice lumps at the back passage.
It must be emphasised that while bleeding from the back passage is most often due to
piles, it can also be due to serious conditions such as cancer. You must never assume that
blood from your back passage is due to piles without seeing a doctor. Simply by looking
the doctor can tell if you have skin tags or external piles and you will be asked to strain as
if opening your bowels, to see if you have piles that pop out. The doctor will then do
internal examination of your back passage with a finger and then with specialised
instruments (proctoscopy and rigid sigmoidoscopy). These usually do not hurt but are a
little uncomfortable. By these means the diagnosis of haemorrhoids will be confirmed
and the grade determined. For some patients this will be all that will be needed before the
doctor decides on how to treat the piles. For others, especially those in the older age
groups and those with other symptoms such as change in bowel habit, further
examination of the bowel will be recommended. This means either a barium enema,
flexible sigmoidoscopy or colonoscopy, and the aim is to rule out cancer or other serious
diseases.
How are piles treated?
The first step is establishing the diagnosis and making sure that there is nothing else
wrong to account for the symptoms. Treatment depends on the grade of the piles.
High fibre diet in all grades: All grades of piles benefit from a high fibre diet. A diet rich
in fibre, coupled with drinking plenty of fluids, produces bulky soft stools and prevents
straining. A good proportion of first-degree piles get better and even completely clear
with this, while with other grades, the symptoms improve. Whatever treatment is
provided, it must be combined with a high fibre diet.
Injection treatment and creams: An agent that shrivels the blood vessels in the piles is
injected into the back passage just above the piles. The injection, useful for first degree
piles, is a bit uncomfortable but it is rare for it to be painful. The doctor must take care
not to inject too deeply for fear of injuring nearby organs. In men, for example, the
injection can be placed inside the prostate or the bladder by mistake and this can cause
pain and bleeding from the urine. Any discomfort and bleeding from the injection will
clear in a day or two. Creams and suppositories containing local anaesthetic and mild
steroids are often recommended for grade 1 piles. They soothe the anus but it is doubtful
if they actually cure piles.
Rubber band treatment: This is a good and frequently used treatment for second- degree
piles. It may also be given to those with third degree piles, who do not want or cannot
have an operation. Tiny rubber bands the size of the tip of a ball-point pen, are stretched
using special equipment and placed above the base of the piles. They help pull up the
piles back into the back passage and reduce their blood supply, thus making them
smaller. The anus is uncomfortable for about 3 days and any bleeding that occurs settles
in a week. Rarely the tissue caught in the bands becomes infected producing an abscess
and such infection can spread. You must report severe pain experienced after this
procedure.
Cutting the haemorrhoids away: This is the traditional method for treating third degree
piles (haemorrhoidectomy). It entails cutting away the piles and any skin tags around the
back passage (see Information Leaflet 46 for more details on this).
Stapling haemorrhoids: A special stapler is used to remove excessive tissue in a circular
fashion, from the rectum above the piles. This is rather like cutting a circular peel off a
potato. The cut edges of the strip are then stapled together and all this is done by the
stapler. This results in pulling up the tissue lining the anus or the lowest part of the back
passage to stop it from dropping down and it also reduces the blood supply to the piles.
This form of treatment is now being used increasing in treating piles and the short and
medium term results are good.
Where to get more information
I have seen blood from my back passage. What should I do? Information Leaflet 25.
High fibre diets. Information Leaflet 28.
Proctoscopy and rigid sigmoidoscopy. Information Leaflet 31
Flexible sigmoidoscopy. Information Leaflet 32
Colonoscopy. Information Leaflet 33.
Haemorrhoidectomy (the operation to cut away piles). Information Leaflet 46.
Patient Information Leaflet 13.
13. Rectal prolapse
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What is rectal prolapse?
In rectal prolapse, the mucous lining of the rectum or the whole of the lower rectum pops
out through the back passage and appears on the outside. In children, the mucosal type is
more common, whereas in adults it is the whole of the lower rectum that comes out.
Treating rectal prolapse in children
Rectal prolapse in childhood is usually seen when the child passes a stool. The red
mucosa or lining of the back passage drops out, and to the lay eye it can be alarming.
