COLON

1
COLON

• James Taclin C. Banez, MD

2
Anatomy / Physiology

• Location, blood supply venous drainage,
  lymphatic drainage and nerve supply
• Function
• absorption of fluid and electrolyte
• Transport and temporary storage of feces

3
Anatomy / Physiology
4
Infectious

• Amebic colitis
• Entamoeba histolytica
• Primary colon secondary liver
• Fecal to oral route (sexual contact,
  contaminated water food)
• Abdominal pain, bloody diarrhea, tenesmus, fever
• Complication
• megacolon / colonic obstruction (partial) ---gt
  AMEBOMA mass of inflammatory tissue
• Dx clin hx / stool exam / indirect
  hemagglutination test
• Tx metronidazole / iodoquinol rare COLECTOMY

5

• Pseudomembranous colitis
• Complication of antibiotics ---gt alteration of
  normal flora
• Overgrowth of Clostridium deficile
• Has cytopathic and enteropathic toxins
• Develops 6wks after
• Clindamycin
• Ampicillin
• Cephalosporin
• Dx - history
• - latex fixation test
• - colonoscopy (Pseudomembrane)
• Tx 1. stopped antibiotic ----gt
  metronidazole/vancomycin
• 2. cholestyramine ---gt binds w/ toxin
• 3. Toxic megacolon---gt total colectomy w/
  ileostomy

6

• Salmonellosis
• Salmonella typhi (typhoid fever)
• Dx perforation / bleeding
• Tx antibiotic / transfusion / right
  hemicolectomy w/ or w/o ileostomy
• Actinomycosis
• A. israeli (gm anaerobic or microaerophilic
  bacterium)
• Characteristic - chronic inflammatory induration
  and sinus formation
• Cervicofacial area most frequent site
• Abdomen involves the cecum after AP
• Tx surgical drainage and antibiotic (penicillin/
  tetracycline)

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Volvulus

• Twisting of an air-filled segment of bowel about
  its narrow mesentery ---gt OBSTRUCTION -------gt
  STRANGULATION ----gt GANGRENE----gt PERFORATION
  ----gt PERITONITIS
• SIGMOID VOLVULUS (90)
• Redundant sigmoid colon
• w/ a narrow based mesocolon
• Sx colicky abd. pain, distention
• obstipation, rectal collapse
• s/sx of dehydration

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Volvulus

• SIGMOID VOLVULUS (90)
• Dx FPA inverted U shaped sausage like loop
  (diagnostic)
• Barium enema bird beaks deformity
• Gangrene chills/fever, leukocytosis w/ s/x of
  peritonitis

9

• SIGMOID VOLVULUS (90)
• Tx
• (-) Signs of Peritonitis
• Reduced the volvulus ---gtprepare for elective
  colonic surgery for the recurrence is 40
• - use of flexible scope
• () Signs of Peritonitis / Unsuccessful
  reduction
• Sigmoidectomy w/ Hartmanns or Divines colostomy

10

• Cecal Volvulus
• Tx reduction is impossible --gt emergency
  exploration
• () Gangrene - right hemicolectomy
• - end to end ileo-transverse colostomy
• (-) Gangrene a) same
• b) Cecopexy
• c) Pure detorsion (recurrence 7 15)
• Transverse colon volvulus
• Rare, due to its broad based and short mesentery
• Tx resection of redundant transverse colon

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DIVERTICULOSIS

• Abnormal pouch from the wall of a hollow organ
• Types
• True diverticula (rare) right side
• False diverticula (common) due to low fiber
  diet left side
• Rare before 30y/o common gt 75 y/o
• Female gt Male
• Etiology
• Unknown
• Theories by Painter et al
• Contraction ring (thickening of circular muscle)
• Depletion of dietary fibers ---gt narrow lumen
• Deteriorating integrity of the bowel wall
  elderly has lower tensile strength, lowest in the
  sigmoid)

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DIVERTICULOSIS

• Pathology
• Site arteriole penetrates the mesenteric side of
  the antimesenteric teniae coli
• Sigmoid (50)
• Descending colon (40)
• Entire colon (2-10)

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DIVERTICULOSIS

• Clinical Manifestation
• Majority are asymptomatic
• Symptomatic patients
• Uncomplicated painful diverticular dse.
• () LLQ pain and tenderness
• () change in bowel habits
• (-) rebound tenderness
• (-) fever nor leukocytosis
• Dx Gastrografin enema
• Tx high fiber diet

14

• Complicated diverticular disease
• Diverticulitis / Peridiverticulitis
• Infected diverticula
• Diverticula is filled up ---gt obstructed ---gt
  mucus secretion and bacteria ---gt inflammation at
  the apex ---gt unresolved --gt extend intramurally
  ---gt perforate.

