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COLON James Taclin C. Banez, MD.

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Presentation on theme: "COLON James Taclin C. Banez, MD."— Presentation transcript:

1 COLON James Taclin C. Banez, MD

2 Anatomy / Physiology: Location, blood supply & venous drainage, lymphatic drainage and nerve supply Function: absorption of fluid and electrolyte Transport and temporary storage of feces

3 Anatomy / Physiology:

4 Infectious: Amebic colitis: Entamoeba histolytica
Primary – colon : secondary – liver Fecal to oral route: (sexual contact, contaminated water & food) Abdominal pain, bloody diarrhea, tenesmus, fever Complication: megacolon / colonic obstruction (partial) ---> AMEBOMA – mass of inflammatory tissue Dx: clin hx / stool exam / indirect hemagglutination test Tx: metronidazole / iodoquinol : rare COLECTOMY

5 Pseudomembranous colitis:
Complication of antibiotics ---> alteration of normal flora Overgrowth of Clostridium deficile: Has cytopathic and enteropathic toxins Develops 6wks after: Clindamycin Ampicillin Cephalosporin Dx: history - latex fixation test - colonoscopy (Pseudomembrane) Tx: 1. stopped antibiotic ----> metronidazole/vancomycin 2. cholestyramine ---> binds w/ toxin 3. Toxic megacolon---> total colectomy w/ ileostomy

6 Salmonellosis: Actinomycosis: Salmonella typhi (typhoid fever)
Dx: perforation / bleeding Tx: antibiotic / transfusion / right hemicolectomy w/ or w/o ileostomy Actinomycosis: A. israeli (gm + anaerobic or microaerophilic bacterium) Characteristic: - chronic inflammatory induration and sinus formation Cervicofacial area most frequent site Abdomen – involves the cecum after AP Tx: surgical drainage and antibiotic (penicillin/ tetracycline)

7 Volvulus: Twisting of an air-filled segment of bowel about its narrow mesentery ---> OBSTRUCTION > STRANGULATION ----> GANGRENE----> PERFORATION ----> PERITONITIS SIGMOID VOLVULUS (90%): Redundant sigmoid colon w/ a narrow based mesocolon Sx: colicky abd. pain, distention obstipation, rectal collapse s/sx of dehydration

8 Volvulus: SIGMOID VOLVULUS (90%):
Dx: FPA – inverted U shaped sausage like loop (diagnostic) Barium enema – bird beaks deformity Gangrene – chills/fever, leukocytosis w/ s/x of peritonitis

9 SIGMOID VOLVULUS (90%): (-) Signs of Peritonitis:
Tx: (-) Signs of Peritonitis: Reduced the volvulus --->prepare for elective colonic surgery for the recurrence is 40%: - use of flexible scope (+) Signs of Peritonitis / Unsuccessful reduction: Sigmoidectomy w/ Hartmanns or Divine’s colostomy

10 Transverse colon volvulus:
Cecal Volvulus: Tx: reduction is impossible --> emergency exploration (+) Gangrene: - right hemicolectomy - end to end ileo-transverse colostomy (-) Gangrene: a) – same – b) Cecopexy c) Pure detorsion (recurrence 7 – 15%) Transverse colon volvulus: Rare, due to it’s broad based and short mesentery Tx: resection of redundant transverse colon

11 DIVERTICULOSIS: Types: Etiology:
Abnormal pouch from the wall of a hollow organ Types: True diverticula (rare) – right side False diverticula (common) – due to low fiber diet: left side Rare before 30y/o; common > 75 y/o Female > Male Etiology: Unknown Theories by Painter et al: Contraction ring (thickening of circular muscle) Depletion of dietary fibers ---> narrow lumen Deteriorating integrity of the bowel wall; elderly has lower tensile strength, lowest in the sigmoid)

Site: arteriole penetrates the mesenteric side of the antimesenteric teniae coli: Sigmoid (50%) Descending colon (40%) Entire colon (2-10%)

13 DIVERTICULOSIS: Clinical Manifestation: Majority are asymptomatic
Symptomatic patients: Uncomplicated painful diverticular dse. (+) LLQ pain and tenderness; (+) change in bowel habits (-) rebound tenderness (-) fever nor leukocytosis Dx: Gastrografin enema Tx: high fiber diet

14 Complicated diverticular disease:
Diverticulitis / Peridiverticulitis: Infected diverticula Diverticula is filled up ---> obstructed ---> mucus secretion and bacteria ---> inflammation at the apex ---> unresolved --> extend intramurally ---> perforate.

