COLON James Taclin C. Banez, MD. Anatomy / Physiology: Location, blood supply & venous drainage, lymphatic drainage and nerve supply Location, blood supply

COLONCOLONJames Taclin C. Banez, MDJames Taclin C. Banez, MD

Anatomy / Physiology:Anatomy / Physiology:• Location, blood supply Location, blood supply

& venous drainage, & venous drainage, lymphatic drainage lymphatic drainage and nerve supplyand nerve supply

• Function: Function: • absorption of fluid absorption of fluid

and electrolyteand electrolyte• Transport and Transport and

temporary storage temporary storage of fecesof feces

Anatomy / Physiology:Anatomy / Physiology:

1.1. Amebic colitis:Amebic colitis:Entamoeba histolyticaEntamoeba histolytica Primary – colon : secondary – liverPrimary – colon : secondary – liver Fecal to oral route: (sexual contact, Fecal to oral route: (sexual contact,

contaminated water & food)contaminated water & food) Abdominal pain, bloody diarrhea, Abdominal pain, bloody diarrhea,

tenesmus, fevertenesmus, fever

Complication:Complication: megacolon / colonic obstruction (partial) ---> megacolon / colonic obstruction (partial) --->

AMEBOMA AMEBOMA – mass of inflammatory tissue– mass of inflammatory tissue

DxDx:: clin hx / stool exam / indirect clin hx / stool exam / indirect hemagglutination testhemagglutination test

Tx:Tx: metronidazole / iodoquinol : rare metronidazole / iodoquinol : rare COLECTOMYCOLECTOMY

Infectious:Infectious:

2.2. Pseudomembranous colitis:Pseudomembranous colitis:• Complication of antibiotics ---> alteration of normal Complication of antibiotics ---> alteration of normal

floraflora• Overgrowth of Overgrowth of Clostridium deficileClostridium deficile::

• Has Has cytopathiccytopathic and and enteropathic toxinsenteropathic toxinsDevelops 6wks after:Develops 6wks after:

a.a. ClindamycinClindamycinb.b. AmpicillinAmpicillinc.c. CephalosporinCephalosporin

Dx:Dx: - history - history - latex fixation test- latex fixation test - colonoscopy (- colonoscopy (PseudomembranePseudomembrane))

Tx:Tx: 1. stopped antibiotic ----> 1. stopped antibiotic ----> metronidazole/vancomycinmetronidazole/vancomycin2. 2. cholestyraminecholestyramine ---> binds w/ toxin ---> binds w/ toxin3. Toxic megacolon---> 3. Toxic megacolon---> total colectomy w/ total colectomy w/ ileostomyileostomy

3.3. Salmonellosis: Salmonellosis: Salmonella typhiSalmonella typhi (typhoid fever) (typhoid fever)

Dx:Dx: perforation / bleeding perforation / bleeding

Tx:Tx: antibiotic / transfusion / right hemicolectomy w/ antibiotic / transfusion / right hemicolectomy w/ or w/o ileostomyor w/o ileostomy

4.4. Actinomycosis:Actinomycosis:A. israeliA. israeli (gm + anaerobic or microaerophilic (gm + anaerobic or microaerophilic

bacterium)bacterium)• Characteristic: - chronic inflammatory induration Characteristic: - chronic inflammatory induration

and sinus formationand sinus formation• Cervicofacial area most frequent siteCervicofacial area most frequent site• Abdomen – involves the cecum after APAbdomen – involves the cecum after AP

Tx:Tx: surgical drainage and antibiotic (penicillin/ surgical drainage and antibiotic (penicillin/ tetracycline)tetracycline)

Volvulus:Volvulus:• Twisting of an air-filled segment of bowel Twisting of an air-filled segment of bowel

about its narrow mesentery ---> about its narrow mesentery ---> OBSTRUCTIONOBSTRUCTION -------> -------> STRANGULATIONSTRANGULATION ----> ----> GANGRENEGANGRENE--------> > PERFORATIONPERFORATION ----> ----> PERITONITISPERITONITIS

1.1. SIGMOID VOLVULUS (90%):SIGMOID VOLVULUS (90%):• Redundant sigmoid colonRedundant sigmoid colon

w/ a narrow based mesocolonw/ a narrow based mesocolonSx:Sx: colicky abd. pain, distention colicky abd. pain, distention

obstipation, rectal collapseobstipation, rectal collapses/sx of dehydration s/sx of dehydration

Volvulus:Volvulus:1.1. SIGMOID SIGMOID

VOLVULUS VOLVULUS (90%):(90%):

Dx:Dx: FPA – FPA – inverted U inverted U shaped sausage shaped sausage like loop like loop (diagnostic)(diagnostic)

• Barium enema – Barium enema – bird beaks bird beaks deformitydeformity

• Gangrene – Gangrene – chills/fever, chills/fever, leukocytosis w/ s/x leukocytosis w/ s/x of peritonitisof peritonitis

1.1. SIGMOID VOLVULUS SIGMOID VOLVULUS (90%):(90%):

Tx: Tx:

(-) Signs of Peritonitis:(-) Signs of Peritonitis: Reduced the volvulus --->prepare for Reduced the volvulus --->prepare for

elective colonic surgery for the elective colonic surgery for the recurrence is 40%:recurrence is 40%:

- use of flexible scope- use of flexible scope

(+) Signs of Peritonitis / (+) Signs of Peritonitis / Unsuccessful reduction:Unsuccessful reduction:

Sigmoidectomy w/ Hartmanns or Sigmoidectomy w/ Hartmanns or Divine’s colostomyDivine’s colostomy

2.2. Cecal Volvulus:Cecal Volvulus:Tx:Tx: reduction is impossible --> emergency reduction is impossible --> emergency

explorationexploration(+) Gangrene:(+) Gangrene: - right hemicolectomy - right hemicolectomy

- end to end ileo-transverse - end to end ileo-transverse colostomycolostomy

(-) Gangrene:(-) Gangrene: a) – same –a) – same –

b) Cecopexyb) Cecopexy

c) Pure detorsion (recurrence 7 – c) Pure detorsion (recurrence 7 – 15%)15%)

3.3. Transverse colon volvulus:Transverse colon volvulus: Rare, due to it’s broad based and short Rare, due to it’s broad based and short

mesenterymesentery

Tx:Tx: resection of redundant transverse colon resection of redundant transverse colon

DIVERTICULOSIS:DIVERTICULOSIS:Abnormal pouchAbnormal pouch from the wall of a hollow organ from the wall of a hollow organ

Types:Types:1.1. True diverticulaTrue diverticula (rare) – right side (rare) – right side

2.2. False diverticulaFalse diverticula (common) – due to low fiber diet: left (common) – due to low fiber diet: left sideside

Rare before 30y/o; common > 75 y/oRare before 30y/o; common > 75 y/o Female > MaleFemale > Male

Etiology:Etiology:1.1. UnknownUnknown

2.2. Theories by Painter et al:Theories by Painter et al:

a)a) Contraction ringContraction ring (thickening of circular muscle) (thickening of circular muscle)

b)b) Depletion of dietary fibersDepletion of dietary fibers ---> narrow lumen ---> narrow lumen

c)c) Deteriorating integrity of the bowel wallDeteriorating integrity of the bowel wall; elderly ; elderly has lower tensile strength, lowest in the sigmoid)has lower tensile strength, lowest in the sigmoid)

DIVERTICULOSIS:DIVERTICULOSIS:Pathology:Pathology:

Site:Site: arteriole arteriole penetrates the penetrates the mesenteric side mesenteric side of the of the antimesenteric antimesenteric teniae coli:teniae coli:1.1. SigmoidSigmoid

(50%)(50%)2.2. Descending Descending

coloncolon (40%) (40%)3.3. Entire colonEntire colon

(2-10%)(2-10%)

DIVERTICULOSIS:DIVERTICULOSIS:Clinical Manifestation:Clinical Manifestation:A.A. Majority are Majority are asymptomaticasymptomatic

B.B. Symptomatic patients:Symptomatic patients:1.1. Uncomplicated painful diverticular Uncomplicated painful diverticular

dse.dse. (+) LLQ (+) LLQ pain and tenderness; pain and tenderness; (+) change in bowel habits(+) change in bowel habits (-) rebound tenderness(-) rebound tenderness (-) fever nor leukocytosis(-) fever nor leukocytosis

Dx:Dx: Gastrografin enema Gastrografin enema

Tx:Tx: high fiber diet high fiber diet

2.2. Complicated diverticular Complicated diverticular disease:disease:

a.a. Diverticulitis / Peridiverticulitis:Diverticulitis / Peridiverticulitis: Infected diverticulaInfected diverticula Diverticula is filled up ---> Diverticula is filled up --->

obstructed ---> mucus secretion obstructed ---> mucus secretion and bacteria ---> inflammation at and bacteria ---> inflammation at the apex ---> unresolved --> the apex ---> unresolved --> extend intramurally ---> extend intramurally ---> perforate.perforate.


a.a. Diverticulitis / Peridiverticulitis:Diverticulitis / Peridiverticulitis:Sx:Sx: - left lower abd. pain / chills - left lower abd. pain / chills

& fever / & fever /

bowel habit changesbowel habit changes

- (+) abd. Tenderness, - (+) abd. Tenderness, distension if w/ distension if w/

partial obstructionpartial obstruction

- para-rectal tenderness - para-rectal tenderness

- frequency / urgency of - frequency / urgency of urination urination

(inflamed bladder)(inflamed bladder)

2.2. Complicated Complicated diverticular disease:diverticular disease:

a.a. Diverticulitis / Diverticulitis / Peridiverticulitis:Peridiverticulitis:

Dx: Dx:

1)1) Cln. Hx.Cln. Hx.

