C O L O N I I

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C O L O N I I

  1. 1. COLON James Taclin C. Banez, MD, FPCS, FPSGS, DPBS, DPSA
  2. 2. Anatomy / Physiology: <ul><li>Location, blood supply & venous drainage, lymphatic drainage and nerve supply </li></ul><ul><li>Function: </li></ul><ul><ul><li>absorption of fluid and electrolyte </li></ul></ul><ul><ul><li>Transport and temporary storage of feces </li></ul></ul>
  3. 3. Anatomy / Physiology:
  4. 4. <ul><li>Amebic colitis: </li></ul><ul><ul><li>Entamoeba histolytica </li></ul></ul><ul><ul><li>Primary – colon : secondary – liver </li></ul></ul><ul><ul><li>Fecal to oral route: (sexual contact, contaminated water & food) </li></ul></ul><ul><ul><li>Abdominal pain, bloody diarrhea, tenesmus, fever </li></ul></ul><ul><ul><li>Complication: megacolon / colonic obstruction (partial) --- > AMEBOMA – mass of inflammatory tissue </li></ul></ul><ul><ul><li>Dx: clin hx / stool exam / indirect hemagglutination test </li></ul></ul><ul><ul><li>Tx: metronidazole / iodoquinol : rare COLECTOMY </li></ul></ul>Infectious:
  5. 5. Infectious: <ul><li>Pseudomembranous colitis: </li></ul><ul><ul><li>Complication of antibiotics ---> alteration of normal flora </li></ul></ul><ul><ul><li>Overgrowth of Clostridium deficile : </li></ul></ul><ul><ul><ul><li>Has cytopathic and enteropathic toxins </li></ul></ul></ul><ul><ul><li>Develops 6wks after: </li></ul></ul><ul><ul><ul><li>Clindamycin </li></ul></ul></ul><ul><ul><ul><li>Ampicillin </li></ul></ul></ul><ul><ul><ul><li>Cephalosporin </li></ul></ul></ul><ul><ul><li>Dx: - history </li></ul></ul><ul><ul><li>- latex fixation test </li></ul></ul><ul><ul><li>- colonoscopy ( Pseudomembrane ) </li></ul></ul><ul><ul><li>Tx: - stopped antibiotic ----> metronidazole/vancomycin </li></ul></ul><ul><ul><li>- cholestyramine ---> binds w/ toxin </li></ul></ul><ul><ul><li>- Toxic megacolon---> total colectomy w/ ileostomy </li></ul></ul>
  6. 6. Infectious: <ul><li>Salmonellosis: </li></ul><ul><ul><li>Salmonella typhi (typhoid fever) </li></ul></ul><ul><ul><li>Dx: perforation / bleeding </li></ul></ul><ul><ul><li>Tx: antibiotic / transfusion / right hemicolectomy w/ or w/o ileostomy </li></ul></ul>
  7. 7. Volvulus: <ul><li>Twisting of an air-filled segment of bowel about its narrow mesentery ---> OBSTRUCTION -------> STRANGULATION ----> GANGRENE ----> PERFORATION ----> PERITONITIS </li></ul><ul><li>SIGMOID VOLVULUS (90%): </li></ul><ul><ul><li>Redundant sigmoid colon </li></ul></ul><ul><ul><li>w/ a narrow based mesocolon </li></ul></ul><ul><ul><li>Sx: colicky abd. pain, distention </li></ul></ul><ul><ul><li>obstipation, rectal collapse </li></ul></ul><ul><ul><li>s/sx of dehydration </li></ul></ul>
  8. 8. Volvulus: <ul><li>SIGMOID </li></ul><ul><li>VOLVULUS (90%): </li></ul><ul><ul><li>Dx: FPA – inverted U shaped sausage like loop (diagnostic) </li></ul></ul><ul><ul><li>Barium enema – bird beaks deformity </li></ul></ul><ul><ul><li>Gangrene – chills/fever, leukocytosis w/ s/x of peritoni </li></ul></ul>
  9. 9. Volvulus: <ul><li>SIGMOID VOLVULUS (90%): </li></ul><ul><ul><li>Tx: </li></ul></ul><ul><ul><li>(-) Signs of Peritonitis: </li></ul></ul><ul><ul><ul><li>Reduced the volvulus --->prepare for elective colonic surgery for the recurrence is 40%: </li></ul></ul></ul><ul><ul><ul><li>- use of flexible scope </li></ul></ul></ul><ul><ul><li>(+) Signs of Peritonitis / Unsuccessful reduction: </li></ul></ul><ul><ul><ul><li>Sigmoidectomy w/ Hartmanns or Divine’s colostomy </li></ul></ul></ul>
  10. 10. Volvulus: <ul><li>Cecal Volvulus: </li></ul><ul><ul><li>Tx: reduction is impossible --> emergency exploration </li></ul></ul><ul><ul><ul><li>(+) Gangrene: - right hemicolectomy </li></ul></ul></ul><ul><ul><ul><li>- end to end ileo-transverse colostomy </li></ul></ul></ul><ul><ul><ul><li>(-) Gangrene: a) – same – </li></ul></ul></ul><ul><ul><ul><li>b) Cecopexy </li></ul></ul></ul><ul><ul><ul><li>c) Pure detorsion (recurrence 7 – 15%) </li></ul></ul></ul><ul><li>Transverse colon volvulus: </li></ul><ul><ul><li>Rare, due to it’s broad based and short mesentery </li></ul></ul><ul><ul><li>Tx: resection of redundant transverse colon </li></ul></ul>
  11. 11. DIVERTICULOSIS: <ul><li>Abnormal pouch from the wall of a hollow organ </li></ul><ul><li>Types: </li></ul><ul><ul><li>True diverticula (rare) – right side </li></ul></ul><ul><ul><li>False diverticula (common – due to low fiber diet: left side) </li></ul></ul><ul><li>Rare before 30y/o; common > 75 y/o </li></ul><ul><li>Female > Male </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>Unknown </li></ul></ul><ul><ul><li>Theories by Painter et al: </li></ul></ul><ul><ul><ul><li>Contraction ring (thickening of circular muscle) </li></ul></ul></ul><ul><ul><ul><li>Depletion of dietary fibers ---> narrow lumen </li></ul></ul></ul><ul><ul><ul><li>Deteriorating integrity of the bowel wall ; elderly has lower tensile strength, lowest in the sigmoid) </li></ul></ul></ul>
  12. 12. DIVERTICULOSIS: <ul><li>Pathology: </li></ul><ul><ul><li>Site: anteriole penetrates the mesenteric side of the antimesenteric teniae coli: </li></ul></ul><ul><ul><ul><li>Sigmoid (50%) </li></ul></ul></ul><ul><ul><ul><li>Descending colon (40%) </li></ul></ul></ul><ul><ul><ul><li>Entire colon (2-10%) </li></ul></ul></ul>