15 Complicated diverticular disease:
Diverticulitis / Peridiverticulitis: Sx: - left lower abd. pain / chills & fever / bowel habit changes - (+) abd. Tenderness, distension if w/ partial obstruction - para-rectal tenderness - frequency / urgency of urination (inflamed bladder)

16 Complicated diverticular disease:
Diverticulitis / Peridiverticulitis: Dx: Cln. Hx. Ct scan of the abd / utrasonography (thickened wall & abscess can be seen) Contrast enema / sigmoidoscopy (risk of spreading infection)

17 Complicated diverticular disease:
Diverticulitis / Peridiverticulitis: Tx: NPO or liquid diet Broad spectrum antibiotic Meperidine (not morphine) If improved  endoscopy to r/o CA

18 Complicated diverticular disease:
Perforated Diverticulitis: Sx: - similar to appendicitis (Phlegmon mass) - (+) pneumoperitoneum Classification of perforated diverticulitis (Hinchy) Stage I: abscess confined by mesentery of colon Stage II: pelvic abscess Stage III: generalized peritonitis Stage IV: fecal peritonitis

19 Complicated diverticular disease:
Perforated Diverticulitis: Tx: initial none operative: - NPO / IVF / Broad spectrum antibiotic/ meperidine Stage I & II: (+) improvement  elective Surgery (4 wks) (-) improvement  percutaneous drainage (-) improvement ---> Surgery

20 Complicated diverticular disease:
Perforated Diverticulitis: Stage III & IV: explore after initial resuscitation a. sigmoidectomy w/ primary anastomosis b. sigmoidectomy w/ Hartmann’s colostomy c. resection w/ primary anastomosis w/ proximal diverting stoma

21 Complicated diverticular disease: Obstructing diverticulitis:
90% partial – due to spasm, edema & ileus 10% complete – fibrosis and stenosis S/Sx: of large intestinal obstruction Tx: conservative mx (3-5 days) ---> (-) response -----> cecum dilates to cm. ---> surgery.

22 Complicated diverticular disease:
Acute hemorrhage: Due to erosion of the peridiverticular arteriole by inspissated stool w/in the diverticulum and thinning of the tunica media

23 DIVERTICULOSIS: Clinical Manifestation: Symptomatic patients:
Complicated diverticular disease: Acute hemorrhage: Resuscitate the patient Locate the site of bleeding (Tc labeled RBC/selective arteriography) Vasopressin infusion, transcatheter emboli infusion using gelfoam Colonoscopy Tx: segmental resection / blind subtotal colectomy

24 DIVERTICULOSIS: Clinical Manifestation: Symptomatic patients:
Complicated diverticular disease: Fistula formation: Bladder, vagina, small bowel, skin Dx: - clin hx & PE (pneumaturia, fecaluria and frequent UTI) - cystoscopy, IE, speculum exam - methylene blue enema - colonoscopy to r/o CA

25 DIVERTICULOSIS: Clinical Manifestation: Symptomatic patients:
Complicated diverticular disease: Fistula formation: Tx: - bowel rest w/ TPN or elemental diet - Foley catheter (10 days postop) / antibiotic - placement of ureteral catheter prior to celiotomy - sigmoidectomy w/ primary anastomosis - fistulectomy and closure of secondary opening

26 Hemorrhage from the Colon:
Diverticular disease Angiodysplasia (Vascular ectasia, AV malformation, Angiectasia)

27 ANGIODYSPLASIA Acquired lesion
Proximal colon (cecum) where tension is greatest (Laplace’s law – tension in the wall is highest in the widest circumference) Rare < 40y/o; common in elderly Etiology: - chronic intermittent obstruction of submucosal veins due to repeated muscular contraction

28 ANGIODYSPLASIA Dx: - Nuclear scan / angiography = (vascular tuft and
early filling of veins) - colonoscopy = distinct red mucosal patch

29 Management of Massive Lower GIB
Bleeding distal to the ligament of Treitz: Diverticular disease Angiodysplasia Inflammatory bowel disease Ischemic colitis Tumor Anticoagulant therapy Gastroduodenal hge -> can present as rectal bleeding It is more important to identify the location of the BLEEDING POINT than the immediate diagnosis as the cause.

