COLON

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

2. Pseudomembranous colitis:

• Complication of antibiotics ---> alteration of normal flora

• Overgrowth of Clostridium deficile:

• Has cytopathic and enteropathic toxins

Develops 6wks after:

a. Clindamycin

b. Ampicillin

c. Cephalosporin

Dx: - 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

1. SIGMOID VOLVULUS (90%):

• Redundant sigmoid colon

w/ a narrow based mesocolon

Sx: colicky abd. pain, distention

obstipation, rectal collapse

s/sx of dehydration

Volvulus:

1. 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

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. True diverticula (rare) – right side

2. 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) Contraction ring (thickening of circular muscle)

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

c) 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 (2-

10%)

DIVERTICULOSIS:

Clinical Manifestation:

A. Majority are asymptomatic

B. 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. Diverticular disease

2. 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 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:

1. Nuclear imaging (bleeding

scan/scintigraphy)

a. Technetium-Sulfur Colloid Scan

 Sensitive (0.5ml/min)

b. Autologous labeled RBC scan

 Stays in the circulation for as long as

24 hrs (monitoring)

 (1ml/min bleeding)

2. 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:

 Extent of vascular occlusion

 Duration of occlusion

 Efficiency of collateral circulation

 Extent of secondary bacterial invasion

1. Reversible or Transient Ischemic Colitis:

 Partial mucosal slough that healed after 2-3 days

2. 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)

 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





2. 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):

 involve the colonic mucosa – only the colon

 male > female

 limited to the colon and rectum

 Chronic inflammation of GI tract



2. 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

Symptoms

diarrhea +++ +++

rectal bleeding + +++

tenesmus 0 +++

abdominal pain +++ +

fever ++ +

vomiting +++ 0

weight loss +++ +

Signs

perianal disease +++ 0

abdominal mass +++ 0

malnutriton +++ +

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, linear w/ transverse

continuous distribution fissures (cobblestone or

skip lesion)

Bowel stricture rare (suspect carcinoma) common

Carcinoma increase incidence increased incidence

Toxic dilatation of Occurs in both

colon (megacolon)

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. Focal inflammation in the mucosa

2. Ileal involvement

3. Linear or fissuring ulcers

4. Rectal sparing

5. Right sided predominance

Highly suggestive of Crohn’s disease:

1. Discontinuous segmental involvement

2. Aphthoid ulcers

Pathognomonic of Crohn’s disease:

1. Sarcoid granulomas

2. Transmural inflammation w/ lymphoid nodules

3. Fistulas (at sites other than anus)

Bowel Involvement in Crohn’s

Disease

(exam question)

1. Ileocolic 44%

2. Colonic 28%

3. Small bowel only 27%

4. Anorectal 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 - 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

Medical Therapy for Ulcerative Colitis &

Crohn’s Disease

1. Sulfasalazine – lowers the inflammation

2. Metronidazole (as well as 2nd gen cephalosporin)

 Crohn’s ileocolitis & colitis

 Perineal colitis

 Not effective in active ulcerative colitis

3. Corticosteroid – lowers antibody

 Oral for mild to moderate active ulcerative colitis and

Crohn’s disease

 Parenteral for severe or toxic ulcerative colitis or Crohn’s

disease

4. Immunosuppressive agents:

 Steroid sparing

 Refractory disease

Indications for Surgical Interventions

for Ulcerative Colitis:



1. Active disease unresponsive to

medical therapy

2. Risks of cancer – based on workup

3. Severe bleeding

Surgical treatment for

Ulcerative Colitis

1. Proctocolectomy w/ Brooke ileostomy (brings

ileum to the skin):

 curative w/ one operation

2. Colectomy w/ ileorectal anastomosis:

 not curative; cancer risk persists (5-50%)

 contraindicated for severe rectal dse, rectal dysplasia and

rectal CA

3. 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:

 Internal fistula and abscess 38%

 Intestinal obstruction 37%

 Perianal fistula 15%

 Poor response to medical therapy 6%

2. Colonic Crohn’s 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%

COLO – RECTAL POLYPS

 Projection from the surface of the

intestinal mucosa regardless of it’s

histologic nature:

 Types:

1. Neoplastic

2. Hamartomatous

3. Inflammatory

4. Unclassified

COLO – RECTAL POLYPS

Neoplastic Polyps:



Types Incidence Malignant

(%) Potential (%)

Tubular 75 5

Villous 10 40

Tubulovillous 15 22



 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:

 not precancerous

 excision

 Swiss cheese appearance from dilated cystic spaces

2. 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:

3. Peutz-jegher Syndrome

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

b. Polyps of small bowel (always), stomach, colon and rectum

(branching of lamina propria like Christmas tree).

