1.1. Alteration in bowel habitAlteration in bowel habit2.2. Rectal bleedingRectal bleeding3.3. PainPain4.4. Diarrhea/constipationDiarrhea/constipation5.5. Obstipation – absence of spontaneous bowel Obstipation – absence of spontaneous bowel

movementsmovements6.6. Hematochezia – fresh blood from the colon Hematochezia – fresh blood from the colon

or distal small intestineor distal small intestine7.7. Tenesmus - retention of stool in the rectumTenesmus - retention of stool in the rectum

- tumors- tumors - colonic inflammation- colonic inflammation

DIAGNOSTIC PROCEDURESDIAGNOSTIC PROCEDURES

Physical examinationPhysical examination Buccal pigmentation or telangiectazia → Buccal pigmentation or telangiectazia →

coexistent small bowel polyposis or intestinal coexistent small bowel polyposis or intestinal telangiectazia: abdominal pain, chronic telangiectazia: abdominal pain, chronic bleedingbleeding

IritisIritis ArthritisArthritis IBDIBD Erytema nodosusErytema nodosus Digital rectal examinationDigital rectal examination Stool examinationStool examination Barium studies – small bowel X-rays – Barium studies – small bowel X-rays –

enteroclysisenteroclysis

Barium enema - diverticulosisBarium enema - diverticulosis

- motility disturbances- motility disturbances

- loss of haustral markings- loss of haustral markings

- tumors- tumors Colonoscopy → detecting of colonic neoplasmsColonoscopy → detecting of colonic neoplasms Sigmoidoscopy → lower 40-60 cm of the colonSigmoidoscopy → lower 40-60 cm of the colon Mesenteric angiography - intestinal ischemiaMesenteric angiography - intestinal ischemia

- ac. GI hemorrhage (> 0,5 - ac. GI hemorrhage (> 0,5 ml/min)ml/min)

Radionuclide bleeding scan – iv injection of Tc99mRadionuclide bleeding scan – iv injection of Tc99m

Rate of 0,1-0,5 ml/min → the location of Rate of 0,1-0,5 ml/min → the location of radioactivity in the abdomen may indicate the radioactivity in the abdomen may indicate the source of bleedingsource of bleeding

DIVERTICULOSIDIVERTICULOSISS

congenital/acquiredcongenital/acquired

DefinitionDefinition herniations of the entire thickness of intestinal herniations of the entire thickness of intestinal

wallwall herniations of the mucosa through the herniations of the mucosa through the

muscularis, generally at the site of a nutrient muscularis, generally at the site of a nutrient arteryartery

Small-intestinal diverticulaSmall-intestinal diverticula Duodenal diverticulaDuodenal diverticula – abdominal pain, – abdominal pain,

fever, GI bleeding, perforationfever, GI bleeding, perforation Jejunal diverticulaJejunal diverticula – abcess or peritonitis – abcess or peritonitis

a) a) Multiple jejunal diverticula may be associated Multiple jejunal diverticula may be associated with a malabsorbtion syndrome → bacterial with a malabsorbtion syndrome → bacterial perforation → mucosal damage → deconjugation perforation → mucosal damage → deconjugation of bile salts + vit. B12 malabsorbtion of bile salts + vit. B12 malabsorbtion

Meckel’s diverticulum:Meckel’s diverticulum: congenital congenital anomaly of the digestive tract – 2% anomaly of the digestive tract – 2% cases/a persistent omphalomesenteric cases/a persistent omphalomesenteric ductduct

arises from the antimesenteric border of the arises from the antimesenteric border of the ileum usually within 100 cm of the ICVileum usually within 100 cm of the ICV

may produce hemorrhage, inflamation and may produce hemorrhage, inflamation and obstruction in children and teenagers.obstruction in children and teenagers.

Diagnosis:Diagnosis: isotope scanning (technetium i.v.)isotope scanning (technetium i.v.)

may mimic acute appendicites in may mimic acute appendicites in young adultsyoung adults

surgical excision of complicationssurgical excision of complications

COLONIC DIVERTICULACOLONIC DIVERTICULA Definition: Definition: herniations or sackke herniations or sackke

protrusion of the mucosa through the protrusion of the mucosa through the muscularis, at the point where a nutrient muscularis, at the point where a nutrient artery penetrates the muscularisartery penetrates the muscularis

occur most commonly in the sigmoid colon and occur most commonly in the sigmoid colon and decrease in frequency in the proximal colondecrease in frequency in the proximal colon

they increase with agethey increase with age 20-50% in western population > 50 years20-50% in western population > 50 years increase pressure produced by colonic muscle increase pressure produced by colonic muscle

contractions/↑ intraluminal pressurecontractions/↑ intraluminal pressure usually asymptomatic, are an incidental finding usually asymptomatic, are an incidental finding

on barium enema for others reasons.on barium enema for others reasons.

