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1. 2. 3. 4. 5. 6. 7. Alteration in bowel habit Rectal bleeding Pain Diarrhea/constipation Obstipation – absence of spontaneous bowel movements Hematochezia – fresh blood from the colon or distal small intestine Tenesmus - retention of stool in the rectum - tumors - colonic inflammation DIAGNOSTIC PROCEDURES Physical examination Buccal pigmentation or telangiectazia → coexistent small bowel polyposis or intestinal telangiectazia: abdominal pain, chronic bleeding Iritis Arthritis IBD Erytema nodosus Digital rectal examination Stool examination Barium studies – small bowel X-rays – enteroclysis Barium enema - diverticulosis - motility disturbances - loss of haustral markings - tumors Colonoscopy → detecting of colonic neoplasms Sigmoidoscopy → lower 40-60 cm of the colon Mesenteric angiography - intestinal ischemia - ac. GI hemorrhage (> 0,5 ml/min) Radionuclide bleeding scan – iv injection of Tc99m Rate of 0,1-0,5 ml/min → the location of radioactivity in the abdomen may indicate the source of bleeding DIVERTICULOSIS congenital/acquired Definition herniations of the entire thickness of intestinal wall herniations of the mucosa through the muscularis, generally at the site of a nutrient artery Small-intestinal diverticula Duodenal diverticula – abdominal pain, fever, GI bleeding, perforation Jejunal diverticula – abcess or peritonitis a) Multiple jejunal diverticula may be associated with a malabsorbtion syndrome → bacterial perforation → mucosal damage → deconjugation of bile salts + vit. B12 malabsorbtion Meckel’s diverticulum: congenital anomaly of the digestive tract – 2% cases/a persistent omphalomesenteric duct arises from the antimesenteric border of the ileum usually within 100 cm of the ICV may produce hemorrhage, inflamation and obstruction in children and teenagers. Diagnosis: isotope scanning (technetium i.v.) may mimic acute appendicites in young adults surgical excision of complications COLONIC DIVERTICULA Definition: herniations or sackke protrusion of the mucosa through the muscularis, at the point where a nutrient artery penetrates the muscularis occur most commonly in the sigmoid colon and decrease in frequency in the proximal colon they increase with age 20-50% in western population > 50 years increase pressure produced by colonic muscle contractions/↑ intraluminal pressure usually asymptomatic, are an incidental finding on barium enema for others reasons. DIVERTICULITIS Definition: inflammation in/around the diverticular sac Pericolic abcess → generalized peritonitis ↑ in men > 3 times in the left colon ACUTE COLONIC DIVERTICULITIS fever left lower quadrant abdominal pain muscle spasm, guarding, rebound tenderness Rectal examination → tender mass-close to the rectum Acute constipation Rectal bleeding 25% cases Leukocytosis Complications: acute peritonitis sepsis/stroke → elderly 1. 2. 3. 4. Differential diagnosis: Neoplasm of the descendent or sigmoid colon Treatment bed rest stool softness liquid diet wide-spectrum antibiotic: tetracycline/ampicilin Repeated attacks of diverticulitis in the same area require surgical resection Usual procedure: diverting colostomy with resection of the involved colon reanastomosis is then performed at a second operation. HEMORRHAGE FROM DIVERTICULA one of the commonest causes of hematochezia > 60 years Mechanism: erosions of a vesel by a fecalith within the diverticular sac bed rest + blood transfusion Bleeding scan/angiography → localization of bleeding ↑ in the ascending colon MEGACOLON Definition: giant colon with masive distension and constipation congenital/aquired is seen in all age groups Acute toxic megacolon is a severe complication of chronic uncerative colitis AGANGLIONIC MEGACOLON (Hirschsprung’s disease) congenital disorder which becomes manifest in early infancy, occuring specially in males; often familial Clinical features massive abdominal distension absent bowel movements impaired nutrition Inability to defecate is caused by the absence of ganglion cells (Meissner’s and Auerbach’s plexuses) in a small segment of the distal colon, near the anus Barium enema reveals a narrowed segment in a RS area, with massive dilatation above Diagnostic: surgical biopsy full-thickness Treatment: surgery which restores normal defecation CHRONIC IDIOPATHIC MEGACOLON severe chronic constipation/rectal ampulla distended by gas Barium enema: entire colon distended with stools, no narrowed segment ACQUIRED MEGACOLON (Chaga’s disease) in Central and South America Tripanosoma cruzi the onset is in adult life patients with depression, schizophrenia, cerebral atrophy, mixedema morphine, codeine IRRITABLE BOWEL SYNDROME I. II. Spastic colitis: chronic abdominal pain constipation Second group: chronic intermittent diarrhea without pain Gr. I + II → alternating constipation and diarrhea alternation of intestinal motility have increased resting colonic motility have decreased resting colonic motility Psychological stress increase motility Abnormality of intestinal neuro-muscular function (↑ in 3 cycle/minute slow wave activity) Depression, hysteria, obsessive-compulsive traits → exacerbate symptoms Clinical features middle-aged adults female/male ratio 2:1 history of chronic constipation/diarrhea or both lower abdominal pain excessive bloating weakness faintness palpitations Diagnosis chronic intermittent nature of symptoms relation of symptoms with emotional stress careful history complete physical exam stool examination – occult blood Colonoscopy excludes neoplasia Barium enema spasticity of the sigmoid, accentuated haustra Lactase deficiency may masquerade IBS Tyrotoxicosis is confused with IBS → lab studies Treatment