Colon,Colon, Rectum,Rectum, andand AnusAnus

SouthSouth CollegeCollege PAPA SurgicalSurgical CourseCourse ColonColon andand RectumRectum

„ TerminalTerminal portionportion ofof GIGI tracttract „ TwoTwo functionsfunctions „ AbsorptionAbsorption ofof water,water, electrolyteselectrolytes „ StorageStorage ofof fecesfeces „ BiologicallyBiologically notnot essentialessential „ DiseaseDisease isis veryvery commoncommon

AnatomyAnatomy

„ MultipleMultiple partsparts „ RetroperitonealRetroperitoneal andand peritonealperitoneal portionsportions „ ExternalExternal longitudinallongitudinal musclemuscle layerslayers——teniaeteniae colicoli „ RectumRectum——1515 cm,cm, externalexternal layerlayer continuouscontinuous „ AnusAnus——33--44 cmcm fromfrom dentatedentate lineline toto analanal vergeverge „ AboveAbove dentatedentate lineline----insensateinsensate

AnatomyAnatomy

„ BloodBlood supplysupply toto coloncolon fromfrom superiorsuperior andand inferiorinferior mesentericmesenteric arteriesarteries „ JunctionJunction——relativelyrelatively poorpoor bloodblood supplysupply „ RectumRectum——threethree sourcessources——IMA,IMA, internalinternal iliac,iliac, internalinternal pudendalpudendal „ VenousVenous drainagedrainage ofof rectumrectum toto IMV/portalIMV/portal andand toto systemicsystemic circulationcirculation „ ConnectedConnected byby venousvenous cushionscushions----rrhoidsrrhoids

DiagnosisDiagnosis

„ DigitalDigital rectalrectal examexam „ EndoscopyEndoscopy——routineroutine afterafter 50,50, qq 33--55 yearsyears „ AbdominalAbdominal seriesseries——pneumoperitoneumpneumoperitoneum,, obstruction,obstruction, volvulusvolvulus „ ContrastContrast studiesstudies „ CTCT scanscan „ Angiography/nuclearAngiography/nuclear studystudy TerminologyTerminology

„ OstomyOstomy——externalexternal openingopening „ Colostomy,Colostomy, ileostomyileostomy „ DistalDistal segmentsegment „ MucusMucus fistula,fistula, HartmannHartmann’’ss pouch,pouch, looploop „ --ectomyectomy——resectionresection „ Colectomy,Colectomy, proctocolectomyproctocolectomy,, abdominoperinealabdominoperineal resectionresection (APR),(APR), lowlow anterioranterior resectionresection

DiverticularDiverticular DiseaseDisease

„ TrueTrue diverticuladiverticula——allall layers,layers, rarerare inin coloncolon „ AcquiredAcquired (false(false oror pseudopseudo--)) diverticuladiverticula—— mucosalmucosal herniationherniation throughthrough musclemuscle „ RelatedRelated toto diet,diet, straining,straining, ageage „ DiverticulosisDiverticulosis——presencepresence ofof diverticuladiverticula „ DiverticulitisDiverticulitis——infectiousinfectious processprocess

DiverticulosisDiverticulosis

„ MultipleMultiple falsefalse diverticuladiverticula ofof coloncolon „ MostMost commonlycommonly inin sigmoidsigmoid „ 80%80% asymptomaticasymptomatic findingfinding onon BE,BE, otherother studystudy „ SymptomsSymptoms——LLQLLQ pain,pain, changechange inin bowelbowel habits,habits, bleedingbleeding „ TreatmentTreatment——highhigh fiberfiber dietdiet

DiverticulitisDiverticulitis

„ Obstructed, infected diverticula „ Micro or macro perforation „ 1/6 of patients with –osis will have –itis „ Pain, change in bowel habits, possible mass, fever, white count, peritoneal signs „ Complications—44% perf or abscess, 8% fistula, 4% obstruction „ Diagnosis—CT, BE, scope later „ Treatment—antibiotics, hydration, NPO „ Surgery for severe complication or repeated bouts

