Transcript Document

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Alteration in bowel habit
Rectal bleeding
Pain
Diarrhea/constipation
Obstipation – absence of spontaneous bowel movements
Hematochezia – fresh blood from the colon or distal small
intestine
Tenesmus - retention of stool in the rectum
- tumors
- colonic inflammation
DIAGNOSTIC PROCEDURES
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Physical examination
Buccal pigmentation or telangiectazia → coexistent small
bowel polyposis or intestinal telangiectazia: abdominal pain,
chronic bleeding
Iritis
Arthritis
IBD
Erytema nodosus
Digital rectal examination
Stool examination
Barium studies – small bowel X-rays – enteroclysis
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Barium enema - diverticulosis
- motility disturbances
- loss of haustral markings
- tumors
Colonoscopy → detecting of colonic neoplasms
Sigmoidoscopy → lower 40-60 cm of the colon
Mesenteric angiography - intestinal ischemia
- ac. GI hemorrhage (> 0,5 ml/min)
Radionuclide bleeding scan – iv injection of Tc99m
Rate of 0,1-0,5 ml/min → the location of radioactivity in the
abdomen may indicate the source of bleeding
DIVERTICULOSIS
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congenital/acquired
Definition
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herniations of the entire thickness of intestinal wall
herniations of the mucosa through the muscularis, generally
at the site of a nutrient artery
Small-intestinal diverticula
 Duodenal
diverticula – abdominal pain, fever, GI
bleeding, perforation
 Jejunal diverticula – abcess or peritonitis
a) Multiple jejunal diverticula may be associated with a
malabsorbtion syndrome → bacterial perforation → mucosal
damage → deconjugation of bile salts + vit. B12
malabsorbtion
 Meckel’s
diverticulum: congenital anomaly of the
digestive tract – 2% cases/a persistent
omphalomesenteric duct
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arises from the antimesenteric border of the ileum usually
within 100 cm of the ICV
may produce hemorrhage, inflamation and obstruction in
children and teenagers.
Diagnosis: isotope scanning (technetium i.v.)
may mimic acute appendicites in young adults
surgical excision of complications
COLONIC DIVERTICULA
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Definition: herniations or sackke protrusion of the
mucosa through the muscularis, at the point where a
nutrient artery penetrates the muscularis
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occur most commonly in the sigmoid colon and decrease in
frequency in the proximal colon
they increase with age
20-50% in western population > 50 years
increase pressure produced by colonic muscle contractions/↑
intraluminal pressure
usually asymptomatic, are an incidental finding on barium
enema for others reasons.
DIVERTICULITIS
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Definition: inflammation in/around the diverticular sac
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Pericolic abcess → generalized peritonitis
↑ in men > 3 times in the left colon
ACUTE COLONIC DIVERTICULITIS
fever
left lower quadrant abdominal pain
muscle spasm, guarding, rebound tenderness
Rectal examination → tender mass-close to the rectum
Acute constipation
Rectal bleeding 25% cases
Leukocytosis
Complications: acute peritonitis
sepsis/stroke → elderly
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Differential diagnosis:
Neoplasm of the descendent or sigmoid colon
Treatment
bed rest
stool softness
liquid diet
wide-spectrum antibiotic: tetracycline/ampicilin
Repeated attacks of diverticulitis in the same area require
surgical resection
Usual procedure:
diverting colostomy with resection of the involved colon
reanastomosis is then performed at a second operation.