Minimaze symptoms impact on life-style Physician will prescribe physical exam, hemograms, occult blood at regular intervals Surg. treatment: constipation → ↑ in dietary burk laxatives → mild sedation ANGIODYSPLASIA OF THE COLON vascular ectasias in the right colon in older that may cause bleeding degenerative lesions of dilated, distorted, thin-walled vessels lined by vascular endothelium 2 nm → 1 cm Φ star-shaped branching vessels in submucosa in the cecum and ascending colon Angiography – extravasation of contrast material into the lumen Colonoscopy – bleeding lesions Right hemicolectomy – multiple sites! COLORECTAL CANCER (CCR) Incidence second to lung cancer as a cause of cancer death in the US males > 50 years old Risk factors 1. Diet more often in urban areas: low intake of dietary fiber meat protein dietary fat and oil (“western” diet) → animal fats ↑ cholesterol concentration mortality from coronary artery disease hereditary syndroms: Polyposis coli (25%) (autosomal dominant) Non-polyposis syndrome deletion in the long arm of chromosome 5 Inflammatory bowel disease (UC) ↑ risk in young patients with pancolitis Dietary fiber accelerates intestinal transit time, reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk. Risk for the CCR is decreased by the addition of calcium supplements to the diet Streptococcus Bovis Bacteriemia Rectosigmoidoscopy – 5-10% of CCr 15-30 years after POLYPS Adenomatous polyps – premalignant 30% middle age elderly people Classification: nonneoplastic hamartoma (juvenile polyps) hyperplastic polyps adenomatous polyps Deletion in chromosoms 5, 18, 17 (short arm) – p53 Adenomatous polypd – pediculated sessile ↑ often premalignant Villous polyps - ↑ premalignant Colonoscopy should be repeated periodically (even 3 years), even in the absence of a previously documented malignancy, since such patients have a 30-50% probability of developing adenoma → risk of CCR CLINICAL FEATURES I. II. Symptoms vary with the anatomic location of the tumor Tumors in the ascending colon fatigue palpitations – AP hypochromic microcytic anemia (↓ iron) Transverse + descending colon tumors abdominal cramps obstruction (occasional) perforation X-rays – “apple-are”, “napkin-sign” III. Rectosigmoid tumors hematochezia tenesmus narrowing in the calibrum of stool anemia Digital rectal examination are necessary! Proctosigmoidoscopy STAGING, PROGNOSTIC FACTORS, PATTERNS OF SPREAD DUKES CLASSIFICATION OF CCR STAGE PATHOLOGIC DESCRIPTION 5 YEAR SURVIVAL % A Cancer limited to mucosa, submucosa > 90% B Cancer extends into muscularis 70-85% C Cancer involves regional lymph nodes 30-60% D Distant metastases (liver, lung, bone) 5% POOR PROGNOSTIC PREDICTORS FOLLOWING TOTAL RESECTION T spread to regional lymph nodes (l.n.) Number of regional l.n. involved T penetration through the bowel wall Poorly differentiated histology Perforation T adherence to adjacent organs Venous invasion Preoperative ↑ CEA (> 5 ng/ml) Aneuploidy SCREENING The earlier detection of localized, spf neoplasms in asymptomatic individuals will increase the surgical cure rate. 60% of early lesions are located in the RS Programs focused on digital rectal examination, testing stool for presence of occult blood 35-50% of CCR have a negative fecal Hemoccult test/intermittent bleeding pattern of these tumors CCR – 5-10% of “test +” cases with benign polyps TREATMENT TOTAL RESECTION of tumor – optimal management when a malignant lesion is endoscopically or radiologically detected in the large bowel Chest X-ray Biochemical assesment of liver function prior to surgery! Plasma CEA level Colonoscopy of the entire large bowel should be performend to identify synchronous neoplasm/polyps RADIATION THERAPY to the pelvis – in those with RC (30-40% regional reccurences after surgical resection of stages B, C tumors. Preoperative therapy is indicated for patients with large potentially unresecable cancers Postoperative radiotherapy reduces pelvic reccurences, but does not appear to prolong survival CHEMOTHERAPY 5FU + acid folinic ↑ the supression of DNA synthesis and accompanying cytotoxicity Chemotherapy + radiotherapy → B + C cancers Levamisol – nonspecific immunomodulator ANORECTAL PROBLEMS HEMORRHOIDS Whenever the internal hemorrhoidal plexus is enlarged it is associated increase in supporting tissue mass and the resultant venous swelling is called internal hemorrhoid. When veins in the external hemorrhoidal plexus became enlarged/thrombosed, resultant is external hemorrhoid. Both types are associated with increased hydrostatic pressure in the portel venous system during: Pregnancy Straining at stool Cirrhosis Pain only in: - thrombosis - infection - erosion of the overlying mucosal surface Other symptoms Bright red blood on the toilet/coating the stool Vague discomfort – prolapses through the anus – edema + sphinteric spasm The overlying mucous membrane may bleed profusely as the result of the trauma or defecation. DIAGNOSIS inspection digital examination direct vision through the anoscope and proctoscope hypochromic anemia acute blood loss – attributed to internal hemorrhoids chronic anemia – search for a polyp, ulcer, cancer TREATMENT Conservative therapy sitz baths suppositories stool softners bed rest Internal hemorrhoids which remain permanently prolapsed, are best treated surgically. Banding or injection by scleroting solutions in milder degrees of prolapse or enlargement with prurites ani or intermitent bleeding. External anus acutely thrombosed are treated by: incision extraction of the clot compression of the incised area following clot removal Rectoscopy and barium enema should always be performed before a patient is subjected to hemorrhoidectomy.