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POTTER STEWART

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DAME ANITA RODDICK

"The time is always right to do what is right"

MARTIN LUTHER KING

"The sole meaning of life is to serve humanity"

LEO TOLSTOY

"Compassion and tolerance are not sign of weakness, but a sigh of strength"

DALAI LAMA

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HENRY FORD

"Do something for somebody every day for which you do not get paid"

ALBERT SCHWEITZER

Keyhole Surgery

Keyhole Surgery (minimally invasive or laparoscopic surgery)

An innovative and safe alternative to open surgery. Keyhole surgeries are minimally invasive procedures that utilize an endoscope to reach internal organs through very small incisions.

Basic description of keyhole surgery.

During endoscopic surgery the surgeon inserts thin, flexible tubes through small incisions. One tube has a video camera, while each of the rest have a channel to utilize tiny surgical instruments, which the surgeon uses while viewing the organs on a computer monitor.
This technique allows the surgeon to see inside the patient’s body and operate through a much smaller incision, typically 5 – 10mm in length, than would otherwise be required in traditional open surgery, which can extend over 30cm. It effectively reduces time and gives surgeons greater control.

Our surgeons can perform complex and delicate procedures through small incisions with unmatched precision. They are among the few in the world that have a wealth of experience as well with LESS (Laparoscopic Single Site Surgery), where the surgery is performed through one hole only, situated within the ambigualcored. Since May 2016 they have performed all Inguinal Hernia and Appendicitis operations by single hole surgery. Galbladder removal surgery, depending on the case, can be performed by single hole surgery.

Benefits of keyhole surgery.
The benefits of minimally invasive surgery can include:

  • Small incisions
  • Less pain
  • Low risk of infection
  • Short hospital stay
  • Quick recovery time
  • Less scarring
  • Reduced blood loss

While minimally invasive surgery is becoming more and more common, and in some areas is used almost exclusively, it isn’t for everyone. Sometimes traditional open surgery provides surgeons better access to the area to be treated, and sometimes a patient’s age, physical condition and surgical history may necessitate open surgery.

Risk factors

Factors that may increase your risk of gallstones include:

  • Being female
  • Being aged 40 or older
  • Being overweight or obese
  • Being sedentary
  • Being pregnant
  • Eating a high-fat diet
  • Eating a high-cholesterol diet
  • Eating a low-fiber diet
  • Having a family history of gallstones
  • Having diabetes
  • Losing weight very quickly
  • Taking medications that contain oestrogen, such as oral contraceptives or hormone therapy drugs
  • Having liver disease

Some conditions treated using keyhole surgery include:

Hernias
  Diaphragm Hernias
    Hiatal Herniа
  Abdominal Wall Hernias
    Inguinal Hernia
    Incisional Hernia
    Femoral Hernia
    Umbilical Hernia

Gallstones
Appendicitis
Splenectomy
Hemorrhoids
Colon Cancer
Diverticulosis and diverticulitis (small, bulging pouches that can form in the lining of your digestive system)

Diaphragm Hernias

Diaphragm hernias are opening(s) that can occur in the diaphragm muscle, and generally occur at a natural opening, such as the hiatus where the esophagus travels through into the abdominal cavity. These are known as hiatal hernias. Diaphragm hernias can also form in other areas of the muscle such as what occurs with a Morgagni Hernia, Bochdalek Hernia, or Traumatic hernia (rupture from blunt force). The most common type of diaphragm hernia is the Hiatal Hernia.

Hiatal Hernia

What is a hiatal hernia?

The diaphragm is a sheet of muscle that separates the abdomen from the chest cavity. It has an opening in the middle called the hiatus. The food pipe, or esophagus, runs through the hiatus in order for it to enter into the stomach. When the hiatus is enlarged, the stomach can bulge up into the chest causing symptoms such as heartburn, regurgitation, reflux, chest pain, and trouble swallowing.

There are several types of hiatal hernias. The first type of hiatal hernia is called a sliding hiatal hernia. This is the most common type of hiatal hernia and is a result of the lower esophagus and top of the stomach sliding up together into the chest through the hiatus.
Other, less common types of hiatal hernias are called paraesophageal hernias. These occur when a section of the stomach goes up into the chest next to the esophagus, or when other organs such as colon, intestine, or spleen go up through the hernia defect into the chest. These types of hernia can be more dangerous because they are not always associated with symptoms and can result in the stomach tissue becoming twisted off from its blood supply resulting in “strangulation” of the stomach. In most cases people have mild symptoms such as heartburn or gastroesophageal reflux disease (GERD due to the structural changes associated with the hiatal or paraesophageal hernia.

What causes a hiatal hernia?

There are many factors that can result in a hiatal hernia, but for most patients, the cause is unknown. It is possible that some people are simply born with a short esophagus or a large hiatus, or develop these conditions over time due to weakened tissue, or chronic scarring of the lining of the lower esophagus from acid reflux resulting in contraction or shortening of the overall esophageal length. Other causes include increased intra-abdominal pressure in the abdomen due to conditions such as obesity, pregnancy, chronic cough or straining during bowel movements. Experts also predict that patients who have gained a considerable amount of weight are at risk for hiatal hernia development, along with people over the age of 50 and people that are smokers.

What are the symptoms of a hiatal hernia?

It is not uncommon for people to have no symptoms associated with their hiatal hernia. When symptoms do occur, they normally consist of heartburn and gastroesophageal reflux. Other symptoms may include pain or discomfort in the stomach or upper abdomen, chest pain, a harsh or sour taste in the back of the throat, as well as bloating and even excessive belching.

Chest pain due to a hiatal hernia feels very similar to that experienced during a heart attack. It is crucial to seek evaluation and treatment immediately so that you can be correctly diagnosed and treated.

Symptoms of a strangulated hiatal hernia or associated obstruction include the inability to have a bowel movement (constipation), the inability to pass gas, or development of nausea and vomiting.

How is a hiatal hernia diagnosed?

A barium swallow study, which is a specific X-ray procedure, can enable the proper evaluation of the esophagus to correctly diagnose a hiatal hernia. Other ways to diagnose a hiatal hernia are by CT scan or esophagoscopy (EGD). The esophagoscopy is a procedure where an endoscope, a long-thin flexible medical video camera, is inserted through the mouth into the esophagus and stomach and allows the examination of the upper digestive system.

How are hiatal hernias treated?

Hernia surgery is not necessary when patients do not have any symptoms associated with their hiatal hernia. Although some mild symptoms such as bloating or stomach displeasure and heartburn can occur, there are ways a hiatal hernia may be treated through healthy lifestyle changes. These changes include maintaining a healthy weight, limiting fatty, acidic, and caffeinated foods, along with avoiding alcoholic beverages and quitting smoking. It is also recommended that the person avoid eating at least 2-3 hours before going to bed and elevating their head while sleeping to reduce the amount of acid exposure into the lower esophagus. Other treatments include taking over the counter antacids to chemically neutralize stomach acid, thereby reducing heartburn symptoms.

When is hernia surgery necessary?

Patients who suffer the following conditions along with a hiatal hernia may be required to undergo surgical repair:

  • Gastroesophageal reflux or GERD with symptoms including regurgitation, difficulty swallowing, and/or heartburn that is no longer responsive to acid-blocking medications.
  • Strangulated hernia or obstruction – symptoms including the inability to have a bowel movement or pass gas, severe pain with eating, or persistent nausea. A strangulated hernia is an emergency situation, and often requires an emergency operation.
  •  
    There is no guarantee that the hernia will not return after surgery. The best way to reduce your chances of recurrence are to avoid smoking, maintain a normal weight, and avoid any abdominal stress such as straining, heavy lifting, and chronic cough. Repairing recurrent hernias (those that have occurred after previous repair) are exceedingly complex difficult cases, and the chance for definitive (lasting repair) goes down with each subsequent repair. Your first chance at repair is therefore the best one, so it is in your best interest to reduce as many personal risk factors for recurrence as much as possible before the first operation, and maintain a healthy lifestyle afterwards.

Abdominal Wall Hernias

What is an abdominal wall hernia?

An abdominal wall hernia is a defect, or abnormal opening, in the muscle or connective tissue layers that make up the abdominal wall. The abdominal wall is what keeps your internal organs inside and protected from the outside world. The abdominal wall extends from the bottom of the breastbone (sternum), down to the pubic bone, and outwards on both sides around to your back. When an abnormal opening, or gap, develops in the abdominal wall it is called a hernia. Intra-abdominal structures can then become entrapped in the opening, leading to pain and even life-threatening situations requiring emergency surgery.
Inguinal (groin), Umbilical (belly button), Femoral, Ventral, and Incisional hernias are all subtypes of abdominal wall hernias.

What causes an abdominal wall hernia?

A weakness in the layers of the abdominal wall is what is responsible for the formation of a hernia. This can be a natural weakness, for example those that commonly occur in the groin or belly button, or can develop at a weak point in a healed incision from prior surgery, called an incisional hernia.