30 Management of Massive Lower GIB
Diagnostic: Nuclear imaging (bleeding scan/scintigraphy) Technetium-Sulfur Colloid Scan Sensitive (0.5ml/min) Autologous labeled RBC scan Stays in the circulation for as long as 24 hrs (monitoring) (1ml/min bleeding) Mesenteric Angiography Done once patient’s condition is stable and hydration is adequate Identify bleeding point ---> 1ml/min Could be therapeutic ---> Vasopressin/emboli Vascular taft (A) Early filling vein (B)

31 Management of Massive Lower GIB
Diagnostic: Emergent colonoscopy: Possible w/ use of GOLYTELY Therapeutic Treatment: Restore intravascular volume (85% stop spontaneously) Persistent --> celiotomy (segmental or total colectomy)

32 Ischemic Colitis Due to occlusion of major mesenteric vessel
Thrombosis, embolization, iatrogenic ligation) Elderly: - contraceptive pills - medical problems: a) cardiovascular disease b) DM c) Rheumatoid arthritis Splenic flexure – most common site in the colon

33 Ischemic Colitis: Clinical Syndrome Based on:
Extent of vascular occlusion Duration of occlusion Efficiency of collateral circulation Extent of secondary bacterial invasion Reversible or Transient Ischemic Colitis: Partial mucosal slough that healed after 2-3 days Stricturing Ischemic Colitis: Arterial occlusion ---> hge’ic infarct of mucosa ---> ulcerates ----> bacterial invasion of bowel ---> fibrosis

34 Ischemic Colitis: Clinical Syndrome Based on:
Gangrenous ischemic Colitis: Complete arterial occlusion ---> full thickness infarction ---> gangrene ---> perforation ----> PERITONITIS.

35 Ischemic Colitis: Symptoms: Depends on the stage of the lesion
Acute mild to moderate generalized or lower abdominal crampy pain ---> HEMATOCHEZIA Hyperactive bowel sound ---> silent Abdominal tenderness ---> persist --->r/o peritonitis

36 Ischemic Colitis: Diagnosis: Clinical hx & PE
FPA ---> adynamic ileus (stops at the involved segment); Pneumoperitoneum Contrast enema (water soluble) - thumb printing in the mucosa Endoscopy (risky)

37 Ischemic Colitis: Treatment: Emergency celiotomy
- segmental resection w/ primary anastomosis or colostomy

38 Megacolon: Large colon due to chronic dilatation, elongation and hypertrophy of the colon Due to chronic partial colonic obstruction w/ associated chronic constipation Degree of megacolon is proportional to duration of obstruction

39 Megacolon: Congenital Megacolon (Hirschsprung disease)
Congenital absence of ganglion cells in the myenteric plexus (submucosa) of the bowel (aganglionosis) Usually involves the rectosigmoid Must be sent to Patho and confirm the presence of ganglion Acquired megacolon Chaga’s disease (trypanosoma cruzi) Neurologic disorders / psychotic patients Cut higher than 2 cm

40 Fecal impaction: Is the arrest and accumulation of the feces in the rectum or colon (dehydrated feces). Overflow diarrhea w/o relief of the sense of rectal fullness Result to stercoral ulcer (in the plating) --> bleeding and perforation Mx: - tap water enema / manual extraction - hot sitz bath

41 Inflammatory Bowel Diseases:
Ulcerative colitis (Mucosal Ulcerative Colitis / Idiopathic Ulcerative Colitis): involve the colonic mucosa – only the colon male > female limited to the colon and rectum Chronic inflammation of GI tract Crohn’s Disease (Chronic Interstitial Enteritis/Regional Ilietis): transmural inflammation anywhere in the GIT – affects entire wall extraintestinal symptoms proceeds those of intestinal symptoms female > male

42 Inflammatory Bowel Disease: Signs and Symptoms
Crohn’s Disease Ulcerative Colitis Symptoms diarrhea +++ rectal bleeding + tenesmus abdominal pain fever ++ vomiting weight loss Signs perianal disease abdominal mass malnutriton

43 Inflammatory Bowel Diseases:
Ulcerative Colitis Crohn’s Colitis Usual Location rectum, left colon anywhere Rectal Bleeding common, continuous uncommon, intermittent Rectal involvement almost always approximate 50% Fistulas rare common Ulcers shaggy, irregular, continuous distribution linear w/ transverse fissures (cobblestone or skip lesion) Bowel stricture rare (suspect carcinoma) Carcinoma increase incidence increased incidence Toxic dilatation of colon (megacolon) Occurs in both

