1. Diseases of Large Bowel

4. Diverticulosis of the Colon I. Diverticula of the colon are acquired herniations of colonic mucosa protruding through the circular muscle and the wall of large bowel. Diverticula of the colon are acquired herniations of colonic mucosa protruding through the circular muscle and the wall of large bowel. Localisation - usually in the left part of the large bowel ( sigmoid colon is involved in 90% cases), but they can occur everywhere in large bowel Localisation - usually in the left part of the large bowel ( sigmoid colon is involved in 90% cases), but they can occur everywhere in large bowel Ethiology - muscular incoordination and hypertrophy resulting in increasing segmentation and intraluminal pressure. Ethiology - muscular incoordination and hypertrophy resulting in increasing segmentation and intraluminal pressure.

5. Diverticulosis of the Colon II. Frequency of the disease is increasing with the age. Frequency of the disease is increasing with the age. Clinical features - the disease is very often asymptomatic, or there are some non specific symptoms due to disordered colonic function ( f.e. distension, flatulence ) Clinical features - the disease is very often asymptomatic, or there are some non specific symptoms due to disordered colonic function ( f.e. distension, flatulence ) But the symptoms of the complications are usually very serious. But the symptoms of the complications are usually very serious.

6. Diverticulosis of the Colon III. Diagnosis Diagnosis clinical examination clinical examination X-ray picture with barium enema X-ray picture with barium enema Ultrasonography Ultrasonography Colonoscopy Colonoscopy Cystoscopy, gynecological examination Cystoscopy, gynecological examination

7. Diverticulosis of the Colon IV. Complications: inflammation ( diverticulitis ) inflammation ( diverticulitis ) perforation perforation bleeding bleeding postinflammatory stenosis postinflammatory stenosis obstruction obstruction fistula with the surrounding organs fistula with the surrounding organs ( urinary bladder, vagina ) ( urinary bladder, vagina )

8. Diverticulosis of the Colon V. Treatment Treatment antibiotics, bed rest, liquid diet, spasmolytics ( acute attack of diverticulitis ) antibiotics, bed rest, liquid diet, spasmolytics ( acute attack of diverticulitis ) operation – 10% patients require operation operation – 10% patients require operation one stage resection one stage resection two stage procedures - colostomy two stage procedures - colostomy - exteriorisation of the affected bowel - exteriorisation of the affected bowel - Hartman´s procedure - Hartman´s procedure - fistulas – resection of the bowel and - fistulas – resection of the bowel and closure of the fistula closure of the fistula

11. Ulcerative Colitis I. Aethiology is inknown – possibly is linked with emotional stress, maybe it is auto- immune disease, secondary infection maybe plays some role. Aethiology is inknown – possibly is linked with emotional stress, maybe it is auto- immune disease, secondary infection maybe plays some role. young people young people Pathology – in 95% cases the disease starts in rectum and spreads proximally. Pathology – in 95% cases the disease starts in rectum and spreads proximally. the disease is characterised by appearance of multiple ulcers, sometimes they are discrete sometimes there is a lot of ulcers. the disease is characterised by appearance of multiple ulcers, sometimes they are discrete sometimes there is a lot of ulcers.

12. Ulcerative Colitis II. Clinical features : watery diarhoe occuring day and night, day and night, rectal discharge of mucus rectal discharge of mucus pain, bleeding pain, bleeding 2 types : 1. fulminating type 5% - 2 types : 1. fulminating type 5% - temperature, diarhoe containing temperature, diarhoe containing blood mucus and pus blood mucus and pus 2. chronic type 95% 2. chronic type 95%

13. Ulcerative Colitis III. Treatment : medicaments (antibiotics,corticosteroids, imunossupresive drugs, Treatment : medicaments (antibiotics,corticosteroids, imunossupresive drugs, Remicade ? ) Remicade ? ) Indications for surgical treatment: Indications for surgical treatment: 1. to save life ( perforation, toxic megacolon ) 1. to save life ( perforation, toxic megacolon ) 2. local complications, general 2. local complications, general complications ( liver changes, skin lesions, complications ( liver changes, skin lesions, renal disease, sclerosis cholangitis) renal disease, sclerosis cholangitis) 3. risk of carcinoma 3. risk of carcinoma The method of choice is The method of choice is restorative proctocolectomy restorative proctocolectomy

14. Toxic megacolon I. Clinical term for an acute toxic colitis with nonobstructive colonic dilatation larger than 6 cm and signs of systemic toxicity Clinical term for an acute toxic colitis with nonobstructive colonic dilatation larger than 6 cm and signs of systemic toxicity The dilatation can be either total or segmental. The dilatation can be either total or segmental. - potentially lethal condition - potentially lethal condition The inflammation extending beyond the mucosa into the smooth-muscle layers and serosa. The inflammation extending beyond the mucosa into the smooth-muscle layers and serosa.