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• Complicated diverticular disease
• Diverticulitis / Peridiverticulitis
• Sx - left lower abd. pain / chills fever /
• bowel habit changes
• - () abd. Tenderness, distension if w/
• partial obstruction
• - para-rectal tenderness
• - frequency / urgency of urination
• (inflamed bladder)

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• Complicated diverticular disease
• Diverticulitis / Peridiverticulitis
• Dx
• Cln. Hx.
• Ct scan of the abd / utrasonography (thickened
  wall abscess can be seen)
• Contrast enema / sigmoidoscopy
• (risk of spreading infection)

17

• Complicated diverticular disease
• Diverticulitis / Peridiverticulitis
• Tx
• NPO or liquid diet
• Broad spectrum antibiotic
• Meperidine (not morphine)
• If improved ? endoscopy to r/o CA

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• Complicated diverticular disease
• Perforated Diverticulitis
• Sx - similar to appendicitis (Phlegmon mass)
• - () pneumoperitoneum
• Classification of perforated diverticulitis
  (Hinchy)
• Stage I abscess confined by mesentery of
  colon
• Stage II pelvic abscess
• Stage III generalized peritonitis
• Stage IV fecal peritonitis

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• Complicated diverticular disease
• Perforated Diverticulitis
• Tx initial none operative
• - NPO / IVF / Broad spectrum antibiotic/
• meperidine
• Stage I II
• () improvement ? elective Surgery (4 wks)
• (-) improvement ? percutaneous drainage
• (-) improvement ---gt Surgery

20

• Complicated diverticular disease
• Perforated Diverticulitis
• Stage III IV explore after initial
  resuscitation
• a. sigmoidectomy w/ primary anastomosis
• b. sigmoidectomy w/ Hartmanns colostomy
• c. resection w/ primary anastomosis w/
• proximal diverting stoma

21

• Complicated diverticular disease
• Obstructing diverticulitis
• 90 partial due to spasm, edema ileus
• 10 complete fibrosis and stenosis
• S/Sx of large intestinal obstruction
• Tx conservative mx (3-5 days) ---gt (-) response
  -----gt cecum dilates to 10-12 cm. ---gt surgery.

22

• Complicated diverticular disease
• Acute hemorrhage
• Due to erosion of the peridiverticular arteriole
  by inspissated stool w/in the diverticulum and
  thinning of the tunica media

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DIVERTICULOSIS

• Clinical Manifestation
• Symptomatic patients
• Complicated diverticular disease
• Acute hemorrhage
• Resuscitate the patient
• Locate the site of bleeding (Tc labeled
  RBC/selective arteriography)
• Vasopressin infusion, transcatheter emboli
  infusion using gelfoam
• Colonoscopy
• Tx segmental resection / blind subtotal colectomy

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DIVERTICULOSIS

• Clinical Manifestation
• Symptomatic patients
• Complicated diverticular disease
• Fistula formation
• Bladder, vagina, small bowel, skin
• Dx - clin hx PE (pneumaturia, fecaluria and
• frequent UTI)
• - cystoscopy, IE, speculum exam
• - methylene blue enema
• - colonoscopy to r/o CA

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DIVERTICULOSIS

• Clinical Manifestation
• Symptomatic patients
• Complicated diverticular disease
• Fistula formation
• Tx - bowel rest w/ TPN or elemental diet
• - Foley catheter (10 days postop) /
  antibiotic
• - placement of ureteral catheter prior to
• celiotomy
• - sigmoidectomy w/ primary anastomosis
• - fistulectomy and closure of secondary
• opening

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Hemorrhage from the Colon

• Diverticular disease
• Angiodysplasia (Vascular ectasia, AV
  malformation, Angiectasia)

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ANGIODYSPLASIA

• Acquired lesion
• Proximal colon (cecum) where tension is greatest
  (Laplaces law tension in the wall is highest
  in the widest circumference)
• Rare lt 40y/o common in elderly
• Etiology - chronic intermittent obstruction of
  submucosal veins due to repeated muscular
  contraction

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ANGIODYSPLASIA

• Dx - Nuclear scan /
• angiography
• (vascular tuft and
• early filling of veins)
• - colonoscopy
• distinct red
• mucosal patch

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Management of Massive Lower GIB

• Bleeding distal to the ligament of Treitz
• Diverticular disease
• Angiodysplasia
• Inflammatory bowel disease
• Ischemic colitis
• Tumor
• Anticoagulant therapy
• Gastroduodenal hge -gt can present as rectal
  bleeding
• It is more important to identify the location of
  the BLEEDING POINT than the immediate diagnosis
  as the cause.