44 Inflammatory Bowel Diseases:
Chronic Ulcerative Colitis: Mild & Mod. acute findings: mucosal edema crypt abscess rectal involvement Severe acute disease: Pseudopolyps w/ marked mucosal inflammation & edema Late changes: Discrete ulcers, pus

45 Inflammatory Bowel Diseases:
Crohn’s Disease: Early findings: rectal sparing perianal disease aphthous ulceration Moderate changes: linear ulcers cobblestoning skip lesions Late changes: Contact bleeding Confluent ulcers Strictures & mucosal bridging

46 Inflammatory Bowel Diseases:

47 Inflammatory Bowel Diseases:
Morphologic Features of Crohn’s Disease: Suggestive of Crohn’s Disease: Focal inflammation in the mucosa Ileal involvement Linear or fissuring ulcers Rectal sparing Right sided predominance Highly suggestive of Crohn’s disease: Discontinuous segmental involvement Aphthoid ulcers Pathognomonic of Crohn’s disease: Sarcoid granulomas Transmural inflammation w/ lymphoid nodules Fistulas (at sites other than anus)

48 Bowel Involvement in Crohn’s Disease (exam question)
Ileocolic 44% Colonic 28% Small bowel only 27% Anorectal 3%

49 Inflammatory Bowel Diseases:
Extra-intestinal Nonhepatic Manifestations of Idiopathic Inflammatory Bowel Disease: (hypothetical autoimmune disease) (don’t need to memorize this list) Musculoskeletal: Blood & Vascular System ankylosing spondylitis and sacroiliitis anemia peripheral arthritis thrombocytosis pelvic osteomyelitis leucocytosis Skin and Mouth: hypercoagulable state erythema nodosum pyoderma gangrenosum Kidneys & Genitourinary aphthous stomatitis nephrolithiasis Eye: obstructive uropathy uveitis (iritis) fistulas to genitourinary episcleritis Other: - Pleurocarditis & Bronchopulmonary vaxculitis

50 Medical Therapy for Ulcerative Colitis & Crohn’s Disease
Sulfasalazine – lowers the inflammation Metronidazole (as well as 2nd gen cephalosporin) Crohn’s ileocolitis & colitis Perineal colitis Not effective in active ulcerative colitis Corticosteroid – lowers antibody Oral for mild to moderate active ulcerative colitis and Crohn’s disease Parenteral for severe or toxic ulcerative colitis or Crohn’s disease Immunosuppressive agents: Steroid sparing Refractory disease

51 Indications for Surgical Interventions for Ulcerative Colitis:
Active disease unresponsive to medical therapy Risks of cancer – based on workup Severe bleeding

52 Surgical treatment for Ulcerative Colitis
Proctocolectomy w/ Brooke ileostomy (brings ileum to the skin): curative w/ one operation Colectomy w/ ileorectal anastomosis: not curative; cancer risk persists (5-50%) contraindicated for severe rectal dse, rectal dysplasia and rectal CA Total proctocolectomy w/ ileoanal anastomosis w/ pouch (best therapy): curative w/ continence contraindicated for Crohn’s dse, diarrhea, rectal CA

53 Surgical treatment for Ulcerative Colitis

54 Indications for Surgical Treatment of Crohn’s Dsease
Ileocolic Crohn’s Disease: Internal fistula and abscess 38% Intestinal obstruction 37% Perianal fistula % Poor response to medical therapy 6% Colonic Crohn’s Disease (when surgery participates): Internal fistula and abscesses 25% Perianal disease 23% Severe dse w/ poor response to medical therapy 21% Toxic megacolon 19% Intestinal obstruction 12%

55 COLO – RECTAL POLYPS Projection from the surface of the intestinal mucosa regardless of it’s histologic nature: Types: Neoplastic Hamartomatous Inflammatory Unclassified

56 Malignant Potential (%)
COLO – RECTAL POLYPS Neoplastic Polyps: Invasive CA are common in polyps smaller than 1 cm in diameter and incidence increases w/ increase in size Types Incidence (%) Malignant Potential (%) Tubular 75 5 Villous 10 40 Tubulovillous 15 22

57 COLO – RECTAL POLYPS Neoplastic Polyps: Diagnosis:
bleeding per rectum (most common) Villous polyp (large) ---> watery diarrhea and in rare cases can have fluid and electrolyte imbalance do complete examination of the colon - colonoscopy biopsy / transrectal ultrasonography

