COLORECTAL POLYPS COLORECTAL POLYPS AND COLORECTAL AND COLORECTAL

CARCINOMACARCINOMA

COLORECTAL POLYPSCOLORECTAL POLYPS

Swelling arising from the colonic mucosa Swelling arising from the colonic mucosa Common finding in the large bowelCommon finding in the large bowel Prone to malignant changesProne to malignant changes Any colorectal polyp must be considered Any colorectal polyp must be considered

malignant until proved otherwisemalignant until proved otherwise Typically present with rectal bleeding or Typically present with rectal bleeding or

anemia due to occult blood lossanemia due to occult blood loss Many polyps cause no symptoms and Many polyps cause no symptoms and

found incidentally on barium enema found incidentally on barium enema examination or colonoscopyexamination or colonoscopy

COLORECTAL POLYPSCOLORECTAL POLYPS

Histopathologically- three patterns of Histopathologically- three patterns of growth:growth:

• tubular adenomas,tubular adenomas,

• villous adenomas,villous adenomas,

• tubulo-villous adenomastubulo-villous adenomas

TUBULAR ADENOMASTUBULAR ADENOMAS

Small pedunculated or sessile lesionsSmall pedunculated or sessile lesions

The least potential for malignant The least potential for malignant changeschanges

High risk in a rare familial disorder of High risk in a rare familial disorder of polyposis coli (adenomatous polyposis)polyposis coli (adenomatous polyposis)

VILLOUS ADENOMASVILLOUS ADENOMAS

Usually sessile and frond-like lesionsUsually sessile and frond-like lesions Tend to secrete mucusTend to secrete mucus Main complaint- passing stool with Main complaint- passing stool with

mucusmucus Symptomatic hypoK- emia may Symptomatic hypoK- emia may

developdevelop Great potential for malignant changeGreat potential for malignant change

TUBULO-VILLOUS ADENOMASTUBULO-VILLOUS ADENOMAS

Intermediate forms between the first twoIntermediate forms between the first two Include the majority of colonic polypsInclude the majority of colonic polyps Most are pedunculated, the stalk 1-10 Most are pedunculated, the stalk 1-10

cm.cm. Early malignant change- invasion Early malignant change- invasion

through the basement membrane into through the basement membrane into the muscularis mucosathe muscularis mucosa

Careful histological examination is Careful histological examination is essentialessential

COLONIC POLYPSCOLONIC POLYPS

May occur in any part of the colonMay occur in any part of the colon Majority of them arise in the rectum and Majority of them arise in the rectum and

sigmoid colonsigmoid colon They tend to cause rectal bleeding (visible They tend to cause rectal bleeding (visible

or occult) and may undergo malignant or occult) and may undergo malignant changechange

If rectal polyps are found, the entire colon If rectal polyps are found, the entire colon must be investigated- total colonoscopymust be investigated- total colonoscopy

The larger the lesion the more likely it is to The larger the lesion the more likely it is to be malignantbe malignant

COLORECTAL POLYPSCOLORECTAL POLYPSDIAGNOSIS DIAGNOSIS

RectoscopyRectoscopy

SigmoidoscopySigmoidoscopy

ColonoscopyColonoscopy

Barium enemaBarium enema

COLORECTAL POLYPSCOLORECTAL POLYPSMANAGEMENTMANAGEMENT

Polyps can be excised using diatermy Polyps can be excised using diatermy snare endoscopicallysnare endoscopically

Pedunculated lesions<2 cm. can be Pedunculated lesions<2 cm. can be removed with easeremoved with ease

Larger polyps or sessile require Larger polyps or sessile require snaring in several piecessnaring in several pieces

If a malignant polyp has been If a malignant polyp has been incompletely removed then bowel incompletely removed then bowel excision is requiredexcision is required

