Diseases Of The Colon And Rectum 2008
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Diseases of the Colon and Rectum
Armando G. Santos, MD, FPCS
Diverticular Disease: Essential Features
Acquired false diverticula (pulsion) Sigmoid colon mostly involved Likely produced by increased intraluminal pressure Diet important etiologic factor Majority of affected people asymptomatic 10-20% present with diverticulitis or LGIB
Diverticulitis
Results from infection and/or microperforation of diverticulum Most common in sigmoid colon Presentation depends on severity Complications: abscess, peritonitis, fistula, obstruction
Diverticulitis: Clinical Diagnosis
Localized to generalized abdominal pain Constipation or frequent BM Nausea, vomiting, abdominal distention, fever, LLQ mass Manifestations of fistula or bowel obstruction Leukocytosis
Diverticulitis: Diagnostic Investigation
Plain radiograph Abdominal ultrasound Abdominal CT with oral and IV contrast Water soluble contrast enema *Colonoscopy and barium enema contraindicated with acute presentation
Diverticulitis: Management
Outpatient Tx for mild cases In-hospital supportive Mx for more advanced cases Subsequent colonoscopy if conservative Tx succeeds CT-guided percutaneous drainage of loculated abscess Surgery if complicated or medical Tx fails
Diverticulitis: Summary Abdominal pain
History & PE Radiography Laboratory
Suspected diverticulitis
Mild
Mild to moderate
Other diagnosis: Treat appropriately
Moderate to severe
Mild
+ No systemic signs No peritoneal signs
+ Diet tolerated
Discharge home on oral antibiotics
Outpatient f ollow-up Colonoscopy or barium enema with proctosigmoidoscopy
Mild to moderate
+ Diagnosis certain
Admit, bowel-rest, IV antibiotics
Response
No response
Response
Discharge home on oral antibiotics
Outpatient follow-up Colonoscopy or barium enema with proctosigmoidoscopy
Div erticulitis conf irmed
First attack & elderly
High fiber diet & medical followup
First attack & <50 years old
Surgical resection of affected segment Primary anastomosis
>Second attack
Moderate to severe
+
No response
Diagnosis uncertain
Other diagnosis: Treat appropriately
CT scan with IV/oral contrast
Normal or other pathology
Multiple abscesses or free air
Single small loculated abscess
Surgical resection of affected segment, Hartmann's procedure
Consider percutaneous drainage under CT scan guidance & IV antibiotics
Colon wall thickening Pericolic fat stranding
Admit, bowelrest, IV antibiotics
Colorectal Polyps: Essential Features
Mucosal, submucosal, or muscular masses protruding into lumen Types: neoplastic (adenomas, CA), hamartomas, inflammatory, hyperplastic Malignant potential related to size, growth pattern, degree of epithelial dysplasia
Colorectal Polyps: Clinical Diagnosis
Symptoms related to size Manifestations: rectal bleeding, bowel habit change, abdominal pain, anemia, obstruction, perforation Physical exam usually unremarkable
Colorectal Polyps: Diagnostic Investigation
CBC Proctosigmoidoscopy Barium enema Colonoscopy with biopsy or polypectomy Virtual colonoscopy *Presence/Absence of malignancy should be established
Colorectal Polyps: Management
Tx options:
Endoscopic polypectomy Surgery
Tx of choice determined by:
Polyp size/type Polyp number Presence of FAP, HNPCC, actual carcinoma
Colorectal Polyps: Management
Tx of choice for invasive carcinoma determined by:
Gross/microscopic margin Degree of differentiation Involvement of stalk Lymphatic/venous invasion
Endoscopic polypectomy generally adequate as Tx for carcinoma in situ
Colorectal Polyps: Summary
Largely asymptomatic Rectal bleeding most common manifestation Adenomas are premalignant; cancer risk depends on size, growth pattern, degree of dysplasia Tx, by polypectomy or surgery, determined by clinical parameters
Colorectal Cancer: Essential Features
Etiology ascribed to some conditions, dietary factors Most cancers initially develop as adenomatous polyps Carcinogenesis results from mutations in proto-oncogenes, tumor suppressor genes Genetic predisposition in FAP, HNPCC
Adenoma-Carcinoma Sequence
Colorectal Cancer: Essential Features
Cancer prevention based on polypcarcinoma sequence: polyp removal prior to development of invasive cancer Mass screening test: fecal occult blood Definitive surveillance via colonoscopy or flexible proctosigmoidoscopy with air-
Colorectal Cancer: Clinical Diagnosis
Symptoms depend on location, stage of tumor Manifestations: rectal bleeding, bowel habit change, abdominal pain, anemia, obstruction, perforation, reduced stool caliber, tenesmus Physical exam: pallor, abdominal/rectal mass, lymphadenopathy