  13. 13. DIVERTICULOSIS: <ul><li>Clinical Manifestation: </li></ul><ul><li>Majority are asymptomatic </li></ul><ul><li>Symptomatic patients: </li></ul><ul><ul><li>Uncomplicated painful diverticular dse. </li></ul></ul><ul><ul><ul><ul><li>(+) LLQ pain and tenderness; </li></ul></ul></ul></ul><ul><ul><ul><ul><li>(+) change in bowel habits </li></ul></ul></ul></ul><ul><ul><ul><ul><li>(-) rebound tenderness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>(-) fever nor leukocytosis </li></ul></ul></ul></ul><ul><ul><ul><li>Dx: Gastrografin enema </li></ul></ul></ul><ul><ul><ul><li>Tx: high fiber diet </li></ul></ul></ul>
  14. 14. DIVERTICULOSIS: <ul><li>Clinical Manifestation: </li></ul><ul><li>Symptomatic patients: </li></ul><ul><ul><li>Complicated diverticular disease: </li></ul></ul><ul><ul><ul><li>Diverticulitis / Peridiverticulitis: </li></ul></ul></ul><ul><ul><ul><ul><li>Infected diverticula </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Diverticula is filled up ---> obstructed ---> mucus secretion and bacteria ---> inflammation at the apex ---> unresolved --> extend intramurally ---> perforate. </li></ul></ul></ul></ul>
  15. 15. DIVERTICULOSIS: <ul><ul><ul><li>Diverticulitis / Peridiverticulitis: </li></ul></ul></ul><ul><ul><ul><ul><li>Sx: - left lower abd. pain / chills & fever / </li></ul></ul></ul></ul><ul><ul><ul><ul><li>bowel habit changes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>- (+) abd. Tenderness, distension if w/ </li></ul></ul></ul></ul><ul><ul><ul><ul><li>partial obstruction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>- pararectal tenderness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>- frequency / urgency of urination </li></ul></ul></ul></ul><ul><ul><ul><ul><li>(inflamed bladder) </li></ul></ul></ul></ul>
  16. 16. DIVERTICULOSIS: <ul><ul><ul><li>Diverticulitis / Peridiverticulitis: </li></ul></ul></ul><ul><ul><ul><ul><li>Dx: </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cln. Hx. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ct scan of the abd / utrasonography (thickened wall & abscess can be seen) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Contrast enema / sigmoidoscopy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>(risk of spreading infection) </li></ul></ul></ul></ul>
  17. 17. DIVERTICULOSIS: <ul><li>Diverticulitis / Peridiverticulitis: </li></ul><ul><ul><ul><li>Tx: </li></ul></ul></ul><ul><ul><ul><li>NPO or liquid diet </li></ul></ul></ul><ul><ul><ul><li>Broad spectrum antibiotic </li></ul></ul></ul><ul><ul><ul><li>Meperidine (not morphine) </li></ul></ul></ul><ul><ul><ul><li>If improved  endoscopy to r/o CA </li></ul></ul></ul>
  18. 18. DIVERTICULOSIS: <ul><li>Complicated diverticular disease: </li></ul><ul><ul><li>Perforated Diverticulitis: </li></ul></ul><ul><ul><ul><li>Sx: - similar to appendicitis (Phlegmon mass) </li></ul></ul></ul><ul><ul><ul><li>- (+) pneumoperitoneum </li></ul></ul></ul><ul><ul><ul><li>- Classification of perforated diverticulitis </li></ul></ul></ul><ul><ul><ul><li>(Hinchy) </li></ul></ul></ul><ul><ul><ul><li>Stage I : abscess confined by mesentery of colon </li></ul></ul></ul><ul><ul><ul><li>Stage II : pelvic abscess </li></ul></ul></ul><ul><ul><ul><li>Stage III : generalized peritonitis </li></ul></ul></ul><ul><ul><ul><li>Stage IV : fecal peritonitis </li></ul></ul></ul>
  19. 19. DIVERTICULOSIS: <ul><li>Perforated Diverticulitis: </li></ul><ul><ul><li>Tx: initial nonoperative: </li></ul></ul><ul><ul><li>- NPO / IVF / Broad spectrum antibiotic/ </li></ul></ul><ul><ul><li>meperidine </li></ul></ul><ul><ul><ul><li>Stage I & II: </li></ul></ul></ul><ul><ul><ul><li>(+) improvement  elective Surgery (4 wks) </li></ul></ul></ul><ul><ul><ul><li>(-) improvement  percutaneous drainage </li></ul></ul></ul><ul><ul><ul><li>(-) improvement ---> Surgery </li></ul></ul></ul>
  20. 20. DIVERTICULOSIS: <ul><li>Perforated Diverticulitis: </li></ul><ul><ul><li>Tx: initial nonoperative: </li></ul></ul><ul><ul><li>- NPO / IVF / Broad spectrum antibiotic/meperidine </li></ul></ul><ul><ul><ul><li>Stage III & IV: </li></ul></ul></ul><ul><ul><ul><li>explore after initial resuscitation </li></ul></ul></ul><ul><ul><ul><li>a. sigmoidectomy w/ primary anastomosis </li></ul></ul></ul><ul><ul><ul><li>b. sigmoidectomy w/ Hartmann’s colostomy </li></ul></ul></ul><ul><ul><ul><li>c. resection w/ primary anastomosis w/ proximal </li></ul></ul></ul><ul><ul><ul><li>diverting stoma </li></ul></ul></ul><ul><ul><ul><li>d. drainage w/ diverting transverse colostomy </li></ul></ul></ul><ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul></ul>
  21. 21. DIVERTICULOSIS: <ul><li>Complicated diverticular disease: </li></ul><ul><ul><li>Obstructing diverticulitis: </li></ul></ul><ul><ul><ul><li>90% partial – due to spasm, edema & ileus </li></ul></ul></ul><ul><ul><ul><li>10% complete – fibrosis and stenosis </li></ul></ul></ul><ul><ul><ul><li>S/Sx: of large intestinal obstruction </li></ul></ul></ul><ul><ul><ul><li>Tx: conservative mx (3-5 days) ---> (-) response -----> cecum dilates to 10-12 cm. ---> surgery. </li></ul></ul></ul><ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul></ul>
