Anterior resection syndrome- leaflet no 2

After your Anterior Resection
Your bowel before your operation
The large bowel or colon is the last part of your intestines. When you eat, the food passes down your oesophagus (gullet), into your stomach and then into your intestines. The first part (small bowel) is where the nutrients are absorbed and by the time it reaches your large bowel all the goodness has been taken into your blood stream. The waste that enters the large bowel is a thick liquid. Its journey through the large bowel can take a couple of days and, in this time, the water is reabsorbed and the result is a formed stool. The end of the large bowel is the rectum and this is the storage part for the motion. When it is full a message is sent to the brain which tells you to go to the toilet and empty your bowels. How has the operation changed your bowel function?
The operation involved removing most or part of the rectum, i.e. the storage part. This means that the capacity to hold motion is smaller and may result in you having to make more frequent visits to the toilet. This will result in a reduced area for water to be reabsorbed back into the body and so the motion will contain more water and be looser. For some patients the symptoms before your operation may have been looser bowel movements and a change in frequency. Do not be alarmed if this seems to be the same because the cause is different. What will your bowel pattern be like after the surgery or when your stoma
has been reversed?

Different bowel patterns are experienced. You may encounter any of the following problems: • Frequency of stool • Urgency of stool • Diarrhoea • Fragmentation of stool (this is when you need to visit the toilet frequently and can pass only small amounts of stool) It is a very individual thing and therefore is difficult to predict what your bowel pattern will be like. Similarly, the remedies will differ and what suits one person might not suit the next. The bowel pattern usually settles quickly (in a matter of months) but it can take up to 2 years before you will learn what is normal for you. This booklet has been written based upon suggestions that previous patients have found helpful. The idea is that you try them and see what works for you. Initially we recommend that you eat foods that are low in fibre. Fibre is a waste product, derived from food that cannot be digested and used by the body. Foods that are high in fibre are fruit, vegetables and some cereals. Different foods have different effects on the bowel. Fibre that is found in cereals such as 'All bran' or brown bread will make the stool softer. Fibre found in vegetables and fruit help to stimulate the bowel and therefore make the bowel work more frequently. Your bowel movements will dictate which foods you need to avoid. You may want to try not eating much fruit and vegetables for the first couple of weeks and then gradually introduce them into your diet. Over the months you will become aware which foods make your stools looser and how best to manage it. As your confidence improves you will find that you don't need to avoid the food but you will know what to expect in terms of bowel pattern. Some patients find that drinking lots of caffeine can cause loose stools. If you like lots of tea and coffee you may need to try to reduce the amount that you drink or choose a caffeine free tea / coffee. Alcohol can have the same effect. This doesn't mean you cannot have a drink, but just be aware that the day after your stools could be loose. Fizzy drinks may make the bowel produce more wind and therefore cause the bowel pattern to be more explosive following the operation. You may want to let the fizz out of the drink or try and avoid them initially. The amount of wind that patients produce is also increased and can be quite strong smelling. Green leafed vegetables can be wind producing so if you find you do have a wind problem maybe avoid eating them for a couple of weeks to see if it improves. Yoghurts with live bacteria or 'friendly bacteria' may help replace the bowel with bacteria that are helpful and that may have been removed by antibiotics Certainly trying them isn't going to do harm and you may find they help your bowel pattern generally. Medications
If diet alone does not improve your bowel pattern medications may be needed. The two main types we use are either anti diarrhoeal (Imodium/Loperamide) or bulk-forming agents such as Fybogel. It is important to speak to one of the nurse specialists (stoma care or colorectal) before taking them as it depends on what your stool is like as to which will be beneficial. If diarrhoea is a problem and you are passing frequent amounts of watery stool then Imodium will be recommended. If you find that you are visiting the toilet frequently but only passing small bits of stool then fybogel will be recommended. Occasionally a combination of both is needed. Both can be bought over the counter without a prescription however, your GP will be able to prescribe them too. Patients that talked about their experiences for the purpose of this booklet found that medication helped but it was very much trial and error and juggling with the dose to suit them. Some found it reassuring to have Imodium in the cupboard in case of a loose day and also if they were going out, just to be on the safe side. How does Imodium work?
