1. Colon disease
Dr.mohammadzadeh

2. Arterial blood supply to the colon

3. Venous drainage of the colon

4. The lining of the anal canal.

5. The distal rectum and anal canal

6. Arterial supply to the rectum and anal canal

7. Inflammatory Bowel Disease
Inflammatory bowel disease includes ulcerative colitis, Crohn's disease, and indeterminate colitis.
Ulcerative colitis occurs in eight to 15 people per 100,000 in the United States and Northern Europe.
The incidence is considerably lower in Asia, Africa, and South America.
Ulcerative colitis incidence peaks during the third decade of life and again in the seventh decade of life.
The incidence of Crohn's disease is slightly lower, one to five people per
In 15% of patients with inflammatory bowel disease, differentiation between ulcerative colitis and Crohn's colitis is impossible; these patients are classified as having indeterminate colitis

8. Principles of Nonoperative Management
:Salicylates
Sulfasalazine (Azulfidine), 5-ASA, and related compounds
Antibiotics
Corticosteroids
Immunosuppressive Agents

9. Indications for surgery in ulcerative colitis
Emergency surgery :
massive life-threatening hemorrhage,
toxic megacolon,
or fulminant colitis who fail to respond rapidly to medical therapy

10. Con… Indications for elective surgery :
intractability despite maximal medical therapy
high-risk development of major complications of medical therapy, such as aseptic necrosis of joints secondary to chronic steroid use.
In patients at significant risk of developing colorectal carcinoma.

11. Risk of malignancy increases with pancolonic disease and the duration of symptoms is approximately 2% after 10 years, 8% after 20 years, and 18% after 30 years

12. Indications for Surgery in Crohn
In Crohn's disease, it is impossible to remove all of the at-risk intestine; therefore, surgical therapy is reserved for complications of the disease.
fistulas and/or intra-abdominal abscesses.
strictures

13. Crohn's Colitis fulminant colitis or toxic megacolon.
In this setting, treatment is identical to treatment of fulminant colitis and toxic megacolon secondary to ulcerative colitis.

14. Anal and Perianal Crohn's Disease
Anal and perianal manifestations of Crohn's disease are very common.
Anal or perianal disease occurs in 35% of all patients with Crohn's disease.
Isolated anal Crohn's disease is uncommon, affecting only 3 to 4% of patients.

15. The most common perianal lesions in Crohn's disease are skin tags that are minimally symptomatic.
Fissures also are common. Typically, a fissure from Crohn's disease is particularly deep or broad and perhaps better described as an anal ulcer. They often are multiple and located in a lateral position rather than anterior or posterior midline as seen in an idiopathic fissure in ano.
Perianal abscess and fistulas are common and can be particularly challenging. Fistulas tend to be complex and often have multiple tracts .
Hemorrhoids are not more common in patients with Crohn's disease than in the general population, although many patients tend to attribute any anal or perianal symptom to "hemorrhoids."

16. Nomenclature Diverticulum = sac-like protrusion of the colonic wall
Diverticulosis = describes the presence of diverticuli
Diverticulitis = inflammation of diverticuli

17. Epidemiology Before the 20th century, diverticular disease was rare
Prevalence has increased over time
First reported resection of complicated diverticulitis by Mayo % %

18. Epidemiology
Increases with age
Age 40 <5%
Age %
Age %

19. Epidemiology Gender prevalence depends on age
M>>F Age less than 40
M > F Age 40-50
F > M Ages 50-70
F>>M Ages > 70

20. Anatomic location of diverticuli varies with the geographic location
“Westernized” nations (North America, Europe, Australia) have predominantly left sided diverticulosis
95% diverticuli are in sigmoid colon
35% can also have proximal diverticuli
4% have only right sided diverticuli

21. Anatomic location of diverticuli varies with the geographic location
Asia and Africa diverticulosis in general is rare and usually right sided
Prevalence < 0.2%
70% diverticuli in right colon in Japan

22. What exactly is a diverticulum?
True diverticulum contains all layers of the GI wall (mucosa to serosa)
Colonic pseudo-diverticulum more like a local hernia
Mucosa-submucosa herniates through the muscle layer (muscularis propria) and then is only covered by serosa