  22. 22. DIVERTICULOSIS: <ul><li>Clinical Manifestation: </li></ul><ul><li>Symptomatic patients: </li></ul><ul><ul><li>Complicated diverticular disease: </li></ul></ul><ul><ul><ul><li>Acute hemorrhage: </li></ul></ul></ul><ul><ul><ul><li>Due to erosion of the peridiverticular arteriole by inspissated stool w/in the diverticulum and thinning of the tunica media </li></ul></ul></ul><ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul></ul>
  23. 23. DIVERTICULOSIS: <ul><li>Acute hemorrhage: </li></ul><ul><li>Resuscitate the patient </li></ul><ul><li>Locate the site of bleeding (Tc labeled RBC/selective arteriography) </li></ul><ul><li>Vasopressin infusion, transcatheter emboli infusion using gelfoam </li></ul><ul><li>Colonoscopy </li></ul><ul><li>Tx: segmental resection / blind subtotal colectomy </li></ul><ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul></ul>
  24. 24. DIVERTICULOSIS: <ul><li>Complicated diverticular disease: </li></ul><ul><ul><li>Fistula formation: </li></ul></ul><ul><ul><ul><li>Bladder, vagina, small bowel, skin </li></ul></ul></ul><ul><ul><ul><li>Dx: - clin hx & PE (pneumaturia, fecaluria and </li></ul></ul></ul><ul><ul><ul><ul><li> frequent UTI) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>- cystoscopy, IE, speculum exam </li></ul></ul></ul></ul><ul><ul><ul><ul><li>- methylene blue enema </li></ul></ul></ul></ul><ul><ul><ul><ul><li>- colonoscopy to r/o CA </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul></ul>
  25. 25. DIVERTICULOSIS: <ul><li>Fistula formation: </li></ul><ul><ul><li>Tx: - bowel rest w/ TPN or elemental diet </li></ul></ul><ul><ul><li> - Foley catheter (10 days postop) / </li></ul></ul><ul><ul><li>antibiotic </li></ul></ul><ul><ul><li> - placement of ureteral catheter prior to </li></ul></ul><ul><ul><li> celiotomy </li></ul></ul><ul><ul><li> - sigmoidectomy w/ primary anastomosis </li></ul></ul><ul><ul><li> - fistulectomy and closure of secondary </li></ul></ul><ul><ul><li>opening </li></ul></ul><ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul></ul>
  26. 26. Hemorrhage from the Colon: <ul><li>Diverticular disease </li></ul><ul><li>Angiodysplasia (Vascular ectasia, AV malformation, Angiectasia ) </li></ul>
  27. 27. ANGIODYSPLASIA <ul><li>Acquired lesion </li></ul><ul><li>Proximal colon (cecum) where tension is greatest (Laplace’s law – tension in the wall is highest in the widest circumference) </li></ul><ul><li>Rare < 40y/o; common in elderly </li></ul><ul><li>Etiology: - chronic intermittent obstruction of submucosal veins due to repeated muscular contraction </li></ul>
  28. 28. ANGIODYSPLASIA <ul><li>Dx: - Nuclear scan / </li></ul><ul><li>angiography = </li></ul><ul><li>(vascular tuft and </li></ul><ul><li>early filling of veins) </li></ul><ul><li>- colonoscopy = </li></ul><ul><li>distinct red </li></ul><ul><li>mucosal patch </li></ul>
  29. 29. <ul><li>Bleeding distal to the ligament of Treitz: </li></ul><ul><ul><li>Diverticular disease </li></ul></ul><ul><ul><li>Angiodysplasia </li></ul></ul><ul><ul><li>Inflammatory bowel disease </li></ul></ul><ul><ul><li>Ischemic colitis </li></ul></ul><ul><ul><li>Tumor </li></ul></ul><ul><ul><li>Anticoagulant therapy </li></ul></ul><ul><li>Gastroduodenal hge -> can present as rectal bleeding </li></ul><ul><li>It is more important to identify the location of the BLEEDING POINT than the immediate diagnosis as the cause. </li></ul>
  30. 30. <ul><li>Diagnostic: </li></ul><ul><li>Nuclear imaging (bleeding scan/scintigraphy) </li></ul><ul><ul><li>Technetium-Sulfur Colloid Scan </li></ul></ul><ul><ul><ul><li>Sensitive (0.5ml/min) </li></ul></ul></ul><ul><ul><li>Autologous labeled RBC scan </li></ul></ul><ul><ul><ul><li>Stays in the circulation for as long as 24 hrs (monitoring) </li></ul></ul></ul><ul><ul><ul><li>(1ml/min bleeding) </li></ul></ul></ul><ul><li>Mesenteric Angiography </li></ul><ul><ul><ul><li>Done once patient’s condition is stable and hydration is adequate </li></ul></ul></ul><ul><ul><ul><li>Identify bleeding point ---> 1ml/min </li></ul></ul></ul><ul><ul><ul><li>Could be therapeutic ---> Vasopressin/emboli </li></ul></ul></ul><ul><li>Vascular taft (A) </li></ul><ul><li>Early filling vein (B) </li></ul>
  31. 31. <ul><li>Diagnostic: </li></ul><ul><li>Emergent colonoscopy: </li></ul><ul><ul><li>Possible w/ use of GOLYTELY </li></ul></ul><ul><ul><li>Therapeutic </li></ul></ul><ul><li>Treatment: </li></ul><ul><li>Restore intravascular volume (85% stop spontaneously) </li></ul><ul><li>Persistent --> celiotomy (segmental or total colectomy) </li></ul>
  32. 32. Ischemic Colitis <ul><li>Due to occlusion of major mesenteric vessel </li></ul><ul><ul><li>Thrombosis, embolization, iatrogenic ligation </li></ul></ul><ul><li>Elderly: - contraceptive pills </li></ul><ul><li>- medical problems: </li></ul><ul><li>a) cardiovascular disease </li></ul><ul><li>b) DM </li></ul><ul><li>c) Rheumatoid arthritis </li></ul><ul><li>Splenic flexure – most common site in the colon </li></ul>
