Information

Everyone’s time is valuable. We make every effort to provide the highest quality care and to minimize your waiting time. In the event a delay or unforeseen emergency arises, you will be notified by the staff and be given the opportunity to reschedule. It is our policy never to rush a patient nor to compromise care. Please be patient as you will receive the same consideration when you are seen by our physicians. Quality care knows no time frame.

Most patients have insurance that covers a portion of the fees charged for surgery, colonoscopy and office visits. Insurance has become increasingly complicated and if you have any questions concerning your coverage, please discuss this with your insurance company prior to surgery.

Our office has always respected the confidentiality of our patients’ personal health information. The federal government has also passed patient privacy regulations under the Health Insurance Portability and Accountability act (HIPAA). These regulations were implemented 2003. Our office will provide you with a copy of our privacy policy which includes your rights regarding your health information.

Dr. Campbell, Dr. Galzarian, Dr. Clark, Dr. Spindler and Dr. Mitchell are fully trained in general surgery as well as colon and rectal surgery. This practice includes evaluation and treatment of colon and rectal diseases and endoscopy of the large intestine (colonoscopy).

One of the doctors will be your primary surgeon. However, if he is unavailable (vacation, after hours, in surgery, etc.) one of the other doctors will be available to see you. The doctors work at Huntsville Hospital, Crestwood Medical Center and Surgery Center of Huntsville. A doctor can be reached by calling 256–533–6070. The phone is answered 24 hours a day.

Patients are seen by appointment. You must obtain an appointment by referral from your family doctor or another doctor.

In some cases, the office may recommend another type of specialist such as a gastroenterologist.

Appointments will be scheduled according to the severity of the problem.

Urgent problems can be seen on the day of the call or the following day. An attempt is made to see new patients within 10 working days. Follow – up appointments are seen at the appropriate time. For long term follow ups, the patients name and address are entered in the computer and a card to send in the month of the follow up appointment. If you have an urgent problem, please call the office as early during the day as possible so that the appropriate management can be made if you cannot keep your appointment, please notify the office as possible.

Office hours are 8:30 a.m. to 4:30 p.m. Monday through Thursday and 8:30 a.m. to 4:00 p.m. on Friday. From noon until 1 a.m. and after 4 p.m. the office uses a digital answering service.  Please listen carefully to the prompts.  Phone calls that are not urgent in nature should not be made after hours.  If your call is Urgent and you do not hear from the doctor within 30 minutes, please call again and be sure you used the Urgent prompt.

For the most part, prescriptions are not refilled after office hours. Therefore, if you need a prescription refilled, please call during the morning hours so that your chart can be reviewed and your surgeon can be contacted.

If you need directions to the office, please call between the hours of 8:30 a.m. and 4 p.m.. The office or one of the doctors will notify you of pathology reports and pertinent laboratory and x-ray results. If you are not contacted within 10 days, especially about a Pathology report, please call the office.

In case of emergency, call the office or go directly to Huntsville Hospital Main and have the emergency room contact the doctor on call.

The office will file your insurance, either electronically or by mail. The surgeons participate in most major insurance plans. Usually the plan pays a percentage of the allowable charges and the office will collect an estimated charge prior to surgery. If you cannot pay the balance at that time, please contact the office manager.

If you have any questions about surgical fees, please ask about them at the time of your office visit or at the time surgery is scheduled.

In addition to our bill for physician services, you may possibly receive statements from the facility where services are rendered, and anesthesiologist, pathologist, a radiologist and any other specialist consulted.

Diverticulosis refers to the formation of diverticula or “pockets” in the colon wall. Diverticula are herniations of the lining of the colon through an area weakened by the penetration of a blood vessel. Diverticula may occur anywhere in the colon but are most commonly found in the lower portion of the left colon in an area called the sigmoid colon. The incidence of diverticulosis increases with age. It affects fifty percent (50%) of Americans by age 55 and almost all by age 80.

Diverticulosis is usually asymptomatic. However, it can cause massive gastrointestinal bleeding. Fortunately, this is an unusual consequence of diverticulosis.

Diverticulitis refers to infection associated with diverticulosis. Diverticulitis causes pain in the left lower abdomen, tenderness on examination of the area, fever, and an elevation of the white blood cell count.

Diverticulosis, the mere presence of diverticula, may be diagnosed by sigmoidoscopy, colonoscopy, or barium enema. It is theorized that the development of diverticula may be encouraged by a diet low in fiber. Therefore, treatment includes the use of a fiber supplement (psyllium, bran, and/or foods high in fiber) and the avoidance of popcorn, peanuts, and seed containing foods.

