Transcript COLON - Caangay.com

COLON
James Taclin C. Banez, MD
Anatomy / Physiology:
•
•
Location, blood supply &
venous drainage, lymphatic
drainage and nerve supply
Function:
• absorption of fluid
and electrolyte
• Transport and
temporary storage of
feces
Anatomy / Physiology:
Infectious:
1.
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) ---> AMEBOMA
– mass of inflammatory tissue
Dx: clin hx / stool exam / indirect hemagglutination test
Tx: metronidazole / iodoquinol : rare COLECTOMY
Pseudomembranous colitis:
2.
Complication of antibiotics ---> alteration of normal flora
•
Overgrowth of Clostridium deficile:
•
Has cytopathic and enteropathic toxins
Develops 6wks after:
•
a.
b.
c.
Dx:
Clindamycin
Ampicillin
Cephalosporin
- history
- latex fixation test
- colonoscopy (Pseudomembrane)
Tx: 1. stopped antibiotic ----> metronidazole/vancomycin
2. cholestyramine ---> binds w/ toxin
3. Toxic megacolon---> total colectomy w/ ileostomy
3.
Salmonellosis:
Salmonella typhi (typhoid fever)
Dx: perforation / bleeding
Tx: antibiotic / transfusion / right hemicolectomy w/ or w/o
ileostomy
4.
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)
Volvulus:
Twisting of an air-filled segment of bowel about its
narrow mesentery ---> OBSTRUCTION ------->
STRANGULATION ----> GANGRENE---->
PERFORATION ----> PERITONITIS
SIGMOID VOLVULUS (90%):
•
1.
Redundant sigmoid colon
w/ a narrow based mesocolon
Sx: colicky abd. pain, distention
obstipation, rectal collapse
s/sx of dehydration
•
Volvulus:
SIGMOID
VOLVULUS (90%):
1.
Dx: FPA – inverted U
•
•
shaped sausage like
loop (diagnostic)
Barium enema – bird
beaks deformity
Gangrene –
chills/fever,
leukocytosis w/ s/x
of peritonitis
1.
SIGMOID VOLVULUS (90%):
Tx:
(-) Signs of Peritonitis:

Reduced the volvulus --->prepare for elective
colonic surgery for the recurrence is 40%:
- use of flexible scope
(+) Signs of Peritonitis / Unsuccessful
reduction:

Sigmoidectomy w/ Hartmanns or Divine’s
colostomy
2.
Cecal Volvulus:
Tx: reduction is impossible --> emergency exploration
(+) Gangrene: - right hemicolectomy
- end to end ileo-transverse colostomy
(-) Gangrene: a) – same –
b) Cecopexy
c) Pure detorsion (recurrence 7 – 15%)
3.
Transverse colon volvulus:
Rare, due to it’s broad based and short mesentery
Tx: resection of redundant transverse colon

DIVERTICULOSIS:
Abnormal pouch from the wall of a hollow organ
Types:
1.
2.
True diverticula (rare) – right side
False diverticula (common) – due to low fiber diet: left side
Rare before 30y/o; common > 75 y/o
Female > Male


Etiology:
1.
Unknown
2.
Theories by Painter et al:
a)
b)
c)
Contraction ring (thickening of circular muscle)
Depletion of dietary fibers ---> narrow lumen
Deteriorating integrity of the bowel wall; elderly has
lower tensile strength, lowest in the sigmoid)
DIVERTICULOSIS:
Pathology:
Site: arteriole penetrates
the mesenteric side
of the
antimesenteric
teniae coli:
1. Sigmoid (50%)
2. Descending
colon (40%)
3. Entire colon (210%)
DIVERTICULOSIS:
Clinical Manifestation:
A.
B.
Majority are asymptomatic
Symptomatic patients:
1.
Uncomplicated painful diverticular dse.

