POLYPS OF THE COLON AND RECTUM

A polyp (P) is any mass of tissue that comes from the intestinal wall and protru
ding into the light. The P can be sessile or pedunculated and vary considerably
in size. Such lesions are classified histologically tubular adenomas, tubulovill
ous adenomas (P vellosoglandulares), villous adenomas (papillary, with or withou
t adenocarcinoma), hyperplastic P, hamartomas, juvenile P, polypoid carcinomas,
pseudopolyps, lipomas, leiomyomas or other less common tumors .
POLYPS OF THE COLON AND RECTUM

The incidence ranges between 7 and 50%, the highest figure includes the very sma
ll P (typically P or hyperplastic adenomas) found at autopsy. P was detected in
about 5% of patients with routine barium enemas or more often with the flexible
fiberoptic sigmoidoscopy, colonoscopy or barium enema and air contrast. The P, o
ften multiple, occur in the rectum and sigmoid colon, and the frequency decrease
s toward the blind. About 25% of patients with cancer of the large bowel adenoma
tous polyps also have satellites.
POLYPS OF THE COLON AND RECTUM

The risk of cancer of tubular adenoma is discussed, but there is evidence that c
an become malignant. Risk of malignancy is proportional to the size, a 1.5-cm tu
bular adenoma is a risk of 2%. With increasing size, the glands become fuzzy. Wh
en are hairy> 50% of the glands is called P vellosoglandular, its potential mali
gnancy is still that of a tubular adenoma. If you are hairy,> 80% of glands call
ed the P villous adenoma, which becomes malignant in about 35% of cases. A villo
us adenoma have an increased risk of malignancy than that of tubular adenoma of
the same size.
POLYPS OF THE COLON AND RECTUM

SYMPTOMS, SIGNS AND DIAGNOSIS P Most are asymptomatic. Rectal bleeding is the mo
st frequent complaint. Spasms, abdominal pain or obstruction may be a sign of a
large lesion. Sometimes, a P with a long pedicle may prolapse through the anus.
Villous adenomas can cause unusually large watery diarrhea that can produce hypo
kalemia.
POLYPS OF THE COLON AND RECTUM

The P may be palpable rectal DRE, but are usually discovered on endoscopy. Given
that rectal P are usually multiple and may coexist with cancer, a full colonosc
opy is mandatory even when the lesion is by flexible sigmoidoscopy. On x-ray bar
ium enema, a P appears as a rounded filling defect. The double-contrast scan is
useful, but is more reliable fiberoptic colonoscopy.
POLYPS OF THE COLON AND RECTUM

TREATMENT P must be completely removed with a snare or electrosurgical biopsy fo

rceps after a total colonoscopy, the electrocautery (linked or fulguration excis
ional) not be used in an unprepared bowel due to risk of explosion of hydrogen a
nd methane produced by colonic bacteria. If unsuccessful colonoscopic removal sh
ould be considered a laparotomy. Large villous adenomas have a high malignant po
tential and should be completely removed.
POLYPS OF THE COLON AND RECTUM

P Treatment of cancer depends on depth of invasion of epithelial stem anaplastic

towards P, the proximity of the line endoscopic resection and the degree of dif
ferentiation of malignant tissue. If the anaplastic epithelium is confined above
the muscle layer of the mucosa, if the line of resection in the stem of P is un
clear or if the lesion is well differentiated, endoscopic excision should be suf
ficient and careful endoscopic follow-up.
POLYPS OF THE COLON AND RECTUM

Invasion through the muscle layer of the mucosa provides access to the lymphatic
vessels and increases the potential for metastasis to lymph nodes. Excision of
the P without a clear line of resection and poorly differentiated lesions should
be followed by a segmental resection of the colon.
POLYPS OF THE COLON AND RECTUM

The scheduling of follow-up examinations after polypectomy is discussed. Most sp

ecialists recommend two annual inspections of the entire colon by colonoscopy (o
r barium enema if total colonoscopy is impossible), with removal of newly discov
ered lesions. After two annual examinations are negative for new lesions, colono
scopy is recommended every 2-3 years.
POLYPS OF THE COLON AND RECTUM

