Rev CT Scan Station-Polyp Recti-Ria, Ayu, Zul, Ita-22102025.pptx

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1. CT Scan Station SPV In Charge: dr. Siswidiyati , Sp. Rad SPV Advisor: dr. Achmad Bayhaqi Nasir A., Sp. Rad (K) Resident: dr. Ria - dr. Ayu - dr. Zul - dr. Ita

2. Patient’s Identity History Taking The patient has had a lump in the rectum for approximately the last 4 years, recurrent bloody stools, and weight loss. Currently, the stools are still bloody, and the lump is getting bigger. The patient has not yet started any treatment or undergone any procedures. Mr . SH/ 58 y.o / 12045011 Hematochezia susp. ca rectum CTS Abdomen with c ontrast

3. Laboratory Findings 16/10/2025

4. Working Diagnosis Hematochezia susp. Rectum carcinoma Clinical Question Is there any other abnormalities or lesion? What to look for imaging The other abnormalities or lesion

5. Conclusions Solid endophytic mass with frond-like appearance in the distal rectal intralumen with fluid retention around it suggestive of Colorectal villous polyps Multiple presacral and bilateral parailiac lymphadenopathy Multiple liver cysts Lumbar spondylosis

6. Thank You

7. Theory

8. Anatomy

9. POLIP COLON Faktor resiko: - Usia>50 thn - Penyakit radang usus kronik🡪Chron disease - Obesitas - Riwayat keluarga - Merokok dan alcohol - Diet tinggi lemak - Kurangnya aktivitas Fisik Abdullah, M. Pendekatan Terkini Polip Kolon. Buku Ajar Ilmu Penyakit Dalam VI. InternaPublishing. Jakarta. 2017:263-70. G ambaran Klinis : Umumnya asimtomatis Perdarahan rektum 🡪 gejala paling sering Diare, konstipasi atau perubahan pola defekasi Nyeri atau obstruksi Perdarahan samar pada feses yang diperiksa dengan tes darah samar Pemeriksaan fisik dan laboratorium 🡪 Tidak ada yang spesifik 🡪 diperlukan RT jika terjadi perdarahan saluran cerna bagian bawah RT 🡪 teraba polip Definisi : Polip 🡪 Massa atau jaringan dari mukosa normal yang menonjol ke dalam lumen terlepas apapun gambaran histopatologinya. Polip Colon 🡪 Tonjolan dari mukosa kolon ke arah lumen .

10. POLIP COLON https://doi.org/10.53347/rID-36561 Keunggulan utama: selain mendeteksi, kolonoskopi juga memungkinkan tindakan intervensi langsung untuk mengangkat polip saat prosedur berlangsung. Kolonoskopi Dianjurkan dilakukan setiap 3-5 tahun sebagai lanjutan dari FOBT rutin untuk skrining kanker kolon Hanya memeriksa bagian colon sigmoid dan rectum saja, tidak memvisualisasi seluruh kolon Sigmoidoskopi fleksibel Dahulu merupakan modalitas utama untuk deteksi polip. Biasanya digunakan double contrast untuk meningkatkan sensitivitas. Sensitivitas dan spesifisitasnya rendah : hanya sekitar 50% polip berukuran >1 cm yang terlihat pada barium enema jika dibandingkan dengan kolonoskopi. Barium Enema Saat ini semakin banyak digunakan karena bersifat non-invasif dan memiliki akurasi lebih baik daripada barium enema. Dapat mendeteksi polip besar dan juga kelainan ekstra-kolonik. CT - Colonography

11. Etiology of Colon Polyps 1. Genetic Factors Gene Mutations : Mutations in tumor suppressor genes (e.g., APC, TP53) and oncogenes (e.g., KRAS) can lead to uncontrolled cell growth. Familial Syndromes :: Familial Adenomatous Polyposis (FAP) – Mutation in APC gene , leading to numerous polyps., Lynch Syndrome (HNPCC) – Defects in DNA mismatch repair genes, increasing cancer risk., MUTYH-Associated Polyposis (MAP) – Caused by MUTYH gene mutations , leading to adenomatous polyps. 2. Inflammatory Conditions Chronic Inflammation : Conditions like ulcerative colitis and Crohn’s disease increase polyp formation and cancer risk. Post-Inflammatory Regeneration : Repeated injury and repair processes can lead to abnormal growths. 3. Diet & Lifestyle Factors High-Fat, Low-Fiber Diet : Excessive red meat and processed food intake may promote polyp formation. Obesity : Associated with insulin resistance and chronic inflammation, increasing risk. Smoking & Alcohol Consumption : Linked to DNA damage and cellular mutations. Physical Inactivity : Slows digestion, leading to prolonged exposure to harmful substances. 4. Age & Hormonal Factors Aging : Risk increases with age, especially after 50 years old . Hormonal Changes : Estrogen levels in postmenopausal women may play a role in polyp development. 5. Microbiome & Gut Health Dysbiosis : An imbalance in gut bacteria may contribute to inflammation and abnormal cell proliferation. 6. Environmental & Chemical Exposure Toxin Exposure : Long-term exposure to certain carcinogens, pesticides, and industrial chemicals may increase polyp risk