Colorectal Cancer: Diagnostic Investigation
CBC Fecal occult blood test CEA assay (nonspecific) Colonoscopy Proctosigmoidoscopy with air-contrast barium enema Virtual colonoscopy
Colorectal Cancer: Cancer Staging
TNM system Dukes classification Modified Astler-Coller classification
Staging Systems
Colorectal Cancer: Management
Upon diagnosis, clinical staging established through:
Chest x-ray Liver function tests CT scan Pelvic MRI (for rectal CA) PET-CT Scan (18F-Fluorodeoxyglucose PET) Endorectal ultrasound (for rectal CA)
Colorectal Cancer: Management
Surgery mainstay of treatment Pre-operative radiotherapy for rectal CA Post-operative chemoTx and radioTx for stage II rectal CA Post-operative chemoTx for stage III colon CA
Segmental Resection of Colon CA based on Location
Resected Right Colon CA
Abdominoperineal Resection for Rectal CA
TME Specimen of Distal Rectal CA
Colorectal Cancer: Postoperative Tx Monitoring
Fecal occult blood tests Surveillance colonoscopy Periodic CEA determination CT scan PET-CT Scan
CEA monitoring – key to early detection of recurrence
Colorectal Cancer: Summary
Produced by series of genetic mutations Cancers arise mainly from adenomas Screening tests aim to:
Prevent cancer development Detect and treat cancer early
Primary Tx is surgery Adjuvant chemotherapy and radiation more useful in rectal than colon cancer
Endoscopy: Sigmoid Diverticulosis
CT: Sigmoid Diverticulitis
Perforated Diverticulitis: (A) Mesenteric phlegmon, (B) Pelvic abscess
Endoscopy: Sigmoid Diverticulitis
Sigmoid Diverticuli and CA
CT: Bladder Air due to Colovesical Fistula from Diverticulitis
Virtual Colonoscopy: Small polyp seen in ascending colon on (A) axial and (C) 3D endoluminal view
Sigmoid Tubular Adenoma: Polypectomy
Sigmoid Tubular Adenoma: Polypectomy
Sigmoid Tubular Adenoma: Polypectomy
Large Sigmoid Villous Adenoma
Rectal Villous Adenoma with Malignancy
Resected Colon with Adenomas and Invasive Cancer
Acquired Adenomas in Right Colon
Familial Adenomatous Polyposis
Endoscopy: Rectal Cancer
Constricting Distal Sigmoid Colon Cancer: Air-contrast Barium Enema
Barium Enema: Polypoid Cecal CA
CT: Proximal Transverse Colon CA
CT: Coronal 3D Image of Constricting Left Colon CA
Endorectal UTZ: T3 N1 Rectal CA
CT of Colon CA with Nodal and Liver Metastases
PET/CT Imaging of Recurrent Rectal Cancer
Thank You!
Armando G. Santos, MD, FPCS
Diverticular Disease: Essential Features
Acquired false diverticula (pulsion) Sigmoid colon mostly involved Likely produced by increased intraluminal pressure Diet important etiologic factor Majority of affected people asymptomatic 10-20% present with diverticulitis or LGIB
Diverticulitis
Results from infection and/or microperforation of diverticulum Most common in sigmoid colon Presentation depends on severity Complications: abscess, peritonitis, fistula, obstruction
Diverticulitis: Clinical Diagnosis
Localized to generalized abdominal pain Constipation or frequent BM Nausea, vomiting, abdominal distention, fever, LLQ mass Manifestations of fistula or bowel obstruction Leukocytosis
Diverticulitis: Diagnostic Investigation
Plain radiograph Abdominal ultrasound Abdominal CT with oral and IV contrast Water soluble contrast enema *Colonoscopy and barium enema contraindicated with acute presentation
Diverticulitis: Management
Outpatient Tx for mild cases In-hospital supportive Mx for more advanced cases Subsequent colonoscopy if conservative Tx succeeds CT-guided percutaneous drainage of loculated abscess Surgery if complicated or medical Tx fails
Diverticulitis: Summary Abdominal pain
History & PE Radiography Laboratory
Suspected diverticulitis
Mild
Mild to moderate
Other diagnosis: Treat appropriately
Moderate to severe
Mild
+ No systemic signs No peritoneal signs
+ Diet tolerated
Discharge home on oral antibiotics
Outpatient f ollow-up Colonoscopy or barium enema with proctosigmoidoscopy
Mild to moderate
+ Diagnosis certain
Admit, bowel-rest, IV antibiotics
Response
No response
Response
Discharge home on oral antibiotics
Outpatient follow-up Colonoscopy or barium enema with proctosigmoidoscopy
Div erticulitis conf irmed
First attack & elderly
High fiber diet & medical followup
First attack & <50 years old
Surgical resection of affected segment Primary anastomosis
>Second attack
Moderate to severe
+
No response
Diagnosis uncertain
Other diagnosis: Treat appropriately
CT scan with IV/oral contrast
Normal or other pathology
Multiple abscesses or free air
Single small loculated abscess
Surgical resection of affected segment, Hartmann's procedure
Consider percutaneous drainage under CT scan guidance & IV antibiotics
