colon diseases
DESCRIPTION
Colon Diseases. Dr. Rezvan Mirzaei. Clinical Evaluation. Symptoms Abdominal Pain Rectal Bleeding, Anemia Bowel Habit Change Weight Loss Mucus Discharge Constipation & Diarrhea Incontinence. History. Medical Surgical Obstetric Family: Polyp, Colorectal Ca, Other Cancers. P/E. - PowerPoint PPT PresentationTRANSCRIPT
Colon Diseases
Colon DiseasesDr. Rezvan MirzaeiClinical EvaluationSymptoms Abdominal PainRectal Bleeding, AnemiaBowel Habit ChangeWeight LossMucus DischargeConstipation & DiarrheaIncontinenceHistoryMedical
Surgical
Obstetric
Family: Polyp, Colorectal Ca, Other Cancers
P/EAbdominal
Perineal
DRE
EndoscopyAnoscopy: 8 cm
Rigid Proctoscopy: 25 cm, Partial Bowel Prep
Colonoscopy: 160 cm, complete oral bowel prep
Laboratory studiesFecal Occult Blood
Stool Studies
Tumor Markers
Genetic Testing
ImagingPlain X-RayContrast StudyCTVirtual ColonoscopyMRIPositron Emission Tomography (PET)Endorectal & Endoanal UltrasoundColon Transit Time (CTT)
Plain X-ray, Hirschprung
CTT
20
Intrarectal Sono-Ca
Diverticular DiseaseFalse Diverticula
Mucosa & Muscularis Mucosa herniation through the colonic wall
Between the taeniae coli where the main blood vessels penetrate the colonic wall
Pulsion Diverticula: resulting from high intraluminal pressure
Diverticular DiseaseDiverticular Disease = Symptomatic Diverticula
Diverticulosis = Diverticula without inflammation
Diverticulitis = Diverticula with inflammation & infection
Barium Enema - Diverticulosis
Diverticular DiseaseMost common site: Sigmoid
Acquired
Low Fiber Diet => Smaller stool volume =>High intraluminal pressure & high colonic wall tension for propulsion
Diverticular DiseaseComplications
Bleeding
Inflammation
Adeno carcinoma Most common malignancy of GI
- Risk factors - Age > 50 - Family hx of colorectal CA (20%) - Diet (High animal Fat-Low fiber) - Alcohol, Smoking - ObesityRisk FactorsIBD: Chronic inflammation predisposes the mucosa to malignant changes(duration & extent of colitis, Primary sclerosing cholangitis)Ulcerative & Crohns Pancolitis 2% after 10 years 8% after 20 years 18 % after 30 yearsIrradiationUreterosigmoidostomyAcromegaly
Symptoms- Change in bowel habit
Rectal bleeding
Unexplained anemia
Weight loss
PolypsAny projection from the surface of the intestinal mucosa
Neoplastic (Tubular, Villous, Tubulovillous, Serrated Polyps)
Hamartomatous (Juvenile, Peutz-jeghers)
Inflmmatory (Pseudopolyp, Benign lymphoid)
Hyper plastic
Pedunculated, Sessile
Adenoma-Carcinoma sequenceRisk of malignant degeneration is related to size & type of polyp - Tubular adenoma 5% - Villous adenoma 40% - Tubulovillous 22%Size: - rare 2 cm
PolypTreatment
- Colonoscopic removal + Follow up
- Colectomy * Impossible colonoscopic removal * Focus of invasive cancer in specimenFamilial Adenamotous Polyposis (FAP)Hundreds to thousands of adenamatous polyps shortly after puberty
Lifetime risk of CA approaches 100% by age of 50
Familial Adenamotous Polyposis (FAP)Screening relatives by APC gene testing Of patients with FAP => 75% APC mutation testing is positive - Positive APC testing => sigmoidoscopy beginning 10-15 years - Negative => Screening starting at the age of 5025% without other affected family members
Barium Enema-Polyposis
FAP treatmentSurgery
- Total proctocolectomy + end Ileostomy
- Restorative proctocolectomy + ileal pouch-anal Anastomosis
Total Proctocolectomy
Total Proctocolectomy
End Ileostomy
Total Proctocolectomy + Ileoanal J Pouch + Diverting Ileostomy
Attenuated FAP10 to 100 polyps dominantly located in the right colon
CA develops in >50%
Also at risk for duodenal polyposis
Treatment: - Total Abdominal colectomy + ileorectal anastomosis + colonoscopic polypectomy (rectum)
Total abdominal-Subtotal colectomy
Inflammatory Polyps (Pseudopolyps)IBD
Amebic colitis
Ischemic Colitis
Not premalignant
Hyperplastic PolypsExtremely common
Usually < 5 mm
Not Premalignant but > 2 cm have slight risk Hamartomatous polyps (Juvenile Polyps)Usually are not premalignant
Bleeding, intussusception, obstruction
Familial Juvenile Polyposis may degenerate into adenoma and eventually CAHereditary Nonpolyposis colon cancer (Lynch Syndrome)Average age: 40 to 45
70% develop colorectal CA (proximal colon)
40% risk of synchronous or metachronous CA
Associated CA: Endometrial, Pancreas, Stomach, Small bowel, Biliary, Urinary tractHereditary Nonpolyposis colon cancer (Lynch Syndrome)Diagnosis: Amsterdam Criteria