(+) LLQ pain and tenderness;
(+) change in bowel habits
 (-) rebound tenderness
 (-) fever nor leukocytosis
Dx: Gastrografin enema
Tx: high fiber diet

2.
Complicated diverticular disease:
a.
Diverticulitis / Peridiverticulitis:
 Infected diverticula
 Diverticula is filled up ---> obstructed --->
mucus secretion and bacteria --->
inflammation at the apex ---> unresolved -->
extend intramurally ---> perforate.
2.
Complicated diverticular disease:
a.
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)
2.
Complicated diverticular
disease:
a.
Diverticulitis /
Peridiverticulitis:
Dx:
1) Cln. Hx.
2) Ct scan of the abd /
utrasonography (thickened
wall & abscess can be seen)
3) Contrast enema /
sigmoidoscopy
(risk of spreading
infection)
2.
Complicated diverticular disease:
a.
Diverticulitis / Peridiverticulitis:
Tx:
1) NPO or liquid diet
2) Broad spectrum antibiotic
3) Meperidine (not morphine)
4) If improved  endoscopy to r/o CA
2.
Complicated diverticular disease:
b.
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
2.
Complicated diverticular disease:
b.
Perforated Diverticulitis:
Tx: initial none operative:
- NPO / IVF / Broad spectrum antibiotic/
meperidine
Stage I & II:
(+) improvement  elective Surgery (4 wks)
(-) improvement  percutaneous drainage
(-) improvement ---> Surgery
2.
Complicated diverticular disease:
b.
Perforated Diverticulitis:
Stage III & IV: explore after initial resuscitation
a. sigmoidectomy w/ primary anastomosis
b. sigmoidectomy w/ Hartmann’s colostomy
c. resection w/ primary anastomosis w/
proximal diverting stoma
2.
Complicated diverticular disease:
c. 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) ---> (-) response ----> cecum dilates to 10-12 cm. ---> surgery.
2.
Complicated
diverticular
disease:
d.
Acute
hemorrhage:

Due to erosion of
the peridiverticular
arteriole by
inspissated stool
w/in the
diverticulum and
thinning of the
tunica media
DIVERTICULOSIS:
Clinical Manifestation:
B.
Symptomatic patients:
2.
Complicated diverticular
disease:
d. 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
DIVERTICULOSIS:
Clinical Manifestation:
B.
Symptomatic patients:
2.
Complicated diverticular disease:
d.
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
DIVERTICULOSIS:
Clinical Manifestation:
B.
Symptomatic patients:
2.
Complicated diverticular disease:
d.
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
Hemorrhage from the Colon:
1.
2.
Diverticular disease
Angiodysplasia (Vascular ectasia, AV
malformation, Angiectasia)
ANGIODYSPLASIA




Acquired lesion
Proximal colon (cecum) where tension is
greatest (Laplace’s law – tension in the wall is
highest in the widest circumference)
Rare < 40y/o; common in elderly
Etiology: - chronic intermittent obstruction of
submucosal veins due to repeated muscular
contraction
ANGIODYSPLASIA
Dx:
- Nuclear scan /
angiography =
(vascular tuft and
early filling of veins)
- colonoscopy =
distinct red
mucosal patch
Management of Massive Lower GIB
Bleeding distal to the ligament of Treitz:

1.
2.
3.
4.
5.
6.


Diverticular disease
Angiodysplasia
Inflammatory bowel disease
Ischemic colitis
Tumor
Anticoagulant therapy
Gastroduodenal hge -> can present as rectal
bleeding
It is more important to identify the location of the
BLEEDING POINT than the immediate diagnosis
as the cause.
Management of Massive Lower GIB
Diagnostic:
Nuclear imaging (bleeding
scan/scintigraphy)
1.
a.
Technetium-Sulfur Colloid Scan

b.
Autologous labeled RBC scan


2.
Sensitive (0.5ml/min)
Stays in the circulation for as long as
24 hrs (monitoring)
(1ml/min bleeding)
Mesenteric Angiography



Done once patient’s condition is
stable and hydration is adequate
Identify bleeding point --->
1ml/min
Could be therapeutic --->
Vasopressin/emboli
Vascular taft (A)
Early filling vein (B)
Management of Massive Lower GIB
Diagnostic:
3. Emergent colonoscopy:


Possible w/ use of GOLYTELY
Therapeutic
Treatment:
 Restore intravascular volume (85% stop
spontaneously)
 Persistent --> celiotomy (segmental or total
colectomy)
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
Ischemic Colitis:
Clinical Syndrome Based on:




1.
Extent of vascular occlusion
Duration of occlusion
Efficiency of collateral circulation
Extent of secondary bacterial invasion
Reversible or Transient Ischemic Colitis:

2.
Partial mucosal slough that healed after 2-3 days
Stricturing Ischemic Colitis:

Arterial occlusion ---> hge’ic infarct of mucosa --->
ulcerates ----> bacterial invasion of bowel ---> fibrosis
Ischemic Colitis:
Clinical Syndrome Based on:
3.
Gangrenous ischemic Colitis:

Complete arterial occlusion ---> full thickness
infarction ---> gangrene ---> perforation ---->
PERITONITIS.
Ischemic Colitis:
Symptoms:
 Depends
on the stage of the lesion
 Acute mild to moderate generalized or lower
abdominal crampy pain --->
HEMATOCHEZIA
 Hyperactive bowel sound ---> silent
 Abdominal tenderness ---> persist --->r/o
peritonitis
Ischemic Colitis:
Diagnosis:
 Clinical
hx & PE
 FPA ---> adynamic ileus (stops at the
involved segment); Pneumoperitoneum
 Contrast enema (water soluble)
- thumb printing in the mucosa
 Endoscopy (risky)
Ischemic Colitis:
Treatment:
 Emergency
celiotomy
- segmental resection w/ primary
anastomosis or colostomy
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
Megacolon:
1.
Congenital Megacolon (Hirschsprung disease)



2.
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



Chaga’s disease (trypanosoma cruzi)
Neurologic disorders / psychotic patients
Cut higher than 2 cm
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) -->
bleeding and perforation
Mx: - tap water enema / manual extraction
- hot sitz bath
Inflammatory Bowel Diseases:
1.
Ulcerative colitis (Mucosal Ulcerative Colitis /
Idiopathic Ulcerative Colitis):




2.
involve the colonic mucosa – only the colon
male > female
limited to the colon and rectum
Chronic inflammation of GI tract
Crohn’s Disease (Chronic Interstitial
Enteritis/Regional Ilietis):




transmural inflammation anywhere in the GIT – affects
entire wall
extraintestinal symptoms proceeds those of intestinal
symptoms
female > male
Chronic inflammation of GI tract
Inflammatory Bowel Disease:
Signs and Symptoms
Crohn’s Disease
Ulcerative Colitis
+++
+++
rectal bleeding
+
+++
tenesmus
0
+++
+++
+
++
+
vomiting
+++
0
weight loss
+++
+
perianal disease
+++
0
abdominal mass
+++
0
malnutriton
+++
+
Symptoms
diarrhea
abdominal pain
fever
Signs
Inflammatory Bowel Diseases:
Ulcerative Colitis
Crohn’s 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
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
Inflammatory Bowel Diseases:
Crohn’s 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
Inflammatory Bowel Diseases:
Inflammatory Bowel Diseases:
Morphologic Features of Crohn’s Disease:
Suggestive of Crohn’s Disease:
1.
2.
3.
4.
5.
Focal inflammation in the mucosa
Ileal involvement
Linear or fissuring ulcers
Rectal sparing
Right sided predominance
Highly suggestive of Crohn’s disease:
1.
2.
Discontinuous segmental involvement
Aphthoid ulcers
Pathognomonic of Crohn’s disease:
1.
2.
3.
Sarcoid granulomas
Transmural inflammation w/ lymphoid nodules
Fistulas (at sites other than anus)
Bowel Involvement in Crohn’s
Disease
(exam question)
1.
2.
3.
4.
Ileocolic
Colonic
Small bowel only
Anorectal
44%
28%
27%
3%
Inflammatory Bowel Diseases:
Extra-intestinal Nonhepatic Manifestations of
Idiopathic Inflammatory Bowel Disease:
(hypothetical autoimmune disease) (don’t need to
memorize this list)
Musculoskeletal:
−
−
−
Blood & Vascular System
ankylosing spondylitis and sacroiliitis
peripheral arthritis
pelvic osteomyelitis
Skin and Mouth:
−
−
−
erythema nodosum
pyoderma gangrenosum
aphthous stomatitis
Eye:
−
−
uveitis (iritis)
episcleritis
- anemia
- thrombocytosis
- leucocytosis
- hypercoagulable state
Kidneys & Genitourinary
- nephrolithiasis
- obstructive uropathy
- fistulas to genitourinary
Other: - Pleurocarditis & Bronchopulmonary vaxculitis
Medical Therapy for Ulcerative Colitis &
Crohn’s Disease
1.
2.
Sulfasalazine – lowers the inflammation
Metronidazole (as well as 2nd gen cephalosporin)