  33. 33. Ischemic Colitis: <ul><li>Clinical Syndrome Based on: </li></ul><ul><ul><li>Extent of vascular occlusion </li></ul></ul><ul><ul><li>Duration of occlusion </li></ul></ul><ul><ul><li>Efficiency of collateral circulation </li></ul></ul><ul><ul><li>Extent of secondary bacterial invasion </li></ul></ul><ul><li>Reversible or Transient Ischemic Colitis: </li></ul><ul><ul><ul><li>Partial mucosal slough that healed after 2-3 days </li></ul></ul></ul><ul><li>Stricturing Ischemic Colitis: </li></ul><ul><ul><ul><li>Arterial occlusion ---> hge’ic infarct of mucosa ---> ulcerates ----> bacterial invasion of bowel ---> fibrosis </li></ul></ul></ul>
  34. 34. Ischemic Colitis: <ul><li>Clinical Syndrome Based on: </li></ul><ul><li>Gangrenous ischemic Colitis: </li></ul><ul><ul><li>Complete arterial occlusion ---> full thickness infarction ---> gangrene ---> perforation ----> PERITONITIS. </li></ul></ul>
  35. 35. Ischemic Colitis: <ul><li>Symptoms: </li></ul><ul><ul><li>Depends on the stage of the lesion </li></ul></ul><ul><ul><li>Acute mild to moderate generalized or lower abdominal crampy pain ---> HEMATOCHEZIA </li></ul></ul><ul><ul><li>Hyperactive bowel sound ---> silent </li></ul></ul><ul><ul><li>Abdominal tenderness ---> persist --->r/o peritonitis </li></ul></ul>
  36. 36. Ischemic Colitis: <ul><li>Diagnosis: </li></ul><ul><ul><li>Clinical hx & PE </li></ul></ul><ul><ul><li>FPA ---> adynamic ileus (stops at the involved segment); Pneumoperitoneum </li></ul></ul><ul><ul><li>Contrast enema (water soluble) </li></ul></ul><ul><ul><li>- thumb printing in the mucosa </li></ul></ul><ul><ul><li>Endoscopy (risky) </li></ul></ul>
  37. 37. Ischemic Colitis: <ul><li>Treatment: </li></ul><ul><ul><li>Emergency celiotomy </li></ul></ul><ul><ul><li>- segmental resection w/ primary </li></ul></ul><ul><ul><li>anastomosis or colostomy </li></ul></ul>
  38. 38. Fecal impaction: <ul><li>Is the arrest and accumulation of the feces in the rectum or colon (dehydrated feces). </li></ul><ul><li>Overflow diarrhea w/o relief of the sense of rectal fullness </li></ul><ul><li>Result to stercoral ulcer --> bleeding and perforation </li></ul><ul><li>Mx: - tap water enema / manual extraction </li></ul><ul><li>- hot sitz bath </li></ul>
  39. 39. Inflammatory Bowel Diseases: <ul><li>Ulcerative colitis (Mucosal Ulcerative Colitis / Idiopathic Ulcerative Colitis): </li></ul><ul><ul><li>involve the colonic mucosa </li></ul></ul><ul><ul><li>male > female </li></ul></ul><ul><ul><li>limited to the colon and rectum </li></ul></ul><ul><li>Crohn’s Disease (Chronic Interstitial Enteritis/Regional Ilietis): </li></ul><ul><ul><li>transmural inflammation anywhere in the GIT </li></ul></ul><ul><ul><li>extraintestinal symptoms proceeds those of intestinal symptoms </li></ul></ul><ul><ul><li>female > male </li></ul></ul>
  40. 40. Inflammatory Bowel Disease: Signs and Symptoms Crohn’s Disease Ulcerative Colitis Symptoms diarrhea +++ +++ rectal bleeding + +++ tenesmus 0 +++ abdominal pain +++ + fever ++ + vomiting +++ 0 weight loss +++ + Signs perianal disease +++ 0 abdominal mass +++ 0 malnutriton +++ +
  41. 41. Inflammatory Bowel Diseases: Ulcerative Colitis Crohn’s Colitis Usual Location rectum, left colon anywhere Rectal Bleeding common, continuous uncommon, intermittent Rectal involvement almost always approximate 50% Fistulas rare common Ulcers shaggy, irregular, continuous distribution linear w/ transverse fissures (cobblestone) Bowel stricture rare (suspect carcinoma) common Carcinoma increase incidence increased incidence Toxic dilatation of colon Occurs in both
  42. 42. Medical Therapy for Ulcerative Colitis & Crohn’s Disease <ul><li>Sulfasalazine </li></ul><ul><li>Metronidazole </li></ul><ul><ul><li>Crohn’s ileocolitis & colitis </li></ul></ul><ul><ul><li>Perineal colitis </li></ul></ul><ul><ul><li>Not effective in active ulcerative colitis </li></ul></ul><ul><li>Corticosteroid </li></ul><ul><ul><li>Oral for mild to moderate active ulcerative colitis and Crohn’s disease </li></ul></ul><ul><ul><li>Parenteral for severe or toxic ulcerative colitis or Crohn’s disease </li></ul></ul><ul><li>Immunosuppressive agents: </li></ul><ul><ul><li>Steroid sparing </li></ul></ul><ul><ul><li>Refractory disease </li></ul></ul>
  43. 43. Indications for Surgical Interventions for Ulcerative Colitis: <ul><li>Active disease unresponsive to medical therapy </li></ul><ul><li>Risks of cancer </li></ul><ul><li>Severe bleeding </li></ul>
  44. 44. Surgical treatment for Ulcerative Colitis <ul><li>Proctocolectomy w/ Brooke ileostomy: </li></ul><ul><ul><li>curative w/ one operation </li></ul></ul><ul><li>Colectomy w/ ileorectal anastomosis: </li></ul><ul><ul><li>not curative; cancer risk persists (5-50%) </li></ul></ul><ul><ul><li>contraindicated for severe rectal dse, rectal dysplasia and rectal CA </li></ul></ul><ul><li>Total proctocolectomy w/ ileoanal anastomosis w/ pouch: </li></ul><ul><ul><li>curative w/ continence </li></ul></ul><ul><ul><li>contraindicated for Crohn’s dse, diarrhea, rectal CA </li></ul></ul>
  45. 45. Surgical treatment for Ulcerative Colitis
  46. 46. Indications for Surgical Treatment of Crohn’s Dsease <ul><li>Ileocolic Crohn’s Disease: </li></ul><ul><ul><li>Internal fistula and abscess 38% </li></ul></ul><ul><ul><li>Intestinal obstruction 37% </li></ul></ul><ul><ul><li>Perianal fistula 15% </li></ul></ul><ul><ul><li>Poor response to medical therapy 6% </li></ul></ul><ul><li>Colonic Crohn’s Disease: </li></ul><ul><ul><li>Internal fistula and abscesses 25% </li></ul></ul><ul><ul><li>Perianal disease 23% </li></ul></ul><ul><ul><li>Severe dse w/ poor response </li></ul></ul><ul><ul><li>to medical therapy 21% </li></ul></ul><ul><ul><li>Toxic megacolon 19% </li></ul></ul><ul><ul><li>Intestinal obstruction 12% </li></ul></ul>