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Management of Massive Lower GIB

• Diagnostic
• Nuclear imaging (bleeding scan/scintigraphy)
• Technetium-Sulfur Colloid Scan
• Sensitive (0.5ml/min)
• Autologous labeled RBC scan
• Stays in the circulation for as long as 24 hrs
  (monitoring)
• (1ml/min bleeding)
• Mesenteric Angiography
• Done once patients condition is stable and
  hydration is adequate
• Identify bleeding point ---gt 1ml/min
• Could be therapeutic ---gt Vasopressin/emboli

• Vascular taft (A)
• Early filling vein (B)

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Management of Massive Lower GIB

• Diagnostic
• Emergent colonoscopy
• Possible w/ use of GOLYTELY
• Therapeutic
• Treatment
• Restore intravascular volume (85 stop
  spontaneously)
• Persistent --gt celiotomy (segmental or total
  colectomy)

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Ischemic Colitis

• Due to occlusion of major mesenteric vessel
• Thrombosis, embolization, iatrogenic ligation)
• Elderly - contraceptive pills
• - medical problems
• a) cardiovascular disease
• b) DM
• c) Rheumatoid arthritis
• Splenic flexure most common site in the colon

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Ischemic Colitis

• Clinical Syndrome Based on
• Extent of vascular occlusion
• Duration of occlusion
• Efficiency of collateral circulation
• Extent of secondary bacterial invasion
• Reversible or Transient Ischemic Colitis
• Partial mucosal slough that healed after 2-3 days
• Stricturing Ischemic Colitis
• Arterial occlusion ---gt hgeic infarct of mucosa
  ---gt ulcerates ----gt bacterial invasion of bowel
  ---gt fibrosis

34
Ischemic Colitis

• Clinical Syndrome Based on
• Gangrenous ischemic Colitis
• Complete arterial occlusion ---gt full thickness
  infarction ---gt gangrene ---gt perforation ----gt
  PERITONITIS.

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Ischemic Colitis

• Symptoms
• Depends on the stage of the lesion
• Acute mild to moderate generalized or lower
  abdominal crampy pain ---gt HEMATOCHEZIA
• Hyperactive bowel sound ---gt silent
• Abdominal tenderness ---gt persist ---gtr/o
  peritonitis

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Ischemic Colitis

• Diagnosis
• Clinical hx PE
• FPA ---gt adynamic ileus (stops at the involved
  segment) Pneumoperitoneum
• Contrast enema (water soluble)
• - thumb printing in the mucosa
• Endoscopy (risky)

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Ischemic Colitis

• Treatment
• Emergency celiotomy
• - segmental resection w/ primary
• anastomosis or colostomy

38
Megacolon

• Large colon due to chronic dilatation, elongation
  and hypertrophy of the colon
• Due to chronic partial colonic obstruction w/
  associated chronic constipation
• Degree of megacolon is proportional to duration
  of obstruction

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Megacolon

• Congenital Megacolon (Hirschsprung disease)
• Congenital absence of ganglion cells in the
  myenteric plexus (submucosa) of the bowel
  (aganglionosis)
• Usually involves the rectosigmoid
• Must be sent to Patho and confirm the presence of
  ganglion
• Acquired megacolon
• Chagas disease (trypanosoma cruzi)
• Neurologic disorders / psychotic patients
• Cut higher than 2 cm

40
Fecal impaction

• Is the arrest and accumulation of the feces in
  the rectum or colon (dehydrated feces).
• Overflow diarrhea w/o relief of the sense of
  rectal fullness
• Result to stercoral ulcer (in the plating) --gt
  bleeding and perforation
• Mx - tap water enema / manual extraction
• - hot sitz bath

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Inflammatory Bowel Diseases

• Ulcerative colitis (Mucosal Ulcerative Colitis /
  Idiopathic Ulcerative Colitis)
• involve the colonic mucosa only the colon
• male gt female
• limited to the colon and rectum
• Chronic inflammation of GI tract
• Crohns Disease (Chronic Interstitial
  Enteritis/Regional Ilietis)
• transmural inflammation anywhere in the GIT
  affects entire wall
• extraintestinal symptoms proceeds those of
  intestinal symptoms
• female gt male
• Chronic inflammation of GI tract

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Inflammatory Bowel Disease Signs and Symptoms
Crohns Disease Ulcerative Colitis
Symptoms
diarrhea
rectal bleeding
tenesmus 0
abdominal pain
fever
vomiting 0
weight loss
Signs
perianal disease 0
abdominal mass 0
malnutriton
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Inflammatory Bowel Diseases
Ulcerative Colitis Crohns Colitis
Usual Location rectum, left colon anywhere
Rectal Bleeding common, continuous uncommon, intermittent
Rectal involvement almost always approximate 50
Fistulas rare common
Ulcers shaggy, irregular, continuous distribution linear w/ transverse fissures (cobblestone or skip lesion)
Bowel stricture rare (suspect carcinoma) common
Carcinoma increase incidence increased incidence
Toxic dilatation of colon (megacolon) Occurs in both Occurs in both
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Inflammatory Bowel Diseases

