Diseases of rectum and anal canal

Diseases of rectum and anal canal

1. Diseases of Rectum and Anal Canal Prof. G. Bandyopadhyay Professor Deptt . of Surgery Medical College, Kolkata

2. Anatomy Rectum – distal part of gastrointestinal tract It´s about 1 2 – 1 8 cm long and it´s divided into three parts: 1. proximal part 2. middle part 3. distal part ( anal canal )

3. Anatomy contd. Blood supply : 1. superior rectal artery ( inferior mesenteric artery ) 2. two middle rectal arteries ( internal iliac artery ) 3. two inferior rectal arteries ( internal pudendal artery ) Internal rectal venous plexus - lies in the submucosa of the anal canal above the level of the dentate line ( internal haemorrhoids) External rectal venous plexus - lies under the skin of the anal canal below the dentate line ( external haemorrhoids )

4. Congenital abnormalities Imperforate anus – one infant in 4500-5000 A. Low abnormalities : anal stenosis ( treatment- dilatation ) anal membrane - anus is covered with a thin membrane ( treatment- incision ) B. High abnormalities : ano – rectal agenesis ( 80-85 % ), often with recto-urethral or recto - vaginal fistula rectal atresia – anal canal is normal but ends blindly above the pelvic floor

5. Congenital abnormalities contd. Examination : inspection, X-ray picture ( infant is held upside down with the coin or metal button in the site of the anus and the gas in the rectum will rise to the top and indicate the distance ) Treatment : operation incisio n , dilatation, colostomy, reconstruction of the anorectum

6. Fissur e -in-ano - longitudinal ulcer in the distal part of anal canal The site of location: - mid-line posteriorly - 80% - mid-line anteriorly - 10% - lateral – 10 % ( Crohn´s disease ) Ethiology – unknown ( passage of a hard stool ) - resting anal pressure is raised, but this may be due to secondary sphincter spasm induced by pain Two types: 1. acute 2. chronic ( hypertrophic anal papila and sentinel tag )

7. Fissur e -in-ano contd. Symptoms : pain, bleeding, pruritus,constipation , discharge Management : 1. conservative ( acute) - sitz baths, laxatives, anal dilatation, local creams 2. operation ( chronic) - excision of fissur e , posterior or lateral sphincterotomy to reduce the high resting anal pressure

8. Haemorrhoids ( Piles ) Haemorhoids ( the dilatate d rectal venous plexus ) consist s of an internal and external component ( haemorhoidal disease ). - very frequent disease Etiology - hereditary ( weakness of the vein walls ) - higher pelvic pressure ( pregnancy ), - constipation, straining at stool

9. Haemorrhoids contd. Symptoms : bleeding, prolapse, pruritus, pain, discharge Diagnosis: inspection - at 3,7 and 11 o´clock in litothomy position rectoscopy, anoscopy Complications : bleeding, thrombosis, inflam m ation

10. Haemorrhoids cond. Classification: 4 degrees I. degree : occasional bleeding only II. degree : prolapse after defecation with spontaneous reposition III. degree : prolapse need s to be replaced manually IV. degree : permane n t prolaps e with inflam m ation, thrombosis etc.

11. Haemorrhoids contd. Management : A. conservative : sitz baths, local creams and suppositories B. sem i conservative : injection sclerotherapy, infrared coagulation, rubber band ligation

12. Haemorrhoids cotd .. C. O perative treatment : - H aemorhoidectomy -open/closed Stapled hemorrhoidectomy / haemorrhoidopexy -PPH (procedure for prolapsed haemorrhoids ) A dv- no external skin wound, recovery is rapid and relatively pain free Disadv .-recurrence rate higher,costly

13. Haemorrhoids cotd .. Complications of PPH Rectal perforation Recto-vaginal fistula Severe pelvic sepsis Anastomotic dehiscence

14. Internal haemorrhoids external haemorrhoids

15. PPH device

16. PPH procedure

17. Peri - a nal Abscess and Fistula Peri -a nal abscess and fistula are two phases of the same disease. Abscess - acute phase Fistula – chronic phase Etiology : - majority of abscesses originate in the intersphincteric space from infection of anal gland.