  47. 47. COLO – RECTAL POLYPS <ul><li>Projection from the surface of the intestinal mucosa regardless of it’s histologic nature: </li></ul><ul><li>Types: </li></ul><ul><ul><li>Neoplastic </li></ul></ul><ul><ul><li>Hamartomatous </li></ul></ul><ul><ul><li>Inflammatory </li></ul></ul><ul><ul><li>Unclassified </li></ul></ul>
  48. 48. COLO – RECTAL POLYPS <ul><li>Neoplastic Polyps: </li></ul><ul><li>Invasive CA are common in polyps smaller than 1 cm in diameter and incidence increases w/ increase in size </li></ul>Types Incidence (%) Malignant Potential (%) Tubular 75 5 Villous 10 40 Tubulovillous 15 22
  49. 49. COLO – RECTAL POLYPS <ul><li>Neoplastic Polyps: </li></ul><ul><li>Diagnosis: </li></ul><ul><ul><li>bleeding per rectum (most common) </li></ul></ul><ul><ul><li>Villous polyp (large) ---> watery diarrhea and in rare cases can have fluid and electrolyte imbalance </li></ul></ul><ul><ul><li>do complete examination of the colon - colonoscopy </li></ul></ul><ul><ul><li>biopsy / transrectal ultrasonography </li></ul></ul>
  50. 50. COLO – RECTAL POLYPS <ul><li>Neoplastic Polyps: </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>Polypectomy for benign ---> follow up </li></ul></ul><ul><ul><li>(+) CA in situ ----> polypectomy </li></ul></ul><ul><ul><li>(+) invasive CA (invade the muscularis mucosa) </li></ul></ul><ul><ul><ul><li>9% metastasize to LN if pedunculated </li></ul></ul></ul><ul><ul><ul><li>20% metastasize to LN if it invades the stalk or neck </li></ul></ul></ul><ul><ul><ul><li>15% metastasize to LN if sessile </li></ul></ul></ul><ul><ul><ul><li>CANCER SURGERY </li></ul></ul></ul>
  51. 51. <ul><li>Neoplastic Polyps: </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>If entire mucosal surface is covered by villous tumor ---> segmental resection, if in rectum can do full thickness proximal protectomy w/ colo-anal anastomosis </li></ul></ul>
  52. 52. <ul><li>Hamartomatous Polyp: </li></ul><ul><li>Juvenile Polyp: </li></ul><ul><ul><li>not precancerous </li></ul></ul><ul><ul><li>excision </li></ul></ul><ul><ul><li>Swiss cheese appearance from dilated cystic spaces </li></ul></ul><ul><li>Familial Juvenile Polyposis Coli: </li></ul><ul><ul><li>thousands polyps in the colon and rectum </li></ul></ul><ul><ul><li>can degenerate to adenoma ----> malignancy </li></ul></ul><ul><ul><li>subtotal colectomy or proctocolectomy </li></ul></ul>
  53. 53. <ul><li>Hamartomatous Polyp: </li></ul><ul><li>Peutz-jegher Syndrome </li></ul><ul><ul><li>Melanin spot on buccal mucosa, lips, face and digits </li></ul></ul><ul><ul><li>Polyps of small bowel (always), stomach, colon and rectum (branching of lamina propria like Christmas tree ). </li></ul></ul><ul><ul><li>Can degenerate into malignancy </li></ul></ul><ul><li>Cronkhite – Canada Syndrome: </li></ul><ul><ul><li>GIT polyposis, alopecia, cutaneous pigmentation, atrophy of fingernails and toe nails </li></ul></ul><ul><li>Cowden’s Syndrome: </li></ul><ul><ul><li>Autosomal dominant, hamartomas of all three embryonal cell layers </li></ul></ul><ul><ul><li>Facial trichilemomas, breast cancer, thyroid dse, GIT polyp </li></ul></ul>
  54. 54. <ul><li>Infammatory Polyp: </li></ul><ul><ul><li>Caused by previous attacks of severe colitis resulting in partial loss of mucosa leaving remnants or islands of normal mucosa </li></ul></ul><ul><ul><li>Occurs after amebic colitis, ischemic colitis and Schistosomal colitis </li></ul></ul><ul><ul><li>Not premalignant </li></ul></ul><ul><li>Hyperplastic Polyp: </li></ul><ul><ul><li>Usually small < 5mm not premalignant </li></ul></ul><ul><ul><li>> 2cm. have a slight risk of malignant degeneration </li></ul></ul><ul><ul><li>Saw tooth appearance of the lining epithelial cells </li></ul></ul>
  55. 55. COLO – RECTAL POLYPS <ul><li>Familial Adenomatous Polyposis Coli: </li></ul><ul><ul><li>Inherited non-sex linked autosomal dominant disease w/ hundreds of adenomatous polyps through the entire colon and rectum </li></ul></ul><ul><li>Gardner’s Syndrome: </li></ul><ul><ul><li>Familial polyposis, osteomatosis, epidermoid cyst, fibromas of the skin (desmoid tumor) – the most important extra-colonic expression. </li></ul></ul><ul><ul><li>Tx: - total proctocolectomy w/ ileostomy </li></ul></ul><ul><ul><li>- colectomy w/ ileorectal anastomosis </li></ul></ul><ul><ul><li>- examine other members of the family </li></ul></ul>
  56. 56. COLO – RECTAL POLYPS <ul><li>Familial Adenomatous Polyposis Coli: </li></ul><ul><li>Turcot’s Syndrome: </li></ul><ul><ul><li>Familial polyposis, brains tumors (gliomas or medulloblastomas) </li></ul></ul><ul><ul><li>Tx: same w/ colorectal involvement </li></ul></ul>
  57. 57. Carcinoma of Colon <ul><li>Most common CA of the GIT </li></ul><ul><li>Older age grp; peak incidence 80y/o </li></ul><ul><li>male ( > rectum) ; female ( > colon) </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>Unknown </li></ul></ul><ul><ul><li>Hereditary </li></ul></ul><ul><ul><li>Diet --> low fiber diet and high animal fat </li></ul></ul><ul><li>Distribution --> shifting to the right side </li></ul>