3.
Corticosteroid – lowers antibody


4.
Crohn’s ileocolitis & colitis
Perineal colitis
Not effective in active ulcerative colitis
Oral for mild to moderate active ulcerative colitis and
Crohn’s disease
Parenteral for severe or toxic ulcerative colitis or Crohn’s
disease
Immunosuppressive agents:


Steroid sparing
Refractory disease
Indications for Surgical
Interventions for Ulcerative Colitis:
1.
2.
3.
Active disease unresponsive to
medical therapy
Risks of cancer – based on workup
Severe bleeding
Surgical treatment for
Ulcerative Colitis
1.
Proctocolectomy w/ Brooke ileostomy (brings
ileum to the skin):

2.
Colectomy w/ ileorectal anastomosis:


3.
curative w/ one operation
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 Crohn’s dse, diarrhea, rectal CA
Surgical treatment for
Ulcerative Colitis
Indications for Surgical
Treatment of Crohn’s Dsease
1.
Ileocolic Crohn’s Disease:




2.
Internal fistula and abscess
Intestinal obstruction
Perianal fistula
Poor response to medical therapy
38%
37%
15%
6%
Colonic Crohn’s Disease (when surgery
participates):





Internal fistula and abscesses
Perianal disease
Severe dse w/ poor response
to medical therapy
Toxic megacolon
Intestinal obstruction
25%
23%
21%
19%
12%
COLO – RECTAL POLYPS


Projection from the surface of the
intestinal mucosa regardless of it’s
histologic nature:
Types:
1.
2.
3.
4.
Neoplastic
Hamartomatous
Inflammatory
Unclassified
COLO – RECTAL POLYPS
Neoplastic Polyps:
Types

Malignant
Potential (%)
Tubular
Incidence
(%)
75
Villous
10
40
Tubulovillous
15
22
5
Invasive CA are common in polyps smaller than 1 cm in
diameter and incidence increases w/ increase in size
COLO – RECTAL POLYPS
Neoplastic Polyps:
Diagnosis:
bleeding per rectum (most common)
 Villous polyp (large) ---> watery diarrhea and in rare
cases can have fluid and electrolyte imbalance
 do complete examination of the colon colonoscopy
 biopsy / transrectal ultrasonography

COLO – RECTAL POLYPS
Neoplastic Polyps:
Treatment:



Polypectomy for benign --->
follow up
(+) CA in situ ---->
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
COLO – RECTAL POLYPS
Neoplastic Polyps:
Treatment:

If entire mucosal surface is covered by villous tumor --->
segmental resection, if in rectum can do full thickness
proximal protectomy w/ coloanal anastomosis
COLO – RECTAL POLYPS
Hamartomatous Polyp:
1.
Juvenile Polyp:



2.
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 ----> malignancy
subtotal colectomy or proctocolectomy
COLO – RECTAL POLYPS
Hamartomatous Polyp:
Peutz-jegher Syndrome
3.
a.
b.

4.
Cronkhite – Canada Syndrome:

5.
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
GIT polyposis, alopecia, cutaneous pigmentation, atrophy
of fingernails and toe nails
Cowden’s Syndrome:


Autosomal dominant, hamartomas of all three embryonal
cell layers
Facial trichilemomas, breast cancer, thyroid dse, GIT polyp
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 < 5mm not premalignant
 > 2cm. have a slight risk of malignant degeneration
 Saw tooth appearance of the lining epithelial cells

COLO – RECTAL POLYPS
Familial Adenomatous Polyposis Coli:

1.
Inherited non-sex linked autosomal dominant
disease w/ hundreds of adenomatous polyps
through the entire colon and rectum
Gardner’s 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
COLO – RECTAL POLYPS
Familial Adenomatous Polyposis Coli:
2.
Turcot’s Syndrome:


Familial polyposis, brains tumors (gliomas or
medulloblastomas)
Tx: same w/ colorectal involvement
Hereditary Nonpolyposis Colon Cancer (HNCC):

Lynch’s 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)


Carcinoma of Colon




Most common CA of the GIT
Older age grp; peak incidence 80y/o
male ( > rectum) ; female ( > colon)
Etiology:
1.
2.
3.