There is often nothing wrong with the back passage itself and prolapse occurs because the
child is constipated and is not using his or her back passage properly. This problem often
resolves without an operation. Simple measures to take are to improve the child’s diet so
as to include a lot more dietary fibre or roughage and to give him or her plenty of fluids
to drink.
When the prolapse occurs, the parent can be taught how to push it back inside. After each
motion, the parent covers his or her finger with a toilet tissue and inserts it into the child’s
back passage, pushing the prolapsed bowel back. The finger is then gently removed,
leaving the paper tissue inside to come out at the next motion. In most cases this problem
resolves within a year or two, but it is worth reassuring the child and parents that there is
nothing seriously wrong.
If the above measures do not prove successful, the rectal area can be injected with
phenol, which causes scarring and tethers the mucous membrane back in place.
Treating rectal prolapse in adults
In adults the problem is more serious as it is often due to weakness of the muscles around
the anus or in the pelvis, and is unlikely to resolve on its own. Some of these patients are
also elderly and frequently suffer from diseases of their lungs or heart, making operations
dangerous for them.
Adults with rectal prolapse go to their doctor because their back passage drops out,
initially after passing stools. As time goes on, the back passage pops out even when the
bowel is not being open, and the prolapse is out all the time.
The lining of this back passage is easily damaged and can bleed a good deal. It also
discharges yellow material, which can be offensive. The individual is sometimes unable
to control his or her motions and stools soil the underclothes. This is a distressing
condition and the only way to alleviate it to operate.
What operations can be done for rectal prolapse
Broadly, these operations are divided into two: a) those that are performed entirely on the
back passage; and b) those that entail opening the abdominal cavity. These are both best
carried out under general anaesthetic.
Operations performed on the back passage. Several operations have been done but the
one currently performed is to strip the lining of the bowel and to concertina the
underlying muscle wall with stitches and then to replace the bowel back into the back
passage. It is not as major as abdominal operations and recovery from it is quick. I has a
high chance of failure, as it does not address the underlying muscle weakness that caused
this problem in the first place. It can be repeated and one addition is to tighten the back
passage muscles at the same time. Such an operation cannot provide new muscle but it
allows the existing muscles to encircle the back passage more tightly. The back passage
is packed with gauze to minimise bleeding.
One complication to watch out for after this operation is bleeding. More padding is all
that is often necessary but occasionally, it is necessary to take the patient back to theatre
to stop bleeding.
Operations in which the abdominal cavity is opened. The aim is to draw the prolapsed
bowel back into the pelvic cavity and to fix it using a special mesh or stitches to the
tissues over the pelvic bones. It is a major operation and carries more risk for the patient,
but the success rate is higher. The main risks are chest infections, infections of the wound
and of the mesh used inside, bleeding from the operation site inside the abdomen and
thromboses or clots in the legs.
Either operation therefore has advantages and disadvantages, and the doctor will help you
choose the one that suits you. After both operations, it is best to keep the stools bulky and
soft with a high fibre diet and opening medicines, so you do not strain to open your
bowels. Straining in the period immediately after the operation risks pushing the bowel
back out before it becomes fixed inside the pelvis.
Patient Information Leaflet 14.
14. Cancer of the colon and rectum, or colorectal cancer
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What is cancer of the colon and rectum?
This is cancer arising from the cells lining the inside of the colon and rectum, the lower
half of the intestines. The colon and rectum are referred to as the large bowel and the
cancer is sometimes called colorectal cancer or CRC. Nearly all CRC arises from a
benign or non-cancerous polyp and it is these polyps that we look for and destroy when
we screen people believed to be at risk of developing CRC. At the earliest stage, the
cancer is confined to the lining of the bowel (Stage A). Later it spreads to the muscle wall
but not the tissues outside or to organs beyond the bowel (Stage B). At a later stage still,
the cancer spreads to the lymph nodes located near the bowel (Stage C) and the most
advanced form is when the tumour has spread to distant organs, notably the liver and
lungs (Stage D). The earlier the stage at which the tumour is diagnosed, the better the
outlook. The tumour within the bowel can grow into the interior of the bowel and can
cause partial or complete blockage of the bowel.
What causes CRC?
The cause of CRC is unknown but certain conditions increase the chances.