What are the symptoms of an abdominal wall hernia?

Usually pain associated with a bulge are the first signs of an abdominal wall hernia. These can occur in the groin, at the bellybutton, or through a prior incision site from surgery, even years after the scar has healed.

How are abdominal wall hernias diagnosed?

Abdominal wall hernias are sometimes diagnosed by the patient who feels a bulge and is sometimes associated with pain. If this is the case, the hernia needs to be confirmed by a physician exam. Hernias can also be diagnosed on imaging studies such as CT scan. If you think you have a hernia, see your doctor right away. If the bulge is associated with severe pain accompanied by persistent nausea and vomiting, and inability to pass gas or stool you may have an intestinal obstruction where a loop of intestine has become stuck (incarcerated) at the hernia defect. This is a serious emergency situation–proceed to your nearest emergency room immediately.

How are abdominal wall hernias treated?

Abdominal wall hernias are treated with surgical repair, and depending on the size of the defect opening and other factors associated with your individual medical profile are often repaired with hernia mesh. These procedures are done either through an open incision or laparoscopically (through small incisions) depending on the type of hernia and work required for repair.

Why should I have my hernia fixed?

If you suspect that you have an abdominal wall hernia, and it is causing you pain or discomfort, you should see your primary doctor for an exam and confirmation of the hernia. You can then request a referral to a hernia repair specialist. All symptomatic hernias in general should be repaired.

What is hernia repair mesh?

Hernia repair meshes are generally similar to the material used to make mosquito nets. However, hernia meshes are highly developed materials engineered specifically for use as sterile medical devices used for abdominal wall reinforcement. Due to ongoing advances in technology, hernia meshes are an intense area of ongoing research and development and therefore require proper selection by a surgeon with specialty training in hernia repair materials. Ours hernia specialists can provide you with more information on which mesh is best for you and why.

Definitive hernia repair

There is no guarantee that a hernia will not return after surgery. The best way to reduce your chances of recurrence are to avoid smoking and achieve a normal body weight prior to surgery. You will also need to avoid abdominal stress such as straining, heavy lifting, chronic cough, and weight regain after surgery. Repairing recurrent hernias (those that have occurred after previous repair) are exceedingly complex difficult cases, and the chance for definitive (lasting repair) goes down with each subsequent operation. Your first hernia surgery therefore represents your best chance at achieving a lasting repair, so you will need to reduce as many personal risk factors for recurrence as much as possible before your first operation and maintain a healthy weight and lifestyle afterwards.

Inguinal Hernia

What causes an Inguinal Hernia?

Everyone has natural weak points in various areas of the abdominal wall due to their normal anatomy. One of these areas is in the groin (inguinal region). For children, hernia development can be congenital, but adults can develop this type of hernia as a result of physical activities, chronic cough, or chronic straining from difficulties with bowel movements or urination.

Symptoms of an Inguinal Hernia

Usually pain associated with a bulge in the groin is the first sign of an inguinal hernia. It can be a sharp pain or an ache that gradually gets worse as the day proceeds. Signs that the hernia is entrapped or strangulated are tenderness, redness of the overlying skin, severe pain, and the bulge not being able to be reduced or pushed back in. These are serious symptoms that must be treated immediately.

Laparoscopic Inguinal Hernia Repair

The surgeons Bulgaria Medical Travel Partner LTD works with, specialize in the laparoscopic approach to inguinal hernia repair, which offers patients a shorter recovery and sooner return to work and daily activities. Laparoscopic inguinal hernia repair with mesh is also associated with a lower risk of long-term chronic pain after repair versus the traditional open approach.

How is the Procedure Performed?

There are two general options for inguinal hernia repair: the open approach and the laparoscopic approach. The open approach requires a five to ten cm incision in the groin area. The hernia defect is identified and repaired using a piece of surgical mesh. Local anesthetic and sedation as well as spinal anesthetic or a general anesthetic are used for this procedure. In a laparoscopic hernia repair, 1 or 3 small incisions are made where a small thin camera called a laparoscope and two working instruments are inserted through the abdominal wall. The layers of the abdominal wall are separated and the space is maintained with carbon dioxide gas. This grants the surgeon access to the hernia defect and the surrounding tissues and allows for dissection and placement of the mesh. Laparoscopic inguinal hernia repair is done under general anesthesia.

What complications can occur?

For laparoscopic hernia repair, primary complications associated with the operation are not common. There is a low risk of injury to blood vessels, nerves, the bladder, the intestines, nerves or the spermatic cord leading into the testicle. Your individual risk for these complications will be reviewed with your surgeon during your consultation for surgery. For many patients after open or laparoscopic repair, there can be swelling and bruising of the abdominal wall and scrotal region. This is normal and will steadily decline and resolve completely with time. Despite the low rates of recurrence of the hernia after it has been repaired, a hernia can come back at any time.

Incisional Hernia

What causes an incisional hernia?

An incisional hernia is one that forms in a previous incision from prior surgery. The incidence of a hernia forming in a previous abdominal scar is about 20%, and is even higher in people who are obese or who are active smokers. The hernia defect itself can form anywhere along the scar tissue of a previous incision, and can be very small to large and complex. Incisional hernias can develop slowly over many or can even occur years after surgery. The underlying cause is usually due to inadequate healing or excessive pressure on the abdominal wall scar.

Who is at risk for incisional hernias?

Conditions that increase strain on the abdominal wall such as obesity, pregnancy, peritoneal dialysis, liver disease, chronic straining/lifting, chronic cough, or chronic difficulties with bowel movements or urination are risk factors for hernia formation. Also smoking, advanced age, malnutrition, poor metabolism, steroid medications, chemotherapy, and hematoma or infection after a prior surgery put a patient at a higher risk of developing an incisional hernia.

What are the symptoms?

Pain is usually the first symptom a person will have with an incisional hernia, regardless of whether or not they have a bulge at the incision site or the abdomen. Once the bulge is present, it can increase in size and gradually cause more symptoms such as nausea and vomiting. If internal organs such as intestine becomes entrapped in the hernia defect, this can be life-threatening if left undiagnosed and untreated.

How is an incisional hernia treated?

The surgical repair of an incisional hernia is largely dependent on reducing or eliminating the tension present at the surgical site. The method that is preferred by most hernia surgeons is a tension-free method and is used by most medical centers. This procedure involves the placement of a mesh patch. Once the mesh is sewn into the area, it bridges the weakened area that is beneath it. The mesh becomes firmly integrated into the abdominal wall as the area heals, and continues to protect the organs of the abdomen.

How is incisional hernia repair performed?

The procedure can be done in two different ways, either by a laparoscopic approach or by a conventional open repair. In a laparoscopic incisional herniorrhaphy, small incisions are made and a tube-like camera and instruments are used to place the mesh. In the conventional open repair procedure, the hernia is accessed through a larger abdominal incision. If intestines are trapped in the hernia (incarcerated), or if they have become twisted off from their blood supply (strangulated) this often requires part of the intestine to be removed with the remaining ends reconnected (resection and anastomosis). The approach to repair depends on many factors, and operative planning often requires preoperative imaging such as CT scan. Our surgeons will meet with you to discuss your best options. The main advantage of laparoscopic incisional hernia repair is reduced risk of mesh infection.

Femoral Hernia

A femoral hernia can appear as a grape sized lump in the inner or upper part of the thigh or groin. This lump is usually painful and may even disappear when you lie down, however straining of the muscles can cause the lump to reappear.

What causes a femoral hernia?

A femoral hernia can occur when fatty tissue or part of an intestine, protrudes through into the groin area at the top of the inner thigh through a weak spot in the surrounding muscle wall of the abdomen and into the femoral canal.

Femoral hernias tend to occur more frequently in women due to the wider shape of the female pelvis. While more common in older women, femoral hernias are highly rare in children.

The hernia can appear suddenly when the muscles of the abdomen are strained. Those who suffer from constipation can aggravate the hernia and cause it to appear suddenly. Femoral hernias have also been linked to obesity, those with heavy coughs and those who carry or push heavy loads.

Why is surgery needed?

The operation pushes the bulge back into place and helps to strengthen the abdominal wall. Femoral hernia repair is a necessary procedure, since this type of hernia, if untreated, has a high risk of intestinal strangulation, which is a potentially life-threatening condition where a section of the intestine can become stuck in the femoral canal and cut off from the blood supply, which causes the tissue to die. Femoral hernia surgery will rid you of your hernia and prevent these complications from happening.

How is the surgery performed?

Femoral hernia repair can be performed one of two ways. It can be done through open surgery where one large cut is made in which the lump can be pushed back into the abdomen, or through laparoscopic surgery. This is a less invasive method where several small incisions are made to repair the hernia. In most cases, you should be able to return home the same day as your surgery.

What are the risks of having surgery?