58 COLO – RECTAL POLYPS Neoplastic Polyps: Treatment:
Polypectomy for benign ---> follow up (+) CA in situ ----> polypectomy (+) invasive CA (invade the muscularis mucosa) 9% metastasize to LN if pedunculated 20% metastasize to LN if it invades the stalk or neck 15% metastasize to LN if sessile CANCER SURGERY

59 COLO – RECTAL POLYPS Neoplastic Polyps: Treatment:
If entire mucosal surface is covered by villous tumor ---> segmental resection, if in rectum can do full thickness proximal protectomy w/ coloanal anastomosis

60 COLO – RECTAL POLYPS Hamartomatous Polyp: Juvenile Polyp:
not precancerous excision Swiss cheese appearance from dilated cystic spaces Familial Juvenile Polyposis Coli: thousands polyps in the colon and rectum can degenerate to adenoma ----> malignancy subtotal colectomy or proctocolectomy

61 COLO – RECTAL POLYPS Hamartomatous Polyp: Peutz-jegher Syndrome
Melanin spot on buccal mucosa, lips, face and digits Polyps of small bowel (always), stomach, colon and rectum (branching of lamina propria like Christmas tree). Can degenerate into malignancy Cronkhite – Canada Syndrome: GIT polyposis, alopecia, cutaneous pigmentation, atrophy of fingernails and toe nails Cowden’s Syndrome: Autosomal dominant, hamartomas of all three embryonal cell layers Facial trichilemomas, breast cancer, thyroid dse, GIT polyp

62 COLO – RECTAL POLYPS Infammatory Polyp: Hyperplastic Polyp:
Caused by previous attacks of severe colitis resulting in partial loss of mucosa leaving remnants or islands of normal mucosa Occurs after amebic colitis, ischemic colitis and Schistosomal colitis Not premalignant Hyperplastic Polyp: Usually small < 5mm not premalignant > 2cm. have a slight risk of malignant degeneration Saw tooth appearance of the lining epithelial cells

63 COLO – RECTAL POLYPS Familial Adenomatous Polyposis Coli:
Inherited non-sex linked autosomal dominant disease w/ hundreds of adenomatous polyps through the entire colon and rectum Gardner’s Syndrome: Familial polyposis, osteomatosis, epidermoid cyst, fibromas of the skin (desmoid tumor) – the most important extra-colonic expression. Tx: - total proctocolectomy w/ ileostomy - colectomy w/ ileorectal anastomosis - examine other members of the family

64 COLO – RECTAL POLYPS Familial Adenomatous Polyposis Coli:
Turcot’s Syndrome: Familial polyposis, brains tumors (gliomas or medulloblastomas) Tx: same w/ colorectal involvement Hereditary Nonpolyposis Colon Cancer (HNCC): Lynch’s syndrome Error in mismatch repair (RER pathway) Appear more common in proximal colon Associated w/ extra-colonic malignancies (endometrial, ovarian, pancreas, stomach, small bowel, biliary & Urinary)

65 Carcinoma of Colon Most common CA of the GIT
Older age grp; peak incidence 80y/o male ( > rectum) ; female ( > colon) Etiology: Unknown Hereditary Diet --> low fiber diet and high animal fat Distribution --> shifting to the right side

66 Carcinoma of Colon Macroscopic form: Ulcerating type most common
Polypoid or fungating Colloid CA bulky growth w/ gelatinous appearance 10-15% Signet ring cell CA intracellular mucinous Infiltrating CA submucosal spread

67 Carcinoma of Colon Microscopic form: adenocarcinoma
Gronnell: based on invasive tendency, glandular arrangement, nuclear polarity and frequency of mitosis. Grade I - low grade / well differentiated Grade II - average grade / mod. differentiated Grade III - high grade / poorly differentiated

68 Carcinoma of Colon Mechanism of Spread: Direct spread
Transperitoneal spread Implantation Lymphatic Hematogenous Liver & Lungs – most common distant spread

69 Carcinoma of Colon Duke’s Stage: Stage A: Stage B:
Depth of bowel wall involvement Presence or absence of LN metastasis Stage A: Invasion at least through the muscularis mucosa but not through the muscularis propria 98% ---> 5yr survival Stage B: Invasion through full thickness of bowel wall; (-) LN 78% ----> 5yr survival

70 Carcinoma of Colon Duke’s Stage: Stage C: Stage D:
LN metastasis, regardless of depth Stage C1: - only adjacent LN metastasis Stage C2: - LN involves are nodes at point of ligature of blood vessels 32% 5 yr survival Stage D: Distant metastasis or w/ adjacent organ involvement 0% 5 yr survival