 People with a rare inherited condition known as familial adenomatous polyposis, in
which there are numerous (hundreds of) benign polyps in the bowel, have a high risk
of developing CRC.
 Longstanding ulcerative colitis, a disease of the lining of the large bowel.
 It is believed that a diet rich in animal fat and protein and low in fibre may increase
the risk of CRC.
 A strong family history of CRC. The risk is high if first-degree relatives (parents and
siblings) are affected under the age of 50 years
What are the symptoms of CRC?
The symptoms include one or more of the following:
 Blood in the stools or black stools in people not taking iron tablets
 Diarrhoea or constipation lasting longer than 2 weeks
 Weight loss


Pain in the tummy
A feeling of not completely emptying the rectum and wanting to keep going to open
bowels.
 Some patients with CRC have no symptoms in the earlier stages
Other conditions can cause these symptoms, but it is important not to make any
assumptions and to contact your doctor.
How is the diagnosis of CRC made?


This begins with the doctor taking a history and doing an examination.
The doctor will then examine your back passage with a gloved finger looking for any
lumps on the bowel and blood in the back passage.
 The doctor will perform proctoscopy and sigmoidoscopy (Information Leaflet 31). If
there are any lumps on the bowel or any abnormal looking areas the doctor will take
pieces (biopsy) for the pathologist to examine.
 The doctor will use either barium enema or colonoscopy (Information Leaflets 39 and
33) to examine the large bowel, depending on which is easier to get and on which the
doctor feels will give the diagnosis more quickly.
 High emphasis is now placed on screening to pick up early cancers even before they
produce any symptoms. Your doctor will tell you about the national colon cancer
screening programme and whether you are eligible to take part in it.
If the above tests show cancer in the large bowel, tests will be done to determine the stage
as described in the first paragraph. One or more of the following will be used:
 Blood tests to check the function of the liver. Other blood tests will be done to look at
your blood haemoglobin level and kidney function.
 X-ray of the chest to rule out or diagnose secondary tumour in the lungs.
 Ultrasound scan of the tummy (Information Leaflet 36).
 CT scan of the tummy and pelvis (Information Leaflet 37). Ultrasound and CT scans
show the size of the cancer, its position, possible spread to the liver and pressure on
the tubes draining the kidney.
How is CRC treated?
There are three main treatments for CRC.
 Surgery is the main treatment and sometimes is the only treatment in many patients
(Information Leaflets 44 and 45).
 Chemotherapy is given into the veins to destroy any possible cancer cells that are
hiding in the circulation. It is referred to as adjuvant chemotherapy if it is given
within a short time of the operation, usually within 6 weeks. Adjuvant chemotherapy
is given after the tumour has been removed but the appearances of the tumour under
the microscope suggest that there is a strong chance the cancer might recur. This is
more likely if the lymph nodes have been affected. Chemotherapy can also be given
for secondary cancer or cancer that has advanced beyond the bowel at the time of
diagnosis (Stage D cancer). It can also be given if the cancer recurs sometime after
the initial treatment.
 Radiotherapy treats cancer by using high-energy rays that destroy the cancer cells,
while doing as little harm as possible to the normal cells. Radiotherapy is used most
often to treat cancer of the rectum and is not commonly used for cancer in the
remainder of the large bowel. This is because the pelvic cavity is a narrow space
compared to the rest of the abdominal cavity, and cancer of the rectum is more likely
to invade the tissues of the pelvic cavity even when the tumour is small.
Where to get more information
Understanding cancer of the colon and rectum: CancerBACUP 0800 18 11 99
Patient Information Leaflet 15.
15. Inflammatory bowel disease
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What is inflammatory bowel disease?
Inflammatory bowel disease (abbreviated as IBD) is the name given to a group of
conditions in which the intestines become swollen, inflamed and covered with ulcers. The
two main types of IBD are Crohn’s disease and ulcerative colitis. The symptoms of IBD
are similar and include abdominal pains, weight loss, diarrhoea, often with blood and
mucus in the stools, and tiredness.
There are other causes of the above symptoms and you must not assume you have IBD
without consulting your doctor. It is important for the doctor to distinguish between these
two diseases, as the treatment and outlook are different.
What will the doctor do?
