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Anatomy
Physiology
Diseases of colon
Diverticular disease
Massive Lower GI Bleeding
Acute colonic obstruction
Colon cancer
Transverse colon
Anatomy
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cecum
Sigmoid
colon
Anatomy
Histology : 4 layers
Teniae coli
Haustra coli
plicae semilunares
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Appendices epiploicae
Anatomy
Anatomy
Lymphatic drainage
Epicolic group
Paracolic group
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Intermediate
group
Main group ( SMA IMA)
Anatomy
Nerve supply
Sympathetic :T7 T12 Supply Rt.colon
L1-L3 Supply Lt.colon and Rectum
inhibit peristalsis
Anatomy
Nerve supply
Parasympathetic : S 2-4 (Nervi ergentes)
Vagus nerve supply Right colon
Sacral nerve supply distal colon
Stimulate Peristalsis
Physiology
Physiology
Colonic microflora
Bacteroides : dominant bacteria
1011 - 1012 bacteria / gm. of feces
E.coli 108 1010 bacteria / gm. of feces
breakdown CHO, protein
produce Vit.K
Physiology
Colonic gas
N2 , O2 , CO2 , H2 , CH4
99% of all gas in gut
N2 , O2 : swallowing air
CO2 , H2 , CH4 : bacterial fermentation
* H2 , CH4 : Combustible gas
Adequate bowel cleansing
Polyethylene glycol No Burst
Physiology
Motility
Retrograde movement
Segmental contractions
Mass movement
Physiology
Factors that effect colonic motility
- Emotion
- Exercise
- Sleep
- Diet : Polysaccharide, cellulose
- Gut hormone : Cholecystokinin
- Drug : Morphine
- Neurogenic control
Diseases of Colon
Diverticulosis
Diverticulum
colon
Diverticular Disease
Definitions
Diverticulum - outpouching from hollow organ
Diverticulosis - presence of diverticula
Diverticulitis - inflammation of diverticula
Diverticular disease presence of diverticula
with symptoms presentation
Complicated diverticular disease presence
diverticulum with perforation , fistula ,
obstruction or bleeding
Diverticular Disease
Epidemiology
Sex (M:F) as 2: 3
Age : More common with increasing age
< 40 incidence 2-29 %
> 60 incidence 60 %
> 80 incidence 70 %
95% in the sigmoid
Diverticular Disease
Pathogenesis
Increased intraluminal pressure + segmentation
Herniation of mucosa through muscular wall,
covered by serosa
Occur where vasa recta penetrate bowel wall
Weakness of colonic walls
Associated with low-fiber diet
Dense packed diverticulosis
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Colonoscopic view
Diverticulosis
Diverticulosis
Diverticulitis
Infection associated with diverticulum
Peridiverticulitis
LLQ pain, bowel habit change,
fever with chills
Tenderness over left lower abdomen
Tender mass at LLQ phlegmon or abscess
Abdominal distention : ileus, obstruction
Pelvic tenderness by DRE
Diverticulitis
Uncomplicated 85%
Complicated 15%
Abscess
Perforation
Fistula
Stricture/obstruction
(Bleeding)
Diverticulitis
Investigation
Limited sigmoidoscopy
CT abdomen
Ultrasonography
Contrast enema
Diverticulitis
CT Scan
Diagnostic of choice
Stages extent of extramural inflammation
Prognostic significance
Diverticulitis
Treatment
Non-operative treatment No peritonitis
Operative treatment
Peritonitis
Recurrence
Special circumstances
Acute Diverticulitis
with
Immunocompromise
d
Can not exclude
malignancy
Diverticulum more
than 4 cm
Surgery
Conservative
Incidence of GI bleeding
UGIB
40-50 episodes/100,000/year
mortality 6-10%
LGIB
20-27 episodes/100,000/year
mortality 4-10%
Lower GI bleeding
Melena
Stool occult blood
Lower GI bleeding
Lower GI bleeding
Prevalence
Upper GI tract
Peptic ulcer disease
Gastritis/duodenitis
Esophageal varices
Mallory-Weiss tear
Esophagitis
Gastric cancer
Dieulafoys lesion
Gastric arteriovenous malformations
Portal gastropathy
40-79%
5-30%
6-21%
3-15%
2-8%
2-3%
<1
<1
<1
Prevalence
70-80%
Prevalence
17-40%
2-30%
9-21%
11-14%
4-10%
-
Colonic
diverticula
Colonic
diverticula
Colonic
diverticula
(Non bleeding)
(bleeding)
(Non bleeding
visible vessel)
Colonoscopy of angiodysplasia
discrete (<5mm.)
