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Diseases We Treat
Diseases We Treat
Click the name of the disease below to read more information about it
Colorectal cancer screening (colonoscopy)
“It is estimated that 143,460 men and women (73,420 men and 70,040 women) will be diagnosed with and 51,690 men and women will die of cancer of the colon and rectum in 2012.” 1 These are a very upsetting numbers, especially if you consider the fact that colorectal cancer is potentially curable if diagnosed in the early stages. The average person’s lifetime risk of developing colorectal cancer is about one in 20.
Colorectal cancer is known as a “silent” disease, because many people do not develop symptoms, such as rectal bleeding, abdominal pain or change in the usual pattern of bowel movements, until the cancer reaches an advanced stage and is therefore difficult to treat. In fact, the possibility of curing patients after symptoms develop is only about 50%.
The risk is increased if there is a family history of colorectal polyps or cancer, and is still higher if there is a personal history of breast, uterine or ovarian cancer. Risk is also higher for people with a history of extensive inflammatory bowel disease, such as ulcerative or Crohn’s colitis.
The American Cancer Society, the American Society of Colon and Rectal Surgeons, as well as other Society uniformly recommend that every individual be enrolled in a screening protocol at age 50, as long as he does not fall in any of the high risk categories.
Screening means that the physician actively looks for cancer in patients that have no symptoms whatsoever. The advantage of screening is that cancers are usually detected very early; colorectal cancers found and treated at an early stage, which is before symptoms develop, the opportunity to cure is 80% or better. Most colon cancers start as non cancerous growths called polyps. If the polyps are removed, then the cancer may be prevented altogether and surgery can usually be avoided. It has been shown over and over that those cancers that are detected by screening are more often curable than those cancers that already showed symptoms.
Surveillance involves testing people who have previously had colorectal cancer or are at increased risk. Because their chance of having cancer is higher, more extensive or more frequent tests are recommended. The most common surveillance protocols will be discussed later.
Screening:
The screening tools for average risk patients consist of:
Combination of occult blood testing of the stool, a digital rectal exam and flexible sigmoidoscopy . The advantage of fecal occult blood testing is low cost and ease of performance. Unfortunately, the fecal occult blood testing gives often false positive and false negative results, which means that it may miss some of the colon and rectal cancers or it may be positive in people that do not have the disease. In order to decrease the risk of false negative results the fecal occult blood testing is performed 3 times on 3 consecutive days; false positive results may be minimized by following certain dietary restrictions before and during the collection of the stool specimen.
If the fecal occult blood test is negative the screening should be completed by performing a flexible fiberoptic sigmoidoscopy. This is an endoscopic procedure that allows direct visualization of the distal 2 feet of large bowel, which is the rectum and the sigmoid colon.
If the Fecal occult blood test is positive the screening should be completed by performing a colonoscopy.
Combination of Air Contrast Barium Enema and flexible sigmoidoscopy. This approach has thedisadvantage of combining two tests that are uncomfortable and have only diagnostic capabilities; if any of the two tests shows a polyp, then a colonoscopy needs to be performed in order to remove it. In the worst case scenario a patient may have a negative sigmoidoscopy, a polyp detected by ACBE in the proximal colon and eventually required to have a full colonoscopy for polyp removal. The advantage of this approach is limited to those patients in which a colonoscopy would be extremely difficult or impossible because of extensive intrabdominal adhesions, diverticular disease or anatomical abnormalities.
Complete Colonoscopy. There is today enough evidence in the literature to support the fact that a full colonoscopy is the most sensitive and most cost effective test for colorectal cancer screening in the patients at average risk
Virtual Colonoscopy is a radiological exam based on the use of Computerized Axial Tomography technique (also known as CAT Scan). It is a strictly diagnostic tool (meaning that it is able to detect colorectal cancers and polyps), however has no therapeutic capabilities. Polyps detected by Virtual Colonoscopy still need to be removed through the use of a conventional colonoscopy.
Surveillance:
The patients that belong to a high risk categories, such as having a family history of colorectal cancer, or a personal history of ulcerative colitis or familial polyposis, need to be screened more thoroughly and more frequently. Patients that have a personal history of colorectal cancer successfully removed in the past or colorectal polyps also belong to the high risk category and should be evaluated endoscopically at regular intervals. The process in these cases is called surveillance, rather than screening
The surveillance tools for high risk patients consist of a colonoscopy or a combination of flexible sigmoidoscopy and air contrast barium enema.
