colorectal carcinoma. A clinical based approach

Good topic of surgery

1. Colorectal Carcinoma Rahul Jha Lecturer MBBS, MS General Surgery KAHS

2. Contents Introduction Risk Factors Clinical Features Investigations Treatment

3. Introduction Incidence ?? Which part ?? 2 nd mc cancer worldwide Increasing in western countries Gender predisposition ?? Female >   male 2 nd mc in female and 3 rd mc ca in male site Lack of high fibre diet Female…. right colon Male ……left colon

4. Site Mc site ?? 2 nd MC site?? Rectum Sigmoid Colon

5. Risk Factors Patient particulars Medical history Surgical history Personal history Drug history Family history 1.Smoking 2. Alcohol 3. L ack of fibre diet, obesity, lack of exercise 4. Smoked food sekuwa IBD, UC,CD Cholecystectomy Opoid overuse Age > 70 yrs Female Adipose tissue…….secrete TNF alpha, IL 6…….Cancer initiation Inflammatory mediators IL 6, IL 1, TNF Increased exposure to bile Decrease peristalsis….more exposure to dietary toxins Nitrate……nitrite…. nitroso amino compound……carcinogen

6. Types Morphological types Histological types Annular Proliferative Ulcerative Adeno ca Squamous cell ca Colloid/mucoid ca

7. Clinical Features PR bleeding Tenesmus Mucus discharge Itching Altered bowel habit Pain ?? Early morning spurious diarrhea Bright red rectum or anal canal Dark red LOT to sigmoid colon Malena above sigmoid colon Mixed with stool On the surface of stool Colloid type Upper 1/3 rd ……..constipation, intestinal obstruction, abdominal mass Middle 1/3 rd ……… Tenesmus Lower 1/3 rd ………..Tape like stool Proliferative type Advanced stage……… mesorectum involvement………..Nerve plexus involvement U lcerative type

8. Revision Session 1. Proliferative type ?? 2. Ulcerative type ?? 3. Annular type ?? 4 . Mucoid/colloid ?? Altered bowel habit Upper 1/3 rd Middle 1/3 rd Lower 1/3rd Tenesmus Spurious Diarrhea Itching, Mucoid discharge Constipation, Intestinal obstruction Tenesmus Tape like stool Constipation, obstruction

9. Investigations Clinical Examination Digital Rectal Examination Proctoscopy To confirm the diagnosis Colonoscopy Sigmoidoscopy CT Colonography Barium Enema To stage the disease CECT A +P +C MRI PET Scan EUS Barium swallow, Barium meal, Barium follow through, Barium Enema

10. Investigations to confirm the diagnosis 1 st clinical examination ?? What next ?? What next ?? Colonoscopy Why ?? To detect the presence of synchronous lesion Metachronous lesion biopsy Digital Rectal Examination to palpate any mass Proctoscopy guided biopsy synchronous lesion vs metachronous lesion Similar lesion present at the time of diagnosis or within 6 months of diagnosis If presents with obstruction ?? sigmoidoscopy If colonoscope or sigmoidoscope not negotiable ?? CT Colonography

11. TNM Staging of rectal ca Early LA

12. Investigations for staging of disease CECT scan o f abdomen pelvis and chest For TNM and Duke’s staging To differentiate early, locally advanced and advanced colorectal ca Early colorectal Ca……… T1N0M0 T2N0M0 Locally Advanced colorectal ca T3/4N0M0 Any T N1M0 Advanced colorectal ca…………….. M1 any t stage or any N stage

13. Locally advanced ca T3/4N0M0 Any T N1 M0

14. Treatment varies according to the stage of colorectal ca Early Locally Advanced Advanced

15. Early Colorectal Ca T1N0MO Directly Definitive Surgery Or Minimally invasive surgery T2NOMO Directly Definitive surgery open Laparoscopic

16. Locally Advanced Ca

17. Advanced Ca or Mets

18. Definitive Surgery