Neoplasm of Large Intestine

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This preparetion was prepared for Prof. Feroze Quder on the eve of 21st Feb for a class for the undergraduate medical students.

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Neoplasm of Large Intestine

  1. 2. Prof. Feroze Quader Dept. of Surgery Begum Khaleda Zia Medical College
  2. 3. <ul><li>Polyp : </li></ul><ul><li>A grape-like protrusion of tissue into the </li></ul><ul><li>bowel lumen . </li></ul><ul><ul><li>Sessile : flat on the mucosal </li></ul></ul><ul><ul><li> surface </li></ul></ul><ul><ul><li>Pedunculated : Has a stalk </li></ul></ul><ul><ul><li>Epithelial or submucosal </li></ul></ul><ul><ul><li>Non-Neoplastic Polyps </li></ul></ul><ul><ul><li>Neoplastic Polyps </li></ul></ul>
  3. 4. <ul><li>Non-neoplastic Polyp </li></ul><ul><ul><li>Hyperplastic polyps </li></ul></ul><ul><ul><li>Juvenile Polyps </li></ul></ul><ul><ul><li>Peutz-Jegher Polyps (Syndrome) </li></ul></ul>
  4. 5. Peutz-Jegher’s syndrome
  5. 6. <ul><li>Neoplastic Polyp (adenoma) </li></ul><ul><ul><li>Tubular adenoma </li></ul></ul><ul><ul><li>Villous Adenoma </li></ul></ul><ul><ul><li>Tubulovillous adenoma </li></ul></ul>
  6. 7. Tubular Adenoma Villous
  7. 8. <ul><li>It is a general neoplastic disorder of the intestine. </li></ul><ul><li>Affected area: Mainly large bowel. </li></ul><ul><li>Other : Stomach, duodenum & small intestine </li></ul>
  8. 9. <ul><li>The most important thing about adenomatous polyposis coli is that colorectal cancer develops before age 40 in nearly all untreated patients. </li></ul><ul><li>  </li></ul><ul><li>It is inherited as a Mendelian dominant . The gene responsible (APC gene) has now been identified on the short arm of chromosome 5. </li></ul><ul><li>  </li></ul><ul><li>Males & females are equally affected. </li></ul>
  9. 10. Symptomatic patients: Loose stool Lower abdominal pain Weight loss Diarrhoea Passage of blood &Mucus. Asymptomatic patients: Usually are diagnosed during screening or incidentally. Clinical features
  10. 11. Clinical features… <ul><li>Polyps are usually visible on sigmoidoscopy by the age of 15 years and will almost always be visible by the age of 30. </li></ul><ul><li>Carcinoma of the large bowel occurs 10-20 years after the onsent of the polyposis . </li></ul>
  11. 12. Some extra-cortical manifestations Benign Endocrine adenome Osteoma Epidermoid cyst Hypertrophic retinal pigmentation Medulloblastoma Malignant Duodenal carcinoma Desmoid tumor Bile duct, pancreatic carcinoma Carcinoma stomach
  12. 13. Treatment <ul><li>Restorative proctocolectomy with an ileoanal anastomosis: </li></ul><ul><li>(Now-a- days more frequently used) </li></ul><ul><ul><li>Indicated specially in cases </li></ul></ul><ul><li>  </li></ul><ul><ul><ul><li>With serious rectal involvement with polyps </li></ul></ul></ul><ul><ul><ul><li>Who are likely to be poor at attending for follow up </li></ul></ul></ul><ul><ul><ul><li>With an established cancer of the rectum or sigmoid. </li></ul></ul></ul>
  13. 14. <ul><li>Colectomy with ileorectal anastomosis : </li></ul><ul><li>was practiced in past as usual operation because it avoids an ileostomy </li></ul><ul><li>in a young patient. </li></ul>Treatment
  14. 15. Treatment <ul><li>Restorative proctocolectomy with an ileoanal anastomosis: </li></ul><ul><li>(Now-a- days more frequently used) </li></ul><ul><ul><li>Indicated specially in cases </li></ul></ul><ul><li>  </li></ul><ul><ul><ul><li>With serious rectal involvement with polyps </li></ul></ul></ul><ul><ul><ul><li>Who are likely to be poor at attending for follow up </li></ul></ul></ul><ul><ul><ul><li>With an established cancer of the rectum or sigmoid. </li></ul></ul></ul>
  15. 17. <ul><li>Diet </li></ul><ul><li>Low fibre containing diet </li></ul><ul><li>Smoked fish </li></ul><ul><li>High content of refined carbohydrate in Diet </li></ul><ul><li>red meat </li></ul><ul><li>Less intake of micronutrients specially Selenium deficiency. </li></ul>Predisposing Factors
