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COLORECTAL SURGICAL

DISEASES
GROSS ANATOMY
LARGE INTESTINE
5 parts: ascending, transverse,
descending, sigmoid colon and rectum
Begins at the cecum - ileocecal valve
Appendix projects from the
convergence of the teniae at the lowest
part of the cecum
Ascending colon is retroperitoneal,
suspended from above at the hepatic
flexure by hepatocolic ligament
LARGE INTESTINE
ANATOMY
Transverse colon is intraperitoneal, from
hepatic flexure to the splenic flexure,
suspended by splenocolic and gastrocolic
ligaments
Descending colon is retroperitoneal,
continued by sigmoid colon
Sigmoid colon is intraperitoneal
Rectum begins at the level of S3, 12-15
cm. in length, passes the pelvic
diaphragm, ends in the anal canal
LARGE INTESTINE
ANATOMY
Rectum describes 3 lateral curves
Rectal ampulla is the most distal portion of
the rectum
Rectum ends at the anorectal junction
Anal canal, 4 cm. in length, ends at the
anal verge
Internal sphincter- smooth inner muscle
with involuntary control
Striated external sphincter- under
voluntary control
LARGE COLON
HISTOLOGY
Colonic wall- 4 layers: mucosa,
submucosa, muscularis propria, serosa
Mucosa is lined by columnar epithelium,
malignant cells confind to this are reffered
to as carcinoma in situ
1-2 cm. above the dentate line is a zone of
transitional epithelium having both
columnar and squamous cells
Below the dentate line, the anal canal is
lined by modified skin- no hair follicle, no
seb. glands
LARGE COLON
HISTOLOGY
Submucosa contains blood vessels and
lymphatics
Tumor cells must penetrate this layer to
gain access to the lymphatic system,
enabling metastatic spread
Submucosa is the strongest layer of the
bowel wall
Muscularis propria is made up of circular
and longitudinal smooth muscles
Rectum lacks a serosal layer
According to the depth invasion- Duke’s
staging
LARGE BOWEL
ARTERIAL SUPPLY
1.- Ileocolic art.- terminal branch of SMA
2.- Right colic art.- from SMA or ileocolic
3.- Middle colic art.- from SMA
4.- Left colic art- from IMA
5.- Rectosigmoid art.- from IMA
6.- Superior rectal art.- from IMA
7.- Middle rectal art.- from internal ileal
8.- Inferior rectal art.- from internal
pudental art.
LARGE BOWEL
VENOUS RETURN

Colorectal veins parallel the arteries


similarly named
Colon veins drain into the portal
system
Rectal veins drain into the portal and
systemic venous system
LARGE BOWEL
PHYSIOLOGY
Storage, transport, concentration of intestinal
waste products
Na, chloride, water are actively absorbed
The absorbative capacity of the colon is about 2
l/ day
Colonic mucosa secretes K and bicarbonate-
excessive diarrhea may result in potassium and
bicarbonate losses and metabolic acidosis
Colonic gas originates from both swallowed air
and the by-products of bacterial reactions
EVALUATION OF THE
COLON, RECTUM AND ANUS
History:

– Recent and past bowel habit


– Pattern of rectal bleeding
– Consistency of stool
– Family history of IBD, colonic polyps,
cancer
– Nature of pain
PHYSICAL EXAMINATION
Anorectal examination in the left
lateral decubitus:
– Inspection of the perianal region
– Digital rectal examination
– Anoscopy
– Sigmoidocopy
– Examination of stools
INVESTIGATIONS

1. Plain abdominal X ray


2. Barium enema
3. Endoscopy +/- biopsy
4. Abdominopelvic CT
5. Endoscopic ultrasonography
PLAIN ABDO X RAY
Assess the pattern of air and fluid
– Pneumoperitoneum
– Gaseous distention of small or large bowel
– Fluid level- topography
Routine examination of an acute
abdomen
Patient in stand up position during
exam.
This upright abdominal x-ray shows multiple air-
fluid levels, which are indicative of a bowel
obstruction.
Dilation of the large intestine,
indicated by the larger caliber
of the air-filled segments and
the transverse lines called
haustra.

The air extends into the left


lower quadrant and pelvis,
indicating that the obstructive
lesion is quite distal, in the
recto-sigmoid region.

Therefore this is a distal large


bowel obstruction
A 50 year old man underwent an above-knee amputation to remove his
gangrenous leg. He developed nausea and dyspneoa on the 4th
postoperative day. On examination he had tachypnoea and
tachycardia, but was apyrexic. On chest auscultation air entry was
reduced bilaterally at the lung bases. The abdomen, though distended,
was not tender and the bowel sounds were audible. Digital rectal
examination was unremarkable.
Acute colonic pseudo-obstruction or
Ogilvie syndrome
The chest radiograph shows dilated loops of large bowel. This finding
is confirmed on the plain abdominal film which shows a picture of
large bowel obstruction. There is no evidence of free gas under the
diaphragm.