hyperemic lesion
with frond-like or
scalloped edges
Internal hemorrhoids
Non bleeding
Internal
hemorrhoids
(bleeding)
Approach to LGIB
How severe?
high risk vs low risk
Severity
BLEED criteria
(predicts outcome for any GI bleeding :UGIB&LGIB)
B
L
E
E
D
ongoing Bleeding
Low systolic blood pressure
Elevated prothrombin time
Erratic mental status
unstable comorbid Disease
odd ratio
Severity of
LGIB
252 Pts. with LGIB
(mean age 66 yr.)
Approach to LGIB
How severe?
high risk vs low risk
Site of bleeding
bedside examination
- PR
- NG tube lavage EGD scopy
- proctoscopy
- rigid sigmoidoscopy
investigation
- Colonoscopy
- Radionuclide scan
- Angiogram
- Barium enema
- MDCT
- Capsule enteroscopy
Colonoscopy
Urgent colonoscopy
(within 6-12 hr.)
Radionuclide scans
Indications
Identification of Gastrointestinal Bleeding site
Preoperative evaluation for occult GI Bleeding
Criteria may include
Early positive Tagged Red Cell Scan
Frequent blood transfusion required
Hemodynamic compromise
ANGIOGRAPHY
Advantages
accurate localization is
specificity - 100%
sensitivity
therapeutic intervention
Disadvantages
requires active bleeding
> 0.5 cc/min
invasive
complication of angiography
ischemia
infarction
ANGIODYSPLASIA
Barium enema
Capsule endoscopy
Advantage
Noninvasive
High
sensitivity
Disadvantage
May
Accurate
Angiography
localization
Variable sensitivity
Does not require bowel prep.
Has to be perform during active
Can use catheter for vasopressin bleeding
infusion or embolization
Complication of angiography
Poor
Colonoscopy
visualization in unprepared
colon
Precise localization
Risks of sedation in acutely
Potential therapeutic intervention
bleeding patient
Variable sensitivity
Management of LGIB
Endoscopic management
Intervention angiography
Surgery
Management of LGIB
Endoscopic management
Intervention angiography
Surgery
Endoscopic management
Management of LGIB
Endoscopic management
Intervention angiography
Surgery
Intervention angiography
Indication angiogram
Intervention angiography
Active bleeding
Superselective embolization
Methylene blue for Guide
Complication : Gangrene or peritonitis
Laparoscopic diagnosis : 48-72 hrs
MESENTERIC CIRCULATION
ANGIOGRA
M
EMBOLIZATION
Management of LGIB
Endoscopic management
Intervention angiography
Surgery
10-20% need Sx
pre-op localization is very important
surgery without bleeding localization should be avoid
lithotomy position
directed segmental resection is preferred
subtotal colectomy if no bleeding site identified
o
o
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LGIB 77 patients
Limited colon resection (LCR) 50 patients
Total or subtotal colon resection (TCR) 27 patients
Recurrent bleeding LCR > TCR
Complication : not different significant
91
Rebleed
Mortality
Right colectomy
(n=78)
19%
5%
Left colectomy
(n=92)
38%
32%
Total colectomy
(n=94)
2%
16%
1989
Option for Sx
Segmental resection
(know site of bleeding)
subtotal colectomy
(with ileorectal anastomosis or ileostomy)
intraoperative colonoscopy
(not popular; may not helpful)
severe hematochezia
initial evaluation and resuscitation
NG tube
aspiration
bile; no blood
all other
negativ
e
exam
colonoscopy
source
identif
y
Rx as
appropiate
negative
exam
bleeding
stop?