Autosomal dominant disease familial polyposis of the colon heterozygous in which

100 or more adenomatous P carpet the colon and rectum.
POLYPS OF THE COLON AND RECTUM

The cause is a dominant mutant gene (FAP) located on the long arm of chromosome
5. The malignancy occurs before 40 years of age in almost all untreated patients
. Proctocolectomy removes this risk, but often return after P rectal abdominal c
olectomy and ileorectal anastomosis, and therefore they were recommended at firs
t by many authors. Subtotal colectomy requires an inspection of the residual rec
tal every 3-6 months should be excised or gleam of P new.
POLYPS OF THE COLON AND RECTUM

If the new P are too fast or prolifically to be removed, it is necessary to remo

ve the rectum and make a permanent ileostomy. They are essential in monitoring t
he patient and family and genetic counseling.
POLYPS OF THE COLON AND RECTUM

Gardner's syndrome is a variant of familial polyposis associated with dermoid tu

mors, osteomas of the skull or jaw and sebaceous cysts. Other rare variants of f
amilial polyposis consist of multiple adenomas of the colon and other injuries.
POLYPS OF THE COLON AND RECTUM
The Peutz-Jeghers syndrome is a congenital disease with autosomal dominant multi
ple hamartomatous P in the stomach, small intestine and colon. Symptoms include
pigmentation of the skin and mucous membranes, especially the lips and gums.
POLYPS OF THE COLON AND RECTUM

Other P: Juvenile polyps are generally non-neoplastic, often outgrow their blood
supply and are autoamputados at puberty. It's just uncontrollable bleeding or i
ntussusception. Hyperplastic polyps, also non-neoplastic, are common in colon an
d rectum. Inflammatory polyps and pseudopolyps occur in chronic ulcerative colit
is and Crohn's disease of the colon.
COLORECTAL CANCER

In Western countries, the colon and rectum account for more new cases of cancer
each year than any other anatomical location other than the lung. In the United
States approximately 75,000 people died of these cancers in 1989, about 70% occu
rred in the rectum and sigmoid colon and 95% were carcinomas. Of all visceral ma
lignancies that affect both sexes, colorectal cancer (CRC) is the cause of death
more frequently.
COLORECTAL CANCER

The incidence begins to rise at the age of 40 years and peaks at 60 and 75 years
. Colon cancer is more common in women, and rectal cancer is more common in men.
In 5% of patients are coincident cancers (more than one).
COLORECTAL CANCER

Genetic predisposition to cancer of the large intestine is low, but have been de
scribed "cancer families" and "families with colon cancer (familial polyposis, L
ynch syndrome), in which the CCR is submitted over several generations usually b
efore 40 years of age and more frequently on the right side of the colon.
COLORECTAL CANCER

In Lynch syndrome has been shown to be mutated at least four genes located on ch
romosomes 2, 3 and 7. Other predisposing factors include chronic ulcerative coli
tis, granulomatous colitis and familial polyposis (including Gardner's syndrome)
in these disorders, cancer risk is related to the age of onset and duration of
the underlying disease.
COLORECTAL CANCER

Populations with high rates of colorectal cancer consume diets low in fiber, but
high in animal protein, fat and refined carbohydrates. Carcinogens can be inges
ted with the diet, but is more likely to be produced from substances from the di
et or bile or intestinal secretions, perhaps by bacterial action. The exact mech
anism is unknown.
COLORECTAL CANCER
The CCR is spread by direct extension through the intestinal wall, hematogenous
metastasis, metastasis to regional lymph nodes, perineural spread and metastasis
intraluminal.
COLORECTAL CANCER

SYMPTOMS, SIGNS AND DIAGNOSIS colorectal adenocarcinoma grows slowly, and a long
interval elapses before it is large enough to cause symptoms. Early diagnosis d
epends on the systematic exploration. The symptoms depend on the location of the
lesion, the type, extent and complications.
COLORECTAL CANCER

The right side of the colon has a larger diameter and a thin wall. Since the con
tents of the colon is liquid, the obstruction is a late event. The tumors, which
are usually fungoides, can become large and palpable through the bowel wall. Bl
eeding is usually hidden. The only discomfort may be fatigue and weakness caused
by severe anemia.
COLORECTAL CANCER