2)2) Ct scan of the abd / Ct scan of the abd / utrasonography utrasonography (thickened wall & (thickened wall & abscess can be seen)abscess can be seen)

3)3) Contrast enema / Contrast enema / sigmoidoscopy sigmoidoscopy

(risk of spreading (risk of spreading infection)infection)


a.a. Diverticulitis / Diverticulitis / Peridiverticulitis:Peridiverticulitis:

Tx:Tx:

1)1) NPO or liquid dietNPO or liquid diet

2)2) Broad spectrum antibioticBroad spectrum antibiotic

3)3) Meperidine (not morphine)Meperidine (not morphine)

4)4) If improved If improved endoscopy to r/o CA endoscopy to r/o CA


b.b. Perforated Diverticulitis:Perforated Diverticulitis:Sx:Sx: - similar to appendicitis - similar to appendicitis

(Phlegmon mass)(Phlegmon mass)- (+) pneumoperitoneum- (+) pneumoperitoneum

Classification of perforated diverticulitis Classification of perforated diverticulitis (Hinchy)(Hinchy)

Stage IStage I: : abscess confined by mesentery of abscess confined by mesentery of coloncolon

Stage IIStage II: : pelvic abscesspelvic abscess

Stage IIIStage III: : generalized peritonitisgeneralized peritonitis

Stage IVStage IV: : fecal peritonitis fecal peritonitis


b.b. Perforated Diverticulitis:Perforated Diverticulitis:TxTx: initial none operative:: initial none operative:

- NPO / IVF / Broad spectrum - NPO / IVF / Broad spectrum antibiotic/antibiotic/

meperidinemeperidine

Stage I & II: Stage I & II:

(+) improvement (+) improvement elective Surgery (4 elective Surgery (4 wks)wks)

(-) improvement (-) improvement percutaneous percutaneous drainagedrainage

(-) improvement ---> Surgery(-) improvement ---> Surgery


b.b. Perforated Diverticulitis:Perforated Diverticulitis:Stage III & IV: Stage III & IV: explore after initial explore after initial

resuscitationresuscitation

a. sigmoidectomy w/ primary a. sigmoidectomy w/ primary anastomosisanastomosis

b. sigmoidectomy w/ Hartmann’s b. sigmoidectomy w/ Hartmann’s colostomycolostomy

c. resection w/ primary anastomosis w/ c. resection w/ primary anastomosis w/

proximal diverting stomaproximal diverting stoma

2.2. Complicated diverticular disease:Complicated diverticular disease:

c.c. Obstructing diverticulitis:Obstructing diverticulitis: 90% partial90% partial – due to spasm, edema & – due to spasm, edema &

ileusileus 10% complete10% complete – fibrosis and stenosis – fibrosis and stenosis S/Sx: of large intestinal obstructionS/Sx: of large intestinal obstruction Tx: conservative mx (3-5 days) ---> (-) Tx: conservative mx (3-5 days) ---> (-)

response -----> cecum dilates to 10-12 response -----> cecum dilates to 10-12 cm. ---> surgery.cm. ---> surgery.

2.2. Complicated Complicated diverticular diverticular disease:disease:

d.d. Acute Acute hemorrhage:hemorrhage:

Due to erosion Due to erosion of the of the peridiverticulaperidiverticular arteriole by r arteriole by inspissated inspissated stool w/in the stool w/in the diverticulum diverticulum and thinning and thinning of the tunica of the tunica mediamedia

DIVERTICULOSIS:DIVERTICULOSIS:Clinical Manifestation:Clinical Manifestation:

B.B. Symptomatic patients:Symptomatic patients:

2.2. Complicated Complicated diverticular disease:diverticular disease:

d.d. Acute hemorrhage:Acute hemorrhage:- Resuscitate the patientResuscitate the patient- Locate the site of Locate the site of

bleeding (Tc labeled bleeding (Tc labeled RBC/selective RBC/selective arteriography)arteriography)

- Vasopressin Vasopressin infusion, infusion, transcatheter embolitranscatheter emboli infusion using gelfoaminfusion using gelfoam

- ColonoscopyColonoscopy- Tx: segmental Tx: segmental

resection / blind resection / blind subtotal colectomysubtotal colectomy

DIVERTICULOSIS:DIVERTICULOSIS:Clinical Manifestation:Clinical Manifestation:B.B. Symptomatic patients:Symptomatic patients:


d.d. Fistula formation:Fistula formation: Bladder, vagina, small bowel, skinBladder, vagina, small bowel, skin Dx: Dx: - clin hx & PE (pneumaturia, - clin hx & PE (pneumaturia,

fecaluria and fecaluria and

frequent UTI)frequent UTI)

- cystoscopy, IE, speculum - cystoscopy, IE, speculum examexam

- methylene blue enema- methylene blue enema

- colonoscopy to r/o CA- colonoscopy to r/o CA

DIVERTICULOSIS:DIVERTICULOSIS:Clinical Manifestation:Clinical Manifestation:B.B. Symptomatic patients:Symptomatic patients:


d.d. Fistula formation:Fistula formation: Tx: - bowel rest w/ TPN or elemental dietTx: - bowel rest w/ TPN or elemental diet

- Foley catheter (10 days - Foley catheter (10 days postop) / antibioticpostop) / antibiotic

- placement of ureteral catheter - placement of ureteral catheter prior to prior to

celiotomyceliotomy - sigmoidectomy w/ primary - sigmoidectomy w/ primary

anastomosisanastomosis - fistulectomy and closure of - fistulectomy and closure of

secondary secondary openingopening

Hemorrhage from the Hemorrhage from the Colon:Colon:1.1. Diverticular diseaseDiverticular disease2.2. AngiodysplasiaAngiodysplasia (Vascular (Vascular

ectasia, AV malformation, ectasia, AV malformation, AngiectasiaAngiectasia))

ANGIODYSPLASIAANGIODYSPLASIA Acquired lesionAcquired lesion Proximal colon (cecum) where Proximal colon (cecum) where

tension is greatest (Laplace’s law – tension is greatest (Laplace’s law – tension in the wall is highest in the tension in the wall is highest in the widest circumference)widest circumference)

Rare < 40y/o; common in elderlyRare < 40y/o; common in elderly Etiology: - chronic intermittent Etiology: - chronic intermittent

obstruction of submucosal veins due obstruction of submucosal veins due to repeated muscular contractionto repeated muscular contraction

ANGIODYSPLASIAANGIODYSPLASIA

Dx: Dx: - - Nuclear scan / Nuclear scan /

angiographyangiography = =

(vascular tuft and (vascular tuft and

early filling of early filling of veins)veins)

- - colonoscopycolonoscopy = =

distinct red distinct red

mucosal patchmucosal patch

Management of Massive Management of Massive Lower GIBLower GIB Bleeding distal to the ligament of Bleeding distal to the ligament of

Treitz:Treitz:1.1. Diverticular diseaseDiverticular disease2.2. AngiodysplasiaAngiodysplasia3.3. Inflammatory bowel diseaseInflammatory bowel disease4.4. Ischemic colitisIschemic colitis5.5. TumorTumor6.6. Anticoagulant therapyAnticoagulant therapy

Gastroduodenal hgeGastroduodenal hge -> can present as -> can present as rectal bleedingrectal bleeding

It is more important to identify the It is more important to identify the location of the BLEEDING POINT than location of the BLEEDING POINT than the immediate diagnosis as the cause.the immediate diagnosis as the cause.