Unknown
Hereditary
Diet --> low fiber diet and high animal fat
Distribution --> shifting to the right side
Carcinoma of Colon
Macroscopic form:
1.
2.
3.
Ulcerating type
Polypoid or fungating
Colloid CA


4.
5.
bulky growth w/ gelatinous appearance
10-15%
Signet ring cell CA

intracellular mucinous
Infiltrating CA

most common
submucosal spread
Carcinoma of Colon
Microscopic form:
adenocarcinoma
Gronnell: based on invasive tendency, glandular
arrangement, nuclear polarity and frequency of
mitosis.
Grade I
Grade II
Grade III
- low grade / well differentiated
- average grade / mod. differentiated
- high grade / poorly differentiated
Carcinoma of Colon
Mechanism of Spread:
Direct spread
2. Transperitoneal spread
3. Implantation
4. Lymphatic
5. Hematogenous
Liver & Lungs – most common distant spread
1.

Carcinoma of Colon
Duke’s 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% ---> 5yr survival
Stage B:


Invasion through full thickness of bowel wall; (-) LN
78% ----> 5yr survival
Carcinoma of Colon
Duke’s 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

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
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
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
Any T
N1
N2, N3
M0
M0
20 – 50% 5y/r survival
Stage IV;
Any T
Any N
< 5% 5 yr survival
M1
Risk Factors for Colorectal CA
1.
2.
Aging is the dominant risk factor w/ rising
incidence after 50 y/o.
Hereditary risk factor:


3.
Dietary factors:



4.
5.
80% colorectal are sporadic
20% w/ known family hx.
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
Premalignant Diseases of Colon &
Rectum
Adenoma
Familial adenomatous polyposis syndrome
Gardner’s syndrome
Hamartomas (familial juvenile polyposis coli &
Peutz-Jegher polyp
Inflammatory bowel disease
1.
2.
3.
4.
5.
a.
b.
6.
7.
Ulcerative colitis
Crohn’s disease
Schistosomiasis (Billharziasis) – S. mansoni &
S. japonicum
Utero-sigmoidostomy
Genetic Defects for Colorectal CA
Mutation may cause:
1. Activation of:

2.
K-ras (an oncogene)
Inactivation of
tumor- suppressor
gene:



APC
DCC (deleted in
colorectal carcinoma)
p53
Genetic Pathways for Tumor
Initiation and Progression
1.
LOH pathway:


2.
Chromosomal deletion and tumor aneuploidy
80% of colorectal carcinoma
RER pathway (replication error):


Error in mismatch repair during DNA replication
20% of colorectal carcinoma
Carcinoma of Colon
Clinical Manifestation:
Change in bowel habit
 Rectal bleeding

classic symptoms
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

Screening Modalities For Colonic
Tumors
1.
Fecal occult blood testing:

2.
3.
Rigid proctoscopy / flexible
sigmoidoscopy
Colonoscopy:

4.
5.
Annual FOBT screening for asymptomatic 50 y/o
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
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 ---> subtotal or total colectomy
 Metachronous tumor (second primary colon CA)
treated similarly
 Hemorrhage in an unresectable tumor can be
controlled w/ angiographic embolization

Therapy for Colonic Carcinoma
Stage 0:



No risk of LN metastasis
Pedunculated / sessile polyp -> endoscopic polypectomy
If polyp cannot be removed completely segmental resection shd
be done
Stage I: (T1,N0,M0):


Polypectomy --> for uninvolved stalk (pedunculated)
Segmental resection:
1. Sessile polyp
2. Pedunculated polyp ( lymphovascular invasion, poorly differentiated or
tumor w/in 1mm. of resection margin ---> high risk of local
recurence and metastatic spread)
Therapy for Colonic Carcinoma
Stage II (T3-4,N0,M0):


Surgical resection
Adjuvant chemotherapy is suggested for:
1.
2.
Young patient
Moderate to poorly differentiated
Stage III (Tany,N1,M0):

Surgical resection + adjuvant chemotherapy (5Fluorouracil, levamisole or leucovorin, capecitabine,
irinotecan, oxaliplatin, angiogenesis inhibitor and
immunotherapy)
Therapy for Colonic Carcinoma
Stage IV: (Tany, Nany, M1)
Palliative resection of primary and isolated liver
metastasis
 Adjuvant chemotherapy
 Irresectable ---> diverting colostomy

THANK
YOU
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
Therapy for Rectal Carcinoma
1.
2.
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.
a.
b.
3.
Total mesorectal excision (TME)
APR
Pelvic exenteration: --> 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.
Therapy for Rectal Carcinoma
Stage 0 (Tis, N0,M0)

Local excision w/ 1 cm margin
Stage I: (T1-2,N0,M0)
Polypectomy --> confined to the head of the polyp
 Radical resection --> sessile uT1N0 and uT2N0
rectal CA