The left side of the colon has a light closer, feces are semisolid and cancer te
nds to surround the intestine, causing alternating constipation and increased st
ool frequency or diarrhea. The clinical presentation may be partial obstruction
with cramping abdominal pain or complete obstruction.
COLORECTAL CANCER

The stool may be streaked or mixed with blood. In rectal cancer the most common
presenting symptom is bleeding with defecation. Whenever rectal bleeding occurs,
even if obvious hemorrhoids or known diverticular disease, it is necessary to e
xclude the presence of rectal cancer. There may be urgency and a sensation of in
complete deposition. The pain is conspicuously absent until it affects the perir
ectal tissue.
COLORECTAL CANCER

We recommend that the exploration of fecal occult blood, simple and inexpensive
part of screening programs and surveillance of high risk. For greater accuracy,
the patient should consume a diet rich in fiber and free of red meat for 3 d pri
or to collection of stool sample. The positive tests require further studies.
COLORECTAL CANCER

About 60% of RCCs are within range of flexible fiberoptic sigmoidoscope. Should
undergo a colonoscopy with optical fiber cancer is suspected when any portion of
the intestine and when the symptoms are attributable to the colon. If the lesio
n is detected on sigmoidoscopy, it should be followed by total colonoscopy and r
emoval of all lesions of the colon.
COLORECTAL CANCER

Endoscopic excision of P matching can reduce the amount of intestine that needs
to be resected. Partial biopsies of P can be misleading in 25% of cases, and a n
egative biopsy does not exclude the possibility of cancer in a P. If the lesion
is sessile or unresectable by colonoscopy, should be seriously considered surgic
al excision.
COLORECTAL CANCER
The radiographic examination with barium enema is usually not reliable in detect
ing rectal cancer, but may be an important preliminary step to diagnose colon ca
ncer. The air contrast examination can visualize smaller lesions (<6 mm) that th
e barium enema entire column, but the pneumocolon may miss large lesions (> 2 cm
) with an unexpected frequency (20-30%).
COLORECTAL CANCER

The essential ingredient of any barium or endoscopic examination of the colon is

well prepared bowel, which often requires cathartics and enemas multiple oral w
ash. The barium can not be administered orally Suspected obstructive lesion of t
he colon, because colon reabsorption of water from the barium suspension may pre
cipitate barium sulfate and produce a complete obstruction of the large intestin
e.
COLORECTAL CANCER
Colonoscopy should be done even if the radiographic diagnosis is reasonably safe
, the barium enema ignores 30% of the tumors and 40% of P, but the simultaneous
colonoscopy identified the lesions, which may make the bowel to dry.
COLORECTAL CANCER

Elevation of carcinoembryonic antigen (CEA) in serum is not specifically associa

ted with colorectal cancer, but levels are high at 70% of patients. If the CEA i
s high before the operation, and low after the removal of a colonic tumor, the C
EA monitoring can help detect recurrence. CA 19-9 and CA 125 are other tumor mar
kers may be elevated.
COLORECTAL CANCER

TREATMENT AND PROGNOSIS The primary treatment is wide surgical resection tion of
colon cancer and the draining regional lymph-tico after bowel preparation. The
choice of operation for rectal cancer depends on the distance of tumor from the
anus and macroscopic extension. Abdominoperitoneal resection of the rectum (Mile
s operation) requires a permanent sigmoid colostomy.
COLORECTAL CANCER

Low anterior resection with anastomosis of the sigmoid colon to the rectum, is t
he curative procedure of choice only if it is possible to resect a margin of 5 c
m of normal bowel below the lesion and if the operation is technically feasible.
The surgical staplers have made possible the low anterior resection and anastom
osis nearest the rectum with preservation of the rectum in a larger number of pa
tients.
COLORECTAL CANCER

Surgical cure is possible in 70% of patients. The best survival rate five years
for the cancer confined to the mucosa is about 90%, with penetration of the lami
na propria of the muscle to 80% with positive lymph nodes,€30%. When there is an
unacceptable surgical risk to patients, some tumors can be controlled locally b
y electrocoagulation.
COLORECTAL CANCER