Diverticulitis is a clinical diagnosis. Sometimes x-rays such as a CT scan or a water soluble enema (dye study) are helpful. Diverticulosis can be confused with other colon problems, especially irritable bowel syndrome which is also very common in the United States. Diverticulitis, being an infection, requires treatment with antibiotics; irritable bowel syndrome is usually due to stress. Following resolution of diverticulitis, the large intestine should be studied by either sigmoidoscopy and barium enema or colonoscopy.

Surgery is required when complications of diverticulitis occur. These include perforation of the colon, intra-abdominal abscess, or stricture formation with obstruction of the colon. Another complication of diverticulitis requiring surgery is the development of fistulas to other organs, especially the bladder (colovesical fistula) or the vagina (colovaginal fistula).

Surgery is also required for repeat attacks of diverticulitis that resolve with antibiotic therapy. This is necessary to prevent the development of the complications described above. The development of a complication is associated with urgent surgery, the possibility of a temporary colostomy, and a higher complication and mortality rate.

Finally, surgery may be required in diverticulosis when massive bleeding or recurrent bleeding requiring transfusion occurs.

An anal fissure is a linear crack or tear of the lining of the anal canal. With time, this tear may become a chronic ulcer. The most common cause of an anal fissure is the passage of a hard stool or constipation. Other causes include chronic diarrhea, hypertrophy of the anal sphincter muscle, and infection. Anal stenosis (narrowing) may follow the removal of excessive amounts of tissue during anorectal surgery, especially hemorrhoidectomy. Anal stenosis may lead to the development of a fissure.

An anal fissure may be diagnosed by history alone, severe pain at the time of a bowel movement. The fissure can be visualized by gentle examination of the patient. “Scopes” are not usually required. The primary treatment of an anal fissure is the avoidance of constipation with the use of fiber (psyllium, bran, diet). Warm soaks, a cleaning agent such as Balneol, and topical ointments may be useful. Nitroglycerin ointment has been used experimentally. When fissures do not heal (about 50%), surgery is required. Surgery may be performed in the office or in an outpatient surgery facility. Several surgical procedures are available, but the most common procedure in the United States involves incision of a portion of the internal anal sphincter. Lateral internal sphincterotomy (the most common operation) when properly applied, results in a cure in almost all cases and has few complications.

Ninety-five percent of anal ulcers conform to the above description. Less than 5% of ulcers are due to other causes such as Crohn’s disease, tuberculosis, HIV infection, anal cancer and other causes.

An anorectal (perirectal) abscess and an anorectal fistula have a common origin. The abscess is an acute problem and the fistula is a subsequent chronic problem. A fistula is an abnormal communication between the anal canal and the perianal skin.

In 90% of cases of perirectal abscess, the source of the abscess is an infection occurring in glands which empty into the anal canal. Usually, no specific cause of this infection can be found and it is termed a cryptoglandular Infection. A cryptoglandular infection may occasionally be seen in association with a diarrheal illness, anal fissure, tuberculosis, Crohn’s disease, and AIDS.

Non-cryptoglandular infection (less than 10%) occurs secondary to trauma, a foreign body or cancer of the rectum. Rarely an intraabdominal source of infection may result in a perirectal abscess.

A patient with a perirectal abscess presents to the surgeon with persistent rectal pain (unlike anal fissure in which the pain occurs following defecation), perirectal swelling, possible fever and drainage if the abscess has ruptured. An abscess may be diagnosed by inspection of the tissue around the rectum or by digital palpation. Occasionally endoscopic examination is required if not too painful. In a small number of patients with severe pain, examination under anesthesia is required for diagnosis. Treatment is rendered at that time.

The treatment of a perirectal abscess is adequate surgical drainage. There is no role for antibiotics as primary treatment; they may be used in conjunction with surgical drainage in some cases. Small abscesses can be drained in the office with the use of local anesthestics. At least one-half of abscesses require drainage under anesthesia, either general anesthesia or spinal anesthesia.

Following rupture of an abscess or following surgical drainage, a fistula may (but not necessarily) develop. Signs of a fistula include persistent drainage and recurrent abscess formation. The presence of a symptomatic fistula is an indication for surgery. Fistulas rarely heal and are associated with recurrent abscesses. Rarely, a long standing fistula may be the site of development of a cancer. Surgical treatment of a fistula usually means complete incision of the fistula (fistulotomy).

The goal of treatment of a fistula is complete eradication of the fistula and maintenance of fecal continence. Fistulas can be simple problems with the diagnosis obvious and treatment straight forward. In a small percentage of cases, the fistula may be difficult to identify and eradicate. Multiple operations may thus follow.