DIVERTICULITISDIVERTICULITIS Definition:Definition: inflammation in/around the inflammation in/around the

diverticular sacdiverticular sac Pericolic abcess → generalized peritonitisPericolic abcess → generalized peritonitis ↑ ↑ in men > 3 times in the left colonin men > 3 times in the left colon

ACUTE COLONIC DIVERTICULITISACUTE COLONIC DIVERTICULITIS feverfever left lower quadrant abdominal painleft lower quadrant abdominal pain muscle spasm, guarding, rebound tendernessmuscle spasm, guarding, rebound tenderness Rectal examinationRectal examination → tender mass-close to the rectum → tender mass-close to the rectum Acute constipationAcute constipation Rectal bleeding 25% casesRectal bleeding 25% cases LeukocytosisLeukocytosis Complications:Complications: acute peritonitis acute peritonitis

sepsis/stroke → elderly sepsis/stroke → elderly

Differential diagnosis:Differential diagnosis: Neoplasm of the descendent or sigmoid colonNeoplasm of the descendent or sigmoid colon TreatmentTreatment

1.1. bed restbed rest

2.2. stool softnessstool softness

3.3. liquid dietliquid diet

4.4. wide-spectrum antibiotic: tetracycline/ampicilinwide-spectrum antibiotic: tetracycline/ampicilin Repeated attacks of diverticulitis in the same Repeated attacks of diverticulitis in the same

area require surgical resectionarea require surgical resection Usual procedure:Usual procedure:

diverting colostomy with resection of the diverting colostomy with resection of the involved coloninvolved colon

reanastomosis is then performed at a reanastomosis is then performed at a second operation.second operation.

HEMORRHAGE FROM HEMORRHAGE FROM DIVERTICULADIVERTICULA

one of the commonest causes of hematochezia > 60 one of the commonest causes of hematochezia > 60 yearsyears

Mechanism:Mechanism: erosions of a vesel by a fecalith within erosions of a vesel by a fecalith within the diverticular sacthe diverticular sac

bed rest + blood transfusionbed rest + blood transfusion Bleeding scan/angiography → localization of bleedingBleeding scan/angiography → localization of bleeding ↑ ↑ in the ascending colonin the ascending colon

MEGACOLONMEGACOLON Definition:Definition: giant colon with masive distension giant colon with masive distension

and constipationand constipation congenital/aquired is seen in all age groupscongenital/aquired is seen in all age groups Acute toxic megacolonAcute toxic megacolon is a severe is a severe

complication of chronic uncerative colitiscomplication of chronic uncerative colitis

AGANGLIONIC MEGACOLON AGANGLIONIC MEGACOLON (Hirschsprung’s disease)(Hirschsprung’s disease)

congenital disorder which becomes manifest in early congenital disorder which becomes manifest in early infancy, occuring specially in males; often familialinfancy, occuring specially in males; often familialClinical featuresClinical features

massive abdominal distensionmassive abdominal distension absent bowel movementsabsent bowel movements impaired nutritionimpaired nutrition

Inability to defecate is caused by the absence of Inability to defecate is caused by the absence of ganglion cells (Meissner’s and Auerbach’s plexuses) ganglion cells (Meissner’s and Auerbach’s plexuses) in a small segment of the distal colon, near the anusin a small segment of the distal colon, near the anus

Barium enemaBarium enema reveals a narrowed segment in a RS reveals a narrowed segment in a RS area, with massive dilatation abovearea, with massive dilatation above

Diagnostic:Diagnostic: surgical biopsy full-thickness surgical biopsy full-thickness Treatment:Treatment: surgery which restores normal surgery which restores normal

defecationdefecation

CHRONIC IDIOPATHIC CHRONIC IDIOPATHIC MEGACOLONMEGACOLON

severe chronic constipation/rectal ampulla distended severe chronic constipation/rectal ampulla distended by gasby gas

Barium enema:Barium enema: entire colon distended with stools, no entire colon distended with stools, no narrowed segment narrowed segment

ACQUIRED MEGACOLON (Chaga’s ACQUIRED MEGACOLON (Chaga’s disease)disease)

in Central and South America Tripanosoma in Central and South America Tripanosoma cruzicruzi

the onset is in adult lifethe onset is in adult life patients with depression, schizophrenia, patients with depression, schizophrenia,

cerebral atrophy, mixedemacerebral atrophy, mixedema morphine, codeinemorphine, codeine