The investigations done depend on the stage at which you present. I will concentrate on
the tests performed during a fairly quiescent phase of the disease. The doctor will:
Take a detailed history and examine you. He or she will ask you when you first noticed
the symptoms, how often they affect you and the length of time between attacks. The
nature of the symptoms and the severity of the attacks will also be noted. In the
examination the doctor will note your general well being, your weight and height, the
state of your tummy and any problems around your back passage. Problems in other areas
such as the eyes, skin and joints will be sought. Enquiry will be made about whether you
smoke and if so, how much. Smoking worsens Crohn’s disease. You will also be asked if
anyone else in the family has suffered from IBD.
Do proctoscopy and rigid sigmoidoscopy (Information Leaflet 31). These will determine
whether there are any piles or other conditions in the anus that may account for the
bleeding. This examination will also enable the doctor to examine the rectum to see if it
is inflamed and if so, to what extent, and he or she will take samples or biopsies for the
pathologist to examine.
Take stool samples for examination: Some infections in the stools can give the same
symptoms. Moreover infections can complicate IBD and should slso be treated.
Do blood tests: These may tell whether you are anaemic from bleeding, whether the
disease is active and whether organs such as the kidneys and liver are working well.
Take a look in the colon: Colonoscopy (Information Leaflet 33) is preferred as it allows
the lining of the bowel to be inspected in detail and samples or biopsies to be taken.
Barium enema (Information Leaflet 39) is sometimes used but does not allow biopsies to
be taken.
Examine the small bowel by barium follow through x-rays: This is used if Crohn’s
disease is suspected, as the commonest part of the bowel affected is the last portion of the
small bowel.
The distribution of the disease in the bowel and the way the biopsy material looks under
the microscope will help the doctor to determine whether you have IBD and if so whether
you are suffering from Crohn’s disease or ulcerative colitis. Sometimes the distinction
between the two diseases is not certain even on biopsy.
Treatment of IBD
Certain aspects of treatment are similar for Crohn’s disease and ulcerative colitis, though
the actual drugs given, the dosages and the duration may be different.
Treatment of an acute flare up: Some patients present with the above symptoms coming
on severely over a short period of time. The patient is often very ill and needs hospital
admission. The diagnosis is established by tests including x-rays of the tummy to look at
the size of the bowel and to determine whether or not the bowel has perforated.
Treatment involves giving intravenous fluids, medicines (including steroids) to reduce
the inflammation in the bowel, special diets to allow the patient to receive nourishment
while allowing the bowel to rest and painkillers. Antibiotics are used if there is evidence
of infection in the bowel. Most people settle on this but a small percentage of patients do
not, or even go on to develop bowel damage and perforation. In such a case, the treatment
is to perform an emergency operation to remove the damaged bowel.
Treatment of on-going symptoms: Several medicines are used to treat chronic symptoms
and are given either by mouth or as suppositories or foam inserted in the back passage.
Drugs given in the back passage are useful for active disease in this area. Drugs and
measures used include:
 A drug named sulphasalazine or newer versions of it such as mesalazine and
budesonide with fewer side effects, and are given by mouth or as rectal preparations;
 Steroids are used to treat flare ups but are not given long term because of their side
effects and no proven benefit; they are useful as short term treatment when given as
rectal preparations.
 Stopping smoking, vital in Crohn’s disease. Disease will relapse in those who
continue to smoke
 The role of diet is controversial. Liquid diets that have little or no fibre are used to
rest the bowel and can be effective in controlling acute attacks but their role in
controlling the long-term effects of the disease is debated.
Operations: IBD usually responds to treatment with medicines, but occasionally,
operations are necessary. Abscesses and other diseases around the back passage, which
may complicate IBD can be removed. Pieces of bowel affected by IBD can also be taken
away to relieve symptoms. Removal of the whole large bowel in ulcerative colitis leads
to cure but the same is not true Crohn’s disease. As your GP and surgeon for details of
the particular type of IBD you suffer from.
For more information contact the IBD Club on 01223 579 329 or www.ibdclub.org.uk
Patient Information Leaflet 16.
16. Diverticular disease
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
Introduction
The bowel is a tube with an inner lining and a muscle wall on the outside. In the large
bowel, there are little gaps in the muscle wall where the blood vessels penetrate the bowel
wall to reach the inner lining. If the pressure in the bowel increases, the inner lining of
the bowel is pushed through these gaps, through the muscle wall, forming small pouches
on the outside. One of these pouches is called a diverticulum; the plural is diverticula.