FistulaFistula formationformation

„ ColovesicalColovesical mostmost commoncommon (4%)(4%) „ UTI,UTI, fecaluriafecaluria,, pneumaturiapneumaturia „ OtherOther causescauses——cancer,cancer, CrohnCrohn’’s,s, radiation,radiation, traumatrauma „ DiagnosisDiagnosis——contrastcontrast——BE,BE, cystocysto,, IVP,IVP, methylenemethylene blueblue „ TreatmentTreatment----surgicalsurgical

DiverticularDiverticular BleedingBleeding

„ BleedingBleeding primaryprimary symptomsymptom inin 55--10%10% „ OccasionallyOccasionally massivemassive (>4(>4 unitsunits inin 2424 hours)hours) „ BleedingBleeding distaldistal toto LigamentLigament ofof TreitzTreitz——70%70% diverticular,diverticular, 25%25% isis massivemassive „ DifferentialDifferential——angiodysplasiaangiodysplasia,, solitarysolitary ulcers,ulcers, varicesvarices,, cancer,cancer, rarelyrarely IBDIBD „ DiagnosisDiagnosis——endoscopy,endoscopy, angioangio ColonicColonic PolypsPolyps

„ InflammatoryInflammatory polypspolyps ((pseudopolypspseudopolyps))——IBDIBD „ HamartomasHamartomas (juvenile(juvenile polyps,polyps, PeutzPeutz--JehgersJehgers syndrome)syndrome)——benign,benign, maymay regressregress „ AdenomasAdenomas——premalignant,premalignant, esp.esp. >2>2--33 cmcm „ Tubular-7%, tubulovillous-20%, villous-33% „ PedunculatedPedunculated——onon stalk,stalk, removeremove byby scopescope „ SessileSessile (flat)(flat)--removeremove surgicallysurgically „ FamilialFamilial polyposispolyposis oror GardnerGardner’’ss syndromesyndrome——totaltotal abdominalabdominal colectomy,colectomy, mucosalmucosal proctectomyproctectomy,, ileoanalileoanal pullthroughpullthrough ColonColon CancerCancer

„ 55,00055,000 deathsdeaths annuallyannually „ 140,000140,000 newnew casescases eacheach yearyear „ MoreMore occuroccur onon lowerlower leftleft side?side? „ SynchronousSynchronous (simultaneous)(simultaneous) inin 5%5% „ MetachronousMetachronous (second(second developsdevelops afterafter resection)resection) inin 33--5%5% th „ PeakPeak atat 70,70, startstart inin 44th decadedecade „ FamilialFamilial polyposispolyposis,, GardnerGardner’’s,s, UC,UC, CrohnCrohn’’s,s, polypspolyps ColonColon CancerCancer

„ 55 yearyear survivalsurvival——60%60% „ EffectiveEffective screeningscreening „ EffectiveEffective screeningscreening strategies,strategies, basedbased onon riskrisk „ Mild risk factors—age, diet, physical inactivity, obesity, smoking, race, alcohol „ Intermediate risk factors—personal history of colon cancer or adenoma or strong family history „ High risk factors—familial polyposis, Gardner’s, patients with UC or Crohn’s for > 10 years ScreeningScreening——MildMild RiskRisk

„ BeginningBeginning atat ageage 50,50, oneone ofof below:below: „ YearlyYearly fecalfecal occultoccult bloodblood testtest plusplus flexibleflexible sigmoidoscopysigmoidoscopy qq 55 yearsyears „ FlexFlex sigsig qq 55 yearsyears „ YearlyYearly fecalfecal occultoccult bloodblood testtest „ ColonoscopyColonoscopy qq 1010 yearsyears „ DoubleDouble contrastcontrast BEBE qq 55 yearsyears ScreeningScreening——GreaterGreater RiskRisk

„ IntermediateIntermediate riskrisk „ BeginBegin atat 4040 „ DoDo moremore frequentlyfrequently——qq 33--55 yearsyears „ HighHigh riskrisk——functionfunction ofof durationduration „ BloodBlood teststests forfor familialfamilial polyposispolyposis,, HNPCCHNPCC „ ScreeningScreening beginbegin inin teensteens „ UC/CrohnUC/Crohn’’ss forfor 1010 years,years, annualannual colonoscopycolonoscopy „ ConsiderConsider prophylacticprophylactic totaltotal colectomycolectomy ColonColon CancerCancer——SignsSigns andand SymptomsSymptoms

