Intestinal and Colorectal Disorders

Inflammatory Bowel Disease

Mount Sinai is a national leader in the surgical treatment of inflammatory bowel disease (IBD). IBD is the name for conditions that cause inflammation of the digestive tract, including Crohn's disease and ulcerative colitis. More than 1.5 million Americans have IBD. Both conditions inflame the intestine and can lead to diarrhea, rectal bleeding, and abdominal cramps, as well as pain, fever, and weight loss.

While Crohn's disease can occur anywhere in the digestive tract, ulcerative colitis usually affects only the large intestine and rectum. The goals of inflammatory bowel disease therapy at Mount Sinai are to eliminate symptoms, prevent flares, and restore quality of life. Surgery is usually needed if medications fail to improve symptoms for precancerous changes in the colon or if serious complications occur.

Crohn's Disease

Crohn's disease (CD) is a condition that was primarily investigated and discovered at Mount Sinai, where Dr. Crohn once practiced. It is because of Dr. Crohn’s important scientific achievements, and the subsequent work of the Mount Sinai physicians that followed him, that our institution is considered a world authority on this disease. Crohn's is a disease that can affect the entire digestive tract. Its cause is unknown but most likely there are a number of different factors with genetic, autoimmune and acquired components. Common symptoms include cramping, abdominal pain, diarrhea, fever, weight loss, and bloating, as well as anal problems such as fistulae and abscesses. Not all patients experience all of these symptoms, and some may experience none of them. People with Crohn’s Disease often have problems outside of the digestive tract such as skin rashes, joint pains, eye inflammation, and liver problems.

While there is no cure for Crohn's, there are multiple medications currently available such as corticosteroids, anti-inflammatory, immunosuppressive, and antibiotic agents. Typically, CD is marked by a series of flares and remissions, and these medications can help to keep the disease under control. If medicine does not control symptoms, surgery is required to remove the diseased part(s) of the intestine.

Approximately 80 percent of people with Crohn's will ultimately require surgery. Although surgery does not cure Crohn's disease, it can allow for resumption of daily activities and a return to a normal lifestyle. The majority of patients will need to continue medical therapy after surgery. Between 85 and 90 percent of people have no symptoms in the first year after surgery. Although Crohn's disease will likely recur in the majority of patients, up to 20 percent of people have no symptoms 15 years after surgery.

The most common surgeries performed at Mount Sinai for Crohn's disease include bowel resection and stricturoplasty. Bowel resection may involve the large intestine or the small intestine depending on the exact location of the disease, and stricturoplasty is typically employed in cases where the small intestine is blocked. At Mount Sinai, we have pioneered minimally invasive surgery for Crohn's disease, and the majority of our patients with Crohn's now receive laparoscopic operations.

Ulcerative Colitis

Ulcerative colitis is a disease in which the lining of the large intestine becomes inflamed and develops sores (ulcers), leading to bleeding and diarrhea. The inflammation almost always affects the rectum and lower part of the colon, but it can affect the entire colon. As with Crohn's disease, the cause of ulcerative colitis is unknown, but most likely there are a number of different factors with genetic, autoimmune and acquired components. Common symptoms of mild disease include intermittent rectal bleeding, mucus discharge from the rectum, mild diarrhea, and crampy abdominal pain. Patients with moderate to severe disease often experience multiple loose bloody stools, anemia, abdominal pain, fever, and weight loss.

Although ulcerative colitis cannot be cured, we can usually control it with medications such as corticosteroid, anti-inflammatory, immunosuppressive, and antibiotic agents. While medical treatments improve symptoms in up to 90 percent of people and induce remission, some people do not respond well to conservative therapy. At Mount Sinai, surgery is indicated for patients who have life-threatening complications of inflammatory bowel diseases, such as massive bleeding, perforation, or infection. It may also be necessary for those who have the chronic form of the disease, which fails to improve with medical therapy, or for those with a precancerous lesion in the colon.

Historically, the standard operation for ulcerative colitis was removal of the entire colon, rectum, and anus with creation of an ileostomy (an artificial opening created in the abdominal wall) and need for a permanent ostomy bag to collect bowel movements. For the vast majority of patients at Mount Sinai, we construct a new rectum from small intestine, called a J-pouch. The J-pouch is connected to the anus and the intestinal system thus remains in continuity from the mouth to the anus. Most patients will experience at least 6 bowel movements per day with the J-pouch in place. The operation is usually conducted in 2-3 stages depending on the patient's severity of illness and may involve a temporary ileostomy. At Mount Sinai, these operations are often performed laparoscopically when appropriate, leaving the patient with a virtually scarless abdomen.

Colorectal Cancer

Colorectal cancer is the fourth most common cancer in the United States (behind lung, prostate and breast), affecting 140,000 people annually and resulting in 60,000 deaths. Although colorectal cancer may occur at any age, the vast majority of patients are older than age 40. Other risk factors include a history of ulcerative colitis, polyps or other cancers, and a family history of colorectal cancer and polyps. Common symptoms of colorectal cancer include abdominal pain, change in bowel habits (constipation or diarrhea), blood in the bowel movements (black or dark-colored stools), weight loss, and anemia.

