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Addendum: Life After Coloanal or Colorectal Anastomosis Surgery

The adjustment period following the closure of the temporary ileostomy can be a frustrating time. This phase will pass—usually within three months—and you will be able to enjoy what matters to you most: family life, work, and play.

Typically, during the adjustment period, you will experience irregularity and diarrhea. In this guide, we will discuss these problems and what steps you can take to help the recovery process.

First, it is important to understand why your bowels are not functioning properly.

The rectum, which is about the size of a melon, works as one single coordinated muscle to empty bowel contents. During your surgery, part of your rectum or the entire rectum was surgically removed, and the upstream colon was brought down and sewn to the lowermost portion of the rectum or to the anal muscle. As a result, the colon must now take over the function of your rectum. However, the colon normally has more of a mixing function than a pushing function—it sloshes bowel contents back and forth—and does not empty bowel contents as well as the rectum.

The goal of the adjustment period is to train the colon to take over the pushing function of the rectum, and to empty more completely and regularly.

Remember: Everyone is different. The adjustment period can be as brief as one or two months, but for most it is about three months.

Note: Chemotherapy causes a significant amount of diarrhea, so if you are taking chemotherapy, your adjustment period will take longer. Indeed it will likely begin after you have completed chemotherapy.

Keep a Diary
Your surgeon or gastroenterologist will be better able to regulate your bowel function if you keep a diary of how many times you move your bowels during the day and at night. It is also important to record if you are having accidents or problems controlling your bowel movements.

Be sure to document what kind of antidiarrheal medications you are taking—i.e., loperamide (Imodium®) or diphenoxylate and atropine (Lomotil®).

How to Improve Bowel Function
By working together with your doctor, you can help regulate your bowel function. Your physician may recommend any of the following, depending on your individual case.

  • Slow It Down
    If you experience diarrhea, your doctor may prescribe one of two common medications.

    Lopermide (Imodium®) is available over-the-counter without a prescription at most pharmacies and grocery stores. Your physician will tell you how many tablets to take. Usually you will start out with one 2 mg tablet daily, which your doctor may gradually increase, according to your response to the medicine. Lopermide works best if taken 15-20 minutes before a meal.

    Diphenoxylate and atropine (Lomotil®) is a prescription medication that is also effective for treating diarrhea. Typically, one lopermide tablet is equivalent to one diphenoxylate and atropine tablet; however, in some people, one medication may work better than the other. This medication also works best if you take it 15-20 minutes before a meal.

    Note: Frequently, people who have had radiation, for example, to treat a rectal cancer, will need the addition of an antidiarrheal. This is because the radiation may have caused a slight burn injury to the small bowel resulting in more frequent stools.
  • Add Fiber
    Most people have small hard bowel movements after total removal or resection of the rectum. The use of fiber products add bulk to your stool to make it easier for the colon to eliminate. Although capsule or tablet fiber products may be easier to take, they may not work as well as powder formulations. While most of these formulations work well, products such as psyllium (Metamucil®) tend to cause more gas than the ones that contain methylcellulose, (i.e, Benefiber®, Citrucel®).

    Note: Fiber products tend to work differently depending on how much water and other liquids you drink during the day. Too much liquid can increase the number of bowel movements, while less fluid will "chunk up" the stool making it difficult to eliminate. The goal is to have less frequent, fluffier, more consistent stools that are easier to pass. You will have to experiment with the amount of water or other fluids you take with the fiber to achieve this. If psyllium works well for you, it does come in the form of a “cookie” that allows you to take it with very little fluid and has the beneficial effect of increasing the bulk of bowel movements.
  • Enema Therapy
    If fiber products and antidiarrheals alone do not help adjust the ability of the colon to empty, small volume generic saline enemas (Fleet®) will help the colon empty more effectively. You may take these either every day or every other day. Importantly, you take these even if you move your bowels. This is because without the enemas, only a small percent of the bowel’s contents empty and stool backs up. In a few days, you would have severe diarrhea as the bowel empties out uncontrollably. Taking the enemas regularly prevents this problem from occurring.

    In many circumstances, enema therapy may be necessary in order to permit you to empty your colon completely and have the remainder of the day free from any bowel activity.

    Usually, enema use is only temporary. However, some individuals may have better results if they continue using enemas on a long-term basis.
  • Change the Consistency
    Sometimes it may be necessary to try a drug that changes the consistency of stool to make it more liquid to facilitate emptying, such as lubiprostone (Amitiza®). This is a prescription medication for constipation, which, in some people who have emptying problems, when taken in a low dose (8 micrograms) at bedtime will help the colon empty more effectively.
  • Get It Moving
    Rarely, it may be worthwhile to consider a "prokinetic" drug that helps the colon empty. Currently, the only way to obtain this medication is to apply to the Food & Drug Administration (FDA) for special permission to use tegaserod (Zelnorm®). This is extremely difficult to obtain. Still, tegaserod is very useful in patients with emptying problems that have not responded to conventional therapies.

Remember: Your recovery will take time and perseverance. Working in partnership with your physician will help ensure you have the best outcome possible. If you have any questions, your healthcare team is just a phone call away.

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