Diverticula can occur anywhere in the bowel but are most common in the lower part of
the large bowel known as the sigmoid colon. Diverticular disease is the name given to
the condition in which diverticula present in the bowel. Stools get trapped in the
diverticula and this can lead to inflammation within the diverticula and the surrounding
bowel. Sometimes doctors refer to this as diverticulitis, distinguishing this from the
uncomplicated diverticular disease. However, the terms are used interchangeably, so do
not be confused if one or other is used. Diverticular disease is not a cancerous condition
and it does not lead to cancer.
What causes diverticular disease
Nobody knows for sure but some observations have led to one theory. The disease is
common in western countries but is rare in rural parts of the third world. In those
countries in which it is common, more than half of people over the age of 70 have the
disease. It is believed that a relative shortage of fibre or roughage in the diet is
responsible for this condition. In ways that are not entirely clear, the smaller stools that
result from the low fibre in the diet cause the pressure in the bowel to increase, leading to
diverticula as explained in the introduction.
How do I know I have diverticular disease?
Luckily, most people with diverticular disease do not know they have it, as it does not
cause them any problems or symptoms. In the small proportion of people in whom the
disease causes symptoms, the following are noticed:



Pain in the tummy, especially in the lower part on the left. Distension or bloating of
the bowel also occurs often, with or without pain. Severe and sudden tummy pain
may rarely occur, necessitating admission to hospital. This may be due either to
diverticulitis or to one or more of the diverticula bursting.
Irregular bowel habit, usually constipation, sometimes with pellet-like stools. Some
people get diarrhoea periodically, rather than constipation.
Small quantities of blood may be passed with the stools, but again, on rare occasions,
severe bleeding can occur.
Do I need tests for diverticular disease?
If you have no symptoms, there is no need for you to have tests. Most diverticular disease
is discovered incidentally in the course of investigations such as barium enema or
colonoscopy, for other bowel problems. If you have one or more of the symptoms in the
section above, your doctor will decide if you need tests. The doctor will request tests if
there are any concerns about more serious conditions such as cancer of the bowel.
Usually simple blood tests and either a barium enema or colonoscopy will suffice.
How is the condition treated?
Treatment depends on how the disease is discovered, what symptoms you have and what
complications have occurred. The following scenarios will apply to most patients:

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Disease discovered incidentally: As mentioned above, most patients have their
diverticular disease discovered by chance and if there are no symptoms, then no
specific treatment is necessary. It is advisable, nevertheless, to increase your intake of
dietary fibre in an attempt to reduce the chances of complications.
Mild abdominal pain, periodic distension of the tummy and change in bowels:
These symptoms usually do not warrant admission to hospital. Simple painkillers
such as paracetamol will suffice, but avoid codeine-containing compounds which
tend to cause constipation. More fibre in the diet is also advisable, and at the doctor’s
discretion, you may be prescribed medicines that supplement your fibre intake but
only for short periods.
Sudden abdominal pain, but located in a limited area on the left side of the lower
part of your tummy: This may be due to diverticulitis and if it is not severe, the
doctor may decide to treat you at home. You will be asked to rest and to take
painkillers and antibiotics. If you have fever, you will be given paracetamol. You
need to drink plenty of fluids and take a soft diet until the pain settles. You will then
be asked gradually to return to a high fibre diet.
Severe pain all over the tummy. This suggests the bowel has ruptured and requires
admission to hospital. An operation is sometimes necessary to remove the affected
portion of bowel with or without the formation of a colostomy.
Massive bleeding from the back passage: Again hospital admission is needed, as
close observation is called for. Blood transfusion may be required and in the
occasional cases in which bleeding does not subside an operation will be required.
Where to get more information
High fibre diets. Information Leaflet 28.
Colonoscopy. Information Leaflet 33.
Patient Information Leaflet 17.
17. Skin cancer
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What is skin cancer?
Please refer to the leaflet on cancer. Skin cancer can occur anywhere on the skin but
certain places are more likely. There are several types of skin cancer. Their diagnosis and
treatment are discussed here because the general surgeon sees them as often as the skin
specialist. The two main types of skin cancer are squamous carcinoma and malignant
melanoma. I shall deal with the first one first and shall spend more time on the second,
which is the most serious type of skin cancer.