24. Pathophysiology
Diverticuli develop in ‘weak’ regions of the colon. Specifically, local hernias develop where the vasa recta penetrate the bowel wall

25. Mucosa
Submucosa
Muscularis
Vasa recta
Serosa

26. Pathophysiology Law of Laplace: P = kT / R
Pressure = K x Tension / Radius
Sigmoid colon has small diameter resulting in highest pressure zone

27. Pathophysiology
Segmentation = motility process in which the segmental muscular contractions separate the lumen into chambers
Segmentation  increased intraluminal pressure  mucosal herniation  Diverticulosis
May explain why high fiber prevents diverticuli by creating a larger diameter colon and less vigorous segmentation

29. Uncomplicated diverticulosis
Usually an incidental finding at time of colonoscopy

32. Uncomplicated diverticulosis
Considered ‘asymptomatic’
However, a significant minority of patients will complain of cramping, bloating, irregular BMs, narrow caliber stools
IBS?
Recent studies demonstrate motility abnormalities in pts with ‘symptomatic’ uncomplicated diverticulosis

33. Uncomplicated diverticulosis
Treatment: Fiber
Bulk content reduces colonic pressure preventing underlying pathophysiology that lead to diverticulosis
20 to 30 g fiber per day is needed; difficult to get with diet alone

34. Pathophysiology of Diverticulitis
Erosion of diverticular wall from increased intraluminal pressure  inflammation  focal necrosis  perforation
Usually inflammation is mild and microperforation is walled off by pericolonic fat and mesentery

35. Diagnosis of Diverticulitis
Classic history: increasing, constant, LLQ abdominal pain over several days prior to presentation with fever
Crescendo quality – each day is worse
Constant – not colicky
Fever occurs in % of cases
In one study, less than 17% of pts with diverticulitis had symptoms for less than 24 hours

36. Diagnosis of Diverticulitis
Right sided diverticulitis tends to cause RLQ abdominal pain; can be difficult to distinguish from appendicitis

37. Diagnosis of Diverticulitis
Clinically, diagnosis can be made with typical history and examination
Radiographic confirmation is often performed
Rules out other causes of an acute abdomen
Determines severity of the diverticulitis

41. Uncomplicated diverticulitis
Bowel rest or restriction
Clear liquids or NPO for 2-3 days
Then advance diet
Antibiotics

42. Uncomplicated diverticulitis
Antibiotics
Coverage of fecal flora
Gram negative rods, anaerobes
Common regimens
Cipro + Flagyl x 10 days

43. Uncomplicated diverticulitis
After resolution of attack  high fiber diet with supplemental fiber

44. Uncomplicated diverticulitis
Follow-up: Colonoscopy in 4-6 weeks
Flexible sigmoidoscopy and BE reasonable alternative
Purpose
Exclude neoplasm
Evaluate extent of the diverticulosis

45. Prognosis after resolution
30-40% of patients will remain asymptomatic
30-40% of pts will have episodic abdominal cramps without frank diverticulitis
20-30% of pts will have a second attack

46. Prognosis after resolution
Second attack
Risk of recurrent attacks is high (>50%)
Some studies suggest a higher rate (60%) of complications (abscess, fistulas, etc) in a second attack and a higher mortality rate (2x compared to initial attack)
After a second attack  elective surgery

47. Prognosis after resolution
Some argue in the elderly recurrent attacks can be managed with medications
Some argue elective surgery should be considered after a first attack in
Young patients under years of age
Immunosuppressed

48. Complicated Diverticulitis
Peritonitis
Resuscitation
Antibiotics
Ampicillin + Gentamycin + Metronidazole
Imipenem/cilastin
Emergency exploration
Mortality 6% purulent peritonitis and 35% fecal peritonitis

49. Complicated Diverticulitis: Abscess
Occurs in 16% of patients with acute diverticulitis
Percutaneous drainage followed by single stage surgery in 60-80% of patients