12. Colon polyps  Pathology adenomatous colon polyps tubular polyp tubulovillous polyp villous colon polyp dysplastic colon polyp hamartomatous colon polyp serrated colonic polyps  / colorectal serrated polyps: pathologically diverse group of lesions that can include hyperplastic colon polyp traditional serrated adenoma  (TSA) sessile serrated polyp  (SSP) inflammatory colon polyp lymphoid colon polyp Adenomatous colon polyps are thought to progress histologically from adenoma to dysplasia, to carcinoma; thus screening detection of precancerous polyps is considered useful. The individual risk for a polyp progressing to cancer is low, in the order of 3% and it is thought that it takes 10-15 years for a polyp to devolve into carcinoma.

13. Air –Double Contrast Barium Enema Sesille polyps Dependent wall : radiolucent filling defect Non dependent wall : ring shadow with barium-coated white rim Bowler hat sign : brim and dome of hat represent base and head of polyp, with dome of hat pointing toward lumen of bowel (en face view) Pedunculated polyps Mexican hat sign : pair of concentric rings with outer and inner rings reprensenting head and stalk og polyp Carpet lession : tiny, coalescent nodules and plaques create a finely nodular or reticular pattern

14. PEDUNCULATED POLYPS🡪MEXICAN HAT SIGN SMALL SESSILE POLYPS 🡪TUBULOVILLOUS ADENOMA LARGE SESSILE POLYPS 🡪VILLOUS ADENOMA

15. Villous Polyp Colorectal villous polyps  refer to villous adenomas of the  large intestine . They are most commonly found in the  rectum  and are the least common of all types of  colon polyps . Epidemiologi Villous adenoma merupakan lesi pramaligna dan mencakup sekitar 10% dari seluruh adenoma kolon . Insidensinya seimbang pada laki-laki dan perempuan . Paling sering ditemukan pada individu usia 50–80 tahun , menjadikannya lesi yang khas pada populasi usia lanjut. Asal dan Karakteristik Histologis Berasal dari epitel permukaan mukosa kolon . Tersusun dari struktur papiler (papillary fronds) yang dilapisi oleh epitel kolumnar penghasil mukus . Memiliki inti fibro-vaskular tipis (slender fibrovascular cores) pada tiap frond. Konfigurasi villous menghasilkan peningkatan luas permukaan epitel dibandingkan dengan mukosa normal, mendukung peningkatan potensi proliferatif. Villous adenoma didefinisikan oleh ≥10 lobulus villous . Lesi ini memiliki potensi tertinggi untuk transformasi ganas dibanding adenoma lainnya.

16. Radiographic Features Fluoroscopy On  barium  examinations, villous adenomas have been described as having broad bases as well as a polypoid surface that projects into the lumen with barium that travels between the clefts of the projections. When they are "carpet" lesions they may present as flat, spreading, lobulated lesions which produce subtle filling defects in the column  1 . 11.5 × 6.0 cm villous adenoma of cecum (cecal malrotation) in 77-year-old man. Image obtained using barium enema shows lesion as large irregular filling defect ( arrows ) in malrotated cecum. 4.0 × 4.0 cm villous adenoma in 83-year-old woman. Image obtained using barium enema showing lesion ( arrow ).

17. CT  and  CT colonography  may reveal the following features  3 : large lesions 2-3 cm or larger in size cerebriform or frondlike appearance , less commonly as "carpet" lesions which are relatively flat and lobulated in their appearance presence of surrounding fluid luminal expansion occasionally associated   intussusception  or obstruction Evaluation of the images in both 2D and 3D formats in both the polyp and soft tissue windows is important. One view should also be obtained with the rectal balloon deflated so as to not disguise "carpet" lesions in the rectum. In a properly prepared bowel along with CO 2  distension , the detection of villous adenomas is similar to that of optical colonoscopy  2 . However, undistended or unprepared bowel may only show large adenomas and cancers, with smaller lesions being more likely to be missed  3 .

18. 11.5 × 6.0 cm villous adenoma of cecum (cecal malrotation) in 77-year-old man. Note enhancing convolutional pattern ( arrows ) visualized in capillary phase of CT scan. Variegated gyral pattern ( arrows ) in capillary phase of CT scan. Low-attenuation areas in lesion ranged from 15-17 H.