Squamous carcinoma
This is sometimes called a rodent ulcer and most frequently occurs on the face above the
level of the lips, but it can occur in other areas of the body. It occurs as often in men as in
women, and is usual under the age of 40 years. The main sign is an ulcer that crusts over
and bleeds, and typically has a raised pearly edge. This ulcer can be removed by means of
an operation, but if it is large, it can be cured by radiation treatment. The cure rates and
cosmetic results are good with both treatments. Fortunately, squamous carcinoma is
much more common that malignant melanoma.
Malignant melanoma
This type of skin cancer is serious. If found and treated early, it can be cured. If
discovered late, it can be fatal. Most malignant melanomas occur in skin moles and then
grow from there. Most people have moles and dark patches on the skin, and these remain
harmless all their lives. However, new, growing and changing moles should be shown to
your doctor who may refer you to a surgeon or skin specialist for a small operation to
take it out. Melanomas can arise from moles anywhere in the body but the commonest
sites to watch out for the legs in women, the back in men and the face in older people.
Who is at risk of developing malignant melanoma?
 This cancer is rare in children and is more common in young people
 White skinned people, those with fair or freckled skin that does not tan, or skin that
burns before it tans are more likely than those with brown or black skin to get
malignant melanoma but no one is completely immune.



People who have lived in sunny countries and exposed their skin a lot to sunlight are
particularly at risk. Also where there is a record of sever sunburn, especially in
childhood
So too are people with lots of moles, over 100 in young people, and over 50 in older
people.
Those with a family history of malignant melanoma and those who have had
malignant melanoma in the past.
How does malignant melanoma develop?
The mole has usually been exposed to excessive sunlight and this is believed to trigger
cancer. If left untreated, this cancer can spread to other parts of the body and some can
spread very fast.
The warning signs that malignant melanoma may have developed are:
 An existing mole or dark patch getting larger or a new one growing rapidly.
 A mole with a ragged outline. Ordinary moles have a smooth outline.
 A mole with a mixture of different shades of brown and black. Benign moles may be
dark brown but are all the same shade.
 Inflammation or redness at the edge of the mole.
 Bleeding, oozing or crusting.
 A change in sensation such as itching.
What should I do if my mole develops any of these features?
Wait for two weeks to see if the change subsides. If it does not you must consult your
doctor without delay. The doctor will then arrange for you have the mole removed,
usually under local anaesthetic. If the mole proves to be a malignant melanoma you will
be referred to a specialist for further treatment. The treatment in most cases is removing
more skin around the site of the mole. If a large gap it left, it may have to be covered by
skin taken from another part of the body.
How do I look after my skin to avoid skin cancer and early ageing?
In short, avoid excessive exposure to the sun by observing the following:
 Try never to have burned skin at the end of the day.
 Exposure to sun is most likely when you are on holiday. This is an important time to
cover up. Keep in the shade as much as possible. Wear sun hats.
 Babies and children burn easily and should always be protected from strong sunlight.
 Avoid the sun during the middle of the day.
 The sun is stronger near the equator.


Use sunscreens with a sun protection factor (SPF) of 15 or more and UVA protection.
Do not use sun beds and sun lamps.
Where to get more information
Contact the Cancer Research Council on free phone 0800 226 237
Patient Information Leaflet 18.
18. Abdominal wall hernias
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What is a hernia?
A hernia is a condition in which some of the contents of the abdomen push through a gap
in the abdominal wall, often to form a pouch or sac, visible on the outside as a lump. The
contents of the abdominal or tummy cavity are held in place by the large abdominal wall
muscles that drape the front and the sides of the abdomen. Occasionally, weaknesses
occur in this normally tough abdominal wall and it is through these weakened areas that
the mobile intestines can protrude, especially when we raise the pressure inside the
abdomen by coughing or straining.
Why do hernias occur and what types are there?
Hernias can occur for many reasons, but often no cause is found. A sudden strain can
open up an already weakened area, and hence the term, ‘rupture’, the lay name for a
hernia. An operation scar produces a potential weakness in the abdominal wall and can
become the site of a hernia. Such hernias are called incisional hernias. Other factors that
increase abdominal pressure, and hence predispose to hernias, are prolonged coughing
and longstanding constipation.