If at the time of drainage of a perirectal abscess a fistula is identified, surgical treatment of the fistula may be carried out. If a definite fistula cannot be identified, the best treatment may be simply to drain the abscess and caution the patient that he may need further surgery should a fistula develop.

A fistula usually involves some portion of the anal sphincter muscle and correction of the fistula requires division of a portion of the muscle. The most significant complication of surgery for a fistula is fecal incontinence. If this occurs, the sphincter muscle can be subsequently repaired.

The treatment for a fistula associated with other conditions is treatment of the primary condition.

Some infections and abscesses may occur near the rectum, but do not originate in the rectum. A Bartholin’s abscess originates in the vagina. Infections may involve the perianal skin or its appendages. These include infected pilonidal cysts, hidradenitis originating in sweat glands, and infected sebaceous cysts.

Infection of the perirectal tissues may also originate from infections of the urinary system. The treatment of these infections is treatment of the underlying source.

Gordon, P.H. Anorectal Abscess and Fistula-in-ano. In Gordon, P.H. and Nivatvongs, S. Principles and Practice of Surgery for the Colon, Rectum, and Anus. St. Louis: Quality Medical Publishing, Inc., 1992, pp. 221-265.

Pruritus ani refers to a sensation of discomfort in the perianal area.  It may be perceived as itching or as burning. Men are more often affected than women by a ratio of 4 to 1.  The majority of cases are idiopathic – there is no apparent cause.  The remainder may be due to local anorectal abnormalities (prolapsing hemorrhoid, anal fistula, etc.) or systemic diseases such as diabetes mellitus.  Symptoms are frequently worse at night.  Poor anal hygiene may cause pruritus ani or may make it worse.  Stress and anxiety may exacerbate pruritus ani.

Anorectal examination should be carried out to identify any obvious cause.  The patient should be asked about any other skin condition or skin rash.  In early cases of idiopathic pruritus ani, the skin may appear erythematous and excoriated.  Ulcerations may be present with “weeping”.  In later stages the skin may appear pale and lichenified (thickened with exaggeration of radiating perianal folds).   Ulceration may also occur.  In women, pelvic examination should be done.  A vaginal infection or discharge may be responsible for symptoms of pruritus.

Anal manometry – measurement of the anal sphincter pressures – in patients with idiopathic pruritus ani has shown transient decreases in the internal anal sphincter pressure.  This suggests that fecal leakage may be causative. Coffee consumption has been shown to decrease the internal anal sphincter pressure.

TREATMENT  The perianal skin should be cleaned several times per day and especially following bowel movements. Balneol is a cleansing agent that is frequently recommended. Medicated soaps should be avoided. The skin should be dried with the use of a hair dryer. Hydrocortisone, 2.5%, may be applied and act as a skin barrier as well as decrease inflammation. (Prolonged use of steroid creams may cause atrophy of the skin with symptoms similar to pruritus ani and should be avoided.)  A cotton pad may be tucked into the area and changed frequently, thus keeping the skin dry.

With improvement the steroid cream should be replaced with cornstarch or talc to keep the skin dry.

If symptoms are worse after a bowel movement or if there is identifiable fecal leakage on the perianal skin, a small tap water enema following a bowel movement may be helpful.

Dietary substances may be causative in pruritus ani and the following should be deleted from the diet for two weeks – coffee (both regular and decaffeinated), tea, colas, alcohol (especially beer), chocolate, nuts, citrus fruit, dairy products (milk, cheese, ice cream), and tomatoes.   If improvement is noted, these items are returned to the diet one at a time.

An antihistamine (Benadryl, 25mg, four times daily) may be helpful.  Estrogen has been useful in postmenopausal women.  Cultures of the perianal area may diagnose secondary bacterial infections or yeast infections.  These can be treated with topical antibiotics or fungicides.  The treatment of the possible anorectal lesion causing pruritus is treatment of the lesion – rubber band ligation of a prolapsing hemorrhoid for example.

Patient’s taking antibiotics may develop pruritus – possibly because of an allergic reaction or due to a change in the bacterial flora of the bowel or vagina.  Severe jaundice, diabetes – due to its association with candida infections – and radiation injury to the perianal skin may be associated with symptoms of pruritus.

Patients may require dermatological consultation, when skin rashes or other skin problems are present and in refractory cases.

Gordon PH, Nivatvongs S. Principles and Practices of Surgery for the Colon, Rectum, and Anus, Second Edition.  St Louis:  Quality Medical Publishing, 1999.