Rectum And Anus
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Slide Content
Rectum and Rectum and
anusanus
Celso M. Fidel, MD, FPCS, FPSGSCelso M. Fidel, MD, FPCS, FPSGS
Diplomate Philippine Board of SurgeryDiplomate Philippine Board of Surgery
anusanus
Celso M. Fidel, MD, FPCS, FPSGSCelso M. Fidel, MD, FPCS, FPSGS
Diplomate Philippine Board of SurgeryDiplomate Philippine Board of Surgery
embRyologyembRyology
The embryonic gastrointestinal tract begins The embryonic gastrointestinal tract begins
developing during the developing during the fouRth weekfouRth week of of
gestation.gestation.
The primitive gut is derived from the endoderm The primitive gut is derived from the endoderm
and divided into and divided into three segmentsthree segments: :
1. Foregut 1. Foregut
2. Midgut 2. Midgut
3. Hindgu3. Hindgutt
Both Both midgutmidgut and and hindguthindgut contribute to the contribute to the
colon, rectum, and anus.colon, rectum, and anus.
The embryonic gastrointestinal tract begins The embryonic gastrointestinal tract begins
developing during the developing during the fouRth weekfouRth week of of
gestation.gestation.
The primitive gut is derived from the endoderm The primitive gut is derived from the endoderm
and divided into and divided into three segmentsthree segments: :
1. Foregut 1. Foregut
2. Midgut 2. Midgut
3. Hindgu3. Hindgutt
Both Both midgutmidgut and and hindguthindgut contribute to the contribute to the
colon, rectum, and anus.colon, rectum, and anus.
embRyologyembRyology
The The hindguthindgut develops into the distal transverse develops into the distal transverse
colon, descending colon, colon, descending colon, RectumRectum, and , and
pRoximal anuspRoximal anus, all of which receive their , all of which receive their
blood supply from the blood supply from the infeRioR mesenteRic infeRioR mesenteRic
aRteRyaRteRy. .
During the During the sixth week sixth week of gestation, the distal-of gestation, the distal-
most end of the hindgut, the most end of the hindgut, the cloacacloaca, is , is
divided by the urorectal septum into the divided by the urorectal septum into the
uRogenital sinus uRogenital sinus and the and the Rectum.Rectum.
The The hindguthindgut develops into the distal transverse develops into the distal transverse
colon, descending colon, colon, descending colon, RectumRectum, and , and
pRoximal anuspRoximal anus, all of which receive their , all of which receive their
blood supply from the blood supply from the infeRioR mesenteRic infeRioR mesenteRic
aRteRyaRteRy. .
During the During the sixth week sixth week of gestation, the distal-of gestation, the distal-
most end of the hindgut, the most end of the hindgut, the cloacacloaca, is , is
divided by the urorectal septum into the divided by the urorectal septum into the
uRogenital sinus uRogenital sinus and the and the Rectum.Rectum.
embRyologyembRyology
The distal anal canal is derived from: The distal anal canal is derived from:
ectodeRm ectodeRm and receives its blood supply from and receives its blood supply from
the internal the internal pudendal aRteRypudendal aRteRy. .
The The dentate line dentate line divides the endodermal divides the endodermal
hindgut from the ectodermal distal anal canal.hindgut from the ectodermal distal anal canal.
The distal anal canal is derived from: The distal anal canal is derived from:
ectodeRm ectodeRm and receives its blood supply from and receives its blood supply from
the internal the internal pudendal aRteRypudendal aRteRy. .
The The dentate line dentate line divides the endodermal divides the endodermal
hindgut from the ectodermal distal anal canal.hindgut from the ectodermal distal anal canal.
anatomyanatomy
The large intestine extends from the ileocecal The large intestine extends from the ileocecal
valve to anus. Anatomically & functionally valve to anus. Anatomically & functionally
divided to the divided to the colon, rectumcolon, rectum, and , and anal canalanal canal. .
The rectum comprise five distinct layers: The rectum comprise five distinct layers:
3.3.MucosaMucosa
4.4.SubmucosaSubmucosa
5.5.Inner circular muscleInner circular muscle
6.6.Outer longitudinal muscleOuter longitudinal muscle
7.7.Serosa. Serosa.
The large intestine extends from the ileocecal The large intestine extends from the ileocecal
valve to anus. Anatomically & functionally valve to anus. Anatomically & functionally
divided to the divided to the colon, rectumcolon, rectum, and , and anal canalanal canal. .
The rectum comprise five distinct layers: The rectum comprise five distinct layers:
3.3.MucosaMucosa
4.4.SubmucosaSubmucosa
5.5.Inner circular muscleInner circular muscle
6.6.Outer longitudinal muscleOuter longitudinal muscle
7.7.Serosa. Serosa.
anatomyanatomy
TThe outer longitudinal muscle is separated into he outer longitudinal muscle is separated into
thRee teniae colithRee teniae coli, which converge , which converge
proximally at the proximally at the appendixappendix and distally at the and distally at the
RectumRectum
The outer longitudinal muscle layer of rectum is The outer longitudinal muscle layer of rectum is
ciRcumfeRentialciRcumfeRential
TThe outer longitudinal muscle is separated into he outer longitudinal muscle is separated into
thRee teniae colithRee teniae coli, which converge , which converge
proximally at the proximally at the appendixappendix and distally at the and distally at the
RectumRectum
The outer longitudinal muscle layer of rectum is The outer longitudinal muscle layer of rectum is
ciRcumfeRentialciRcumfeRential
anatomyanatomy
In the distal rectum, the In the distal rectum, the inneR smooth-muscle inneR smooth-muscle
layer coalesces to form the layer coalesces to form the inteRnal anal inteRnal anal
sphincteR.sphincteR.
The The intRapeRitoneal colon intRapeRitoneal colon and and pRoximal pRoximal
one thiRd one thiRd of the rectum are covered by of the rectum are covered by
seRosaseRosa; the mid and lower rectum lack serosa.; the mid and lower rectum lack serosa.
In the distal rectum, the In the distal rectum, the inneR smooth-muscle inneR smooth-muscle
layer coalesces to form the layer coalesces to form the inteRnal anal inteRnal anal
sphincteR.sphincteR.
The The intRapeRitoneal colon intRapeRitoneal colon and and pRoximal pRoximal
one thiRd one thiRd of the rectum are covered by of the rectum are covered by
seRosaseRosa; the mid and lower rectum lack serosa.; the mid and lower rectum lack serosa.
anatomyanatomy
The rectosigmoid junction is found The rectosigmoid junction is found
at approximately the level of the at approximately the level of the sacRal sacRal
pRomontoRypRomontoRy and is arbitrarily described as and is arbitrarily described as
the point at which the three the point at which the three teniae coliteniae coli coalesce coalesce
to form the outer longitudinal smooth muscle to form the outer longitudinal smooth muscle
layer of the rectum layer of the rectum
The rectosigmoid junction is found The rectosigmoid junction is found
at approximately the level of the at approximately the level of the sacRal sacRal
pRomontoRypRomontoRy and is arbitrarily described as and is arbitrarily described as
the point at which the three the point at which the three teniae coliteniae coli coalesce coalesce
to form the outer longitudinal smooth muscle to form the outer longitudinal smooth muscle
layer of the rectum layer of the rectum
ARTERIAL SUPPLYARTERIAL SUPPLY
MCA IMA
SMA LCA
SRA Sig. A
ICA
RCA
MCA IMA
SMA LCA
SRA Sig. A
ICA
RCA
Marginal artery of Drummond
Blood SupplyBlood Supply
The The inferior mesenteric arteryinferior mesenteric artery branches into the branches into the
left colic arteryleft colic artery, which supplies the , which supplies the descending descending
colon,colon, several several sigmoidal branchessigmoidal branches, which , which
supply the supply the sigmoid colonsigmoid colon, and the , and the supeRioR supeRioR
Rectal aRteRyRectal aRteRy,, which supplies the which supplies the proximal proximal
rectumrectum. .
The terminal branches of each artery form The terminal branches of each artery form
anastomoses with the terminal branches of the anastomoses with the terminal branches of the
adjacent artery and communicate via the adjacent artery and communicate via the
marginal artery of Drummondmarginal artery of Drummond. .
The The inferior mesenteric arteryinferior mesenteric artery branches into the branches into the
left colic arteryleft colic artery, which supplies the , which supplies the descending descending
colon,colon, several several sigmoidal branchessigmoidal branches, which , which
supply the supply the sigmoid colonsigmoid colon, and the , and the supeRioR supeRioR
Rectal aRteRyRectal aRteRy,, which supplies the which supplies the proximal proximal
rectumrectum. .
The terminal branches of each artery form The terminal branches of each artery form
anastomoses with the terminal branches of the anastomoses with the terminal branches of the
adjacent artery and communicate via the adjacent artery and communicate via the
marginal artery of Drummondmarginal artery of Drummond. .
Venous dRainageVenous dRainage
Except for the Except for the inferior mesenteric veininferior mesenteric vein, the , the
veins of the colon parallel their corresponding veins of the colon parallel their corresponding
arteries and bear the same terminology arteries and bear the same terminology
The inferior mesenteric vein ascends in the The inferior mesenteric vein ascends in the
retroperitoneal plane over the psoas muscle retroperitoneal plane over the psoas muscle
and continues posterior to the pancreas to join and continues posterior to the pancreas to join
the splenic vein. the splenic vein.
During a colectomy, this vein is often mobilized During a colectomy, this vein is often mobilized
independently and ligated at the inferior edge of independently and ligated at the inferior edge of
the pancreas.the pancreas.
Except for the Except for the inferior mesenteric veininferior mesenteric vein, the , the
veins of the colon parallel their corresponding veins of the colon parallel their corresponding
arteries and bear the same terminology arteries and bear the same terminology
The inferior mesenteric vein ascends in the The inferior mesenteric vein ascends in the
retroperitoneal plane over the psoas muscle retroperitoneal plane over the psoas muscle
and continues posterior to the pancreas to join and continues posterior to the pancreas to join
the splenic vein. the splenic vein.
During a colectomy, this vein is often mobilized During a colectomy, this vein is often mobilized
independently and ligated at the inferior edge of independently and ligated at the inferior edge of
the pancreas.the pancreas.
LYMPHATIC DRAINAGELYMPHATIC DRAINAGE
lymphatic dRainagelymphatic dRainage
The lymphatic drainage of the colon originates in The lymphatic drainage of the colon originates in
a network of lymphatics in the muscularis a network of lymphatics in the muscularis
mucosa.mucosa.
Lymphatic vessels and lymph nodes follow the Lymphatic vessels and lymph nodes follow the
regional arteries. regional arteries.
The lymphatic drainage of the colon originates in The lymphatic drainage of the colon originates in
a network of lymphatics in the muscularis a network of lymphatics in the muscularis
mucosa.mucosa.
Lymphatic vessels and lymph nodes follow the Lymphatic vessels and lymph nodes follow the
regional arteries. regional arteries.
lymphatic dRainagelymphatic dRainage
Lymph nodes are found on:Lymph nodes are found on:
1. The bowel wall (epicolic)1. The bowel wall (epicolic)
2. Inner margin of the bowel adjacent to the 2. Inner margin of the bowel adjacent to the
arterial arcades (paracolic)arterial arcades (paracolic)
3. Around the named mesenteric vessels 3. Around the named mesenteric vessels
(intermediate)(intermediate)
4. Origin of the superior and inferior mesenteric 4. Origin of the superior and inferior mesenteric
arteries (main). arteries (main).
Lymph nodes are found on:Lymph nodes are found on:
1. The bowel wall (epicolic)1. The bowel wall (epicolic)
2. Inner margin of the bowel adjacent to the 2. Inner margin of the bowel adjacent to the
arterial arcades (paracolic)arterial arcades (paracolic)
3. Around the named mesenteric vessels 3. Around the named mesenteric vessels
(intermediate)(intermediate)
4. Origin of the superior and inferior mesenteric 4. Origin of the superior and inferior mesenteric
arteries (main). arteries (main).
lymphatic dRainagelymphatic dRainage
The The sentinel lymph nodessentinel lymph nodes are the first one to are the first one to
four lymph nodes to drain a specific segment of four lymph nodes to drain a specific segment of
the colon, and are thought to be the first site of the colon, and are thought to be the first site of
metastasis in colon cancer. The utility of metastasis in colon cancer. The utility of
sentinel lymph node dissection and analysis in sentinel lymph node dissection and analysis in
colon cancer remains controversial.colon cancer remains controversial.
The The sentinel lymph nodessentinel lymph nodes are the first one to are the first one to
four lymph nodes to drain a specific segment of four lymph nodes to drain a specific segment of
the colon, and are thought to be the first site of the colon, and are thought to be the first site of
metastasis in colon cancer. The utility of metastasis in colon cancer. The utility of
sentinel lymph node dissection and analysis in sentinel lymph node dissection and analysis in
colon cancer remains controversial.colon cancer remains controversial.
anoRectal landmaRksanoRectal landmaRks
The rectum is approximately The rectum is approximately 12 to 15 12 to 15 cm in length. cm in length.
Three distinct submucosal folds:Three distinct submucosal folds:
1.Valves of Houston1.Valves of Houston, extend into the rectal lumen., extend into the rectal lumen.
2. Posteriorly, the 2. Posteriorly, the presecral fasciapresecral fascia separates the separates the
rectum from the presacral venous plexus and the rectum from the presacral venous plexus and the
pelvic nerves. pelvic nerves.
3. At S4, the 3. At S4, the rectosacral fascia rectosacral fascia ((Waldeyer's fasciaWaldeyer's fascia) )
extends forward and downward and attaches to the extends forward and downward and attaches to the
fascia propria at the anorectal junction. fascia propria at the anorectal junction.
The rectum is approximately The rectum is approximately 12 to 15 12 to 15 cm in length. cm in length.
Three distinct submucosal folds:Three distinct submucosal folds:
1.Valves of Houston1.Valves of Houston, extend into the rectal lumen., extend into the rectal lumen.
2. Posteriorly, the 2. Posteriorly, the presecral fasciapresecral fascia separates the separates the
rectum from the presacral venous plexus and the rectum from the presacral venous plexus and the
pelvic nerves. pelvic nerves.
3. At S4, the 3. At S4, the rectosacral fascia rectosacral fascia ((Waldeyer's fasciaWaldeyer's fascia) )
extends forward and downward and attaches to the extends forward and downward and attaches to the
fascia propria at the anorectal junction. fascia propria at the anorectal junction.
anoRectal anatomyanoRectal anatomy
Rectosigmoid (fusion of taenia coli) to anal Rectosigmoid (fusion of taenia coli) to anal
canalcanal
3 distinct intraluminal curves 3 distinct intraluminal curves (Valves of (Valves of
Houston)Houston)
- Proximal & distal curves convex to the right- Proximal & distal curves convex to the right
- Middle curve marks the - Middle curve marks the anterior peritoneal anterior peritoneal
reflectionreflection
- Posterior peritoneal reflection - Posterior peritoneal reflection 12-15 cm from 12-15 cm from
anal vergeanal verge
Rectosigmoid (fusion of taenia coli) to anal Rectosigmoid (fusion of taenia coli) to anal
canalcanal
3 distinct intraluminal curves 3 distinct intraluminal curves (Valves of (Valves of
Houston)Houston)
- Proximal & distal curves convex to the right- Proximal & distal curves convex to the right
- Middle curve marks the - Middle curve marks the anterior peritoneal anterior peritoneal
reflectionreflection
- Posterior peritoneal reflection - Posterior peritoneal reflection 12-15 cm from 12-15 cm from
anal vergeanal verge
anoRectal landmaRksanoRectal landmaRks
Anteriorly, Anteriorly, Denonvilliers' fasciaDenonvilliers' fascia separates the rectum separates the rectum
from the prostate and seminalfrom the prostate and seminal vesicles in men and vesicles in men and
from the vagina in womenfrom the vagina in women
The The lateral ligamentslateral ligaments support the lower rectum. support the lower rectum.
The The surgical anal canal surgical anal canal measures 2 to 4 cm in measures 2 to 4 cm in
length and is generally longer in men than in length and is generally longer in men than in
women. It women. It beginsbegins at the at the anorectal junction anorectal junction and and
terminatesterminates at the at the anal vergeanal verge. .
Anteriorly, Anteriorly, Denonvilliers' fasciaDenonvilliers' fascia separates the rectum separates the rectum
from the prostate and seminalfrom the prostate and seminal vesicles in men and vesicles in men and
from the vagina in womenfrom the vagina in women
The The lateral ligamentslateral ligaments support the lower rectum. support the lower rectum.
The The surgical anal canal surgical anal canal measures 2 to 4 cm in measures 2 to 4 cm in
length and is generally longer in men than in length and is generally longer in men than in
women. It women. It beginsbegins at the at the anorectal junction anorectal junction and and
terminatesterminates at the at the anal vergeanal verge. .
anoRectal landmaRksanoRectal landmaRks
The The dentatedentate or or pectinate linepectinate line marks the marks the transition transition
pointpoint between between columnar rectal mucosa and columnar rectal mucosa and
squamous anoderm.squamous anoderm.
The 1 to 2 cm of mucosa just proximal to the The 1 to 2 cm of mucosa just proximal to the
dentate line shares histologic characteristics of dentate line shares histologic characteristics of
columnar, cuboidal, and squamous epithelium columnar, cuboidal, and squamous epithelium
and is referred to as the and is referred to as the anal transition zoneanal transition zone. .
The The dentatedentate or or pectinate linepectinate line marks the marks the transition transition
pointpoint between between columnar rectal mucosa and columnar rectal mucosa and
squamous anoderm.squamous anoderm.
The 1 to 2 cm of mucosa just proximal to the The 1 to 2 cm of mucosa just proximal to the
dentate line shares histologic characteristics of dentate line shares histologic characteristics of
columnar, cuboidal, and squamous epithelium columnar, cuboidal, and squamous epithelium
and is referred to as the and is referred to as the anal transition zoneanal transition zone. .
anoRectal landmaRksanoRectal landmaRks
The dentate line is surrounded by longitudinal The dentate line is surrounded by longitudinal
mucosal folds, known as the mucosal folds, known as the columns of columns of
MorgagniMorgagni, into which the anal crypts empty. , into which the anal crypts empty.