Colon wall thickening Pericolic fat stranding
Admit, bowelrest, IV antibiotics
Colorectal Polyps: Essential Features
Mucosal, submucosal, or muscular masses protruding into lumen Types: neoplastic (adenomas, CA), hamartomas, inflammatory, hyperplastic Malignant potential related to size, growth pattern, degree of epithelial dysplasia
Colorectal Polyps: Clinical Diagnosis
Symptoms related to size Manifestations: rectal bleeding, bowel habit change, abdominal pain, anemia, obstruction, perforation Physical exam usually unremarkable
Colorectal Polyps: Diagnostic Investigation
CBC Proctosigmoidoscopy Barium enema Colonoscopy with biopsy or polypectomy Virtual colonoscopy *Presence/Absence of malignancy should be established
Colorectal Polyps: Management
Tx options:
Endoscopic polypectomy Surgery
Tx of choice determined by:
Polyp size/type Polyp number Presence of FAP, HNPCC, actual carcinoma
Colorectal Polyps: Management
Tx of choice for invasive carcinoma determined by:
Gross/microscopic margin Degree of differentiation Involvement of stalk Lymphatic/venous invasion
Endoscopic polypectomy generally adequate as Tx for carcinoma in situ
Colorectal Polyps: Summary
Largely asymptomatic Rectal bleeding most common manifestation Adenomas are premalignant; cancer risk depends on size, growth pattern, degree of dysplasia Tx, by polypectomy or surgery, determined by clinical parameters
Colorectal Cancer: Essential Features
Etiology ascribed to some conditions, dietary factors Most cancers initially develop as adenomatous polyps Carcinogenesis results from mutations in proto-oncogenes, tumor suppressor genes Genetic predisposition in FAP, HNPCC
Adenoma-Carcinoma Sequence
Colorectal Cancer: Essential Features
Cancer prevention based on polypcarcinoma sequence: polyp removal prior to development of invasive cancer Mass screening test: fecal occult blood Definitive surveillance via colonoscopy or flexible proctosigmoidoscopy with air-
Colorectal Cancer: Clinical Diagnosis
Symptoms depend on location, stage of tumor Manifestations: rectal bleeding, bowel habit change, abdominal pain, anemia, obstruction, perforation, reduced stool caliber, tenesmus Physical exam: pallor, abdominal/rectal mass, lymphadenopathy
Colorectal Cancer: Diagnostic Investigation
CBC Fecal occult blood test CEA assay (nonspecific) Colonoscopy Proctosigmoidoscopy with air-contrast barium enema Virtual colonoscopy
Colorectal Cancer: Cancer Staging
TNM system Dukes classification Modified Astler-Coller classification
Staging Systems
Colorectal Cancer: Management
Upon diagnosis, clinical staging established through:
Chest x-ray Liver function tests CT scan Pelvic MRI (for rectal CA) PET-CT Scan (18F-Fluorodeoxyglucose PET) Endorectal ultrasound (for rectal CA)
Colorectal Cancer: Management
Surgery mainstay of treatment Pre-operative radiotherapy for rectal CA Post-operative chemoTx and radioTx for stage II rectal CA Post-operative chemoTx for stage III colon CA
Segmental Resection of Colon CA based on Location
Resected Right Colon CA
Abdominoperineal Resection for Rectal CA
TME Specimen of Distal Rectal CA
Colorectal Cancer: Postoperative Tx Monitoring
Fecal occult blood tests Surveillance colonoscopy Periodic CEA determination CT scan PET-CT Scan
CEA monitoring – key to early detection of recurrence
Colorectal Cancer: Summary
Produced by series of genetic mutations Cancers arise mainly from adenomas Screening tests aim to:
Prevent cancer development Detect and treat cancer early
Primary Tx is surgery Adjuvant chemotherapy and radiation more useful in rectal than colon cancer
Endoscopy: Sigmoid Diverticulosis
CT: Sigmoid Diverticulitis
Perforated Diverticulitis: (A) Mesenteric phlegmon, (B) Pelvic abscess
Endoscopy: Sigmoid Diverticulitis
Sigmoid Diverticuli and CA
CT: Bladder Air due to Colovesical Fistula from Diverticulitis
Virtual Colonoscopy: Small polyp seen in ascending colon on (A) axial and (C) 3D endoluminal view
Sigmoid Tubular Adenoma: Polypectomy
Sigmoid Tubular Adenoma: Polypectomy
Sigmoid Tubular Adenoma: Polypectomy
Large Sigmoid Villous Adenoma
Rectal Villous Adenoma with Malignancy
Resected Colon with Adenomas and Invasive Cancer
Acquired Adenomas in Right Colon
Familial Adenomatous Polyposis
Endoscopy: Rectal Cancer
Constricting Distal Sigmoid Colon Cancer: Air-contrast Barium Enema
Barium Enema: Polypoid Cecal CA
CT: Proximal Transverse Colon CA
CT: Coronal 3D Image of Constricting Left Colon CA
Endorectal UTZ: T3 N1 Rectal CA
CT of Colon CA with Nodal and Liver Metastases
PET/CT Imaging of Recurrent Rectal Cancer
Thank You!
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