Three affected relatives (one must be a first degree relative of one of the others) in two successive generations of a family with one patient diagnosed before age 50
Hereditary Nonpolyposis colon cancer (Lynch Syndrome)Treatment:
- Total colectomy + ileorectal anastomosis + annual proctoscopy + TAHBSO Familial colocrectal cancerRisk of CA - No family Hx: 6% (average risk population) - One first degree: 12% - Two first degree: 35%Colorectal cancer: 80% sporadically, 20% known Family History
Screening Familial colorectal CA - Every 5 years at age 40 or 10 y before the age of the earliest diagnosed patient in the pedigreeIBD
Pancolitis: after 8 years
Left sided colitis after 12-15 years
Therapy of Colonic CarcinomaRemove the primary tumor along with its lymphovascular supply+Resection of any adjacent organ involved + chemotherapy
Total colectomy - Synchronous CA or adenoma - Strong family Hx - Metachronous tumor (second primary colon CA)Right Hemicolectomy
Right Hemicolectomy + Ileotransverse Anastomosis
Transverse Colectomy
Left Hemicolectomy
Sigmoidectomy
End
Loop
Double Barrel StomaTypes of StomasEnd Ileostomy
End colostomy
End colostomy
End colostomy
Loop colostomy
Double Barrel Ostomy
Double Barrel Ostomy
Colonic VolvulusAir filled segment of the colon twists about its mesentery
90% sigmoid is involved
Redundant colon due to chronic constipation predisposes to volvulus especially if the mesenteric base is narrow
Colonic VolvulusSymptoms:
- Abdominal distention
- Nausea vomiting
- Generalized abdominal pain & tenderness (Fever Leukocytosis)Colonic VolvulusPlain X-ray - Bent inner tube or coffee bean appearance convexity of the loop in R.U.Q
Gastrografin enema:Narrowing at the site of the volvulus (birds beak)
Sigmoid Volvulus
Sigmoid Volvulus
82Colonic VolvulusManagement
- Resuscitation + Endoscopic decompression
- Because of 40% Recurrence => Elective sigmoid colectomy Colonic VolvulusClinical Evidence of gangrene or perforation
Necrotic Mucosa, ulceration, dark blood on endoscopy
Emergency sigmoid colectomy
Colonic Pseudo-Obstruction (Ogilvies Syndrome)Massive dilated colon (Predominantly the right & transverse colon) in the absence of mechanical obstruction
Commonly in hospitalized patients, narcotics, bedrest, comorbid disease
Autonomic dysfunction & severe adynamic ileusColonic Pseudo-Obstruction (Ogilvies Syndrome)Treatment - Cessasion of narcotics, anticholinergics, - Bowel rest + IV hydration - Colonoscopic decompression - Gastrografin or barium enema to exclude mechanical obstruction - IV neostigmine (acetylcholinesterase inhibitor) inappropriate in cardiopulmonary diseaseIschemic ColitisSmall vessel occlusion Splenic flexture is most common siteRisk factors - Vascular disease - Diabetes Mellitus - Vasculitis - Hypotension - Ligation of IMA during aortic surgery
Ischemic ColitisMild: Diarrhea (usually bloody)
More Severe: Intense abdominal pain, tenderness, fever, leukocytosis, peritonitisIschemic ColitisPlain film: Thumb printing (mucosal edema & submucosal hemorrhage)
Sigmoidoscopy & contrast studies: contraindicated during acute phase
Ischemic ColitisTreatment
- Bowel rest + Antibiotics => 80% will recover
- Surgical exploration: failure to improve after 2-3 days deterioration in clinical condition => resection + ostomy
Pseudomembranous Colitis (Clostridium Difficile colitis)C. difficile gram positive bacillus nosocomially acquired diarrhea
Watery diarrhea to life-threatening colitis
C. difficile is carried in the large intestine of many healthy adults
Antibiotics => Decreased normal flora =>Overgrowth of C.difficile (even a single dose of an antibiotics)Pseudomembranous Colitis (Clostridium Difficile colitis)Risk increased:
- Immuno suppression
- Medical comorbidities
- Prolonged hospitalization
- Bowel Surgery Pseudomembranous Colitis (Clostridium Difficile colitis)Endoscopy:
- Ulcers
- Plaques
- Pseudoembranes Detection of toxin by cytotoxic assays or immunoassays
Pseudomembranous Colitis (Clostridium Difficile colitis)Treatmeant:
- Antibiotic cessation
- Fever Abdominal pain - => Outpatient 10 days metronidazol (oral vancomycin is second choice)
- Probiotics
- Vancomycin Enema
- Stool Transplantation
Pseudomembranous Colitis (Clostridium Difficile colitis) - Severe diarrhea + dehydration + fever & abdominal pain => Bowel rest + IV hydration + Oral metronidazol or Vancomycin
- Fulminant colitis => Septicemia or evidence of Perforation => Total abdominal colectomy + end ileostomy