Management of Massive Management of Massive Lower GIBLower GIB

Diagnostic:Diagnostic:1.1. Nuclear imaging Nuclear imaging

(bleeding (bleeding scan/scintigraphy)scan/scintigraphy)

a.a. Technetium-Sulfur Colloid Technetium-Sulfur Colloid ScanScan

Sensitive (0.5ml/min)Sensitive (0.5ml/min)

b.b. Autologous labeled RBC scanAutologous labeled RBC scan Stays in the circulation for as Stays in the circulation for as

long as 24 hrs (monitoring)long as 24 hrs (monitoring) (1ml/min bleeding)(1ml/min bleeding)

2.2. Mesenteric AngiographyMesenteric Angiography Done once patient’s condition Done once patient’s condition

is stable and hydration is is stable and hydration is adequateadequate

Identify bleeding point ---> Identify bleeding point ---> 1ml/min1ml/min

Could be therapeutic ---> Could be therapeutic ---> Vasopressin/emboliVasopressin/emboli

Vascular taft (A)Vascular taft (A)

Early filling vein (B)Early filling vein (B)

Management of Massive Management of Massive Lower GIBLower GIB

Diagnostic:Diagnostic:

3.3. Emergent colonoscopy:Emergent colonoscopy: Possible w/ use of GOLYTELYPossible w/ use of GOLYTELY TherapeuticTherapeutic

Treatment:Treatment: Restore intravascular volume (85% Restore intravascular volume (85%

stop spontaneously)stop spontaneously) Persistent --> celiotomy (segmental Persistent --> celiotomy (segmental

or total colectomy)or total colectomy)

Ischemic ColitisIschemic Colitis Due to occlusion of major mesenteric Due to occlusion of major mesenteric

vesselvessel Thrombosis, embolization, iatrogenic ligation)Thrombosis, embolization, iatrogenic ligation)

Elderly:Elderly: - contraceptive pills- contraceptive pills

- medical problems:- medical problems:

a) cardiovascular diseasea) cardiovascular disease

b) DMb) DM

c) Rheumatoid arthritisc) Rheumatoid arthritis Splenic flexureSplenic flexure – most common site in – most common site in

the colonthe colon

Ischemic Colitis:Ischemic Colitis:Clinical Syndrome Based on:Clinical Syndrome Based on:

Extent of vascular occlusionExtent of vascular occlusion Duration of occlusionDuration of occlusion Efficiency of collateral circulationEfficiency of collateral circulation Extent of secondary bacterial invasionExtent of secondary bacterial invasion

1.1. Reversible or Transient Ischemic Reversible or Transient Ischemic Colitis:Colitis:

Partial mucosal slough that healed after 2-3 daysPartial mucosal slough that healed after 2-3 days

2.2. Stricturing Ischemic Colitis:Stricturing Ischemic Colitis: Arterial occlusion ---> hge’ic infarct of mucosa ---Arterial occlusion ---> hge’ic infarct of mucosa ---

> ulcerates ----> bacterial invasion of bowel ---> > ulcerates ----> bacterial invasion of bowel ---> fibrosisfibrosis

Ischemic Colitis:Ischemic Colitis:

Clinical Syndrome Based on:Clinical Syndrome Based on:3.3. Gangrenous ischemic Colitis:Gangrenous ischemic Colitis:

Complete arterial occlusion ---> full Complete arterial occlusion ---> full thickness infarction ---> gangrene ---> thickness infarction ---> gangrene ---> perforation ----> PERITONITIS.perforation ----> PERITONITIS.

Ischemic Colitis:Ischemic Colitis:Symptoms:Symptoms:

Depends on the stage of the lesionDepends on the stage of the lesion Acute mild to moderate generalized Acute mild to moderate generalized

or lower abdominal crampy pain ---or lower abdominal crampy pain ---> HEMATOCHEZIA> HEMATOCHEZIA

Hyperactive bowel sound ---> silentHyperactive bowel sound ---> silent Abdominal tenderness ---> persist Abdominal tenderness ---> persist

--->r/o peritonitis--->r/o peritonitis


Diagnosis:Diagnosis: Clinical hx & PEClinical hx & PE FPAFPA ---> ---> adynamic ileusadynamic ileus (stops at (stops at

the involved segment); the involved segment); PneumoperitoneumPneumoperitoneum

Contrast enemaContrast enema (water soluble) (water soluble)

- - thumb printingthumb printing in the in the mucosamucosa

EndoscopyEndoscopy (risky) (risky)


Treatment:Treatment:Emergency celiotomyEmergency celiotomy

- segmental resection - segmental resection w/ primary w/ primary

anastomosis or anastomosis or colostomycolostomy

Megacolon:Megacolon: Large colon due to chronic Large colon due to chronic

dilatation, elongation and dilatation, elongation and hypertrophy of the colonhypertrophy of the colon

Due to chronic partial colonic Due to chronic partial colonic obstruction w/ associated chronic obstruction w/ associated chronic constipationconstipation

Degree of megacolon is proportional Degree of megacolon is proportional to duration of obstructionto duration of obstruction

Megacolon:Megacolon:1.1. Congenital MegacolonCongenital Megacolon (Hirschsprung (Hirschsprung

disease)disease) Congenital absence of ganglion cells in the Congenital absence of ganglion cells in the

myenteric plexus (submucosa) of the bowel myenteric plexus (submucosa) of the bowel ((aganglionosisaganglionosis))

Usually involves the rectosigmoidUsually involves the rectosigmoid Must be sent to Patho and confirm the presence of Must be sent to Patho and confirm the presence of

ganglionganglion

2.2. Acquired megacolonAcquired megacolon Chaga’s disease (trypanosoma cruzi)Chaga’s disease (trypanosoma cruzi) Neurologic disorders / psychotic patientsNeurologic disorders / psychotic patients Cut higher than 2 cm Cut higher than 2 cm

Fecal impaction:Fecal impaction: Is the arrest and accumulation of the Is the arrest and accumulation of the

feces in the rectum or colon (dehydrated feces in the rectum or colon (dehydrated feces).feces).

Overflow diarrhea w/o relief of the sense Overflow diarrhea w/o relief of the sense of rectal fullnessof rectal fullness

Result to Result to stercoral ulcer (in the stercoral ulcer (in the plating)plating) --> bleeding and perforation --> bleeding and perforation

Mx:Mx: - tap water enema / manual - tap water enema / manual extractionextraction

- hot sitz bathhot sitz bath

Inflammatory Bowel Inflammatory Bowel Diseases:Diseases:1.1. Ulcerative colitis (Mucosal Ulcerative Ulcerative colitis (Mucosal Ulcerative

Colitis / Idiopathic Ulcerative Colitis):Colitis / Idiopathic Ulcerative Colitis): involve the colonic mucosa – only the coloninvolve the colonic mucosa – only the colon male > femalemale > female limited to the colon and rectumlimited to the colon and rectum Chronic inflammation of GI tractChronic inflammation of GI tract

2.2. Crohn’s Disease (Chronic Interstitial Crohn’s Disease (Chronic Interstitial Enteritis/Regional Ilietis):Enteritis/Regional Ilietis):

transmural inflammation anywhere in the GIT – transmural inflammation anywhere in the GIT – affects entire wallaffects entire wall

extraintestinal symptoms proceeds those of extraintestinal symptoms proceeds those of intestinal symptomsintestinal symptoms

female > malefemale > male Chronic inflammation of GI tractChronic inflammation of GI tract

Inflammatory Bowel Inflammatory Bowel Disease: Disease:

Signs and SymptomsSigns and SymptomsCrohn’s DiseaseCrohn’s Disease Ulcerative Ulcerative

ColitisColitis

SymptomsSymptomsdiarrheadiarrhea ++++++ ++++++

rectal bleedingrectal bleeding ++ ++++++

tenesmustenesmus 00 ++++++

abdominal painabdominal pain ++++++ ++

feverfever ++++ ++

vomitingvomiting ++++++ 00

weight lossweight loss ++++++ ++

SignsSigns

perianal diseaseperianal disease ++++++ 00

abdominal massabdominal mass ++++++ 00

malnutritonmalnutriton ++++++ ++

Inflammatory Bowel Inflammatory Bowel Diseases:Diseases:

Ulcerative Ulcerative ColitisColitis

Crohn’s Crohn’s ColitisColitis

Usual LocationUsual Location rectum, left colonrectum, left colon anywhereanywhere

Rectal BleedingRectal Bleeding common, common, continuouscontinuous

uncommon, uncommon, intermittentintermittent

Rectal Rectal involvementinvolvement

almost alwaysalmost always approximate 50%approximate 50%

FistulasFistulas rarerare commoncommon

UlcersUlcers shaggy, irregular, shaggy, irregular, continuous continuous distributiondistribution

linear w/ linear w/ transverse fissures transverse fissures (cobblestone or (cobblestone or skip lesion)skip lesion)

Bowel strictureBowel stricture rare (suspect rare (suspect carcinoma)carcinoma)

commoncommon

CarcinomaCarcinoma increase incidenceincrease incidence increased increased incidenceincidence