IRRITABLE BOWEL SYNDROMEIRRITABLE BOWEL SYNDROMEI.I. Spastic colitis: chronic abdominal painSpastic colitis: chronic abdominal pain

constipationconstipationII.II. Second group: chronic intermittent diarrheaSecond group: chronic intermittent diarrhea

without painwithout painGr. I + II → alternating constipation and diarrheaGr. I + II → alternating constipation and diarrhea

alternation of intestinal motilityalternation of intestinal motility have increased resting colonic motilityhave increased resting colonic motility have decreased resting colonic motilityhave decreased resting colonic motility Psychological stress increase motilityPsychological stress increase motility Abnormality of intestinal neuro-muscular Abnormality of intestinal neuro-muscular

function (↑ in 3 cycle/minute slow wave function (↑ in 3 cycle/minute slow wave activity)activity)

Depression, hysteria, obsessive-compulsive Depression, hysteria, obsessive-compulsive traits → exacerbate symptomstraits → exacerbate symptoms

Clinical featuresClinical features middle-aged adults female/male ratio 2:1middle-aged adults female/male ratio 2:1 history of chronic constipation/diarrhea or bothhistory of chronic constipation/diarrhea or both lower abdominal painlower abdominal pain excessive bloatingexcessive bloating weaknessweakness faintnessfaintness palpitationspalpitations

DiagnosisDiagnosis chronic intermittent nature of symptomschronic intermittent nature of symptoms relation of symptoms with emotional stressrelation of symptoms with emotional stress careful historycareful history complete physical examcomplete physical exam stool examination – occult bloodstool examination – occult blood

ColonoscopyColonoscopy excludes neoplasia excludes neoplasia Barium enema Barium enema spasticity of the sigmoid, spasticity of the sigmoid,

accentuated haustraaccentuated haustra Lactase deficiency may masquerade IBSLactase deficiency may masquerade IBS Tyrotoxicosis is confused with IBS → lab studiesTyrotoxicosis is confused with IBS → lab studies

TreatmentTreatment Minimaze symptoms impact on life-styleMinimaze symptoms impact on life-style Physician will prescribe physical exam, Physician will prescribe physical exam,

hemograms, occult blood at regular intervalshemograms, occult blood at regular intervals Surg. treatment: constipation → ↑ in dietary Surg. treatment: constipation → ↑ in dietary

burk laxativesburk laxatives

→ → mild sedationmild sedation

ANGIODYSPLASIA OF THE ANGIODYSPLASIA OF THE COLONCOLON

vascular ectasias in the right colon in older vascular ectasias in the right colon in older that may cause bleedingthat may cause bleeding

degenerative lesions of dilated, distorted, thin-degenerative lesions of dilated, distorted, thin-walled vessels lined by vascular endotheliumwalled vessels lined by vascular endothelium

2 nm → 1 cm 2 nm → 1 cm ΦΦ star-shaped branching vessels star-shaped branching vessels in submucosa in the cecum and ascending in submucosa in the cecum and ascending coloncolon

Angiography Angiography – extravasation of contrast – extravasation of contrast material into the lumenmaterial into the lumen

ColonoscopyColonoscopy – bleeding lesions – bleeding lesions Right hemicolectomy – multiple sites!Right hemicolectomy – multiple sites!

COLORECTAL CANCER (CCR)COLORECTAL CANCER (CCR)IncidenceIncidence

second to lung cancer as a cause of cancer death second to lung cancer as a cause of cancer death in the USin the US

males > 50 years oldmales > 50 years oldRisk factorsRisk factors

1.1. DietDiet more often in urban areas: low intake of dietary more often in urban areas: low intake of dietary

fiberfiber meat proteinmeat protein dietary fat and oil (“western” diet) → animal fatsdietary fat and oil (“western” diet) → animal fats ↑ ↑ cholesterol concentrationcholesterol concentration mortality from coronary artery diseasemortality from coronary artery disease hereditary syndroms:hereditary syndroms: Polyposis coli (25%)Polyposis coli (25%) (autosomal dominant)(autosomal dominant) Non-polyposis syndromeNon-polyposis syndrome

deletion in the long arm of chromosome 5 deletion in the long arm of chromosome 5

Inflammatory bowel disease (UC)Inflammatory bowel disease (UC)

↑ ↑ risk in young patients with risk in young patients with pancolitispancolitis Dietary fiber accelerates intestinal transit time, Dietary fiber accelerates intestinal transit time,

reducing the exposure of colonic mucosa to reducing the exposure of colonic mucosa to potential carcinogens and diluting these potential carcinogens and diluting these carcinogens because of enhanced fecal bulk.carcinogens because of enhanced fecal bulk.