The most common surveillance protocols are as follows:
A Personal history of Colorectal Cancer. Yearly colonoscopy for 2-3 year after the initial diagnosis, the every 2-3 years.
B Personal history of Colorectal Polyps. Colonoscopy every 3 years, after the colon has been declared “polyp free”.
C Personal history of ulcerative colitis or Crohn’s disease. Yearly colonoscopy after the ninth year from the actual beginning of the disease ( keep in mind that the actual beginning of the disease may be several years before the initial diagnosis of inflammatory bowel disease).
D Family history of colorectal cancer. Colonoscopy starting at an age 5 years younger then the age of diagnosis in the affected relative or at age 40, whichever occurs first. In order to qualify for “family history” the relative affected by colorectal cancer must be a “first degree blood relative”. After an initial negative colonoscopy they follow the same protocol as average risk patients.
E People with a family history of an inherited disease called familial adenomatous polyposis (FAP) should receive counseling and consider genetic testing to see if they are carriers for the gene that causes the disease. People with this gene or whose tests are inconclusive should have a flexible sigmoidocopy annually beginning at puberty to see if they are expressing the gene. If polyposis is present, they should discuss with their physician the need for total colectomy, which involves removing all the colon and rectum.
F People with a family history of colorectal cancer in several close relatives and several generations, especially cancers occurring at a young age, should receive genetic counseling and consider genetic testing for a condition called hereditary nonpolyposis colorectal cancer. People with this family medical history should have an examination of the entire colon preferably colonoscopy every two years starting between the age of 20 and 30, and every year after age 40
G Women with a personal history of breast or female genital cancer (ovary or uterine) have a 15% lifetime risk (1 in 6) of developing colon cancer. They should undergo colonoscopy every 5 years, beginning at age 40.
ASCRS Info about colonoscopy
ASCRS Info about colorectal cancer risk
Removal of polyps from the colon or rectum
The average detection rate of polyps during screening colonoscopy is somewhere around 25%. The majority of these polyps can be removed at the time of detection. There are some polyps which are challenging to remove at the time of detection. These polyps are typically biopsied (if possible) and the area marked by the physician performing the colonoscopy. Removal of large or flat polyps may result in perforation, a serious but known complication.
As surgeons with expertise in both interventional colonoscopy and abdominal surgery, we will assess the situation.
In some cases, a repeat colonoscopy is recommended to attempt to remove the polyp or reassess the location. Some polyps which cannot be removed by colonoscopy alone may require either a combined endoscopic and laparoscopic approach to remove the polyp safely using CO2 colonoscopic insufflation and other may require a formal resection. Since a significant percentage of endoscopically unresectable colorectal polyps may harbor cancer, we routinely perform an adequate oncologic resection to ensure accurate diagnosis and the best outcome.
Once the polyp has been removed by any of the above methods, you will be asked to continue your screening and future colonoscopies with the gastroenterologist who referred you to us.
Colon Cancer
Colorectal cancer represents the second most common cause of cancer-related deaths in the United States, after cancer of the lung.
The peak incidence is in the sixth decade, which means after age 50. Some cases have been observed in patients younger than 40, a group whose incidence is unfortunately on the rise. For this reason, we strive to investigate the possibility of this diagnosis, even in patients who present with what appears to be benign disease.
While the type of cells that lead to cancer of the colon and rectum are similar, the workup and treatment of each is different based on anatomic reasons.
Causes / risk of colon cancer
Most of the colon and rectal cancers start as benign neoplasms, known as polyps.
The polyp-cancer sequence is now an accepted concept that has scientific validity and is based on several undisputable observations. This concept is extremely important since early detection and complete removal of colon and rectal polyps would prevent the development of most of the cancers of the colon and rectum. These goals are achieved by screening the population before symptoms appear.
The most common screening tools are stool test for occult blood, air contrast barium enema, flexible sigmoidoscopy and colonoscopy.
The symptoms of colon and rectal cancers are both nonspecific and late. The presence of bleeding, change in bowel habits, abdominal pain and discharge of mucus should alert the patient and require a physicians immediate attention.