Toxic dilatation Toxic dilatation of colon of colon (megacolon)(megacolon)

Occurs in bothOccurs in both

Inflammatory Bowel Inflammatory Bowel Diseases:Diseases:Chronic Chronic

Ulcerative Ulcerative Colitis:Colitis:

Mild & Mod. acute Mild & Mod. acute findings:findings: mucosal edemamucosal edema crypt abscesscrypt abscess rectal involvementrectal involvement

Severe acute Severe acute disease:disease: Pseudopolyps w/ Pseudopolyps w/

marked mucosal marked mucosal inflammation & inflammation & edemaedema

Late changes:Late changes: Discrete ulcers, pusDiscrete ulcers, pus

Inflammatory Bowel Inflammatory Bowel Diseases:Diseases:Crohn’s Disease:Crohn’s Disease:

Early findings:Early findings: rectal sparing rectal sparing perianal diseaseperianal disease aphthous ulcerationaphthous ulceration

Moderate changes:Moderate changes: linear ulcerslinear ulcers cobblestoningcobblestoning skip lesionsskip lesions

Late changes:Late changes: Contact bleedingContact bleeding Confluent ulcersConfluent ulcers Strictures & mucosal Strictures & mucosal

bridgingbridging



Morphologic Features of Crohn’s Morphologic Features of Crohn’s Disease:Disease:

Suggestive of Crohn’s Disease:Suggestive of Crohn’s Disease:1.1. Focal inflammation in the mucosaFocal inflammation in the mucosa2.2. Ileal involvementIleal involvement3.3. Linear or fissuring ulcersLinear or fissuring ulcers4.4. Rectal sparingRectal sparing5.5. Right sided predominanceRight sided predominance

Highly suggestive of Crohn’s disease:Highly suggestive of Crohn’s disease:1.1. Discontinuous segmental involvementDiscontinuous segmental involvement2.2. Aphthoid ulcersAphthoid ulcers

Pathognomonic of Crohn’s disease:Pathognomonic of Crohn’s disease:1.1. Sarcoid granulomasSarcoid granulomas2.2. Transmural inflammation w/ lymphoid nodulesTransmural inflammation w/ lymphoid nodules3.3. Fistulas (at sites other than anus)Fistulas (at sites other than anus)

Bowel Involvement in Bowel Involvement in Crohn’s DiseaseCrohn’s Disease(exam question)(exam question)

1.1. Ileocolic Ileocolic 44%44%

2.2. ColonicColonic 28%28%

3.3. Small bowel onlySmall bowel only 27%27%

4.4. AnorectalAnorectal 3% 3%


Extra-intestinal Nonhepatic Manifestations of Extra-intestinal Nonhepatic Manifestations of Idiopathic Inflammatory Bowel Disease: Idiopathic Inflammatory Bowel Disease: (hypothetical autoimmune disease) (don’t (hypothetical autoimmune disease) (don’t need to memorize this list)need to memorize this list)

Musculoskeletal:Musculoskeletal: Blood & Vascular SystemBlood & Vascular System− ankylosing spondylitis and sacroiliitisankylosing spondylitis and sacroiliitis - anemia - anemia− peripheral arthritisperipheral arthritis - thrombocytosis - thrombocytosis− pelvic osteomyelitispelvic osteomyelitis - leucocytosis - leucocytosis

Skin and Mouth:Skin and Mouth: - - hypercoagulable statehypercoagulable state− erythema nodosumerythema nodosum− pyoderma gangrenosumpyoderma gangrenosum Kidneys & Kidneys &

GenitourinaryGenitourinary − aphthous stomatitisaphthous stomatitis - nephrolithiasis - nephrolithiasis

Eye:Eye: - obstructive uropathy- obstructive uropathy− uveitis (iritis)uveitis (iritis) - fistulas to genitourinary - fistulas to genitourinary− episcleritis episcleritis Other:Other: - Pleurocarditis & - Pleurocarditis &

Bronchopulmonary vaxculitisBronchopulmonary vaxculitis

Medical Therapy for Ulcerative Medical Therapy for Ulcerative Colitis & Crohn’s DiseaseColitis & Crohn’s Disease

1.1. Sulfasalazine – lowers the inflammationSulfasalazine – lowers the inflammation2.2. Metronidazole (as well as 2Metronidazole (as well as 2ndnd gen gen

cephalosporin)cephalosporin) Crohn’s ileocolitis & colitisCrohn’s ileocolitis & colitis Perineal colitisPerineal colitis Not effective in active ulcerative colitisNot effective in active ulcerative colitis

3.3. Corticosteroid – lowers antibody Corticosteroid – lowers antibody Oral for mild to moderate active ulcerative Oral for mild to moderate active ulcerative

colitis and Crohn’s diseasecolitis and Crohn’s disease Parenteral for severe or toxic ulcerative colitis Parenteral for severe or toxic ulcerative colitis

or Crohn’s diseaseor Crohn’s disease

4.4. Immunosuppressive agents:Immunosuppressive agents: Steroid sparingSteroid sparing Refractory diseaseRefractory disease

Indications for Surgical Indications for Surgical Interventions for Ulcerative Interventions for Ulcerative

Colitis:Colitis:

1.1. Active disease Active disease unresponsive to medical unresponsive to medical therapytherapy

2.2. Risks of cancer – based on Risks of cancer – based on workupworkup

3.3. Severe bleedingSevere bleeding

Surgical treatment for Surgical treatment for Ulcerative ColitisUlcerative Colitis

1.1. Proctocolectomy w/ Brooke ileostomy Proctocolectomy w/ Brooke ileostomy (brings ileum to the skin):(brings ileum to the skin):

curative w/ one operationcurative w/ one operation

2.2. Colectomy w/ ileorectal anastomosis:Colectomy w/ ileorectal anastomosis: not curative; cancer risk persists (5-50%)not curative; cancer risk persists (5-50%) contraindicated for severe rectal dse, rectal contraindicated for severe rectal dse, rectal

dysplasia and rectal CAdysplasia and rectal CA

3.3. Total proctocolectomy w/ ileoanal Total proctocolectomy w/ ileoanal anastomosis w/ pouch (best therapy):anastomosis w/ pouch (best therapy):

curative w/ continencecurative w/ continence contraindicated for Crohn’s dse, diarrhea, contraindicated for Crohn’s dse, diarrhea,

rectal CA rectal CA

Surgical treatment for Surgical treatment for Ulcerative ColitisUlcerative Colitis

Indications for Indications for Surgical Treatment of Surgical Treatment of

Crohn’s DseaseCrohn’s Dsease1.1. Ileocolic Crohn’s Disease:Ileocolic Crohn’s Disease: Internal fistula and abscessInternal fistula and abscess 38%38% Intestinal obstructionIntestinal obstruction 37%37% Perianal fistulaPerianal fistula 15%15% Poor response to medical therapyPoor response to medical therapy 6%6%

2.2. Colonic Crohn’s Disease (when Colonic Crohn’s Disease (when surgery participates):surgery participates):

Internal fistula and abscessesInternal fistula and abscesses25%25%

Perianal diseasePerianal disease 23%23% Severe dse w/ poor response Severe dse w/ poor response to medical therapyto medical therapy 21%21% Toxic megacolonToxic megacolon 19%19% Intestinal obstructionIntestinal obstruction 12%12%

COLO – RECTAL POLYPSCOLO – RECTAL POLYPS Projection from the surface of Projection from the surface of

the intestinal mucosa regardless the intestinal mucosa regardless of it’s histologic nature:of it’s histologic nature:

Types:Types:1.1. NeoplasticNeoplastic2.2. HamartomatousHamartomatous3.3. InflammatoryInflammatory4.4. UnclassifiedUnclassified

COLO – RECTAL POLYPSCOLO – RECTAL POLYPSNeoplastic Polyps:Neoplastic Polyps:

Invasive CA are common in polyps smaller Invasive CA are common in polyps smaller than 1 cm in diameter and incidence than 1 cm in diameter and incidence increases w/ increase in sizeincreases w/ increase in size

TypesTypes IncidenceIncidence

(%)(%)Malignant Malignant Potential Potential

(%)(%)

TubularTubular 7575 55

VillousVillous 1010 4040

TubulovillouTubulovillouss

1515 2222

COLO – RECTAL POLYPSCOLO – RECTAL POLYPS

Neoplastic Polyps:Neoplastic Polyps:Diagnosis:Diagnosis:

bleeding per rectum (most common)bleeding per rectum (most common) Villous polyp (large) ---> watery diarrhea Villous polyp (large) ---> watery diarrhea

and in rare cases can have fluid and and in rare cases can have fluid and electrolyte imbalanceelectrolyte imbalance

do complete examination of the colon - do complete examination of the colon - colonoscopycolonoscopy

biopsy / transrectal ultrasonographybiopsy / transrectal ultrasonography

COLO – RECTAL POLYPSCOLO – RECTAL POLYPSNeoplastic Polyps:Neoplastic Polyps:Treatment:Treatment:

Polypectomy for benign Polypectomy for benign ---> follow up---> follow up

(+) CA in situ ----> (+) CA in situ ----> polypectomypolypectomy

(+) invasive CA (invade (+) invasive CA (invade the muscularis mucosa) the muscularis mucosa)

9% metastasize to LN if 9% metastasize to LN if pedunculated pedunculated

20% metastasize to LN if 20% metastasize to LN if it invades the stalk or neckit invades the stalk or neck

15% metastasize to LN if 15% metastasize to LN if sessilesessile

CANCER SURGERYCANCER SURGERY

COLO – RECTAL POLYPSCOLO – RECTAL POLYPSNeoplastic Polyps:Neoplastic Polyps:Treatment:Treatment:

If entire mucosal surface is covered by villous If entire mucosal surface is covered by villous tumor ---> segmental resection, if in rectum tumor ---> segmental resection, if in rectum can do full thickness proximal protectomy w/ can do full thickness proximal protectomy w/ coloanal anastomosiscoloanal anastomosis

COLO – RECTAL POLYPSCOLO – RECTAL POLYPSHamartomatous Polyp:Hamartomatous Polyp:1.1. Juvenile Polyp:Juvenile Polyp:

not precancerousnot precancerous excisionexcision Swiss cheese appearanceSwiss cheese appearance from dilated cystic from dilated cystic

spacesspaces

2.2. Familial Juvenile Polyposis Coli:Familial Juvenile Polyposis Coli: thousands polyps in the colon and rectumthousands polyps in the colon and rectum can degenerate to adenoma ----> malignancycan degenerate to adenoma ----> malignancy subtotal colectomy or proctocolectomysubtotal colectomy or proctocolectomy

COLO – RECTAL POLYPSCOLO – RECTAL POLYPSHamartomatous Polyp:Hamartomatous Polyp:3.3. Peutz-jegher SyndromePeutz-jegher Syndrome

a.a. Melanin spot on buccal mucosa, lips, face and Melanin spot on buccal mucosa, lips, face and digitsdigits

b.b. Polyps of small bowel (always), stomach, colon Polyps of small bowel (always), stomach, colon and rectum (branching of lamina propria like and rectum (branching of lamina propria like Christmas treeChristmas tree).).

Can degenerate into malignancyCan degenerate into malignancy

4.4. Cronkhite – Canada Syndrome:Cronkhite – Canada Syndrome: GIT polyposis, alopecia, cutaneous pigmentation, GIT polyposis, alopecia, cutaneous pigmentation,

atrophy of fingernails and toe nailsatrophy of fingernails and toe nails

5.5. Cowden’s Syndrome:Cowden’s Syndrome: Autosomal dominant, hamartomas of all three Autosomal dominant, hamartomas of all three

embryonal cell layersembryonal cell layers Facial trichilemomas, breast cancer, thyroid dse, Facial trichilemomas, breast cancer, thyroid dse,

GIT polypGIT polyp

COLO – RECTAL POLYPSCOLO – RECTAL POLYPSInfammatory Polyp:Infammatory Polyp:

Caused by previous attacks of severe colitis Caused by previous attacks of severe colitis resulting in partial loss of mucosa leaving resulting in partial loss of mucosa leaving remnants or islands of normal mucosaremnants or islands of normal mucosa

Occurs after amebic colitis, ischemic colitis Occurs after amebic colitis, ischemic colitis and Schistosomal colitisand Schistosomal colitis

Not premalignantNot premalignant

Hyperplastic Polyp:Hyperplastic Polyp: Usually small < 5mm not premalignantUsually small < 5mm not premalignant > 2cm. have a slight risk of malignant > 2cm. have a slight risk of malignant

degenerationdegeneration Saw tooth appearance of the lining Saw tooth appearance of the lining

epithelial cellsepithelial cells

COLO – RECTAL POLYPSCOLO – RECTAL POLYPSFamilial Adenomatous Polyposis Coli:Familial Adenomatous Polyposis Coli:

Inherited non-sex linked autosomal dominant Inherited non-sex linked autosomal dominant disease w/ hundreds of adenomatous polyps disease w/ hundreds of adenomatous polyps through the entire colon and rectumthrough the entire colon and rectum

1.1. Gardner’s Syndrome:Gardner’s Syndrome: Familial polyposis, osteomatosis, epidermoid Familial polyposis, osteomatosis, epidermoid

cyst, fibromas of the skin (desmoid tumor) – the cyst, fibromas of the skin (desmoid tumor) – the most important extra-colonic expression.most important extra-colonic expression.

Tx: Tx: - total proctocolectomy w/ ileostomy- total proctocolectomy w/ ileostomy

- colectomy w/ ileorectal anastomosis- colectomy w/ ileorectal anastomosis

- examine other members of the family- examine other members of the family

COLO – RECTAL POLYPSCOLO – RECTAL POLYPSFamilial Adenomatous Polyposis Coli:Familial Adenomatous Polyposis Coli:2.2. Turcot’s Syndrome:Turcot’s Syndrome:

Familial polyposis, brains tumors (gliomas or Familial polyposis, brains tumors (gliomas or medulloblastomas)medulloblastomas)

Tx:Tx: same w/ colorectal involvementsame w/ colorectal involvement

Hereditary Nonpolyposis Colon Cancer Hereditary Nonpolyposis Colon Cancer (HNCC):(HNCC):

Lynch’s syndromeLynch’s syndrome Error in mismatch repair (RER pathway)Error in mismatch repair (RER pathway) Appear more common in proximal colonAppear more common in proximal colon Associated w/ extra-colonic malignancies Associated w/ extra-colonic malignancies

(endometrial, ovarian, pancreas, stomach, small (endometrial, ovarian, pancreas, stomach, small bowel, biliary & Urinary)bowel, biliary & Urinary)

Carcinoma of ColonCarcinoma of Colon Most common CA of the GITMost common CA of the GIT Older age grp; peak incidence 80y/oOlder age grp; peak incidence 80y/o male ( > rectum) ; female ( > colon)male ( > rectum) ; female ( > colon) Etiology:Etiology:

1.1. UnknownUnknown

2.2. HereditaryHereditary

3.3. Diet --> low fiber diet and high animal fatDiet --> low fiber diet and high animal fat Distribution --> shifting to the right Distribution --> shifting to the right

side side

Carcinoma of ColonCarcinoma of ColonMacroscopic form:Macroscopic form:1.1. Ulcerating typeUlcerating type most most

commoncommon2.2. Polypoid or fungatingPolypoid or fungating3.3. Colloid CA Colloid CA

bulky growth w/ gelatinous appearancebulky growth w/ gelatinous appearance 10-15%10-15%

4.4. Signet ring cell CASignet ring cell CA intracellular mucinous intracellular mucinous

5.5. Infiltrating CAInfiltrating CA submucosal spreadsubmucosal spread

Carcinoma of ColonCarcinoma of Colon

Microscopic form:Microscopic form:adenocarcinomaadenocarcinoma

GronnellGronnell: based on invasive tendency, : based on invasive tendency, glandular arrangement, nuclear polarity glandular arrangement, nuclear polarity and frequency of mitosis.and frequency of mitosis.Grade IGrade I - low grade / well differentiated- low grade / well differentiated

Grade IIGrade II - average grade / mod. - average grade / mod. differentiateddifferentiated

Grade IIIGrade III - high grade / poorly differentiated- high grade / poorly differentiated

Carcinoma of ColonCarcinoma of ColonMechanism of Spread:Mechanism of Spread:

1.1. Direct spreadDirect spread

2.2. Transperitoneal spreadTransperitoneal spread

3.3. ImplantationImplantation

4.4. LymphaticLymphatic

5.5. HematogenousHematogenous Liver & LungsLiver & Lungs – most common – most common

distant spreaddistant spread

Carcinoma of ColonCarcinoma of ColonDuke’s Stage:Duke’s Stage:

Depth of bowel wall involvementDepth of bowel wall involvement Presence or absence of LN metastasisPresence or absence of LN metastasis

Stage A:Stage A: Invasion at least through the muscularis Invasion at least through the muscularis

mucosa but not through the muscularis mucosa but not through the muscularis propriapropria

98% ---> 5yr survival98% ---> 5yr survival

Stage B:Stage B: Invasion through full thickness of bowel wall; Invasion through full thickness of bowel wall;

(-) LN(-) LN 78% ----> 5yr survival78% ----> 5yr survival

Carcinoma of ColonCarcinoma of ColonDuke’s Stage:Duke’s Stage:Stage C:Stage C:

LN metastasis, regardless of depthLN metastasis, regardless of depth

Stage C1Stage C1:: - only adjacent LN metastasis- only adjacent LN metastasis

Stage C2Stage C2: - LN involves are nodes at : - LN involves are nodes at point of ligature of blood vesselspoint of ligature of blood vessels

32% 5 yr survival32% 5 yr survival

Stage D:Stage D: Distant metastasis or w/ adjacent organ Distant metastasis or w/ adjacent organ

involvementinvolvement 0% 5 yr survival0% 5 yr survival

TNM Staging of Colonic TNM Staging of Colonic CACA

Primary Tumor (T):Primary Tumor (T):TXTX - Primary tumor cannot be assessed- Primary tumor cannot be assessedT0 T0 - No evidence of primary tumor- No evidence of primary tumorT1T1 - Tumor invades submucosa- Tumor invades submucosaT2T2 - Tumor invades muscularis proper- Tumor invades muscularis properT3T3 - Tumor invades through the muscularis - Tumor invades through the muscularis properproper

into the subserosa or into into the subserosa or into nonperitonealized nonperitonealized

pericolic or perirectal tissuepericolic or perirectal tissueT4T4 - Tumor perforates the visceral peritoneum - Tumor perforates the visceral peritoneum or or

directly invades the organs or structuresdirectly invades the organs or structures

TNM Staging of Colonic TNM Staging of Colonic CACARegional Lymph Node (N):Regional Lymph Node (N):

NXNX – Regional LN cannot be assessed – Regional LN cannot be assessedN0N0 - No regional LN metastasis - No regional LN metastasisN1 N1 - Metastasis in 1 to 3 pericolic or perirectal - Metastasis in 1 to 3 pericolic or perirectal LNLNN2N2 - metastasis in 4 or more pericolic or - metastasis in 4 or more pericolic or

perirectal LNperirectal LNN3N3 - Metastasis in any LN along the course of a - Metastasis in any LN along the course of a

named vascular trunknamed vascular trunk

Distant Metastasis (M):Distant Metastasis (M):MXMX – Presence of distant metastasis cannot be – Presence of distant metastasis cannot be assessedassessedM0 M0 - No distant metastasis- No distant metastasisM1 M1 - w/ distant metastasis - w/ distant metastasis

TNM Staging of Colonic TNM Staging of Colonic CACA

StageStage I:I: T1 –T2T1 –T2 N0N0 M0M090% 5y/r Survival90% 5y/r Survival

Stage II:Stage II: T3 – T4T3 – T4 N0N0 M0M060 – 80% 5 y/r survival60 – 80% 5 y/r survival

Stage III:Stage III: Any TAny T N1N1 M0M0Any TAny T N2, N3N2, N3 M0M020 – 50% 5y/r survival20 – 50% 5y/r survival

Stage IV;Stage IV; Any TAny T Any NAny N M1M1< 5% 5 yr survival< 5% 5 yr survival

Risk Factors for Risk Factors for Colorectal CAColorectal CA

1.1. Aging is the dominant risk factorAging is the dominant risk factor w/ w/ rising incidence after rising incidence after 50 y/o.50 y/o.

2.2. Hereditary risk factor:Hereditary risk factor: 80% colorectal are sporadic80% colorectal are sporadic 20% w/ known family hx.20% w/ known family hx.

3.3. Dietary factors:Dietary factors: high animal fathigh animal fat (saturated or polyunsaturated (saturated or polyunsaturated

fats), but oleic acid (coconut & fish oil does not).fats), but oleic acid (coconut & fish oil does not). Vegetable fiber, Ca, selenium, Vits. A, C, & E Vegetable fiber, Ca, selenium, Vits. A, C, & E

are protectiveare protective Alcohol Alcohol increase colonic CAincrease colonic CA

4.4. Obesity and sedentary lifestyle Obesity and sedentary lifestyle contributorycontributory

5.5. SmokingSmoking increased the incidence increased the incidence

Premalignant Diseases of Premalignant Diseases of Colon & RectumColon & Rectum

1.1. AdenomaAdenoma

2.2. Familial adenomatous polyposis Familial adenomatous polyposis syndromesyndrome

3.3. Gardner’s syndromeGardner’s syndrome

4.4. HamartomaHamartomas (familial juvenile polyposis s (familial juvenile polyposis coli & Peutz-Jegher polypcoli & Peutz-Jegher polyp

5.5. Inflammatory bowel diseaseInflammatory bowel diseasea.a. Ulcerative colitisUlcerative colitis

b.b. Crohn’s diseaseCrohn’s disease

6.6. SchistosomiasisSchistosomiasis (Billharziasis) – S. mansoni (Billharziasis) – S. mansoni & &

S. japonicumS. japonicum

7.7. Utero-sigmoidostomy Utero-sigmoidostomy

Genetic Defects for Genetic Defects for Colorectal CAColorectal CA

Mutation may cause:Mutation may cause:

1.1. Activation of:Activation of: K-ras (an K-ras (an

oncogene)oncogene)

2.2. Inactivation of Inactivation of tumortumor- suppressor gene:suppressor gene:

APCAPC DCC (deleted in DCC (deleted in

colorectal colorectal carcinoma)carcinoma)

p53p53

Genetic Pathways for Genetic Pathways for Tumor Initiation and Tumor Initiation and

ProgressionProgression1.1. LOH pathway:LOH pathway:

Chromosomal deletion and tumor Chromosomal deletion and tumor aneuploidyaneuploidy

80% of colorectal carcinoma80% of colorectal carcinoma

2.2. RER pathwayRER pathway (replication error): (replication error): Error in mismatch repair during DNA Error in mismatch repair during DNA

replicationreplication 20% of colorectal carcinoma20% of colorectal carcinoma

Carcinoma of ColonCarcinoma of ColonClinical Manifestation:Clinical Manifestation:

Change in bowel habitChange in bowel habit classic symptoms classic symptoms Rectal bleedingRectal bleeding Weight lossWeight loss Abdominal pain, bloating and other signs of Abdominal pain, bloating and other signs of

obstructionobstruction Anemia and anorexiaAnemia and anorexia Tenesmus, feeling of incomplete evacuation, Tenesmus, feeling of incomplete evacuation,

and rectal bleeding if lesion is in the rectumand rectal bleeding if lesion is in the rectum

Screening Modalities For Screening Modalities For Colonic TumorsColonic Tumors

1.1. Fecal occult blood testing:Fecal occult blood testing: Annual FOBT screening for asymptomatic 50 Annual FOBT screening for asymptomatic 50

y/oy/o

2.2. Rigid proctoscopy / flexible Rigid proctoscopy / flexible sigmoidoscopysigmoidoscopy

3.3. Colonoscopy:Colonoscopy: The most accurate and most complete method The most accurate and most complete method

for examining the colonfor examining the colon

4.4. Air contrast Barium enema:Air contrast Barium enema:5.5. CT colonography (virtual CT colonography (virtual

colonoscopy):colonoscopy): Colon is insufflated with air and a spiral CT is Colon is insufflated with air and a spiral CT is

performed.performed. Useful for imaging the proximal colon in case of Useful for imaging the proximal colon in case of

obstructionobstruction

Therapy for Colonic Therapy for Colonic CarcinomaCarcinoma

Principle:Principle: Objective is to remove the primary tumor Objective is to remove the primary tumor

w/ its lymphovascular supplyw/ its lymphovascular supply Adjacent organs or tissue invaded shd be Adjacent organs or tissue invaded shd be

resected en block w/ the tumorresected en block w/ the tumor Tumors cannot be removed, a palliative Tumors cannot be removed, a palliative

procedure shd be done.procedure shd be done. Synchronous CASynchronous CA ---> subtotal or total ---> subtotal or total

colectomycolectomy Metachronous tumorMetachronous tumor (second primary (second primary

colon CA) treated similarlycolon CA) treated similarly Hemorrhage in an unresectable tumor can Hemorrhage in an unresectable tumor can

be controlled w/ angiographic be controlled w/ angiographic embolizationembolization


Stage 0:Stage 0: No risk of LN metastasisNo risk of LN metastasis Pedunculated / sessile polyp -> Pedunculated / sessile polyp -> endoscopic endoscopic

polypectomypolypectomy If polyp cannot be removed completely segmental If polyp cannot be removed completely segmental

resection shd be doneresection shd be done

Stage I: (T1,N0,M0):Stage I: (T1,N0,M0): PolypectomyPolypectomy --> for uninvolved stalk (pedunculated) --> for uninvolved stalk (pedunculated) Segmental resection:Segmental resection:

1.1. Sessile polypSessile polyp

2.2. Pedunculated polyp ( Pedunculated polyp ( lymphovascular invasion, lymphovascular invasion, poorly differentiated or tumor w/in 1mm. of poorly differentiated or tumor w/in 1mm. of resection marginresection margin ---> high risk of local recurence ---> high risk of local recurence and metastatic spread)and metastatic spread)


Stage II (T3-4,N0,M0):Stage II (T3-4,N0,M0): Surgical resection Surgical resection Adjuvant chemotherapy is suggested for:Adjuvant chemotherapy is suggested for:

1.1. Young patientYoung patient2.2. Moderate to poorly differentiatedModerate to poorly differentiated

Stage III (Tany,N1,M0):Stage III (Tany,N1,M0): Surgical resection + adjuvant Surgical resection + adjuvant

chemotherapy chemotherapy (5-Fluorouracil, (5-Fluorouracil, levamisole or leucovorin, capecitabine, levamisole or leucovorin, capecitabine, irinotecan, oxaliplatin, angiogenesis irinotecan, oxaliplatin, angiogenesis inhibitor and immunotherapy)inhibitor and immunotherapy)


Stage IV: (Tany, Nany, M1)Stage IV: (Tany, Nany, M1) Palliative resection of primary and Palliative resection of primary and

isolated liver metastasis isolated liver metastasis Adjuvant chemotherapyAdjuvant chemotherapy Irresectable ---> diverting colostomyIrresectable ---> diverting colostomy

THANK THANK YOUYOU

Therapy of Rectal Therapy of Rectal CarcinomaCarcinoma

Principle the same w/ colonic CA, Principle the same w/ colonic CA, but more difficult to achieve but more difficult to achieve negative radial margins bec. of negative radial margins bec. of anatomic limitations of the pelvisanatomic limitations of the pelvis

Local recurrence is higher w/ similar Local recurrence is higher w/ similar stage of colonic CA.stage of colonic CA.

Easier to treat rectal tumors w/ Easier to treat rectal tumors w/ radiations due to less structures radiations due to less structures radiation-sensitive structures in the radiation-sensitive structures in the pelvispelvis

Therapy for Rectal Therapy for Rectal CarcinomaCarcinoma

1.1. Transanal endoscopic microsurgeryTransanal endoscopic microsurgery

2.2. Radical resectionRadical resection: - removal of the : - removal of the involved segment of the rectum along with involved segment of the rectum along with its lymphovascular supply w/ a margin of 2 its lymphovascular supply w/ a margin of 2 cm distal mural margin. cm distal mural margin.

a.a. Total mesorectal excision (TME)Total mesorectal excision (TME)

b.b. APRAPR

3.3. Pelvic exenterationPelvic exenteration: --> enbloc resection : --> enbloc resection of the ureters, bladder, prostate, uterus and of the ureters, bladder, prostate, uterus and vagina together w/ APR. w/ permanent vagina together w/ APR. w/ permanent colostomy and ileal conduit. Sacrectomy up colostomy and ileal conduit. Sacrectomy up to level of S2-S3 junction if necessary.to level of S2-S3 junction if necessary.


Stage 0 (Tis, N0,M0)Stage 0 (Tis, N0,M0) Local excision w/ 1 cm marginLocal excision w/ 1 cm margin

Stage I: (T1-2,N0,M0)Stage I: (T1-2,N0,M0) Polypectomy --> confined to the head of Polypectomy --> confined to the head of

the polypthe polyp Radical resection --> sessile uT1N0 and Radical resection --> sessile uT1N0 and

uT2N0 rectal CAuT2N0 rectal CA


Stage II (T3-4,N0,M0):Stage II (T3-4,N0,M0): 2 school of thought 2 school of thought1.1. Total mesorectal resection onlyTotal mesorectal resection only2.2. Radical resection w/ chemo-radiation Radical resection w/ chemo-radiation

given preoperatively or postoperativelygiven preoperatively or postoperatively

Advantages of preop chemoradiation:Advantages of preop chemoradiation: Down grade the tumor can increased Down grade the tumor can increased

likelihood of resection and sphincter saving likelihood of resection and sphincter saving procedureprocedure

Disadvantages of preop chemoradiation:Disadvantages of preop chemoradiation:1.1. Over treatment of early stage tumorsOver treatment of early stage tumors2.2. Impaired wound healingImpaired wound healing3.3. Pelvic fibrosis increases the risk of operative Pelvic fibrosis increases the risk of operative

complications complications


Advantages of postoperative radiation:Advantages of postoperative radiation:1.1. Allows accurate pathologic staging of the Allows accurate pathologic staging of the

resected tumor and LNresected tumor and LN2.2. Avoids wound healing problems associated w/ Avoids wound healing problems associated w/

preop radiationpreop radiation

Stage III (Tany,N1,M0):Stage III (Tany,N1,M0): Radical resection followed w/ neodjuvant Radical resection followed w/ neodjuvant

therapytherapy

Stage IV (Tany, Nany, M1)Stage IV (Tany, Nany, M1) Proximal diverting colostomy for obstruction Proximal diverting colostomy for obstruction

(lower) / intraluminal stenting (upper)(lower) / intraluminal stenting (upper) Radical resection to control bleeding, pain and Radical resection to control bleeding, pain and

tenesmustenesmus

Follow-up and Surveillance Follow-up and Surveillance for Colorectal CAfor Colorectal CA

Annual colonoscopyAnnual colonoscopy CEA determinationCEA determination CT scan done if CEA is elevatedCT scan done if CEA is elevated

Anal Canal & Perianal Anal Canal & Perianal TumorsTumors

Uncommon; 2% Uncommon; 2% colorectal CAcolorectal CA

Anal margin – distal to Anal margin – distal to dentate linedentate line

Anal canal – proximal Anal canal – proximal to dentate lineto dentate line


1.1. Anal intraepithelial neoplasm (AIN) Anal intraepithelial neoplasm (AIN) Bowen’s diseaseBowen’s disease Squamous cell CA in situ of the anusSquamous cell CA in situ of the anus Precursor to an invasive squamous cell CAPrecursor to an invasive squamous cell CA Associated w/ infection of Associated w/ infection of human papilloma human papilloma

virus, HIV-positive homosexualvirus, HIV-positive homosexual Tx: Tx: resection / ablationresection / ablation High recurrence ---> 3-6 months follow upHigh recurrence ---> 3-6 months follow up


2.2. Epidermoid carcinomaEpidermoid carcinoma Squamous cell CA, Cloacogenic CA, Squamous cell CA, Cloacogenic CA,

Transitional CA, Basaloid CA.Transitional CA, Basaloid CA. Slow growing; present as mass or perianal Slow growing; present as mass or perianal

massmass Anal margin --> wide local excisionAnal margin --> wide local excision Anal canal or invading anal sphincter --> Anal canal or invading anal sphincter -->

Nigro protocolNigro protocol ( 5-fluorouracil, mitomycin ( 5-fluorouracil, mitomycin C, 3000cGy external beam radiation). 80% C, 3000cGy external beam radiation). 80% are curedare cured

Recurrence ---> APRRecurrence ---> APR


3.3. Verrucous carcinomaVerrucous carcinoma Buschke-Lowenstein Tumor, Giant Buschke-Lowenstein Tumor, Giant

condyloma accuminatacondyloma accuminata.. Do not metastasizeDo not metastasize Wide excision / radical resectionWide excision / radical resection

4.4. Basal cell carcinomaBasal cell carcinoma Rarely metastasizeRarely metastasize Wide excision tx of choice; recurrence Wide excision tx of choice; recurrence

--->APR &/or radiation therapy--->APR &/or radiation therapy


5.5. Adenocarcinoma:Adenocarcinoma: Usually a downward spread of low rectal CAUsually a downward spread of low rectal CA Could arise from anal glds or developed from Could arise from anal glds or developed from

chronic fistula; also from apocrine gld (Paget’s chronic fistula; also from apocrine gld (Paget’s dse)dse)

Tx: Tx: - radical resection w/ or w/o - radical resection w/ or w/o chemoradiationchemoradiation

- Paget’s dse = wide excision- Paget’s dse = wide excision

6.6. Melanoma:Melanoma: Poor prognosis; 5yr survival --> 10% due to Poor prognosis; 5yr survival --> 10% due to

sytemic metastasis &/or deeply invasive tumorssytemic metastasis &/or deeply invasive tumors Wide local resection / APR Wide local resection / APR Adjuvant chemotherapy, biochemotherapy, Adjuvant chemotherapy, biochemotherapy,

vaccines, radiotherapyvaccines, radiotherapy

Anorectal AbscessAnorectal Abscess5 potential 5 potential

spaces:spaces:1.1. Perianal spacePerianal space2.2. Ischiorectal Ischiorectal

spacespace3.3. Intersphincteric Intersphincteric

spacespace4.4. Deep posterior Deep posterior

anal spaceanal space5.5. Supralevator Supralevator

spacespace

Anorectal AbscessAnorectal AbscessEtiology:Etiology:

Infection of anal glandInfection of anal gland Organism (fecal & cutaneous flora)Organism (fecal & cutaneous flora)

1.1. E. coliE. coli 4. Clostridium sp.4. Clostridium sp.2.2. Bacteroides fragilisBacteroides fragilis 5. 5.

StaphylococcusStaphylococcus3.3. StreptococcusStreptococcus

Manifestation:Manifestation: Pain in the anal regionPain in the anal region

Treatment:Treatment: Drainage / antibioticDrainage / antibiotic HygieneHygiene Hot sitz bathHot sitz bath

Anorectal AbscessAnorectal AbscessTypes :Types :

1.1. Perianal abscessPerianal abscess

2.2. Ischiorectal abscessIschiorectal abscess – diffuse – diffuse

swelling of ischiorectal fossaswelling of ischiorectal fossa

Anorectal AbscessAnorectal Abscess3.3. Intersphincteric abscess:Intersphincteric abscess:

No apparent sign of swelling or induration in No apparent sign of swelling or induration in the perianal areathe perianal area

CLUE: --> deep seated tenderness when CLUE: --> deep seated tenderness when circum-anal pressure is applied above the circum-anal pressure is applied above the dentate line.dentate line.

Drainage: thru the anal canal lining or thru Drainage: thru the anal canal lining or thru internal sphincteric muscleinternal sphincteric muscle

4.4. Supralevator abscess:Supralevator abscess: UncommonUncommon Mimmic acute intra-abdominal conditionMimmic acute intra-abdominal condition Etiology: extension ofEtiology: extension of

a.a. Intersphincteric abscessIntersphincteric abscessb.b. Ischiorectal abscessIschiorectal abscessc.c. Intra-abdominal abscess Intra-abdominal abscess

Necrotizing Peri-anal & Perineal Necrotizing Peri-anal & Perineal Infection:Infection:

Etiology:Etiology:1.1. Neglected or delayed treatment of primary Neglected or delayed treatment of primary

anorectal infectionanorectal infection

2.2. Extension of UTI particularly the periurethral glandExtension of UTI particularly the periurethral gland

Manifestation:Manifestation: Pain, tenderness and swelling with crepitation of Pain, tenderness and swelling with crepitation of

perianal and scrotum or labiaperianal and scrotum or labia Black spot on the site (necrosis)Black spot on the site (necrosis)

Treatment:Treatment: Broad spectrum antibioticBroad spectrum antibiotic Debridement Debridement Hyperalimentation / diverting colostomy &/or Hyperalimentation / diverting colostomy &/or

cystostomycystostomy

Fistula-In-Fistula-In-Ano:Ano:

Inflammatory tract w/ Inflammatory tract w/ secondary opening secondary opening (external) and a primary (external) and a primary opening (internal) in the opening (internal) in the anal canal.anal canal.

Etiology:Etiology: Complication of perianal Complication of perianal

abscessabscess

Goodsalls Rule: Goodsalls Rule: to locate internal openingto locate internal opening

Classification of Fistula-Classification of Fistula-in-ano:in-ano:

1.1. Inter-sphinctericInter-sphincteric

2.2. Trans-sphinctericTrans-sphincteric

3.3. Supra-sphinctericSupra-sphincteric

4.4. Extra-sphinctericExtra-sphincteric

Fistula-in-anoFistula-in-anoManifestation:Manifestation:

Previous history of Previous history of perianal abscessperianal abscess

Rule out ulcerative Rule out ulcerative colitis and Crohn’s colitis and Crohn’s dse (colonoscopy / dse (colonoscopy / barium enema)barium enema)

Treatment:Treatment:1.1. Identify the primary Identify the primary

opening opening (probing/methylene (probing/methylene blue/fistulography)blue/fistulography)

2.2. Fistulotomy / Fistulotomy / fistulectomy fistulectomy (healing by (healing by secondary intensionsecondary intension

Fistula-in-anoFistula-in-ano If fistula is high in relation to anorectal If fistula is high in relation to anorectal

ring do 2 stage procedure:ring do 2 stage procedure:1.1. Insert a seton wire or suture to the tract Insert a seton wire or suture to the tract

for several wks to create fibrosisfor several wks to create fibrosis2.2. Open the fibrous track on the second stage Open the fibrous track on the second stage

after 6-8 wksafter 6-8 wks

HemorrhoidHemorrhoid Are cushions of submucosal tissue in Are cushions of submucosal tissue in

the anal canal composed of the anal canal composed of connective tissue containing venules, connective tissue containing venules, arterioles and smooth muscle fibers.arterioles and smooth muscle fibers.

Purposed – aids in anal continence Purposed – aids in anal continence and cushion the anal canal and and cushion the anal canal and support the lining during defecationsupport the lining during defecation

1.1. External skin tagExternal skin tag Redundant fibrotic skin at the anal Redundant fibrotic skin at the anal

verge due to previous thrombosed verge due to previous thrombosed external hemorrhoid of past operationexternal hemorrhoid of past operation

HemorrhoidHemorrhoid 2.2. External hemorrhoidExternal hemorrhoid

Dilated venules of the inferior Dilated venules of the inferior hemorrhoidal plexus located distal to hemorrhoidal plexus located distal to the pectinate or dentate linethe pectinate or dentate line

HemorrhoidHemorrhoid3.3. Internal hemorrhoid:Internal hemorrhoid:

Manifestation:Manifestation: Painless bright red rectal bleeding associated w/ Painless bright red rectal bleeding associated w/

bowel movementbowel movement Feeling of incomplete evacuation of fecesFeeling of incomplete evacuation of feces Pain is experienced if w/ complication of anal Pain is experienced if w/ complication of anal

fissure, stenosis of thrombosisfissure, stenosis of thrombosis

Grade According to Degree of Prolapse:Grade According to Degree of Prolapse:11stst degree degree: anal cushion slide down beyond : anal cushion slide down beyond the the

dentate line on strainingdentate line on strainingMx: Mx: - painless rectal bleeding- painless rectal bleedingTx: Tx: - bulk forming agents (psyllium - bulk forming agents (psyllium seed)seed)- rubber band ligation- rubber band ligation

HemorrhoidHemorrhoidRubber band ligation:Rubber band ligation:

HemorrhoidHemorrhoid22ndnd degree: degree:

Prolapse through the anus on straining but Prolapse through the anus on straining but spontaneously reducedspontaneously reduced

33rdrd degree: degree: Requires manual reduction into the anal canalRequires manual reduction into the anal canal Tx: rubber band ligation / hemorrhoidectomyTx: rubber band ligation / hemorrhoidectomy

44thth degree: degree: Prolapse cannot be reducedProlapse cannot be reduced hemorrhoidectomyhemorrhoidectomy

Anal FissureAnal Fissure Tear from the dentate line up to the Tear from the dentate line up to the

anal verge lined by skinanal verge lined by skin Seen in young and middle age groupSeen in young and middle age group Majority occurs at the at the Majority occurs at the at the

posterior midline due to poor posterior midline due to poor muscular supportmuscular support

Anal FissureAnal FissureEtiology:Etiology:1.1. Passage of large hard stoolPassage of large hard stool2.2. Conditions ( Crohn’s dse, ulcerative colitis, Conditions ( Crohn’s dse, ulcerative colitis,

syphilis’ tuberculosis and leukemia)syphilis’ tuberculosis and leukemia)Manifestation:Manifestation:

Burning pain during and after bowel movementBurning pain during and after bowel movement Bright red blood on toilet paperBright red blood on toilet paper

Diagnosis: Diagnosis: Rectal examination / proctosigmoidoscopyRectal examination / proctosigmoidoscopy

Treatment:Treatment: Conservative:Conservative: - anal hygiene / bulk forming - anal hygiene / bulk forming

agentsagents- hot sitz bathhot sitz bath- local anesthetic jelly- local anesthetic jelly

Surgical: - chronic stage (lateral internal Surgical: - chronic stage (lateral internal sphincterotomy)sphincterotomy)

Anal FissureAnal FissureTreatment:Treatment:

Conservative:Conservative: anal hygiene / bulk anal hygiene / bulk

forming agentsforming agents hot sitz bathhot sitz bath local anesthetic local anesthetic

jellyjelly

Surgical: Surgical: chronic stage chronic stage

(lateral internal (lateral internal sphincterotomy)sphincterotomy)

Documents

COLON James Taclin C. Banez, MD. Anatomy / Physiology: Location, blood supply & venous drainage, lymphatic drainage and nerve supply Location, blood supply