Femoral hernia repair has very few risks, however 1% of femoral hernia cases reported a return of their hernia after the operation. Complications of femoral hernia repair are extremely rare, however they can include the development of a lump under the incision site, difficulty passing urine, narrowing of the femoral vein, injury of the bowel, weakness (temporarily) of the leg, and damage to nerves which can lead to pain or numbness in the groin area.

Umbilical Hernia

What is an umbilical hernia?

An umbilical hernia is a protrusion, or abnormal bulge, that can be felt or seen over the belly button. This condition develops when a portion of the intestine protrudes through the muscle of the abdominal wall.

Umbilical hernias in children are caused by an opening in the abdominal wall that is present at birth. The bulge can be seen and felt all the time or only when the child is crying, coughing, or straining during bowel movements. This protrusion may disappear when the child is relaxed.

One in every six children has an umbilical hernia, and it can affect both boys and girls equally. This condition is more common among African-American children than Caucasian children and low birth weight and premature infants have a higher risk of developing umbilical hernias. Umbilical hernias also often occur in adults, and should be repaired if they are causing symptoms of pain or intestinal entrapment.

What are the symptoms of an umbilical hernia?

The most common symptoms associated with umbilical hernia are pain and a bulge. Usually symptoms are stable over time, but often the bulge can become larger or can involve entrapment of internal organs such as intestine. Anyone with a known umbilical hernia who develops persistent nausea and vomiting with severe abdominal pain and inability to pass gas or stool may have intestinal entrapment (incarceration or strangulation) resulting in is a potentially life-threatening situation. This is a medical emergency which requires immediate evaluation; proceed to your nearest emergency room without delay.

What causes an umbilical hernia?

The abdominal organs are formed on the outside of a baby’s body during their development in the womb. These organs return to the abdominal cavity around the 10th week of gestation. If the wall of the abdomen fails to close around the abdominal organs, an umbilical hernia can form.

On occasion, the intestines can become trapped in this muscular defect, which causes umbilical pain and tenderness. This is condition is called an incarcerated hernia and must be evaluated immediately to prevent the cause of damage to the intestines. Symptoms of an incarcerated hernia include severe pain and redness of the bulge.

When should an Umbilical hernia be repaired?

In children, most umbilical hernias will go away on their own by age 3 or 4. This is why it may be recommended to wait until your child has reached this age to consider surgical repair. If, however, the defect is greater than 2cm in diameter, it will need to be surgically repaired. In adults, any symptomatic umbilical hernia should be evaluated for repair.

The Surgical Procedure

If it is determined that your child will need to undergo umbilical hernia repair, a small incision will be made at the base of the belly button where the bulging intestine can be identified. Then the intestine can be pushed back into its proper place, while the hernia sac is removed. Multiple stitches are put in place around the muscle wall to prevent another hernia. The skin around the belly button will be then sewn down and attached to the underlying muscle so that the belly button looks like an “innie” instead of an “outie.” Most children are able to return home within a few hours after surgery, however children with certain medical conditions and premature infants may need to remain under observation for one night.

Gallstones

Gallstones are hardened deposits of digestive fluid that can form in your gallbladder. Your gallbladder is a small, pear-shaped organ on the right side of your abdomen, just beneath your liver. The gallbladder holds a digestive fluid called bile that’s released into your small intestine.
Gallstones range in size from as small as a grain of sand to as large as a golf ball. Some people develop just one gallstone, while others develop many gallstones at the same time.
People who experience symptoms from their gallstones usually require gallbladder removal surgery. Gallstones that don’t cause any signs and symptoms typically don’t need treatment

Symptoms:

Gallstones may cause no signs or symptoms. If a gallstone lodges in a duct and causes a blockage, the resulting signs and symptoms may include:

  • Sudden and rapidly intensifying pain in the upper right portion of your abdomen
  • Sudden and rapidly intensifying pain in the center of your abdomen, just below your breastbone
  • Back pain between your shoulder blades
  • Pain in your right shoulder
  • Nausea or vomiting
  • Gallstone pain may last several minutes to a few hours.

When to see a doctor

Make an appointment with your doctor if you have any signs or symptoms that worry you. Seek immediate care if you develop signs and symptoms of a serious gallstone complication, such as:

  • Abdominal pain so intense that you can’t sit still or find a comfortable position
  • Yellowing of your skin and the whites of your eyes
  • High fever with chills

Causes

It’s not clear what causes gallstones to form. Doctors think gallstones may result when:

  • Your bile contains too much cholesterol. Normally, your bile contains enough chemicals to dissolve the cholesterol excreted by your liver. But if your liver excretes more cholesterol than your bile can dissolve, the excess cholesterol may form into crystals and eventually into stones.
  • Your bile contains too much bilirubin. Bilirubin is a chemical that’s produced when your body breaks down red blood cells. Certain conditions cause your liver to make too much bilirubin, including liver cirrhosis, biliary tract infections and certain blood disorders. The excess bilirubin contributes to gallstone formation.
  • Your gallbladder doesn’t empty correctly. If your gallbladder doesn’t empty completely or often enough, bile may become very concentrated, contributing to the formation of gallstones.

Types of gallstones.

Types of gallstones that can form in the gallbladder include:

  • Cholesterol gallstones. The most common type of gallstone, called a cholesterol gallstone, often appears yellow in color. These gallstones are composed mainly of undissolved cholesterol, but may contain other components.
  • Pigment gallstones. These dark brown or black stones form when your bile contains too much bilirubin.

Complications of gallstones may include:

  • Inflammation of the gallbladder. A gallstone that becomes lodged in the neck of the gallbladder can cause inflammation of the gallbladder (cholecystitis). Cholecystitis can cause severe pain and fever.
  • Blockage of the common bile duct. Gallstones can block the tubes (ducts) through which bile flows from your gallbladder or liver to your small intestine. Jaundice and bile duct infection can result.
  • Blockage of the pancreatic duct. The pancreatic duct is a tube that runs from the pancreas to the common bile duct. Pancreatic juices, which aid in digestion, flow through the pancreatic duct.  A gallstone can cause a blockage in the pancreatic duct, which can lead to inflammation of the pancreas (pancreatitis). Pancreatitis causes intense, constant abdominal pain and usually requires hospitalization.
  • Gallbladder cancer. People with a history of gallstones have an increased risk of gallbladder cancer. But gallbladder cancer is very rare, so even though the risk of cancer is elevated, the likelihood of gallbladder cancer is still very small.

Tests and procedures used to diagnose gallstones include:

  • Tests to create pictures of your gallbladder. Your doctor may recommend an abdominal ultrasound and a computerized tomography (CT) scan to create pictures of your gallbladder. These images can be analyzed to look for signs of gallstones.
  • Tests to check your bile ducts for gallstones. A test that uses a special dye to highlight your bile ducts on images may help your doctor determine whether a gallstone is causing a blockage. Tests may include a hepatobiliary iminodiacetic acid (HIDA) scan, magnetic resonance imaging (MRI) or endoscopic retrograde cholangiopancreatography (ERCP). Gallstones discovered using ERCP can be removed during the procedure.
  • Blood tests to look for complications. Blood tests may reveal an infection, jaundice, pancreatitis or other complications caused by gallstones.

Treatment
Laparoscopic cholecystectomy

Most people with gallstones that don’t cause symptoms will never need treatment. Your doctor will determine if treatment for gallstones is indicated based on your symptoms and the results of diagnostic testing.

Your doctor may recommend you be alert for symptoms of gallstone complications, such as intensifying pain in your upper right abdomen. If gallstone signs and symptoms occur in the future, you can have treatment.
Treatment options for gallstones include:

  • Surgery to remove the gallbladder (cholecystectomy). Your doctor may recommend surgery to remove your gallbladder, since gallstones frequently recur. Once your gallbladder is removed, bile flows directly from your liver into your small intestine, rather than being stored in your gallbladder. You don’t need your gallbladder to live, and gallbladder removal doesn’t affect your ability to digest food, but it can cause diarrhea, which is usually temporary.
  • Medications to dissolve gallstones. Medications you take by mouth may help dissolve gallstones. But it may take months or years of treatment to dissolve your gallstones in this way and gallstones will likely form again if treatment is stopped.     Sometimes medications don’t work. Medications for gallstones aren’t commonly used and are reserved for people who can’t undergo surgery.

Prevention

You can reduce your risk of gallstones if you:

Don’t skip meals. Try to stick to your usual mealtimes each day. Skipping meals or fasting can increase the risk of gallstones.

Lose weight slowly. If you need to lose weight, go slow. Rapid weight loss can increase the risk of gallstones. Aim to lose 1 or 2 pounds (about 0.5 to 1 kilogram) a week.

Maintain a healthy weight. Obesity and being overweight increase the risk of gallstones. Work to achieve a healthy weight by reducing the number of calories you eat and increasing the amount of physical activity you get. Once you achieve a healthy weight, work to maintain that weight by continuing your healthy diet and continuing to exercise.