  58. 58. Carcinoma of Colon <ul><li>Macroscopic form: </li></ul><ul><li>Ulcerating type most common </li></ul><ul><li>Polypoid or fungating </li></ul><ul><li>Colloid CA </li></ul><ul><ul><li>bulky growth w/ gelatinous appearance </li></ul></ul><ul><ul><li>10-15% </li></ul></ul><ul><li>Signet ring cell CA </li></ul><ul><ul><li>intracellular mucinous </li></ul></ul><ul><li>Infiltrating CA </li></ul><ul><ul><li>submucosal spread </li></ul></ul>
  59. 59. Carcinoma of Colon <ul><li>Microscopic form: adenocarcinoma </li></ul><ul><li>Gronnell : based on invasive tendency, glandular arrangement, nuclear polarity and frequency of mitosis. </li></ul><ul><ul><li>Grade I - low grade / well differentiated </li></ul></ul><ul><ul><li>Grade II - average grade / mod. differentiated </li></ul></ul><ul><ul><li>Grade III - high grade / poorly differentiated </li></ul></ul>
  60. 60. Carcinoma of Colon <ul><li>Mechanism of Spread: </li></ul><ul><ul><li>Direct spread </li></ul></ul><ul><ul><li>Transperitoneal spread </li></ul></ul><ul><ul><li>Implantation </li></ul></ul><ul><ul><li>Lymphatic </li></ul></ul><ul><ul><li>Hematogenous </li></ul></ul><ul><li>Liver & Lungs – most common distant spread </li></ul>
  61. 61. Carcinoma of Colon <ul><li>Duke’s Stage: </li></ul><ul><ul><li>Depth of bowel wall involvement </li></ul></ul><ul><ul><li>Presence or absence of LN metastasis </li></ul></ul><ul><li>Stage A: </li></ul><ul><ul><ul><li>Invasion at least through the muscularis mucosa but not through the muscularis propria </li></ul></ul></ul><ul><ul><ul><li>98% ---> 5yr survival </li></ul></ul></ul><ul><li>Stage B: </li></ul><ul><ul><ul><li>Invasion through full thickness of bowel wall; (-) LN </li></ul></ul></ul><ul><ul><ul><li>78% ----> 5yr survival </li></ul></ul></ul>
  62. 62. Carcinoma of Colon <ul><li>Duke’s Stage: </li></ul><ul><li>Stage C: </li></ul><ul><ul><li>LN metastasis, regardless of depth </li></ul></ul><ul><ul><li>Stage C1 : - only adjacent LN metastasis </li></ul></ul><ul><ul><li>Stage C2 : - LN involves are nodes at point of ligature of blood vessels </li></ul></ul><ul><ul><li>32% 5 yr survival </li></ul></ul><ul><li>Stage D: </li></ul><ul><ul><li>Distant metastasis or w/ adjacent organ involvement </li></ul></ul><ul><ul><li>0% 5 yr survival </li></ul></ul>
  63. 63. TNM Staging of Colonic CA <ul><li>Primary Tumor (T): </li></ul><ul><li>TX - Primary tumor cannot be assessed </li></ul><ul><li>T0 - No evidence of primary tumor </li></ul><ul><li>T1 - Tumor invades submucosa </li></ul><ul><li>T2 - Tumor invades muscularis proper </li></ul><ul><li>T3 - Tumor invades through the muscularis proper </li></ul><ul><li>into the subserosa or into nonperitonealized </li></ul><ul><li>pericolic or perirectal tissue </li></ul><ul><li>T4 - Tumor perforates the visceral peritoneum or </li></ul><ul><li>directly invades the organs or structures </li></ul>
  64. 64. TNM Staging of Colonic CA <ul><li>Regional Lymph Node (N): </li></ul><ul><li>NX – Regional LN cannot be assessed </li></ul><ul><li>N0 - No regional LN metastasis </li></ul><ul><li>N1 - Metastasis in 1 to 3 pericolic or perirectal LN </li></ul><ul><li>N2 - metastasis in 4 or more pericolic or </li></ul><ul><li> perirectal LN </li></ul><ul><li>N3 - Metastasis in any LN along the course of a </li></ul><ul><li> named vascular trunk </li></ul><ul><li>Distant Metastasis (M): </li></ul><ul><li>MX – Presence of distant metastasis cannot be assessed </li></ul><ul><li>M0 - No distant metastasis </li></ul><ul><li>M1 - w/ distant metastasis </li></ul>
  65. 65. TNM Staging of Colonic CA <ul><li>Stage I: T1 –T2 N0 M0 </li></ul><ul><li>90% 5y/r Survival </li></ul><ul><li>Stage II: T3 – T4 N0 M0 </li></ul><ul><li>60 – 80% 5 y/r survival </li></ul><ul><li>Stage III: Any T N1 M0 </li></ul><ul><li>Any T N2, N3 M0 </li></ul><ul><li>20 – 50% 5y/r survival </li></ul><ul><li>Stage IV; Any T Any N M1 </li></ul><ul><li>< 5% 5 yr survival </li></ul>
  66. 66. Risk Factors for Colorectal CA <ul><li>Aging is the dominant risk factor w/ rising incidence after 50 y/o. </li></ul><ul><li>Hereditary risk factor: </li></ul><ul><ul><li>80% colorectal are sporadic </li></ul></ul><ul><ul><li>20% w/ known family hx. </li></ul></ul><ul><li>Dietary factors: </li></ul><ul><ul><li>high animal fat (saturated or polyunsaturated fats), but oleic acid (coconut & fish oil does not). </li></ul></ul><ul><ul><li>Vegetable fiber, Ca, selenium, Vits. A, C, & E are protective </li></ul></ul><ul><ul><li>Alcohol increase colonic CA </li></ul></ul><ul><li>Obesity and sedentary lifestyle contributory </li></ul><ul><li>Smoking increased the incidence </li></ul>
  67. 67. Premalignant Diseases of Colon & Rectum <ul><li>Adenoma </li></ul><ul><li>Familial adenomatous polyposis syndrome </li></ul><ul><li>Gardner’s syndrome </li></ul><ul><li>Hamartoma s (familial juvenile polyposis coli & Peutz-Jegher polyp </li></ul><ul><li>Inflammatory bowel disease </li></ul><ul><ul><li>Ulcerative colitis </li></ul></ul><ul><ul><li>Crohn’s disease </li></ul></ul><ul><li>Schistosomiasis (Billharziasis) – S. mansoni & </li></ul><ul><li>S. japonicum </li></ul><ul><li>Utero-sigmoidostomy </li></ul>
