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 • 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
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
congenital/acquired Definition • 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 • 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 • Definition: herniations or sackke protrusion of the mucosa through the muscularis, at the point where a nutrient artery penetrates the muscularis • 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 • Definition: inflammation in/around the diverticular sac • 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
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 • 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 • 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) • 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 • severe chronic constipation/rectal ampulla distended by gas • Barium enema: entire colon distended with stools, no narrowed segment ACQUIRED MEGACOLON (Chaga’s disease) • 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 • 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 • middle-aged adults female/male ratio 2:1 • history of chronic constipation/diarrhea or both • lower abdominal pain • excessive bloating • weakness • faintness • palpitations Diagnosis • chronic intermittent nature of symptoms • relation of symptoms with emotional stress • careful history • complete physical exam • stool examination – occult blood
Colonoscopy excludes neoplasia • Barium enema spasticity of the sigmoid, accentuated haustra • Lactase deficiency may masquerade IBS • Tyrotoxicosis is confused with IBS → lab studies Treatment • 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 • 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 • second to lung cancer as a cause of cancer death in the US • males > 50 years old Risk factors • 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
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 BovisBacteriemia • Rectosigmoidoscopy – 5-10% of CCr 15-30 years after
POLYPS • Adenomatous polyps – premalignant 30% middle age elderly people Classification: • 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 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”
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
POOR PROGNOSTIC PREDICTORS FOLLOWING TOTAL RESECTION • 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 • 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 TOTAL RESECTION of tumor – optimal management when a malignant lesion is endoscopically or radiologicallydetected 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
CHEMOTHERAPY • 5FU + acid folinic ↑ the supression of DNA synthesis and accompanying cytotoxicity • Chemotherapy + radiotherapy → B + C cancers • Levamisol – nonspecific immunomodulator
ANORECTAL PROBLEMS HEMORRHOIDS • 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
Other symptoms • Brightred 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
TREATMENT • Conservative therapy • sitz baths • suppositories • stool softners • bed rest • Internal hemorrhoids which remain permanently prolapsed, are best treated surgically. • Banding or injection by scleroting solutions in milder degrees of prolapse or enlargement with pruritesani or intermitent bleeding. • External anus acutely thrombosed are treated by: • incision • extraction of the clot • compression of the incised area following clot removal • Rectoscopy and barium enema should always be performed before a patient is subjected to hemorrhoidectomy.