COLONIC POLYPSCOLONIC POLYPS

PEDUNCULATED COLONIC PEDUNCULATED COLONIC POLYPPOLYP

SESSILE POLYPSESSILE POLYP

PEDUNCULATED POLYP PEDUNCULATED POLYP ADENOCARCINOMA IN SITUADENOCARCINOMA IN SITU

COLONIC POLYPCOLONIC POLYPADENOCARCINOMA IN SITUADENOCARCINOMA IN SITU

MULTIPLE COLONIC POLYPSMULTIPLE COLONIC POLYPS

BLEEDING COLONIC POLYPBLEEDING COLONIC POLYP

SNARE POLYPECTOMYSNARE POLYPECTOMY

BLEEDING POSTPOLYPECTOMYBLEEDING POSTPOLYPECTOMY

ENDOSCOPIC VIEWENDOSCOPIC VIEW

Inflammatory pseudopolypsInflammatory pseudopolyps

Can occur as a complication of Can occur as a complication of ulcerative colitis or or Crohn's disease of the colon. of the colon.

They are completely harmless and They are completely harmless and carry no risk of cancer but they can carry no risk of cancer but they can be confused with adenomatous be confused with adenomatous polyps on examination. polyps on examination.

Peutz-Jeghers syndromePeutz-Jeghers syndrome

It is an autosomal dominant inherited disorder It is an autosomal dominant inherited disorder characterized by intestinal hamartomatous polyps characterized by intestinal hamartomatous polyps in association with mucocutaneous melanocytic in association with mucocutaneous melanocytic macules. macules.

Patients with Peutz-Jeghers syndrome (PJS) have Patients with Peutz-Jeghers syndrome (PJS) have a 15-fold increased risk of developing intestinal a 15-fold increased risk of developing intestinal cancer compared with that of the general cancer compared with that of the general population. population.

Such cancer locations includes gastrointestinal Such cancer locations includes gastrointestinal and extraintestinal sites.and extraintestinal sites.

Facial Facial photograph of a photograph of a patient with patient with Peutz-Jeghers Peutz-Jeghers syndrome. syndrome.

Note the Note the mucocutaneous mucocutaneous pigmentationpigmentation

Photo of oral Photo of oral pigmented lesion pigmented lesion from a patient from a patient with Peutz-with Peutz-Jeghers Jeghers syndrome.syndrome.

Peuts-Jeghers syndrome Peuts-Jeghers syndrome gastroscopygastroscopy

The gastrointestinal polyps found The gastrointestinal polyps found in Peutz-Jeghers syndrome are in Peutz-Jeghers syndrome are typical hamartomas. typical hamartomas.

Their histology is characterized by Their histology is characterized by extensive smooth muscle extensive smooth muscle arborization throughout the polyp. arborization throughout the polyp.

Nevertheless, cancer may develop Nevertheless, cancer may develop in the gastrointestinal tract of in the gastrointestinal tract of patients with Peutz-Jeghers patients with Peutz-Jeghers syndrome (PJS) with a higher syndrome (PJS) with a higher frequency than in the general frequency than in the general populationpopulation

COCAINE COLITIS.COCAINE COLITIS.44 year-old man, a frequent user of cocaine, who presented with 44 year-old man, a frequent user of cocaine, who presented with

bloody diarrhea. Colonoscopy revealed a range of findings from areas bloody diarrhea. Colonoscopy revealed a range of findings from areas of congestion to sessile polyps to lesions resembling pedunculated of congestion to sessile polyps to lesions resembling pedunculated polyps. Stool cultures were all negative. Biopsies revealed mucosal polyps. Stool cultures were all negative. Biopsies revealed mucosal

congestion and inflammation. congestion and inflammation.

COLORECTAL CANCERCOLORECTAL CANCERPATHOLOGYPATHOLOGY

Adenocarcinoma of the colon is Adenocarcinoma of the colon is growing outside from the mucosa growing outside from the mucosa and later ulcerate and invade the and later ulcerate and invade the muscular layermuscular layer

Next invades the serosa and Next invades the serosa and surrounding structuressurrounding structures

Stromal fibrosis causes narrowing- Stromal fibrosis causes narrowing- bowel obstructionbowel obstruction

COLORECTAL CANCERCOLORECTAL CANCERPATHOLOGYPATHOLOGY

Lymphatic spread is sequential first to Lymphatic spread is sequential first to mesenteric nodes and then paraaortic nodesmesenteric nodes and then paraaortic nodes