18. Inter- sphincteric abscess & Routes of spread Rectal lumen Abscess Internal sphincter External sphincter

19. Peri -a nal Abscess and Fistula contd. Fistula-in-ano ( anal fistula ) usually consists of : - internal opening - primary tract - external opening Primary tract connects the internal and external openings.

20. Intersphincteric fistula Transsphincteric fistula External sphincter Internal sphincter Fistula tract Fistula tract puborectalis

21. Suprasphincteric fistula Extrasphincteric fistula Fistula tract Levator ani

22. Peri -a nal Abscess and Fistula contd. Symptoms : acute abscess – pain, fe v er fistula- in- ano – chronic purulent discharge Management : Acute abscess– surgical inicision and drainage (Hilton’s method) cavity is dressed with gau z e ( changing every 24 hours ) wound is left open for secondary healing

23. Peri -a nal Abscess and Fistula contd . Anal fistula – treatment according to the type of fistula 1. In cision( lay open the primary track ) - fistulotomy 2. Excision- fistulectomy 3. Seton 4. Anal Plug 5 . A dvancement flap 6. Kharsutra

24. Fistula tract Fistulectomy : step-I

25. Fistulectomy : step-II

26. Fistulectomy : step-III

27. Multiple Fistulae

28. Benign rectal tumors The most frequent are polyps. Polyp is a localised elevated lesion arising from an epithelial surface. Polyp - adenoma : 90% - other ( inflammatory, hyperplastic etc. ) : 10% 2 types of adenoma : tubular ( pedunculated ) 20% villous ( sessile ) 80% Symptoms : bleeding, muc oid discharge ( villous ) Treatment : polypectomy by colonoscopy surgical excision – large sessile polyp

29. Colonoscopic polypectomy

30. Colorectal Cancer

31. Epidemiology Most common internal cancer in Western Societies Second most common cancer death after lung cancer Generally affect patients > 50 years (>90% of cases)

32. Colorectal Cancer Forms Hereditary Family history, younger age of onset, specific gene defects E.g. Familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal cancer (HNPCC or Lynch syndrome) Sporadic Absence of family history, older population, isolated lesion Familial

33. Pathology Spreads circumferentially 6 months required to involve a quarter and 18 months to 2 years for complete encirclement. Histopathology Generally adenocarcinoma Squamous cell carcinoma in some cases of anal CA

34. Colorectal CA

35. Duke’s classification of rectal CA A- limited to rectal wall- excellent prognosis B- extended to the extrarectal tissues but no mets to lymph nodes- reasonable prognosis C- secondary deposites in the regional lymph nodes C1- local pararectal lymph nodes only C2- nodes along blood vessels also

36. Histological Grading Low grade - well differentiated- 11% -good prognosis Average grade - 64%- fair prognosis High grade- 25%- poor prognosis

37. Clinical Presentation Depends on location of cancer Locations ⅔ in descending colon and rectum ½ in sigmoid colon and rectum (i.e. within reach of flexible sigmoidoscope ) Caecal and right sided cancer Iron deficiency anaemia (most common) Distal ileum obstruction (late) Palpable mass (late)

38. Clinical Presentation Left sided colon and sigmoid carcinoma Change of bowel habit Alternating constipation + diarrhoea Tenesmus Thin stool PR bleeding, mucus

39. Clinical Presentation Rectal carcinoma PR bleeding, mucus Change of bowel habits Anal, perineal , sacral pain Constitutional symptoms Loss of appetite, loss of wt., malaise Bowel obstruction

40. Clinical Presentation Local invasion Anterior - prostate(male),vagina, uterus(female) bladder, posterior - sacrum, sacral plexus, laterally - pararectal tissue, ureter Metastasis Liver (hepatic pain, jaundice) Lung (cough) Bone ( pain,leucoerythroblastic anaemia) Regional lymph nodes Peritoneum (Sister Marie Joseph nodule) Others

41. Examination Signs of primary cancer Abdominal tenderness and distension – large bowel obstruction Intra-abdominal mass Digital rectal examination – most are in the lower part of rectum and can be reached by examining finger Sigmoidoscopy & biopsy Signs of metastasis and complications Signs of anaemia Hepatomegaly ( mets ) Bone pain

42. Investigations Faecal occult blood Guaiac test ( Hemoccult ) – based on pseudoperoxidase activity of haematin Immunochemical test ( HemeSelect , Hemolex ) – based on antibodies to human haemoglobins Used for screening and NOT for diagnosis