19. Polypoid lesion ( large arrow ) visible on CT scan with lumen collapsed around it. Mass has oral contrast in its interstices producing corrugated pattern. Unusual cluster of mesenteric vessels ( small arrows ) is adjacent to lesion. CT scan reveals contiguous section 7 mm superior to  A . Lesion is filling defect ( black arrows ) within opacified lumen. Prominent vessel ( white arrows ) is in continuity with cluster of mesenteric vessels in  A .

20. MRI On MR imaging villous adenomas have the following appearances  3 : T1: low signal intensity vegetating shape polycyclic margins may appear less commonly as flat T2: thick hyperintense layer along the surface of the lesion heterogenous intermediate to high signal intensity inside the lesion may have a thin central area of enhancement representing a central vascular stalk

21. Villous adenoma of the rectum; Sag T2 Axial T2 Coronal T2 Axial T1 C + Fat sat The appearance is consistent with an unusually large carpet-like rectal villous adenoma. Certainly an element of carcinoma may well co-exist. 

22. Differential Diagnose Diagnosis Gambaran Radiologi Utama Perbedaan dari Villous Polyp Tubular adenoma (pedunculated polyp) Stalked lesion, homogeneous round shape, more uniform enhancement Does not have a villous/frond surface. Usually smaller and more regular. Sessile Serrated Adenoma / Hyperplastic Polyp Flat or sessile lesion with smooth edges, sometimes covered with a mucus cap (hypodense) Does not show frond structure or villous-like segmentation Inflammatory pseudopolyp (IBD related) Multiple, irregular lesions, often in the colon with haustral loss and wall thickening Seen in chronic colitis settings, not solitary lesions Colorectal carcinoma (superficial) Segmental or focal wall thickening with ulceration, 'shouldering sign' Villus polyps can be difficult to distinguish if they have undergone malignant transformation – the presence of submucosal invasion or hard nodularity points to cancer.

23. A 52-year-old male patient who underwent screening CT colonography was shown to have a pedunculated polyp with the polyp head Pedunculated polyp

24. Sessile serrated adenoma A 77-year-old male patient presented for CT colonography following an incomplete colonoscopy for an obstructing sigmoid colonic mass. An 8-mm sessile polyp (arrow) is identified in the proximal sigmoid colon on the (A) three-dimensional endoluminal view, (B) axial prone view, and (C) axial supine view. Note that the polyp has a broad base without a neck or stalk.

25. Inflammatory Pseudopolyp An  inflammatory pseudopolyp  is an island of normal colonic mucosa which only appears raised because it is surrounded by atrophic tissue (denuded ulcerative mucosa). It is seen in long-standing  ulcerative colitis . It must be distinguished from  inflammatory polyps , which are regions of inflamed and elevated mucosa surrounded by granular mucosa.

26. Colorectal carcinoma Axial thin-section (2.5 mm) MDCT scan of the rectum in the arterial phase and with rectal administration of water demonstrates focal thickening of the anterior and right lateral rectal wall (  long arrows  ). The outer margin of the rectum is smooth and well preserved. The rectal tube also is seen (  arrowhead  ). Rectal carcinoma with microextension into perirectal fat, T3N0M0. The wall of the distal sigmoid colon is circumferentially thickened as a result of a concentric adenocarcinoma, and its outer margins are smooth. No adenopathy or invasion of fat is demonstrated

27. A.  There is a small sessile polyp (  arrow  ) behind a fold at the rectosigmoid junction. B.  A small polyp (  arrow  ) is situated behind a fold at an area of angulation at the junction of the sigmoid and the descending colon. C. Polypoid carcinoma is just proximal to the rectosigmoid junction. This lesion was missed on several sigmoidoscopic and colonoscopic examinations and was confirmed only at surgery.  D. Polypoid carcinoma at the hepatic flexure

28. Treatment and prognosis The risk of malignancy of a colon polyp varies with its size <5 mm: <1% risk of cancer 5-9 mm: <1-2% chance of cancer 10-20 mm: ~10% chance of cancer >20 mm: 40-50% chance of cancer Other features may indicate that a polyp is higher risk ≥3 adenomas high-grade dysplasia villous features

29. The risk of malignancy of a colon polyp varies with its size <5 mm: <1% risk of cancer 5-9 mm: <1-2% chance of cancer 10-20 mm: ~10% chance of cancer >20 mm: 40-50% chance of cancer

30. Polyposis syndromes The presence of a systemic process that promotes the development of multiple gastro-intestinal polyps is termed ‘polyposis’ . Hereditary gastro-intestinal polyposis syndromes account for approximately 1% of all cases of colorectal cancer and are associated with a broad spectrum of extra-colonic tumors Intestinal polyposis syndromes can be divided into the broad categories of familial adenomatous polyposis (like Gardner syndrome), hamartomatous polyposis syndromes (like Peutz-Jeghers syndrome) and other rare polyposis syndromes. Patients with these syndromes often have multiple small bowel polyps. Larger polyps can become malignant and can mimic primary small bowel neoplasms.