Large paraaortic nodes- duodenal obstructionLarge paraaortic nodes- duodenal obstruction Large nodes compressing porta hepatis- Large nodes compressing porta hepatis-

jaundicejaundice Hematogenous spread- to the liver, usually Hematogenous spread- to the liver, usually

follows lymphatic spreadfollows lymphatic spread By the time of diagnosis 25% of pts. already By the time of diagnosis 25% of pts. already

have widespread metastaseshave widespread metastases

COLORECTAL CANCERCOLORECTAL CANCERCLINICAL PRESENTATIONCLINICAL PRESENTATION

Cecal cancer- occult bleeding- iron Cecal cancer- occult bleeding- iron defficiency anemia, palpable mass in defficiency anemia, palpable mass in RIFRIF

Colorectal cancers ulcerate earlier- Colorectal cancers ulcerate earlier- lower digestive bleeding- hematochezialower digestive bleeding- hematochezia

Bowel obstruction, partial or total in Bowel obstruction, partial or total in stenotic lesions, usually in the left colonstenotic lesions, usually in the left colon

Bowel perforation- fecal peritonitisBowel perforation- fecal peritonitis Malignant fistula into the: stomach, Malignant fistula into the: stomach,

bladder, uterus, vagina, skin bladder, uterus, vagina, skin

COLORECTAL CANCERCOLORECTAL CANCERSYMPTOMS AND SIGNSSYMPTOMS AND SIGNS

Cecal tumor: anemia, diarrhea, palpable Cecal tumor: anemia, diarrhea, palpable massmass

Descending colon: rectal bleeding, change in Descending colon: rectal bleeding, change in bowel habit, colicky pain, perforationbowel habit, colicky pain, perforation

Rectal tumor: rectal bleeding, tenesmus, Rectal tumor: rectal bleeding, tenesmus, mucus diarrheamucus diarrhea

Compressing symptoms: jaundice, duodenal Compressing symptoms: jaundice, duodenal obstruction, ureterohydronephrosisobstruction, ureterohydronephrosis

Systemic effects: malaise, anorexia, weight Systemic effects: malaise, anorexia, weight lossloss

COLORECTAL CANCERCOLORECTAL CANCER

Premalignant conditionsPremalignant conditions

• Poliposis coli- genetic familial disorderPoliposis coli- genetic familial disorder

• Ulcerative colitis- inflammatory bowel Ulcerative colitis- inflammatory bowel diseasedisease

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

General examination- features General examination- features suggesting malignant disease:suggesting malignant disease:• Obvious weight lossObvious weight loss• Palor of the skinPalor of the skin• Abdominal distentionAbdominal distention• HepatomegalyHepatomegaly• Abdominal massAbdominal mass

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Rectal examination:Rectal examination:• Finger can reach lesions as far as the its Finger can reach lesions as far as the its

length 7-9 cmlength 7-9 cm• Palpable fixed mass in Douglas pouch-Palpable fixed mass in Douglas pouch-

sigmoid tumor dropped retrorectallysigmoid tumor dropped retrorectally• The glove inspected for blood and The glove inspected for blood and

mucusmucus

COLORECTAL CANCERCOLORECTAL CANCERINVESTIGATIONSINVESTIGATIONS

Rectosigmoidoscopy- about 50% of Rectosigmoidoscopy- about 50% of colorectal cancer lie within reach of the colorectal cancer lie within reach of the rigid sigmoidoscope- biopsyrigid sigmoidoscope- biopsy

Barium enema- synchronous tumorsBarium enema- synchronous tumors ColonoscopyColonoscopy Abdominal CT- stagingAbdominal CT- staging Urography- ureterohydronephrososUrography- ureterohydronephrosos Barium meal- duodenal compressionBarium meal- duodenal compression Plain abdominal X ray- bowel obstructionPlain abdominal X ray- bowel obstruction