71 TNM Staging of Colonic CA
Primary Tumor (T): TX - Primary tumor cannot be assessed T0 - No evidence of primary tumor T1 - Tumor invades submucosa T2 - Tumor invades muscularis proper T3 - Tumor invades through the muscularis proper into the subserosa or into nonperitonealized pericolic or perirectal tissue T4 - Tumor perforates the visceral peritoneum or directly invades the organs or structures

72 TNM Staging of Colonic CA
Regional Lymph Node (N): NX – Regional LN cannot be assessed N0 - No regional LN metastasis N1 - Metastasis in 1 to 3 pericolic or perirectal LN N2 - metastasis in 4 or more pericolic or perirectal LN N3 - Metastasis in any LN along the course of a named vascular trunk Distant Metastasis (M): MX – Presence of distant metastasis cannot be assessed M0 - No distant metastasis M1 - w/ distant metastasis

73 TNM Staging of Colonic CA
Stage I: T1 –T2 N0 M0 90% 5y/r Survival Stage II: T3 – T4 N0 M0 60 – 80% 5 y/r survival Stage III: Any T N1 M0 Any T N2, N3 M0 20 – 50% 5y/r survival Stage IV; Any T Any N M1 < 5% 5 yr survival

74 Risk Factors for Colorectal CA
Aging is the dominant risk factor w/ rising incidence after 50 y/o. Hereditary risk factor: 80% colorectal are sporadic 20% w/ known family hx. Dietary factors: high animal fat (saturated or polyunsaturated fats), but oleic acid (coconut & fish oil does not). Vegetable fiber, Ca, selenium, Vits. A, C, & E are protective Alcohol increase colonic CA Obesity and sedentary lifestyle contributory Smoking increased the incidence

75 Premalignant Diseases of Colon & Rectum
Adenoma Familial adenomatous polyposis syndrome Gardner’s syndrome Hamartomas (familial juvenile polyposis coli & Peutz-Jegher polyp Inflammatory bowel disease Ulcerative colitis Crohn’s disease Schistosomiasis (Billharziasis) – S. mansoni & S. japonicum Utero-sigmoidostomy

76 Genetic Defects for Colorectal CA
Mutation may cause: Activation of: K-ras (an oncogene) Inactivation of tumor- suppressor gene: APC DCC (deleted in colorectal carcinoma) p53

77 Genetic Pathways for Tumor Initiation and Progression
LOH pathway: Chromosomal deletion and tumor aneuploidy 80% of colorectal carcinoma RER pathway (replication error): Error in mismatch repair during DNA replication 20% of colorectal carcinoma

78 Carcinoma of Colon Clinical Manifestation:
Change in bowel habit classic symptoms Rectal bleeding Weight loss Abdominal pain, bloating and other signs of obstruction Anemia and anorexia Tenesmus, feeling of incomplete evacuation, and rectal bleeding if lesion is in the rectum

79 Screening Modalities For Colonic Tumors
Fecal occult blood testing: Annual FOBT screening for asymptomatic 50 y/o Rigid proctoscopy / flexible sigmoidoscopy Colonoscopy: The most accurate and most complete method for examining the colon Air contrast Barium enema: CT colonography (virtual colonoscopy): Colon is insufflated with air and a spiral CT is performed. Useful for imaging the proximal colon in case of obstruction

80 Therapy for Colonic Carcinoma
Principle: Objective is to remove the primary tumor w/ its lymphovascular supply Adjacent organs or tissue invaded shd be resected en block w/ the tumor Tumors cannot be removed, a palliative procedure shd be done. Synchronous CA ---> subtotal or total colectomy Metachronous tumor (second primary colon CA) treated similarly Hemorrhage in an unresectable tumor can be controlled w/ angiographic embolization

81 Therapy for Colonic Carcinoma
Stage 0: No risk of LN metastasis Pedunculated / sessile polyp -> endoscopic polypectomy If polyp cannot be removed completely segmental resection shd be done Stage I: (T1,N0,M0): Polypectomy --> for uninvolved stalk (pedunculated) Segmental resection: Sessile polyp Pedunculated polyp ( lymphovascular invasion, poorly differentiated or tumor w/in 1mm. of resection margin ---> high risk of local recurence and metastatic spread)