50. Complicated Diverticulitis: Abscess
CT guided drain
Leave in until drain output less than 10 mL in 24 hours
May take up to 30 days
Catheter sinograms helpful to show persistent communication between abcess and bowel

51. Complicated Diverticulitis: Fistulas

52. Complicated Diverticulitis: Fistulas
Major types
Colovesical fistula 65%
Colovaginal 25%
Coloenteric, colouterine 10%

53. Complicated Diverticulitis: Fistulas - Symptoms
Passage of gas and stool from the affected organ
Colovesical fistula:
pneumaturia, dysuria, fecaluria
50% of patients can have diarrhea and passage of urine per rectum

54. Complicated Diverticulitis: Fistulas
Diagnosis
CT: thickened bladder with associated colonic diverticuli adjacent and air in the bladder
BE: direct visualization of fistula track only occurs in 20-26% of cases
Flexible sigmoidoscopy is low yield (0-3%)
Some argue cystoscopy helpful

55. Complicated Diverticulitis: Treatment of Fistulas
Surgery
Resection of affected colon (origin of the fistula)
Fistula tract can be “pinched off” most of the time
Suture closure for larger defects
Foley left in 7-10 days

56. Diverticular bleeding
Most common cause of brisk hematochezia (30-50% of cases)
15% of patients with diverticulosis will bleed
75% of diverticular bleeding stops without need for intervention

57. Diverticular bleeding
Patients requiring less than 4 units of PRBC/ day  99% will stop bleeding
Risk of rebleeding  14-38%
After second episode of bleeding, risk of rebleeding  21-50%

58. Diverticular bleeding: Pathophysiology
Diverticulum herniates at site of vasa recta
Over time, the vessel becomes draped over the dome of the diverticulum separated only by mucosa
Over time, there is segmental weakening of the artery  ruptures and bleeds

59. Diverticular bleeding: Pathophysiology

60. Diverticular bleeding: Pathophysiology

61. Diverticular bleeding: Symptoms
Most only have symptoms of bloating and diarrhea but no significant abdominal pain
Painless hematochezia
Start – stop pattern; “water faucet”
Diverticulitis rarely causes bleeding

62. Diverticular bleeding: Localization
Right colon is the source of diverticular bleeding in 50-90% of patients
Possible reasons
Right colon diverticuli have wider necks and domes exposing vasa recta over a great length of injury
Thinner wall of the right colon

63. bleeding: Diverticular Localization
Colonoscopy after rapid prep
Can localize site of bleeding
Offers possible therapeutic intervention (cautery, clip, etc)
Often limited by either brisk bleeding obscuring lumen OR no active bleeding with clots in every diverticuli

64. Diverticular bleeding: Management

65. Diverticular bleeding: Localization
Angiography
Accurate localization
30-47% sensitive
100% specific
Need brisk active bleeding: mL/min
Offers therapy: embolization, vasopressin
20% risk of intestinal infarction

66. Diverticular bleeding: Surgery
Segmental resection
If site can be localized
Rebleeding rate of 0-14%
Subtotal colectomy
Rebleeding rate is 0%
High morbidity (37%)
High mortality (11-33%)

67. Hemorrhoids
Hemorrhoids are cushions of submucosal tissue containing venules, arterioles, and smooth-muscle fibers that are located in the anal canal.
hemorrhoidal cushions are found in the left lateral, right anterior, and right posterior positions

68. The distal rectum and anal canal

69. Excessive straining, increased abdominal pressure, and hard stools increase venous engorgement of the hemorrhoidal plexus and cause prolapse of hemorrhoidal tissue.

70. External hemorrhoids
located distal to the dentate line and are covered with anoderm.
Because the anoderm is richly innervated, thrombosis of an external hemorrhoid may cause significant pain.
A skin tag is redundant fibrotic skin at the anal verge, often persisting as the residua of a thrombosed external hemorrhoid. Skin tags are often confused with symptomatic hemorrhoids.
External hemorrhoids and skin tags may cause itching and difficulty with hygiene if they are large.
Treatment of external hemorrhoids and skin tags are only indicated for symptomatic relief

71. Internal hemorrhoids
located proximal to the dentate line and covered by insensate anorectal mucosa.
Internal hemorrhoids may prolapse or bleed, but rarely become painful unless they develop thrombosis and necrosis (usually related to severe prolapse, incarceration, and/or strangulation).