  68. 68. Carcinoma of Colon <ul><li>Clinical Manifestation: </li></ul><ul><ul><li>Change in bowel habit classic symptoms </li></ul></ul><ul><ul><li>Rectal bleeding </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Abdominal pain, bloating and other signs of obstruction </li></ul></ul><ul><ul><li>Anemia and anorexia </li></ul></ul><ul><ul><li>Tenesmus, feeling of incomplete evacuation, and rectal bleeding if lesion is in the rectum </li></ul></ul>
  69. 69. Screening Modalities For Colonic Tumors <ul><li>Fecal occult blood testing: </li></ul><ul><ul><ul><li>Annual FOBT screening for asymptomatic 50 y/o </li></ul></ul></ul><ul><li>Rigid proctoscopy / flexible sigmoidoscopy </li></ul><ul><li>Colonoscopy: </li></ul><ul><ul><ul><li>The most accurate and most complete method for examining the colon </li></ul></ul></ul><ul><li>Air contrast Barium enema: </li></ul><ul><li>CT colonography (virtual colonoscopy): </li></ul><ul><ul><ul><li>Colon is insufflated with air and a spiral CT is performed. </li></ul></ul></ul><ul><ul><ul><li>Useful for imaging the proximal colon in case of obstruction </li></ul></ul></ul>
  70. 70. Therapy for Colonic Carcinoma <ul><li>Principle: </li></ul><ul><ul><li>Objective is to remove the primary tumor w/ its lymphovascular supply </li></ul></ul><ul><ul><li>Adjacent organs or tissue invaded shd be resected en block w/ the tumor </li></ul></ul><ul><ul><li>Tumors cannot be removed, a palliative procedure shd be done. </li></ul></ul><ul><ul><li>Synchronous CA ---> subtotal or total colectomy </li></ul></ul><ul><ul><li>Metachronous tumor (second primary colon CA) treated similarly </li></ul></ul><ul><ul><li>Hemorrhage in an unresectable tumor can be controlled w/ angiographic embolization </li></ul></ul>
  71. 71. Therapy for Colonic Carcinoma <ul><li>Stage 0: </li></ul><ul><ul><li>No risk of LN metastasis </li></ul></ul><ul><ul><li>Pedunculated / sessile polyp -> endoscopic polypectomy </li></ul></ul><ul><ul><li>If polyp cannot be removed completely segmental resection shd be done </li></ul></ul><ul><li>Stage I: (T1,N0,M0): </li></ul><ul><ul><li>Polypectomy --> for uninvolved stalk (pedunculated) </li></ul></ul><ul><ul><li>Segmental resection: </li></ul></ul><ul><ul><ul><li>Sessile polyp </li></ul></ul></ul><ul><ul><ul><li>Pedunculated polyp ( lymphovascular invasion, poorly differentiated or tumor w/in 1mm. of resection margin ---> high risk of local recurence and metastatic spread) </li></ul></ul></ul>
  72. 72. Therapy for Colonic Carcinoma <ul><li>Stage II (T3-4,N0,M0): </li></ul><ul><ul><li>Surgical resection </li></ul></ul><ul><ul><li>Adjuvant chemotherapy is suggested for: </li></ul></ul><ul><ul><ul><li>Young patient </li></ul></ul></ul><ul><ul><ul><li>Moderate to poorly differentiated </li></ul></ul></ul><ul><li>Stage III (Tany,N1,M0): </li></ul><ul><ul><li>Surgical resection + adjuvant chemotherapy (5-Fluorouracil, levamisole or leucovorin, capecitabine, irinotecan, oxaliplatin, angiogenesis inhibitor and immunotherapy) </li></ul></ul>
  73. 73. Therapy for Colonic Carcinoma <ul><li>Stage IV: (Tany, Nany, M1) </li></ul><ul><ul><li>Palliative resection of primary and isolated liver metastasis </li></ul></ul><ul><ul><li>Adjuvant chemotherapy </li></ul></ul><ul><ul><li>Irresectable ---> diverting colostomy </li></ul></ul>
  74. 74. THANK YOU
  75. 75. Anorectal Abscess <ul><li>5 potential spaces: </li></ul><ul><ul><li>Perianal space </li></ul></ul><ul><ul><li>Ischiorectal space </li></ul></ul><ul><ul><li>Intersphincteric space </li></ul></ul><ul><ul><li>Deep posterior anal space </li></ul></ul><ul><ul><li>Supralevator space </li></ul></ul>
  76. 76. Anorectal Abscess <ul><li>Etiology: </li></ul><ul><ul><li>Infection of anal gland </li></ul></ul><ul><ul><li>Organism (fecal & cutaneous flora) </li></ul></ul><ul><ul><ul><li>E. coli 4. Clostridium sp. </li></ul></ul></ul><ul><ul><ul><li>Bacteroides fragilis 5. Staphylococcus </li></ul></ul></ul><ul><ul><ul><li>Streptococcus </li></ul></ul></ul><ul><li>Manifestation: </li></ul><ul><ul><li>Pain in the anal region </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Drainage / antibiotic </li></ul></ul><ul><ul><li>Hygiene </li></ul></ul><ul><ul><li>Hot sitz bath </li></ul></ul>
  77. 77. Anorectal Abscess <ul><li>Types : </li></ul><ul><li>Perianal abscess </li></ul><ul><li>Ischiorectal abscess – diffuse </li></ul><ul><li>swelling of ischiorectal fossa </li></ul>
  78. 78. Anorectal Abscess <ul><li>Intersphincteric abscess: </li></ul><ul><ul><li>No apparent sign of swelling or induration in the perianal area </li></ul></ul><ul><ul><li>CLUE: --> deep seated tenderness when circum-anal pressure is applied above the dentate line. </li></ul></ul><ul><ul><li>Drainage: thru the anal canal lining or thru internal sphincteric muscle </li></ul></ul><ul><li>Supralevator abscess: </li></ul><ul><ul><li>Uncommon </li></ul></ul><ul><ul><li>Mimmic acute intra-abdominal condition </li></ul></ul><ul><ul><li>Etiology: extension of </li></ul></ul><ul><ul><ul><li>Intersphincteric abscess </li></ul></ul></ul><ul><ul><ul><li>Ischiorectal abscess </li></ul></ul></ul><ul><ul><ul><li>Intra-abdominal abscess </li></ul></ul></ul>