These crypts are the source of cryptoglandular These crypts are the source of cryptoglandular
abscesses abscesses
In the distal rectum, the inner smooth muscle is In the distal rectum, the inner smooth muscle is
thickened and comprises the thickened and comprises the internal anal internal anal
sphinctersphincter that is surrounded by the that is surrounded by the
subcutaneoussubcutaneous, , superficialsuperficial, and , and deep external deep external
sphinctersphincter. .
The dentate line is surrounded by longitudinal The dentate line is surrounded by longitudinal
mucosal folds, known as the mucosal folds, known as the columns of columns of
MorgagniMorgagni, into which the anal crypts empty. , into which the anal crypts empty.
These crypts are the source of cryptoglandular These crypts are the source of cryptoglandular
abscesses abscesses
In the distal rectum, the inner smooth muscle is In the distal rectum, the inner smooth muscle is
thickened and comprises the thickened and comprises the internal anal internal anal
sphinctersphincter that is surrounded by the that is surrounded by the
subcutaneoussubcutaneous, , superficialsuperficial, and , and deep external deep external
sphinctersphincter. .
anoRectal landmaRksanoRectal landmaRks
The The deep external anal sphincterdeep external anal sphincter is an extension is an extension
of the of the puborectalis musclepuborectalis muscle. .
MusclesMuscles that form the that form the levator ani musclelevator ani muscle of the of the
pelvic floor:pelvic floor:
1. Puborectalis1. Puborectalis
2. Iliococcygeus2. Iliococcygeus
3. Pubococcygeus3. Pubococcygeus
The The deep external anal sphincterdeep external anal sphincter is an extension is an extension
of the of the puborectalis musclepuborectalis muscle. .
MusclesMuscles that form the that form the levator ani musclelevator ani muscle of the of the
pelvic floor:pelvic floor:
1. Puborectalis1. Puborectalis
2. Iliococcygeus2. Iliococcygeus
3. Pubococcygeus3. Pubococcygeus
the anoRectumthe anoRectum
VALVES OF HOUSTON
DENTATE LINE
ANAL SPHINCTERS
ANAL VERGE
HEMORRHOIDAL Plx.
VALVES OF HOUSTON
DENTATE LINE
ANAL SPHINCTERS
ANAL VERGE
HEMORRHOIDAL Plx.
anoRectal VasculaR supplyanoRectal VasculaR supply
The The superior rectal artery superior rectal artery arises from the arises from the terminal terminal
branch of the inferior mesenteric artery branch of the inferior mesenteric artery and and
supplies the upper rectum. supplies the upper rectum.
The The middle rectal artery middle rectal artery arises from the arises from the internal internal
iliaciliac; the presence and size of these arteries ; the presence and size of these arteries
are highly variable.are highly variable.
The The superior rectal artery superior rectal artery arises from the arises from the terminal terminal
branch of the inferior mesenteric artery branch of the inferior mesenteric artery and and
supplies the upper rectum. supplies the upper rectum.
The The middle rectal artery middle rectal artery arises from the arises from the internal internal
iliaciliac; the presence and size of these arteries ; the presence and size of these arteries
are highly variable.are highly variable.
anoRectal VasculaR supplyanoRectal VasculaR supply
The The inferior rectal artery inferior rectal artery arises from the arises from the internal internal
pudendal arterypudendal artery, which is a branch of the , which is a branch of the
internal iliac artery. internal iliac artery.
A A rich network of collaterals connects the rich network of collaterals connects the
terminal arterioles of each of these arteriesterminal arterioles of each of these arteries, ,
thus making the rectum relatively resistant to thus making the rectum relatively resistant to
ischemia ischemia
The The inferior rectal artery inferior rectal artery arises from the arises from the internal internal
pudendal arterypudendal artery, which is a branch of the , which is a branch of the
internal iliac artery. internal iliac artery.
A A rich network of collaterals connects the rich network of collaterals connects the
terminal arterioles of each of these arteriesterminal arterioles of each of these arteries, ,
thus making the rectum relatively resistant to thus making the rectum relatively resistant to
ischemia ischemia
aRteRial supplyaRteRial supply
MCA IMA
SMA LCA
SRA Sig. A
ICA
RCA
MCA IMA
SMA LCA
SRA Sig. A
ICA
RCA
anoRectal VasculaR supplyanoRectal VasculaR supply
The venous drainage of the rectum parallels the The venous drainage of the rectum parallels the
arterial supply.arterial supply.
The The superior rectal veinsuperior rectal vein drains into the drains into the portal portal
system system via the via the inferior mesenteric veininferior mesenteric vein..
The The middle rectal vein middle rectal vein drains into the drains into the internal internal
iliac vein.iliac vein.
The The inferior rectal vein inferior rectal vein drains into the drains into the internal internal
pudendal veinpudendal vein, and subsequently into the , and subsequently into the
internal iliac veininternal iliac vein. .
The venous drainage of the rectum parallels the The venous drainage of the rectum parallels the
arterial supply.arterial supply.
The The superior rectal veinsuperior rectal vein drains into the drains into the portal portal
system system via the via the inferior mesenteric veininferior mesenteric vein..
The The middle rectal vein middle rectal vein drains into the drains into the internal internal
iliac vein.iliac vein.
The The inferior rectal vein inferior rectal vein drains into the drains into the internal internal
pudendal veinpudendal vein, and subsequently into the , and subsequently into the
internal iliac veininternal iliac vein. .
anoRectal VasculaR supplyanoRectal VasculaR supply
A submucosal plexus deep to the columns of A submucosal plexus deep to the columns of
Morgagni forms the Morgagni forms the hemorrhoidal plexushemorrhoidal plexus and and
drains into all three veins.drains into all three veins.
HEMORRHOIDAL PLEXUSHEMORRHOIDAL PLEXUS
- Subepithelial vascular cushion- Subepithelial vascular cushion
a. a. INTERNAL HINTERNAL H – – aboveabove dentate line; dentate line;
insensate mucosainsensate mucosa
b. b. EXTERNAL H EXTERNAL H –– below below dentate line; lined by dentate line; lined by
richly innervated anodermrichly innervated anoderm
A submucosal plexus deep to the columns of A submucosal plexus deep to the columns of
Morgagni forms the Morgagni forms the hemorrhoidal plexushemorrhoidal plexus and and
drains into all three veins.drains into all three veins.
HEMORRHOIDAL PLEXUSHEMORRHOIDAL PLEXUS
- Subepithelial vascular cushion- Subepithelial vascular cushion
a. a. INTERNAL HINTERNAL H – – aboveabove dentate line; dentate line;
insensate mucosainsensate mucosa
b. b. EXTERNAL H EXTERNAL H –– below below dentate line; lined by dentate line; lined by
richly innervated anodermrichly innervated anoderm
anoRectal VasculaR supplyanoRectal VasculaR supply
Lymphatic drainage of the rectum parallels the Lymphatic drainage of the rectum parallels the
vascular supply.vascular supply.
2.2.Lymphatic channels in the upper and middle Lymphatic channels in the upper and middle
rectum drain superiorly into the inferior rectum drain superiorly into the inferior
mesenteric lymph nodes.mesenteric lymph nodes.
3.3. Lymphatic channels in the lower rectum drain Lymphatic channels in the lower rectum drain
both superiorly into the inferior mesenteric both superiorly into the inferior mesenteric
lymph nodes and laterally into the internal iliac lymph nodes and laterally into the internal iliac
lymph nodes. lymph nodes.
Lymphatic drainage of the rectum parallels the Lymphatic drainage of the rectum parallels the
vascular supply.vascular supply.
2.2.Lymphatic channels in the upper and middle Lymphatic channels in the upper and middle
rectum drain superiorly into the inferior rectum drain superiorly into the inferior
mesenteric lymph nodes.mesenteric lymph nodes.
3.3. Lymphatic channels in the lower rectum drain Lymphatic channels in the lower rectum drain
both superiorly into the inferior mesenteric both superiorly into the inferior mesenteric
lymph nodes and laterally into the internal iliac lymph nodes and laterally into the internal iliac
lymph nodes. lymph nodes.
anoRectal VasculaR supplyanoRectal VasculaR supply
The anal canal has a more complex pattern The anal canal has a more complex pattern
of lymphatic drainage. of lymphatic drainage.
1. Proximal to the dentate line, lymph drains into 1. Proximal to the dentate line, lymph drains into
both the inferior mesenteric lymph nodes and both the inferior mesenteric lymph nodes and
the internal iliac lymph nodes. the internal iliac lymph nodes.
2. Distal to the dentate line, lymph primarily 2. Distal to the dentate line, lymph primarily
drains into the inguinal lymph nodes, but can drains into the inguinal lymph nodes, but can
also drain into the inferior mesenteric lymph also drain into the inferior mesenteric lymph
nodes and internal iliac lymph nodes.nodes and internal iliac lymph nodes.
The anal canal has a more complex pattern The anal canal has a more complex pattern
of lymphatic drainage. of lymphatic drainage.
1. Proximal to the dentate line, lymph drains into 1. Proximal to the dentate line, lymph drains into
both the inferior mesenteric lymph nodes and both the inferior mesenteric lymph nodes and
the internal iliac lymph nodes. the internal iliac lymph nodes.
2. Distal to the dentate line, lymph primarily 2. Distal to the dentate line, lymph primarily
drains into the inguinal lymph nodes, but can drains into the inguinal lymph nodes, but can
also drain into the inferior mesenteric lymph also drain into the inferior mesenteric lymph
nodes and internal iliac lymph nodes.nodes and internal iliac lymph nodes.
anoRectal anoRectal neRVe supplyneRVe supply
Both sympathetic and parasympathetic nerves Both sympathetic and parasympathetic nerves
innervate the anorectum. innervate the anorectum.
1.Sympathetic nerve fibers from 1.Sympathetic nerve fibers from L1-L3L1-L3 join the join the
preaortic plexus whose nerve fibers then preaortic plexus whose nerve fibers then
extend below the aorta to form the extend below the aorta to form the hypogastric hypogastric
plexusplexus, which subsequently joins the , which subsequently joins the
parasympathetic fibers to form the pelvic parasympathetic fibers to form the pelvic
plexus.plexus.
2. Parasympathetic nerve fibers known as the 2. Parasympathetic nerve fibers known as the
nervi erigentesnervi erigentes and originate from and originate from S2-S4. S2-S4.
These fibers join the sympathetic fibers to form These fibers join the sympathetic fibers to form
the pelvic plexus. the pelvic plexus.
Both sympathetic and parasympathetic nerves Both sympathetic and parasympathetic nerves
innervate the anorectum. innervate the anorectum.
1.Sympathetic nerve fibers from 1.Sympathetic nerve fibers from L1-L3L1-L3 join the join the
preaortic plexus whose nerve fibers then preaortic plexus whose nerve fibers then
extend below the aorta to form the extend below the aorta to form the hypogastric hypogastric
plexusplexus, which subsequently joins the , which subsequently joins the
parasympathetic fibers to form the pelvic parasympathetic fibers to form the pelvic
plexus.plexus.
2. Parasympathetic nerve fibers known as the 2. Parasympathetic nerve fibers known as the
nervi erigentesnervi erigentes and originate from and originate from S2-S4. S2-S4.
These fibers join the sympathetic fibers to form These fibers join the sympathetic fibers to form
the pelvic plexus. the pelvic plexus.
anoRectal anoRectal neRVe supplyneRVe supply
Sympathetic and parasympathetic fibers then Sympathetic and parasympathetic fibers then
supply the anorectum and adjacent urogenital supply the anorectum and adjacent urogenital
organs.organs.
Sympathetic and parasympathetic fibers then Sympathetic and parasympathetic fibers then
supply the anorectum and adjacent urogenital supply the anorectum and adjacent urogenital
organs.organs.
anoRectal anoRectal neRVe supplyneRVe supply
The The internal anal sphincter internal anal sphincter is innervated by is innervated by
sympathetic and parasympathetic nerve fibers; sympathetic and parasympathetic nerve fibers;
both types of fibers inhibit sphincter contraction.both types of fibers inhibit sphincter contraction.
The The external anal sphincter external anal sphincter and puborectalis and puborectalis
muscles are innervated by the muscles are innervated by the inferior rectal inferior rectal
branchbranch of the of the internal pudendal nerveinternal pudendal nerve..
The The internal anal sphincter internal anal sphincter is innervated by is innervated by
sympathetic and parasympathetic nerve fibers; sympathetic and parasympathetic nerve fibers;
both types of fibers inhibit sphincter contraction.both types of fibers inhibit sphincter contraction.
The The external anal sphincter external anal sphincter and puborectalis and puborectalis
muscles are innervated by the muscles are innervated by the inferior rectal inferior rectal
branchbranch of the of the internal pudendal nerveinternal pudendal nerve..
anoRectal anoRectal neRVe supplyneRVe supply
The The levator ani levator ani receives innervation from both receives innervation from both
the the internal pudendal nerveinternal pudendal nerve and direct and direct
branches of S3 to S5. branches of S3 to S5.
Sensory innervation to the anal canal is provided Sensory innervation to the anal canal is provided
by the by the inferior rectal branchinferior rectal branch of the of the pudendal pudendal
nervenerve..
The The rectum is relatively insensaterectum is relatively insensate, the anal canal , the anal canal
below the dentate line is sensate.below the dentate line is sensate.
The The levator ani levator ani receives innervation from both receives innervation from both
the the internal pudendal nerveinternal pudendal nerve and direct and direct
branches of S3 to S5. branches of S3 to S5.
Sensory innervation to the anal canal is provided Sensory innervation to the anal canal is provided
by the by the inferior rectal branchinferior rectal branch of the of the pudendal pudendal
nervenerve..
The The rectum is relatively insensaterectum is relatively insensate, the anal canal , the anal canal
below the dentate line is sensate.below the dentate line is sensate.
congenital congenital anomaliesanomalies
Perturbation of the embryologic development of Perturbation of the embryologic development of
the midgut and hindgut the midgut and hindgut may result in anatomic may result in anatomic
abnormalities of the colon, rectum, and anus abnormalities of the colon, rectum, and anus
Incomplete descent of the urogenital septum Incomplete descent of the urogenital septum
may result in imperforate anus and associated may result in imperforate anus and associated
fistulas to the genitourinary tractfistulas to the genitourinary tract
Perturbation of the embryologic development of Perturbation of the embryologic development of
the midgut and hindgut the midgut and hindgut may result in anatomic may result in anatomic
abnormalities of the colon, rectum, and anus abnormalities of the colon, rectum, and anus
Incomplete descent of the urogenital septum Incomplete descent of the urogenital septum
may result in imperforate anus and associated may result in imperforate anus and associated
fistulas to the genitourinary tractfistulas to the genitourinary tract
motility, defecation, and continencemotility, defecation, and continence
motilitymotility
Unlike the small intestine, the large intestine Unlike the small intestine, the large intestine
does not demonstrate cyclic motor activity does not demonstrate cyclic motor activity
characteristic of the migratory motor complexcharacteristic of the migratory motor complex
Bursts of "rectal motor complexes" Bursts of "rectal motor complexes" also have also have
been described. In general, cholinergic been described. In general, cholinergic
activation increases colonic motility.activation increases colonic motility.
motilitymotility
Unlike the small intestine, the large intestine Unlike the small intestine, the large intestine
does not demonstrate cyclic motor activity does not demonstrate cyclic motor activity
characteristic of the migratory motor complexcharacteristic of the migratory motor complex
Bursts of "rectal motor complexes" Bursts of "rectal motor complexes" also have also have
been described. In general, cholinergic been described. In general, cholinergic
activation increases colonic motility.activation increases colonic motility.
motility, defecation, and continencemotility, defecation, and continence
defecationdefecation
Defecation is a complex, coordinated mechanism Defecation is a complex, coordinated mechanism
involving: involving:
1. Colonic mass movement1. Colonic mass movement
2. Increased intra-abdominal and rectal pressure2. Increased intra-abdominal and rectal pressure
3. Relaxation of the pelvic floor. 3. Relaxation of the pelvic floor.
defecationdefecation
Defecation is a complex, coordinated mechanism Defecation is a complex, coordinated mechanism
involving: involving:
1. Colonic mass movement1. Colonic mass movement
2. Increased intra-abdominal and rectal pressure2. Increased intra-abdominal and rectal pressure
3. Relaxation of the pelvic floor. 3. Relaxation of the pelvic floor.
motility, defecation, and continence motility, defecation, and continence
defecationdefecation
Distention of the rectum causes a reflex Distention of the rectum causes a reflex
relaxation of the internal anal sphincter (the relaxation of the internal anal sphincter (the
rectoanal inhibitory reflex) that allows the rectoanal inhibitory reflex) that allows the
contents to make contact with the anal canal.contents to make contact with the anal canal.
This "sampling reflex" allows the sensory This "sampling reflex" allows the sensory
epithelium to distinguish solid stool from liquid epithelium to distinguish solid stool from liquid
stool and gas. If defecation does not occur, the stool and gas. If defecation does not occur, the
rectum relaxes and the urge to defecate passes rectum relaxes and the urge to defecate passes
(the (the accommodation responseaccommodation response
defecationdefecation
Distention of the rectum causes a reflex Distention of the rectum causes a reflex
relaxation of the internal anal sphincter (the relaxation of the internal anal sphincter (the
rectoanal inhibitory reflex) that allows the rectoanal inhibitory reflex) that allows the
contents to make contact with the anal canal.contents to make contact with the anal canal.