72. Internal hemorrhoids are graded according to the extent of prolapse :
First-degree hemorrhoids bulge into the anal canal and may prolapse beyond the dentate line on straining.
Second-degree hemorrhoids prolapse through the anus but reduce spontaneously.
Third-degree hemorrhoids prolapse through the anal canal and require manual reduction.
Fourth-degree hemorrhoids prolapse but cannot be reduced and are at risk for strangulation

73. Combined internal and external hemorrhoids
Postpartum hemorrhoids
Portal hypertension and Rectal varices

74. Treatment Medical Therapy Rubber Band Ligation
Infrared Photocoagulation
Sclerotherapy
Excision of Thrombosed External Hemorrhoids
Closed Submucosal Hemorrhoidectomy
Open Hemorrhoidectomy
Whitehead's Hemorrhoidectomy

75. Rubber band ligation of internal hemorrhoids.

76. Technique of closed submucosal hemorrhoidectomy

77. Complications of Hemorrhoidectomy
Postoperative pain
Urinary retention
fecal impaction
Bleeding
Infection
incontinence
anal stenosis
ectropion (Whitehead's deformity).

78. Anal Fissure
A fissure in ano is a tear in the anoderm distal to the dentate line.
The pathophysiology of anal fissure is thought to be related to trauma from either the passage of hard stool or prolonged diarrhea.
The vast majority of anal fissures occur in the posterior midline.
Ten to 15% occur in the anterior midline.
Less than 1% of fissures occur off midline

79. Anal fissure is extremely common.88,89
Characteristic symptoms include tearing pain with defecation and hematochezia (usually described as blood on the toilet paper).

80. An acute fissure is a superficial tear of the distal anoderm and almost always heals with medical management.
Chronic fissures develop ulceration and heaped-up edges with the white fibers of the internal anal sphincter visible at the base of the ulcer.
There often is an associated external skin tag and/or a hypertrophied anal papilla internally

81. Open lateral internal sphincterotomy for fissure in ano

82. Closed lateral internal sphincterotomy for fissure in ano

83. Anorectal Sepsis and Cryptoglandular Abscess

84. Anatomy of perianorectal spaces. Anterior view

85. lateral view

86. Pathways of anorectal infection in perianal spaces

87. Technique of drainage of perianal abscess

88. Drainage of horseshoe abscess

89. Fistula in Ano

90. Goodsall's rule

91. Intersphincteric fistula with simple low tract

92. Uncomplicated transsphincteric fistula

93. Uncomplicated suprasphincteric fistula

94. Extrasphincteric fistula secondary to anal fistula

95. Rectal Prolapse Rectal prolapse Procidentia Internal prolapse
internal intussusception
Mucosal prolapse

96. A thorough preoperative evaluation, including colonic transit studies, anorectal manometry, tests of pudendal nerve terminal motor latency, electromyography (EMG), and cinedefecography, may be useful.
The colon should be evaluated by colonoscopy or air-contrast barium enema to exclude neoplasms or diverticular disease.
Cardiopulmonary condition should be thoroughly evaluated because comorbidities may influence the choice of surgical procedure

97. The primary therapy for rectal prolapse is surgery, and more than 100 different procedures have been described to treat this condition.
Operations can be categorized as either abdominal or perineal

98. Transabdominal proctopexy

99. Perineal rectosigmoidectomy

100. Volvulus
Volvulus occurs when an air-filled segment of the colon twists about its mesentery.
The sigmoid colon is involved in up to 90% of cases, but volvulus can involve the cecum (<20%) or transverse colon

101. The symptoms of volvulus are those of acute bowel obstruction.
Patients present with abdominal distention, nausea, and vomiting.
Symptoms rapidly progress to generalized abdominal pain and tenderness.
Fever and leukocytosis are heralds of gangrene and/or perforation

102. Sigmoid volvulus