 Can degenerate into malignancy

4. Cronkhite – Canada Syndrome:

 GIT polyposis, alopecia, cutaneous pigmentation, atrophy

of fingernails and toe nails

5. 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 2cm. have a slight risk of malignant degeneration

 Saw tooth appearance of the lining epithelial cells

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

1. 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. Unknown

2. Hereditary

3. Diet --> low fiber diet and high animal fat

 Distribution --> shifting to the right side

Carcinoma of Colon

Macroscopic form:

1. Ulcerating type most common

2. Polypoid or fungating

3. Colloid CA

 bulky growth w/ gelatinous appearance

 10-15%

4. Signet ring cell CA

 intracellular mucinous

5. Infiltrating CA

 submucosal spread

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

Carcinoma of Colon

Mechanism of Spread:

1. Direct spread

2. Transperitoneal spread



3. Implantation



4. Lymphatic



5. Hematogenous



 Liver & Lungs – most common distant spread

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 N1 M0

Any T N2, N3 M0

20 – 50% 5y/r survival

Stage IV; Any T Any N M1

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. Young patient

2. 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)

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. Transanal endoscopic microsurgery

2. 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. Total mesorectal excision (TME)

b. APR

3. 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. Over treatment of early stage tumors

2. Impaired wound healing

3. Pelvic fibrosis increases the risk of operative complications

Therapy for Rectal Carcinoma

Advantages of postoperative radiation:

1. Allows accurate pathologic staging of the resected tumor

and LN

2. 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

 Buschke-Lowenstein Tumor, Giant condyloma

accuminata.

 Do not metastasize

 Wide excision / radical resection





4. Basal cell carcinoma

 Rarely metastasize

 Wide excision tx of choice; recurrence --->APR

&/or radiation therapy

Anal Canal & Perianal Tumors

5. Adenocarcinoma:

 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





6. 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. Perianal space

2. Ischiorectal space

3. Intersphincteric

space

4. Deep posterior

anal space

5. Supralevator

space

Anorectal Abscess

Etiology:

 Infection of anal gland

 Organism (fecal & cutaneous flora)

1. E. coli 4. Clostridium sp.

2. Bacteroides fragilis 5. Staphylococcus

3. Streptococcus

Manifestation:

 Pain in the anal region

Treatment:

 Drainage / antibiotic

 Hygiene

 Hot sitz bath

Anorectal Abscess

Types :

1. Perianal abscess









2. Ischiorectal abscess – diffuse

swelling of ischiorectal fossa

Anorectal Abscess

3. Intersphincteric abscess:

 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

4. Supralevator abscess:

 Uncommon

 Mimmic acute intra-abdominal condition

 Etiology: extension of

a. Intersphincteric abscess

b. Ischiorectal abscess

c. Intra-abdominal abscess

Necrotizing Peri-anal & Perineal Infection:

Etiology:

1. Neglected or delayed treatment of primary anorectal infection

2. 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-in-

ano:

1. Inter-sphincteric

2. Trans-sphincteric

3. Supra-sphincteric

4. Extra-sphincteric

Fistula-in-ano

Manifestation:

 Previous history of

perianal abscess

 Rule out ulcerative colitis

and Crohn’s dse

(colonoscopy / barium

enema)

Treatment:

1. Identify the primary

opening

(probing/methylene

blue/fistulography)

2. Fistulotomy /

fistulectomy (healing by

secondary intension

Fistula-in-ano

 If fistula is high in relation to anorectal ring do 2 stage

procedure:

1. Insert a seton wire or suture to the tract for several wks

to create fibrosis

2. Open the fibrous track on the second stage after 6-8

wks

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

1. 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)