Expert Q&A

A: The ileocecal valve is an anatomic landmark that connects the ileum (small intestine) and colon (large intestine). Unfortunately, many questions concerning its function and structure remain unanswered. We do know that the intestinal contents pass from the ileum and into colon through this valve, and the passage is controlled by chemicals in the blood stream and nerves supplying the intestine. Furthermore, the valve may help maintain a difference in the bacteria found in the colon compared to the ileum. Most patients who have their ileocecal valve removed do not experience any long-term change in their bowel habits. The frequent or loose stools (diarrhea) that do occur in others can result from multiple causes that must be sorted to determine the best treatment. If a large amount of the ileum has been removed with the ileocecal valve, the body is unable to manage fat in the diet, and the resultant diarrhea (steatorrhea) tends to be associated with oily stools that may float and are particularly foul-smelling. In this instance, a medication (cholestyramine) taken at mealtime can improve the diarrhea. In other patients, the diarrhea occurs because of colon bacteria now residing in the ileum (small intestine bacterial overgrowth). This overgrowth can also cause bloating and pain, and is usually managed with antibiotics taken for 1-2 weeks, but repeated courses may be required. Lastly, the diarrhea can result from the intestinal contents passing too quickly along the length of the bowel. Anti-diarrheal agents (diphenoxylate plus atropine, loperamide) can slow this passage to decrease the frequency of the stool. Moreover, over-the-counter fiber products may help increase the stool’s consistency. hide answer

A: Irritation of the skin around the anal area (perineum) caused by frequent stools (diarrhea) or poor control (incontinence) is caused by many factors working together. Frequent cleansing causes damage from abrasions and alters the skin’s protective acid content (pH). Excessive moisture further alters the skin’s pH, which increases its porousness (permeability). In addition to the local inflammation caused by cleansing and moisture, infection may develop as germs contained in the stool can penetrate the traumatized and porous skin. Management of the perineal skin damage requires local measures as well as identification and treatment of the underlying cause. Perineal skin cleansing should be performed after each stool or incontinent episode. Specific cleansers are available in many forms (emulsion, foam, liquid, towelette). Bar soaps, skin cleansing agents, and antibacterial hand-washing products can worsen the problem. The affected skin needs to be moisturized to reinstate the depleted factors. Humectants (glycerin, lanolin, methyl glucose esters, mineral oil) contained in perineal cleansers replace the skin’s natural oils. No-rinse perineal cleansers with humectants minimize drying because they remain on the skin rather than being rinsed away. Moisture barriers (protectants) contain active ingredients (dimethicone, lanolin, petroleum jelly, zinc oxide) to shield the skin from exposure to irritants and moisture. A moisture barrier may be incorporated into skin cleansers or separately applied as a cream, ointment, or paste. Ointments and pastes are longer lasting and more occlusive. Liquid barrier films or skin sealants combine a solvent that evaporates and a polymer that dries to form a barrier when applied. Some solvents may irritate the damaged skin, and any product should be accordingly used only if not associated with stinging during application. A liquid film barrier should not be combined with a moisture barrier because these agents are typically incompatib hide answer

A: A rectovaginal fistula is a communication between the rectum and the vagina. Most are due to obstetric injuries. Other causes include irradiation, malignancy, congenital malformations, and inflammatory bowel disease. Rectovaginal fistulas are uncommon complications of chronic ulcerative colitis, and are more often associated with Crohn’s Disease. Many are asymptomatic and found incidentally. If the fistula is symptomatic, methods of treatment such as excision and primary layered repair, fistula plug placement, endorectal mucosal advancement flap can be performed. Success rates range from 50-95%. Rectovaginal fistulas associated with Inflammatory Bowel Disease have lower success rates. Having UC for 30+ years places a person at risk for the development of dysplasia and malignancy. Surveillance colonoscopies are done annually to identify these changes. If high grade dysplasia or malignancy is found, a total procto-colectomy with either end ileostomy or construction of an ileal pouch-anal anastomosis is performed. These procedures are also done for medically refractory cases of ulcerative colitis. Removal of the entire colon and rectum with creation of an end ileostomy is usually performed if the patient has poor anal sphincter function and incontinence is an issue. The total procto-colectomy with ileal pouch-anal anastomosis or “J-pouch” procedure restores near-normal bowel function by creating a neorectum from the terminal ileum. A mucosectomy (stripping the mucosa of the anal canal to the dentate line) with a hand-sewn pouch-anal anastomosis can be performed. Mucosectomy is often associated with injury to the anal sphincters, and impaired fecal continence may be a problem post-operatively. A diverting loop ileostomy is usually performed to allow the anastomosis to heal, and the ileostomy reversed 8-12 weeks later. The operation can be done via an open or a laparoscopic approach. A pouch procedure may be an option for you. hide answer

A: Any of the intestine affected by Crohn’s disease is at risk for developing Crohn’s disease, and out-of-circuit diseased rectum develops cancer in approximately 10% of cases after 15 years of follow-up. And, the longer the rectum remains in place, the greater is the risk for cancer. Accordingly, it is recommended that the unused rectum is inspected and biopsied every year to detect any precancerous or cancerous changes. If these changes are noted, the rectum must be removed. If the rectum can no longer be endoscopically evaluated because of a narrowing, or stricture, its removal is usually advised if adequate surveillance has not been performed for more than 5 years. hide answer

A: Intra-abdominal adhesions are commonly seen in anyone who has undergone prior abdominal surgery. These adhesions begin to develop within 7-10 days of surgery and continue to increase for a period of time. The body then starts to dissolve these adhesions until they no longer disappear, and this usually occurs 6-12 months after surgery. Any adhesions that remain after that time interval are likely permanent. hide answer