RESECTED ILEOCOLONRESECTED ILEOCOLONCECAL CANCERCECAL CANCER

COLONIC CANCERCOLONIC CANCER

ULCERATED COLON ULCERATED COLON CANCERCANCER

STENOTIC COLON CANCERSTENOTIC COLON CANCER

ULCERATED RECTAL ULCERATED RECTAL CANCERCANCER

BARIUM ENEMABARIUM ENEMATRANSVERSE COLON CANCERTRANSVERSE COLON CANCER

BARIUM ENEMABARIUM ENEMACECAL CANCERCECAL CANCER

BARIUM ENEMABARIUM ENEMARECTAL CANCERRECTAL CANCER

RECTAL CANCERRECTAL CANCER

ENDOSCOPIC ULTRASOUNDENDOSCOPIC ULTRASOUND

RECTAL CANCERRECTAL CANCER

STENOTIC COLON CANCERSTENOTIC COLON CANCER

SIGMOID STENOTIC CANCERSIGMOID STENOTIC CANCERLIVER AND PERITONEAL MTSLIVER AND PERITONEAL MTS

COLORECTAL CANCERCOLORECTAL CANCERMANAGEMENTMANAGEMENT

Surgical resection is the only curative Surgical resection is the only curative therapeutic modalitytherapeutic modality

Radio/chemotherapy- neoadjuvant or Radio/chemotherapy- neoadjuvant or adjuvant treatmentadjuvant treatment

Radio/chemo neoadjuvant therapy- Radio/chemo neoadjuvant therapy- decreases locoregional recurrences decreases locoregional recurrences in rectal cancerin rectal cancer

Adjuvant chemotherapy- useful for Adjuvant chemotherapy- useful for colon cancercolon cancer

COLORECTAL CANCERCOLORECTAL CANCERMANAGEMENTMANAGEMENT

Loco-regional recurrence= tumor re-Loco-regional recurrence= tumor re-growth at the anastomosis or within growth at the anastomosis or within operative areaoperative area

Loco-regional recurrence may Loco-regional recurrence may develop from either retained develop from either retained microscopic tissue in the lateral microscopic tissue in the lateral margins of resection or microscopic margins of resection or microscopic positive nodes left in the positive nodes left in the mesorectummesorectum

COLORECTAL CANCERCOLORECTAL CANCERPROGNOSTIC FACTORSPROGNOSTIC FACTORS

Age (young or very old)Age (young or very old) Histological type (coloid type is Histological type (coloid type is

worse)worse) Vascular and lymphatic invasionVascular and lymphatic invasion Histological grade (poor Histological grade (poor

differentiated)differentiated) The degree of wall invasion (Dukes The degree of wall invasion (Dukes

classification)classification)

STAGING- DUKES STAGING- DUKES CLASSIFICATIONCLASSIFICATION

After histological examination of the After histological examination of the resected specimenresected specimen

Dukes A- tu.confined to the bowel wallDukes A- tu.confined to the bowel wall Dukes B- tu. spread into the extrarectal Dukes B- tu. spread into the extrarectal

or extracolic tissues, no+ lymph nodesor extracolic tissues, no+ lymph nodes Dukes C- tu. spread extrarectally or Dukes C- tu. spread extrarectally or

extracolic with + lymph nodesextracolic with + lymph nodes Dukes D- distant metastasesDukes D- distant metastases

SURVIVAL RATESSURVIVAL RATES

½ of the pts. are incurable at ½ of the pts. are incurable at presentationpresentation

¼ of the pts. with radical surgery are ¼ of the pts. with radical surgery are alive and well at 5 yearsalive and well at 5 years

Very few pts. surviving 5 years die Very few pts. surviving 5 years die later of recurrent diseaselater of recurrent disease

COLORECTAL CANCERCOLORECTAL CANCEROPERATIONSOPERATIONS

The principles of tumor resection:The principles of tumor resection:• The affected segment of bowel resected The affected segment of bowel resected

with a margin of normal tissuewith a margin of normal tissue• The precise lines of resection are The precise lines of resection are

determined by the distribution of determined by the distribution of mesenteric blood vesselsmesenteric blood vessels

• No touch, isolation techniqueNo touch, isolation technique• The mesentry resected with its lymph nodesThe mesentry resected with its lymph nodes• The cut ends of bowel can be rejoined at The cut ends of bowel can be rejoined at

the same operationthe same operation

COLORECTAL CANCERCOLORECTAL CANCEROPERATIONSOPERATIONS

Right colon tu.- right colectomy with ileocolic Right colon tu.- right colectomy with ileocolic anastomosisanastomosis