HEMORRHAGE FROM DIVERTICULA
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one of the commonest causes of hematochezia > 60 years
Mechanism: erosions of a vesel by a fecalith within the
diverticular sac
bed rest + blood transfusion
Bleeding scan/angiography → localization of bleeding
↑ in the ascending colon
MEGACOLON
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Definition: giant colon with masive distension and
constipation
congenital/aquired is seen in all age groups
Acute toxic megacolon is a severe complication of chronic
uncerative colitis
AGANGLIONIC MEGACOLON
(Hirschsprung’s disease)
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congenital disorder which becomes manifest in early infancy,
occuring specially in males; often familial
Clinical features
massive abdominal distension
absent bowel movements
impaired nutrition
Inability to defecate is caused by the absence of ganglion cells
(Meissner’s and Auerbach’s plexuses) in a small segment of
the distal colon, near the anus
Barium enema reveals a narrowed segment in a RS area,
with massive dilatation above
Diagnostic: surgical biopsy full-thickness
Treatment: surgery which restores normal defecation
CHRONIC IDIOPATHIC MEGACOLON
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severe chronic constipation/rectal ampulla distended by gas
Barium enema: entire colon distended with stools, no
narrowed segment
ACQUIRED MEGACOLON (Chaga’s disease)
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in Central and South America Tripanosoma cruzi
the onset is in adult life
patients with depression, schizophrenia, cerebral atrophy,
mixedema
morphine, codeine
IRRITABLE BOWEL SYNDROME
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Spastic colitis: chronic abdominal pain
constipation
Second group: chronic intermittent diarrhea
without pain
Gr. I + II → alternating constipation and diarrhea
alternation of intestinal motility
have increased resting colonic motility
have decreased resting colonic motility
Psychological stress increase motility
Abnormality of intestinal neuro-muscular function (↑ in 3
cycle/minute slow wave activity)
Depression, hysteria, obsessive-compulsive traits →
exacerbate symptoms
Clinical features
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middle-aged adults female/male ratio 2:1
history of chronic constipation/diarrhea or both
lower abdominal pain
excessive bloating
weakness
faintness
palpitations
Diagnosis
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chronic intermittent nature of symptoms
relation of symptoms with emotional stress
careful history
complete physical exam
stool examination – occult blood
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Colonoscopy excludes neoplasia
Barium enema spasticity of the sigmoid, accentuated haustra
Lactase deficiency may masquerade IBS
Tyrotoxicosis is confused with IBS → lab studies
Treatment
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Minimaze symptoms impact on life-style
Physician will prescribe physical exam, hemograms, occult
blood at regular intervals
Surg. treatment: constipation → ↑ in dietary burk laxatives
→ mild sedation
ANGIODYSPLASIA OF THE COLON
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vascular ectasias in the right colon in older that may cause
bleeding
degenerative lesions of dilated, distorted, thin-walled vessels
lined by vascular endothelium
2 nm → 1 cm Φ star-shaped branching vessels in submucosa
in the cecum and ascending colon
Angiography – extravasation of contrast material into the
lumen
Colonoscopy – bleeding lesions
Right hemicolectomy – multiple sites!
COLORECTAL CANCER (CCR)
Incidence
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second to lung cancer as a cause of cancer death in the US
males > 50 years old
Risk factors
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Diet
more often in urban areas: low intake of dietary fiber
meat protein
dietary fat and oil (“western” diet) → animal fats
↑ cholesterol concentration
mortality from coronary artery disease
hereditary syndroms: Polyposis coli (25%)
(autosomal dominant)
Non-polyposis syndrome
deletion in the long arm of chromosome 5
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Inflammatory bowel disease (UC)
↑ risk in young patients with pancolitis
Dietary fiber accelerates intestinal transit time, reducing the
exposure of colonic mucosa to potential carcinogens and
diluting these carcinogens because of enhanced fecal bulk.
Risk for the CCR is decreased by the addition of calcium
supplements to the diet
Streptococcus Bovis Bacteriemia
Rectosigmoidoscopy – 5-10% of CCr 15-30 years after
POLYPS
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Adenomatous polyps – premalignant 30% middle age
elderly people
Classification:
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nonneoplastic hamartoma (juvenile polyps)
hyperplastic polyps
adenomatous polyps
Deletion in chromosoms 5, 18, 17 (short arm) – p53
Adenomatous polypd – pediculated
sessile ↑ often premalignant
Villous polyps - ↑ premalignant
Colonoscopy should be repeated periodically (even 3 years),
even in the absence of a previously documented malignancy,
since such patients have a 30-50% probability of developing
adenoma → risk of CCR
CLINICAL FEATURES
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Symptoms vary with the anatomic location of the tumor
Tumors in the ascending colon
fatigue
palpitations – AP
hypochromic microcytic anemia (↓ iron)
Transverse + descending colon tumors
abdominal cramps
obstruction (occasional)
perforation
X-rays – “apple-are”, “napkin-sign”
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Rectosigmoid tumors
hematochezia
tenesmus
narrowing in the calibrum of stool
anemia
Digital rectal examination
are necessary!
