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Investigation and treatment
• Serum electrolyte
• Per anal polypectomy
• Resection anastomosis
• Total polypectomy if
Familial adenomatous polyposis (FAP)
Extracolonic manifestations of FAP
• Endodermal derivatives:
Younger age group- 15-20 years.
– Adenomas and carcinomas of the
80 % with a positive family
duodenum, stomach, small intestine,
thyroid and biliary tree.
history. The remainder arise as a
– Fundic gland polyps.
result of new mutations in the
adenomatous polyposis coli (APC)
• Ectodermal derivatives:
– Epidermoid cysts.
This has been identified on the
short arm of chromosome 5.
– Congenital hypertrophy of the retinal
pigment epithelium (CHRPE).
Clinical features– Brain tumours.
• Mesodermal derivatives:
Loose stool with blood and
– Desmoid tumours.
– Dental problems.
• Autosomal dominant.
FAP + Benign mesodermal tumours (such as
desmoid tumours)+ Osteomas+ Epidermoid cysts
can also occur= Gardner’s syndrome.
• FAP+ Brain tumor= Turcot’s syndrome.
Investigations and treatment
– Double contrast barium
– Proctocolectomy with
• At-risk family members are offered
– Genetic testing in early teens.
– Should be examined at the age of 10–12 years, repeated
• Who are going to get polyps will have them at 20 years,
• If there are no polyps at 20 years, 5 yearly
colonoscopy upto 50 years.
• If still no polyps, there is probably no inherited gene.
• Carcinomatous change may exceptionally occur before
the age of 20 years
Hereditary non-polyposis colorectal cancer
(HNPCC: Lynch syndrome)
• Increased risk of colorectal cancer and also cancers of
the endometrium, ovary, stomach and small intestines.
• Autosomal dominant condition.
• Cause-a mutation in one of the DNA mismatch repair
genes. ( MLH1 and MSH2).
• The lifetime risk of developing colorectal cancer 80%.
• Mean age of diagnosis is 45 years.
• Most cancers develop in the proximal colon.
• Females with HNPCC have a 30–50% lifetime risk of
developing endometrial cancer.
COLORECTAL CARCINOMA (CRC)
• One of the most common cancers in the world.
4th most common cancer (after lung,
prostate, and breast cancers).
2nd most common cause of cancer death
(after lung cancer).
130,000 new cases of CRC
56,500 deaths caused by CRC
High intake of fat, alcohol, red meat;
Sedentary life style,
Inflammatory bowel disease,
Family history of colorectal cancer.
Development of CRC
• Result of interplay between environmental and
• Central environmental factors.
• Diet and lifestyle.
• 35% of all cancers are attributable to diet.
• 50%-75% of CRC in the US may be preventable
through dietary modifications.
Colon cancers result from a series of pathologic changes that
transform normal colonic epithelium into invasive carcinoma.
Specific genetic events, shown by vertical arrows, accompany this
multistep process. The various chemopreventive agents exert their
effects at different steps in this pathway, and this is depicted on
the basis of the available epidemiologic evidence.
Types of colon CA
• Synchrous- Multiple primary ca in different
parts of colon at the same time.
• Metachronus- Growth in different parts of
colon in different time.
• Gross type– Annular (left side)
– Tubular (left side)
– Ulcerative (right side)
– Cauliflower type (right side).
Staging of CRC
Dukes staging system
invade Into (B1)/ through (B2) Muscularis propria
B1 + LN Involvement
B2 + LN Involvement
Distant metastatic spread
Staging of CRC
Primary tumor (T)
Regional lymph nodes (N)
Distant metastasis (M)
TNM classification for colonic cancer
T1: Into submucosa
T2: Into muscularis propria
T3: Into pericolic fat or sub-serosa but not breaching serosa
T4: Breaches serosa or directly involving another organ
N- Nodal stage
N0: No nodes involved
N1: 1–3 nodes involved
N2: ≥4 nodes involved
M0: No metastases
Typical sites and incidence of colon cancer
After 50 years
Loss of appetite
Night sweats, Fever
Abdominal pain & mass
Acute intestinal obstruction- 20%
Rt sided growth- anaemia, palpable mass in RIF.
LT sided growth- colicky pain, rectal bleeding,
change in bowel habits, sub acute obstruction.
Elective setting-prepared colon
Type of anastomosis
• Adjuvant chemotherapy
• Venous spread
• Poorly differentiated CA
• Change in CEA
• 5FU + Folinic acid- 6 month.
• Preoperative neoadjuvant therapy.
• No role of radiotherapy as colonic tumour is radioresistant.
• For 3 years regular interval once in 3-6 month
– Regular CEA
– Barium enema
– Serum Alkaline phosphatase (ALP)
Lymph node status
What is screening?
A public health service in which members
of a defined population are examined to
identify those individuals who would benefit
from treatment to reduce the risk of a disease or
Types of Screening
Fecal occult blood test (FOBT)
Chemical test for blood in a stool sample.
Annual screening by FOBT reduces colorectal cancer
deaths by 33%.
Flexible sigmoidoscopy can detect about 65%–75% of
polyps and 40%–65% of colorectal cancers.
Rectum and sigmoid colon are visually inspected.
Current Screening Guidelines
Regular screening for all adults aged 50 years or
older is recommended
FOBT every year
Flexible sigmoidoscopy every 5 years
Total colon examination by colonoscopy
every 10 years or by barium enema every
• A colostomy is a surgical procedure in which a
stoma is formed by drawing the healthy end
of the large intestine or colon through an
incision in the anterior abdominal wall and
suturing it into place. This opening, in
conjunction with the attached stoma
appliance, provides an alternative channel for
feces to leave the body.
• Double barrel
Temporary Loop colostomy, Devine’s double barrel
For diversion to facilitate distal healing