Colon, Rectum, Colon, Rectum, and Anusand Anus

Chapter 15Chapter 15

IntroductionIntroduction

AnatomyAnatomy Diverticular DiseaseDiverticular Disease Polyps and CarcinomaPolyps and Carcinoma Ulcerative Colitis and Crohn’s DiseaseUlcerative Colitis and Crohn’s Disease Colonic ObstructionColonic Obstruction HemorrhoidsHemorrhoids Perianal infectionsPerianal infections Anal malignancyAnal malignancy

AnatomyAnatomy

Diverticular DiseaseDiverticular Disease

Common colonic diverticula are false Common colonic diverticula are false diverticuladiverticula Only consist of mucosa and submucosa that Only consist of mucosa and submucosa that

protrude through the colonic wallprotrude through the colonic wall Occur on the mesenteric side of the colon Occur on the mesenteric side of the colon

where the arterioles penetrate the where the arterioles penetrate the muscularis muscularis

Incidence increases with ageIncidence increases with age < 30 y/o - < 2% incidence< 30 y/o - < 2% incidence >80 y/o - >75% incidence>80 y/o - >75% incidence

Complications of Complications of Diverticular DiseaseDiverticular Disease

InfectionInfection Generalized peritonitisGeneralized peritonitis Diverticular abscessDiverticular abscess FistulaFistula BleedingBleeding

Diverticular InfectionDiverticular Infection Presentation: left lower quadrant pain, Presentation: left lower quadrant pain,

fever, localized tenderness, elevated wbcfever, localized tenderness, elevated wbc Diagnosis – CT scan, U/SDiagnosis – CT scan, U/S Tx – tailored to Sx severityTx – tailored to Sx severity

Mild –outpt tx. Clear liquid diet, po AbxMild –outpt tx. Clear liquid diet, po Abx Severe – inpt tx. Bowel rest, IVF, IV AbxSevere – inpt tx. Bowel rest, IVF, IV Abx

Recurrence – 30% after 1Recurrence – 30% after 1stst episode, episode, >50% after 2>50% after 2ndnd. Resection recommended . Resection recommended after 2after 2ndnd episode episode

Resection margin – to noninflammed Resection margin – to noninflammed bowelbowel

Generalized PeritonitisGeneralized Peritonitis

Results from perforation with Results from perforation with widespread fecal contaminationwidespread fecal contamination

Presentation – diffuse severe Presentation – diffuse severe abdominal pain and peritonitis abdominal pain and peritonitis

Tx – Emergent laparotomy and Tx – Emergent laparotomy and Hartmann’s procedure is performed Hartmann’s procedure is performed most commonly. Reconstruction of most commonly. Reconstruction of GI continuity 2 months laterGI continuity 2 months later

Diverticular AbscessDiverticular Abscess

Dx – CT scanDx – CT scan Tx – Percutaneous drainage under Tx – Percutaneous drainage under

CT guidanceCT guidance Surgery – if percutaneous drainage Surgery – if percutaneous drainage

is satisfactory, can wait for infection is satisfactory, can wait for infection to clear and perform a one-stage to clear and perform a one-stage resection (instead of a 2 stage i.e. resection (instead of a 2 stage i.e. Hartmann’s)Hartmann’s)

Diverticular FistulaDiverticular Fistula

Colovesicular – most common in menColovesicular – most common in men Pneumaturia or fecaluriaPneumaturia or fecaluria UTIs UTIs CT scan – shows air in the bladderCT scan – shows air in the bladder

Colovaginal – most common in womenColovaginal – most common in women ColocutaneousColocutaneous EnterocolicEnterocolic Tx – Several weeks of Abx, resectionTx – Several weeks of Abx, resection

Diverticular BleedingDiverticular Bleeding

From penetrating artery in dome of From penetrating artery in dome of diverticulumdiverticulum

BRBPRBRBPR Not associated with previous melenaNot associated with previous melena Resection of affected bowelResection of affected bowel

Polyps and CarcinomaPolyps and Carcinoma

Polyp TypesPolyp Types Tubular - PedunculatedTubular - Pedunculated Tubulovillous - PedunculatedTubulovillous - Pedunculated Villous - SessileVillous - Sessile HamartomaHamartoma Inflammatory - IBDInflammatory - IBD HyperplasticHyperplastic