15. Toxic megacolon II. Symptoms: Symptoms: High fever High fever Abdominal pain and tenderness Abdominal pain and tenderness Tachycardia Tachycardia Dehydration Dehydration Mortality : 5 – 10 % Mortality : 5 – 10 %

16. Toxic megacolon III. Three main goals: Three main goals: 1. reduce colonic distension to prevent perforation 1. reduce colonic distension to prevent perforation 2. correct fluid and electrolyte disturbances 2. correct fluid and electrolyte disturbances 3. treat toxemia and precipitating factors 3. treat toxemia and precipitating factors Conservative treatment: fluid replacement, antibiotics, steroids, remicade, nasogastric tube, bowel rest Surgical treatment : subtotal or total colectomy.

20. Tumors of Large Bowel A. Benign tumors B. Malignant tumors

21. Benign tumors I. 2 types - tubular adenoma - pedunculated 2 types - tubular adenoma - pedunculated villous adenoma - sessile villous adenoma - sessile They have malignant potential,so they should be removed. They have malignant potential,so they should be removed. Malignancy depends on size and type Malignancy depends on size and type of adenoma. of adenoma. More dangerous are large and villous adenomas More dangerous are large and villous adenomas

22. Benign tumors II. Complications - bleeding, Complications - bleeding, - diarrhoe, hypokalaemia - diarrhoe, hypokalaemia / villous / / villous / Treatment - fibre endoscopic removal Treatment - fibre endoscopic removal - operation - partial colon - operation - partial colon resection (very large polyps ) resection (very large polyps )

26. Familial adenomatous polyposis (FAP) hereditary disease. hereditary disease. The gene for FAP is on the long arm The gene for FAP is on the long arm of chromosome 5 and is called the APC gene. of chromosome 5 and is called the APC gene. There are a lot of polyps / hundreds/ at the colon and rectal mucosa There are a lot of polyps / hundreds/ at the colon and rectal mucosa very strong malignant potential very strong malignant potential Diagnosis : colonoscopy, genetic tests Diagnosis : colonoscopy, genetic tests

27. Familial adenomatous polyposis II. Treatment is surgical 1. colectomy + ileo-rectal anastomosis 1. colectomy + ileo-rectal anastomosis 2. total colectomy with permanent ileostomy 2. total colectomy with permanent ileostomy ( cancer ) ( cancer ) 3. „ restorative proctocolectomy“ 3. „ restorative proctocolectomy“ - proctocolectomy with ileal pouch – anal - proctocolectomy with ileal pouch – anal anastomosis anastomosis

33. Carcinoma of the Colon I. Colon carcinoma originating in the epithelial cells of the colon Colon carcinoma originating in the epithelial cells of the colon M : W = 3 : 2 M : W = 3 : 2 25 % of cases present as emergencies with intestinal obstruction or perforation and peritonitis 25 % of cases present as emergencies with intestinal obstruction or perforation and peritonitis The spread of carcinoma – local spread The spread of carcinoma – local spread ( penetration through intestinal wall ( penetration through intestinal wall to surrounding organs ) to surrounding organs ) lymphatic spread to regional or distant lymphatic spread to regional or distant lymphonodes lymphonodes spread by the blood-stream to liver spread by the blood-stream to liver

34. Carcinoma of the Colon II. Typing, Grading, Staging Typing - the type of tumor – Typing - the type of tumor – adenocarcinoma - 90% adenocarcinoma - 90% „Signet ring cell “ carcinoma „Signet ring cell “ carcinoma Grading well differential carcinoma Grading - well differential carcinoma - moderate differential - moderate differential - poor differential - poor differential Staging spread of the carcinoma Staging - spread of the carcinoma Dukes classification Dukes classification TNM classification TNM classification

35. Carcinoma of the Colon III. Clinical Features Clinical Features carcinoma of the left side (75% cases): pain, alteration of bowel habit ( irregularity ), palpable tumor, bleeding carcinoma of the left side (75% cases): pain, alteration of bowel habit ( irregularity ), palpable tumor, bleeding carcinoma of the right side : aneamia, the presence of a mass in the right iliac fossa carcinoma of the right side : aneamia, the presence of a mass in the right iliac fossa Diagnosis Diagnosis endoscopy - sigmoidoscopy, colonoscopy endoscopy - sigmoidoscopy, colonoscopy radiography with the barium enema radiography with the barium enema ultrasonography ultrasonography CT CT

36. Carcinoma of the Colon IV. Complications - obstruction Complications - obstruction - perforation with stercoral peritonitis - perforation with stercoral peritonitis - bleeding - bleeding Treatment - operation Treatment - operation A. radical A. radical B. paliative : intestinal by-pass, B. paliative : intestinal by-pass, colostomy colostomy Clasic or laparoscopic procedures Clasic or laparoscopic procedures

39. Right side hemicolectomy

40. Left side hemicolectomy

41. Resection of rectum

42. Abdominoperineal rescetion of rectum