It is known that first degree relatives of patients with carcinoma of the colon and rectum have a much higher risk than the general population to develop the disease. The increased risk is difficult to quantify, but it may be twice as high if one relative is affected and ten times if two family members are affected. The risk is even higher in familial conditions such as familial polyposis and Lynch syndrome (also known as Non Polyposis Familial Colorectal Cancer Syndrome).
Dietary factors are also extremely important. Population with diets high in fat and protein, especially if associated with low fiber ingestion, are at higher risk of developing carcinoma of the colon and rectum. The type of fat is also extremely important. Olive oil, coconut oil and fish oil do not increase the incidence of colon carcinoma, while beef fat increases the risk of colon cancer. A diet that is high in fibers seems to have a protective effect against the development of colon cancer.
Vitamins and micro elements have raised some hopes: some reports have been published and raised public hope that prevention could also be increased by the intake of vitamins A,C, or E, a different variety of vegetable products. The clinical application of these products needs to be evaluated and should not be used in an dangerous fashion.
Staging / Treatment of Colon Cancer
The diagnosis of colon cancer is typically made by obtaining a sample of the tumor from colonoscopy since these cancer begin from the lining of the colon. The staging of the cancer is not obtainable by colonoscopy and requires some form of diagnostic radiologic study such as a CT scan. You may also be asked to get a blood test called a CEA level which is a tumor marker that can be helpful to follow but does not contribute to the staging.
Treatment of cancer of the colon depends on the stage of the cancer.
Cancers that are limited to the colon or the lymph nodes that drain the colon are treated with surgery followed by chemotherapy for high risk tumors or those that involve the lymph nodes. Determination of lymph node involvement is usually only detectable after the pathologist examines the specimen removed at surgery. Not all colon resections are equal and regardless of the approach (open versus laparoscopic), a good oncologic (cancer) resection is one that removes the tumor along with all the lymph nodes associated with that section of the colon.
Cancers that have spread to other organs in the body will be assessed for possible surgical removal by a liver or lung surgeon and be given chemotherapy by a medical oncologist. Radiation therapy is not typically recommended for colon cancer. We typically make recommendations regarding the timing and necessity of removal of the primary tumor based on our assessment of the overall clinical picture.
In complex cases, a multidisciplinary approach that involves a focused communication between all the involved specialties is helpful to optimize the likelihood of cure and improve your quality of life. Each hospital has its own tumor board to facilitate this communication.
Follow-up after surgery
Depending on your geographic and other involved health-care professionals, we offer colorectal cancer surveillance and follow our patients until the risk of recurrence is negligible. The specific follow-up is customized to the patient and involves routine check-ups and may involve blood tests, CT scans, or other tests.
Except in particular situations, you will be asked to continue your surveillance colonoscopies with the gastroenterologist or surgeon who referred you to us.
Rectal Cancer
Colorectal cancer represents the second most common cause of cancer-related deaths in the United States, after cancer of the lung.
The peak incidence is in the sixth decade, which means after age 50. Some cases have been observed in patients younger than 40, a group whose incidence is unfortunately on the rise. For this reason, we strive to investigate the possibility of this diagnosis, even in patients who present with what appears to be benign disease.
While the type of cells that lead to cancer of the colon and rectum are similar, the workup and treatment of each is different based on anatomic reasons.
Causes / risk of rectal cancer
Most of the colon and rectal cancers start as benign neoplasms, known as polyps.
The polyp-cancer sequence is now an accepted concept that has scientific validity and is based on several undisputable observations. This concept is extremely important since early detection and complete removal of colon and rectal polyps would prevent the development of most of the cancers of the colon and rectum. These goals are achieved by screening the population before symptoms appear.
The most common screening tools are stool test for occult blood, air contrast barium enema, flexible sigmoidoscopy and colonoscopy.
The symptoms of colon and rectal cancers are both nonspecific and late. The presence of bleeding, change in bowel habits, abdominal pain and discharge of mucus should alert the patient and require a physicians immediate attention.
It is known that first degree relatives of patients with carcinoma of the colon and rectum have a much higher risk than the general population to develop the disease. The increased risk is difficult to quantify, but it may be twice as high if one relative is affected and ten times if two family members are affected. The risk is even higher in familial conditions such as familial polyposis and Lynch syndrome (also known as Non Polyposis Familial Colorectal Cancer Syndrome).