Appendicitis

Appendicitis is an inflammation of the appendix, a finger-shaped pouch that projects from your colon on the lower right side of your abdomen. The appendix doesn’t seem to have a specific purpose.

Appendicitis causes pain in your lower right abdomen. However, in most people, pain begins around the navel and then moves. As inflammation worsens, appendicitis pain typically increases and eventually becomes severe.

Although anyone can develop appendicitis, most often it occurs in people between the ages of 10 and 30. Standard treatment is surgical removal of the appendix.

Signs and symptoms of appendicitis may include:

  • Sudden pain that begins on the right side of the lower abdomen
  • Sudden pain that begins around your navel and often shifts to your lower right abdomen
  • Pain that worsens if you cough, walk or make other jarring movements
  • Nausea and vomiting
  • Loss of appetite
  • Low-grade fever that may worsen as the illness progresses
  • Constipation or diarrhea
  • Abdominal bloating

The site of your pain may vary, depending on your age and the position of your appendix. When you’re pregnant, the pain may seem to come from your upper abdomen because your appendix is higher during pregnancy.

Appendicitis can cause serious complications, such as:

  • A ruptured appendix. A rupture spreads infection throughout your abdomen (peritonitis). Possibly life-threatening, this condition requires immediate surgery to remove the appendix and clean your abdominal cavity.
  • A pocket of pus that forms in the abdomen. If your appendix bursts, you may develop a pocket of infection (abscess). In most cases, a surgeon drains the abscess by placing a tube through your abdominal wall into the abscess. The tube is left in place for two weeks, and you’re given antibiotics to clear the infection.

Once the infection is clear, you’ll have surgery to remove the appendix. In some cases, the abscess is drained, and the appendix is removed immediately.
Appendicitis treatment usually involves surgery to remove the inflamed appendix. Before surgery you may be given a dose of antibiotics to prevent infection.

Surgery to remove the appendix (appendectomy)

Appendectomy can be performed as open surgery using one abdominal incision about 2 to 4 inches (5 to 10 centimeters) long (laparotomy). Alternatively the surgery can be done through a few small abdominal incisions (laparoscopic surgery). During a laparoscopic appendectomy, the surgeon inserts special surgical tools and a video camera into your abdomen to remove your appendix.

In general, laparoscopic surgery allows you to recover faster and heal with less pain and scarring. It may be better for people who are elderly or obese. However laparoscopic surgery isn’t appropriate for everyone. If your appendix has ruptured and infection has spread beyond the appendix or you have an abscess, you may need an open appendectomy, which allows your surgeon to clean the abdominal cavity.

Expect to spend one or two days in the hospital after your appendectomy.

Expect a few weeks of recovery from an appendectomy, or longer if your appendix burst. To help your body heal:

  • Avoid strenuous activity at first. If your appendectomy was done laparoscopically, limit your activity for three to five days. If you had an open appendectomy, limit your activity for 10 to 14 days. Always ask your doctor about limitations on your activity and when you can resume normal activities following surgery.
  • Support your abdomen when you cough. Place a pillow over your abdomen and apply pressure before you cough, laugh or move to help reduce pain.
  • Call your doctor if your pain medications aren’t helping. Being in pain puts extra stress on your body and slows the healing process. If you’re still in pain despite your pain medications, call your doctor.
  • Get up and move when you’re ready. Start slowly and increase your activity as you feel up to it. Start with short walks.
  • Sleep when tired. As your body heals, you may find you feel sleepier than usual. Take it easy and rest when you need to.
  • Discuss returning to work or school with your doctor. You can return to work when you feel up to it. Children may be able to return to school less than a week after surgery. They should wait two to four weeks to resume strenuous activity.

Splenectomy

Splenectomy is a surgical procedure to remove your spleen. The spleen is an organ that sits under your rib cage on the upper left side of your abdomen. It helps fight infection and filters unneeded material, such as old or damaged blood cells.

The most common reason for splenectomy is to treat a ruptured spleen, often caused by an abdominal injury. Splenectomy may be used to treat other conditions, including an enlarged spleen (splenomegaly), some blood disorders, certain cancers, infection, and noncancerous cysts or tumors.

Splenectomy is most commonly performed using a tiny video camera and special surgical tools (laparoscopic splenectomy). With this type of surgery, you may be able to leave the hospital the same day and recover fully in two weeks.

Splenectomy is used to treat a wide variety of diseases and conditions. Your doctor may recommend splenectomy if you have one of the following:

  • Ruptured spleen. If your spleen ruptures due to a severe abdominal injury or because of an enlarged spleen (splenomegaly), the result may be life-threatening, internal bleeding.
  • Enlarged spleen. A spleen may be removed to ease the symptoms of an enlarged spleen, which include pain and a feeling of fullness.
  • Blood disorder. Blood disorders that may be treated with splenectomy include idiopathic thrombocytopenic purpura, polycythemia vera, thalassemia and sickle cell anemia. But splenectomy is typically performed only after other treatments have failed to reduce the symptoms of these disorders.
  • Cancer. Cancers that may be treated with splenectomy include chronic lymphocytic leukemia, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma and hairy cell leukemia.
  • Infection. A severe infection or a large collection of pus surrounded by inflammation (abscess) in your spleen may require spleen removal if it doesn’t respond to other treatment.
  • Cyst or tumor. Noncancerous cysts or tumors inside the spleen may require splenectomy if they become large or are difficult to remove completely.

Your doctor may also remove the spleen to help diagnose a condition, especially if you have an enlarged spleen and he or she can’t determine why.

Risks

Splenectomy is generally a safe procedure. But as with any surgery, splenectomy carries the potential risk of complications, including:

  • Bleeding
  • Blood clots
  • Infection
  • Injury to nearby organs, including your stomach, pancreas and colon

Long term risk of infection

After spleen removal, you’re more likely to contract serious or life-threatening infections. Your doctor may recommend you receive vaccines against pneumonia, influenza, Haemophilus influenza type b (Hib) and meningococci. He or she may also recommend that you take preventive antibiotics, especially if you have other conditions that increase your risk of serious infections.

How to prepare

To prepare for splenectomy and if you have time before the surgery, you may need to:

  • Receive blood transfusions to ensure you have enough blood cells after your spleen is removed.
  • Receive a pneumococcal vaccine and possibly other vaccines to help prevent infection after your spleen is removed.
  • Temporarily stop taking certain medications and supplements.
  • Avoid eating or drinking for a certain amount of time.

Your doctor will give you specific instructions to help you prepare.

Draining an abscess before appendix surgery

If your appendix has burst and an abscess has formed around it, the abscess may be drained by placing a tube through your skin into the abscess. Appendectomy can be performed several weeks later after controlling the infection.

What you can expect

During splenectomy

Right before your surgery, you will be given a general anaesthetic. The anaesthesiologist or anaesthetist gives you an anaesthetic medication as a gas — to breathe through a mask — or injects a liquid medication into a vein. The surgical team monitors your heart rate, blood pressure and blood oxygen throughout the procedure. You will have a blood pressure cuff on your arm and heart-monitor leads attached to your chest.

After you’re unconscious, your surgeon begins the surgery using either a minimally invasive (laparoscopic) or open (traditional) procedure. The method used often depends on the size of the spleen. The larger the spleen, the more likely your surgeon will choose to do an open splenectomy.

  • Laparoscopic splenectomy. During laparoscopic splenectomy, the surgeon makes four small incisions in your abdomen. He or she then inserts a tube with a tiny video camera into your abdomen through one of the incisions. Your surgeon watches the video images on a monitor and removes the spleen with special surgical tools that are put in the other three incisions. Then he or she closes the incisions.

Laparoscopic splenectomy isn’t appropriate for everyone. A ruptured spleen usually requires open splenectomy. In some cases your surgeon may begin with a laparoscopic approach and find it necessary to make a larger incision because of scar tissue from previous operations or other complications.

  • Open splenectomy. During open splenectomy, your surgeon makes an incision in the middle of your abdomen and moves aside muscle and other tissue to reveal your spleen. He or she then removes the spleen and closes the incision.

After splenectomy

  • In the hospital. After surgery you’re moved to a recovery room. If you had laparoscopic surgery, you’ll likely go home the same day or the day after. If you have open surgery, you may be able to go home after two to six days.
  • After you go home. Talk to your doctor about how long to wait until resuming your daily activities. If you had laparoscopic surgery, it may be two weeks. After open surgery it may be six weeks.

Results

If you had splenectomy due to a ruptured spleen, further treatment usually isn’t necessary. If it was done to treat another disorder, additional treatment may be required.

Life without a spleen

After splenectomy other organs in your body take over most of the functions previously performed by your spleen. You can be active without a spleen, but you’re at increased risk of becoming sick or getting serious infections. This risk is highest shortly after surgery. People without a spleen may also have a harder time recovering from an illness or injury.