„ RightRight--sidedsided——occultoccult bloodblood loss,loss, anemiaanemia „ LeftLeft--sidedsided——obstruction,obstruction, macromacro bleedingbleeding „ RectalRectal——bleeding,bleeding, obstruction,obstruction, alternatingalternating diarrheadiarrhea andand constipationconstipation „ ChangeChange inin bowelbowel habitshabits and/orand/or bleeding:bleeding: „ RectalRectal exam,exam, occultoccult bloodblood testtest „ BEBE oror colonoscopycolonoscopy ColonColon CancerCancer——PreopPreop EvaluationEvaluation

„ ColonoscopyColonoscopy——synchronoussynchronous lesionslesions „ CTCT---- ++ oror –– „ CEACEA bloodblood testtest „ TreatmentTreatment——surgerysurgery toto removeremove primary,primary, evaluateevaluate extentextent ofof spread,spread, allowallow stagingstaging andand planplan furtherfurther therapytherapy ColonColon CancerCancer----StagingStaging

„ DukesDukes--AstlerAstler--CollerColler SystemSystem „ TMNTMN StagingStaging „ BothBoth evaluateevaluate extentextent ofof penetrationpenetration throughthrough colon,colon, nodalnodal involvement,involvement, andand distaldistal metsmets „ AdjuvantAdjuvant chemotherapychemotherapy——5FU,5FU, othersothers „ Radiation,Radiation, especiallyespecially inin pelvispelvis StagingStaging

AJCC/TNM Dukes Astler-Coller

0

IAA, B1

IIA B B2

IIB B B3

IIIA C C1

IIIB C C2, C3

IIIC C C1, C2, C3

IV D ColonColon CancerCancer----FollowupFollowup

„ CurativeCurative resection,resection, nono adjuvantadjuvant therapytherapy indicatedindicated „ MonthlyMonthly exam,exam, bimonthlybimonthly CEA,CEA, scopescope oror BEBE qq 66 monthsmonths forfor firstfirst twotwo yearsyears „ PETPET scanscan „ CTCT scansscans IBDIBD——UlcerativeUlcerative ColitisColitis

„ MucosaMucosa andand submucosasubmucosa ofof coloncolon andand rectumrectum „ BimodalBimodal distributiondistribution——2/32/3 occuroccur atat 1515--30,30, remainderremainder atat 5555 „ 10/100,00010/100,000 populationpopulation „ FamilyFamily historyhistory inin 20%20% „ RectumRectum involvedinvolved inin >90%>90% withwith proximalproximal extensionextension UlcerativeUlcerative ColitisColitis

„ PresentationPresentation——variablevariable „ Watery diarrhea with blood, pus, mucus „ Cramping, abdominal pain, tenesmus, urgency „ Weight loss, dehydration, pain, fever „ Fulminant—toxic megacolon, sepsis, shock „ Extraintestinal signs: ankylosing spondylitis, peripheral arthritis, uveitis, pyoderma gangrenosum, sclerosing cholangitis, pericholangitis, pericarditis „ Complications: toxic megacolon, colon perforation, massive hemorrhage, anorectal complication, cancer IBDIBD——CrohnCrohn’’ss DiseaseDisease

„ TransmuralTransmural disease,disease, anywhereanywhere inin GIGI tracttract „ MinorityMinority——limitedlimited toto colorectalcolorectal „ AlsoAlso bimodalbimodal distributiondistribution „ CommonlyCommonly inin terminalterminal ileumileum „ DiffersDiffers fromfrom UC:UC: rectalrectal sparing,sparing, skipskip lesions,lesions, aphthousaphthous sores,sores, linearlinear ulcersulcers ColonColon ObstructionObstruction

„ 1010--15%15% ofof intestinalintestinal obstructionsobstructions „ MostMost commonlycommonly sigmoidsigmoid „ AdenocarcinomaAdenocarcinoma——65%,65%, diverticulitisdiverticulitis scarringscarring——20%,20%, volvulusvolvulus——5%5% „ InflammatoryInflammatory disorders,disorders, benignbenign tumors,tumors, foreignforeign bodies,bodies, fecalfecal impactionimpaction „ AdhesiveAdhesive bandsbands——rarerare inin coloncolon ColonColon ObstructionObstruction