Dietary factors are also extremely important. Population with diets high in fat and protein, especially if associated with low fiber ingestion, are at higher risk of developing carcinoma of the colon and rectum. The type of fat is also extremely important. Olive oil, coconut oil and fish oil do not increase the incidence of colon carcinoma, while beef fat increases the risk of colon cancer. A diet that is high in fibers seems to have a protective effect against the development of colon cancer.
Vitamins and micro elements have raised some hopes: some reports have been published and raised public hope that prevention could also be increased by the intake of vitamins A,C, or E, a different variety of vegetable products. The clinical application of these products needs to be evaluated and should not be used in an dangerous fashion.
Staging and Treatment of Rectal Cancer
The staging of rectal cancer is more complicated than that of colon cancer. The first goal of staging is to assess whether the cancer has spread to other organs (metastases) such as the liver or lung. This is typically done with a CT scan. Local staging is also done for rectal cancer. This is typically done by ultrasound (link), MRI or a combination of the two. Pelvic MRI for rectal cancer staging is only done at specialized facilities and our office staff can help arrange these tests. The goal of local staging is to determine how far through the wall of the rectum the tumor has spread (T-staging) as well as to determine if there are suspicious lymph nodes in the area (N-staging). The accuracy of these tests is not 100% but can help in the decision-making process.
Cancers that are limited to the wall of the rectum without evidence of lymph node spread are often treated with surgery alone. Whether this can be done as a local excision (removal from inside the rectum) or a radical resection (removal of the rectum and surrounding tissue) depends on the overall condition of the patient, the location of the tumor, and the risk of lymph-node involvement.
Tumors that have lymph-node involvement, those that encroach on the anal control muscles, or spread beyond the wall of the rectum into the surrounding fat are typically referred for a combination of chemotherapy and radiation therapy prior to surgery to decrease the possibility of local recurrence. Chemotherapy after surgery is also often recommended in this situation.
Cancers that have spread to other organs in the body will be assessed for possible surgical removal by a liver or lung surgeon and be given chemotherapy by a medical oncologist. Radiation therapy may be involved at some point in the treatment plan. We typically make recommendations regarding the timing and necessity of removal of the primary tumor based on our assessment of the overall clinical picture.
In complex cases, a multidisciplinary approach that involves a focused communication between all the involved specialties is helpful to optimize the likelihood of cure and improve your quality of life. Each hospital has its own tumor board to facilitate this communication.
Cancer of the Anal Canal
Anal cancer is that which originates from the lining of the anal canal. It is much less common than colorectal cancer. The estimated new cases and deaths from anal cancer in the United States in 2012: new cases – 6,230 and deaths -780. This cancer affects men and women (2,250 men and 3,980 women). Most, if not all cases of anal cancer are related to human papillomavirus (HPV) infection. HPV infection is also what leads to cervical cancer in women and abnormal Pap tests.
The rates of anal cancer have been increasing, particularly in gay or bisexual men and in people with weakened immune systems. The precursor of anal cancer is anal dysplasia and can be suspected by anal Pap tests and diagnosed by high resolution anoscopy.
Anal cancer is typically diagnosed by physical examination and confirmed with a biopsy. Staging consists of radiographic studies and ultrasound.
The standard treatment of anal cancers is not surgery but chemoradiation which is highly successful in obtaining a cure of the cancer. Surgery is typically reserved only for the minority of cancers that have not responded to the chemoradiation or for patients who have a recurrence of cancer after an initial response. While we do not operate on the majority of patients with anal cancer and prefer it that way, we take surveillance seriously and routinely follow patients until the risk of recurrence is negligible. This surveillance may be routine check-ups, ultrasounds, radiologic studies, or biopsies.
Additional information from our Society
Hemorrhoids
Hemorrhoids are cushions, made out of blood vessels. They are located inside the anus to seal the opening and prevent leakage of gas or stools.
Hemorrhoids are divided into internal ones which are usually not visible and are covered by a shiny lining called mucosa, and external ones which are covered by normal skin. When the internal and external hemorrhoids become so big that they blend one with the other, then they are called complex hemorrhoids.
The cause of hemorrhoids is usually due to multiple factors such as :
- Chronic constipation,
- The lack of adequate of an adequate amount of fiber in our diet,
- Family history,
- Pregnancy,
- The habit of spending several hours a day in the sitting position.
