Case Study: Rectal Bleeding

Blood in the stools or rectal bleeding is often an alarming thing to happen. It can happen at any age and is often sudden. It may be small in quantity in the form of few drops at time or it may be a large amount mixed with stools. It may be associated with pain while passing stools or can be absolutely painless. It often causes concern and scare, especially if it is large in amount.

Mark (name changed) was an otherwise healthy fifty-year-old gentleman who came to us with complaints of passing small quantity of fresh blood with stools for one week. He had no other complaints. He had similar blood in the stools 3 months ago and had shown to a doctor. He was told to have hemorrhoids (piles) and given some pills. He remained fine till the current episode of bleeding.

Blood in the stools is most commonly due to piles or hemorrhoids. The blood is usually in the form of drops of blood seen separate from the stools. Usually there is no pain. Hemorrhoids are common in those who have habitual constipation and strain a lot to pass stools. Minor bleeding from hemorrhoids can be treated with medicines. For recurrent bleeding and severe bleeding, surgery is required.

Another common cause of blood in the stools is anal fissure which is actually a sharp cut in the anal skin. This type is bleeding is usually associated with severe pain while passing stools unlike bleeding from piles which is painless. Anal fissure is usually treated with medicines and ointments.

A serious cause of bleeding in stools is inflammatory bowel disease also known as ulcerative colitis. This type of bleeding usually occurs for several days, blood is usually mixed with stools and stools itself are loose or soft. There is no pain while passing stools but there can be lower abdominal pain. The diagnosis of ulcerative colitis has to be confirmed on a biopsy from the colon. This is a chronic disease and needs treated with medications over several years.

The most alarming cause of blood in the stools is colon or rectal cancer. It can present with intermittent blood in the stools, usually painless. Person may have recent change in bowel habits especially development of constipation. Colon cancers can be effectively treated if diagnosed early.

A proper assessment of a patient with blood in the stools is essential. While hemorrhoids and anal fissure can be diagnosed by a simple rectal examination, it is often necessary to do a sigmoidoscopy to visualize the rectum and lower colon if other diseases such as colon cancer or ulcerative colitis are suspected. Flexible sigmoidoscopy is a very safe and simple procedure to perform and takes hardly 10 minutes to ascertain the exact cause of bleeding.

Mark finally underwent a sigmoidoscopy and found to have a small cancer in the lower part of the colon. He also had small hemorrhoids. Since the diagnosis was made quite early, Mark underwent a successful surgery for removal of the colon cancer.  

Some important points to remember:

• Any blood that is mixed with the stool should be investigated further
• Hemorrhoids bleeding is usually in the form of drops and blood is seen separately from stools.
• Presence of hemorrhoids does not mean that bleeding is necessarily from hemorrhoids. There can be other causes of bleeding that often go missed if proper investigations are not done.
• Any bleeding that occurs repeatedly should be investigated

Case Study: How Effective is Treatment for Colon Cancer?

A 70-year-old man had presented to a general practitioner for bleeding in stools. The person examined him in OPD and diagnosed him to have grade 4 hemorrhoids. He posted him for surgery but at the time of operation he realized that the patient has a tumor in the rectum. He abandoned the procedure and took biopsy from the growth.

The patient was diagnosed with a low carcinoma of the rectum. The plan of treatment changed completely. The patient had undergone different investigative tests like CT scan, MRI, PET scan to stage the disease and was advised to have a neoadjuvant treatment with chemotherapy and radiation to shrink the size of the tumor. The patient also had diabetes and hypertension in addition to chronic renal disease. The patient a course of therapy and then had the surgery done after 6 months. Laparoscopic surgery was done, and the patient responded excellently.

He still remains on my follow up with a continuous evaluation and monitoring of symptoms.

Colon and rectal cancers have a good outcome in the long run. They can be effectively treated by a multidisciplinary team of surgeon, medical oncologist and radiation oncologists. The long-term cure rates of colon cancer are very high. We have an aggressive approach to these group of malignancies. Early diagnosis remains the key. The biology of the tumor is another deciding factor. All patients should have complete access to state of art therapies available and aim to get a cure.

Are Women in Surgery a Different Class!!!

We had a “Women in surgery” seminar with “Patricia L Turner” who came all the way from US as a representative of American College of Surgeons. The event was followed by our media partner, The Marketing Heaven, who promoted the seminar on social media and thus highlighted the representation of women in surgery. The girls attending the seminar shared that they formed 50 percent of the workforce in Rashid Hospital Surgery department. The students of Mohammed Bin Rashid University highlighted that the women to men ratio in their batch of medical college was 70:30.

