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