Risk for the CCR is decreased by the addition of Risk for the CCR is decreased by the addition of calcium supplementscalcium supplements to the diet to the diet

Streptococcus Bovis BacteriemiaStreptococcus Bovis Bacteriemia RectosigmoidoscopyRectosigmoidoscopy – 5-10% of CCr 15-30 years – 5-10% of CCr 15-30 years

after after

POLYPSPOLYPS Adenomatous polypsAdenomatous polyps – premalignant 30% – premalignant 30%

middle age elderly peoplemiddle age elderly peopleClassification:Classification:

nonneoplastic hamartoma (juvenile polyps)nonneoplastic hamartoma (juvenile polyps) hyperplastic polypshyperplastic polyps adenomatous polypsadenomatous polyps

Deletion in chromosoms 5, 18, 17 (short arm) – Deletion in chromosoms 5, 18, 17 (short arm) – p53p53

Adenomatous polypd – pediculatedAdenomatous polypd – pediculatedsessile ↑ often premalignantsessile ↑ often premalignant

Villous polypsVillous polyps - ↑ premalignant - ↑ premalignantColonoscopyColonoscopy should be repeated periodically should be repeated periodically (even 3 years), even in the absence of a (even 3 years), even in the absence of a previously documented malignancy, since such previously documented malignancy, since such patients have a 30-50% probability of developing patients have a 30-50% probability of developing adenoma → risk of CCRadenoma → risk of CCR

CLINICAL FEATURESCLINICAL FEATURES

Symptoms vary with the anatomic location Symptoms vary with the anatomic location of the tumorof the tumor

I.I. Tumors in the ascending colonTumors in the ascending colon fatiguefatigue palpitations – APpalpitations – AP hypochromic microcytic anemia (↓ iron)hypochromic microcytic anemia (↓ iron)

II.II. Transverse + descending colon tumorsTransverse + descending colon tumors abdominal crampsabdominal cramps obstruction (occasional)obstruction (occasional) perforationperforation X-rays – “apple-are”, “napkin-sign”X-rays – “apple-are”, “napkin-sign”

III.III. Rectosigmoid tumorsRectosigmoid tumors hematocheziahematochezia tenesmustenesmus narrowing in the calibrum of stoolnarrowing in the calibrum of stool anemiaanemia

Digital rectal examination Digital rectal examination

are necessary!are necessary!

ProctosigmoidoscopyProctosigmoidoscopy

STAGING, PROGNOSTIC STAGING, PROGNOSTIC FACTORS, PATTERNS OF SPREADFACTORS, PATTERNS OF SPREAD

DUKES CLASSIFICATION OF CCRDUKES CLASSIFICATION OF CCR

STAGSTAGEE

PATHOLOGIC DESCRIPTIONPATHOLOGIC DESCRIPTION5 YEAR 5 YEAR

SURVIVAL SURVIVAL %%

AACancer limited to mucosa, Cancer limited to mucosa, submucosasubmucosa > 90%> 90%

BBCancer extends into Cancer extends into muscularismuscularis 70-85%70-85%

CCCancer involves regional Cancer involves regional lymph nodeslymph nodes 30-60%30-60%

DDDistant metastases (liver, Distant metastases (liver, lung, bone)lung, bone) 5%5%

POOR PROGNOSTIC PREDICTORS POOR PROGNOSTIC PREDICTORS FOLLOWING TOTAL RESECTIONFOLLOWING TOTAL RESECTION

T spread to regional lymph nodes (l.n.)T spread to regional lymph nodes (l.n.) Number of regional l.n. involvedNumber of regional l.n. involved T penetration through the bowel wallT penetration through the bowel wall Poorly differentiated histologyPoorly differentiated histology PerforationPerforation T adherence to adjacent organsT adherence to adjacent organs Venous invasionVenous invasion Preoperative ↑ CEA (> 5 ng/ml)Preoperative ↑ CEA (> 5 ng/ml) AneuploidyAneuploidy

SCREENINGSCREENING

The earlier detection of localized, spf neoplasms in The earlier detection of localized, spf neoplasms in asymptomatic individuals will increase the surgical asymptomatic individuals will increase the surgical cure rate.cure rate.