May be premalignant

PolypsPolyps

PresentationPresentation Usually asymptomaticUsually asymptomatic May bleedMay bleed Detected during routine colonoscopyDetected during routine colonoscopy

TreatmentTreatment Pedunculated – snared and removed Pedunculated – snared and removed

endoscopicallyendoscopically Villous – may be removed endoscopically if smallVillous – may be removed endoscopically if small Villous – if >1.5 cm Bx, then do segmental Villous – if >1.5 cm Bx, then do segmental

resectionresection

Colon CancerColon Cancer

Common presenting symptomsCommon presenting symptoms Weight lossWeight loss MassMass Rectal bleedingRectal bleeding Virchow’s nodeVirchow’s node Blumer’s shelfBlumer’s shelf AnemiaAnemia ObstructionObstruction

Dukes Staging of Colon Dukes Staging of Colon CACA

STAGSTAGEE

DESCRIPTIONDESCRIPTION5 YR 5 YR

SURVIVAL SURVIVAL (%)(%)

AA Mucosa onlyMucosa only 85-9085-90

B1B1 Into, not through, Into, not through, Propria N(-)Propria N(-) 70-7570-75

B2B2 Through Propria N(-)Through Propria N(-) 60-6560-65

C1C1 B1 with N(+)B1 with N(+) 30-3530-35

C2C2 B2 with N(+)B2 with N(+) 2525

DD Distant metsDistant mets <5<5

Ulcerative ColitisUlcerative Colitis

MucosalMucosal inflammatory process of inflammatory process of the colon with sx of bloody the colon with sx of bloody diarrhea and tenesmusdiarrhea and tenesmus

Initially – mucosal ulcers and Initially – mucosal ulcers and crypt abscessescrypt abscesses

Later – mucosal edema and Later – mucosal edema and pseudopolypspseudopolyps

Crohn’s DiseaseCrohn’s Disease

TransmuralTransmural inflammatory process inflammatory process most commonly of the distal ileum, most commonly of the distal ileum, can involve any area of the GI tractcan involve any area of the GI tract

Slight female predominanceSlight female predominance Gross appearance of bowel: Gross appearance of bowel:

Creeping fat, wall thickeningCreeping fat, wall thickening

Crohn’s DiseaseCrohn’s Disease

Common path changesCommon path changes fissures and fistulasfissures and fistulas Transmural inflammationTransmural inflammation GranulomasGranulomas Discontinuous distributionDiscontinuous distribution Aphthoid ulcersAphthoid ulcers

Colonic ObstructionColonic Obstruction EtiologiesEtiologies

Most CommonMost Common Adenocarcinoma (65%)Adenocarcinoma (65%) Diverticulitis (20%)Diverticulitis (20%) Volvulus (5%)Volvulus (5%)

OtherOther Inflammatory diseaseInflammatory disease Benign tumorsBenign tumors Foreign bodiesForeign bodies Fecal impactionFecal impaction

ObstructionObstruction

PresentationPresentation DistensionDistension Cramping abdominal painCramping abdominal pain N/VN/V ObstipationObstipation

X-ray findingsX-ray findings Distended colonDistended colon Air-fluid levelsAir-fluid levels No rectal airNo rectal air

ObstructionObstruction

Physical ExamPhysical Exam DistentionDistention TympanyTympany High pitched or tinkling bowel soundsHigh pitched or tinkling bowel sounds May feel massMay feel mass

ObstructionObstruction

Complete vs. incomplete bowel Complete vs. incomplete bowel obstructionobstruction

Important b/c if complete – requires Important b/c if complete – requires emergent operationemergent operation

Cecal diameter of >10-12 cm needs Cecal diameter of >10-12 cm needs some form of decompressionsome form of decompression

Partial obstruction – drip and suckPartial obstruction – drip and suck

ObstructionObstruction

TreatmentTreatment IVFIVF NGTNGT Observation vs. definitive therapyObservation vs. definitive therapy

