Anatomy of the colon: - caecum –RIF, 6 cm. long- intraperit.- ascending colon-13 cm.cecum-right flexure, retroperitoneally- transverse colon-38 cm. right to left colic flexure, transverse mesocolon, intraperit.- descending colon-25 cm.long,left flexure-pelvic brim, retroperit. - sigmoid colon- 35 cm.pelvic brim- S3, mesocolon, intraperit.

1. Colorectal cancer is a malignant tumor arising from the inner wall of the large intestine.

2. Risk factors for colorectal cancer include heredity, colon polyps, and long standing ulcerative colitis.

3. Most colorectal cancers develop from polyps. Removal of colon polyps can prevent colorectal cancer.

4. Colon polyps and early cancer can have no symptoms. Therefore regular screening is important.

5. Diagnosis of colorectal cancer can be made by barium enema or by colonoscopy with biopsy confirmation of cancer tissue.

6. Treatment of colorectal cancer depends on the location, size, and extent of cancer spread, as well as the age and health of the patient.

7. Surgery is the most common treatment for colorectal cancer

Early stage- asymptomatic-silent cancer

Late stage- RIF pain, bowel obstruction, weight loss, anorexia, asthenia- chronic blood loss-anemia, change in bowel habit, palpable lump if large tumor.

GA- thin and pale patient

Abdomen:◦ Distended or “full” in the RIF◦ Palpable mass RIF; fixed or mobile◦ Palpable liver-MTS◦ Dullness over the mass◦ NBS or hyperactive in bowel obstruction◦ DRE-normal

Frequent location: sigmoid colon, recto-sigmoid junction

Usually, small, annular, obstructive, ulcerated

Age>50 years old, Young adults- cancer on UC or familial

polyposis coli Symptoms: pain LIF, change in bowel habit

GA- pale patient due to chronic blood loss

Abdomen:◦ Swelling LIF, ceacal distension if left colon

obstruction◦ LIF palpable mass, mobile on sigmoid location◦ Tender mass if pericolic inflamation - pericolic

abscess◦ Hepatomegaly- liver MTS◦ BS hyperactive- bowel obstruction◦ DRE- color of feces, pelvic palpable mass.

Sudden inability to micturate in the presence of a painful bladder

Hypogastric region severe pain The patient cannot pass urine inspite of a

desperate desire to do so Causes: Mechanichal: urethral stones, rupture of the

urethra, urethral stricture, prostatic enlargement, paraphimosis

Neurogenic: postop. retention, spinal cord injury, anticholinergic drugs

Symptoms: severe pain, feels like grossly exaggerated desire to micturate

The patient knows that his bladder is overdistended

Physical examination: ◦ distended bladder is palpable as a tense, dull, rounded

mass, arising out of the pelvis◦ Pressure on the swelling exagerbates the p’s desire to

micturateDRE- prostate or uterus is pushed backwards and

downwards-you can not assess the size of the prostate gland when the bladder is full

Often the patient - always an elderly gentleman with gray hair and cataract - arrives in severe agony with a huge, distended bladder due to acute retention of urine.

 

Carcinoma of the esophagus

Reflux esophagitis

Pyloric stenosis

Rarely produces any physical signs apart from: ◦- wasting and ◦- perhaps a palpable supraclavicular lymph node

The main symptom is DYSPHAGIA

Progressive dysphagia from solids to fluids

Dysphagia= late symptom in the natural history of the disease – 60% of circumference is infiltrated with cancer

 Squamous cell carcinoma of the esophagus is largely associated with a poor prognosis.

Direct invasion of adjacent

organs such as the aorta, respiratory tract and lungs,

and distant metastasis to other organs such as the liver, lungs and bone are commonly found in advanced esophageal cancer cases. I

 

 Examination of geographic areas of high incidence have identified a number of environmental factors strongly linked to the development of esophageal dysplasia and squamous carcinoma 

In the United States and Europe alcohol and smoking

 In China nitrosamine containing foods, fungal contamination of foods and vitamin and essential metal deficiency

 The only known genetic predisposition occurs in hereditary tylosis, an autosomal dominant symmetrical keratosis of the palms and soles.

 This 73 year old, male presented progressive dysphagia for solid and liquid and lost of weight of 20 pounds.

Endoscopy revealed a large tumor.

Esophageal cancer is a treatable disease, but it is rarely curable.

The overall 5-year survival rate in patients amenable to definitive treatment ranges from 5% to 30%. 

The occasional patient with very early disease has a better chance of survival.

Patients with severe dysplasia in distal esophageal Barrett’s mucosa often have in situ or even invasive cancer within the dysplastic area.

Following resection, these patients usually have excellent prognoses.

 

This 72 year-old man with progressive dysphagia (difficulty swallowing) to solids, who was found to have this malign neoplasia.

  Cancer of the esophagus

remains a devastating disease because it is usually not detected until it has progressed to an advanced incurable stage.