• Chronic Ulcerative Colitis
• Mild Mod. acute findings
• mucosal edema
• crypt abscess
• rectal involvement
• Severe acute disease
• Pseudopolyps w/ marked mucosal inflammation
  edema
• Late changes
• Discrete ulcers, pus

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Inflammatory Bowel Diseases

• Crohns Disease
• Early findings
• rectal sparing
• perianal disease
• aphthous ulceration
• Moderate changes
• linear ulcers
• cobblestoning
• skip lesions
• Late changes
• Contact bleeding
• Confluent ulcers
• Strictures mucosal bridging

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Inflammatory Bowel Diseases
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Inflammatory Bowel Diseases

• Morphologic Features of Crohns Disease
• Suggestive of Crohns Disease
• Focal inflammation in the mucosa
• Ileal involvement
• Linear or fissuring ulcers
• Rectal sparing
• Right sided predominance
• Highly suggestive of Crohns disease
• Discontinuous segmental involvement
• Aphthoid ulcers
• Pathognomonic of Crohns disease
• Sarcoid granulomas
• Transmural inflammation w/ lymphoid nodules
• Fistulas (at sites other than anus)

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Bowel Involvement in Crohns Disease(exam
question)

1. Ileocolic 44
2. Colonic 28
3. Small bowel only 27
4. Anorectal 3

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Inflammatory Bowel Diseases

• Extra-intestinal Nonhepatic Manifestations of
  Idiopathic Inflammatory Bowel Disease
  (hypothetical autoimmune disease) (dont need to
  memorize this list)
• Musculoskeletal Blood Vascular System
• ankylosing spondylitis and sacroiliitis
  - anemia
• peripheral arthritis -
  thrombocytosis
• pelvic osteomyelitis -
  leucocytosis
• Skin and Mouth - hypercoagulable
  state
• erythema nodosum
• pyoderma gangrenosum Kidneys Genitourinary
• aphthous stomatitis -
  nephrolithiasis
• Eye - obstructive uropathy
• uveitis (iritis) - fistulas to
  genitourinary
• episcleritis Other -
  Pleurocarditis Bronchopulmonary vaxculitis

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Medical Therapy for Ulcerative Colitis Crohns
Disease

• Sulfasalazine lowers the inflammation
• Metronidazole (as well as 2nd gen cephalosporin)
• Crohns ileocolitis colitis
• Perineal colitis
• Not effective in active ulcerative colitis
• Corticosteroid lowers antibody
• Oral for mild to moderate active ulcerative
  colitis and Crohns disease
• Parenteral for severe or toxic ulcerative colitis
  or Crohns disease
• Immunosuppressive agents
• Steroid sparing
• Refractory disease

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Indications for Surgical Interventions for
Ulcerative Colitis

1. Active disease unresponsive to medical therapy
2. Risks of cancer based on workup
3. Severe bleeding

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Surgical treatment for Ulcerative Colitis

• Proctocolectomy w/ Brooke ileostomy (brings ileum
  to the skin)
• curative w/ one operation
• Colectomy w/ ileorectal anastomosis
• not curative cancer risk persists (5-50)
• contraindicated for severe rectal dse, rectal
  dysplasia and rectal CA
• Total proctocolectomy w/ ileoanal anastomosis w/
  pouch (best therapy)
• curative w/ continence
• contraindicated for Crohns dse, diarrhea, rectal
  CA

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Surgical treatment for Ulcerative Colitis
54
Indications for Surgical Treatment of Crohns
Dsease

• Ileocolic Crohns Disease
• Internal fistula and abscess 38
• Intestinal obstruction 37
• Perianal fistula 15
• Poor response to medical therapy 6
• Colonic Crohns Disease (when surgery
  participates)
• Internal fistula and abscesses 25
• Perianal disease 23
• Severe dse w/ poor response
• to medical therapy 21
• Toxic megacolon 19
• Intestinal obstruction 12

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COLO RECTAL POLYPS

• Projection from the surface of the intestinal
  mucosa regardless of its histologic nature
• Types
• Neoplastic
• Hamartomatous
• Inflammatory
• Unclassified

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COLO RECTAL POLYPS

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

Types Incidence () Malignant Potential ()
Tubular 75 5
Villous 10 40
Tubulovillous 15 22
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COLO RECTAL POLYPS

• Neoplastic Polyps
• Diagnosis
• bleeding per rectum (most common)
• Villous polyp (large) ---gt watery diarrhea and in
  rare cases can have fluid and electrolyte
  imbalance
• do complete examination of the colon -
  colonoscopy
• biopsy / transrectal ultrasonography

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COLO RECTAL POLYPS

• Neoplastic Polyps
• Treatment
• Polypectomy for benign ---gt follow up
• () CA in situ ----gt polypectomy
• () invasive CA (invade the muscularis mucosa)
  