Proctosigmoidoscopy
STAGING, PROGNOSTIC FACTORS,
PATTERNS OF SPREAD
DUKES CLASSIFICATION OF CCR
STAGE
PATHOLOGIC DESCRIPTION
5 YEAR
SURVIVAL %
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Cancer limited to mucosa, submucosa
> 90%
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Cancer extends into muscularis
70-85%
C
Cancer involves regional lymph nodes
30-60%
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Distant metastases (liver, lung, bone)
5%
POOR PROGNOSTIC PREDICTORS
FOLLOWING TOTAL RESECTION
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T spread to regional lymph nodes (l.n.)
Number of regional l.n. involved
T penetration through the bowel wall
Poorly differentiated histology
Perforation
T adherence to adjacent organs
Venous invasion
Preoperative ↑ CEA (> 5 ng/ml)
Aneuploidy
SCREENING
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The earlier detection of localized, spf neoplasms in
asymptomatic individuals will increase the surgical cure rate.
60% of early lesions are located in the RS
Programs focused on digital rectal examination, testing stool
for presence of occult blood
35-50% of CCR have a negative fecal Hemoccult
test/intermittent bleeding pattern of these tumors
CCR – 5-10% of “test +” cases with benign polyps
TREATMENT
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TOTAL RESECTION of tumor – optimal management
when a malignant lesion is endoscopically or radiologically
detected in the large bowel
Chest X-ray
Biochemical assesment of liver function
prior to surgery!
Plasma CEA level
Colonoscopy of the entire large bowel should be performend to
identify synchronous neoplasm/polyps
RADIATION THERAPY to the pelvis – in those with RC
(30-40% regional reccurences after surgical resection of stages B,
C tumors.
Preoperative therapy is indicated for patients with large
potentially unresecable cancers
Postoperative radiotherapy reduces pelvic reccurences, but does
not appear to prolong survival
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CHEMOTHERAPY
5FU + acid folinic ↑ the supression of DNA synthesis and
accompanying cytotoxicity
Chemotherapy + radiotherapy → B + C cancers
Levamisol – nonspecific immunomodulator
ANORECTAL PROBLEMS
HEMORRHOIDS
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Whenever the internal hemorrhoidal plexus is enlarged it is
associated increase in supporting tissue mass and the
resultant venous swelling is called internal hemorrhoid.
When veins in the external hemorrhoidal plexus became
enlarged/thrombosed, resultant is external hemorrhoid.
Both types are associated with increased hydrostatic pressure
in the portel venous system during:
 Pregnancy
 Straining at stool
 Cirrhosis
Pain only in: - thrombosis
- infection
- erosion of the overlying mucosal surface
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Other symptoms
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Bright red blood on the toilet/coating the stool
Vague discomfort – prolapses through the anus – edema +
sphinteric
spasm
The overlying mucous membrane may bleed profusely as the
result of the trauma or defecation.
DIAGNOSIS
inspection
digital examination
direct vision through the anoscope and proctoscope
hypochromic anemia
acute blood loss – attributed to internal hemorrhoids
chronic anemia – search for a polyp, ulcer, cancer
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TREATMENT
Conservative therapy
sitz baths
 suppositories
 stool softners
 bed rest
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Internal hemorrhoids which remain permanently prolapsed,
are best treated surgically.
Banding or injection by scleroting solutions in milder degrees
of prolapse or enlargement with prurites ani or intermitent
bleeding.
External anus acutely thrombosed are treated by:
incision
 extraction of the clot
 compression of the incised area following clot removal
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Rectoscopy and barium enema should always be performed
before a patient is subjected to hemorrhoidectomy.