Colo rectal bleeding Colorectal Bleeding: A Multidisciplinary Approach First Joint Meeting with Mayo Clinic and University of Minnesota Colo rectal bleeding (minor Chronic) Dott. Edoardo Formento Dott.ssa Elisabetta Radice Università degli Studi di Torino Azienda Sanitaria Ospedaliera Molinette S.Giovanni Battista di Torino Torino, 31 Marzo – 1 Aprile 2006

Colo rectal bleeding (minor Chronic) Patients evaluation and diagnosis 1. Clinical History 2. Physical exam 3. Anoscopy 4. Rigid Sigmoidoscopy 5. Flexible Sigmoidoscopy Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006

Clinical History Age Family history for cancer Kind of bleeding Colour Colour Quantity Quantity Frequency Frequency Relation to defecation Relation to defecation ClinicalHistory 1 Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006 Symptoms associated Constipation Constipation Diarrhea Diarrhea Abdominal pain Abdominal pain Anorexia Anorexia Weight loss Weight loss Addominal mass Addominal mass Colo rectal bleeding (minor Chronic)

Addominal mass Inguinal linfglands Perineal exam Physical exam 2 Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006 Colo rectal bleeding (minor Chronic) Addominal and Perineal exam

Inspection Perineal Perineal Dermatosis Dermatosis Prolapsing haemorrhoids Prolapsing haemorrhoids Rectal prolapse Rectal prolapse Solitary rectal ulcer Solitary rectal ulcer Anal cancers Anal cancers Sexual transmitted diseases Sexual transmitted diseasesAnalFissures Physical exam 2 Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006 Colo rectal bleeding (minor Chronic)

Rectal digital examination Anal canal Rectal ampulla till 8-10 cm (better then endo us?) Anorectal spaces Anal sphincter complex Pelvic mass Physical exam 2 Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006 Colo rectal bleeding (minor Chronic)

Anoscopy Anal canal Dentate line Anoderm Anoscopy 3 Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006 Colo rectal bleeding (minor Chronic)

Rigid sigmoidoscopy Indications assesment in youg people with bleeding (under 40 years old) assesment in youg people with bleeding (under 40 years old) to mesure the exact distance of a rectal tumor from the anal verge to mesure the exact distance of a rectal tumor from the anal verge to give the precise location of the lesion on the wall to give the precise location of the lesion on the wall follow up of patients treated for rectal adenomas and rectal cancer follow up of patients treated for rectal adenomas and rectal cancer follow up of patients with aspecific proctitis follow up of patients with aspecific proctitis RigidSigm. 4 Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006 Colo rectal bleeding (minor Chronic)

Flexible sigmoidoscopy Preparation ( 2 enemac 4 and 2 hours bifore) Reaches the splenic flexure 80% (M.Sleisenger, Gastrointestinal and liver disease, 2002) Why? 33% right colon cancer diagnosed for anemia 30% “ “ “ “ “ addominal mass 30% “ “ “ “ “ addominal mass 36% “ “ “ “ “ rapid loss weight 36% “ “ “ “ “ rapid loss weight 1% “ “ “ “ “ massive haemorrhage 1% “ “ “ “ “ massive haemorrhage (S.Kelly,Queen Alexandra Hospital, Porthsmouth 2003) (S.Kelly,Queen Alexandra Hospital, Porthsmouth 2003) Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006 FlexibleSigm. 5 Colo rectal bleeding (minor Chronic)

Flexible sigmoidoscopy Indications All patients age > 40 years old All patients age > 40 years old All patients age < 40 years old: All patients age < 40 years old: With an adenoma or carcinoma of the colon in their history out follow-up. With an adenoma or carcinoma of the colon in their history out follow-up. With a carcinoma in any other organ; as in colorectal cancer HNPCC associated (endometrio, gastric and small bowel carcinoma). With a carcinoma in any other organ; as in colorectal cancer HNPCC associated (endometrio, gastric and small bowel carcinoma). With positive family history for colon cancer: relative of 1st degree (if years old risk > 3, if 45 years old risk > 4). If relative of 2nd degree the risk increases more less. With positive family history for colon cancer: relative of 1st degree (if years old risk > 3, if 45 years old risk > 4). If relative of 2nd degree the risk increases more less. With proctocolite already diagnosed. With proctocolite already diagnosed. FlexibleSigm. 5 Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006 Colo rectal bleeding (minor Chronic)

Rectal bleeding unit Positions for ispection Left lateral Jackknife Jackknife Trolley for proctology Anoscopy Sigmoidoscopy Sigmoidoscopy Rubber band ligation Rubber band ligation Biopsy BiopsyVideocolonoscopy Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006 Colo rectal bleeding (minor Chronic)

Colo rectal bleeding (minor Chronic) Colorectal bleeding (minor chronic) Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006

Conclusions 1 The goal of the meeting is to demonstrate the importance for the surgeons who treat the rectal bleeding (haemorrhoids and colorectal adenoma and carcinoma) to use the modern flexible sigmoidoscope and colonscope. For assessment and treatment. For assessment and treatment. Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006 Colo rectal bleeding (minor Chronic)

Conclusions 2 Unit of Physiology 1970 Sir Alan Parks Sir Alan Parks St. Mark’s Hospital St. Mark’s Hospital European school of colorectal surgery European school of colorectal surgery Unit of Rectal Bleeding 1980 Stan Goldberg Stan Goldberg S.Nivatvongs S.Nivatvongs University of Minnesota University of Minnesota American School of Colorectal Surgery American School of Colorectal Surgery Colorectal Bleeding: a Multidisciplinary Approach – Turin, March 2006 Colo rectal bleeding (minor Chronic)