This "sampling reflex" allows the sensory This "sampling reflex" allows the sensory
epithelium to distinguish solid stool from liquid epithelium to distinguish solid stool from liquid
stool and gas. If defecation does not occur, the stool and gas. If defecation does not occur, the
rectum relaxes and the urge to defecate passes rectum relaxes and the urge to defecate passes
(the (the accommodation responseaccommodation response
motility, defecation, and continence motility, defecation, and continence
defecationdefecation
Defecation proceeds Defecation proceeds
1. By coordination of increasing intra-abdominal 1. By coordination of increasing intra-abdominal
pressure via the Valsalva maneuverpressure via the Valsalva maneuver
2. Increased rectal contraction2. Increased rectal contraction
3. Relaxation of the puborectalis muscle3. Relaxation of the puborectalis muscle
4. Opening of the anal canal.4. Opening of the anal canal.
defecationdefecation
Defecation proceeds Defecation proceeds
1. By coordination of increasing intra-abdominal 1. By coordination of increasing intra-abdominal
pressure via the Valsalva maneuverpressure via the Valsalva maneuver
2. Increased rectal contraction2. Increased rectal contraction
3. Relaxation of the puborectalis muscle3. Relaxation of the puborectalis muscle
4. Opening of the anal canal.4. Opening of the anal canal.
motility, defecation, and continencemotility, defecation, and continence
continencecontinence
The maintenance of fecal continence is at least The maintenance of fecal continence is at least
as complex as the mechanism of defecation. as complex as the mechanism of defecation.
Continence requires:Continence requires:
3.3.Adequate rectal wall compliance to Adequate rectal wall compliance to
accommodate the fecal bolusaccommodate the fecal bolus
4.4.Appropriate neurogenic control of the pelvic Appropriate neurogenic control of the pelvic
floor and sphincter mechanism floor and sphincter mechanism
5.5.Functional internal and external sphincter Functional internal and external sphincter
muscles. muscles.
continencecontinence
The maintenance of fecal continence is at least The maintenance of fecal continence is at least
as complex as the mechanism of defecation. as complex as the mechanism of defecation.
Continence requires:Continence requires:
3.3.Adequate rectal wall compliance to Adequate rectal wall compliance to
accommodate the fecal bolusaccommodate the fecal bolus
4.4.Appropriate neurogenic control of the pelvic Appropriate neurogenic control of the pelvic
floor and sphincter mechanism floor and sphincter mechanism
5.5.Functional internal and external sphincter Functional internal and external sphincter
muscles. muscles.
motility, defecation, and continencemotility, defecation, and continence
continencecontinence
4. At rest, the puborectalis muscle creates a 4. At rest, the puborectalis muscle creates a
"sling" around the distal rectum, forming a "sling" around the distal rectum, forming a
relatively acute angle that distributes relatively acute angle that distributes
intraabdominal forces onto the pelvic floor.intraabdominal forces onto the pelvic floor.
5. With defecation, this angle straightens, 5. With defecation, this angle straightens,
allowing downward force to be applied along allowing downward force to be applied along
the axis of the rectum and anal canal. the axis of the rectum and anal canal.
6.The internal and external sphincters are 6.The internal and external sphincters are
tonically active at rest. tonically active at rest.
continencecontinence
4. At rest, the puborectalis muscle creates a 4. At rest, the puborectalis muscle creates a
"sling" around the distal rectum, forming a "sling" around the distal rectum, forming a
relatively acute angle that distributes relatively acute angle that distributes
intraabdominal forces onto the pelvic floor.intraabdominal forces onto the pelvic floor.
5. With defecation, this angle straightens, 5. With defecation, this angle straightens,
allowing downward force to be applied along allowing downward force to be applied along
the axis of the rectum and anal canal. the axis of the rectum and anal canal.
6.The internal and external sphincters are 6.The internal and external sphincters are
tonically active at rest. tonically active at rest.
motility, defecation, and continencemotility, defecation, and continence
ContinenceContinence
. The internal sphincter is responsible for most of . The internal sphincter is responsible for most of
the resting, involuntary sphincter tone (resting the resting, involuntary sphincter tone (resting
pressure). pressure).
The external sphincter is responsible for most of The external sphincter is responsible for most of
the voluntary sphincter tone (squeeze the voluntary sphincter tone (squeeze
pressure). pressure).
Branches of the pudendal nerve innervate both Branches of the pudendal nerve innervate both
the internal and external sphincter the internal and external sphincter
ContinenceContinence
. The internal sphincter is responsible for most of . The internal sphincter is responsible for most of
the resting, involuntary sphincter tone (resting the resting, involuntary sphincter tone (resting
pressure). pressure).
The external sphincter is responsible for most of The external sphincter is responsible for most of
the voluntary sphincter tone (squeeze the voluntary sphincter tone (squeeze
pressure). pressure).
Branches of the pudendal nerve innervate both Branches of the pudendal nerve innervate both
the internal and external sphincter the internal and external sphincter
motility, defecation, and continencemotility, defecation, and continence
continencecontinence
Finally, the hemorrhoidal cushions may Finally, the hemorrhoidal cushions may
contribute to continence by mechanically contribute to continence by mechanically
blocking the anal canal. Thus, impaired blocking the anal canal. Thus, impaired
continence may result from poor rectal continence may result from poor rectal
compliance, injury to the internal and/or compliance, injury to the internal and/or
external sphincter or puborectalis, or nerve external sphincter or puborectalis, or nerve
damage or neuropathydamage or neuropathy
continencecontinence
Finally, the hemorrhoidal cushions may Finally, the hemorrhoidal cushions may
contribute to continence by mechanically contribute to continence by mechanically
blocking the anal canal. Thus, impaired blocking the anal canal. Thus, impaired
continence may result from poor rectal continence may result from poor rectal
compliance, injury to the internal and/or compliance, injury to the internal and/or
external sphincter or puborectalis, or nerve external sphincter or puborectalis, or nerve
damage or neuropathydamage or neuropathy
clinical eValuationclinical eValuation
A A complete history and physical examination complete history and physical examination is is
the starting point for evaluating any patient with the starting point for evaluating any patient with
suspected disease of the colon and rectum.suspected disease of the colon and rectum.
Special attention should be paid to the patient's Special attention should be paid to the patient's
past medical and surgical history past medical and surgical history to detect to detect
underlying conditions that might contribute to a underlying conditions that might contribute to a
gastrointestinal problem.gastrointestinal problem.
If patients have had prior intestinal surgery, it is If patients have had prior intestinal surgery, it is
essential that one understand the essential that one understand the resultant resultant
gastrointestinal anatomy gastrointestinal anatomy
A A complete history and physical examination complete history and physical examination is is
the starting point for evaluating any patient with the starting point for evaluating any patient with
suspected disease of the colon and rectum.suspected disease of the colon and rectum.
Special attention should be paid to the patient's Special attention should be paid to the patient's
past medical and surgical history past medical and surgical history to detect to detect
underlying conditions that might contribute to a underlying conditions that might contribute to a
gastrointestinal problem.gastrointestinal problem.
If patients have had prior intestinal surgery, it is If patients have had prior intestinal surgery, it is
essential that one understand the essential that one understand the resultant resultant
gastrointestinal anatomy gastrointestinal anatomy
clinical eValuationclinical eValuation
In addition, family history of colorectal disease, In addition, family history of colorectal disease,
especially inflammatory bowel disease, polyps, especially inflammatory bowel disease, polyps,
and colorectal cancer, is crucial.and colorectal cancer, is crucial.
Medication use must be detailed as many drugs Medication use must be detailed as many drugs
cause gastrointestinal symptoms. cause gastrointestinal symptoms.
Before recommending operative intervention, the Before recommending operative intervention, the
adequacy of medical treatment must be adequacy of medical treatment must be
ascertained. ascertained.
In addition to examining the abdomen, visual In addition to examining the abdomen, visual
inspection of the anus and perineum and inspection of the anus and perineum and
careful digital rectal exam are essential.careful digital rectal exam are essential.
EndoscopyEndoscopy
In addition, family history of colorectal disease, In addition, family history of colorectal disease,
especially inflammatory bowel disease, polyps, especially inflammatory bowel disease, polyps,
and colorectal cancer, is crucial.and colorectal cancer, is crucial.
Medication use must be detailed as many drugs Medication use must be detailed as many drugs
cause gastrointestinal symptoms. cause gastrointestinal symptoms.
Before recommending operative intervention, the Before recommending operative intervention, the
adequacy of medical treatment must be adequacy of medical treatment must be
ascertained. ascertained.
In addition to examining the abdomen, visual In addition to examining the abdomen, visual
inspection of the anus and perineum and inspection of the anus and perineum and
careful digital rectal exam are essential.careful digital rectal exam are essential.
EndoscopyEndoscopy
clinical eValuationclinical eValuation
endoscopyendoscopy
2.2.anoscopyanoscopy
The anoscope is a useful instrument for The anoscope is a useful instrument for
examination of the anal canal. Anoscopes are examination of the anal canal. Anoscopes are
made in a variety of sizes and measure made in a variety of sizes and measure
approximately 8 cm in length. A larger approximately 8 cm in length. A larger
anoscope provides better exposure for anal anoscope provides better exposure for anal
procedures such as rubber band ligation or procedures such as rubber band ligation or
sclerotherapy of hemorrhoids. sclerotherapy of hemorrhoids.
22. pRoctoscopy. pRoctoscopy
endoscopyendoscopy
2.2.anoscopyanoscopy
The anoscope is a useful instrument for The anoscope is a useful instrument for
examination of the anal canal. Anoscopes are examination of the anal canal. Anoscopes are
made in a variety of sizes and measure made in a variety of sizes and measure
approximately 8 cm in length. A larger approximately 8 cm in length. A larger
anoscope provides better exposure for anal anoscope provides better exposure for anal
procedures such as rubber band ligation or procedures such as rubber band ligation or
sclerotherapy of hemorrhoids. sclerotherapy of hemorrhoids.
22. pRoctoscopy. pRoctoscopy
clinical eValuationclinical eValuation
imagingimaging
Plain X-Rays and Contrast StudiesPlain X-Rays and Contrast Studies
Computed TomographyComputed Tomography
Virtual ColonoscopyVirtual Colonoscopy
Magnetic Resonance ImagingMagnetic Resonance Imaging
Positron Emission TomographyPositron Emission Tomography
AngiographyAngiography
Endorectal and Endoanal UltrasoundEndorectal and Endoanal Ultrasound
imagingimaging
Plain X-Rays and Contrast StudiesPlain X-Rays and Contrast Studies
Computed TomographyComputed Tomography
Virtual ColonoscopyVirtual Colonoscopy
Magnetic Resonance ImagingMagnetic Resonance Imaging
Positron Emission TomographyPositron Emission Tomography
AngiographyAngiography
Endorectal and Endoanal UltrasoundEndorectal and Endoanal Ultrasound
clinical eValuationclinical eValuation
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
Anorectal physiologic testing uses a variety of Anorectal physiologic testing uses a variety of
techniques to investigate the function of the techniques to investigate the function of the
pelvic floor. These techniques are useful in the pelvic floor. These techniques are useful in the
evaluation of patients with incontinence, evaluation of patients with incontinence,
constipation, rectal prolapse, obstructed constipation, rectal prolapse, obstructed
defecation, and other disorders of the pelvic defecation, and other disorders of the pelvic
floorfloor
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
Anorectal physiologic testing uses a variety of Anorectal physiologic testing uses a variety of
techniques to investigate the function of the techniques to investigate the function of the
pelvic floor. These techniques are useful in the pelvic floor. These techniques are useful in the
evaluation of patients with incontinence, evaluation of patients with incontinence,
constipation, rectal prolapse, obstructed constipation, rectal prolapse, obstructed
defecation, and other disorders of the pelvic defecation, and other disorders of the pelvic
floorfloor
clinical eValuationclinical eValuation
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
11. manometRy. manometRy
2. neuRophysiology2. neuRophysiology
3, Rectal eVacuation studies3, Rectal eVacuation studies
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
11. manometRy. manometRy
2. neuRophysiology2. neuRophysiology
3, Rectal eVacuation studies3, Rectal eVacuation studies
clinical eValuationclinical eValuation
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
manometRymanometRy
Anorectal manometry is performed by placing a Anorectal manometry is performed by placing a
pressure-sensitive catheter in the lower rectum. pressure-sensitive catheter in the lower rectum.
The catheter is then withdrawn through the anal The catheter is then withdrawn through the anal
canal and pressures recorded.canal and pressures recorded.
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
manometRymanometRy
Anorectal manometry is performed by placing a Anorectal manometry is performed by placing a
pressure-sensitive catheter in the lower rectum. pressure-sensitive catheter in the lower rectum.
The catheter is then withdrawn through the anal The catheter is then withdrawn through the anal
canal and pressures recorded.canal and pressures recorded.
clinical eValuationclinical eValuation
Physiologic and Pelvic Floor InvestigationsPhysiologic and Pelvic Floor Investigations
manometRymanometRy
A balloon attached to the tip of the catheter also A balloon attached to the tip of the catheter also
can be used to test anorectal sensation.can be used to test anorectal sensation.
The The resting pressureresting pressure in the anal canal reflects the in the anal canal reflects the
function of the internal anal sphincter (normal: function of the internal anal sphincter (normal:
40 to 80 mm Hg )40 to 80 mm Hg )
Physiologic and Pelvic Floor InvestigationsPhysiologic and Pelvic Floor Investigations
manometRymanometRy
A balloon attached to the tip of the catheter also A balloon attached to the tip of the catheter also
can be used to test anorectal sensation.can be used to test anorectal sensation.
The The resting pressureresting pressure in the anal canal reflects the in the anal canal reflects the
function of the internal anal sphincter (normal: function of the internal anal sphincter (normal:
40 to 80 mm Hg )40 to 80 mm Hg )
clinical eValuationclinical eValuation
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
manometRymanometRy
The The squeeze pRessuResqueeze pRessuRe, defined as the , defined as the
maximum voluntary contraction pressure minus maximum voluntary contraction pressure minus
the resting pressure, reflects function of the the resting pressure, reflects function of the
external anal sphincter (normal: 40 to 80 mm external anal sphincter (normal: 40 to 80 mm
Hg above resting pressure). Hg above resting pressure).
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
manometRymanometRy
The The squeeze pRessuResqueeze pRessuRe, defined as the , defined as the
maximum voluntary contraction pressure minus maximum voluntary contraction pressure minus
the resting pressure, reflects function of the the resting pressure, reflects function of the
external anal sphincter (normal: 40 to 80 mm external anal sphincter (normal: 40 to 80 mm
Hg above resting pressure). Hg above resting pressure).
clinical eValuationclinical eValuation
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
manometRymanometRy
The The high-pressurezonehigh-pressurezone estimates the length of estimates the length of
the anal canal (normal: 2.0 to 4.0 cm).the anal canal (normal: 2.0 to 4.0 cm).
The The rectoanal inhibitory reflexrectoanal inhibitory reflex can be detected can be detected
by inflating a balloon in the distal rectum; by inflating a balloon in the distal rectum;
absence of this reflex is characteristic of absence of this reflex is characteristic of
hiRschspRung's diseasehiRschspRung's disease
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
manometRymanometRy
The The high-pressurezonehigh-pressurezone estimates the length of estimates the length of
the anal canal (normal: 2.0 to 4.0 cm).the anal canal (normal: 2.0 to 4.0 cm).
The The rectoanal inhibitory reflexrectoanal inhibitory reflex can be detected can be detected
by inflating a balloon in the distal rectum; by inflating a balloon in the distal rectum;
absence of this reflex is characteristic of absence of this reflex is characteristic of
hiRschspRung's diseasehiRschspRung's disease
clinical eValuationclinical eValuation
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
neuRophysiologyneuRophysiology
Neurophysiologic testing assesses function of the Neurophysiologic testing assesses function of the
pudendal nerves and recruitment of pudendal nerves and recruitment of
puborectalis muscle fibers. Pudendal nerve puborectalis muscle fibers. Pudendal nerve
terminal motor latency measures the speed of terminal motor latency measures the speed of
transmission of a nerve impulse through the transmission of a nerve impulse through the
distal pudendal nerve fibers (normal: 1.8 to 2.2 distal pudendal nerve fibers (normal: 1.8 to 2.2
msec); msec);
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
neuRophysiologyneuRophysiology
Neurophysiologic testing assesses function of the Neurophysiologic testing assesses function of the
pudendal nerves and recruitment of pudendal nerves and recruitment of
puborectalis muscle fibers. Pudendal nerve puborectalis muscle fibers. Pudendal nerve
terminal motor latency measures the speed of terminal motor latency measures the speed of
transmission of a nerve impulse through the transmission of a nerve impulse through the
distal pudendal nerve fibers (normal: 1.8 to 2.2 distal pudendal nerve fibers (normal: 1.8 to 2.2
msec); msec);
clinical eValuationclinical eValuation
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
neuRophysiologyneuRophysiology
Needle EMG has been used to map both the Needle EMG has been used to map both the
pudendal nerves and the anatomy of the pudendal nerves and the anatomy of the
internal and external sphincters. However, this internal and external sphincters. However, this
examination is painful and poorly tolerated by examination is painful and poorly tolerated by
most patients. most patients.
Needle EMG has largely been replaced by Needle EMG has largely been replaced by
pudendal nerve motor-latency testingpudendal nerve motor-latency testing to assess to assess
pudendal nerve function and pudendal nerve function and endoanal endoanal
ultrasound to map the sphincters.ultrasound to map the sphincters.
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
neuRophysiologyneuRophysiology
Needle EMG has been used to map both the Needle EMG has been used to map both the
pudendal nerves and the anatomy of the pudendal nerves and the anatomy of the
internal and external sphincters. However, this internal and external sphincters. However, this
examination is painful and poorly tolerated by examination is painful and poorly tolerated by
most patients. most patients.
Needle EMG has largely been replaced by Needle EMG has largely been replaced by
pudendal nerve motor-latency testingpudendal nerve motor-latency testing to assess to assess
pudendal nerve function and pudendal nerve function and endoanal endoanal
ultrasound to map the sphincters.ultrasound to map the sphincters.
clinical eValuationclinical eValuation
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
Rectal eVacuation studiesRectal eVacuation studies
Rectal evacuation studies include the balloon Rectal evacuation studies include the balloon
expulsion test and video defecography. Balloon expulsion test and video defecography. Balloon
expulsion assesses a patient's ability to expel expulsion assesses a patient's ability to expel
an intrarectal balloon. Video defecography an intrarectal balloon. Video defecography
provides a more detailed assessment of provides a more detailed assessment of
defecation. In this test, barium paste is placed defecation. In this test, barium paste is placed
in the rectum and defecation is then recorded in the rectum and defecation is then recorded
fluoroscopically. fluoroscopically.