82 Therapy for Colonic Carcinoma
Stage II (T3-4,N0,M0): Surgical resection Adjuvant chemotherapy is suggested for: Young patient Moderate to poorly differentiated Stage III (Tany,N1,M0): Surgical resection + adjuvant chemotherapy (5-Fluorouracil, levamisole or leucovorin, capecitabine, irinotecan, oxaliplatin, angiogenesis inhibitor and immunotherapy)

83 Therapy for Colonic Carcinoma
Stage IV: (Tany, Nany, M1) Palliative resection of primary and isolated liver metastasis Adjuvant chemotherapy Irresectable ---> diverting colostomy


85 Therapy of Rectal Carcinoma
Principle the same w/ colonic CA, but more difficult to achieve negative radial margins bec. of anatomic limitations of the pelvis Local recurrence is higher w/ similar stage of colonic CA. Easier to treat rectal tumors w/ radiations due to less structures radiation-sensitive structures in the pelvis

86 Therapy for Rectal Carcinoma
Transanal endoscopic microsurgery Radical resection: - removal of the involved segment of the rectum along with its lymphovascular supply w/ a margin of 2 cm distal mural margin. Total mesorectal excision (TME) APR Pelvic exenteration: --> enbloc resection of the ureters, bladder, prostate, uterus and vagina together w/ APR. w/ permanent colostomy and ileal conduit. Sacrectomy up to level of S2-S3 junction if necessary.

87 Therapy for Rectal Carcinoma
Stage 0 (Tis, N0,M0) Local excision w/ 1 cm margin Stage I: (T1-2,N0,M0) Polypectomy --> confined to the head of the polyp Radical resection --> sessile uT1N0 and uT2N0 rectal CA

88 Therapy for Rectal Carcinoma
Stage II (T3-4,N0,M0): 2 school of thought Total mesorectal resection only Radical resection w/ chemo-radiation given preoperatively or postoperatively Advantages of preop chemoradiation: Down grade the tumor can increased likelihood of resection and sphincter saving procedure Disadvantages of preop chemoradiation: Over treatment of early stage tumors Impaired wound healing Pelvic fibrosis increases the risk of operative complications

89 Therapy for Rectal Carcinoma
Advantages of postoperative radiation: Allows accurate pathologic staging of the resected tumor and LN Avoids wound healing problems associated w/ preop radiation Stage III (Tany,N1,M0): Radical resection followed w/ neodjuvant therapy Stage IV (Tany, Nany, M1) Proximal diverting colostomy for obstruction (lower) / intraluminal stenting (upper) Radical resection to control bleeding, pain and tenesmus

90 Follow-up and Surveillance for Colorectal CA
Annual colonoscopy CEA determination CT scan done if CEA is elevated

91 Anal Canal & Perianal Tumors
Uncommon; 2% colorectal CA Anal margin – distal to dentate line Anal canal – proximal to dentate line

92 Anal Canal & Perianal Tumors
Anal intraepithelial neoplasm (AIN) Bowen’s disease Squamous cell CA in situ of the anus Precursor to an invasive squamous cell CA Associated w/ infection of human papilloma virus, HIV-positive homosexual Tx: resection / ablation High recurrence ---> 3-6 months follow up

93 Anal Canal & Perianal Tumors
Epidermoid carcinoma Squamous cell CA, Cloacogenic CA, Transitional CA, Basaloid CA. Slow growing; present as mass or perianal mass Anal margin --> wide local excision Anal canal or invading anal sphincter --> Nigro protocol ( 5-fluorouracil, mitomycin C, 3000cGy external beam radiation). 80% are cured Recurrence ---> APR

94 Anal Canal & Perianal Tumors
Verrucous carcinoma Buschke-Lowenstein Tumor, Giant condyloma accuminata. Do not metastasize Wide excision / radical resection Basal cell carcinoma Rarely metastasize Wide excision tx of choice; recurrence --->APR &/or radiation therapy

95 Anal Canal & Perianal Tumors
Adenocarcinoma: Usually a downward spread of low rectal CA Could arise from anal glds or developed from chronic fistula; also from apocrine gld (Paget’s dse) Tx: - radical resection w/ or w/o chemoradiation - Paget’s dse = wide excision Melanoma: Poor prognosis; 5yr survival --> 10% due to sytemic metastasis &/or deeply invasive tumors Wide local resection / APR Adjuvant chemotherapy, biochemotherapy, vaccines, radiotherapy