Patients are able to locate the level of obstruction

Extension of the tumor into the tracheo-bronchial tree- fistula formation:◦ - Stridor◦ - Coughing◦ - Choking◦ - Aspiration pneumonia

Distant metastasis- liver, lung, peritoneum

Regurgitation of gastric contents into the lower esophagus:

◦ Incompetent lower esophageal sphincter

◦ Slinding hiatus hernia

Factors that decrease the LOS pressure: Alcohol Cigarette smoking Morphine Estrogen therapy Fatty foods Presence of a NG tube

Main symptom-heartburn-retrosternal burning sensation

Associated symptom- dysphagia- inflammation- fibrous stenosis

Relationship of pain to posture of the patient: Bending Stooping Heavy lifting Tight clothes All forces acid up into the esophagus

Gastric outlet obstruction:

Chronic complication- 5% of GDU

Neo-nates-congenital HT pyloric stenosis

Adults- carcinoma of the gastric antrum

Main symptom- vomiting The vomit is large in volume, not bile-

stained containing undigested food

Associated symptom- epigastric discomfort Signs:

◦ epigastric distension, ◦ visible peristalsis, ◦ succusion splash

Infections in food

Ulcerative colitis

Crohn’s disease

Cholera

Rectal villous tumor

Inflammatory bowel disease Main symptom: diarrhea Ulcerative colitis - loose bloodstained stools - frequency-up to 20 stools/day - preceded by cramping abdo. pain - urgency to defecate- the worst symptom Crohn’s disease: Diarrhea is watery with mucus Abdo. pain is colicky in nature

Progressive inflammation- muscle paralysis- dilatation- toxic megacolon

Diarrhea - dehydration - electrolyte disturbance - anemia due to bloody diarhhea Toxic megacolon- colonic perforation- fatal

peritonitis

is a disorder characterized by diffuse mucosal inflammation limited to the colon.

UC is usually a chronic disease which involves the rectum and may extend proximally in a symmetrical, circumferential, and uninterrupted pattern to involve parts or all of the large intestine.

The hallmark clinical symptom is bloody diarrhea often with prominent symptoms of rectal urgency and tenesmus (painful straining at stool).

The clinical course is marked by exacerbations and remissions, which may occur spontaneously or in response to treatment changes or intercurrent illnesses.

Inflammatory bowel disease (IBD) is a general term that covers two disorders:

Ulcerative colitis Crohn's Some evidence suggests that they

are part of a biologic continuum, but at this time they are considered distinct disorders with somewhat different treatment options.

The basic distinctions are location and severity.

As many as 10% of patients with IBD have features and symptoms that match the criteria for both disorders, at least in the early stages. (This is called indeterminate colitis.)

Plain radiograph of the abdomen show moderate dilation of the colon with loss of haustration in the descending colon.

Thickening of the wall of the colon indicating edema is also visible .

Affects any part of the digestive system Inflammation involves the whole thickness

Complications:◦ Stenosis◦ Fistula formation◦ Abscess formation

Crohn’s disease is a chronic inflammatory disease of the intestines that can affect the digestive system from the mouth to the anus. The most commonly affected areas tend to be in the small and the large intestines.Terminal ileitis (inflammation that affects the end of the small intestine (terminal ileum), the part of the small intestine closest to the colon

Acute inflammation of the peritoneal serosa

Acute peritonitis - localized - generalized

If you can not determine the cause of peritonitis you must decide whether the patient needs a laparotomy

Two circumstances in which a laparotomy is essential

1. If there is evidence of ischemic bowel caused by strangulation or vascular occlusion

2. If there is an unexplained general peritonitis where lapatomy is needed to make the diagnosis

- Increasing tachycardia - Pyrexia - Tenderness and guarding - Rebound tenderness - Localized pain during distant palpation - Absence of the bowel sounds

Causes in relation with the age: Neo-nates: congenital pyloric stenosis 6-9 months: intussusception Teenagers: intussusception of Meckel’s

diverticulum Young adult: hernia, adhesions, Crohn’s

stenosis, bowel tumors Elderly: bowel tumors, diverticulitis,sigmoid

volvulus

A segment of bowel which becomes invaginated into the bowel immediately distal to it

The invaginated segment progressively elongates as it is propelled distally by peristalsis

Ileo-cecal invagination is the most common variety

A huge sigmoid loop, heavy with faeces that becomes twisted on its mesenteric pedicle to produce a close loop obstruction

Venous infarction with perforation and faecal peritonitis might appear unless emergent surgical intervention is decided

Is there intestinal obstruction ??◦ Obstruction: colicky pain, vomiting, abdominal

distention and absolute constipation

Is the bowel strangulated??◦ Strangulation: pain, tenderness, guarding and

rebound tenderness

It is a true colic

There are severe gripping exacerbations mixed with periods of little or no pain

Small bowel colic is felt in the central abdomen

Large bowel colic in the lower third of the abdomen

The nature of the vomitus depends upon the level of the obstruction:

◦ Pyloric stenosis- vomitus is watery and acid

◦ High small-bowel obstruction- greenish bile-stained vomit

◦ Middle small bowel obstruction- brown vomit, thick and foul smelling as the obstruction persists

The lower down the gut the obstruction, the more bowels is available to distend and the greater the distention

High obstruction is not associated with much distention, particularly if the patient vomits frequently

Obstruction in the left colon- distention extends into the small bowel if the ileo-cecal valve is incompetent

If the valve remains closed, the caecum becomes grossly distended-visible assymetry

Complete obstruction with bowel below it empty- absolute constipation