To reduce your risk of infection, your doctor may recommend vaccines against pneumonia, influenza, Haemophilus influenza type b (Hib) and meningococci. In some cases, he or she may also recommend preventive antibiotics, especially for children under 5 and those with other conditions that increase their risk of serious infections.

After splenectomy, notify your doctor at the first sign of an infection, such as:

  • A fever of 38 C or higher
  • Redness or tender spots anywhere on the body
  • A sore throat
  • Chills that cause you to shake or shiver
  • A cold that lasts longer than usual

Make sure anyone caring for you knows that you’ve had your spleen removed. Consider wearing a medical alert bracelet that indicates you don’t have a spleen.

Hemorrhoids

Hemorrhoids (HEM-uh-roids), also called piles, are swollen veins in your anus and lower rectum, similar to varicose veins. Hemorrhoids have a number of causes, although often the cause is unknown. They may result from straining during bowel movements or from the increased pressure on these veins during pregnancy. Hemorrhoids may be located inside the rectum (internal hemorrhoids), or they may develop under the skin around the anus (external hemorrhoids).

Hemorrhoids are very common. Nearly three out of four adults will have hemorrhoids from time to time. Sometimes they don’t cause symptoms but at other times they cause itching, discomfort and bleeding.

Occasionally, a clot may form in a hemorrhoid (thrombosed hemorrhoid). These are not dangerous but can be extremely painful and sometimes need to be lanced and drained.
Fortunately, many effective options are available to treat hemorrhoids. Many people can get relief from symptoms with home treatments and lifestyle changes.

Signs and symptoms of hemorrhoids may include:

  • Painless bleeding during bowel movements — you might notice small amounts of bright red blood on your toilet tissue or in the toilet
  • Itching or irritation in your anal region
  • Pain or discomfort
  • Swelling around your anus
  • A lump near your anus, which may be sensitive or painful (may be a thrombosed hemorrhoid)

Hemorrhoid symptoms usually depend on the location.

Internal hemorrhoids. These lie inside the rectum. You usually can’t see or feel these hemorrhoids, and they rarely cause discomfort. However, straining or irritation when passing stool can damage a hemorrhoid’s surface and cause it to bleed.

Occasionally, straining can push an internal hemorrhoid through the anal opening. This is known as a protruding or prolapsed hemorrhoid and can cause pain and irritation.

External hemorrhoids. These are under the skin around your anus. When irritated, external hemorrhoids can itch or bleed.

Thrombosed hemorrhoids. Sometimes blood may pool in an external hemorrhoid and form a clot (thrombus) that can result in severe pain, swelling, inflammation and a hard lump near your anus.

When to see a doctor
Bleeding during bowel movements is the most common sign of hemorrhoids. Your doctor can do a physical examination and perform other tests to confirm hemorrhoids and rule out more-serious conditions or diseases.

Also talk to your doctor if you know you have hemorrhoids and they cause pain, bleed frequently or excessively, or don’t improve with home remedies.

Don’t assume rectal bleeding is due to hemorrhoids, especially if you are over 40 years old. Rectal bleeding can occur with other diseases, including colorectal cancer and anal cancer. If you have bleeding along with a marked change in bowel habits or if your stools change in color or consistency, consult your doctor. These types of stools can signal more extensive bleeding elsewhere in your digestive tract.

Seek emergency care if you experience large amounts of rectal bleeding, lightheadedness, dizziness or faintness.

Causes
The veins around your anus tend to stretch under pressure and may bulge or swell. Swollen veins (hemorrhoids) can develop from increased pressure in the lower rectum due to:

  • Straining during bowel movements
  • Sitting for long periods of time on the toilet
  • Chronic diarrhea or constipation
  • Obesity
  • Pregnancy
  • Anal intercourse
  • Low-fiber diet

Hemorrhoids are more likely with aging because the tissues that support the veins in your rectum and anus can weaken and stretch.

Complications
Complications of hemorrhoids are very rare but include:

  • Anemia. Rarely, chronic blood loss from hemorrhoids may cause anemia, in which you don’t have enough healthy red blood cells to carry oxygen to your cells.
  • Strangulated hemorrhoid. If the blood supply to an internal hemorrhoid is cut off, the hemorrhoid may be “strangulated,” another cause of extreme pain.

Your doctor may be able to see if you have external hemorrhoids simply by looking. Tests and procedures to diagnose internal hemorrhoids may include examination of your anal canal and rectum.

  • Digital examination. During a digital rectal exam, your doctor inserts a gloved, lubricated finger into your rectum. He or she feels for anything unusual, such as growths. The exam can suggest to your doctor whether further testing is needed.
  • Visual inspection. Because internal hemorrhoids are often too soft to be felt during a rectal exam, your doctor may also examine the lower portion of your colon and rectum with an anoscope, proctoscope or sigmoidoscope.

Your doctor may want to examine your entire colon using colonoscopy if:

  • Your signs and symptoms suggest you might have another digestive system disease
  • You have risk factors for colorectal cancer
  • You’re middle-aged and haven’t had a recent colonoscopy

Home remedies

You can often relieve the mild pain, swelling and inflammation of hemorrhoids with home treatments. Often these are the only treatments needed.

  • Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can worsen symptoms from existing hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.
  • Use topical treatments. Apply an over-the-counter hemorrhoid cream or suppository containing hydrocortisone, or use pads containing witch hazel or a numbing agent.
  • Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water 10 to 15 minutes two to three times a day. A sitz bath fits over the toilet.
  • Keep the anal area clean. Bathe (preferably) or shower daily to cleanse the skin around your anus gently with warm water. Avoid alcohol-based or perfumed wipes. Gently pat the area dry or use a hair dryer.
  • Don’t use dry toilet paper. To help keep the anal area clean after a bowel movement, use moist towelettes or wet toilet paper that doesn’t contain perfume or alcohol.
  • Apply cold. Apply ice packs or cold compresses on your anus to relieve swelling.
  • Take oral pain relievers. You can use acetaminophen (Tylenol, others), aspirin or ibuprofen (Advil, Motrin IB, others) temporarily to help relieve your discomfort.

With these treatments, hemorrhoid symptoms often go away within a week. See your doctor if you don’t get relief in a week, or sooner if you have severe pain or bleeding.

Medications

If your hemorrhoids produce only mild discomfort, your doctor may suggest over-the-counter creams, ointments, suppositories or pads. These products contain ingredients, such as witch hazel, or hydrocortisone and lidocaine, that can relieve pain and itching, at least temporarily.

Don’t use an over-the-counter steroid cream for more than a week unless directed by your doctor because it may cause your skin to thin.

External hemorrhoid thrombectomy

If a painful blood clot (thrombosis) has formed within an external hemorrhoid, your doctor can remove the clot with a simple incision and drainage, which may provide prompt relief. This procedure is most effective if done within 72 hours of developing a clot.

Minimally invasive procedures
Rubber band ligation of hemorrhoid

For persistent bleeding or painful hemorrhoids, your doctor may recommend one of the other minimally invasive procedures available. These treatments can be done in your doctor’s office or other outpatient setting and do not usually require anesthesia.

  • Rubber band ligation. Your doctor places one or two tiny rubber bands around the base of an internal hemorrhoid to cut off its circulation. The hemorrhoid withers and falls off within a week. This procedure is effective for many people.

Hemorrhoid banding can be uncomfortable and may cause bleeding, which might begin two to four days after the procedure but is rarely severe. Occasionally, more-serious complications can occur.

  • Injection (sclerotherapy). In this procedure, your doctor injects a chemical solution into the hemorrhoid tissue to shrink it. While the injection causes little or no pain, it may be less effective than rubber band ligation.
  • Coagulation (infrared, laser or bipolar). Coagulation techniques use laser or infrared light or heat. They cause small, bleeding, internal hemorrhoids to harden and shrivel.

While coagulation has few side effects and may cause little immediate discomfort, it’s associated with a higher rate of hemorrhoids coming back (recurrence) than is the rubber band treatment.
Surgical procedures
If other procedures haven’t been successful or you have large hemorrhoids, your doctor may recommend a surgical procedure. Your surgery may be done as an outpatient or may require an overnight hospital stay.

  • Hemorrhoid removal. In this procedure, called hemorrhoidectomy, your surgeon removes excessive tissue that causes bleeding. Various techniques may be used. The surgery may be done with a local anesthetic combined with sedation, a spinal anesthetic or a general anesthetic.

Hemorrhoidectomy is the most effective and complete way to treat severe or recurring hemorrhoids. Complications may include temporary difficulty emptying your bladder and resulting urinary tract infections.

Most people experience some pain after the procedure. Medications can relieve your pain. Soaking in a warm bath also may help.

  • Hemorrhoid stapling. This procedure, called stapled hemorrhoidectomy or stapled hemorrhoidopexy, blocks blood flow to hemorrhoidal tissue. It is typically used only for internal hemorrhoids.