96 Anorectal Abscess 5 potential spaces: Perianal space
Ischiorectal space Intersphincteric space Deep posterior anal space Supralevator space

97 Anorectal Abscess Etiology: Manifestation: Treatment:
Infection of anal gland Organism (fecal & cutaneous flora) E. coli Clostridium sp. Bacteroides fragilis Staphylococcus Streptococcus Manifestation: Pain in the anal region Treatment: Drainage / antibiotic Hygiene Hot sitz bath

98 Anorectal Abscess Types : Perianal abscess
Ischiorectal abscess – diffuse swelling of ischiorectal fossa

99 Anorectal Abscess Intersphincteric abscess: Supralevator abscess:
No apparent sign of swelling or induration in the perianal area CLUE: --> deep seated tenderness when circum-anal pressure is applied above the dentate line. Drainage: thru the anal canal lining or thru internal sphincteric muscle Supralevator abscess: Uncommon Mimmic acute intra-abdominal condition Etiology: extension of Intersphincteric abscess Ischiorectal abscess Intra-abdominal abscess

100 Necrotizing Peri-anal & Perineal Infection:
Etiology: Neglected or delayed treatment of primary anorectal infection Extension of UTI particularly the periurethral gland Manifestation: Pain, tenderness and swelling with crepitation of perianal and scrotum or labia Black spot on the site (necrosis) Treatment: Broad spectrum antibiotic Debridement Hyperalimentation / diverting colostomy &/or cystostomy

101 Fistula-In-Ano: Etiology: Goodsalls Rule:
Inflammatory tract w/ secondary opening (external) and a primary opening (internal) in the anal canal. Etiology: Complication of perianal abscess Goodsalls Rule: to locate internal opening Classification of Fistula-in-ano: Inter-sphincteric Trans-sphincteric Supra-sphincteric Extra-sphincteric

102 Fistula-in-ano Manifestation: Treatment:
Previous history of perianal abscess Rule out ulcerative colitis and Crohn’s dse (colonoscopy / barium enema) Treatment: Identify the primary opening (probing/methylene blue/fistulography) Fistulotomy / fistulectomy (healing by secondary intension

103 Fistula-in-ano If fistula is high in relation to anorectal ring do 2 stage procedure: Insert a seton wire or suture to the tract for several wks to create fibrosis Open the fibrous track on the second stage after 6-8 wks

104 Hemorrhoid Are cushions of submucosal tissue in the anal canal composed of connective tissue containing venules, arterioles and smooth muscle fibers. Purposed – aids in anal continence and cushion the anal canal and support the lining during defecation External skin tag Redundant fibrotic skin at the anal verge due to previous thrombosed external hemorrhoid of past operation

105 Hemorrhoid External hemorrhoid
Dilated venules of the inferior hemorrhoidal plexus located distal to the pectinate or dentate line

106 Hemorrhoid Internal hemorrhoid: Manifestation:
Painless bright red rectal bleeding associated w/ bowel movement Feeling of incomplete evacuation of feces Pain is experienced if w/ complication of anal fissure, stenosis of thrombosis Grade According to Degree of Prolapse: 1st degree: anal cushion slide down beyond the dentate line on straining Mx: - painless rectal bleeding Tx: - bulk forming agents (psyllium seed) - rubber band ligation

107 Hemorrhoid Rubber band ligation:

108 Hemorrhoid 2nd degree: 3rd degree: 4th degree:
Prolapse through the anus on straining but spontaneously reduced 3rd degree: Requires manual reduction into the anal canal Tx: rubber band ligation / hemorrhoidectomy 4th degree: Prolapse cannot be reduced hemorrhoidectomy

109 Anal Fissure Tear from the dentate line up to the anal verge lined by skin Seen in young and middle age group Majority occurs at the at the posterior midline due to poor muscular support

110 Anal Fissure Etiology: Passage of large hard stool
Conditions ( Crohn’s dse, ulcerative colitis, syphilis’ tuberculosis and leukemia) Manifestation: Burning pain during and after bowel movement Bright red blood on toilet paper Diagnosis: Rectal examination / proctosigmoidoscopy Treatment: Conservative: - anal hygiene / bulk forming agents - hot sitz bath - local anesthetic jelly Surgical: - chronic stage (lateral internal sphincterotomy)

111 Anal Fissure Treatment: Conservative: Surgical:
anal hygiene / bulk forming agents hot sitz bath local anesthetic jelly Surgical: chronic stage (lateral internal sphincterotomy)

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