y
e
small bowel study
s
EGD
UGI
sourc
e
not
Rx as
possible
appropiate
due to
severity
n of
o bleedinarteriography
g(+ nuclear scan first)
1998
Colon cancer
Colon cancer
Etiology
Genetic predisposition
Environment factors
Premalignant conditions
Genetic predisposition
Colorectal cancer is a genetic disease
Familial Adenomatous Polyposis( FAP )
Autosomal dominant
Diagnosis
1. >100 adenomatous polyps in large bowel
2. Detection of colonic adenomas in member of FAP family
Total proctocolectomy
AMSTERDUM CRITERIA II
At least three relatives with an HNPCC-associated cancer
[ Colorectal cancer, cancer of the endometrium, small bowel,
ureter, or renal pelvis ]
Environment factor
Premalignant conditions
Ulcerative colitis :
10 years
(Pancolitis)
after 20 years
Colitis
Normal colon
Mild
Severe
ulcerative
colitis
ulcerative colitis
Colitis
Polyps
( gastrointestinal mucosa )
Adenoma
potential
Adenoma
Cancer screening
National Comprehensive
Cancer Network (NCCN)
UC > 10 years
Crohns disease with stricture
FAP
HNPCC
Previous history of colonic polyps
Colon cancer
Signs and Symptoms
Right colon
Left colon
Colon cancer
Diagnosis
LFT : Increase ALP R/O liver metastasis
CXR : R/O pulmonary metastasis
BE : Demonstrate primary lesion and
synchronous lesion ( 3-5% )
Diagnosis
Carcinoembryonic antigen (CEA) test
Elevated in tumors of lung, breast, stomach,
pancreas, smoker, cirrhosis, pancreatitis,
renal failure and UC
- Not useful for screening
- Useful in F/U for detection tumor
recurrence or metastasis
Diagnosis
Colonoscopy : Most accurate
evaluted synchronous
carcinomas and polyps
CT abdomen : Extent of invasive of primary tumor
: Search for intraabdominal metastasis
Colon cancer
Prognosis
Stage
Stage
Stage
Stage
I
II
III
IV
5 - year
survival
90 %
60 - 80 %
20 - 50 %
<5%
Surgical therapy
Bowel margin > 5 cm
Extent of lymphatic resection
and vascular ligation
Adjacent organ invasion en bloc resection
70 % recurrence in 2 years
90 % recurrence in 4 years
Surveillance
Physical examination
Lab investigation
( CBC , CEA , LFT , CXR )
Every 3 months for 2 years
Every 6 months for 2 years
After that once time / year
Surveillance
Colonoscopy
after surgery 3-6 months
Every years for 4 years
After that every 3-5 years
Acute colonic
obstruction
o
o
o
Acute colonic
Pathogenesis
obstruction
Hypovolumia
Bacterial translocation
Collagen degradation
What is your
differential
diagnosis?
Differential diagnosis
Malignancy
Volvulus
Diverticulitis
Psuedocolonic obstruction (Ogilvies syndrome)
Inflammatory bowel disease and infection
(Toxic megacolon)
Investigation
Investigation
Contrast enema
Exclude from Colonic
pseudo-obstruction
Water soluble single
contrast enema better
Evaluated site of
decompress obstruction
: Sens 84% and spec 72%
Investigation
CT scan
Identified point obstruction
Cause of obstruction
Staging and metastatic disease
Other cause of obstruction :
diverticulitis or intussusceptions
Investigation
Endoscopy (Sigmoidoscopy,Colonoscopy)
Location
Biopsy
Diagnosis : Benign stricture
Synchronous lesion
Preoperative management
Management
Non operative management :
( without signs of perforation,peritonitis or close loop obstruction )
Decompression tubes
Laser therapy
Self-expanding metal stents
(SEMS)
Contraindication in
- Suspect perforation
- Tumor below 4 cms from anal verge
Surgical management
Volvulus
Twisting of an air-filled
segment of bowel about
its narrow mesentery
Sigmoid, cecum,
transverse colon
Sigmoid volvulus
Sigmoid volvulus
Investigation
Plain abdomen
Inverted U-shaped
Sigmoid volvulus
Investigation
Water-soluble
contrast enema
Birds beak
deformity
Sigmoid volvulus
Treatment
Peritonitis : Emergency operation
Volvulus
Cecal volvulus
: Plain film
: Emergency Rt. hemicolectomy
Transverse colon volvulus
: + Colonoscopic detortion
: Emergency resection
OGILVIES SYNDROME
mechanical obstruction
Etiology : Unknown
: Related with secretin,
glucagon
: Underlying disease
Plain film
OGILVIES SYNDROME
Rx 1. NPO + hydration
2. Stop narcotic drug
3. Fail colonoscopy 1-2 times
4. Fail iv neostigmine
5. Fail explore : cecostomy or resection
Others topic