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
Rectal eVacuation studiesRectal eVacuation studies
Rectal evacuation studies include the balloon Rectal evacuation studies include the balloon
expulsion test and video defecography. Balloon expulsion test and video defecography. Balloon
expulsion assesses a patient's ability to expel expulsion assesses a patient's ability to expel
an intrarectal balloon. Video defecography an intrarectal balloon. Video defecography
provides a more detailed assessment of provides a more detailed assessment of
defecation. In this test, barium paste is placed defecation. In this test, barium paste is placed
in the rectum and defecation is then recorded in the rectum and defecation is then recorded
fluoroscopically. fluoroscopically.
clinical eValuationclinical eValuation
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
Rectal eVacuation studiesRectal eVacuation studies
Defecography is used to differentiate Defecography is used to differentiate
nonrelaxation of the puborectalis, obstructed nonrelaxation of the puborectalis, obstructed
defecation, increased perineal descent, rectal defecation, increased perineal descent, rectal
prolapse and intussusception, rectocele, and prolapse and intussusception, rectocele, and
enterocele. The addition of vaginal contrast and enterocele. The addition of vaginal contrast and
intraperitoneal contrast is useful in delineating intraperitoneal contrast is useful in delineating
complex disorders of the pelvic floorcomplex disorders of the pelvic floor
physiologic and pelVic flooR inVestigationsphysiologic and pelVic flooR inVestigations
Rectal eVacuation studiesRectal eVacuation studies
Defecography is used to differentiate Defecography is used to differentiate
nonrelaxation of the puborectalis, obstructed nonrelaxation of the puborectalis, obstructed
defecation, increased perineal descent, rectal defecation, increased perineal descent, rectal
prolapse and intussusception, rectocele, and prolapse and intussusception, rectocele, and
enterocele. The addition of vaginal contrast and enterocele. The addition of vaginal contrast and
intraperitoneal contrast is useful in delineating intraperitoneal contrast is useful in delineating
complex disorders of the pelvic floorcomplex disorders of the pelvic floor
laboRatoRy studieslaboRatoRy studies
1. fecal occult blood testing1. fecal occult blood testing
2. stool studies2. stool studies
3. seRum tests3. seRum tests
4. tumoR maRkeRs4. tumoR maRkeRs
5. genetic testing5. genetic testing
1. fecal occult blood testing1. fecal occult blood testing
2. stool studies2. stool studies
3. seRum tests3. seRum tests
4. tumoR maRkeRs4. tumoR maRkeRs
5. genetic testing5. genetic testing
laboRatoRy studieslaboRatoRy studies
1. Fecal Occult Blood Testing1. Fecal Occult Blood Testing
Fecal occult blood testing (FOBT) is used as a Fecal occult blood testing (FOBT) is used as a
screening test for colonic neoplasms in screening test for colonic neoplasms in
asymptomatic, average-risk individuals. The asymptomatic, average-risk individuals. The
efficacy of this test is based upon serial testing efficacy of this test is based upon serial testing
because the majority of colorectal malignancies because the majority of colorectal malignancies
will bleed intermittently. FOBT has been a will bleed intermittently. FOBT has been a
nonspecific test for peroxidase contained in nonspecific test for peroxidase contained in
hemoglobinhemoglobin
1. Fecal Occult Blood Testing1. Fecal Occult Blood Testing
Fecal occult blood testing (FOBT) is used as a Fecal occult blood testing (FOBT) is used as a
screening test for colonic neoplasms in screening test for colonic neoplasms in
asymptomatic, average-risk individuals. The asymptomatic, average-risk individuals. The
efficacy of this test is based upon serial testing efficacy of this test is based upon serial testing
because the majority of colorectal malignancies because the majority of colorectal malignancies
will bleed intermittently. FOBT has been a will bleed intermittently. FOBT has been a
nonspecific test for peroxidase contained in nonspecific test for peroxidase contained in
hemoglobinhemoglobin
laboRatoRy studieslaboRatoRy studies
Stool StudiesStool Studies
Stool studies are often helpful in evaluating the Stool studies are often helpful in evaluating the
etiology of diarrhea. Wet-mount examination etiology of diarrhea. Wet-mount examination
reveals the presence of fecal leukocytes, which reveals the presence of fecal leukocytes, which
may suggest colonic inflammation or the may suggest colonic inflammation or the
presence of an invasive organism such as presence of an invasive organism such as
invasive invasive E. coliE. coli or or ShigellaShigella. Stool cultures can . Stool cultures can
detect pathogenic bacteria, ova, and parasites. detect pathogenic bacteria, ova, and parasites.
C. difficileC. difficile colitis is diagnosed by detecting colitis is diagnosed by detecting
bacterial toxin in the stool. Steatorrhea may be bacterial toxin in the stool. Steatorrhea may be
diagnosed by adding Sudan red stain to a stool diagnosed by adding Sudan red stain to a stool
sample.sample.
Stool StudiesStool Studies
Stool studies are often helpful in evaluating the Stool studies are often helpful in evaluating the
etiology of diarrhea. Wet-mount examination etiology of diarrhea. Wet-mount examination
reveals the presence of fecal leukocytes, which reveals the presence of fecal leukocytes, which
may suggest colonic inflammation or the may suggest colonic inflammation or the
presence of an invasive organism such as presence of an invasive organism such as
invasive invasive E. coliE. coli or or ShigellaShigella. Stool cultures can . Stool cultures can
detect pathogenic bacteria, ova, and parasites. detect pathogenic bacteria, ova, and parasites.
C. difficileC. difficile colitis is diagnosed by detecting colitis is diagnosed by detecting
bacterial toxin in the stool. Steatorrhea may be bacterial toxin in the stool. Steatorrhea may be
diagnosed by adding Sudan red stain to a stool diagnosed by adding Sudan red stain to a stool
sample.sample.
laboRatoRy studieslaboRatoRy studies
Serum TestsSerum Tests
Specific laboratory tests that should be Specific laboratory tests that should be
performed will be dictated by the clinical performed will be dictated by the clinical
scenario. Preoperative studies generally scenario. Preoperative studies generally
include a complete blood count and electrolyte include a complete blood count and electrolyte
panel. The addition of coagulation studies, liver panel. The addition of coagulation studies, liver
function tests, and blood typing/cross-matching function tests, and blood typing/cross-matching
depends upon the patient's medical condition depends upon the patient's medical condition
and the proposed surgical procedureand the proposed surgical procedure
Serum TestsSerum Tests
Specific laboratory tests that should be Specific laboratory tests that should be
performed will be dictated by the clinical performed will be dictated by the clinical
scenario. Preoperative studies generally scenario. Preoperative studies generally
include a complete blood count and electrolyte include a complete blood count and electrolyte
panel. The addition of coagulation studies, liver panel. The addition of coagulation studies, liver
function tests, and blood typing/cross-matching function tests, and blood typing/cross-matching
depends upon the patient's medical condition depends upon the patient's medical condition
and the proposed surgical procedureand the proposed surgical procedure
laboRatoRy studieslaboRatoRy studies
Tumor MarkersTumor Markers
Carcinoembryonic antigen (CEA) may be Carcinoembryonic antigen (CEA) may be
elevated in 60 to 90% of patients with colorectal elevated in 60 to 90% of patients with colorectal
cancer. Despite this, CEA is not an effective cancer. Despite this, CEA is not an effective
screening tool for this malignancy. Many screening tool for this malignancy. Many
practitioners follow serial CEA levels after practitioners follow serial CEA levels after
curative-intent surgery in order to detect early curative-intent surgery in order to detect early
recurrence of colorectal cancer. However, this recurrence of colorectal cancer. However, this
tumor marker is nonspecific, and no survival tumor marker is nonspecific, and no survival
benefit has yet been proven . benefit has yet been proven .
Tumor MarkersTumor Markers
Carcinoembryonic antigen (CEA) may be Carcinoembryonic antigen (CEA) may be
elevated in 60 to 90% of patients with colorectal elevated in 60 to 90% of patients with colorectal
cancer. Despite this, CEA is not an effective cancer. Despite this, CEA is not an effective
screening tool for this malignancy. Many screening tool for this malignancy. Many
practitioners follow serial CEA levels after practitioners follow serial CEA levels after
curative-intent surgery in order to detect early curative-intent surgery in order to detect early
recurrence of colorectal cancer. However, this recurrence of colorectal cancer. However, this
tumor marker is nonspecific, and no survival tumor marker is nonspecific, and no survival
benefit has yet been proven . benefit has yet been proven .
laboRatoRy studieslaboRatoRy studies
Tumor MarkersTumor Markers
Other biochemical markers (ornithine Other biochemical markers (ornithine
decarboxylase, urokinase) have been decarboxylase, urokinase) have been
proposed, but none has yet proven sensitive or proposed, but none has yet proven sensitive or
specific for detection, staging, or predicting specific for detection, staging, or predicting
prognosis of colorectal carcinoma prognosis of colorectal carcinoma
Tumor MarkersTumor Markers
Other biochemical markers (ornithine Other biochemical markers (ornithine
decarboxylase, urokinase) have been decarboxylase, urokinase) have been
proposed, but none has yet proven sensitive or proposed, but none has yet proven sensitive or
specific for detection, staging, or predicting specific for detection, staging, or predicting
prognosis of colorectal carcinoma prognosis of colorectal carcinoma
laboRatoRy studieslaboRatoRy studies
Genetic TestingGenetic Testing
Although familial colorectal cancer syndromes, Although familial colorectal cancer syndromes,
such as familial adenomatous polyposis (FAP) such as familial adenomatous polyposis (FAP)
and hereditary nonpolyposis colon cancer and hereditary nonpolyposis colon cancer
(HNPCC) are rare, information about the (HNPCC) are rare, information about the
specific genetic abnormalities underlying these specific genetic abnormalities underlying these
disorders has led to significant interest in the disorders has led to significant interest in the
role of genetic testing for colorectal cancer. role of genetic testing for colorectal cancer.
Genetic TestingGenetic Testing
Although familial colorectal cancer syndromes, Although familial colorectal cancer syndromes,
such as familial adenomatous polyposis (FAP) such as familial adenomatous polyposis (FAP)
and hereditary nonpolyposis colon cancer and hereditary nonpolyposis colon cancer
(HNPCC) are rare, information about the (HNPCC) are rare, information about the
specific genetic abnormalities underlying these specific genetic abnormalities underlying these
disorders has led to significant interest in the disorders has led to significant interest in the
role of genetic testing for colorectal cancer. role of genetic testing for colorectal cancer.
laboRatoRy studieslaboRatoRy studies
Genetic TestingGenetic Testing
Tests for mutations in the adenomatous Tests for mutations in the adenomatous
polyposis coli (APC) gene responsible for FAP, polyposis coli (APC) gene responsible for FAP,
and in mismatch repair genes responsible for and in mismatch repair genes responsible for
HNPCC, are commercially available and HNPCC, are commercially available and
extremely accurate in families with known extremely accurate in families with known
mutations. Although many of these mutations mutations. Although many of these mutations
are also present in sporadic colorectal cancer, are also present in sporadic colorectal cancer,
the accuracy of genetic testing in average-risk the accuracy of genetic testing in average-risk
individuals is considerably lower. individuals is considerably lower.
Genetic TestingGenetic Testing
Tests for mutations in the adenomatous Tests for mutations in the adenomatous
polyposis coli (APC) gene responsible for FAP, polyposis coli (APC) gene responsible for FAP,
and in mismatch repair genes responsible for and in mismatch repair genes responsible for
HNPCC, are commercially available and HNPCC, are commercially available and
extremely accurate in families with known extremely accurate in families with known
mutations. Although many of these mutations mutations. Although many of these mutations
are also present in sporadic colorectal cancer, are also present in sporadic colorectal cancer,
the accuracy of genetic testing in average-risk the accuracy of genetic testing in average-risk
individuals is considerably lower. individuals is considerably lower.
laboRatoRy studieslaboRatoRy studies
Genetic TestingGenetic Testing
These tests are not recommended for screening. These tests are not recommended for screening.
Because of the potential psychosocial Because of the potential psychosocial
implications of genetic testing, it is strongly implications of genetic testing, it is strongly
recommended that professional genetic recommended that professional genetic
counselors be involved in the care of any counselors be involved in the care of any
patient considering these tests.patient considering these tests.
Genetic TestingGenetic Testing
These tests are not recommended for screening. These tests are not recommended for screening.
Because of the potential psychosocial Because of the potential psychosocial
implications of genetic testing, it is strongly implications of genetic testing, it is strongly
recommended that professional genetic recommended that professional genetic
counselors be involved in the care of any counselors be involved in the care of any
patient considering these tests.patient considering these tests.
eValuation of common symptomseValuation of common symptoms
Abdominal PainAbdominal Pain
Abdominal pain is a nonspecific symptom with Abdominal pain is a nonspecific symptom with
a myriad of causes. Abdominal pain related to a myriad of causes. Abdominal pain related to
the colon and rectum can result from the colon and rectum can result from
obstruction (either inflammatory or neoplastic), obstruction (either inflammatory or neoplastic),
inflammation, perforation, or ischemia. Plain x-inflammation, perforation, or ischemia. Plain x-
rays and judicious use of contrast studies rays and judicious use of contrast studies
and/or a CT scan can often confirm the and/or a CT scan can often confirm the
diagnosis. Gentle retrograde contrast studies diagnosis. Gentle retrograde contrast studies
(barium or Gastrografin enema) may be useful (barium or Gastrografin enema) may be useful
in delineating the degree of colonic obstruction. in delineating the degree of colonic obstruction.
Abdominal PainAbdominal Pain
Abdominal pain is a nonspecific symptom with Abdominal pain is a nonspecific symptom with
a myriad of causes. Abdominal pain related to a myriad of causes. Abdominal pain related to
the colon and rectum can result from the colon and rectum can result from
obstruction (either inflammatory or neoplastic), obstruction (either inflammatory or neoplastic),
inflammation, perforation, or ischemia. Plain x-inflammation, perforation, or ischemia. Plain x-
rays and judicious use of contrast studies rays and judicious use of contrast studies
and/or a CT scan can often confirm the and/or a CT scan can often confirm the
diagnosis. Gentle retrograde contrast studies diagnosis. Gentle retrograde contrast studies
(barium or Gastrografin enema) may be useful (barium or Gastrografin enema) may be useful
in delineating the degree of colonic obstruction. in delineating the degree of colonic obstruction.
eValuation of common symptomseValuation of common symptoms
Abdominal PainAbdominal Pain
Sigmoidoscopy and/or colonoscopy performed by Sigmoidoscopy and/or colonoscopy performed by
an experienced endoscopist can assist in the an experienced endoscopist can assist in the
diagnosis of ischemic colitis, infectious colitis, diagnosis of ischemic colitis, infectious colitis,
and inflammatory bowel disease. and inflammatory bowel disease.
However, if perforation is suspected, However, if perforation is suspected,
colonoscopy and/or sigmoidoscopy are colonoscopy and/or sigmoidoscopy are
generally contraindicated. generally contraindicated.
Abdominal PainAbdominal Pain
Sigmoidoscopy and/or colonoscopy performed by Sigmoidoscopy and/or colonoscopy performed by
an experienced endoscopist can assist in the an experienced endoscopist can assist in the
diagnosis of ischemic colitis, infectious colitis, diagnosis of ischemic colitis, infectious colitis,
and inflammatory bowel disease. and inflammatory bowel disease.
However, if perforation is suspected, However, if perforation is suspected,
colonoscopy and/or sigmoidoscopy are colonoscopy and/or sigmoidoscopy are
generally contraindicated. generally contraindicated.
eValuation of common symptomseValuation of common symptoms
Abdominal PainAbdominal Pain
..
Evaluation and treatment of abdominal pain from Evaluation and treatment of abdominal pain from
a colorectal source should follow the usual a colorectal source should follow the usual
surgical principles of a thorough history and surgical principles of a thorough history and
physical examination, appropriate diagnostic physical examination, appropriate diagnostic
tests, resuscitation, and appropriately timed tests, resuscitation, and appropriately timed
surgical intervention surgical intervention
Abdominal PainAbdominal Pain
..
Evaluation and treatment of abdominal pain from Evaluation and treatment of abdominal pain from
a colorectal source should follow the usual a colorectal source should follow the usual
surgical principles of a thorough history and surgical principles of a thorough history and
physical examination, appropriate diagnostic physical examination, appropriate diagnostic
tests, resuscitation, and appropriately timed tests, resuscitation, and appropriately timed
surgical intervention surgical intervention
eValuation of common symptomseValuation of common symptoms
Pelvic PainPelvic Pain
Pelvic pain can originate from the distal colon Pelvic pain can originate from the distal colon
and rectum or from adjacent urogenital and rectum or from adjacent urogenital
structures. Tenesmus may result from proctitis structures. Tenesmus may result from proctitis
or from a rectal or retrorectal mass. Cyclical or from a rectal or retrorectal mass. Cyclical
pain associated with menses, especially when pain associated with menses, especially when
accompanied by rectal bleeding, suggests a accompanied by rectal bleeding, suggests a
diagnosis of endometriosis. Pelvic inflammatory diagnosis of endometriosis. Pelvic inflammatory
disease also can produce significant abdominal disease also can produce significant abdominal
and pelvic pain. and pelvic pain.
Pelvic PainPelvic Pain
Pelvic pain can originate from the distal colon Pelvic pain can originate from the distal colon
and rectum or from adjacent urogenital and rectum or from adjacent urogenital
structures. Tenesmus may result from proctitis structures. Tenesmus may result from proctitis
or from a rectal or retrorectal mass. Cyclical or from a rectal or retrorectal mass. Cyclical
pain associated with menses, especially when pain associated with menses, especially when
accompanied by rectal bleeding, suggests a accompanied by rectal bleeding, suggests a
diagnosis of endometriosis. Pelvic inflammatory diagnosis of endometriosis. Pelvic inflammatory
disease also can produce significant abdominal disease also can produce significant abdominal
and pelvic pain. and pelvic pain.
eValuation of common symptomseValuation of common symptoms
Pelvic PainPelvic Pain
The extension of a peridiverticular abscess or The extension of a peridiverticular abscess or
periappendiceal abscess into the pelvis may periappendiceal abscess into the pelvis may
also cause pain. CT scan and/or MRI may be also cause pain. CT scan and/or MRI may be
useful in differentiating these diseases. useful in differentiating these diseases.