  16. 18. Pathology Microscopically The neoplasm is a columnar cell Carcinoma originating in the colonic epithelium.   Macroscopically The tumor may take one of four forms . Type 4 is the least malignant form.
  17. 19. Pathology Types of growth
  18. 20. <ul><li>Local spreading </li></ul><ul><li>Lymphatic apreading </li></ul><ul><li>Hematogenous spreading </li></ul>Spreading
  19. 21. Staging Dukes’ classification   A Confined to bowel wall. B Through the bowel wall but not involving the free Peritoneal serosal surface . C Lymph nodes involved.   D advanced local disease or metastasis to liver.
  20. 22. CARCINOMA COLON Clinical Feature Carcinoma of the left side of the colon: Pain Alteration of bowel habit Palpable lump Distension
  21. 23. CARCINOMA COLON Clinical Feature… Carcinoma of the sigmoid: Pain Tenesmus Bladder symptoms
  22. 24. CARCINOMA COLON Clinical Feature Carcinoma of the transverse colon: Palpable lump Anaemia Lassitude
  23. 25. CARCINOMA COLON Clinical Feature Carcinoma of the caecum and ascending colon: Anemia Lump in right iliac fossa Acute appendicitis Intermittent obstruction
  24. 26. CARCINOMA COLON Clinical Feature <ul><li>May present with features of metastasis </li></ul><ul><li>Palpable Liver </li></ul><ul><li>Jaundice </li></ul><ul><li>Ascites </li></ul>
  25. 27. CARCINOMA COLON Investigations Diagnostic: Endoscopy Sigmoidescopy Colonscopy With tissue biopsy
  26. 28. Investigations Radiology Double contrast barium enema Shows Irregular filling defect Ultra-sonography Liver metastasis CT Scan Local invasion specially in Pelvis
  27. 29. <ul><li>Preoperative preparation: </li></ul><ul><li>General : </li></ul><ul><ul><ul><li>Correction of anaemia by blood </li></ul></ul></ul><ul><ul><ul><li>Correction of nutritional imbalance </li></ul></ul></ul><ul><ul><ul><li>Correction of electrolyte imbalance </li></ul></ul></ul><ul><ul><ul><li>Resuscitation </li></ul></ul></ul><ul><ul><ul><ul><li>if there is - intestinal Obstruction, perforation </li></ul></ul></ul></ul>Treatment
  28. 30. <ul><li>Special preparation: </li></ul><ul><li>Bowel preparation by </li></ul><ul><ul><li>Dietary restriction to fluids for 2 days before operation. </li></ul></ul><ul><ul><li>Laxative </li></ul></ul><ul><ul><li>Enema </li></ul></ul><ul><ul><li>prophylatic antibiotic </li></ul></ul>Treatment
  29. 31. <ul><li>Operation: </li></ul><ul><li>Laparotomy is done </li></ul><ul><li>The tumor is assessed for resectibility by checking involvement in </li></ul><ul><li>Liver </li></ul><ul><li>Peritoneum </li></ul><ul><li>Local lymph nodes </li></ul><ul><li>Tumor itself for Mobility </li></ul>Treatment
  30. 32. <ul><li>In case of operable cases: </li></ul><ul><ul><li>Operations are done to remove the primary tumor and the draining lymph nodes. </li></ul></ul><ul><ul><li>Removal of the portion of colon surrounding the tumor area depends on site of original of tumor. </li></ul></ul><ul><ul><li>Carcinoma of the caecum/ascending colon . Right hemicolectomy </li></ul></ul><ul><ul><li>Carcinoma of the hepatic flexure : resection will be extended correspondingly </li></ul></ul>Treatment…
  31. 33. <ul><li>In case of operable cases: </li></ul><ul><ul><li>Carcinoma of transverse colon: </li></ul></ul><ul><ul><ul><li>Excision of transverse colon & the two flexures together with the transverse mesocolon and the two flexures together with the transverse mesocolon and the greater omentum followed by end – to – end anastomosis. </li></ul></ul></ul><ul><ul><ul><li>Alternative is an extended right hemicolectomy. </li></ul></ul></ul><ul><ul><li>Carcinoma of the splenic flexure or descending colon: </li></ul></ul><ul><ul><ul><li>Resection from right colon to descending colon. Sometimes removal of colon upto the ileum, with an ileorectal anastomosis. </li></ul></ul></ul>Treatment…
  32. 34. <ul><li>In case of inoperable cases: </li></ul><ul><li>Palliative procedure is done: </li></ul><ul><ul><li>Transverse colostomy if growth in upper part left colon </li></ul></ul><ul><ul><li>Left Illiac fossa colostomy for Pelvic colonic growth </li></ul></ul><ul><ul><li>By-pass Illio-colic anastomosis for ascending colon-growth </li></ul></ul>Treatment

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