Preliminary results of studies of adjuvant radiation therapy after curative rese

ction of rectal cancer (but not the colon) indicate that in patients with limite
d lymph node involvement, it is possible to control local tumor growth, delay re
currence and improve survival.
COLORECTAL CANCER

Patients with rectal cancer and one to four nodes positive nodes get more benefi
t from combined radiation and chemotherapy, if they are more than four nodes in
the resection, combined modalities are less effective. The effective pattern is
studied fluorouracil (5-FU) with or without folinic acid. When using these patte
rns of combined chemotherapy and radiotherapy is essential to carefully plan the
physical radiation, with special attention to avoid injury to the small intesti
ne.
COLORECTAL CANCER

At issue is the use of preoperative radiotherapy to improve the rate of resectab

ility of rectal cancer, the experts argue about whether this treatment increases
the operability or the incidence of detection of regional lymph node metastases
. There are controlled studies that explore the use of preoperative chemotherapy
and radiotherapy compared to postoperative rectal cancer patients.
COLORECTAL CANCER

Chemotherapy with 5-FU combined with levamisole or folinic acid was shown to be
effective as an adjunct to surgery in properly controlled clinical trials of col
on cancer with positive lymph nodes (stage III, Dukes' C). The frequency of foll
ow-up after curative surgery for RCC is discussed. Nearly all experts recommend
two annual inspections of the remaining intestine with colonoscopy and x-rays an
d, if negative, repeat evaluations at intervals of 2-3 years.
COLORECTAL CANCER

If surgery is not curative, may be indicated for palliative surgery, the surviva
l is 7 months. The only effective drug for advanced colorectal cancer is 5-FU, b
ut only 15-20% of patients treated with 5-FU demonstrable experience tumor shrin
kage and an elongation of life. 5-FU is given daily for a period from May 4-5 da
week, but doctors are not familiar with risks of chemotherapy and the pace of n
adirs of blood counts should not administer these treatments.
COLORECTAL CANCER

Other drugs, alone or with 5-FU, have generally shown better results, but some o
ncologists believe that 5-FU combined with leucovorin is superior to 5-FU alone.
A new drug, irinotecan, seems to have single agent activity in advanced colon c
ancer and will be evaluated as part of combination chemotherapy programs. Chemot
herapy for advanced colon cancer should be checked by an experienced chemotherap
ist.
COLORECTAL CANCER

In metastases confined to the liver, hepatic artery ambulatory infusion with flo
xuridine or radioactive microspheres through implantable subcutaneous pump or an
external pump worn on the belt, may be more beneficial than systemic chemothera
py, however, infusion therapy into the hepatic artery are expensive, and its use
fulness is awaiting final confirmation in clinical trials.
COLORECTAL CANCER

When extrahepatic metastases are also, by intrahepatic arterial chemotherapy inf

usion pump has no advantage over systemic chemotherapy. TERMINAL CARE. Once that
aggressive treatment is not appropriate, assistance should be directed to relie
ve pain and suffering.
Anorectal CANCER
Anorectal cancer (CAR) is the most common adenocarcinoma. Others are cloacogénic
o squamous cell carcinoma, melanoma, lymphoma and various sarcomas. Squamous cel
l carcinoma (non-keratinizing squamous cell or basaloid) anorectal represents 3-
5% of cancers of the distal intestine. Predisposing causes: chronic fistula, ana
l skin irradiated leukoplakias, lymphogranuloma venereum, Bowen's disease (intra
epithelial carcinoma) and condyloma acuminata.
Anorectal CANCER

It showed significant association with human papillomavirus infection. Metastase

s occur along the lymphatics of the rectum and lymph nodes. Less common are basa
l cell carcinoma, Bowen's disease (carcinoma intradermal), extramammary Paget's
disease, carcinoma and malignant melanoma cloacogénico.
Anorectal CANCER

Wide local excision is usually successful treatment of anal carcinoma. Combined

chemotherapy and radiotherapy produce high cure rate when used in anal squamous
cell tumors and cloacogénicos. Abdominoperineal resection is indicated when chem
otherapy and radiation do not result in complete tumor regression.