DISEASES OF THE COLON AND RECTUM presentation

DISEASES OF THE COLON AND RECTUM.pptx

1. DISEASES OF THE COLON AND RECTUM JUNE 2011 BERHANU KOTISSO, M.D ASSOCIATE PROFESSOR

2. Introduction Neoplastic Vs non- neoplastic →Neoplastic -Benign Vs malignant →Non-neoplastic -inflammatory Vs non-inflammatory Age Gender Geographic variation

3. MANIFESTATIONS Pain Bleeding Discharge Altered bowel habit Constipation

4. Manifestations Cont….. Diarrhea Tenesmus Sense of incomplete defecation Symptoms of anemia Weight loss Fever Extra intestinal manifestations

5. Diagnostic workup Hx that stresses on the above symptoms Additional Hx on past medical and surgical conditions, previous surgery on Colon and rectum, family H x of colorectal disease, and Hx of drug intake

6. Diagnosis Cont’d Physical examination -signs of anemia -assess lung and cardiac status -Abdominal mass -hepatomegaly -Ascites -DRE

7. Diagnostic workup Cont’d Physical exam Cont’d - Inginal LAP - Extrimity for edema,leg swelling and joint swelling -Integument for subcutaneous nodules

8. Diagnostic workup cont’d Laboratory investigation -CBC, HCT, ESR -OFT -LFT, RFT -Serum electrolyte -fecal occult blood

9. Diagnostic workup Cont’d Endoscopy - Proctoscopy - sigmoidoscopy - Colonoscopy

10. Diagnostic workup Cont’d Imaging -Barium enema -Ultra sound - CT scan -PET scan - Angiography

11. Colorectal cancer Introduction -a disease of western/developed -a disease of elderly -almost similar incidence in male and female - mainly sporadic in about 80% - familial only in 20 % -Adenocarcinoma in 98 %

12. Introduction cont’d Risk factors -Aging -High fat diet -Alcohol indulgence -Smoking - Low fiber diet - diet poor in fruit and vegetables - family hx -Inflammatory bowel disease (10 fold risk ) Cholecystectomy due to inc bile acid secretion

13. Pathogenesis Adenoma-Carcinoma sequence mucosal proliferation ↓ polyp formation with dysplasia ↓ noninvasive premalignant lesion ↓ subsequent tumor cells with invasive and metastatic capacity

14. Pathology Distribution Rectum 38% Sigmoid colon 29% Cecum 15% Transverse colon + flexures 10% Ascending 5% Descending colon 3%

15. Pathology cont’d Gross: Four variants - ulcerative- bleed - polypoid/fungating- bleed - annular/encircling- obstructing - diffuse infiltrative- bleed Histology: Well→Poorly differentiated

16. Pathology cont’d Route of spread Intramucosal Direct Lymphatic intraperitoneal Haematogenous Anastomotic implantation Staging TNM Vs Modified Dukes

17. Clinical presentation Based on the site Right sided Vs Left side Rectal Based on mode of presentation Emergency Vs elective

18. Diagnosis Hx & PE Endoscopic and immaging modalities Barium enema proctoscopy sigmoidoscopy colonoscopy endorectal U/S Abdominal U/S Abdominal CT scan

19. Treatment Modalities -Surgery -Chemotherapy -Radiotherapy

20. Colonic Diverticulosis Saclike protrusions of the colonic wall A disease of westerners Affects male and female equally Starts to be seen at the age of 30 and continuously increases with advancing age

21. Pathogenesis Low fiber diet Small caliber, hard stool that urge vigorous peristalsis and increases the intraluminal pressure As a result mucosa is forced to herniate through the weak point where the blood vessels traverse the wall Hence a false diverticulum is created

22. DISTRIBUTION Sigmoid and Descending colon are involved in majority of the patients 90-95% of patients will have involvement of the sigmod Approximately 65% will have disease limited to the sigmoid alone Isolated Rt colon affection is very rare

23. Natural History Most cases remain asymptomatic 10-25% develop sign and sx of diverticulitis -one third will have second attack -one third will suffer intermittent abdominal pain -0ne third will remain symptom free

24. Natural Hx cont’d Diverticulitis could be complicated -Abscess formation (40-50%) -free perforation (10-15%) -intestinal obstruction (10-30%) -fistulization (4-10%) 15% present with hemorrhage

25. Diagnosis Hx and PE Imaging -Colonoscopy -Barium enema -CT scan

26. Treatment Mainly conservative Massive bleeding may warrant surgical resection Surgical intervention is mandatory in cases of complicated diverticulitis

27. Inflammatory bowel disease Ulcerative colitis -a diffuse inflammatory disease of the rectum and colon -Etiology is unknown -a disease of westerners -very high incidence in Jews -starts at early age (2 nd to 3 rd decade) - Women are more often affected than men

28. Pathology and clinical presentation - inflammation is limited to the mucosa and submucosa -Starts from the rectum and progresses up in a continuous fashion to involve the whole colon ( Pancolitis ) -Risk for malignancy increases steadily after 10 years and may reach 20% - Recurrent bloody diarrhea is the major sx - Toxic mega colon and fulminant colitis are life threatening complications

29. Treatment Mainly medical -Steroid -treatment for anemia Surgery reserved for complication -massive uncontrolled bleeding -Failed medical Rx -Toxic Megacolon where perforation is imminent Pancolectomy with ileoanal anastomosis is the surgical Rx

30. Crohn's colitis Non specific inflammation of the colon Mainly affects the westerners Equally affects male and female Can coexist with regional ileitis or as isolated colitis in 30% of the case Any part of the colon can be affected Can be encountered in any age

31. Pathology Involves the whole layer of the wall Mesenteric fat padding Results in stricture and obstructive sx Could perforate and result in localized abscess May end up in colo -enteric, colo-vesical and colo -vaginal fistula Could be a cause for high fistula in ano

32. Clinical presentation Abdominal cramp Diarrhea either bloody or non bloody Acute sx of either colonic obstruction or localized peritonitis

33. Treatment Mainly Medical -steroid - metronidazole Surgery reserved for complication

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