- The most common symptoms of hemorrhoids are:
- Rectal bleeding, which is usually bright red, painless and follows bowel movements.
We want to stress the fact that even though bleeding is a very common sign of hemorrhoids, the presence of hemorrhoids does not exclude that the bleeding could be coming from a tumor in the rectum or lower bowel.
Another common symptom is the presence of swelling or lumps in the anal area. Internal hemorrhoids are also known as piles. They are usually reducible, which means that they could be pushed back in at the end of bowel movements.
Itching and burning are also very common symptoms of hemorrhoids, as it is pain, especially if the hemorrhoids become thrombosed.
The treatment of hemorrhoids has challenged physicians for the last 4,000 years.
The medical treatment of hemorrhoids is based on adding bulk to the diet. The rationale of adding bulk to the diet is to eliminate the need to straining and push too hard or too long during bowel movements.
Ideally, we should consume about 25 grams of dietary fibers per day. Potatoes, beans, onions, strawberries, have a very high fiber content.
Green salads contain mostly water, and much less fibers than we may believe.
Fibers need to be ingested withban adequate volume of water in order to produce the desired effect, otherwise, they could be counter-productive. Psyllium products, such as Konsyl, Metamucil, BeneFiber, etc. are an excellent source of soluble fibers.
The usage of creams and suppositories usually causes dramatic relief of symptoms, but it is almost always temporary. Those preparations that contain hydrocortisone should not be used for more than one week, since they can cause atrophy and thinning of the skin.
SURGICAL TREATMENT OF HEMORRHOIDS:
Internal hemorrhoids are not provided with by pain fibers and therefore we cannot feel when they are either cut, burned or undergo ligation.
Small or medium size internal hemorrhoids can be treated by a variety of office procedures. Among those, rubber band ligation, is one of the most effective. It consists of the application of a small rubber band around the base of the hemorrhoid with a special applicator. Usually the rubber band falls off in a few days leaving a shallow ulceration that heals rather quickly.
Infra-red coagulation consists of the application of a probe heated by infra-red light to the feeding vessels of the hemorrhoids. It is a painless and effective method for minor hemorrhoidal enlargement.
Sclerotherapy and cryotherapy are techniques that are rarely used in our days.
A surgical hemorrhoidectomy is the gold standard of operation to remove all hemorrhoidal tissue. It is usually performed as an outpatient surgery under sedation and local anesthesia.
The judicious use of medical management, rubber band ligation and other techniques make a surgical hemorrhoidectomy necessary only in the minority of cases.
The use of laser, harmonic scalpel, or bipolar vessel sealing device has been promoted as an alternative to the traditional scalpel and scissors hemorrhoidectomy; we employ each of these excisional technique on a case-by-case basis.
The PPH (Procedure for Prolapsing Hemorrhoids), also known as stapled hemorrhoidopexy, is a relatively new and less painful method to address the problem of prolapse of internal hemorrhoids. It is an outpatient procedure that addresses all the internal hemorrhoids at once but does little to manage external hemorrhoids.
THD (or transanal hemorrhoidal dearterialization) is the latest technique we have added to address symptomatic internal hemorrhoids.
Additional information from our Society
Anal fissures
The anal fissure is among the most painful of the perianal conditions; it is a lesion present right at the opening of the anus. It usually starts as a small split in the skin of the anus, after a hard bowel movement or an episode of diarrhea and subsequently progresses becoming a rather large open sore.
The symptoms of a fissure are very similar to the symptoms of hemorrhoids, and to complicate things even further, a fissure is also often associated with a variable degree of hemorrhoids as well.
The cardinal symptom of an anal fissure is pain in the anal area, which starts during the bowel movements and lasts a variable amount of time afterwards. This pain is usually described as sharp, cutting and tearingduring the actual passage of stool and subsequently it may turn into a burning discomfort that may persist for a few minutes to several hours after the bowel movement.
Because of the anticipated pain, the patient may put off his bowel movements when the natural urge occurs, and this leads to harder stools and subsequently even more painful bowel movements.
Bleeding is also very common with fissure, usually bright red and of variable amounts.
Constipation is frequent cause as well as a consequence of an anal fissure.
Patients with painful fissures sometimes develop disturbances with urination as well.
