Transcript Surgery of gastrointestinal tract

Diseases
of
Large Bowel
Diverticulosis of the Colon I.
Diverticula of the colon are acquired
herniations of colonic mucosa protruding
through the circular muscle and the wall of
large bowel.
Localisation - usually in the left part of the
large bowel ( sigmoid colon is involved in
90% cases), but they can occur everywhere
in large bowel
Ethiology - muscular incoordination and
hypertrophy resulting in increasing
segmentation and intraluminal pressure.
Diverticulosis of the Colon II.
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Frequency of the disease is increasing with
the age.
Clinical features - the disease is very often
asymptomatic, or there are some non specific
symptoms due to disordered colonic function
( f.e. distension, flatulence )
But the symptoms of the complications are
usually very serious.
Diverticulosis of the Colon III.
Diagnosis
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clinical examination
X-ray picture with barium enema
Ultrasonography
Colonoscopy
Cystoscopy, gynecological examination
Diverticulosis of the Colon IV.
Complications:
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inflammation ( diverticulitis )
perforation
bleeding
postinflammatory stenosis
obstruction
fistula with the surrounding organs
( urinary bladder, vagina )
Diverticulosis of the Colon V.
Treatment
antibiotics, bed rest, liquid diet, spasmolytics
( acute attack of diverticulitis )
operation – 10% patients require operation
one stage resection
two stage procedures - colostomy
- exteriorisation of the affected bowel
- Hartman´s procedure
- fistulas – resection of the bowel and
closure of the fistula
Ulcerative Colitis I.
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Aethiology is inknown – possibly is linked
with emotional stress, maybe it is autoimmune disease, secondary infection
maybe plays some role.
young people
Pathology – in 95% cases the disease
starts in rectum and spreads proximally.
the disease is characterised by appearance
of multiple ulcers, sometimes they are
discrete sometimes there is a lot of ulcers.
Ulcerative Colitis II.
Clinical features : watery diarhoe occuring
day and night,
rectal discharge of mucus
pain, bleeding
2 types :
1. fulminating type 5% temperature, diarhoe containing
blood mucus and pus
2. chronic type 95%
Ulcerative Colitis III.
Treatment : medicaments
(antibiotics,corticosteroids, imunossupresive drugs ,
Remicade ? )
Indications for surgical treatment:
1. to save life ( perforation, toxic megacolon )
2. local complications, general
complications ( liver changes, skin lesions,
renal disease, sclerosis cholangitis)
3. risk of carcinoma
The method of choice is
restorative proctocolectomy
Toxic megacolon I.
Clinical term for an acute toxic colitis with
nonobstructive colonic dilatation larger than
6 cm and signs of systemic toxicity
The dilatation can be either total or segmental.
- potentially lethal condition
The inflammation extending beyond the
mucosa into the smooth-muscle layers and
serosa.
Toxic megacolon II.
Symptoms:
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High fever
Abdominal pain and tenderness
Tachycardia
Dehydration
Mortality :
5 – 10 %
Toxic megacolon III.
Three main goals:
1. reduce colonic distension to prevent perforation
2. correct fluid and electrolyte disturbances
3. treat toxemia and precipitating factors
Conservative treatment: fluid replacement,
antibiotics, steroids, remicade, nasogastric tube,
bowel rest
Surgical treatment : subtotal or total colectomy.
Tumors of Large Bowel
A. Benign tumors
B. Malignant tumors
Benign tumors I.
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2 types - tubular adenoma - pedunculated
villous adenoma - sessile
They have malignant potential ,so they should
be removed.
Malignancy depends on size and type
of adenoma.
More dangerous are large and villous
adenomas
Benign tumors II.
Complications - bleeding,
- diarrhoe, hypokalaemia
/ villous /
Treatment - fibre endoscopic removal
- operation - partial colon
resection (very large polyps )
Familial adenomatous polyposis (FAP)
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hereditary disease .
The gene for FAP is on the long arm
of chromosome 5 and is called the APC gene.
There are a lot of polyps / hundreds/ at the
colon and rectal mucosa
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very strong malignant potential
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Diagnosis : colonoscopy, genetic tests
Familial adenomatous polyposis II.
Treatment is surgical
1. colectomy + ileo-rectal anastomosis
2. total colectomy with permanent ileostomy
( cancer )
3. „ restorative proctocolectomy“
- proctocolectomy with ileal pouch – anal
anastomosis
Carcinoma of the Colon I.
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Colon carcinoma originating in the epithelial
cells of the colon
M:W=3:2
25 % of cases present as emergencies with
intestinal obstruction or perforation and
peritonitis
The spread of carcinoma – local spread
( penetration through intestinal wall
to surrounding organs )
lymphatic spread to regional or distant
lymphonodes
spread by the blood-stream to liver
Carcinoma of the Colon II.
Typing, Grading, Staging
 Typing - the type of tumor –
adenocarcinoma - 90%
„Signet ring cell “ carcinoma
 Grading - well differential carcinoma
- moderate differential
- poor differential
 Staging - spread of the carcinoma
Dukes classification
TNM classification
Carcinoma of the Colon III.
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Clinical Features
carcinoma of the left side (75% cases): pain,
alteration of bowel habit ( irregularity ),
palpable tumor, bleeding
carcinoma of the right side : aneamia, the
presence of a mass in the right iliac fossa
Diagnosis
endoscopy - sigmoidoscopy, colonoscopy
radiography with the barium enema
ultrasonography
CT
Carcinoma of the Colon IV.
Complications
- obstruction
- perforation with stercoral peritonitis
- bleeding
Treatment - operation
A. radical
B. paliative : intestinal by-pass,
colostomy
Clasic or laparoscopic procedures
Right side hemicolectomy
Left side hemicolectomy
Resection of rectum
Abdominoperineal rescetion of
rectum