• 9 metastasize to LN if pedunculated
• 20 metastasize to LN if it invades the stalk or
  neck
• 15 metastasize to LN if sessile
• CANCER SURGERY

59
COLO RECTAL POLYPS

• Neoplastic Polyps
• Treatment
• If entire mucosal surface is covered by villous
  tumor ---gt segmental resection, if in rectum can
  do full thickness proximal protectomy w/ coloanal
  anastomosis

60
COLO RECTAL POLYPS

• Hamartomatous Polyp
• Juvenile Polyp
• not precancerous
• excision
• Swiss cheese appearance from dilated cystic
  spaces
• Familial Juvenile Polyposis Coli
• thousands polyps in the colon and rectum
• can degenerate to adenoma ----gt malignancy
• subtotal colectomy or proctocolectomy

61
COLO RECTAL POLYPS

• Hamartomatous Polyp
• Peutz-jegher Syndrome
• Melanin spot on buccal mucosa, lips, face and
  digits
• Polyps of small bowel (always), stomach, colon
  and rectum (branching of lamina propria like
  Christmas tree).
• Can degenerate into malignancy
• Cronkhite Canada Syndrome
• GIT polyposis, alopecia, cutaneous pigmentation,
  atrophy of fingernails and toe nails
• Cowdens Syndrome
• Autosomal dominant, hamartomas of all three
  embryonal cell layers
• Facial trichilemomas, breast cancer, thyroid dse,
  GIT polyp

62
COLO RECTAL POLYPS

• Infammatory Polyp
• Caused by previous attacks of severe colitis
  resulting in partial loss of mucosa leaving
  remnants or islands of normal mucosa
• Occurs after amebic colitis, ischemic colitis and
  Schistosomal colitis
• Not premalignant
• Hyperplastic Polyp
• Usually small lt 5mm not premalignant
• gt 2cm. have a slight risk of malignant
  degeneration
• Saw tooth appearance of the lining epithelial
  cells

63
COLO RECTAL POLYPS

• Familial Adenomatous Polyposis Coli
• Inherited non-sex linked autosomal dominant
  disease w/ hundreds of adenomatous polyps through
  the entire colon and rectum
• Gardners Syndrome
• Familial polyposis, osteomatosis, epidermoid
  cyst, fibromas of the skin (desmoid tumor) the
  most important extra-colonic expression.
• Tx - total proctocolectomy w/ ileostomy
• - colectomy w/ ileorectal anastomosis
• - examine other members of the family

64
COLO RECTAL POLYPS

• Familial Adenomatous Polyposis Coli
• Turcots Syndrome
• Familial polyposis, brains tumors (gliomas or
  medulloblastomas)
• Tx same w/ colorectal involvement
• Hereditary Nonpolyposis Colon Cancer (HNCC)
• Lynchs syndrome
• Error in mismatch repair (RER pathway)
• Appear more common in proximal colon
• Associated w/ extra-colonic malignancies
  (endometrial, ovarian, pancreas, stomach, small
  bowel, biliary Urinary)

65
Carcinoma of Colon

• Most common CA of the GIT
• Older age grp peak incidence 80y/o
• male ( gt rectum) female ( gt colon)
• Etiology
• Unknown
• Hereditary
• Diet --gt low fiber diet and high animal fat
• Distribution --gt shifting to the right side

66
Carcinoma of Colon

• Macroscopic form
• Ulcerating type most common
• Polypoid or fungating
• Colloid CA
• bulky growth w/ gelatinous appearance
• 10-15
• Signet ring cell CA
• intracellular mucinous
• Infiltrating CA
• submucosal spread

67
Carcinoma of Colon

• Microscopic form adenocarcinoma
• Gronnell based on invasive tendency, glandular
  arrangement, nuclear polarity and frequency of
  mitosis.
• Grade I - low grade / well differentiated
• Grade II - average grade / mod. differentiated
• Grade III - high grade / poorly differentiated

68
Carcinoma of Colon

• Mechanism of Spread
• Direct spread
• Transperitoneal spread
• Implantation
• Lymphatic
• Hematogenous
• Liver Lungs most common distant spread

69
Carcinoma of Colon

• Dukes Stage
• Depth of bowel wall involvement
• Presence or absence of LN metastasis
• Stage A
• Invasion at least through the muscularis mucosa
  but not through the muscularis propria
• 98 ---gt 5yr survival
• Stage B
• Invasion through full thickness of bowel wall
  (-) LN
• 78 ----gt 5yr survival

70
Carcinoma of Colon

• Dukes Stage
• Stage C
• LN metastasis, regardless of depth
• Stage C1 - only adjacent LN metastasis
• Stage C2 - LN involves are nodes at point of
  ligature of blood vessels
• 32 5 yr survival
• Stage D
• Distant metastasis or w/ adjacent organ
  involvement
• 0 5 yr survival