Transverse colon tu. Segmental colectomy with Transverse colon tu. Segmental colectomy with colo-colic anastomosiscolo-colic anastomosis

Left colon tu.- left colectomy with colorectal Left colon tu.- left colectomy with colorectal anastomosisanastomosis

Upper rectal tu.- anterior resection of the rectum Upper rectal tu.- anterior resection of the rectum with colorectal anastomosiswith colorectal anastomosis

Low rectal tu.- abdominoperineal resection of the Low rectal tu.- abdominoperineal resection of the rectum with definitive left colostomyrectum with definitive left colostomy

Stenotic recto-sigmoid tu.-Hartmann op.= Stenotic recto-sigmoid tu.-Hartmann op.= rectosigmoidectomy, closure of the rectal stump, rectosigmoidectomy, closure of the rectal stump, left colostomyleft colostomy

ADVANCED DISEASEADVANCED DISEASE Palliative resection when distant metastases are Palliative resection when distant metastases are

present- survival within 1 yearpresent- survival within 1 year If liver metastases are confined in a lobe- If liver metastases are confined in a lobe-

lobectomy can be associated to bowel resection if lobectomy can be associated to bowel resection if the pt. is relatively fit.the pt. is relatively fit.

Bone metastases- local radiotherapyBone metastases- local radiotherapy Unresectable right colon cancer- ileotransverso. Unresectable right colon cancer- ileotransverso.

by-passby-pass Unresectable left colon cancer- transverso-Unresectable left colon cancer- transverso-

sigmoidostomysigmoidostomy Unresectable rectosigmoid cancer- loop Unresectable rectosigmoid cancer- loop

colostomy colostomy

FAMILIAL POLIPOSIS COLIFAMILIAL POLIPOSIS COLI

It is a rare autosomal dominant It is a rare autosomal dominant disorderdisorder

Multiple colorectal polypsMultiple colorectal polyps Rectal bleeding/ change in bowel habitRectal bleeding/ change in bowel habit The treatment- colorectal removal The treatment- colorectal removal

with ileoanal anastomosis, or with ileoanal anastomosis, or panproctocolectomy with definitive panproctocolectomy with definitive ileostomyileostomy

POLIPOSIS COLIPOLIPOSIS COLI

POLIPOSIS COLIPOLIPOSIS COLI

COMPLICATIONS OF LARGE COMPLICATIONS OF LARGE BOWEL SURGERYBOWEL SURGERY

Wound infection and dehiscenceWound infection and dehiscence Intraperitoneal abscessIntraperitoneal abscess PeritonitisPeritonitis

• Causes:- fecal spillage intraoperativeCauses:- fecal spillage intraoperative

- anastomotic leak- anastomotic leak

EARLY COMPLICATIONSEARLY COMPLICATIONS

Wound infectionWound infection Intra-abdominal abscessIntra-abdominal abscess Stoma problemsStoma problems

LATE COMPLICATIONSLATE COMPLICATIONS

Diarrhea due to short bowelDiarrhea due to short bowel Small bowel obstruction- adhesions, Small bowel obstruction- adhesions,

fibrous band, internal herniation, fibrous band, internal herniation, kinkingkinking

Abdominoperineal resection- Abdominoperineal resection- hypogastric plexus damaged- hypogastric plexus damaged- micturition problems and impotencemicturition problems and impotence

STOMASSTOMASINDICATIONSINDICATIONS

CANCER SURGERYCANCER SURGERY ULCERATIVE COLITISULCERATIVE COLITIS FAMILIAL POLIPOSISFAMILIAL POLIPOSIS DIVERTICULITISDIVERTICULITIS

STOMASSTOMAS

PERMANENT STOMASPERMANENT STOMAS

TEMPORARY STOMAS:TEMPORARY STOMAS:

- BOWEL - BOWEL OBSTRUCTION,OBSTRUCTION,

- PROTECTIVE STOMAS,- PROTECTIVE STOMAS,

- UNPREPARED BOWEL- UNPREPARED BOWEL

STOMA TYPESSTOMA TYPES

CECOSTOMYCECOSTOMY LOOP COLOSTOMYLOOP COLOSTOMY END COLOSTOMYEND COLOSTOMY