Proctoscopy (if tolerated) also can be helpful. Proctoscopy (if tolerated) also can be helpful.
Occasionally, laparoscopy will yield a Occasionally, laparoscopy will yield a
diagnosis.diagnosis.
Pelvic PainPelvic Pain
The extension of a peridiverticular abscess or The extension of a peridiverticular abscess or
periappendiceal abscess into the pelvis may periappendiceal abscess into the pelvis may
also cause pain. CT scan and/or MRI may be also cause pain. CT scan and/or MRI may be
useful in differentiating these diseases. useful in differentiating these diseases.
Proctoscopy (if tolerated) also can be helpful. Proctoscopy (if tolerated) also can be helpful.
Occasionally, laparoscopy will yield a Occasionally, laparoscopy will yield a
diagnosis.diagnosis.
eValuation of common symptomseValuation of common symptoms
Anorectal PainAnorectal Pain
Anorectal pain is most often secondary to an Anorectal pain is most often secondary to an
anal fissure or perirectal abscess and/or fistula. anal fissure or perirectal abscess and/or fistula.
Physical examination can usually differentiate Physical examination can usually differentiate
these conditions. Other, less common causes these conditions. Other, less common causes
of anorectal pain include anal canal neoplasms, of anorectal pain include anal canal neoplasms,
perianal skin infection, and dermatologic perianal skin infection, and dermatologic
conditions. Proctalgia fugax results from levator conditions. Proctalgia fugax results from levator
spasm and may present without any other spasm and may present without any other
anorectal findings. anorectal findings.
Anorectal PainAnorectal Pain
Anorectal pain is most often secondary to an Anorectal pain is most often secondary to an
anal fissure or perirectal abscess and/or fistula. anal fissure or perirectal abscess and/or fistula.
Physical examination can usually differentiate Physical examination can usually differentiate
these conditions. Other, less common causes these conditions. Other, less common causes
of anorectal pain include anal canal neoplasms, of anorectal pain include anal canal neoplasms,
perianal skin infection, and dermatologic perianal skin infection, and dermatologic
conditions. Proctalgia fugax results from levator conditions. Proctalgia fugax results from levator
spasm and may present without any other spasm and may present without any other
anorectal findings. anorectal findings.
eValuation of common symptomseValuation of common symptoms
Anorectal PainAnorectal Pain
Physical exam is critical in evaluating patients Physical exam is critical in evaluating patients
with anorectal pain. If a patient is too tender to with anorectal pain. If a patient is too tender to
examine in the office, an examination under examine in the office, an examination under
anesthesia is necessary. MRI may be helpful in anesthesia is necessary. MRI may be helpful in
select cases where the etiology of pain is select cases where the etiology of pain is
elusive.elusive.
Anorectal PainAnorectal Pain
Physical exam is critical in evaluating patients Physical exam is critical in evaluating patients
with anorectal pain. If a patient is too tender to with anorectal pain. If a patient is too tender to
examine in the office, an examination under examine in the office, an examination under
anesthesia is necessary. MRI may be helpful in anesthesia is necessary. MRI may be helpful in
select cases where the etiology of pain is select cases where the etiology of pain is
elusive.elusive.
eValuation of common symptomseValuation of common symptoms
Lower Gastrointestinal BleedingLower Gastrointestinal Bleeding
The first goal in evaluating and treating a patient The first goal in evaluating and treating a patient
with gastrointestinal hemorrhage is adequate with gastrointestinal hemorrhage is adequate
resuscitation.resuscitation.
The principles of ensuring a patent airway, The principles of ensuring a patent airway,
supporting ventilation, and optimizing supporting ventilation, and optimizing
hemodynamic parameters apply and hemodynamic parameters apply and
coagulopathy and/or thrombocytopenia should coagulopathy and/or thrombocytopenia should
be corrected. be corrected.
Lower Gastrointestinal BleedingLower Gastrointestinal Bleeding
The first goal in evaluating and treating a patient The first goal in evaluating and treating a patient
with gastrointestinal hemorrhage is adequate with gastrointestinal hemorrhage is adequate
resuscitation.resuscitation.
The principles of ensuring a patent airway, The principles of ensuring a patent airway,
supporting ventilation, and optimizing supporting ventilation, and optimizing
hemodynamic parameters apply and hemodynamic parameters apply and
coagulopathy and/or thrombocytopenia should coagulopathy and/or thrombocytopenia should
be corrected. be corrected.
eValuation of common symptomseValuation of common symptoms
Lower Gastrointestinal BleedingLower Gastrointestinal Bleeding
The second goal is to identify the source of The second goal is to identify the source of
hemorrhage. Because the most common hemorrhage. Because the most common
source of gastrointestinal hemorrhage is source of gastrointestinal hemorrhage is
esophageal, gastric, or duodenal, nasogastric esophageal, gastric, or duodenal, nasogastric
aspiration should always be performed; return aspiration should always be performed; return
of bile suggests that the source of bleeding is of bile suggests that the source of bleeding is
distal to the ligament of Treitz. If aspiration distal to the ligament of Treitz. If aspiration
reveals blood or nonbile secretions, or if reveals blood or nonbile secretions, or if
symptoms suggest an upper intestinal source, symptoms suggest an upper intestinal source,
esophagogastroduodenoscopy is performed. esophagogastroduodenoscopy is performed.
Lower Gastrointestinal BleedingLower Gastrointestinal Bleeding
The second goal is to identify the source of The second goal is to identify the source of
hemorrhage. Because the most common hemorrhage. Because the most common
source of gastrointestinal hemorrhage is source of gastrointestinal hemorrhage is
esophageal, gastric, or duodenal, nasogastric esophageal, gastric, or duodenal, nasogastric
aspiration should always be performed; return aspiration should always be performed; return
of bile suggests that the source of bleeding is of bile suggests that the source of bleeding is
distal to the ligament of Treitz. If aspiration distal to the ligament of Treitz. If aspiration
reveals blood or nonbile secretions, or if reveals blood or nonbile secretions, or if
symptoms suggest an upper intestinal source, symptoms suggest an upper intestinal source,
esophagogastroduodenoscopy is performed. esophagogastroduodenoscopy is performed.
eValuation of common symptomseValuation of common symptoms
Lower Gastrointestinal BleedingLower Gastrointestinal Bleeding
Anoscopy and/or limited proctoscopy can Anoscopy and/or limited proctoscopy can
identify hemorrhoidal bleeding.identify hemorrhoidal bleeding.
A technetium-99 (A technetium-99 (
99m99m
Tc)-tagged red blood cell Tc)-tagged red blood cell
(RBC) scan is extremely sensitive and is able (RBC) scan is extremely sensitive and is able
to detect as little as 0.1 mL/h of bleeding; to detect as little as 0.1 mL/h of bleeding;
however, localization is imprecise. however, localization is imprecise.
If the If the
99m99m
Tc-tagged RBC scan is positive, Tc-tagged RBC scan is positive,
angiography can then be employed to localize angiography can then be employed to localize
bleedingbleeding
Lower Gastrointestinal BleedingLower Gastrointestinal Bleeding
Anoscopy and/or limited proctoscopy can Anoscopy and/or limited proctoscopy can
identify hemorrhoidal bleeding.identify hemorrhoidal bleeding.
A technetium-99 (A technetium-99 (
99m99m
Tc)-tagged red blood cell Tc)-tagged red blood cell
(RBC) scan is extremely sensitive and is able (RBC) scan is extremely sensitive and is able
to detect as little as 0.1 mL/h of bleeding; to detect as little as 0.1 mL/h of bleeding;
however, localization is imprecise. however, localization is imprecise.
If the If the
99m99m
Tc-tagged RBC scan is positive, Tc-tagged RBC scan is positive,
angiography can then be employed to localize angiography can then be employed to localize
bleedingbleeding
eValuation of common symptomseValuation of common symptoms
Lower Gastrointestinal BleedingLower Gastrointestinal Bleeding
Infusion of vasopressin or angioembolization may Infusion of vasopressin or angioembolization may
be therapeutic. Alternatively, a catheter can be be therapeutic. Alternatively, a catheter can be
left in the bleeding vessel to allow localization left in the bleeding vessel to allow localization
at the time of laparotomy. If the patient is at the time of laparotomy. If the patient is
hemodynamically stable, a rapid bowel hemodynamically stable, a rapid bowel
preparation (over 4 to 6 hours) can be preparation (over 4 to 6 hours) can be
performed to allow colonoscopy.performed to allow colonoscopy.
Lower Gastrointestinal BleedingLower Gastrointestinal Bleeding
Infusion of vasopressin or angioembolization may Infusion of vasopressin or angioembolization may
be therapeutic. Alternatively, a catheter can be be therapeutic. Alternatively, a catheter can be
left in the bleeding vessel to allow localization left in the bleeding vessel to allow localization
at the time of laparotomy. If the patient is at the time of laparotomy. If the patient is
hemodynamically stable, a rapid bowel hemodynamically stable, a rapid bowel
preparation (over 4 to 6 hours) can be preparation (over 4 to 6 hours) can be
performed to allow colonoscopy.performed to allow colonoscopy.
eValuation of common symptomseValuation of common symptoms
Lower Gastrointestinal Bleeding.Lower Gastrointestinal Bleeding.
Colonoscopy may identify the cause of the Colonoscopy may identify the cause of the
bleeding, and cautery or injection of bleeding, and cautery or injection of
epinephrine into the bleeding site may be used epinephrine into the bleeding site may be used
to control hemorrhage. Colectomy may be to control hemorrhage. Colectomy may be
required if bleeding persists despite these required if bleeding persists despite these
interventionsinterventions
Lower Gastrointestinal Bleeding.Lower Gastrointestinal Bleeding.
Colonoscopy may identify the cause of the Colonoscopy may identify the cause of the
bleeding, and cautery or injection of bleeding, and cautery or injection of
epinephrine into the bleeding site may be used epinephrine into the bleeding site may be used
to control hemorrhage. Colectomy may be to control hemorrhage. Colectomy may be
required if bleeding persists despite these required if bleeding persists despite these
interventionsinterventions
eValuation of common symptomseValuation of common symptoms
Lower Gastrointestinal Bleeding.Lower Gastrointestinal Bleeding.
Intraoperative colonoscopy and/or enteroscopy Intraoperative colonoscopy and/or enteroscopy
may assist in localizing bleeding. If colectomy is may assist in localizing bleeding. If colectomy is
required, a segmental resection is preferred if required, a segmental resection is preferred if
the bleeding source can be localized. "Blind" the bleeding source can be localized. "Blind"
subtotal colectomy may very rarely be required subtotal colectomy may very rarely be required
in a patient who is hemodynamically unstable in a patient who is hemodynamically unstable
with ongoing colonic hemorrhage of unknown with ongoing colonic hemorrhage of unknown
source. It is crucial to irrigate rectum & examine source. It is crucial to irrigate rectum & examine
the mucosa by proctoscopy to ensure source of the mucosa by proctoscopy to ensure source of
bleeding is not distal to the resection margin bleeding is not distal to the resection margin
Lower Gastrointestinal Bleeding.Lower Gastrointestinal Bleeding.
Intraoperative colonoscopy and/or enteroscopy Intraoperative colonoscopy and/or enteroscopy
may assist in localizing bleeding. If colectomy is may assist in localizing bleeding. If colectomy is
required, a segmental resection is preferred if required, a segmental resection is preferred if
the bleeding source can be localized. "Blind" the bleeding source can be localized. "Blind"
subtotal colectomy may very rarely be required subtotal colectomy may very rarely be required
in a patient who is hemodynamically unstable in a patient who is hemodynamically unstable
with ongoing colonic hemorrhage of unknown with ongoing colonic hemorrhage of unknown
source. It is crucial to irrigate rectum & examine source. It is crucial to irrigate rectum & examine
the mucosa by proctoscopy to ensure source of the mucosa by proctoscopy to ensure source of
bleeding is not distal to the resection margin bleeding is not distal to the resection margin
eValuation of common symptomseValuation of common symptoms
Lower Gastrointestinal Bleeding.Lower Gastrointestinal Bleeding.
Intraoperative colonoscopy and/or enteroscopy Intraoperative colonoscopy and/or enteroscopy
may assist in localizing bleeding. If colectomy is may assist in localizing bleeding. If colectomy is
required, a segmental resection is preferred if required, a segmental resection is preferred if
the bleeding source can be localized. "Blind" the bleeding source can be localized. "Blind"
subtotal colectomy may very rarely be required subtotal colectomy may very rarely be required
in a patient who is hemodynamically unstable in a patient who is hemodynamically unstable
with ongoing colonic hemorrhage of unknown with ongoing colonic hemorrhage of unknown
source. It is crucial to irrigate rectum & examine source. It is crucial to irrigate rectum & examine
the mucosa by proctoscopy to ensure source of the mucosa by proctoscopy to ensure source of
bleeding is not distal to the resection margin bleeding is not distal to the resection margin
Lower Gastrointestinal Bleeding.Lower Gastrointestinal Bleeding.
Intraoperative colonoscopy and/or enteroscopy Intraoperative colonoscopy and/or enteroscopy
may assist in localizing bleeding. If colectomy is may assist in localizing bleeding. If colectomy is
required, a segmental resection is preferred if required, a segmental resection is preferred if
the bleeding source can be localized. "Blind" the bleeding source can be localized. "Blind"
subtotal colectomy may very rarely be required subtotal colectomy may very rarely be required
in a patient who is hemodynamically unstable in a patient who is hemodynamically unstable
with ongoing colonic hemorrhage of unknown with ongoing colonic hemorrhage of unknown
source. It is crucial to irrigate rectum & examine source. It is crucial to irrigate rectum & examine
the mucosa by proctoscopy to ensure source of the mucosa by proctoscopy to ensure source of
bleeding is not distal to the resection margin bleeding is not distal to the resection margin
eValuation of common symptomseValuation of common symptoms
Lower Gastrointestinal Bleeding.Lower Gastrointestinal Bleeding.
Occult blood loss from the gastrointestinal tract Occult blood loss from the gastrointestinal tract
may manifest as iron-deficiency anemia or may may manifest as iron-deficiency anemia or may
be detected with fecal occult blood testing. be detected with fecal occult blood testing.
Because colon neoplasms bleed intermittently Because colon neoplasms bleed intermittently
and rarely present with rapid hemorrhage, the and rarely present with rapid hemorrhage, the
presence of occult fecal blood should always presence of occult fecal blood should always
prompt a colonoscopy. Unexplained iron-prompt a colonoscopy. Unexplained iron-
deficiency anemia is also an indication for deficiency anemia is also an indication for
colonoscopy.colonoscopy.
Lower Gastrointestinal Bleeding.Lower Gastrointestinal Bleeding.
Occult blood loss from the gastrointestinal tract Occult blood loss from the gastrointestinal tract
may manifest as iron-deficiency anemia or may may manifest as iron-deficiency anemia or may
be detected with fecal occult blood testing. be detected with fecal occult blood testing.
Because colon neoplasms bleed intermittently Because colon neoplasms bleed intermittently
and rarely present with rapid hemorrhage, the and rarely present with rapid hemorrhage, the
presence of occult fecal blood should always presence of occult fecal blood should always
prompt a colonoscopy. Unexplained iron-prompt a colonoscopy. Unexplained iron-
deficiency anemia is also an indication for deficiency anemia is also an indication for
colonoscopy.colonoscopy.
eValuation of common symptomseValuation of common symptoms
Lower Gastrointestinal Bleeding.Lower Gastrointestinal Bleeding.
Hematochezia is commonly caused by Hematochezia is commonly caused by
hemorrhoids or fissure. hemorrhoids or fissure.
Sharp, knife-like pain and bright-red rectal Sharp, knife-like pain and bright-red rectal
bleeding with bowel movements suggest the bleeding with bowel movements suggest the
diagnosis of fissure. diagnosis of fissure.
Lower Gastrointestinal Bleeding.Lower Gastrointestinal Bleeding.
Hematochezia is commonly caused by Hematochezia is commonly caused by
hemorrhoids or fissure. hemorrhoids or fissure.
Sharp, knife-like pain and bright-red rectal Sharp, knife-like pain and bright-red rectal
bleeding with bowel movements suggest the bleeding with bowel movements suggest the
diagnosis of fissure. diagnosis of fissure.
eValuation of common symptomseValuation of common symptoms
Constipation and Obstructed DefecationConstipation and Obstructed Defecation
Constipation is an extremely common Constipation is an extremely common
complaint, affecting more than 4 million people complaint, affecting more than 4 million people
in the United States. Despite the prevalence of in the United States. Despite the prevalence of
this problem, there is lack of agreement about this problem, there is lack of agreement about
an appropriate definition of constipation.an appropriate definition of constipation.
Patients may describe infrequent bowel Patients may describe infrequent bowel
movements, hard stools, or excessive straining. movements, hard stools, or excessive straining.
A careful history of these symptoms often A careful history of these symptoms often
clarifies the nature of the problem.clarifies the nature of the problem.
Constipation and Obstructed DefecationConstipation and Obstructed Defecation
Constipation is an extremely common Constipation is an extremely common
complaint, affecting more than 4 million people complaint, affecting more than 4 million people
in the United States. Despite the prevalence of in the United States. Despite the prevalence of
this problem, there is lack of agreement about this problem, there is lack of agreement about
an appropriate definition of constipation.an appropriate definition of constipation.
Patients may describe infrequent bowel Patients may describe infrequent bowel
movements, hard stools, or excessive straining. movements, hard stools, or excessive straining.
A careful history of these symptoms often A careful history of these symptoms often
clarifies the nature of the problem.clarifies the nature of the problem.
eValuation of common symptomseValuation of common symptoms
Constipation and Obstructed DefecationConstipation and Obstructed Defecation
Constipation has a myriad of causes.Constipation has a myriad of causes.
1.Underlying metabolic 1.Underlying metabolic
2.Pharmacologic2.Pharmacologic
3.Endocrine 3.Endocrine
4.Psychologic4.Psychologic
5.Neurologic causes often contribute to the 5.Neurologic causes often contribute to the
problemproblem
Constipation and Obstructed DefecationConstipation and Obstructed Defecation
Constipation has a myriad of causes.Constipation has a myriad of causes.