A subsequent CT scan of the abdomen did not reveal a mechanical


cause of the condition and colonoscopic decompression was
theraputic.

Differential
Mechanical colonic obstruction
Toxic megacolon
Mesenteric ischaemia
Acute colonic pseudo-obstruction or Ogilvie syndrome is a
condition with clinical and radiological features of colonic
obstruction without any evidence of a mechanical cause.
Abdominal distension in this patient accounted for the respiratory
distress

Pathophysiology of Ogilvie syndrome is not clearly understood,


though it is thought to be due to an imbalance in the autonomic
innervation leading to a functional bowel obstruction.

Ogilvie syndrome typically occurs in patients hospitalized with a


significant illness e.g. severe cardio-respiratory disorders, sepsis,
electrolyte imbalance and postoperatively.

Left untreated it can progress to colonic perforation and peritonitis.


Complete colonic obstruction from an obstructing
carcinoma in the descending left colon with proximal air-
fluid levels.
The absence of air distally in the rectum or the sigmoid is
suggestive of complete obstruction.
The ileocecal valve is competent, and thus, there is no
small bowel air.
Upright radiograph: complete small bowel
obstruction
Upright radiograph shows
multiple air-fluid levels of
varying size arranged in
inverted Us.

In the right lower pelvis, a


loop of small bowel is seen
a finding suggestive of
adhesive obstruction.
CONTRAST ENEMA
It is not an emergent investigation
Requires bowel preparation
Instant enema in rare occasions
Indicated in assessing colon polyps,
tumors or diverticulosis.
If perforation is suspected- contrast
substance used-gastrografin
SINGLE CONTRAST
BARIUM ENEMA
DOUBLE CONTRAST
BARIUM ENEMA
ENDOSCOPIC STUDIES
Rigid proctorectoscopy- can examine
25 cm. from the anal verge

Position of the patient-lateral


decubitus or prone jacknife position

Bowel preparation- 2 enemas only


COLONOSCOPY
Can assess the entire length of the
colon
Concurrent biopsy and polypectomy
is possible
Inssuflation of air induces some
discomfort for the patient
Bowel preparation mandatory
COLONOSCOPY
INDICATIONS:
– The treatment of polyps
– Suspicious colon cancer
– Evaluation of a positive fecal occult blood test
– Follow-up in pts. with IBD
Bowel preparation:
- Nil by mouth for 8 h. prior to the procedure
- Laxatives
- Enemas
COLONOSCOPY
NORMAL COLONIC SURFACE
IRRITABLE BOWEL SYNDROME
Named in the past “spastic colon”
Clinical features:
– Episodic cramping abdo pain at any time of the
day
– Episodes can last from 15 min.- several hours
– The pain is unrelated to meals
– It may occur anywhere in the abdomen
– Symptoms occur daily for weeks at a time
– Worse at times of sress
– Eratic bowel habit- loose stools/constipation
– Abdominal distention/excess flatus
IRRITABLE BOWEL SYNDROME
Pathophysiology- low fiber diet seems
to play a part
Colonic motility studies
– abnormal rises in intraluminal pressure,
– disordered peristalsis
The small volume of feces-dehydrated,
fragmented- rabbit pallets
Imbalance in gut hormonal and
autonomic control systems
IRRITABLE BOWEL SYNDROME
Management
– Carcinoma and diverticulosis must be excluded by
colonoscopy/barium enema

Treatment:
- reasurence
- adjusting the diet to include adequate fibre
- bulking agents, antispasmodic drugs
- codeine phosphate-analgesic for occasional use
- relaxation therapy
SIGMOID VOLVULUS
Pathophysiology
Chronic constipation- enlarged, elongated,
atonic sigmoid colon= dolicomegacolon
Occasionally, the huge sygmoid loop, heavy
with feces becomes twisted on its
mesenteric pedicle- closed loop obstruction
Venous infarction- perforation-peritonitis
SIGMOID VOLVULUS
Clinical features:
– Elderly, mentally handicaped
– Abdominal distension, abdominal pain
– Assymetrical distension, tympanism
– Variable degree of tenderness
– Absolute constipation for at least 24
hours
– Perforation- peritonitis
– PR- the rectum is empty
SIGMOID VOLVULUS
Management:
– Plain abdominal x ray- single grossly dilated
sigmoid loop often reaching the xiphisternum
– An erect film- a characteristic” inverted U” of
bowel gas in the upper abdomen with fluid
level at the same height in the two bowel limbs
in the lower abdomen
– An abdominal lateral decubitus x ray may
reveal two parallel fluid levels running the full
length of the abdomen
SIGMOID VOLVULUS
Management
– Rectoscope is passed as far as possible into the
rectum and a flatus tube inserted through it
– The end of the flatus tube is then gently
manipulated through the twisted bowel into the
obstructed loop
– If this is successful there is a gush of liquid
feces and flatus relieving the obstruction
– The flatus tube left in-situ for 24 hours
SIGMOID VOLVULUS
Acute large bowel obstruction-
instant enema may define the lesion
Persistent volvulus- urgent operation
Sigmoidectomy with colorectal
anastomosis / Hartmann procedure
After a period of recovery following
Hartmann op.- redo colorectal
anastomosis
DIVERTICULAR DISEASE
Common condition- chronic lack of
dietary fiber