71
TNM Staging of Colonic CA

• Primary Tumor (T)
• TX - Primary tumor cannot be assessed
• T0 - No evidence of primary tumor
• T1 - Tumor invades submucosa
• T2 - Tumor invades muscularis proper
• T3 - Tumor invades through the muscularis proper
• into the subserosa or into
  nonperitonealized
• pericolic or perirectal tissue
• T4 - Tumor perforates the visceral peritoneum or
  
• directly invades the organs or
  structures

72
TNM Staging of Colonic CA

• Regional Lymph Node (N)
• NX Regional LN cannot be assessed
• N0 - No regional LN metastasis
• N1 - Metastasis in 1 to 3 pericolic or
  perirectal LN
• N2 - metastasis in 4 or more pericolic or
• perirectal LN
• N3 - Metastasis in any LN along the course of a
  
• named vascular trunk
• Distant Metastasis (M)
• MX Presence of distant metastasis cannot be
  assessed
• M0 - No distant metastasis
• M1 - w/ distant metastasis

73
TNM Staging of Colonic CA

• Stage I T1 T2 N0 M0
• 90 5y/r Survival
• Stage II T3 T4 N0 M0
• 60 80 5 y/r survival
• Stage III Any T N1 M0
• Any T N2, N3 M0
• 20 50 5y/r survival
• Stage IV Any T Any N M1
• lt 5 5 yr survival

74
Risk Factors for Colorectal CA

• Aging is the dominant risk factor w/ rising
  incidence after 50 y/o.
• Hereditary risk factor
• 80 colorectal are sporadic
• 20 w/ known family hx.
• Dietary factors
• high animal fat (saturated or polyunsaturated
  fats), but oleic acid (coconut fish oil does
  not).
• Vegetable fiber, Ca, selenium, Vits. A, C, E
  are protective
• Alcohol increase colonic CA
• Obesity and sedentary lifestyle contributory
• Smoking increased the incidence

75
Premalignant Diseases of Colon Rectum

• Adenoma
• Familial adenomatous polyposis syndrome
• Gardners syndrome
• Hamartomas (familial juvenile polyposis coli
  Peutz-Jegher polyp
• Inflammatory bowel disease
• Ulcerative colitis
• Crohns disease
• Schistosomiasis (Billharziasis) S. mansoni
• S. japonicum
• Utero-sigmoidostomy

76
Genetic Defects for Colorectal CA

• Mutation may cause
• Activation of
• K-ras (an oncogene)
• Inactivation of tumor- suppressor gene
• APC
• DCC (deleted in colorectal carcinoma)
• p53

77
Genetic Pathways for Tumor Initiation and
Progression

• LOH pathway
• Chromosomal deletion and tumor aneuploidy
• 80 of colorectal carcinoma
• RER pathway (replication error)
• Error in mismatch repair during DNA replication
• 20 of colorectal carcinoma

78
Carcinoma of Colon

• Clinical Manifestation
• Change in bowel habit classic symptoms
• Rectal bleeding
• Weight loss
• Abdominal pain, bloating and other signs of
  obstruction
• Anemia and anorexia
• Tenesmus, feeling of incomplete evacuation, and
  rectal bleeding if lesion is in the rectum

79
Screening Modalities For Colonic Tumors

• Fecal occult blood testing
• Annual FOBT screening for asymptomatic 50 y/o
• Rigid proctoscopy / flexible sigmoidoscopy
• Colonoscopy
• The most accurate and most complete method for
  examining the colon
• Air contrast Barium enema
• CT colonography (virtual colonoscopy)
• Colon is insufflated with air and a spiral CT is
  performed.
• Useful for imaging the proximal colon in case of
  obstruction

80
Therapy for Colonic Carcinoma

• Principle
• Objective is to remove the primary tumor w/ its
  lymphovascular supply
• Adjacent organs or tissue invaded shd be resected
  en block w/ the tumor
• Tumors cannot be removed, a palliative procedure
  shd be done.
• Synchronous CA ---gt subtotal or total colectomy
• Metachronous tumor (second primary colon CA)
  treated similarly
• Hemorrhage in an unresectable tumor can be
  controlled w/ angiographic embolization

81
Therapy for Colonic Carcinoma

• Stage 0
• No risk of LN metastasis
• Pedunculated / sessile polyp -gt endoscopic
  polypectomy
• If polyp cannot be removed completely segmental
  resection shd be done
• Stage I (T1,N0,M0)
• Polypectomy --gt for uninvolved stalk
  (pedunculated)
• Segmental resection
• Sessile polyp
• Pedunculated polyp ( lymphovascular invasion,
  poorly differentiated or tumor w/in 1mm. of
  resection margin ---gt high risk of local
  recurence and metastatic spread)