60% of early lesions are located in the RS60% of early lesions are located in the RS Programs focused on digital rectal examination, Programs focused on digital rectal examination,

testing stool for presence of occult bloodtesting stool for presence of occult blood 35-50% of CCR have a negative fecal Hemoccult 35-50% of CCR have a negative fecal Hemoccult

test/intermittent bleeding pattern of these tumorstest/intermittent bleeding pattern of these tumors CCR – 5-10% of “test +” cases with benign polypsCCR – 5-10% of “test +” cases with benign polyps

TREATMENTTREATMENT

TOTAL RESECTION of tumorTOTAL RESECTION of tumor – optimal – optimal management when a malignant lesion is management when a malignant lesion is endoscopically or radiologicallyendoscopically or radiologically detected in the large detected in the large bowelbowel

Chest X-rayChest X-ray Biochemical assesment of liver function prior to Biochemical assesment of liver function prior to

surgery!surgery! Plasma CEA levelPlasma CEA level Colonoscopy of the entire large bowel should be Colonoscopy of the entire large bowel should be

performend to identify synchronous neoplasm/polypsperformend to identify synchronous neoplasm/polyps

RADIATION THERAPYRADIATION THERAPY to the pelvis – in those with to the pelvis – in those with RC (30-40% regional reccurences after surgical RC (30-40% regional reccurences after surgical resection of stages B, C tumors.resection of stages B, C tumors.

Preoperative therapyPreoperative therapy is indicated for patients with is indicated for patients with large potentially unresecable cancerslarge potentially unresecable cancers

Postoperative radiotherapy Postoperative radiotherapy reduces pelvic reduces pelvic reccurences, but does not appear to prolong survival reccurences, but does not appear to prolong survival

CHEMOTHERAPYCHEMOTHERAPY 5FU + acid folinic ↑ the supression of DNA 5FU + acid folinic ↑ the supression of DNA

synthesis and accompanying cytotoxicitysynthesis and accompanying cytotoxicity Chemotherapy + radiotherapy → B + C Chemotherapy + radiotherapy → B + C

cancerscancers Levamisol – nonspecific immunomodulatorLevamisol – nonspecific immunomodulator

ANORECTAL PROBLEMSANORECTAL PROBLEMSHEMORRHOIDSHEMORRHOIDS

Whenever the internal hemorrhoidal plexus is Whenever the internal hemorrhoidal plexus is enlarged it is associated increase in supporting tissue enlarged it is associated increase in supporting tissue mass and the resultant venous swelling is called mass and the resultant venous swelling is called internal hemorrhoid.internal hemorrhoid.

When veins in the external hemorrhoidal plexus When veins in the external hemorrhoidal plexus became enlarged/thrombosed, resultant is external became enlarged/thrombosed, resultant is external hemorrhoid.hemorrhoid.

Both types are associated with increased hydrostatic Both types are associated with increased hydrostatic pressure in the portel venous system during:pressure in the portel venous system during:

PregnancyPregnancy Straining at stoolStraining at stool CirrhosisCirrhosis

Pain only in: - thrombosisPain only in: - thrombosis - infection- infection - erosion of the overlying mucosal - erosion of the overlying mucosal

surface surface

Other symptomsOther symptoms BrightBright red blood on the toilet/coating the stoolred blood on the toilet/coating the stool Vague discomfort – prolapses through the anus – Vague discomfort – prolapses through the anus –

edema +edema + sphinteric sphinteric

spasmspasm The overlying mucous membrane may bleed The overlying mucous membrane may bleed

profusely as the result of the trauma or defecation.profusely as the result of the trauma or defecation. DIAGNOSISDIAGNOSIS inspectioninspection digital examinationdigital examination direct vision through the anoscope and direct vision through the anoscope and

proctoscopeproctoscope hypochromic anemiahypochromic anemia acute blood loss – attributed to internal acute blood loss – attributed to internal

hemorrhoidshemorrhoids chronic anemia – search for a polyp, ulcer, cancerchronic anemia – search for a polyp, ulcer, cancer

TREATMENTTREATMENT Conservative therapyConservative therapy

sitz bathssitz baths suppositoriessuppositories stool softnersstool softners bed restbed rest

Internal hemorrhoids which remain permanently Internal hemorrhoids which remain permanently prolapsed, are best treated surgically.prolapsed, are best treated surgically.

Banding or injection by scleroting solutions in Banding or injection by scleroting solutions in milder degrees of prolapse or enlargement with milder degrees of prolapse or enlargement with prurites ani or intermitent bleeding.prurites ani or intermitent bleeding.

External anus acutely thrombosed are treated by: External anus acutely thrombosed are treated by: incisionincision extraction of the clotextraction of the clot compression of the incised area following clot compression of the incised area following clot

removalremoval Rectoscopy and barium enema should always be Rectoscopy and barium enema should always be

performed before a patient is subjected to performed before a patient is subjected to hemorrhoidectomy.hemorrhoidectomy.