Stapling generally involves less pain than hemorrhoidectomy and allows for earlier return to regular activities. Compared with hemorrhoidectomy, however, stapling has been associated with a greater risk of recurrence and rectal prolapse, in which part of the rectum protrudes from the anus. Complications can also include bleeding, urinary retention and pain, as well as, rarely, a life-threatening blood infection (sepsis). Talk with your doctor about the best option for you.

  • Transanal hemorrhoidal dearterialization (THD) is an effective treatment for hemorrhoidal disease.

The ligation of hemorrhoidal arteries (called “dearterialization”) can provide a significant reduction of the arterial overflow to the hemorrhoidal piles. Plication of the redundant rectal mucosa/submucosa (called “mucopexy”) can provide a repositioning of prolapsing tissue to the anatomical site. In this paper, the surgical technique and perioperative patient management are illustrated. Following adequate clinical assessment, patients undergo THD under general or spinal anesthesia, in either the lithotomy or the prone position. In all patients, distal Doppler-guided dearterialization is performed, providing the selective ligation of hemorrhoidal arteries identified by Doppler. In patients with hemorrhoidal/muco-hemorrhoidal prolapse, the mucopexy is performed with a continuous suture including the redundant and prolapsing mucosa and submucosa. The description of the surgical procedure is complemented by an accompanying video (see supplementary material). In long-term follow-up, there is resolution of symptoms in the vast majority of patients. The most common complication is transient tenesmus, which sometimes can result in rectal discomfort or pain. Rectal bleeding occurs in a very limited number of patients. Neither fecal incontinence nor chronic pain should occur. Anorectal physiology parameters should be unaltered, and anal sphincters should not be injured by following this procedure. When accurately performed and for the correct indications, THD is a safe procedure and one of the most effective treatments for hemorrhoidal disease.

Lifestyle and home remedies.
You can often relieve the mild pain, swelling and inflammation of hemorrhoids with home treatments. Often these are the only treatments needed.

  • Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can worsen symptoms from existing hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.
  • Use topical treatments. Apply an over-the-counter hemorrhoid cream or suppository containing hydrocortisone, or use pads containing witch hazel or a numbing agent.
  • Soak regularly in a warm bath or sitz bath. Soak your anal area in plain warm water 10 to 15 minutes two to three times a day. A sitz bath fits over the toilet.
  • Keep the anal area clean. Bathe (preferably) or shower daily to cleanse the skin around your anus gently with warm water. Avoid alcohol-based or perfumed wipes. Gently pat the area dry or use a hair dryer.
  • Don’t use dry toilet paper. To help keep the anal area clean after a bowel movement, use moist towelettes or wet toilet paper that doesn’t contain perfume or alcohol.
  • Apply cold. Apply ice packs or cold compresses on your anus to relieve swelling.
  • Take oral pain relievers. You can use acetaminophen (Tylenol, others), aspirin or ibuprofen (Advil, Motrin IB, others) temporarily to help relieve your discomfort.

With these treatments, hemorrhoid symptoms often go away within a week. See your doctor if you don’t get relief in a week, or sooner if you have severe pain or bleeding.

Prevention
The best way to prevent hemorrhoids is to keep your stools soft, so they pass easily. To prevent hemorrhoids and reduce symptoms of hemorrhoids, follow these tips:

  • Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can cause hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.
  • Drink plenty of fluids. Drink six to eight glasses of water and other liquids (not alcohol) each day to help keep stools soft.
  • Consider fiber supplements. Most people don’t get enough of the recommended amount of fiber — 25 grams a day for women and 38 grams a day for men — in their diet. Studies have shown that over-the-counter fiber supplements, such as Metamucil and Citrucel, improve overall symptoms and bleeding from hemorrhoids. These products help keep stools soft and regular.

If you use fiber supplements, be sure to drink at least eight glasses of water or other fluids every day. Otherwise, the supplements can cause constipation or make constipation worse.

  • Don’t strain. Straining and holding your breath when trying to pass a stool creates greater pressure in the veins in the lower rectum.
  • Go as soon as you feel the urge. If you wait to pass a bowel movement and the urge goes away, your stool could become dry and be harder to pass.
  • Exercise. Stay active to help prevent constipation and to reduce pressure on veins, which can occur with long periods of standing or sitting. Exercise can also help you lose excess weight that may be contributing to your hemorrhoids.
  • Avoid long periods of sitting. Sitting too long, particularly on the toilet, can increase the pressure on the veins in the anus.

Colon cancer

Colon cancer is cancer of the large intestine (colon), the lower part of your digestive system. Rectal cancer is cancer of the last several inches of the colon. Together, they’re often referred to as colorectal cancers.

Most cases of colon cancer begin as small, noncancerous (benign) clumps of cells called adenomatous polyps. Over time some of these polyps become colon cancers.

Polyps may be small and produce few, if any, symptoms. For this reason, doctors recommend regular screening tests to help prevent colon cancer by identifying and removing polyps before they become colon cancer.

Symptoms
Signs and symptoms of colon cancer include:

  • A change in your bowel habits, including diarrhea or constipation or a change in the consistency of your stool, that lasts longer than four weeks
  • Rectal bleeding or blood in your stool
  • Persistent abdominal discomfort, such as cramps, gas or pain
  • A feeling that your bowel doesn’t empty completely
  • Weakness or fatigue
  • Unexplained weight loss

Many people with colon cancer experience no symptoms in the early stages of the disease. When symptoms appear, they’ll likely vary, depending on the cancer’s size and location in your large intestine.
When to see a doctor
If you notice any symptoms of colon cancer, such as blood in your stool or a persistent change in bowel habits, make an appointment with your doctor.

Talk to your doctor about when you should begin screening for colon cancer. Guidelines generally recommend that colon cancer screenings begin at age 50. Your doctor may recommend more frequent or earlier screening if you have other risk factors, such as a family history of the disease.

Colon cancer
In most cases, it’s not clear what causes colon cancer. Doctors know that colon cancer occurs when healthy cells in the colon develop errors in their DNA.

Healthy cells grow and divide in an orderly way to keep your body functioning normally. But when a cell’s DNA is damaged and becomes cancerous, cells continue to divide — even when new cells aren’t needed. As the cells accumulate, they form a tumor.

With time, the cancer cells can grow to invade and destroy normal tissue nearby. And cancerous cells can travel to other parts of the body.

Inherited gene mutations that increase the risk of colon cancer

Inherited gene mutations that increase the risk of colon cancer can be passed through families, but these inherited genes are linked to only a small percentage of colon cancers. Inherited gene mutations don’t make cancer inevitable, but they can increase an individual’s risk of cancer significantly.

The most common forms of inherited colon cancer syndromes are:

  • Hereditary nonpolyposis colorectal cancer (HNPCC). HNPCC, also called Lynch syndrome, increases the risk of colon cancer and other cancers. People with HNPCC tend to develop colon cancer before age 50.
  • Familial adenomatous polyposis (FAP). FAP is a rare disorder that causes you to develop thousands of polyps in the lining of your colon and rectum. People with untreated FAP have a greatly increased risk of developing colon cancer before age 40.

FAP, HNPCC and other, rarer inherited colon cancer syndromes can be detected through genetic testing. If you’re concerned about your family’s history of colon cancer, talk to your doctor about whether your family history suggests you have a risk of these conditions.

Association between diet and increased colon cancer risk
Studies of large groups of people have shown an association between a typical Western diet and an increased risk of colon cancer. A typical Western diet is high in fat and low in fiber.

When people move from areas where the typical diet is low in fat and high in fiber to areas where the typical Western diet is most common, the risk of colon cancer in these people increases significantly. It’s not clear why this occurs, but researchers are studying whether a high-fat, low-fiber diet affects the microbes that live in the colon or causes underlying inflammation that may contribute to cancer risk. This is an area of active investigation and research is ongoing.

Risk factors
Factors that may increase your risk of colon cancer include:

  • Older age. The great majority of people diagnosed with colon cancer are older than 50. Colon cancer can occur in younger people, but it occurs much less frequently.
  • African-American race. African-Americans have a greater risk of colon cancer than do people of other races.
  • A personal history of colorectal cancer or polyps. If you’ve already had colon cancer or adenomatous polyps, you have a greater risk of colon cancer in the future.
  • Inflammatory intestinal conditions. Chronic inflammatory diseases of the colon, such as ulcerative colitis and Crohn’s disease, can increase your risk of colon cancer.
  • Inherited syndromes that increase colon cancer risk. Genetic syndromes passed through generations of your family can increase your risk of colon cancer. These syndromes include familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer, which is also known as Lynch syndrome.
  • Family history of colon cancer. You’re more likely to develop colon cancer if you have a parent, sibling or child with the disease. If more than one family member has colon cancer or rectal cancer, your risk is even greater.
  • Low-fiber, high-fat diet. Colon cancer and rectal cancer may be associated with a diet low in fiber and high in fat and calories. Research in this area has had mixed results. Some studies have found an increased risk of colon cancer in people who eat diets high in red meat and processed meat.
  • A sedentary lifestyle. If you’re inactive, you’re more likely to develop colon cancer. Getting regular physical activity may reduce your risk of colon cancer.
  • Diabetes. People with diabetes and insulin resistance may have an increased risk of colon cancer.
  • Obesity. People who are obese have an increased risk of colon cancer and an increased risk of dying of colon cancer when compared with people considered normal weight.
  • Smoking. People who smoke may have an increased risk of colon cancer.
  • Alcohol. Heavy use of alcohol may increase your risk of colon cancer.
  • Radiation therapy for cancer. Radiation therapy directed at the abdomen to treat previous cancers may increase the risk of colon cancer.