„ PresentationPresentation——abdominalabdominal distention,distention, crampingcramping abdominalabdominal pain,pain, nauseanausea andand vomiting,vomiting, obstipationobstipation „ RadiographsRadiographs——distendeddistended proximalproximal colon,colon, airair--fluidfluid levels,levels, nono rectalrectal airair „ BariumBarium enemaenema oror scopescope maymay definedefine areaarea ofof obstructionobstruction „ IVIV fluids,fluids, NPO,NPO, NGNG suctionsuction „ EmergentEmergent laplap forfor cecumcecum >> 1212 cmcm oror peritonealperitoneal signssigns ColonColon ObstructionObstruction

„ OgilvieOgilvie’’ss syndromesyndrome——nonobstructivenonobstructive dilationdilation „ VolvulusVolvulus——rotationrotation onon axisaxis ofof mesenterymesentery „ 55--10%10% ofof largelarge bowelbowel obstructionsobstructions „ SigmoidSigmoid——70%70% „ CecalCecal——30%30% „ MoreMore commoncommon inin elderlyelderly

CecalCecal VolvulusVolvulus SigmoidSigmoid VolvulusVolvulus AnusAnus andand rectumrectum

„ Pain,Pain, protrusion,protrusion, bleeding,bleeding, dischargedischarge „ EveryoneEveryone complainscomplains ofof hemorrhoidshemorrhoids „ MustMust examine,examine, butbut bebe gentlegentle „ InspectionInspection——fissures,fissures, skinskin tags,tags, hemorrhoids,hemorrhoids, fistulae,fistulae, tumors,tumors, dermatologicdermatologic oror infectiousinfectious conditionsconditions „ DigitalDigital examexam——tumors,tumors, polyps,polyps, sphinctersphincter weaknessweakness RectalRectal ProlapseProlapse

„ ProcidentiaProcidentia „ FullFull thicknessthickness intussusceptionintussusception ofof rectumrectum throughthrough analanal openingopening „ MoreMore commoncommon inin thinthin womenwomen „ SymptomsSymptoms——rectalrectal pain,pain, mildmild bleeding,bleeding, incontinence,incontinence, mucousmucous discharge,discharge, moisturemoisture

HemorrhoidsHemorrhoids

„ PrecipitatedPrecipitated byby constipation,constipation, straining,straining, pregnancy,pregnancy, increasedincreased pelvicpelvic pressurepressure ((ascitesascites,, tumor),tumor), portalportal hypertension,hypertension, diarrheadiarrhea „ FoundFound inin 33 positions:positions: leftleft lateral,lateral, rightright anterior,anterior, rightright posteriorposterior „ InternalInternal——aboveabove dentatedentate line,line, externalexternal belowbelow

HemorrhoidsHemorrhoids

„ PresentationPresentation——protrusion,protrusion, bleeding,bleeding, painpain st nd „ ProtrusionProtrusion——44 degrees,degrees, 11st dondon’’t,t, 22nd dodo withwith stool,stool, thenthen reduce,reduce, 33rd mustmust bebe reduced,reduced, 44th wonwon’’tt reducereduce „ BleedingBleeding usuallyusually minimal,minimal, coatscoats stoolstool „ PainPain withwith thrombosis,thrombosis, ulcer,ulcer, gangrenegangrene

PainPain inin thethe --

„ PerianalPerianal oror perirectalperirectal abscessesabscesses——pain,pain, fever,fever, swellingswelling „ FistulaFistula--inin--anoano——connectionconnection betweenbetween anusanus andand skinskin——chronicallychronically draindrain puspus „ AnalAnal fissuresfissures——mostmost commoncommon causecause ofof anorectalanorectal painpain „ Linear tears in lining of anal canal „ Worse with defecation „ Sphincter spasm OtherOther AnorectalAnorectal ConditionsConditions

„ AnalAnal malignancymalignancy——33--4%4% ofof colorectalcolorectal CACA „ EpidermoidEpidermoid CACA oror malignantmalignant melanomamelanoma „ STDSTD’’ss——analanal condylomacondyloma (HPV),(HPV), ChlamydiaChlamydia andand lymphogranulomalymphogranuloma venereumvenereum,, gonorrhea,gonorrhea, herpesherpes simplexsimplex