There are several weak points that occur naturally in the abdomen. The first is in the
groin at the point at which the testicles migrated from the abdomen to the scrotum in
boys. Although the testes originated in the abdomen, they have to be in the scrotum to
develop and function normally, as the temperature there is lower. Women can also get
hernias at an equivalent point in the groin, but not as frequently as men. A hernia at this
point is known as an inguinal hernia. The second is around the navel. A hernia at the
exact centre of the navel is referred to as an umbilical hernia; and one just to one side of
the navel is a paraumbilical hernia. The third is where the veins from the legs enter the
abdomen, and a hernia here is known as a femoral hernia. There are other types of
hernias in the abdominal wall but they are rare.
Who gets hernias?
All of the hernias above can occur at any age and in both sexes. However, some are
commoner in some age groups and in one sex compared to the other. Babies tend to have
umbilical hernias and male toddlers sometimes get inguinal hernias. Femoral hernias are
commoner in older women. Inguinal hernias are by far the commonest and are seen most
often in men. On the whole men are more prone to hernias than women.
What are the dangers of hernias?
Hernias are usually a discomfort in the vast majority of people but when complications
occur they can be life threatening. Most hernias have a wide mouth that allows the
contents of the abdomen to move in and out freely. On rare occasions, however, this may
not happen; such a hernia is said to be irreducible. The bowel inside becomes trapped in
the hernia and cannot drop back or cannot be pushed back. The bowel can become
obstructed. If the bowel inside the sac gets squeezed too hard, it loses its blood supply
and dies. This is called strangulation and the hernia is said to be strangulated. The
suffer will die unless treated urgently. For this reason, if your hernia becomes painful,
you must see your doctor at once. Some types of hernias are more prone to these
complications than others. For instance, femoral hernias and some types of inguinal
hernia are more dangerous.
How are hernias treated?
Leaving well alone: A person with diseases affecting the heart and lungs will get into
serious problems if he or she undergoes an operation, and a decision has to be made
whether it is more dangerous to leave the hernia alone than to operate. Hernias with wide
mouths such as some incisional and some inguinal hernias fall in this category, but the
way to decide about the width of the mouth of hernia is sometimes inaccurate.
Truss: Another way to treat a hernia in those who do not want an operation or cannot
safely have an operation is to wear a truss. A truss is a belt with a padded leather ball that
presses on and supports the weakened hernia area. Trusses are bulky and uncomfortable
to wear under clothing and are difficult to keep clean. They do not prevent complications
from happening and merely keep the bulge held in.
Operating on hernias: This is the preferred way of dealing with hernias. The general aim
with all hernias is to push the contents of the hernia back inside, where appropriate to
remove the sac, and then to strengthen the weakened abdominal wall. There are several
ways of doing this. In those in whom a general anaesthetic is dangerous, a local
anaesthetic can be given. Indeed, some centres now repair the vast majority of hernias
entirely under local anaesthetic and some patients prefer this.
In many cases a cut or incision is made over the site of the hernia. A preferred technique
in many cases is to use an artificial mesh or cloth-like material, to reinforce the weak area
– this is the so-called tension free, mesh repair. Less commonly nowadays, the
abdominal wall is buttressed with layers of strong, non-dissolving stitches.
A newer way of repairing inguinal hernias is with the use of the laparoscope or the keyhole method. The hernia is approached through a small hole made at the navel and the
mesh sewn in from inside. This is particularly appropriate where the hernia is on two
sides at the same time or where the hernia has come back after a previous operation or
operations. An inguinal hernia is used to illustrate the way people recover from hernia
operations (Information Leaflet 42)
Patient Information Leaflet 19.
19. Pilonidal sinus
Mr David Sellu, MSc ChM FRCS
Consultant General and Gastrointestinal Surgeon
NHS base: Ealing Hospital, Uxbridge Road, Southall, Middlesex HA13RX
Consults privately at BMI The Clementine Churchill Hospital, Sudbury Hill, Harrow,
Middlesex HA1 3RX. Appointments there: 020 8872 3939
___________________________________________________________
What is a pilonidal sinus?
