colon lecturecolon lecture

John R Pender, M.D.John R Pender, M.D.

Dept. of SurgeryDept. of Surgery

BSOM, East Carolina BSOM, East Carolina UniversityUniversity

PatientPatient

58 y/o with wt loss and abd pain58 y/o with wt loss and abd pain

symptomssymptoms

Wt lossWt loss Change in caliber of stoolsChange in caliber of stools Blood in stool/ FOBT (fecal occult Blood in stool/ FOBT (fecal occult

blood test)blood test) AnemiaAnemia Abd painAbd pain constipationconstipation

Work upWork up

H&PH&P CEA (carcinoembryonic antigen)CEA (carcinoembryonic antigen) CBCCBC CXRCXR ColonoscopyColonoscopy CT scan abd/pelvisCT scan abd/pelvis

PolypsPolyps

Sessile vs pedunculatedSessile vs pedunculated HyperplasticHyperplastic AdenomaAdenoma MalignantMalignant

– VillousVillous– tubulovilloustubulovillous

Follow up after Follow up after polypectomypolypectomy

Q 6 months for first year, then @ 3 and 5 Q 6 months for first year, then @ 3 and 5 years. years.

Once clear at five years, repeat Q 5 yearsOnce clear at five years, repeat Q 5 years HNPCC (hereditary nonpolyposis col ca)HNPCC (hereditary nonpolyposis col ca)

– Average # polyps ~80% cancer by 45%Average # polyps ~80% cancer by 45% FAP (familial adenomatous polyposis)FAP (familial adenomatous polyposis)

– Cancer by age 40 ~100%Cancer by age 40 ~100%– 5% cancer by age 205% cancer by age 20

CHEMO?CHEMO?

5-FU and leucovorin5-FU and leucovorin Stage III (+/- poorly differentiated Stage III (+/- poorly differentiated

stage II)stage II)– coloncolon

Sage II and III Sage II and III – rectal carectal ca

XRTXRT

Not for colonNot for colon Only helps with local control in Only helps with local control in

rectal cancer if T3 or greaterrectal cancer if T3 or greater Does not improve survivalDoes not improve survival

Post operative Post operative surveillancesurveillance

PatientPatient

60y.o. with BRBPR60y.o. with BRBPR– What do you doWhat do you do

GI BLEEDGI BLEED

PatientPatient

45 y/o with left LQ pain, fever45 y/o with left LQ pain, fever– What do you doWhat do you do

w/uw/u

CBC CBC U/AU/A AASAAS CT CT Contrast enemaContrast enema

Diverticular DiseaseDiverticular Disease

ManagementManagement

Iv fluidIv fluid antibioticsantibiotics nponpo

Resuscitation Resuscitation AntibioticsAntibiotics Hartmann’s Hartmann’s

procedure procedure – Blind rectal Blind rectal

pouch&colostomypouch&colostomy OperationOperation

– free air free air – obstructionobstruction– AbscessAbscess– Uncontrolled sepsisUncontrolled sepsis

Indications for SurgeryIndications for Surgery

PerforationPerforation FistulaFistula AbscessAbscess ObstructionObstruction Age < 40Age < 40

PatientPatient

30 y/o with anal pain30 y/o with anal pain– What do you do? What do you do? – Examine pt.Examine pt.

Differential of Anal Differential of Anal painpain HemorrhoidsHemorrhoids abscessabscess FissureFissure Fistula-in-anoFistula-in-ano CodylomaCodyloma Puritis aniPuritis ani CancerCancer FBFB

Hemorrhoid TXHemorrhoid TX

First and second degree/ First and second degree/ thrombosedthrombosed– Sitz bathSitz bath– Bulk laxativeBulk laxative– topical analgesiatopical analgesia

Acute thrombosed, third/fourth Acute thrombosed, third/fourth degreedegree– HemorrhoidectomyHemorrhoidectomy

hemorrhoidectomyhemorrhoidectomy

FissureFissure

cycle of sphincter spasmcycle of sphincter spasm Nitrates, Botox, digital stretchNitrates, Botox, digital stretch Bulky laxativeBulky laxative WaterWater Sitz bathsSitz baths

FistulaFistula

PatientPatient

23 y/o with R LQ pain, fever23 y/o with R LQ pain, fever

what else do you want know?what else do you want know?

bowel habitsbowel habits

operationoperation

You operate for presumed You operate for presumed appendicitis and find an inflamed appendicitis and find an inflamed cecum and terminal ileum with cecum and terminal ileum with creeping fatcreeping fat..– What do you do?What do you do?

Inflammatory bowel Inflammatory bowel diseasesdiseases

Crohn’sCrohn’s– Mouth to anusMouth to anus– Skip areasSkip areas– Perianal Perianal – Granulomatous/Granulomatous/

full thicknessfull thickness– Fistula, strictureFistula, stricture– Extraintesatinal Extraintesatinal

dz dz

Ulcerative ColitisUlcerative Colitis– COLON AND COLON AND

RECTUM ONLYRECTUM ONLY– Toxic megacolonToxic megacolon– Rectal bleedingRectal bleeding– Higher risk of Higher risk of

colon cancercolon cancer

Indications for surgeryIndications for surgery

ObstructionObstruction BleedingBleeding Abscess/perforationAbscess/perforation cancercancer FistulaFistula Megacolon unresponsive Megacolon unresponsive Unresponsive/intolerance to medical Unresponsive/intolerance to medical

managementmanagement

Associated SXAssociated SX

Erythema nodosumErythema nodosum Pyoderma gangrenosumPyoderma gangrenosum Aphthous ulcersAphthous ulcers EpiscleritisEpiscleritis Ankylosing spondylitisAnkylosing spondylitis Sclerosing cholangitisSclerosing cholangitis

PatientPatient

80 y/o nursing home pt with 80 y/o nursing home pt with distend abdomen, feculent distend abdomen, feculent emesis, obstipationemesis, obstipation– What do you do?What do you do?

w/uw/u

IVFIVF NGNG AASAAS CBC, ectCBC, ect

DifferentialDifferentialof of colonic colonic obstructionobstruction CancerCancer AdhesionsAdhesions HerniaHernia VolvulusVolvulus Ogilvie’s pseudo-obstructionOgilvie’s pseudo-obstruction