82
Therapy for Colonic Carcinoma

• Stage II (T3-4,N0,M0)
• Surgical resection
• Adjuvant chemotherapy is suggested for
• Young patient
• Moderate to poorly differentiated
• Stage III (Tany,N1,M0)
• Surgical resection adjuvant chemotherapy
  (5-Fluorouracil, levamisole or leucovorin,
  capecitabine, irinotecan, oxaliplatin,
  angiogenesis inhibitor and immunotherapy)

83
Therapy for Colonic Carcinoma

• Stage IV (Tany, Nany, M1)
• Palliative resection of primary and isolated
  liver metastasis
• Adjuvant chemotherapy
• Irresectable ---gt diverting colostomy

84
THANK YOU
85
Therapy of Rectal Carcinoma

• Principle the same w/ colonic CA, but more
  difficult to achieve negative radial margins bec.
  of anatomic limitations of the pelvis
• Local recurrence is higher w/ similar stage of
  colonic CA.
• Easier to treat rectal tumors w/ radiations due
  to less structures radiation-sensitive structures
  in the pelvis

86
Therapy for Rectal Carcinoma

• Transanal endoscopic microsurgery
• Radical resection - removal of the involved
  segment of the rectum along with its
  lymphovascular supply w/ a margin of 2 cm distal
  mural margin.
• Total mesorectal excision (TME)
• APR
• Pelvic exenteration --gt enbloc resection of the
  ureters, bladder, prostate, uterus and vagina
  together w/ APR. w/ permanent colostomy and ileal
  conduit. Sacrectomy up to level of S2-S3 junction
  if necessary.

87
Therapy for Rectal Carcinoma

• Stage 0 (Tis, N0,M0)
• Local excision w/ 1 cm margin
• Stage I (T1-2,N0,M0)
• Polypectomy --gt confined to the head of the polyp
• Radical resection --gt sessile uT1N0 and uT2N0
  rectal CA

88
Therapy for Rectal Carcinoma

• Stage II (T3-4,N0,M0) 2 school of thought
• Total mesorectal resection only
• Radical resection w/ chemo-radiation given
  preoperatively or postoperatively
• Advantages of preop chemoradiation
• Down grade the tumor can increased likelihood of
  resection and sphincter saving procedure
• Disadvantages of preop chemoradiation
• Over treatment of early stage tumors
• Impaired wound healing
• Pelvic fibrosis increases the risk of operative
  complications

89
Therapy for Rectal Carcinoma

• Advantages of postoperative radiation
• Allows accurate pathologic staging of the
  resected tumor and LN
• Avoids wound healing problems associated w/ preop
  radiation
• Stage III (Tany,N1,M0)
• Radical resection followed w/ neodjuvant therapy
• Stage IV (Tany, Nany, M1)
• Proximal diverting colostomy for obstruction
  (lower) / intraluminal stenting (upper)
• Radical resection to control bleeding, pain and
  tenesmus

90
Follow-up and Surveillance for Colorectal CA

• Annual colonoscopy
• CEA determination
• CT scan done if CEA is elevated

91
Anal Canal Perianal Tumors

• Uncommon 2 colorectal CA
• Anal margin distal to dentate line
• Anal canal proximal to dentate line

92
Anal Canal Perianal Tumors

• Anal intraepithelial neoplasm (AIN)
• Bowens disease
• Squamous cell CA in situ of the anus
• Precursor to an invasive squamous cell CA
• Associated w/ infection of human papilloma virus,
  HIV-positive homosexual
• Tx resection / ablation
• High recurrence ---gt 3-6 months follow up

93
Anal Canal Perianal Tumors

• Epidermoid carcinoma
• Squamous cell CA, Cloacogenic CA, Transitional
  CA, Basaloid CA.
• Slow growing present as mass or perianal mass
• Anal margin --gt wide local excision
• Anal canal or invading anal sphincter --gt Nigro
  protocol ( 5-fluorouracil, mitomycin C, 3000cGy
  external beam radiation). 80 are cured
• Recurrence ---gt APR

94
Anal Canal Perianal Tumors

• Verrucous carcinoma
• Buschke-Lowenstein Tumor, Giant condyloma
  accuminata.
• Do not metastasize
• Wide excision / radical resection
• Basal cell carcinoma
• Rarely metastasize
• Wide excision tx of choice recurrence ---gtAPR
  /or radiation therapy

95
Anal Canal Perianal Tumors

• Adenocarcinoma
• Usually a downward spread of low rectal CA
• Could arise from anal glds or developed from
  chronic fistula also from apocrine gld (Pagets
  dse)
• Tx - radical resection w/ or w/o chemoradiation
• - Pagets dse wide excision
• Melanoma
• Poor prognosis 5yr survival --gt 10 due to
  sytemic metastasis /or deeply invasive tumors
• Wide local resection / APR
• Adjuvant chemotherapy, biochemotherapy, vaccines,
  radiotherapy

