Patient Safety

Anal fissure is a tear in the mucosa and submucosa of the anal canal below the dentate line. It can be acute or chronic if it persists for more than 6 weeks. Anal fissures are often accompanied by pain and bleeding during bowel movements and are commonly seen in patients with chronic constipation or diarrhoea. They are also common in women after childbirth.

Although the exact cause of anal fissure formation is not completely understood, experts believe that the imbalance between rectal pressures and anal pressures is a key factor. Passing hard stool, straining during defecation, and the inability of the anal sphincter to fully relax can lead to a traumatic tear of the anoderm. Most anal fissures (90%) are posterior and only 10% are anterior. Anterior anal fissures are more common in females.

Severe and sharp pain during defecation, which lasts from a few minutes to several hours after that is the main symptom of anal fissure. In more than 70% of the cases bleeding is reported, where blood spots are either seen on the toilet paper or dropping on top of the stool.

Most anal fissures will heal with remedial measures without the need for surgery. Treating constipation and avoiding straining and other causes of anal trauma are part of the treatment. Apart from that dietary changes (high fibre diet and increased water intake) are advised and stool softeners are prescribed. Sitz baths may reduce pain and anal spasm. Anal muscle relaxant ointments (GTN, nifedipine, diltiazem) or botulinum toxin injection are also prescribed for the treatment of anal fissure in some cases.

Anal fissure surgery is recommended as the last resort as most of the time proper conservative treatment is effective. Many surgical procedures have been described for anal fissure including Botox Injection, lateral internal sphincterotomy, and advancement flaps.

An anal fistula is a tract between the inside of the anal canal and the perianal skin. Anal fistulas can be submucosal, inter-sphincteric, trans-sphincteric, suprasphincteric, or extrasphincteric. An anal fistula may have a single tract or multiple tracts with secondary branches.

Most fistulas are caused by infection of the anal glands situated in the space between the anal muscles. When the ducts in the anal canal experience blockage it may cause infection. If left untreated, it can cause the formation of abscess and ultimately a fistula.

Patients usually experience anal pain, discharge, fever, perianal induration, or an abscess. Doctors also consider other diseases such as hidradenitis suppurativa, furuncles, pilonidal disease, etc. in the differential diagnosis of the condition. Most anal fistulas are diagnosed based on medical history and physical examination. Sometimes doctors recommend an endo-anal ultrasound scan or an MRI to find the presence of a complex anal fistula. A CT scan may be conducted to discover the origin and causes of supra levator abscesses.

Anal fistula requires surgical treatments and a variety of techniques depending on the number of muscles involved and the associated presence of infection or abscess.
Surgery aims to treat the fistula avoiding or minimising injury to the sphincter muscles that may lead to faecal incontinence. Anal fistula surgery encompasses a wide variety of techniques such as traditional fistulotomy, fistulectomy, loose seton, cutting seton. Doctors also recommend minimally invasive techniques including Ligation of the Inter-sphincteric Fistula Tract (LIFT), Video-Assisted Anal Fistula Treatment (VAAFT), Fistula Laser Closure (FLAC), endoanal and endorectal advancement flap, fibrin glue, bioprosthetic plugs and stem cell treatment depending upon the advancement of anal fistula.

Haemorrhoids are a disease of the anal cushions that consist of clusters of connective tissue, smooth muscle and vascular structures covered by mucosa. When haemorrhoids enlarge, they may protrude outside of the anus. If injured, it may lead to easy bleeding especially after the passage of stool. There are two types of haemorrhoids: internal and external. External haemorrhoids can be seen from the outside, while internal haemorrhoids are not usually visible unless they prolapse out of the anus.

Constipation and excessive straining during defecation are considered the main risk factor for haemorrhoids. Posture in the course of defecation may also be a reason.

Internal haemorrhoids show symptoms like painless rectal bleeding and/or prolapse. Prolapse leads to soiling, mucous discharge, and skin irritation. Painful internal haemorrhoids are usually the result of thrombosis, incarceration, and strangulation. Complicated external haemorrhoids are often very painful. This may happen in the case of a hematoma or thrombosis within the external haemorrhoids.

Doctors initially recommend preventive haemorrhoids with fibre supplementation which decrease rectal bleeding by 50%. However, it doesn’t help much with prolapse, pain, and itching. Topical medications such as steroids or local anaesthetics can temporarily reduce the symptoms. Phlebotomists are generally prescribed to improve bleeding, itching, discharge, and leakage. When conservative measures fail, doctors advise surgery. Surgical haemorrhoids treatment includes office-based procedures that do not require anaesthesia like Rubber Band Ligation and other treatments that are performed under local, regional, spinal, or general anaesthesia.

Colorectal cancer is cancer that affects the large bowel which consists of the colon and rectum. It is the third most common cancer and second most common cause of cancer death worldwide.

Symptoms like recent changes in bowel habits with constipation or diarrhoea, weight loss, rectal bleeding, abdominal pain, rectal pain, anal pain, the urgency to open bowels, anaemia and the presence of a mass are often indicators of colorectal cancer. However, colorectal cancer may sometimes give no symptoms, especially in the early stages.

People with a family history of colon and rectal cancer are at higher risk, especially when more than one close family member is affected before the age of 50. Particular hereditary diseases are associated with a high risk of colorectal cancer (e.g. Familial Adenomatous Polyposis -FAP, Hereditary Nonpolyposis Colorectal Cancer- HNPCC)

A low rectal cancer can be diagnosed through finger examination or can be seen on visual inspection. A rigid proctoscopy allows for assessment and biopsy of rectal cancer in the clinic. Colonic cancers are assessed and biopsied using flexible endoscopic instruments. A full colonoscopy is recommended in all cases to rule out synchronous cancers. CT scan and MRI are used to stage the disease.

What is Colon and Rectal Cancer Screening?
There are many screening tests available for colorectal cancer and some can be done at home such as faecal occult blood test –FOBT- and faecal immunochemical test – FIT. The Colorectal cancer screening program in Dubai is active and has already been shown to be successful in the early diagnosis of colon and rectal cancer. As a result, cancer is diagnosed at an early age with many patients. There are two ways in which screening is done. One is to identify the disease at an early stage and treat it with a higher possibility of recovery. The other is to remove benign polyps by endoscopy before they can transform into cancer and, therefore, preventing the disease altogether.

Colorectal cancer treatment is mostly treated with surgery, chemotherapy and radiotherapy. In the case of colon cancer, radiotherapy is not usually an option unless it is used to radiate a postoperative surgical field having a high risk for recurrence. Chemotherapy in colon cancer can be given before surgery to downstage an advanced disease or more commonly postoperatively in early high-risk cancers.