1.Underlying metabolic 1.Underlying metabolic
2.Pharmacologic2.Pharmacologic
3.Endocrine 3.Endocrine
4.Psychologic4.Psychologic
5.Neurologic causes often contribute to the 5.Neurologic causes often contribute to the
problemproblem
eValuation of common symptomseValuation of common symptoms
Constipation and Obstructed DefecationConstipation and Obstructed Defecation
A stricture or mass lesion should be excluded by A stricture or mass lesion should be excluded by
colonoscopy or barium enema. After these colonoscopy or barium enema. After these
causes have been excluded causes have been excluded
Evaluation focuses upon differentiating Evaluation focuses upon differentiating slow-slow-
transit constipationtransit constipation from from outlet obstructionoutlet obstruction. .
Transit studies, in which radiopaque markers Transit studies, in which radiopaque markers
are swallowed and followed radiographically, are swallowed and followed radiographically,
are useful for diagnosing slow-transit are useful for diagnosing slow-transit
constipation. constipation.
Constipation and Obstructed DefecationConstipation and Obstructed Defecation
A stricture or mass lesion should be excluded by A stricture or mass lesion should be excluded by
colonoscopy or barium enema. After these colonoscopy or barium enema. After these
causes have been excluded causes have been excluded
Evaluation focuses upon differentiating Evaluation focuses upon differentiating slow-slow-
transit constipationtransit constipation from from outlet obstructionoutlet obstruction. .
Transit studies, in which radiopaque markers Transit studies, in which radiopaque markers
are swallowed and followed radiographically, are swallowed and followed radiographically,
are useful for diagnosing slow-transit are useful for diagnosing slow-transit
constipation. constipation.
eValuation of common symptomseValuation of common symptoms
Constipation and Obstructed DefecationConstipation and Obstructed Defecation
Anorectal manometry and electromyography can Anorectal manometry and electromyography can
detect nonrelaxation of the puborectalis, which detect nonrelaxation of the puborectalis, which
contributes to outlet obstruction. The absence contributes to outlet obstruction. The absence
of an anorectal inhibitory reflex suggests of an anorectal inhibitory reflex suggests
Hirschsprung's disease and may prompt a Hirschsprung's disease and may prompt a
rectal mucosal biopsy.rectal mucosal biopsy.
Defecography can identify rectal prolapse, Defecography can identify rectal prolapse,
intussusception, rectocele, or enteroceleintussusception, rectocele, or enterocele
Constipation and Obstructed DefecationConstipation and Obstructed Defecation
Anorectal manometry and electromyography can Anorectal manometry and electromyography can
detect nonrelaxation of the puborectalis, which detect nonrelaxation of the puborectalis, which
contributes to outlet obstruction. The absence contributes to outlet obstruction. The absence
of an anorectal inhibitory reflex suggests of an anorectal inhibitory reflex suggests
Hirschsprung's disease and may prompt a Hirschsprung's disease and may prompt a
rectal mucosal biopsy.rectal mucosal biopsy.
Defecography can identify rectal prolapse, Defecography can identify rectal prolapse,
intussusception, rectocele, or enteroceleintussusception, rectocele, or enterocele
eValuation of common symptomseValuation of common symptoms
Constipation and Obstructed DefecationConstipation and Obstructed Defecation
Medical management is the mainstay of Medical management is the mainstay of
therapy for constipation and includes fiber, therapy for constipation and includes fiber,
increased fluid intake, and laxatives. Outlet increased fluid intake, and laxatives. Outlet
obstruction from nonrelaxation of the obstruction from nonrelaxation of the
puborectalis often responds to biofeedback. 7 puborectalis often responds to biofeedback. 7
Surgery to correct rectocele and rectal prolapse Surgery to correct rectocele and rectal prolapse
has a variable effect on symptoms of has a variable effect on symptoms of
constipation, but can be successful in selected constipation, but can be successful in selected
patients. patients.
Constipation and Obstructed DefecationConstipation and Obstructed Defecation
Medical management is the mainstay of Medical management is the mainstay of
therapy for constipation and includes fiber, therapy for constipation and includes fiber,
increased fluid intake, and laxatives. Outlet increased fluid intake, and laxatives. Outlet
obstruction from nonrelaxation of the obstruction from nonrelaxation of the
puborectalis often responds to biofeedback. 7 puborectalis often responds to biofeedback. 7
Surgery to correct rectocele and rectal prolapse Surgery to correct rectocele and rectal prolapse
has a variable effect on symptoms of has a variable effect on symptoms of
constipation, but can be successful in selected constipation, but can be successful in selected
patients. patients.
eValuation of common symptomseValuation of common symptoms
Constipation and Obstructed DefecationConstipation and Obstructed Defecation
Subtotal colectomy is considered only for Subtotal colectomy is considered only for
patients with severe slow-transit constipation patients with severe slow-transit constipation
(colonic inertia) refractory to maximal medical (colonic inertia) refractory to maximal medical
interventions. While this operation almost interventions. While this operation almost
always increases bowel movement frequency, always increases bowel movement frequency,
complaints of diarrhea, incontinence, and complaints of diarrhea, incontinence, and
abdominal pain are not infrequent, and patients abdominal pain are not infrequent, and patients
should be carefully selected. should be carefully selected.
Constipation and Obstructed DefecationConstipation and Obstructed Defecation
Subtotal colectomy is considered only for Subtotal colectomy is considered only for
patients with severe slow-transit constipation patients with severe slow-transit constipation
(colonic inertia) refractory to maximal medical (colonic inertia) refractory to maximal medical
interventions. While this operation almost interventions. While this operation almost
always increases bowel movement frequency, always increases bowel movement frequency,
complaints of diarrhea, incontinence, and complaints of diarrhea, incontinence, and
abdominal pain are not infrequent, and patients abdominal pain are not infrequent, and patients
should be carefully selected. should be carefully selected.
eValuation of common symptomseValuation of common symptoms
Diarrhea and Irritable Bowel SyndromeDiarrhea and Irritable Bowel Syndrome
Diarrhea is also a common complaint and is Diarrhea is also a common complaint and is
usually a self-limited symptom of infectious usually a self-limited symptom of infectious
gastroenteritis. If diarrhea is chronic or is gastroenteritis. If diarrhea is chronic or is
accompanied by bleeding or abdominal pain, accompanied by bleeding or abdominal pain,
further investigation is warranted. further investigation is warranted.
Diarrhea and Irritable Bowel SyndromeDiarrhea and Irritable Bowel Syndrome
Diarrhea is also a common complaint and is Diarrhea is also a common complaint and is
usually a self-limited symptom of infectious usually a self-limited symptom of infectious
gastroenteritis. If diarrhea is chronic or is gastroenteritis. If diarrhea is chronic or is
accompanied by bleeding or abdominal pain, accompanied by bleeding or abdominal pain,
further investigation is warranted. further investigation is warranted.
eValuation of common symptomseValuation of common symptoms
Diarrhea and Irritable Bowel Syndrome. Diarrhea and Irritable Bowel Syndrome.
Bloody diarrhea and pain are characteristic of Bloody diarrhea and pain are characteristic of
colitis; etiology can be an infection:colitis; etiology can be an infection:
1.Invasive 1.Invasive E. ColiE. Coli
2. Shigella2. Shigella
3.Salmonella3.Salmonella
4. Campylobacter4. Campylobacter
5.Entamoeba histolytica5.Entamoeba histolytica
6.C. Difficile6.C. Difficile
Diarrhea and Irritable Bowel Syndrome. Diarrhea and Irritable Bowel Syndrome.
Bloody diarrhea and pain are characteristic of Bloody diarrhea and pain are characteristic of
colitis; etiology can be an infection:colitis; etiology can be an infection:
1.Invasive 1.Invasive E. ColiE. Coli
2. Shigella2. Shigella
3.Salmonella3.Salmonella
4. Campylobacter4. Campylobacter
5.Entamoeba histolytica5.Entamoeba histolytica
6.C. Difficile6.C. Difficile
eValuation of common symptomseValuation of common symptoms
Diarrhea and Irritable Bowel Syndrome. Diarrhea and Irritable Bowel Syndrome.
Inflammatory bowel disease (ulcerative colitis or Inflammatory bowel disease (ulcerative colitis or
Crohn's colitis), or ischemia.Crohn's colitis), or ischemia.
Stool wet-mount and culture can often diagnose Stool wet-mount and culture can often diagnose
infection. infection.
Sigmoidoscopy or colonoscopy can be helpful in Sigmoidoscopy or colonoscopy can be helpful in
diagnosing inflammatory bowel disease or diagnosing inflammatory bowel disease or
ischemia. However, if the patient has ischemia. However, if the patient has
abdominal tenderness, particularly with abdominal tenderness, particularly with
peritoneal signs, or any other evidence of peritoneal signs, or any other evidence of
perforation, endoscopy is contraindicated.perforation, endoscopy is contraindicated.
Diarrhea and Irritable Bowel Syndrome. Diarrhea and Irritable Bowel Syndrome.
Inflammatory bowel disease (ulcerative colitis or Inflammatory bowel disease (ulcerative colitis or
Crohn's colitis), or ischemia.Crohn's colitis), or ischemia.
Stool wet-mount and culture can often diagnose Stool wet-mount and culture can often diagnose
infection. infection.
Sigmoidoscopy or colonoscopy can be helpful in Sigmoidoscopy or colonoscopy can be helpful in
diagnosing inflammatory bowel disease or diagnosing inflammatory bowel disease or
ischemia. However, if the patient has ischemia. However, if the patient has
abdominal tenderness, particularly with abdominal tenderness, particularly with
peritoneal signs, or any other evidence of peritoneal signs, or any other evidence of
perforation, endoscopy is contraindicated.perforation, endoscopy is contraindicated.
eValuation of common symptomseValuation of common symptoms
Diarrhea and Irritable Bowel Syndrome. Diarrhea and Irritable Bowel Syndrome.
Rarely, carcinoid syndrome and islet cell tumors Rarely, carcinoid syndrome and islet cell tumors
(vasoactive intestinal peptide-secreting tumor (vasoactive intestinal peptide-secreting tumor
[VIPoma], somatostatinoma, gastrinoma) [VIPoma], somatostatinoma, gastrinoma)
present with this symptom. present with this symptom.
Large villous lesions may cause secretory Large villous lesions may cause secretory
diarrhea. diarrhea.
Collagenous colitis can cause diarrhea without Collagenous colitis can cause diarrhea without
any obvious mucosal abnormality. any obvious mucosal abnormality.
Diarrhea and Irritable Bowel Syndrome. Diarrhea and Irritable Bowel Syndrome.
Rarely, carcinoid syndrome and islet cell tumors Rarely, carcinoid syndrome and islet cell tumors
(vasoactive intestinal peptide-secreting tumor (vasoactive intestinal peptide-secreting tumor
[VIPoma], somatostatinoma, gastrinoma) [VIPoma], somatostatinoma, gastrinoma)
present with this symptom. present with this symptom.
Large villous lesions may cause secretory Large villous lesions may cause secretory
diarrhea. diarrhea.
Collagenous colitis can cause diarrhea without Collagenous colitis can cause diarrhea without
any obvious mucosal abnormality. any obvious mucosal abnormality.
eValuation of common symptomseValuation of common symptoms
Diarrhea and Irritable Bowel Syndrome. Diarrhea and Irritable Bowel Syndrome.
Along with stool cultures, tests for Along with stool cultures, tests for
malabsorption, and metabolic investigations, malabsorption, and metabolic investigations,
colonoscopy can be invaluable in differentiating colonoscopy can be invaluable in differentiating
these causes. Biopsies should be taken even if these causes. Biopsies should be taken even if
the colonic mucosa appears grossly normalthe colonic mucosa appears grossly normal
Diarrhea and Irritable Bowel Syndrome. Diarrhea and Irritable Bowel Syndrome.
Along with stool cultures, tests for Along with stool cultures, tests for
malabsorption, and metabolic investigations, malabsorption, and metabolic investigations,
colonoscopy can be invaluable in differentiating colonoscopy can be invaluable in differentiating
these causes. Biopsies should be taken even if these causes. Biopsies should be taken even if
the colonic mucosa appears grossly normalthe colonic mucosa appears grossly normal
eValuation of common symptomseValuation of common symptoms
Diarrhea and Irritable Bowel Syndrome. Diarrhea and Irritable Bowel Syndrome.
Irritable bowel syndromeIrritable bowel syndrome is a particularly is a particularly
troubling constellation of symptoms consisting troubling constellation of symptoms consisting
1. Crampy abdominal pain1. Crampy abdominal pain
2. Bloating2. Bloating
3. Constipation3. Constipation
4. Urgent diarrhea. 4. Urgent diarrhea.
Diarrhea and Irritable Bowel Syndrome. Diarrhea and Irritable Bowel Syndrome.
Irritable bowel syndromeIrritable bowel syndrome is a particularly is a particularly
troubling constellation of symptoms consisting troubling constellation of symptoms consisting
1. Crampy abdominal pain1. Crampy abdominal pain
2. Bloating2. Bloating
3. Constipation3. Constipation
4. Urgent diarrhea. 4. Urgent diarrhea.
eValuation of common symptomseValuation of common symptoms
Diarrhea and Irritable Bowel Syndrome. Diarrhea and Irritable Bowel Syndrome.
Irritable bowel syndromeIrritable bowel syndrome
Work-up reveals no underlying anatomic or Work-up reveals no underlying anatomic or
physiologic abnormality. physiologic abnormality.
Once other disorders have been excluded, Once other disorders have been excluded,
dietary restrictions and avoidance of caffeine, dietary restrictions and avoidance of caffeine,
alcohol, and tobacco may help to alleviate alcohol, and tobacco may help to alleviate
symptoms.symptoms.
Antispasmodics and bulking agents may be Antispasmodics and bulking agents may be
helpfulhelpful
Diarrhea and Irritable Bowel Syndrome. Diarrhea and Irritable Bowel Syndrome.
Irritable bowel syndromeIrritable bowel syndrome
Work-up reveals no underlying anatomic or Work-up reveals no underlying anatomic or
physiologic abnormality. physiologic abnormality.
Once other disorders have been excluded, Once other disorders have been excluded,
dietary restrictions and avoidance of caffeine, dietary restrictions and avoidance of caffeine,
alcohol, and tobacco may help to alleviate alcohol, and tobacco may help to alleviate
symptoms.symptoms.
Antispasmodics and bulking agents may be Antispasmodics and bulking agents may be
helpfulhelpful
eValuation of common symptomseValuation of common symptoms
IncontinenceIncontinence
The incidence of fecal incontinence has been The incidence of fecal incontinence has been
estimated to occur in 10 to 13 individuals per estimated to occur in 10 to 13 individuals per
1000 people older than age 65 years. 1000 people older than age 65 years.
Incontinence ranges in severity from Incontinence ranges in severity from
occasional leakage of gas and liquid stool tooccasional leakage of gas and liquid stool to
daily loss of solid stool. daily loss of solid stool.
IncontinenceIncontinence
The incidence of fecal incontinence has been The incidence of fecal incontinence has been
estimated to occur in 10 to 13 individuals per estimated to occur in 10 to 13 individuals per
1000 people older than age 65 years. 1000 people older than age 65 years.
Incontinence ranges in severity from Incontinence ranges in severity from
occasional leakage of gas and liquid stool tooccasional leakage of gas and liquid stool to
daily loss of solid stool. daily loss of solid stool.
eValuation of common symptomseValuation of common symptoms
IncontinenceIncontinence
The underlying cause of incontinence is often The underlying cause of incontinence is often
multifactorial and diarrhea is often contributory. multifactorial and diarrhea is often contributory.
In general, causes of incontinence can be In general, causes of incontinence can be
classifiedclassified
as as neurogenicneurogenic
anatomicanatomic. .
Neurogenic causes include diseases of the Neurogenic causes include diseases of the
central nervous system and spinal cord along central nervous system and spinal cord along
with pudendal nerve injury.with pudendal nerve injury.
IncontinenceIncontinence
The underlying cause of incontinence is often The underlying cause of incontinence is often
multifactorial and diarrhea is often contributory. multifactorial and diarrhea is often contributory.
In general, causes of incontinence can be In general, causes of incontinence can be
classifiedclassified
as as neurogenicneurogenic
anatomicanatomic. .
Neurogenic causes include diseases of the Neurogenic causes include diseases of the
central nervous system and spinal cord along central nervous system and spinal cord along
with pudendal nerve injury.with pudendal nerve injury.
eValuation of common symptomseValuation of common symptoms
Incontinence.Incontinence.
Anatomic causes include Anatomic causes include
1. congenital abnormalities1. congenital abnormalities
2. procidentia 2. procidentia
overflow incontinence secondary to impaction overflow incontinence secondary to impaction
or neoplasm, or neoplasm,
Incontinence.Incontinence.
Anatomic causes include Anatomic causes include
1. congenital abnormalities1. congenital abnormalities
2. procidentia 2. procidentia
overflow incontinence secondary to impaction overflow incontinence secondary to impaction
or neoplasm, or neoplasm,
eValuation of common symptomseValuation of common symptoms
Incontinence.Incontinence.
trauma. trauma.
The most common traumatic cause of The most common traumatic cause of
incontinence is injury to the anal sphincter incontinence is injury to the anal sphincter
during vaginal delivery.during vaginal delivery.
Other causes includeOther causes include
Anorectal surgery, Anorectal surgery,
Impalement, Impalement,
Pelvic fracture.Pelvic fracture.
Incontinence.Incontinence.
trauma. trauma.
The most common traumatic cause of The most common traumatic cause of
incontinence is injury to the anal sphincter incontinence is injury to the anal sphincter
during vaginal delivery.during vaginal delivery.