Therapy for Rectal Carcinoma
Stage II (T3-4,N0,M0): 2 school of thought
1.
Total mesorectal resection only
2.
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:
1.
2.
3.
Over treatment of early stage tumors
Impaired wound healing
Pelvic fibrosis increases the risk of operative complications
Therapy for Rectal Carcinoma
Advantages of postoperative radiation:
1.
2.
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
Follow-up and Surveillance for
Colorectal CA
Annual colonoscopy
 CEA determination
 CT scan done if CEA is elevated

Anal Canal & Perianal Tumors
Uncommon; 2% colorectal
CA
Anal margin – distal to dentate
line
Anal canal – proximal to
dentate line

Anal Canal & Perianal Tumors
1.
Anal intraepithelial neoplasm (AIN)

Bowen’s 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 ---> 3-6 months follow up




Anal Canal & Perianal Tumors
2.
Epidermoid carcinoma




Squamous cell CA, Cloacogenic CA,
Transitional CA, Basaloid CA.
Slow growing; present as mass or perianal mass
Anal margin --> wide local excision
Anal canal or invading anal sphincter --> Nigro
protocol ( 5-fluorouracil, mitomycin C, 3000cGy
external beam radiation). 80% are cured

Recurrence ---> APR
Anal Canal & Perianal Tumors
3.
Verrucous carcinoma



4.
Buschke-Lowenstein Tumor, Giant condyloma
accuminata.
Do not metastasize
Wide excision / radical resection
Basal cell carcinoma


Rarely metastasize
Wide excision tx of choice; recurrence --->APR
&/or radiation therapy
Anal Canal & Perianal Tumors
5.
Adenocarcinoma:



6.
Usually a downward spread of low rectal CA
Could arise from anal glds or developed from chronic fistula;
also from apocrine gld (Paget’s dse)
Tx: - radical resection w/ or w/o chemoradiation
- Paget’s dse = wide excision
Melanoma:



Poor prognosis; 5yr survival --> 10% due to sytemic
metastasis &/or deeply invasive tumors
Wide local resection / APR
Adjuvant chemotherapy, biochemotherapy, vaccines,
radiotherapy
Anorectal Abscess
5 potential spaces:
1.
2.
3.
4.
5.
Perianal space
Ischiorectal space
Intersphincteric
space
Deep posterior
anal space
Supralevator
space
Anorectal Abscess
Etiology:


Infection of anal gland
Organism (fecal & cutaneous flora)
1.
2.
3.
E. coli
Bacteroides fragilis
Streptococcus
Manifestation:

Pain in the anal region
Treatment:



Drainage / antibiotic
Hygiene
Hot sitz bath
4. Clostridium sp.
5. Staphylococcus
Anorectal Abscess
Types :
1. Perianal abscess
2.
Ischiorectal abscess – diffuse
swelling of ischiorectal fossa
Anorectal Abscess
3.
Intersphincteric abscess:



4.
No apparent sign of swelling or induration in the perianal
area
CLUE: --> 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
a.
b.
c.
Intersphincteric abscess
Ischiorectal abscess
Intra-abdominal abscess
Necrotizing Peri-anal & Perineal Infection:
Etiology:
1.
2.
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
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-inano:
1.
2.
3.
4.
Inter-sphincteric
Trans-sphincteric
Supra-sphincteric
Extra-sphincteric
Fistula-in-ano
Manifestation:


Previous history of
perianal abscess
Rule out ulcerative colitis
and Crohn’s dse
(colonoscopy / barium
enema)
Treatment:
1.
2.
Identify the primary
opening
(probing/methylene
blue/fistulography)
Fistulotomy / fistulectomy
(healing by secondary
intension
Fistula-in-ano

1.
2.
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
Hemorrhoid


1.
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
Hemorrhoid
2.
External hemorrhoid

Dilated venules of the inferior hemorrhoidal
plexus located distal to the pectinate or dentate line
Hemorrhoid
3.
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
Hemorrhoid
Rubber band ligation:
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
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
Anal Fissure
Etiology:
1.
Passage of large hard stool
2.
Conditions ( Crohn’s 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)
Anal Fissure
Treatment:

Conservative:




anal hygiene / bulk
forming agents
hot sitz bath
local anesthetic jelly
Surgical:

chronic stage (lateral
internal sphincterotomy)