The treatment of colorectal cancer usually involves surgery, which may be offered in conjunction with chemotherapy and radiation therapy. In most people, the two ends of the colon can be reconnected immediately after the cancerous part has been removed, but in cases where the surgeon feels that the tissues are inflamed and need time to heal, a temporary ostomy may be created. Mount Sinai offers advanced surgical and minimally invasive options to treat the disease and preserve normal function.

Diverticulitis

Diverticular disease is a common problem that affects men and women equally. The risk of disease increases with age. A diverticulum is a pouch-like area that can form in the muscular wall of the colon, particularly at points where blood vessels enter. Diverticulitis occurs due to inflammation of diverticula. Typical symptoms include causes left lower sided pain, nausea, vomiting, and diarrhea.

Diverticulitis can be grouped into simple diverticulitis and complex diverticulitis. While 85 percentof people present with only simple diverticulitis, which involves a combination of the symptoms listed above and typically respond to antibiotics, complicated diverticulitis occurs in 15 percent of cases and usually requires surgery either during the event or as an elective procedure after recovery. Findings in complex diverticulitis include abscess (a localized collection of pus), fistula (a connection between 2 organs), blockage or perforation with peritonitis (gross spillage within the abdomen).

Surgical treatment of diverticulitis depends on the severity of symptoms. Emergency surgery typically requires removal of the diseased portion of bowel and a temporary ostomy prior to a second surgery for reconnection. Patients who present to Mount Sinai for elective surgery are often candidates for laparoscopic surgery, and the majority do not require an ostomy. Recommendations regarding surgery are controversial. While some advocate surgery after an initial attack in people younger than 40-50 years of age to reduce the chances of worse disease later on, the decision to undergo surgery ultimately depends on the patient's preferences.

Gastrointestinal Bleeding

It is not uncommon to see blood in the toilet, with wiping after a bowel movement on the outside of your stool. It is important to note that gastrointestinal (GI) bleeding is not a disorder, but a symptom of a disorder. While it is possible for this blood to be related to serious conditions such as colorectal cancer, the vast majority of cases are due to benign conditions such as hemorrhoids and anal fissures.

Causes:

1. Hemorrhoids: swollen blood vessels in the rectum or anus that can be painful, itchy, and can sometimes bleed. Painless rectal bleeding with a bowel movement is a common symptom of hemorrhoids.

2. Anal fissure: a tear in the lining of the anus, which can lead to a feeling of tearing, ripping, or burning during or after a bowel movement.

3. Diverticulosis: A diverticulum is a pouch-like area that can form in the muscular wall of the colon, particularly at points where blood vessels enter, cauisng painless bleeding.

4. Colitis: Please see the sections on inflammatory bowel disease, Crohn's disease, and ulcerative colitis.

5. Polyps: This is a potential precancerous condition of the colon.

6. Colorectal cancer: Please see the section on colorectal cancer.

7. If there are black, tarry bowel movements, bleeding may emanate from higher in the digestive tract, such as the stomach or esophagus, where ulcers, varices, or even cancer may be the culprit.

Mount Sinai has a variety of state-of-the-art tools to investigate GI bleeding. Diagnosis typically involves initially a rectal exam, and may require more extensive testing ranging from anoscopy (inspection of the anus and lower rectum done in the office without sedation) to colonoscopy, depending on the patient's age and symptoms. In cases of obscure bleeding, our physicians at Mount Sinai are ready to employ additional imaging studies such as bleeding scans, angiography, multiphase CT enterography, and capsule endoscopy.

Laparoscopic Surgery for the Gastrointestinal Tract

Mount Sinai offers minimally invasive laparoscopic surgical options for disorders of the small and large bowel. Instead of one large abdominal incision,typically used in traditional open surgery, several small (5 mm) peripheral incisions are made through which the laparoscope and surgical instruments are inserted. Adhesions are removed in situ and diseased bowel is typically extracted though a 15-20mm incision. Compared to open surgery, laparoscopic bowel surgery provides:

  1. Less post-surgical pain and reduced requirements for pain medicine
  2. Shorter hospital stays and faster recovery times
  3. Fewer post operative small bowel obstructions
  4. Fewer wound infections

The laparoscopic bowel procedures that are offered by the faculty practice at Mount Sinai include:

  1. Colon resection: Colon Cancer, Ulcerative Colitis, Diverticulitis, Large Colonic Polyps
  2. Colostomy and Colostomy Closure
  3. Small Bowel Resection and Strictureplasty: Crohn's disease, Small Bowel Cancer
  4. Ileostomy creation
  5. J-Pouch Surgery: Ulcerative Colitis, Familial Adenomatous Polyposis
  6. Lysis of Adhesions: occasionally needed for small bowel obstruction

 


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Division of General Surgery
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