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Colon Diseases Dr. Rezvan Mirzaei.

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Presentation on theme: "Colon Diseases Dr. Rezvan Mirzaei."— Presentation transcript:

1 Colon Diseases Dr. Rezvan Mirzaei

2 Clinical Evaluation Symptoms Abdominal Pain Rectal Bleeding, Anemia
Bowel Habit Change Weight Loss Mucus Discharge Constipation & Diarrhea Incontinence

3 History Medical Surgical Obstetric
Family: Polyp, Colorectal Ca, Other Cancers

4 P/E Abdominal Perineal DRE

5 Endoscopy Anoscopy: 8 cm Rigid Proctoscopy: 25 cm, Partial Bowel Prep
Colonoscopy: 160 cm, complete oral bowel prep

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15 Laboratory studies Fecal Occult Blood Stool Studies Tumor Markers
Genetic Testing

16 Imaging Plain X-Ray Contrast Study CT Virtual Colonoscopy MRI
Positron Emission Tomography (PET) Endorectal & Endoanal Ultrasound Colon Transit Time (CTT)

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19 Plain X-ray, Hirschprung

20 CTT

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23 Intrarectal Sono-Ca

24 Diverticular Disease False Diverticula
Mucosa & Muscularis Mucosa herniation through the colonic wall Between the taeniae coli where the main blood vessels penetrate the colonic wall Pulsion Diverticula: resulting from high intraluminal pressure

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26 Diverticular Disease Diverticular Disease = Symptomatic Diverticula
Diverticulosis = Diverticula without inflammation Diverticulitis = Diverticula with inflammation & infection

27 Barium Enema - Diverticulosis

28 Diverticular Disease Most common site: Sigmoid Acquired
Low Fiber Diet => Smaller stool volume =>High intraluminal pressure & high colonic wall tension for propulsion

29 Diverticular Disease Complications Bleeding Inflammation

30 Adeno carcinoma Most common malignancy of GI - Risk factors
- Age > 50 - Family hx of colorectal CA (20%) - Diet (High animal Fat-Low fiber) - Alcohol, Smoking - Obesity

31 Risk Factors IBD: Chronic inflammation predisposes the mucosa to malignant changes(duration & extent of colitis, Primary sclerosing cholangitis) Ulcerative & Crohn’s Pancolitis 2% after 10 years 8% after 20 years 18 % after 30 years Irradiation Ureterosigmoidostomy Acromegaly

32 Symptoms - Change in bowel habit Rectal bleeding Unexplained anemia
Weight loss

33 Polyps Any projection from the surface of the intestinal mucosa
Neoplastic (Tubular, Villous, Tubulovillous, Serrated Polyps) Hamartomatous (Juvenile, Peutz-jeghers) Inflmmatory (Pseudopolyp, Benign lymphoid) Hyper plastic Pedunculated, Sessile

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36 Adenoma-Carcinoma sequence
Risk of malignant degeneration is related to size & type of polyp - Tubular adenoma 5% - Villous adenoma 40% - Tubulovillous 22% Size: - rare <1 cm % >2 cm

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38 Polyp Treatment - Colonoscopic removal + Follow up - Colectomy
* Impossible colonoscopic removal * Focus of invasive cancer in specimen

39 Familial Adenamotous Polyposis (FAP)
Hundreds to thousands of adenamatous polyps shortly after puberty Lifetime risk of CA approaches 100% by age of 50

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41 Familial Adenamotous Polyposis (FAP)
Screening relatives by APC gene testing Of patients with FAP => 75% APC mutation testing is positive - Positive APC testing => sigmoidoscopy beginning years - Negative => Screening starting at the age of 50 25% without other affected family members

42 Barium Enema-Polyposis

43 FAP treatment Surgery - Total proctocolectomy + end Ileostomy
- Restorative proctocolectomy + ileal pouch-anal Anastomosis

44 Total Proctocolectomy

45 Total Proctocolectomy

46 End Ileostomy

47 Total Proctocolectomy + Ileoanal J Pouch + Diverting Ileostomy

48 Attenuated FAP 10 to 100 polyps dominantly located in the right colon
CA develops in >50% Also at risk for duodenal polyposis Treatment: - Total Abdominal colectomy + ileorectal anastomosis + colonoscopic polypectomy (rectum)

49 Total abdominal-Subtotal colectomy

50 Inflammatory Polyps (Pseudopolyps)
IBD Amebic colitis Ischemic Colitis Not premalignant

51 Hyperplastic Polyps Extremely common Usually < 5 mm
Not Premalignant but > 2 cm have slight risk

52 Hamartomatous polyps (Juvenile Polyps)
Usually are not premalignant Bleeding, intussusception, obstruction Familial Juvenile Polyposis may degenerate into adenoma and eventually CA

53 Hereditary Nonpolyposis colon cancer (Lynch Syndrome)
Average age: 40 to 45 70% develop colorectal CA (proximal colon) 40% risk of synchronous or metachronous CA Associated CA: Endometrial, Pancreas, Stomach, Small bowel, Biliary, Urinary tract