Other causes includeOther causes include
Anorectal surgery, Anorectal surgery,
Impalement, Impalement,
Pelvic fracture.Pelvic fracture.
eValuation of common symptomseValuation of common symptoms
After a thorough medical evaluation to detect After a thorough medical evaluation to detect
underlying conditions that might contribute to underlying conditions that might contribute to
incontinence, evaluation focuses on: incontinence, evaluation focuses on:
1. Assessment of anal sphincter & pudendal 1. Assessment of anal sphincter & pudendal
nerves. nerves. Pudendal nerve terminal motor latency Pudendal nerve terminal motor latency
testing mtesting may detect neuropathy. ay detect neuropathy. Anal Anal
manometry manometry can detect low resting and squeeze can detect low resting and squeeze
pressures. pressures. DefecographDefecography can detect rectal y can detect rectal
prolapse. prolapse. Endoanal ultrasound Endoanal ultrasound is invaluable in is invaluable in
diagnosing sphincter defects diagnosing sphincter defects
After a thorough medical evaluation to detect After a thorough medical evaluation to detect
underlying conditions that might contribute to underlying conditions that might contribute to
incontinence, evaluation focuses on: incontinence, evaluation focuses on:
1. Assessment of anal sphincter & pudendal 1. Assessment of anal sphincter & pudendal
nerves. nerves. Pudendal nerve terminal motor latency Pudendal nerve terminal motor latency
testing mtesting may detect neuropathy. ay detect neuropathy. Anal Anal
manometry manometry can detect low resting and squeeze can detect low resting and squeeze
pressures. pressures. DefecographDefecography can detect rectal y can detect rectal
prolapse. prolapse. Endoanal ultrasound Endoanal ultrasound is invaluable in is invaluable in
diagnosing sphincter defects diagnosing sphincter defects
eValuation of common symptomseValuation of common symptoms
Therapy depends upon underlying abnormality. Therapy depends upon underlying abnormality.
1.Diarrhea should be treated medically. Even in 1.Diarrhea should be treated medically. Even in
the absence of frank diarrhea the absence of frank diarrhea
2.Addition of dietary fiber may improve 2.Addition of dietary fiber may improve
continence.continence.
3.Some patients may respond to biofeedback. 3.Some patients may respond to biofeedback.
Therapy depends upon underlying abnormality. Therapy depends upon underlying abnormality.
1.Diarrhea should be treated medically. Even in 1.Diarrhea should be treated medically. Even in
the absence of frank diarrhea the absence of frank diarrhea
2.Addition of dietary fiber may improve 2.Addition of dietary fiber may improve
continence.continence.
3.Some patients may respond to biofeedback. 3.Some patients may respond to biofeedback.
eValuation of common symptomseValuation of common symptoms
Therapy depends upon underlying abnormality. Therapy depends upon underlying abnormality.
4.Many patients with a sphincter defect are 4.Many patients with a sphincter defect are
candidates for an overlapping sphincteroplasty. candidates for an overlapping sphincteroplasty.
5.Innovative technologies such as sacral nerve 5.Innovative technologies such as sacral nerve
stimulation or artificial bowel sphincter are stimulation or artificial bowel sphincter are
proving useful in patients who fail other proving useful in patients who fail other
interventionsinterventions
Therapy depends upon underlying abnormality. Therapy depends upon underlying abnormality.
4.Many patients with a sphincter defect are 4.Many patients with a sphincter defect are
candidates for an overlapping sphincteroplasty. candidates for an overlapping sphincteroplasty.
5.Innovative technologies such as sacral nerve 5.Innovative technologies such as sacral nerve
stimulation or artificial bowel sphincter are stimulation or artificial bowel sphincter are
proving useful in patients who fail other proving useful in patients who fail other
interventionsinterventions
geneRal suRgical consideRationsgeneRal suRgical consideRations
Anterior ResectionAnterior Resection
High Anterior ResectionHigh Anterior Resection
Low Anterior ResectionLow Anterior Resection
Extended Low Anterior ResectionExtended Low Anterior Resection
Hartmann's Procedure and Mucus FistulaHartmann's Procedure and Mucus Fistula
Abdominoperineal ResectionAbdominoperineal Resection
Anterior ResectionAnterior Resection
High Anterior ResectionHigh Anterior Resection
Low Anterior ResectionLow Anterior Resection
Extended Low Anterior ResectionExtended Low Anterior Resection
Hartmann's Procedure and Mucus FistulaHartmann's Procedure and Mucus Fistula
Abdominoperineal ResectionAbdominoperineal Resection
POLYPSPOLYPS
Neoplastic-Tubular, villous, tubulovillousNeoplastic-Tubular, villous, tubulovillous
Hamartomatous- juvenile, Peutz-JeghersHamartomatous- juvenile, Peutz-Jeghers
Hyperlastic - <5mm- >2cmHyperlastic - <5mm- >2cm
Inflammatory- pseudopolypInflammatory- pseudopolyp
Polyps less than 1 cm - Polyps less than 1 cm - 1-10%1-10%
1 to 2 cm – 1 to 2 cm – 7 -10%7 -10%
2 cm – 2 cm – 35 -50%35 -50%
Neoplastic-Tubular, villous, tubulovillousNeoplastic-Tubular, villous, tubulovillous
Hamartomatous- juvenile, Peutz-JeghersHamartomatous- juvenile, Peutz-Jeghers
Hyperlastic - <5mm- >2cmHyperlastic - <5mm- >2cm
Inflammatory- pseudopolypInflammatory- pseudopolyp
Polyps less than 1 cm - Polyps less than 1 cm - 1-10%1-10%
1 to 2 cm – 1 to 2 cm – 7 -10%7 -10%
2 cm – 2 cm – 35 -50%35 -50%
RECTAL POLYPS
SESSILE PEDUNCULATED
SESSILE PEDUNCULATED
CASE: MULTIPLE
COLORECTAL POLYPS
CLINICAL
PRESENTATION
BARIUM ENEMA
COLORECTAL POLYPS
CLINICAL
PRESENTATION
BARIUM ENEMA
CASE: MULTIPLE COLORECTAL
POLYPS
LOCATION OF
COLORECTAL POLYPS
POLYPS
LOCATION OF
COLORECTAL POLYPS
Familial polyposis of the colon is most oftenFamilial polyposis of the colon is most often
associated with which of the following associated with which of the following
conditionsconditions
A. Carcinoma of the pancreasA. Carcinoma of the pancreas
B. Carcinoma of the colonB. Carcinoma of the colon
C. Granulomatous disease of the colonC. Granulomatous disease of the colon
D. Pneumatosis cystoides intestinalesD. Pneumatosis cystoides intestinales
E. Sigmoid volvulusE. Sigmoid volvulus
associated with which of the following associated with which of the following
conditionsconditions
A. Carcinoma of the pancreasA. Carcinoma of the pancreas
B. Carcinoma of the colonB. Carcinoma of the colon
C. Granulomatous disease of the colonC. Granulomatous disease of the colon
D. Pneumatosis cystoides intestinalesD. Pneumatosis cystoides intestinales
E. Sigmoid volvulusE. Sigmoid volvulus
CASE: POST- SURGICAL RESECTION
INFLAMMATORY BOWEL DISEASEINFLAMMATORY BOWEL DISEASE
ULCERATIVE COLITISULCERATIVE COLITIS
Rare in FilipinosRare in Filipinos
Common in caucasians esp. in JewsCommon in caucasians esp. in Jews
Non-specific, idiopathic mucosal Non-specific, idiopathic mucosal
inflammation of the colon and the inflammation of the colon and the
rectumrectum
ULCERATIVE COLITISULCERATIVE COLITIS
Rare in FilipinosRare in Filipinos
Common in caucasians esp. in JewsCommon in caucasians esp. in Jews
Non-specific, idiopathic mucosal Non-specific, idiopathic mucosal
inflammation of the colon and the inflammation of the colon and the
rectumrectum
INFLAMMATORY BOWEL DISEASEINFLAMMATORY BOWEL DISEASE
ULCERATIVE COLITISULCERATIVE COLITIS
Usually begins at the rectum moving Usually begins at the rectum moving
proximally by direct extension (mucosa proximally by direct extension (mucosa
and submucosa)and submucosa)
inflammation stops at the ileocolic inflammation stops at the ileocolic
junctionjunction
Bloody mucoid diarrheaBloody mucoid diarrhea, abdominal pain, , abdominal pain,
tenesmus, fevertenesmus, fever
ULCERATIVE COLITISULCERATIVE COLITIS
Usually begins at the rectum moving Usually begins at the rectum moving
proximally by direct extension (mucosa proximally by direct extension (mucosa
and submucosa)and submucosa)
inflammation stops at the ileocolic inflammation stops at the ileocolic
junctionjunction
Bloody mucoid diarrheaBloody mucoid diarrhea, abdominal pain, , abdominal pain,
tenesmus, fevertenesmus, fever
INFLAMMATORY BOWEL DISEASEINFLAMMATORY BOWEL DISEASE
ULCERATIVE COLITISULCERATIVE COLITIS
Treatment:Treatment:
Sulfasalazine -4g/day relapse rate 9%/yr.Sulfasalazine -4g/day relapse rate 9%/yr.
Rowasa- topical enema of 5-ASA.Rowasa- topical enema of 5-ASA.
steroids , azathioprine, cyclosporine, steroids , azathioprine, cyclosporine,
6-mercaptopurine, tacrolimus.6-mercaptopurine, tacrolimus.
Total abdominal colectomy with end Total abdominal colectomy with end
ileostomy.ileostomy.
ULCERATIVE COLITISULCERATIVE COLITIS
Treatment:Treatment:
Sulfasalazine -4g/day relapse rate 9%/yr.Sulfasalazine -4g/day relapse rate 9%/yr.
Rowasa- topical enema of 5-ASA.Rowasa- topical enema of 5-ASA.
steroids , azathioprine, cyclosporine, steroids , azathioprine, cyclosporine,
6-mercaptopurine, tacrolimus.6-mercaptopurine, tacrolimus.
Total abdominal colectomy with end Total abdominal colectomy with end
ileostomy.ileostomy.
INFLAMMATORY BOWEL DISEASEINFLAMMATORY BOWEL DISEASE
Crohn’s diseaseCrohn’s disease
Nonspecific, transmural inflammationNonspecific, transmural inflammation
-exacerbation/remissionexacerbation/remission
-Mouth to anus, Mouth to anus, bloody diarrheabloody diarrhea
-Extraintestinal manifestationExtraintestinal manifestation
-Skip lesion , rectal sparing(40%)Skip lesion , rectal sparing(40%)
-Terminal ileum and cecum (41%), SI(35%)Terminal ileum and cecum (41%), SI(35%)
-Fistula,abscess,obstruction,strictureFistula,abscess,obstruction,stricture
Crohn’s diseaseCrohn’s disease
Nonspecific, transmural inflammationNonspecific, transmural inflammation
-exacerbation/remissionexacerbation/remission
-Mouth to anus, Mouth to anus, bloody diarrheabloody diarrhea
-Extraintestinal manifestationExtraintestinal manifestation
-Skip lesion , rectal sparing(40%)Skip lesion , rectal sparing(40%)
-Terminal ileum and cecum (41%), SI(35%)Terminal ileum and cecum (41%), SI(35%)
-Fistula,abscess,obstruction,strictureFistula,abscess,obstruction,stricture
ANORECTAL DISEASESANORECTAL DISEASES
HemorrhoidsHemorrhoids
Ischiorectal AbscessIschiorectal Abscess
Fistula in anoFistula in ano
Fissure in anoFissure in ano
WartsWarts
Fournier’s gangreneFournier’s gangrene
Foreign BodyForeign Body
HemorrhoidsHemorrhoids
Ischiorectal AbscessIschiorectal Abscess
Fistula in anoFistula in ano
Fissure in anoFissure in ano
WartsWarts
Fournier’s gangreneFournier’s gangrene
Foreign BodyForeign Body
Right Right
AnteriorAnterior
Right Right
PosteriorPosterior
Left LateralLeft Lateral
3 MAJOR 3 MAJOR
PILESPILES
AnteriorAnterior
Right Right
PosteriorPosterior
Left LateralLeft Lateral
3 MAJOR 3 MAJOR
PILESPILES
HEMORRHOIDAL DISEASEHEMORRHOIDAL DISEASE
A
P
LR
Primary Locations
3-7-11 o’clock positons
(Left Lateral, Right Anterior
and Right Posterior)
A
P
LR
Primary Locations
3-7-11 o’clock positons
(Left Lateral, Right Anterior
and Right Posterior)
HEMORRHOIDAL DISEASEHEMORRHOIDAL DISEASE
Submucosal cushion contains venules, Submucosal cushion contains venules,
arterioles, smooth muscle fibers.arterioles, smooth muscle fibers.
Part of continence mechanism.Part of continence mechanism.
Excessive straing, increase abdominal Excessive straing, increase abdominal
pressure, hard stools.pressure, hard stools.
Bleeding, thrombosis, prolapse.Bleeding, thrombosis, prolapse.
External hemorrhoids distal to dentate lineExternal hemorrhoids distal to dentate line
Internal hemorrhoids proximal to dentate lineInternal hemorrhoids proximal to dentate line
Submucosal cushion contains venules, Submucosal cushion contains venules,
arterioles, smooth muscle fibers.arterioles, smooth muscle fibers.
Part of continence mechanism.Part of continence mechanism.
Excessive straing, increase abdominal Excessive straing, increase abdominal
pressure, hard stools.pressure, hard stools.
Bleeding, thrombosis, prolapse.Bleeding, thrombosis, prolapse.
External hemorrhoids distal to dentate lineExternal hemorrhoids distal to dentate line
Internal hemorrhoids proximal to dentate lineInternal hemorrhoids proximal to dentate line
HEMORRHOIDAL DISEASEHEMORRHOIDAL DISEASE
Grading :Grading :
2.2.First degree – bulge into anal canal First degree – bulge into anal canal
,prolapse beyond dentate line,prolapse beyond dentate line
3.3.Second degree- prolapse through anus, Second degree- prolapse through anus,
reduce spontaneouslyreduce spontaneously
4.4.Third degree- require manual reductionThird degree- require manual reduction
5.5.Fourth degree- cannot be reduced, Fourth degree- cannot be reduced,
prone to strangulationprone to strangulation
Grading :Grading :
2.2.First degree – bulge into anal canal First degree – bulge into anal canal
,prolapse beyond dentate line,prolapse beyond dentate line
3.3.Second degree- prolapse through anus, Second degree- prolapse through anus,
reduce spontaneouslyreduce spontaneously
4.4.Third degree- require manual reductionThird degree- require manual reduction
5.5.Fourth degree- cannot be reduced, Fourth degree- cannot be reduced,
prone to strangulationprone to strangulation
Retrograde View from
Colonoscopy
Hemorrhoids Hemorrhoids
Colonoscopy
Hemorrhoids Hemorrhoids
Hemorrhoids: ManagementHemorrhoids: Management
MedicalMedical
DietDiet
Sitz BathSitz Bath
SuppositoriesSuppositories
SurgicalSurgical
Milligan MorganMilligan Morgan
Rubber Band Rubber Band LigationLigation
Harmonic ScalpelHarmonic Scalpel
MedicalMedical
DietDiet
Sitz BathSitz Bath
SuppositoriesSuppositories
SurgicalSurgical
Milligan MorganMilligan Morgan
Rubber Band Rubber Band LigationLigation
Harmonic ScalpelHarmonic Scalpel
Hemorrhoidectomy
Rubber Band
Ligation
Harmonic
Scalpel
Rubber Band
Ligation
Harmonic
Scalpel
Hemorrhoidectomy
Stapler Technique Ferguson or Excision
Stapler Technique Ferguson or Excision
Anorectal Abscess and FAnorectal Abscess and Fiistulastula
What is an anal fistula?What is an anal fistula?
An abnormal communication between An abnormal communication between
anal canal &skinanal canal &skin
What is the assoc. bet. Abscess/Fistula?What is the assoc. bet. Abscess/Fistula?
Approx. 50% of abscess occur Approx. 50% of abscess occur
secondary to anal fistula. Abscess is the secondary to anal fistula. Abscess is the
acute signacute sign..
What is an anal fistula?What is an anal fistula?
An abnormal communication between An abnormal communication between
anal canal &skinanal canal &skin
What is the assoc. bet. Abscess/Fistula?What is the assoc. bet. Abscess/Fistula?
Approx. 50% of abscess occur Approx. 50% of abscess occur
secondary to anal fistula. Abscess is the secondary to anal fistula. Abscess is the
acute signacute sign..
Anorectal Abscess and FAnorectal Abscess and Fiistulastula
What is the P/E in anorectal abscess?What is the P/E in anorectal abscess?
Inflamed and tender perianal swellingInflamed and tender perianal swelling
Treatment for anorectal abscess/fistula?Treatment for anorectal abscess/fistula?
I & D “asap” for abscess.I & D “asap” for abscess.
Elective surgery for fistula.Elective surgery for fistula.
What is the P/E in anorectal abscess?What is the P/E in anorectal abscess?
Inflamed and tender perianal swellingInflamed and tender perianal swelling
Treatment for anorectal abscess/fistula?Treatment for anorectal abscess/fistula?
I & D “asap” for abscess.I & D “asap” for abscess.
Elective surgery for fistula.Elective surgery for fistula.