It just took me reminiscing to three decades back when in my medical college the women force formed half the class, may be more. It was a kind of unsaid practice amongst the middle-class parents in India, “boys took engineering and girls took medical” and the parents took great pride in the fact that they have nurtured their own girls into something!!

In 1997, I joined a reputed institution for surgery residency through an All India Examination and a rank in two figures, little did I know and realize within a week’s time that fifty percent of my colleagues were girls or ladies. And our registrars were more than glad, because they thought ladies are very sincere. Not only us, most of the lecturers were ladies; and continued to be so for the next four years.

So, what changed, or has something changed over the last four decades. Perhaps yes!! One is an acknowledgment that we exist! Then comes the success through struggle or otherwise to be able to rise up the ranks and deliver and last but not the least comes the admiration from the people who joined in later who may have been inspired or at least had the reassurance to know that the same desire and the fire in belly was there in many more all around the world. All had similar stories to share; all had similar choices to make; all had similar desire to break free and to prove if not to someone else but to themselves that they can.

The tribe grew stronger and stronger year by year as we stand shoulder to shoulder and claim to have an even exposure and equally even skill set, and deserve an equal allowance, an equal opportunity, an equal platform compared to men. No, we do not ask for a “privilege” to be of a different gender neither do we ask for a reservation or a special treatment.

What we ask ourselves is “Are we equal?”
When there is a surgical disaster in the OR or ER, or ward can we respond as well as they do. Or are we limited by our physical in-adeptness or unavailability due to other commitments to family or otherwise?
We ask When there is a case which is complicated and needs an evaluation and attention; can we deal with as good as they do! Or are we limited by our lack of experience and training.
We ask when there is a need for an authority or a command in a surgical scenario; are we recognized and respected enough or ridiculed for our lack of physical form, height, stature or even the baritone of the voice.
We ask when there is need for communication to the patient or convincing the patients, are we acknowledged for our capabilities or are subject to prejudice and preconceived notions.
We ask “when we have a similar experience and depth of knowledge for presentation in a conference; are we left on shorelines for not having a mentor who would recommend our name for a live surgery or a faculty position.

The struggles come in all forms to this gender not just in surgery but in all streams of life at work place. The solution is to recognize our weaknesses and work towards making them easier. We need to upgrade our craft and skill set; need to improve the confidence and presentation; need to learn to take control of a situation without bias or fear; need to generate flexibility in our schedules and have added help to make ourselves available when needed; we need to develop leadership and encourage role modeling; we need to conquer our misgivings and guilt for not being able to attend all functions at school or family; we need a commitment stronger than our desire to seek entitlement; and most important we need to take pride in our femininity.

Perhaps we have an added responsibility to be able to perform at both fronts and to communicate more in action than in words that though formidable it is definitely achievable. That sincerity, hard work and an intent to heal does not recognize the distinction between the “xx” or “xy” chromosome.

“ The author of the article is a surgeon who graduated from Mumbai but is committed to women’s surgical health and is a laparoscopic surgeon based in Dubai, and strongly advocates raising the bar and setting a mark for all of her peer mainly through performance and zeal”

Pilodidal Sinus: Traditional Treatment or the Latest for a Painless Recovery

A young girl presented with a swelling on the lower back with severe pain . On examination she had a pilonidal abscess. She was admitted in emergency and drainage of the abscess was done. There was a large wound after the surgery. It took around 2 months of regular dressing to heal it. One year later she had a recurrent abscess. This burst on its own. The doctor then advised her surgery to remove the sinus. There was a sutured wound after Third surgery. It developed a seroma and a olorcollection. This was drained and pressure dressing was applied. Slowly it resolved. Patient is on a continuous follow up to remove the hair in the area to prevent another recurrence on cialis treatment.

This is one of the usual stories of a pilonidal sinus. Sometimes you would realise the patient had 6-7 radical surgeries.

Is there another way out. Endoscopic treatment of the Pilonidal sinus (EpSIT) is on e such techniques. It uses a camera to eliminate the root cause of the evil. The ingrowing hair in the area. It minimizes the trauma because of the surgery. It is a day care procedure. The pain is minimal. There are higher chances of recurrence, but those remain in open surgery too. The concept of radical surgeries is being questioned. The amount of trauma for a simplistic problem is being challenged.

What can be done or at-least attempted in a minimally invasive manner should become the front line of treatment. The radical procedures should be reserved for more complicated or recurrent cases.

Young women need a personalized care with best cosmetic results. EpSIT is  being  offered as a laser or minimally invasive alternative for treatment of pilonidal sinus by our colorectal surgeon Dr Ritu Khare in Dubai, Sharjah and AbuDhabi.

She has practiced all methods from traditional drainage; Karyadakis Flap, laser and EpSIT and can counsel what would be considered as the best option for a particular patient.