The bowel works by squeezing the food through it in wave like movements.
Imodium slows this action down thereby allowing the food to stay longer in the
bowel which means more is reabsorbed. To allow the bowel to slow down prior
to food getting to it we would recommend you take Imodium 30 - 60 minutes
before a meal. Imodium comes in different preparations including capsules,
caplets, syrup or melts.
On the packet instructions it says to take it after every bout of diarrhoea but this advice is for people who take it to treat a tummy bug. How does fybogel work?
This helps to bulk out the stool so if you are finding that you are passing small and frequent bits of stool, fybogel may help to pass it all in one go. Fibre in breakfast cereals is also bulk. You may, therefore, want to try this first. All-Bran is highest in fibre content but not everyone likes the taste. Cereal packets usually state the fibre content, so have a look and experiment. Skin care
If you are having frequent visits to the toilet the skin around your back passage can get sore. The aim of skin care is to prevent this becoming a problem. Moist toilet wipes can be bought from the toilet paper section in most supermarkets. Please do not use 'wet wipes' because this will make the skin around the anus red and inflamed from the chemicals in them. If your stool is very soft and you need to wipe the skin a lot, using the moist wipes will cut down on the amount of dry paper you need. Many of the main toilet paper companies now make paper that is very soft and some include Aloe Vera which is soothing for the skin. Although they may be more expensive you may find having a packet in the cupboard for loose days is helpful. Applying a barrier cream onto the skin is also helpful in protecting it. Sudocreme is one of the many over the counter creams that you can buy and is usually found in the baby section along with nappies and wipes. Protecting your underwear
Although incontinence isn't a common problem the fear is that due to the urgency to pass a stool, you will lose control. Wearing a pad in your underwear means that if you were 'caught short' you will have some protection. Many patients will wear a pad of some description just to be on the 'safe side'. Patients often wear ladies sanitary pads or pant liners. Exercise
Please refer to separate information leaflet regarding exercises to help improve your back passage muscles. Will my bowel pattern affect my social life?
Due to the erratic and unpredictable nature of the bowel pattern some patients don't feel confident enough to go out much in the early weeks. There are no magic words that we can say that will make you feel safe and confident. If all comes with time and by trying the various remedies described, you will develop a protection package that suits you. The vast majority of patients who have had their operation look forward to getting on with their lives. Having a positive attitude helps you to adjust to your new bowel pattern and knowing that what you are experiencing is normal is also reassuring. Patients look forward to getting back to 'being normal' again and for most of us that means going to the toilet once a day after breakfast. Due to the changed anatomy of the bowel this is very unlikely to happen. Striving to achieve what you were like before your operation will mean you will only be disappointed when it doesn't happen. Try to forget what was normal for you pre-operation and instead think that your new bowel pattern is the new norm. However, as mentioned earlier, it may take months before you can be confident to say what is normal. By the time you have read this booklet you may well be feeling daunted and disheartened about what the future holds in terms of bowel function. Please don't be. This booklet is aimed at giving you some tips and reassurance. There are patients who, following their surgery, have a very good bowel function and it doesn't disrupt their social life at all, so please keep positive as it will improve. Further information
Please feel free to contact either the colorectal cancer nurse specialist or the stoma care department with any further questions you may have. We are used to dealing with this problem so you will not be bothering us by telephoning. Colorectal Clinical Nurse Specialist - Clare Ferris (01872) 252693 Additional Information regarding bowel cancer can be obtained by logging into the following websites: Beating Bowel Cancer
Colon Cancer Concern
Adapted with permission from Lynn de Snoo, Colorectal Cancer CNS, Ashford and St Peter's NHS Trust


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