Salmon Goodsalls rule:
Anterior - straight tracts
Posterior- curved tracts
Exception: > 3cm curved
Fistula in Ano
Anterior - straight tracts
Posterior- curved tracts
Exception: > 3cm curved
Fistula in Ano
Fistula in Ano
COMPLICATED FISTULA IN
ANO
ANO
Anal FissureAnal Fissure
Anal fissure Anal fissure
Linear ulcer (anal canal) dentate to anusLinear ulcer (anal canal) dentate to anus
Symptoms of anal fissure Symptoms of anal fissure
Bleeding / anal pain during / after BMBleeding / anal pain during / after BM
Physical findings Physical findings
Split in anal canal, posterior midline,Split in anal canal, posterior midline,
sentinel pile, DRE extremely painfulsentinel pile, DRE extremely painful
Anal fissure Anal fissure
Linear ulcer (anal canal) dentate to anusLinear ulcer (anal canal) dentate to anus
Symptoms of anal fissure Symptoms of anal fissure
Bleeding / anal pain during / after BMBleeding / anal pain during / after BM
Physical findings Physical findings
Split in anal canal, posterior midline,Split in anal canal, posterior midline,
sentinel pile, DRE extremely painfulsentinel pile, DRE extremely painful
Fissure in AnoFissure in Ano
Anal Anal
FissureFissure
Treatment of acute anal fissure Treatment of acute anal fissure
High fiber diet, wheat bran, steroid High fiber diet, wheat bran, steroid
creamcream
Treatment of chronic anal fissure Treatment of chronic anal fissure
Lateral internal sphincterotomyLateral internal sphincterotomy
FissureFissure
Treatment of acute anal fissure Treatment of acute anal fissure
High fiber diet, wheat bran, steroid High fiber diet, wheat bran, steroid
creamcream
Treatment of chronic anal fissure Treatment of chronic anal fissure
Lateral internal sphincterotomyLateral internal sphincterotomy
Incidence of Cancer-PhilippinesIncidence of Cancer-Philippines
MaleMale
LungsLungs
LiverLiver
Colon/RectumColon/Rectum
StomachStomach
5. Prostate5. Prostate
FemaleFemale
BreastBreast
Cervix /UterusCervix /Uterus
Colon/ RectumColon/ Rectum
LungsLungs
ThyroidThyroid
OvaryOvary
LiverLiver
MaleMale
LungsLungs
LiverLiver
Colon/RectumColon/Rectum
StomachStomach
5. Prostate5. Prostate
FemaleFemale
BreastBreast
Cervix /UterusCervix /Uterus
Colon/ RectumColon/ Rectum
LungsLungs
ThyroidThyroid
OvaryOvary
LiverLiver
Colorectal CarcinomaColorectal Carcinoma
Colon CancerColon Cancer
3rd most common type /Filipino Male3rd most common type /Filipino Male
(11.5 per 100,000) (11.5 per 100,000)
Male : female ratio = 1.21Male : female ratio = 1.21
Incidence in the Philippines is Incidence in the Philippines is lower thanlower than those those
elsewhere with the exception of Thailandelsewhere with the exception of Thailand
Incidence among Incidence among Filipino migrantsFilipino migrants to the USA is to the USA is
higherhigher than than those observed in the Philippines those observed in the Philippines
Colon CancerColon Cancer
3rd most common type /Filipino Male3rd most common type /Filipino Male
(11.5 per 100,000) (11.5 per 100,000)
Male : female ratio = 1.21Male : female ratio = 1.21
Incidence in the Philippines is Incidence in the Philippines is lower thanlower than those those
elsewhere with the exception of Thailandelsewhere with the exception of Thailand
Incidence among Incidence among Filipino migrantsFilipino migrants to the USA is to the USA is
higherhigher than than those observed in the Philippines those observed in the Philippines
Colorectal CarcinomaColorectal Carcinoma
Colon Cancer- Colon Cancer- GlobalGlobal
Highest among western countriesHighest among western countries
15% of all malignancies15% of all malignancies
Age related- 7Age related- 7
thth
decade; <40y/o (5%) decade; <40y/o (5%)
Rectum(30%) Rectum(30%)
sigmoid(28%),cecum(13%),transverse sigmoid(28%),cecum(13%),transverse
(11%),ascending/descending(9%).(11%),ascending/descending(9%).
Calcium supplement- (RTC) protective.Calcium supplement- (RTC) protective.
Colon Cancer- Colon Cancer- GlobalGlobal
Highest among western countriesHighest among western countries
15% of all malignancies15% of all malignancies
Age related- 7Age related- 7
thth
decade; <40y/o (5%) decade; <40y/o (5%)
Rectum(30%) Rectum(30%)
sigmoid(28%),cecum(13%),transverse sigmoid(28%),cecum(13%),transverse
(11%),ascending/descending(9%).(11%),ascending/descending(9%).
Calcium supplement- (RTC) protective.Calcium supplement- (RTC) protective.
RISK FACTORSRISK FACTORS
Familial Adenomatous polyposisFamilial Adenomatous polyposis
Inflammatory bowel diseaseInflammatory bowel disease
Familial Cancer SyndromesFamilial Cancer Syndromes
Family HistoryFamily History
Adenomatous polypsAdenomatous polyps
DietDiet
Colorectal CarcinomaColorectal Carcinoma
Familial Adenomatous polyposisFamilial Adenomatous polyposis
Inflammatory bowel diseaseInflammatory bowel disease
Familial Cancer SyndromesFamilial Cancer Syndromes
Family HistoryFamily History
Adenomatous polypsAdenomatous polyps
DietDiet
Colorectal CarcinomaColorectal Carcinoma
Distribution of Cancer : Left side total = 81 %
narrowing
Modified Dukes’ Modified Dukes’
ClassificationClassification
Stage A- CA confined to wall of bowelStage A- CA confined to wall of bowel
Stage B- CA spread to pericolonic tissuesStage B- CA spread to pericolonic tissues
Stage C- Mets. present in lymph nodesStage C- Mets. present in lymph nodes
Stage D- Omental implant; peritoneal Stage D- Omental implant; peritoneal
seeding; metastasis beyond the confinesseeding; metastasis beyond the confines
of surgical resectionof surgical resection
ClassificationClassification
Stage A- CA confined to wall of bowelStage A- CA confined to wall of bowel
Stage B- CA spread to pericolonic tissuesStage B- CA spread to pericolonic tissues
Stage C- Mets. present in lymph nodesStage C- Mets. present in lymph nodes
Stage D- Omental implant; peritoneal Stage D- Omental implant; peritoneal
seeding; metastasis beyond the confinesseeding; metastasis beyond the confines
of surgical resectionof surgical resection
Colorectal CancerColorectal Cancer
Dukes' Classification / Survival(5 years)Dukes' Classification / Survival(5 years)
Dukes’ A 83 %Dukes’ A 83 %
B 57%B 57%
C 31 %C 31 %
D 0%D 0%
Dukes' Classification / Survival(5 years)Dukes' Classification / Survival(5 years)
Dukes’ A 83 %Dukes’ A 83 %
B 57%B 57%
C 31 %C 31 %
D 0%D 0%
Survival By TNMSurvival By TNM
Stage I T1-2NOMO,75-90%Stage I T1-2NOMO,75-90%
Stage II T3-4NOMO,54-65%Stage II T3-4NOMO,54-65%
Stage III anyTN1-3MO <50 Stage III anyTN1-3MO <50
Stage IV 0-5% Stage IV 0-5%
Stage I T1-2NOMO,75-90%Stage I T1-2NOMO,75-90%
Stage II T3-4NOMO,54-65%Stage II T3-4NOMO,54-65%
Stage III anyTN1-3MO <50 Stage III anyTN1-3MO <50
Stage IV 0-5% Stage IV 0-5%
Colorectal Cancer-ScreeningColorectal Cancer-Screening
FOBTFOBT
- low specificity, low sensitivity- low specificity, low sensitivity
- test repeated annually >50y/o- test repeated annually >50y/o
Flexible sigmoidoscopeFlexible sigmoidoscope
- repeat every 5 years,safe.- repeat every 5 years,safe.
DCBEDCBE
- sensitivity 50%-80%(<1cm polyps) , - sensitivity 50%-80%(<1cm polyps) ,
70-90%(>1cm); 55-85% Duke’s A & B. 70-90%(>1cm); 55-85% Duke’s A & B.
ColonoscopyColonoscopy
- cecum visualized in 98.6%- cecum visualized in 98.6%
FOBTFOBT
- low specificity, low sensitivity- low specificity, low sensitivity
- test repeated annually >50y/o- test repeated annually >50y/o
Flexible sigmoidoscopeFlexible sigmoidoscope
- repeat every 5 years,safe.- repeat every 5 years,safe.
DCBEDCBE
- sensitivity 50%-80%(<1cm polyps) , - sensitivity 50%-80%(<1cm polyps) ,
70-90%(>1cm); 55-85% Duke’s A & B. 70-90%(>1cm); 55-85% Duke’s A & B.
ColonoscopyColonoscopy
- cecum visualized in 98.6%- cecum visualized in 98.6%
Colorectal Cancer-ScreeningColorectal Cancer-Screening
Guidelines Common to Most Guidelines Common to Most
OrganizationsOrganizations::
50 years or more50 years or more
- Annual FOBT- Annual FOBT
- Flexible Sigmoidoscopy - Flexible Sigmoidoscopy
- DCBE q 6 years- DCBE q 6 years
Guidelines Common to Most Guidelines Common to Most
OrganizationsOrganizations::
50 years or more50 years or more
- Annual FOBT- Annual FOBT
- Flexible Sigmoidoscopy - Flexible Sigmoidoscopy
- DCBE q 6 years- DCBE q 6 years
Colorectal Cancer-ScreeningColorectal Cancer-Screening
Guidelines Common to Most Guidelines Common to Most
OrganizationsOrganizations::
11
stst
degree relative w/ cancer/adenoma degree relative w/ cancer/adenoma
- Flex Sig ,DCBE or colonoscopy q 5 - Flex Sig ,DCBE or colonoscopy q 5
years at 50 years oldyears at 50 years old
- relative Dx < 55 y/o, colonoscopy done at - relative Dx < 55 y/o, colonoscopy done at
5050
Guidelines Common to Most Guidelines Common to Most
OrganizationsOrganizations::
11
stst
degree relative w/ cancer/adenoma degree relative w/ cancer/adenoma
- Flex Sig ,DCBE or colonoscopy q 5 - Flex Sig ,DCBE or colonoscopy q 5
years at 50 years oldyears at 50 years old
- relative Dx < 55 y/o, colonoscopy done at - relative Dx < 55 y/o, colonoscopy done at
5050
Proctosigmoidosco
py
py
ColonoscopyColonoscopy
Screening for HNPCC* and FAP*Screening for HNPCC* and FAP*
Genetic consult Genetic consult
Annual colonoscopy from age 25Annual colonoscopy from age 25
* * Hereditary Non Polyposis Cancer/ColonHereditary Non Polyposis Cancer/Colon
(Lynch Syndrome I - 5 to 10 %)(Lynch Syndrome I - 5 to 10 %)
* Familial Adenomatous Polyposis* Familial Adenomatous Polyposis
Colorectal Carcinoma / ScreeningColorectal Carcinoma / Screening
Genetic consult Genetic consult
Annual colonoscopy from age 25Annual colonoscopy from age 25
* * Hereditary Non Polyposis Cancer/ColonHereditary Non Polyposis Cancer/Colon
(Lynch Syndrome I - 5 to 10 %)(Lynch Syndrome I - 5 to 10 %)
* Familial Adenomatous Polyposis* Familial Adenomatous Polyposis
Colorectal Carcinoma / ScreeningColorectal Carcinoma / Screening
Synchronous and Synchronous and
Metachronous CAMetachronous CA
Synchronous CarcinomaSynchronous Carcinoma - two or more - two or more
sites of cancer .sites of cancer .
Metachronous CarcinomaMetachronous Carcinoma - another - another
cancer found two or more years aftercancer found two or more years after
Metachronous CAMetachronous CA
Synchronous CarcinomaSynchronous Carcinoma - two or more - two or more
sites of cancer .sites of cancer .
Metachronous CarcinomaMetachronous Carcinoma - another - another
cancer found two or more years aftercancer found two or more years after
Colorectal Colorectal CA-ClinicalCA-Clinical PresentationPresentation
Rectal bleedingRectal bleeding
Change/bowel habits Change/bowel habits
Tenesmus / fatigueTenesmus / fatigue
Rectal bleedingRectal bleeding
Change/bowel habits Change/bowel habits
Tenesmus / fatigueTenesmus / fatigue
Colorectal CA Clinical PresentationColorectal CA Clinical Presentation
Persistent narrowing of stoolsPersistent narrowing of stools
Feeling / incomplete emptying Feeling / incomplete emptying
after b.m.after b.m.
Unexplained weight loss/AnemiaUnexplained weight loss/Anemia
Persistent narrowing of stoolsPersistent narrowing of stools
Feeling / incomplete emptying Feeling / incomplete emptying
after b.m.after b.m.
Unexplained weight loss/AnemiaUnexplained weight loss/Anemia
An elderly woman is admitted with weaknessAn elderly woman is admitted with weakness
anemia, anemia, weight loss, and a palpableweight loss, and a palpable abdominal abdominal
mass. She has colonic carcinoma. The mostmass. She has colonic carcinoma. The most
likely anatomic site would be:likely anatomic site would be:
A. RectumA. Rectum
B. Sigmoid colonB. Sigmoid colon
C. Left colonC. Left colon
D. Transverse colonD. Transverse colon
E. CecumE. Cecum
anemia, anemia, weight loss, and a palpableweight loss, and a palpable abdominal abdominal
mass. She has colonic carcinoma. The mostmass. She has colonic carcinoma. The most
likely anatomic site would be:likely anatomic site would be:
A. RectumA. Rectum
B. Sigmoid colonB. Sigmoid colon
C. Left colonC. Left colon
D. Transverse colonD. Transverse colon
E. CecumE. Cecum
RECTALRECTAL CANCERCANCER
Rectal bleedingRectal bleeding( bright red)( bright red)
Altered bowel habits( incomplete Altered bowel habits( incomplete
evacuation and unproductiveevacuation and unproductive
urge to defecate)urge to defecate)
Rectal massRectal mass
Rectal bleedingRectal bleeding( bright red)( bright red)
Altered bowel habits( incomplete Altered bowel habits( incomplete
evacuation and unproductiveevacuation and unproductive
urge to defecate)urge to defecate)
Rectal massRectal mass
TNM Staging of TNM Staging of
Colorectal CancerColorectal Cancer
Definition of TNMDefinition of TNM
Primary Tumor (T)Primary Tumor (T)
Tx Cannot be assessedTx Cannot be assessed
Tis Carcinoma in situTis Carcinoma in situ
T1 Tumor invades submucosaT1 Tumor invades submucosa
T2 Tumor invades Muscularis propiaT2 Tumor invades Muscularis propia
T3 thru muscularis propia to serosaT3 thru muscularis propia to serosa
T4 directly invades other organsT4 directly invades other organs
or perforatesor perforates
Colorectal CancerColorectal Cancer
Definition of TNMDefinition of TNM
Primary Tumor (T)Primary Tumor (T)
Tx Cannot be assessedTx Cannot be assessed
Tis Carcinoma in situTis Carcinoma in situ
T1 Tumor invades submucosaT1 Tumor invades submucosa
T2 Tumor invades Muscularis propiaT2 Tumor invades Muscularis propia
T3 thru muscularis propia to serosaT3 thru muscularis propia to serosa
T4 directly invades other organsT4 directly invades other organs
or perforatesor perforates
Regional Lymph Nodes(N)Regional Lymph Nodes(N)
NX cannot be assessedNX cannot be assessed
NO no lymph node metastasisNO no lymph node metastasis
N1 Metastasis in one to three N1 Metastasis in one to three
N2 Metastasis in four or moreN2 Metastasis in four or more
N3 any lymph node along namedN3 any lymph node along named
vascular trunkvascular trunk
NX cannot be assessedNX cannot be assessed
NO no lymph node metastasisNO no lymph node metastasis
N1 Metastasis in one to three N1 Metastasis in one to three
N2 Metastasis in four or moreN2 Metastasis in four or more
N3 any lymph node along namedN3 any lymph node along named
vascular trunkvascular trunk
Distant Metastasis ( M )Distant Metastasis ( M )
MX Cannot be assessedMX Cannot be assessed
MO No distant metastasisMO No distant metastasis
M1 Distant MetastasisM1 Distant Metastasis
MX Cannot be assessedMX Cannot be assessed
MO No distant metastasisMO No distant metastasis
M1 Distant MetastasisM1 Distant Metastasis
Colorectal CancerColorectal Cancer
Stage Groupings (TNM)Stage Groupings (TNM)
Stage O T1sNOMO N/AStage O T1sNOMO N/A
I T1NOMO Stage AI T1NOMO Stage A
T2NOMO Stage B1T2NOMO Stage B1
II T3NOMO Stage B2II T3NOMO Stage B2
T4NOMO Stage B3T4NOMO Stage B3
III Any TN1MO Stage CIII Any TN1MO Stage C
IV Any T AnyNM1 StageIV Any T AnyNM1 Stage DD
Stage Groupings (TNM)Stage Groupings (TNM)
Stage O T1sNOMO N/AStage O T1sNOMO N/A
I T1NOMO Stage AI T1NOMO Stage A
T2NOMO Stage B1T2NOMO Stage B1
II T3NOMO Stage B2II T3NOMO Stage B2
T4NOMO Stage B3T4NOMO Stage B3
III Any TN1MO Stage CIII Any TN1MO Stage C
IV Any T AnyNM1 StageIV Any T AnyNM1 Stage DD
Colorectal CancerColorectal Cancer
Stage II – High Risk GroupStage II – High Risk Group
- tumor fixation- tumor fixation
- tumor perforation- tumor perforation
- complete obstruction- complete obstruction
- poor histologic grades- poor histologic grades
Stage II – High Risk GroupStage II – High Risk Group
- tumor fixation- tumor fixation
- tumor perforation- tumor perforation
- complete obstruction- complete obstruction
- poor histologic grades- poor histologic grades
CEA
• for prognostication
• not for diagnosis or screening
• rising titer postop indicates
recurrence
• for prognostication
• not for diagnosis or screening
• rising titer postop indicates
recurrence
Is there any role for surgery in patients
with liver metastasis?
In highly selected patients with less than
four metastasis and
no evidence of any other disease ( no local
recurrence or further metastasis )
with liver metastasis?
In highly selected patients with less than
four metastasis and
no evidence of any other disease ( no local
recurrence or further metastasis )
• 5 year survival is 25 to 30 % in patients
who undergo a successful resection
• 100 % of patients die within 2 years with
untreated liver metastasis
who undergo a successful resection
• 100 % of patients die within 2 years with
untreated liver metastasis
Colostomy
Squamous typeSquamous type
TreatmentTreatment
Nigro ProtocolNigro Protocol
5FU chemotherapy5FU chemotherapy
RadiotherapyRadiotherapy
ANAL CANCERANAL CANCER
TreatmentTreatment
Nigro ProtocolNigro Protocol
5FU chemotherapy5FU chemotherapy
RadiotherapyRadiotherapy
ANAL CANCERANAL CANCER
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