  79. 79. <ul><li>Necrotizing Peri-anal & Perineal Infection: </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>Neglected or delayed treatment of primary anorectal infection </li></ul></ul><ul><ul><li>Extension of UTI particularly the periurethral gland </li></ul></ul><ul><li>Manifestation: </li></ul><ul><ul><li>Pain, tenderness and swelling with crepitation of perianal and scrotum or labia </li></ul></ul><ul><ul><li>Black spot on the site (necrosis) </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Broad spectrum antibiotic </li></ul></ul><ul><ul><li>Debridement </li></ul></ul><ul><ul><li>Hyperalimentation / diverting colostomy &/or cystostomy </li></ul></ul>
  80. 80. <ul><li>Fistula-In-Ano: </li></ul><ul><ul><li>Inflammatory tract w/ secondary opening (external) and a primary opening (internal) in the anal canal. </li></ul></ul><ul><li>Etiology: </li></ul><ul><ul><li>Complication of perianal abscess </li></ul></ul><ul><li>Goodsalls Rule: </li></ul><ul><ul><li>to locate internal opening </li></ul></ul><ul><li>Classification of Fistula-in-ano: </li></ul><ul><ul><li>Inter-sphincteric </li></ul></ul><ul><ul><li>Trans-sphincteric </li></ul></ul><ul><ul><li>Supra-sphincteric </li></ul></ul><ul><ul><li>Extra-sphincteric </li></ul></ul>
  81. 81. Fistula-in-ano <ul><li>Manifestation: </li></ul><ul><ul><li>Previous history of perianal abscess </li></ul></ul><ul><ul><li>Rule out ulcerative colitis and Crohn’s dse (colonoscopy / barium enema) </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Identify the primary opening (probing/methylene blue/fistulography) </li></ul></ul><ul><ul><li>Fistulotomy / fistulectomy (healing by secondary intension </li></ul></ul>
  82. 82. Fistula-in-ano <ul><li>If fistula is high in relation to anorectal ring do 2 stage procedure: </li></ul><ul><li>Insert a seton wire or suture to the tract for several wks to create fibrosis </li></ul><ul><li>Open the fibrous track on the second stage after 6-8 wks </li></ul>
  83. 83. Hemorrhoid <ul><li>Are cushions of submucosal tissue in the anal canal composed of connective tissue containing venules, arterioles and smooth muscle fibers. </li></ul><ul><li>Purposed – aids in anal continence and cushion the anal canal and support the lining during defecation </li></ul><ul><li>External skin tag </li></ul><ul><ul><li>Redundant fibrotic skin at the anal verge due to previous thrombosed external hemorrhoid of past operation </li></ul></ul>
  84. 84. Hemorrhoid <ul><li>External hemorrhoid </li></ul><ul><ul><li>Dilated venules of the inferior hemorrhoidal plexus located distal to the pectinate or dentate line </li></ul></ul>
  85. 85. Hemorrhoid <ul><li>Internal hemorrhoid: </li></ul><ul><ul><li>Manifestation: </li></ul></ul><ul><ul><ul><li>Painless bright red rectal bleeding associated w/ bowel movement </li></ul></ul></ul><ul><ul><ul><li>Feeling of incomplete evacuation of feces </li></ul></ul></ul><ul><ul><ul><li>Pain is experienced if w/ complication of anal fissure, stenosis of thrombosis </li></ul></ul></ul><ul><ul><li>Grade According to Degree of Prolapse: </li></ul></ul><ul><ul><li>1 st degree : anal cushion slide down beyond the </li></ul></ul><ul><ul><li>dentate line on straining </li></ul></ul><ul><ul><li>Mx: - painless rectal bleeding </li></ul></ul><ul><ul><li>Tx: - bulk forming agents (psyllium seed) </li></ul></ul><ul><ul><li>- rubber band ligation </li></ul></ul>
  86. 86. Hemorrhoid <ul><li>Rubber band ligation: </li></ul>
  87. 87. Hemorrhoid <ul><li>2 nd degree: </li></ul><ul><ul><li>Prolapse through the anus on straining but spontaneously reduced </li></ul></ul><ul><li>3 rd degree: </li></ul><ul><ul><li>Requires manual reduction into the anal canal </li></ul></ul><ul><ul><li>Tx: rubber band ligation / hemorrhoidectomy </li></ul></ul><ul><li>4 th degree: </li></ul><ul><ul><li>Prolapse cannot be reduced </li></ul></ul><ul><ul><li>hemorrhoidectomy </li></ul></ul>
  88. 88. Anal Fissure <ul><li>Tear from the dentate line up to the anal verge lined by skin </li></ul><ul><li>Seen in young and middle age group </li></ul><ul><li>Majority occurs at the at the posterior midline due to poor muscular support </li></ul>
  89. 89. Anal Fissure <ul><li>Etiology: </li></ul><ul><li>Passage of large hard stool </li></ul><ul><li>Conditions ( Crohn’s dse, ulcerative colitis, syphilis’ tuberculosis and leukemia) </li></ul><ul><li>Manifestation: </li></ul><ul><ul><li>Burning pain during and after bowel movement </li></ul></ul><ul><ul><li>Bright red blood on toilet paper </li></ul></ul><ul><li>Diagnosis: </li></ul><ul><ul><li>Rectal examination / proctosigmoidoscopy </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Conservative: - anal hygiene / bulk forming agents </li></ul></ul><ul><ul><li>- hot sitz bath </li></ul></ul><ul><ul><li>- local anesthetic jelly </li></ul></ul><ul><ul><li>Surgical: - chronic stage (lateral internal sphincterotomy) </li></ul></ul>
  90. 90. Anal Fissure <ul><li>Treatment: </li></ul><ul><ul><li>Conservative: </li></ul></ul><ul><ul><ul><li>anal hygiene / bulk forming agents </li></ul></ul></ul><ul><ul><ul><li>hot sitz bath </li></ul></ul></ul><ul><ul><ul><li>local anesthetic jelly </li></ul></ul></ul><ul><ul><li>Surgical: </li></ul></ul><ul><ul><ul><li>chronic stage (lateral internal sphincterotomy) </li></ul></ul></ul>
  91. 91. THANK YOU

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