96
Anorectal Abscess

• 5 potential spaces
• Perianal space
• Ischiorectal space
• Intersphincteric space
• Deep posterior anal space
• Supralevator space

97
Anorectal Abscess

• Etiology
• Infection of anal gland
• Organism (fecal cutaneous flora)
• E. coli 4. Clostridium sp.
• Bacteroides fragilis 5. Staphylococcus
• Streptococcus
• Manifestation
• Pain in the anal region
• Treatment
• Drainage / antibiotic
• Hygiene
• Hot sitz bath

98
Anorectal Abscess

• Types
• Perianal abscess
• Ischiorectal abscess diffuse
• swelling of ischiorectal fossa

99
Anorectal Abscess

• Intersphincteric abscess
• No apparent sign of swelling or induration in the
  perianal area
• CLUE --gt deep seated tenderness when circum-anal
  pressure is applied above the dentate line.
• Drainage thru the anal canal lining or thru
  internal sphincteric muscle
• Supralevator abscess
• Uncommon
• Mimmic acute intra-abdominal condition
• Etiology extension of
• Intersphincteric abscess
• Ischiorectal abscess
• Intra-abdominal abscess

100

• Necrotizing Peri-anal Perineal Infection
• Etiology
• Neglected or delayed treatment of primary
  anorectal infection
• Extension of UTI particularly the periurethral
  gland
• Manifestation
• Pain, tenderness and swelling with crepitation of
  perianal and scrotum or labia
• Black spot on the site (necrosis)
• Treatment
• Broad spectrum antibiotic
• Debridement
• Hyperalimentation / diverting colostomy /or
  cystostomy

101

• Fistula-In-Ano
• Inflammatory tract w/ secondary opening
  (external) and a primary opening (internal) in
  the anal canal.
• Etiology
• Complication of perianal abscess
• Goodsalls Rule
• to locate internal opening
• Classification of Fistula-in-ano
• Inter-sphincteric
• Trans-sphincteric
• Supra-sphincteric
• Extra-sphincteric

102
Fistula-in-ano

• Manifestation
• Previous history of perianal abscess
• Rule out ulcerative colitis and Crohns dse
  (colonoscopy / barium enema)
• Treatment
• Identify the primary opening (probing/methylene
  blue/fistulography)
• Fistulotomy / fistulectomy (healing by secondary
  intension

103
Fistula-in-ano

• If fistula is high in relation to anorectal ring
  do 2 stage procedure
• Insert a seton wire or suture to the tract for
  several wks to create fibrosis
• Open the fibrous track on the second stage after
  6-8 wks

104
Hemorrhoid

• Are cushions of submucosal tissue in the anal
  canal composed of connective tissue containing
  venules, arterioles and smooth muscle fibers.
• Purposed aids in anal continence and cushion
  the anal canal and support the lining during
  defecation
• External skin tag
• Redundant fibrotic skin at the anal verge due to
  previous thrombosed external hemorrhoid of past
  operation

105
Hemorrhoid

• External hemorrhoid
• Dilated venules of the inferior hemorrhoidal
  plexus located distal to the pectinate or dentate
  line

106
Hemorrhoid

• Internal hemorrhoid
• Manifestation
• Painless bright red rectal bleeding associated w/
  bowel movement
• Feeling of incomplete evacuation of feces
• Pain is experienced if w/ complication of anal
  fissure, stenosis of thrombosis
• Grade According to Degree of Prolapse
• 1st degree anal cushion slide down beyond the
• dentate line on straining
• Mx - painless rectal bleeding
• Tx - bulk forming agents (psyllium seed)
• - rubber band ligation

107
Hemorrhoid

• Rubber band ligation

108
Hemorrhoid

• 2nd degree
• Prolapse through the anus on straining but
  spontaneously reduced
• 3rd degree
• Requires manual reduction into the anal canal
• Tx rubber band ligation / hemorrhoidectomy
• 4th degree
• Prolapse cannot be reduced
• hemorrhoidectomy

109
Anal Fissure

• Tear from the dentate line up to the anal verge
  lined by skin
• Seen in young and middle age group
• Majority occurs at the at the posterior midline
  due to poor muscular support

110
Anal Fissure

• Etiology
• Passage of large hard stool
• Conditions ( Crohns dse, ulcerative colitis,
  syphilis tuberculosis and leukemia)
• Manifestation
• Burning pain during and after bowel movement
• Bright red blood on toilet paper
• Diagnosis
• Rectal examination / proctosigmoidoscopy
• Treatment
• Conservative - anal hygiene / bulk forming
  agents
• - hot sitz bath
• - local anesthetic jelly
• Surgical - chronic stage (lateral internal
  sphincterotomy)

111
Anal Fissure

• Treatment
• Conservative
• anal hygiene / bulk forming agents
• hot sitz bath
• local anesthetic jelly
• Surgical
• chronic stage (lateral internal sphincterotomy)