Diagnosis
Screening for colon cancer
Doctors recommend certain screening tests for healthy people with no signs or symptoms in order to look for early signs of colon cancer. Finding colon cancer at its earliest stage provides the greatest chance for a cure. Screening has been shown to reduce your risk of dying of colon cancer.

People with an average risk of colon cancer can consider screening beginning at age 50. But people with an increased risk, such as those with a family history of colon cancer, should consider screening sooner. African-Americans and American Indians may consider beginning colon cancer screening at age 45.

Several screening options exist — each with its own benefits and drawbacks. Talk about your options with your doctor, and together you can decide which tests are appropriate for you.

Diagnosing colon cancer

Colonoscopy
If your signs and symptoms indicate that you could have colon cancer, your doctor may recommend one or more tests and procedures, including:

  • Using a scope to examine the inside of your colon. Colonoscopy uses a long, flexible and slender tube attached to a video camera and monitor to view your entire colon and rectum. If any suspicious areas are found, your doctor can pass surgical tools through the tube to take tissue samples (biopsies) for analysis.
  • Blood tests. No blood test can tell you if you have colon cancer. But your doctor may test your blood for clues about your overall health, such as kidney and liver function tests.

Your doctor may also test your blood for a chemical sometimes produced by colon cancers (carcinoembryonic antigen or CEA). Tracked over time, the level of CEA in your blood may help your doctor understand your prognosis and whether your cancer is responding to treatment.
Colon cancer stages
Once you’ve been diagnosed with colon cancer, your doctor will order tests to determine the extent (stage) of your cancer. Staging helps determine what treatments are most appropriate for you.
Staging tests may include imaging procedures such as abdominal and chest CT scans. In many cases, the stage of your cancer may not be determined until after colon cancer surgery.
The stages of colon cancer are:

  • Stage I. Your cancer has grown through the superficial lining (mucosa) of the colon or rectum but hasn’t spread beyond the colon wall or rectum.
  • Stage II. Your cancer has grown into or through the wall of the colon or rectum but hasn’t spread to nearby lymph nodes.
  • Stage III. Your cancer has invaded nearby lymph nodes but isn’t affecting other parts of your body yet.
  • Stage IV. Your cancer has spread to distant sites, such as other organs — for instance, to your liver or lung.

Treatment

The type of treatment your doctor recommends will depend largely on the stage of your cancer. The three primary treatment options are surgery, chemotherapy and radiation.
Surgery for early-stage colon cancer
If your colon cancer is very small, your doctor may recommend a minimally invasive approach to surgery, such as:

  • Removing polyps during colonoscopy. If your cancer is small, localized in a polyp and in a very early stage, your doctor may be able to remove it completely during a colonoscopy.
  • Endoscopic mucosal resection. Removing larger polyps may require also taking a small amount of the lining of the colon in a procedure called endoscopic mucosal resection.
  • Minimally invasive surgery. Polyps that can’t be removed during colonoscopy may be removed using laparoscopic surgery. In this procedure, your surgeon performs the operation through several small incisions in your abdominal wall, inserting instruments with attached cameras that display your colon on a video monitor. The surgeon may also take samples from lymph nodes in the area where the cancer is located.

Surgery for invasive colon cancer
If your colon cancer has grown into or through your colon, your surgeon may recommend:

  • Partial colectomy. During this procedure, the surgeon removes the part of your colon that contains the cancer, along with a margin of normal tissue on either side of the cancer. Your surgeon is often able to reconnect the healthy portions of your colon or rectum.
  • Surgery to create a way for waste to leave your body. When it’s not possible to reconnect the healthy portions of your colon or rectum, you may need to have a permanent or temporary colostomy. This involves creating an opening in the wall of your abdomen from a portion of the remaining bowel for the elimination of body waste into a special bag.
    Sometimes the colostomy is only temporary, allowing your colon or rectum time to heal after surgery. In some cases, however, the colostomy may be permanent.
  • Lymph node removal. Nearby lymph nodes are usually also removed during colon cancer surgery and tested for cancer.

Surgery for advanced cancer

If your cancer is very advanced or your overall health very poor, your surgeon may recommend an operation to relieve a blockage of your colon or other conditions in order to improve your symptoms. This surgery isn’t done to cure cancer, but instead to relieve signs and symptoms, such as bleeding and pain.

In specific cases where the cancer has spread only to the liver and if your overall health is otherwise good, your doctor may recommend surgery to remove the cancerous lesion from your liver. Chemotherapy may be used before or after this type of surgery. This treatment may improve your prognosis.
Chemotherapy

Chemotherapy uses drugs to destroy cancer cells. Chemotherapy for colon cancer is usually given after surgery if the cancer has spread to the lymph nodes. In this way, chemotherapy may help reduce the risk of cancer recurrence. Chemotherapy may be used before surgery to shrink the cancer before an operation. Chemotherapy can also be given to relieve symptoms of colon cancer that has spread to other areas of the body. In people with rectal cancer, chemotherapy is typically used along with radiation therapy. This combination is often used before and after surgery.

Radiation therapy

Radiation therapy uses powerful energy sources, such as X-rays, to kill cancer cells that might remain after surgery, to shrink large tumors before an operation so that they can be removed more easily, or to relieve symptoms of colon cancer and rectal cancer.

Radiation therapy is rarely used in early-stage colon cancer, but is a routine part of treating rectal cancer, especially if the cancer has penetrated through the wall of the rectum or traveled to nearby lymph nodes. Radiation therapy, usually combined with chemotherapy, may be used before surgery in order to make the operation easier and to reduce the chance that an ostomy will be necessary. It can also be used after surgery to reduce the risk that the cancer may recur in the area of the rectum where it began.

Targeted drug therapy

Drugs that target specific defects that allow cancer cells to grow are available to people with advanced colon cancer, including:

  • Bevacizumab (Avastin)
  • Cetuximab (Erbitux)
  • Panitumumab (Vectibix)
  • Ramucirumab (Cyramza)
  • Regorafenib (Stivarga)
  • Ziv-aflibercept (Zaltrap)

Targeted drugs can be given along with chemotherapy or alone. Targeted drugs are typically reserved for people with advanced colon cancer.

Some people are helped by targeted drugs, while others are not. Researchers are working to determine who is most likely to benefit from targeted drugs. Until then, doctors carefully weigh the limited benefit of targeted drugs against the risk of side effects and the expensive cost when deciding whether to use these treatments.
Supportive (palliative) care
Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care.

When palliative care is used along with all of the other appropriate treatments, people with cancer may feel better and live longer.

Palliative care is provided by a team of doctors, nurses and other specially trained professionals. Palliative care teams aim to improve the quality of life for people with cancer and their families. This form of care is offered alongside curative or other treatments you may be receiving.
Prevention

Get screened for colon cancer

People with an average risk of colon cancer can consider screening beginning at age 50. But people with an increased risk, such as those with a family history of colon cancer, should consider screening sooner.

Several screening options exist — each with its own benefits and drawbacks. Talk about your options with your doctor, and together you can decide which tests are appropriate for you.
Make lifestyle changes to reduce your risk

You can take steps to reduce your risk of colon cancer by making changes in your everyday life. Take steps to:

  • Eat a variety of fruits, vegetables and whole grains. Fruits, vegetables and whole grains contain vitamins, minerals, fiber and antioxidants, which may play a role in cancer prevention.
  • Choose a variety of fruits and vegetables so that you get an array of vitamins and nutrients.
  • Drink alcohol in moderation, if at all. If you choose to drink alcohol, limit the amount of alcohol you drink to no more than one drink a day for women and two for men.
  • Stop smoking. Talk to your doctor about ways to quit that may work for you.
  • Exercise most days of the week. Try to get at least 30 minutes of exercise on most days. If you’ve been inactive, start slowly and build up gradually to 30 minutes. Also, talk to your doctor before starting any exercise program.
  • Maintain a healthy weight. If you are at a healthy weight, work to maintain your weight by combining a healthy diet with daily exercise. If you need to lose weight, ask your doctor about healthy ways to achieve your goal. Aim to lose weight slowly by increasing the amount of exercise you get and reducing the number of calories you eat.