The word ‘pilonidal’ means a nest of hairs. In this condition, there is a little opening (or
possibly more than one) in the midline of the body, in the crease between the buttocks, at
the very lowest part of the back. Doctors refer to this area as the natal cleft. It is believed
that hairs in this region dig their way into skin and form a nest or cavity underneath the
skin. This cavity is liable to get infected from time to time and discharges blood, yellow
liquid or pus through the hole or holes. The condition, first seen in people in their
twenties and thirties, is commoner in hairy young men, but can occur in women also.
How do I know I have a pilonidal sinus?
Many people with this problem do not know they have it, as in the early stages it does not
cause any symptoms. As the openings are located in the back, they cannot be seen or felt
unless they hurt or begin to discharge. The first thing some people notice is blood or a
yellow stain on their underclothes. Later, the sinus becomes infected and the area hurts. If
a full-blown abscess develops there, the individual will feel feverish and will notice a
painful lump at the site. This lump may burst and discharge pus.
How is pilonidal sinus treated?
Treatment depends on the stage at which it is detected.
Abscess: If an abscess is present, the doctor will give you antibiotics and painkillers and
you will be advised to rest to see if the infection resolves. The abscess may burst,
discharging its content and all the infection may clear. If it does not, you will need an
operation under general anaesthesia to lance the abscess. The aim of the operation at such
a stage is merely to relieve the abscess, and it is not appropriate to attempt to eradicate
the sinus. The abscess cavity will need to be dressed regularly until the abscess heals. Of
course there is a small possibility that when the abscess heals the sinus will clear
completely, but in most cases, the original problem persists.
Inflamed area but without an abscess: The area may simply be inflamed and red but there
is not a pocket of pus. In such a case, antibiotics and painkillers for a week or so will
suffice to clear the inflammation.
Pilonidal sinus without abscess or inflammation: It is at this stage that a definitive
operation is need to eradicate this problem completely. Several operations have been
devised to deal finally with this disease and can be divided into two.
The first are operations to lay the sinus open and to clean out the cavity. Such operations
are best done under general anaesthetic. The patient is placed on his tummy on the
operating table and the surgeon makes a cut over the opening or openings. This will lead
to the cavity underneath that may contain nests of hairs and inflamed tissue. The hairs are
removed and the inflamed tissue scraped out, leaving a hole. This hole is packed with
antiseptic dressings regularly until the whole area heals completely.
The advantage of such operations is that they are relatively minor and can be done as day
procedures. The disadvantages are that the cavity takes several weeks and sometimes
even months to heal; dressings may initially need to be done daily and this puts enormous
strain on the patient. A silastic foam dressing can be used to simplify the dressings. A
foam ‘stent’ that fits the cavity exactly is made by pouring two liquids that set in the
cavity. The patient removes this stent each day, washes the area and then replaces the
stent. It is not necessary for a nurse to see the patient every day. A doctor or nurse makes
a new stent once a week as the previous one will now be too small. Another disadvantage
is that the chances of recurrence are high and repeat operations are not uncommon when
pilonidal sinus is dealt with this way.
The second operations are designed to remove the whole area, including the holes and the
underlying cavity and any tracks. The resulting wound is stitched together and a tube
drain is often left to suck out any liquid that collects underneath. The drain is removed
when the amount of fluid draining has lessened, and the stitches are removed between 10
and 14 days after the operation. Sitting and driving will be painful for about 3 weeks but
pain clears after that time.
There are several disadvantages. Such excisional operations are more major. The wound
could get infected and may even break down leaving a larger problem for the patient and
the surgeon to deal with, but such a major complication is rare. The area is numb for
several months afterwards but feeling gradually returns.
These operations have several benefits. Repeat dressings are not required and once the
stitches are removed, the individual can return to normal work. The cure rate is very high
and if the operation is successful, the whole treatment is over very quickly. The
recurrence rate is very low when compared to the smaller operations.
An important piece of advice for the patient once the sinus has healed, by whichever of
the above methods, is to keep this area clean and free of hairs. One reason these sinuses
recur is because hairs regrow into this area after the operation and cause this whole
problem to start all over again. It is better to get someone else to do the shaving, as it is
difficult for you to see this area easily.