54 Hereditary Nonpolyposis colon cancer (Lynch Syndrome)
Diagnosis: Amsterdam Criteria Three affected relatives (one must be a first – degree relative of one of the others) in two successive generations of a family with one patient diagnosed before age 50

55 Hereditary Nonpolyposis colon cancer (Lynch Syndrome)
Treatment: - Total colectomy + ileorectal anastomosis + annual proctoscopy + TAHBSO

56 Familial colocrectal cancer
Risk of CA - No family Hx: 6% (average – risk population) - One first degree: 12% - Two first degree: 35% Colorectal cancer: 80% sporadically, 20% known Family History

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59 Screening Familial colorectal CA
- Every 5 years at age 40 or 10 y before the age of the earliest diagnosed patient in the pedigree IBD Pancolitis: after 8 years Left sided colitis after years

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62 Therapy of Colonic Carcinoma
Remove the primary tumor along with its lymphovascular supply+Resection of any adjacent organ involved + chemotherapy Total colectomy - Synchronous CA or adenoma - Strong family Hx - Metachronous tumor (second primary colon CA)

63 Right Hemicolectomy

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66 Right Hemicolectomy + Ileotransverse Anastomosis

67 Transverse Colectomy

68 Left Hemicolectomy

69 Sigmoidectomy

70 Types of Stomas End Loop Double Barrel Stoma

71 End Ileostomy

72 End colostomy

73 End colostomy

74 End colostomy

75 Loop colostomy

76 Double Barrel Ostomy

77 Double Barrel Ostomy

78 Colonic Volvulus Air filled segment of the colon twists about its mesentery 90% sigmoid is involved Redundant colon due to chronic constipation predisposes to volvulus especially if the mesenteric base is narrow

79 Colonic Volvulus Symptoms: - Abdominal distention - Nausea – vomiting
- Generalized abdominal pain & tenderness (Fever – Leukocytosis)

80 Colonic Volvulus Plain X-ray
- Bent inner tube or coffee bean appearance convexity of the loop in R.U.Q Gastrografin enema: Narrowing at the site of the volvulus (bird’s beak)

81 Sigmoid Volvulus

82 Sigmoid Volvulus

83 Colonic Volvulus Management - Resuscitation + Endoscopic decompression
- Because of 40% Recurrence => Elective sigmoid colectomy

84 Colonic Volvulus Clinical Evidence of gangrene or perforation
Necrotic Mucosa, ulceration, dark blood on endoscopy Emergency sigmoid colectomy

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87 Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
Massive dilated colon (Predominantly the right & transverse colon) in the absence of mechanical obstruction Commonly in hospitalized patients, narcotics, bedrest, comorbid disease Autonomic dysfunction & severe adynamic ileus

88 Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
Treatment - Cessasion of narcotics, anticholinergics, … - Bowel rest + IV hydration - Colonoscopic decompression - Gastrografin or barium enema to exclude mechanical obstruction - IV neostigmine (acetylcholinesterase inhibitor) inappropriate in cardiopulmonary disease

89 Ischemic Colitis Small vessel occlusion
Splenic flexture is most common site Risk factors - Vascular disease - Diabetes Mellitus - Vasculitis - Hypotension - Ligation of IMA during aortic surgery

90 Ischemic Colitis Mild: Diarrhea (usually bloody)
More Severe: Intense abdominal pain, tenderness, fever, leukocytosis, peritonitis

91 Ischemic Colitis Plain film: Thumb printing (mucosal edema & submucosal hemorrhage) Sigmoidoscopy & contrast studies: contraindicated during acute phase

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93 Ischemic Colitis Treatment
- Bowel rest + Antibiotics => 80% will recover - Surgical exploration: failure to improve after 2-3 days deterioration in clinical condition => resection + ostomy

94 Pseudomembranous Colitis (Clostridium Difficile colitis)
C. difficile gram positive bacillus nosocomially acquired diarrhea Watery diarrhea to life-threatening colitis C. difficile is carried in the large intestine of many healthy adults Antibiotics => Decreased normal flora =>Overgrowth of C.difficile (even a single dose of an antibiotics)

95 Pseudomembranous Colitis (Clostridium Difficile colitis)
Risk increased: - Immuno suppression - Medical comorbidities - Prolonged hospitalization - Bowel Surgery

96 Pseudomembranous Colitis (Clostridium Difficile colitis)
Endoscopy: - Ulcers - Plaques - Pseudoembranes Detection of toxin by cytotoxic assays or immunoassays

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98 Pseudomembranous Colitis (Clostridium Difficile colitis)
Treatmeant: - Antibiotic cessation - Fever – Abdominal pain - => Outpatient 10 days metronidazol (oral vancomycin is second choice) - Probiotics - Vancomycin Enema - Stool Transplantation

99 Pseudomembranous Colitis (Clostridium Difficile colitis)
- Severe diarrhea + dehydration + fever & abdominal pain => Bowel rest + IV hydration + Oral metronidazol or Vancomycin - Fulminant colitis => Septicemia or evidence of Perforation => Total abdominal colectomy + end ileostomy


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