Colon cancer prevention for people with a high risk

Some medications have been found to reduce the risk of precancerous polyps or colon cancer. However, not enough evidence exists to recommend these medications to people who have an average risk of colon cancer. These options are generally reserved for people with a high risk of colon cancer.

For instance, some evidence links a reduced risk of polyps and colon cancer to regular use of aspirin. But it’s not clear what dose and what length of time would be needed to reduce the risk of colon cancer. Taking aspirin daily has some risks, including gastrointestinal bleeding and ulcers, so doctors typically don’t recommend this as a prevention strategy unless you have an increased risk of colon cancer.

Diverticulosis and diverticulitis

Diverticula are small, bulging pouches that can form in the lining of your digestive system. They are found most often in the lower part of the large intestine (colon). Diverticula are common, especially after age 40, and seldom cause problems.

Sometimes, however, one or more of the pouches become inflamed or infected. That condition is known as diverticulitis (die-vur-tik-yoo-LIE-tis). Diverticulitis can cause severe abdominal pain, fever, nausea and a marked change in your bowel habits.

Mild diverticulitis can be treated with rest, changes in your diet and antibiotics. Severe or recurring diverticulitis may require surgery.

The signs and symptoms of diverticulitis include:

  • Pain, which may be constant and persist for several days. Pain is usually felt in the lower left side of the abdomen, but may occur on the right, especially in people of Asian descent.
  • Nausea and vomiting.
  • Fever.
  • Abdominal tenderness.
  • Constipation or, less commonly, diarrhea.

Causes

  • Diverticula usually develop when naturally weak places in your colon give way under pressure. This causes marble-sized pouches to protrude through the colon wall.
  • Diverticulitis occurs when diverticula tear, resulting in inflammation or infection or both.

Several factors may increase your risk of developing diverticulitis:

  • Aging. The incidence of diverticulitis increases with age.
  • Obesity. Being seriously overweight increases your odds of developing diverticulitis. Morbid obesity may increase your risk of needing more-invasive treatments for diverticulitis.
  • Smoking. People who smoke cigarettes are more likely than nonsmokers to experience diverticulitis.
  • Lack of exercise. Vigorous exercise appears to lower your risk of diverticulitis.
  • Diet high in animal fat and low in fiber, although the role of low fiber alone isn’t clear.
  • Certain medications. Several drugs are associated with an increased risk of diverticulitis, including steroids, opiates and nonsteroidal anti-inflammatory drugs, such as ibuprofen and naproxen.

About 25 percent of people with acute diverticulitis develop complications, which may include:

  • An abscess, which occurs when pus collects in the pouch.
  • A blockage in your colon or small intestine caused by scarring.
  • An abnormal passageway (fistula) between sections of bowel or the bowel and bladder.
  • Peritonitis, which can occur if the infected or inflamed pouch ruptures, spilling intestinal contents into your abdominal cavity. Peritonitis is a medical emergency and requires immediate care.

Tests and diagnosis

Diverticulitis is usually diagnosed during an acute attack. Because abdominal pain can indicate a number of problems, your doctor will need to rule out other causes for your symptoms.

Your doctor will likely start with a physical examination, including checking your abdomen for tenderness. Women, in addition, generally have a pelvic examination to rule out pelvic disease.

After that, your doctor will likely recommend:

  • Blood and urine tests, to check for signs of infection.
  • Pregnancy test for women of childbearing age, to rule out pregnancy as a cause of abdominal pain.
  • Liver function tests, to rule out other causes of abdominal pain.
  • Stool test, to rule out infection in people who have diarrhea.
  • CT scan, which can indicate inflamed or infected pouches and confirm a diagnosis of diverticulitis. CT can also indicate the severity of diverticulitis and guide treatment.

Treatments and drugs

Treatment depends on the severity of your signs and symptoms.

Uncomplicated diverticulitis

If your symptoms are mild, you may be treated at home. Your doctor is likely to recommend:

  • Antibiotics, to treat infection.
  • A liquid diet for a few days while your bowel heals. Once your symptoms improve, you can gradually add solid food to your diet.
  • An over-the-counter pain reliever, such as acetaminophen (Tylenol, others).
  • This treatment is successful in 70 to 100 percent of people with uncomplicated diverticulitis.

Complicated diverticulitis

If you have a severe attack or have other health problems, you’ll likely need to be hospitalized. Treatment generally involves:

  • Intravenous antibiotics
  • Insertion of a tube to drain an abscess, if one has formed

Surgery

You’ll likely need surgery to treat diverticulitis if:

  • You have a complication, such as perforation, abscess, fistula or bowel obstruction
  • You have had multiple episodes of uncomplicated diverticulitis
  • You are immune compromised

There are two main types of surgery:

  • Primary bowel resection. The surgeon removes diseased segments of your intestine and then reconnects the healthy segments (anastomosis). This allows you to have normal bowel movements. Depending on the amount of inflammation, you may have open surgery or a minimally invasive (laparoscopic) procedure.
  • Bowel resection with colostomy. If you have so much inflammation that it’s not possible to rejoin your colon and rectum, the surgeon will perform a colostomy. An opening (stoma) in your abdominal wall is connected to the healthy part of your colon. Waste passes through the opening into a bag. Once the inflammation has eased, the colostomy may be reversed and the bowel reconnected.

Follow-up care

Your doctor may recommend colonoscopy six weeks after you recover from diverticulitis, especially if you haven’t had the test in the previous year. There doesn’t appear to be a direct link between diverticular disease and colon or rectal cancer. But colonoscopy — which isn’t possible during a diverticulitis attack — can exclude colon cancer as a cause of your symptoms.

Sometimes, surgery is recommended. But previous recommendations for surgery based on the number of attacks have been questioned, since most people do well even after two or more attacks. The decision on surgery is an individual one, and is often based on the frequency of attacks and whether complications have occurred.

To help prevent diverticulitis:

  • Exercise regularly. Exercise promotes normal bowel function and reduces pressure inside your colon. Try to exercise at least 30 minutes on most days.
  • Eat more fiber. High-fiber foods, such as fresh fruits and vegetables and whole grains, soften waste material and help it pass more quickly through your colon. This reduces pressure inside your digestive tract. However, it isn’t clear whether a high-fiber diet decreases the risk of diverticulitis. Eating seeds and nuts isn’t associated with developing diverticulitis.
  • Drink plenty of fluids. Fiber works by absorbing water and increasing the soft, bulky waste in your colon. But if you don’t drink enough liquid to replace what’s absorbed, fiber can be constipating.

As with all surgery procedures, it is important not to rush into any decision, and to discuss with your surgeon comprehensively beforehand, so you are aware of the risks involved and any concerns you may have.

Disclaimer

Please be aware the material published on the website of Bulgaria Medical Travel Partner is only for informative purposes and in no way should be considered exhaustive. Any medical narrations are to be considered as a guide only, and not to be regarded as advise specific to any particular case. It does not substitute the need for thorough consultation with a suitably qualified medical professional. Bulgaria Medical Travel Partner does not accept any liability for any decision taken by the reader in respect of the treatment they decide to undertake.

Price guide

 Operation DurationHospital StayInitial consultation feeeDiagnostic investigationsMain treatment Package PriceEstimated Total
Laparoscopic surgery for GERD diaphragmatic/hiatal hernias, achalasia1-3 hours3-4 day€ 150€ 450€ 4100€ 4700
Laparoscopic abdominal wall hernia operations (ventral, recurrent, incisional)1-3 hours4-8 days€ 150€ 450€ 4100€ 4700
Laparoscopic groin hernia repair1 hour1-2 days€ 150€ 350€1700 uni €1900 bilat€2200 uni €2400 bilat
Laparoscopic umbilical hernia repair1 hour1-2 days€ 150€ 350€ 2000€ 2500
Laparoscopic surgery for gallbladder and bile duct diseases including CBD obstruction1-2 hours1-5 days€ 150€ 450€ 1900€ 2500
Laparoscopic surgery for acute and chronic appendicitis1 hour1-2 days€ 150€ 350€ 1500€ 2000
Laparoscopic esophagus and stomach operations2-6 hours8-12 days€ 150€ 650€ 8700€ 9500
Laparoscopic surgery for intestinal diseases2-5 hours6-10 days€ 150€ 650€ 6000€ 6800
Laparoscopic surgery for liver diseases including liver cysts, echinococcus cysts3-5 hours6-10 days€ 150€ 450€ 4600€ 5200
Laparoscopic surgery for spleen diseases2-3 hours3-8 days€ 150€ 450€ 4100€ 4700
Laparoscopic surgery for adhesion disease1-3 hours3-8 days€ 150€ 350€ 3700€ 4200
Proctology contemporary diagnosis and treatment of anal and rectal diseases0.5-1 hour3-5 days€ 150€ 350€ 3000€ 3500
Diagnostic laparoscopy1-2 hours1-2 days€ 150€ 350€ 1500€ 2000