An ulceration in the anus could also represent:
- a infective ulcer,
- a tuberculous ulcer,
- a cancer of the anus,
- a lesion associated with inflammatory bowel disease and
- a lesion associated with HIV infecton.
Treatment of an acute fissure consists of medical management with stool softeners, bulking agents (Konsyl, Perdiem, Citrucel, etc.), warm sitz baths, and the application of anesthetic ointments. In the last several years we had good success with the use of Nitroglycerin ointment, applied directly in the perianal area 3 times a day. The course of treatment lasts 4-8 weeks and can be repeated in case of incomplete healing. The main side effect of the treatment is headache. The combination of Nifedipine/Lidocaine ointment is slightly less effective but much better tolerated. The efficacy of intrasphincteric injection of Botulin Toxin has been proven by several studies, however it has not achieved widespread use so far, mostly because of the high cost of the medication.
If the fissure becomes chronic or fails to respond to medical management, then surgical treatment is indicated; a LATERAL SPHINCTEROTOMY is the standard surgical treatment, and consists of the division of a small part of the internal sphincter muscle. A FISSURECTOMY, which consist of the excision of the fissure itself is also an option.
These procedures are usually performed as outpatient under sedation and local anesthesia.
Link to American Society of Colon and Rectal Surgeons Info regarding this condition
Anal dysplasia / warts
Anal warts are a common sexually transmitted disease of the anal area. It is caused by the human papillomavirus. The presence of anal warts does NOT necessarily indicate a history of anal intercourse.
The virus that causes these lesions may also lead to precancerous changes in the lining of the anal canal and surrounding skin. This is referred to as anal dysplasia. Patients with a weakened immune system are particularly susceptible to this condition. An anal Pap test is sometimes used to diagnose this condition in high-risk individuals similar to Pap tests to detect dysplasia of the cervix in women.
Dr. Grasso has an extensive experience and expertise with the diagnosis and management of anal dysplasia performing over 200 exams per year. He offers comprehensive surveillance and treatment of this precursor to anal cancer.
Link to American Society of Colon and Rectal Surgeons Info regarding this condition
Constipation
Abscesses and anal fistulas
Abscesses are pockets of pus that could either be superficial around the anus or deep around the rectum.
A superficial abscess is called a perianal abscess. It is usually a red painful swelling around the anal opening.
A deep abscess or perirectal (ichioanal) abscess could be the cause of very severe pain in the anal or pelvic area, but may not be visible during a routine external examination. These deep abscesses, because of their location, are usually diagnosed late, and may be the source of complications such as gangrene or sepsis diffused to the whole body, especially in diabetics or in patients with disorders of the immune system.
Sometimes a perianal or perirectal abscess, may result in a fistula, which is a communication between the inside of the rectum and the skin.
If the abscess causes damage to the sphincter muscle or causes too much scarring, incontinence may result.
The gold standard treatment of a perianal abscess is surgical drainage of the pus as soon as possible.
Antibiotics often are not needed and sometimes they may be counter-productive because they may delay the diagnosis and the proper treatment.
Patients calling with symptoms suggestive of an abscess will be given an appointment within 1 day of calling provided your insurance will cover the visit.
The treatment of anal fistulas is typically surgical and may employ one of a variety of procedures to heal the fistula while preserving anal sphincter function and continence. We balance the risk of recurrence with the risk of incontinence on an individualized basis.
Additional information from our society
Fecal incontinence (Incontinence to stool)
ASCRS info about fecal incontinence
Anal itching (Pruritis Ani)
Rectal Prolapse
ASCRS info about rectal prolapse
Inflammatory bowel disease
Ulcerative colitis – ASCRS infoabout ulcerative colitis
Crohn’s Disease – ASCRS info about Crohn’s Disease
Diverticulitis
ASCRS info about diverticular disease
Other forms of inflammation or infection of the intestines
Pilonidal disease
ASCRS info about pilonidal disease
Rectocele
Location Info
- GBMC
- Bel Air Office
- Endoscopy Center at Bel Air
6569 N Charles St, Suite 502, Towson, MD 21204
3333 North Calvert Street Suite 665B Baltimore, MD 21218
208 Plumtree Rd., Suite F, Bel Air 21015
208 Plumtree Rd Suite G, Bel Air, MD 21015