ObstructionObstruction

Indications for emergent laparotomyIndications for emergent laparotomy Cecal distention > 12 cmCecal distention > 12 cm Generalized sepsisGeneralized sepsis Acute abdomen – signs of Acute abdomen – signs of

perforation/peritonitisperforation/peritonitis

ObstructionObstruction

VolvulusVolvulus Rotation of a segment of intestine on the Rotation of a segment of intestine on the

mesenterymesentery Sigmoid Colon – 70%Sigmoid Colon – 70% Cecum – 30%Cecum – 30% Accounts for 5-10% of colonic obstructionAccounts for 5-10% of colonic obstruction Second most common cause of complete Second most common cause of complete

obstructionobstruction Ischemia leads to Ischemia leads to

gangrene/infection/perforationgangrene/infection/perforation

ObstructionObstruction

Presentation of VolvulusPresentation of Volvulus Similar to other obstruction causesSimilar to other obstruction causes X-Rays – Classic coffee bean signX-Rays – Classic coffee bean sign

Treatment of VolvulusTreatment of Volvulus Sigmoidoscopy with rectal tube Sigmoidoscopy with rectal tube

insertion to decompress sigmoidinsertion to decompress sigmoid Elective sigmoidectomy when pt is Elective sigmoidectomy when pt is

recoveredrecovered Emergent laparotomy if signs of bowel Emergent laparotomy if signs of bowel

ischemia/perforation are presentischemia/perforation are present

HemorrhoidsHemorrhoids

Definition: 3 vascular and connective Definition: 3 vascular and connective tissue cushions in the anal canal, R tissue cushions in the anal canal, R anterolateral, R posteriolateral and L anterolateral, R posteriolateral and L laterallateral

Internal hemorrhoids – above the dentate Internal hemorrhoids – above the dentate lineline May bleed and prolapse, Do Not cause painMay bleed and prolapse, Do Not cause pain

External hemorrhoids – below the dentate External hemorrhoids – below the dentate lineline May thrombose causing pain and itchingMay thrombose causing pain and itching

Hemorrhoid GradesHemorrhoid Grades

First degree – bleed onlyFirst degree – bleed only Second degree – bleed and prolapse Second degree – bleed and prolapse

but reduce spontaneouslybut reduce spontaneously Third degree – bleed, prolapse and Third degree – bleed, prolapse and

require manual reductionrequire manual reduction Fourth degree – bleed and are Fourth degree – bleed and are

incarceratedincarcerated

Hemorrhoid TreatmentHemorrhoid Treatment

Medical for 1Medical for 1stst and 2 and 2ndnd degree degree Stool softeners, increased dietary fiber, etcStool softeners, increased dietary fiber, etc

Surgical for refractory 3Surgical for refractory 3rdrd and 4 and 4thth degreedegree I&D/BandingI&D/Banding Excisional hemorrhoidectomyExcisional hemorrhoidectomy

Complications: Complications: 10-50% incidence of urinary 10-50% incidence of urinary

retention, bleeding, infection, retention, bleeding, infection, sphincter injury and anal stenosissphincter injury and anal stenosis

Perianal InfectionsPerianal Infections Cryptoglandular abscessCryptoglandular abscess – in the – in the

intrasphincteric space. Dx – fluctuant intrasphincteric space. Dx – fluctuant mass. Tx – I&Dmass. Tx – I&D

Necrotising anorectal infection Necrotising anorectal infection (Fournier’s gangrene)(Fournier’s gangrene) – Dx – systemic – Dx – systemic signs of infection and perianal pain. signs of infection and perianal pain. Immediate wide surgical debridement. Immediate wide surgical debridement. 50% mortality50% mortality

Fistula in anoFistula in ano – Goodsall’s rule: posterior – Goodsall’s rule: posterior fistulas open to posterior midline, fistulas open to posterior midline, anterior fistulas penetrate in a radial anterior fistulas penetrate in a radial direction toward the dentate linedirection toward the dentate line

Anal MalignancyAnal Malignancy

Squamous cell CA – wide local Squamous cell CA – wide local excision with chemo/rads tx if largeexcision with chemo/rads tx if large

Epidermoid CAs – Nigro protocol Epidermoid CAs – Nigro protocol (Chemo/rad), then surgical treatment (Chemo/rad), then surgical treatment reserved for local recurrencereserved for local recurrence

AdenoCA – usually an extention of AdenoCA – usually an extention of rectal CA, poor prognosisrectal CA, poor prognosis

Melanoma 1-3% of anal CA. Wide Melanoma 1-3% of anal CA. Wide local excision. 5 yr survival <20%local excision. 5 yr survival <20%