43. Investigations Colonoscopy & biopsy Can visualize lesions < 5mm Small polyps can be removed or at a later stage by endoscopic mucosal resection Performed under sedation lesion colonoscope

44. Investigations Double contrast barium enema Cannot detect very small lesions All lesions need to be confirmed by colonoscopy and biopsy Performed with sigmoidoscopy Second line in patients who failed / cannot undergo colonoscopy

45. Other Investigations CT colonoscopy Endorectal ultrasound CT and MRI – staging prior to treatment Blood tests - Complete blood count, Ur/Cr, LFT, coagulation profile Tumour marker CEA Useful for monitoring progress but not specific for diagnosis

46. management

47. principles Surgery is the treatment of choice whenever possible In cases of locally advanced tumors pre-op chemoradiotherapy may downstage the tumor Palliative treatment in inoperable cases

48. Management Caecum or ascending colon Right hemicolectomy Vessels divided – ileocaecal and right colic Anastamosis between terminal ileum and transverse colon Transverse colon Close to hepatic flexure  right hemicolectomy Mid-transverse  extended right hemicolectomy (up to descending) + omentum removed en-bloc with tumour Splenic flexure  subtotal colectomy (up to sigmoid)

49. Management Descending colon Left hemicolectomy Vessels divided – inferior mesenteric, left colic, sigmoid Sigmoid colon High anterior resection Vessels ligated – inferior mesenteric, left colic and sigmoid Anastomoses of mid-descending colon to upper rectum

50. Management Obstructing colon carcinoma Right and transverse colon – resection and primary anastomosis Left sided obstruction Hartmann’s procedure – proximal end colostomy (LIF) + oversewing distal bowel + reversal in 4-6 months Primary anastamosis – subtotal colectomy ( ileosigmoid or ileorectal anastomosis ) Intraoperative bowel prep with primary anastomosis (5% bowel leak) Proximal diverting stoma then resection 2 weeks later Palliative stent

51. Resection

52. Rectal Cancer Options Low anterior resection Transanal local excision Abdomino-perineal resection Palliative procedure

53. Rectal Cancer Anterior resection Upper and mid rectum cacinoma Sigmoid and rectum resected Vessels divided – inferior mesenteric and left colic Mesorectum resected Coloanal anastomosis High – intraperitoneal anastamosis (upper 1/3 of rectum) Low – extra-peritoneal anastomosis Post-op recovery Increased stool frequency 12-18 month to acquire normal bowel function 1~4% anastamotic leak

54. Rectal Cancer Abdominoperineal resection Larger T2 and T3 or poorly differentiated tumour Rectum mobilised to pelvic floor through abdominal incision Sigmoid end colostomy Separate perianal elliptical incision to mobilise and deliver anus and distal rectum Vessels ligated – inferior mesenteric

55. Rectal Cancer Hartmann’s procedure Acute obstruction Palliative Transanal local exision Early stage Too low to allow restorative surgery En block resection – for locally advanced colorectal carcinoma (remove adherent viscera and abdominal wall)

56. Palliative procedures Diverting stoma Radiotherapy Chemotherapy Local therapy – laser, electrocoagulation , cryosurgery Nerve block

57. Complications Liver metastasis Local invasion → perineal and pelvic pain Bowel obstruction Fistula to skin or bladder Rectal discharge and bleeding Hypoproteinaemia Poor appetite

58. Prognosis 5 yr survivals T1 = >90%, T2 = >80%. T3 = >50% LN involvement = 30~40% Distant mets = <5%

59. Hereditary Colorectal Cancer Familial adenomatous polyposis FAP account for <1% of all colorectal cancers Due to mutation of the adenomatous polyposis coli (APC) gene Numerous adenomas appear as early as childhood and virtually 100% have colorectal cancer by age 50 if untreated  

60. Hereditary Colorectal Cancer Hereditary non- polyposis colorectal cancer / Lynch syndrome More common than FAP and account for ~1-5% of all colonic adenocarcinomas Due to a mutation in one of the mismatch repair genes Earlier age onset of colorectal cancer and predominantly involve the right colon HNPCC also increases the risk of Endometrial, ovarian, breast ca Stomach, small bowel, hepatobiliary ca Renal pelvis or ureter ca

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