Which Doctor Can Help My Colon? One Cuts Butts and One Deals With Guts
By: Carmen Fong
Tags: Health, Surgery, Wellness, Science, Medicine

Which Doctor Can Help My Colon? One Cuts Butts and One Deals With Guts

The difference between a gastroenterologist and a colorectal surgeon

Tools of the Colorectal trade. copyright Carmen Fong 2020

This is one of the most common questions I am not asked, as the majority of my patients believe we are one and the same. While we treat a lot of the same diseases and some of our procedural skills overlap, there is one major difference. Colorectal surgeons do surgery and gastroenterologists don’t. To date, I have not seen much online about this, likely because people don’t know to ask.

Training

When we graduate from medical school, we have to decide on a path. The algorithm divides into medicine and surgery. Wait, you ask, isn’t it all medicine? You graduate from medical school, not surgery school.

Yes, it’s all under the big umbrella of Medicine, but we have to choose our specialties, so the two branches are medicine (Internal Medicine) and Surgery. There are a ton of other specialties that are categories of their own, but generally, you have to decide whether you want to operate on people or not.

Just Google ‘medicine specialty decision tree’ and you will see algorithms people have made up over the years for how to decide what to do with your life, like this classic one from BMJ, “Physician, Know Thyself”. Some are more humorous than others.

The split between medicine and surgery. copyright Carmen Fong 2020

Gastroenterology

Gastroenterology (abbrev. GI), is a subspecialty of Internal Medicine, another 3 years of training on top of 3 years of residency training. Since they are a branch of medicine, they do not do surgery — that is, ‘large’ operations that generally involve cutting open the belly and general anesthesia.

Part of the confusion stems from the fact that gastroenterologists perform a lot of procedures — generally, smaller things that can be done in the office or in an outpatient setting. Most notably, these involve scopes- colonoscopy (for the colon/large bowel), or esophagogastroduodenoscopy (EGD), which is an upper GI endoscopy for the esophagus, stomach, and duodenum.

This is sometimes is just called ‘endoscopy’ even though endoscopy actually refers to anything involving a scope. Because GI is a medical subspecialty, they have the knowledge to treat a lot of diseases with medication. While some surgeons will do that, they generally leave medical management to the GI docs.

Colorectal surgery

Colorectal surgery is a subspecialty of General Surgery. This requires another one year on top of five years of surgical training. We are trained to diagnose all diseases, but especially diseases that may eventually require surgery.

We consider the abdomen our domain because once you have seen the inside of the abdomen during surgery, you have a much better correlation between things that happen on the outside and things that happen on the inside.

Surgical emergencies generally include bleeding, perforation of the colon, or obstruction of the colon (usually by tumor or infection), or ischemic colon which is colon devoid of functional blood supply. Sometimes, these issues are diagnosed by GI, and then a surgeon is consulted. Most often, surgeons are involved from the beginning.

Similarities

GI and Colorectal surgeons have overlapping areas of disease pathologies that we treat. The list is quite extensive and encompasses both benign and malignant colon, anal and rectal diseases (and some small intestine as well). These problems include colon or rectal cancer, diverticulitis, inflammatory bowel diseases such as Crohn’s and ulcerative colitis, hemorrhoids, chronic constipation, fecal incontinence, and sometimes small bowel tumors or benign idiopathic abdominal or pelvic pain.

Both GI and Colorectal surgeons do colonoscopies, though I will be the first to admit that, in their training, GI physicians perform many more colonoscopes than we do in our surgery training. While we may do 1000 surgeries and 300 scopes, GI does 1000 scopes.

This makes for a natural divide, one that I am happy to facilitate: GI is much better at routine, screening colonoscopies. I will also do screening colonoscopies, generally for patients who specifically ask me to because I am their surgeon, but I try not to step on the toes of the lovely GI docs who refer cancer patients to me.

What I will do are diagnostic colonoscopies — that is, patients who are already known to have a tumor in order to determine the location and mark it before surgery. I also perform colonoscopies on patients whom I’ve operated on, and I have first-hand knowledge that their colon anatomy has deviated from normal.

GI physicians will also do smaller, in-office procedures such as banding hemorrhoids, which colorectal surgeons do as well. But here we start to delve into our differences.

Differences

GI can also subspecialize into upper GI, which is the first part of the digestive tract including the esophagus, stomach, and the liver (hepatologists treat diseases of the liver and bile duct, such as Hepatitis C). Some GI do upper GI procedures via endoscopy, such as clearing out gallstones from the biliary tract (ERCP).

Colorectal surgery deals with the hindgut, that is, the last part of the digestive tract, including small bowel, colon, rectum, and anus. (Some of us are also board-certified general surgeons and can operate on the upper digestive tract, such as stomach, gallbladder, liver.)

copyright Carmen Fong 2020

Colorectal surgeons spend a lot of time learning about anal and pelvic anatomy. This sets us apart from any other specialty. This allows us to be specialists in anal fistulas, fissures, anal warts, anal cancer — all of which may require small surgeries or pathologies of the rectum such as fecal incontinence and rectal prolapse.

Gastroenterologists tend not to do anorectal procedures, aside from hemorrhoid banding. What we learn in training are the eight other ways to surgically treat hemorrhoids (some are better than others), which I will not go into here, but include excision, laser, injection, stapling, and a ‘minimally-invasive’ approach that I do call transanal hemorrhoidal dearterialization.

Gastroenterologists and colorectal surgeons have a lot of overlap in terms of the diseases we treat and the procedures we do, in fact, we work very closely most of the time and even have joint conferences on complicated patients.

The main difference is that while gastroenterologists will treat conditions medically, only colorectal surgeons can treat them surgically. In general, if you are seeing a doctor and not quite sure the scope of their practice (no pun intended), just ask! We are always happy to elucidate.