Patients over 60 years of age

Female are more affected


DIVERTICULAR DISEASE
Pathophysiology
– Chronic constipation- hypertrophy of the
colonic wall muscle
– Increased intestinal pressure- pockets of
mucosa herniating through weak points
in the bowel wall
– Potential defects are where mucosal
blood vessels penetrate the wall from
outside
DIVERTICULAR DISEASE
Sigmoid colon is most affected
Isolated diverticula- congenital
Asymptomatic condition- diverticulosis
Complications:
– Acute diverticulitis
– Pericolic abscess
– Fistula formation
– Hematochesis
– Bowel obstruction: strictures, adhesions
DIVERTICULAR PERFORATION
Diverticular abscess ruptures within
peritoneal cavity- fecal peritonitis
Acute abdomen
Abdominal X ray- pneumoperitoneum
Treatment
– i.v.antibiotics
– Laparotomy, diversion of fecal stream
with resection of the affected bowel,
after 3 months, re-do anastomosis
ACUTE INFLAMMATION
MECKEL DIVERTICULUM
MECKEL’S DIVERTICULUM
Common congenital diverticulum on
the wall of the terminal small bowel
May contain stomach or pancreatic
tissue
Complications:
– Diverticulitis, perforation, peritonitis
– GI bleeding- melena
– Intussusception- bowel obstruction
Surgery- removal, enteroraphy
MECKEL DIVERTICULUM
FISTULA FORMATION
Occurs when an inflammed diverticulum
lies in close proximity to another hollow
viscus
Fistula formation:
– Colo- intestinal fistula- diarrhea
– Colo-vesical fistula- pneumaturia
– Colo-vaginal fistula- fecal vaginal discharge
Differential diagnosis- Crohn’s or tumoral fistula
Diagnosis: endoscopy, barium enema
Treatment- excision of the affected segment of
bowel
ACUTE RECTAL BLEEDING
Hematochezia
Bleeding always stops spontaneously
Differential diagnosis- ischemic colitis,
carcinoma, piles
Management- rarely surgical
The patient is kept under observation, on
conservative treatment
Check barium enema
BOWEL OBSTRUCTION
Due to: acute inflamm. wall thickening
muscle hypertrophy, bowel spasm
Incomplete obstruction- more common
Chronic diverticular inflammation-
fibrous bands, adhesions
Barium enema, colonoscopy
Treatment-segmental colectomy
CLINICAL PRESENTATION
DIVERTICULAR DISEASE
Chronic grumbling diverticular pain
– Chronic pain and low-grade
– Erratic bowel habit
– Mild iliac fossa tenderness
– Abdo x ray- fecal loading
– Barium enema- excludes malignancy
– Symptoms relieved by high fiber diet
and bulking agents
ACUTE DIVERTICULITIS
Acute inflammation with local extension
to pericolic tissue and parietal
peritoneum
Continuous LIF pain
Fever, tachycardia, malaise
Tenderness LIF
Antibiotics against colonic flora:
cefalosporins, gentamycine,
metronidazol
PERICOLIC ABSCESS
Pus formation following further extension
of acute inflammation
Antibiotics fail to resolve the problem
Swinging pyrexia
Persistent pain and tenderness
Abdominal distension- partial bowel
obstruction
Diagnosis: USS, barium enema
Treatment: bowel resection, Hartmann-
redo anastomosis later
COMPLICATIONS OF
ILEOSTOMY AND COLOSTOMY
Early complications
– Mucosal necrosis due to ischemia- refashion
– Obstruction of stoma due to edema of fecal
impaction
– Persistent leakage between skin and appliance-
skin erosion and patient distress
Late complications
– Prolapse of bowel-refashioning of stoma
– Parastomal hernia-resiting of stoma
– Retraction- refashioning of stoma