Rectum And Anus

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  • 1. Rectum and anus Celso M. Fidel, MD, FPCS, FPSGS Diplomate Philippine Board of Surgery
  • 2. Embryology
    • The embryonic gastrointestinal tract begins developing during the fourth week of gestation.
    • The primitive gut is derived from the endoderm and divided into three segments :
    • 1. Foregut
    • 2. Midgut
    • 3. Hindgu t
    • Both midgut and hindgut contribute to the colon, rectum, and anus.
  • 3. Embryology
    • The hindgut develops into the distal transverse colon, descending colon, rectum , and proximal anus , all of which receive their blood supply from the inferior mesenteric artery .
    • During the sixth week of gestation, the distal-most end of the hindgut, the cloaca , is divided by the urorectal septum into the urogenital sinus and the rectum.
  • 4. Embryology
    • The distal anal canal is derived from:
    • ectoderm and receives its blood supply from the internal pudendal artery .
    • The dentate line divides the endodermal hindgut from the ectodermal distal anal canal.
  • 5. Anatomy
    • The large intestine extends from the ileocecal valve to anus. Anatomically & functionally divided to the colon, rectum , and anal canal .
    • The rectum comprise five distinct layers:
    • Mucosa
    • Submucosa
    • Inner circular muscle
    • Outer longitudinal muscle
    • Serosa.
  • 6. Anatomy
    • T he outer longitudinal muscle is separated into three teniae coli , which converge proximally at the appendix and distally at the rectum
    • The outer longitudinal muscle layer of rectum is circumferential
  • 7. Anatomy
    • In the distal rectum, the inner smooth-muscle layer coalesces to form the internal anal sphincter.
    • The intraperitoneal colon and proximal one third of the rectum are covered by serosa ; the mid and lower rectum lack serosa.
  • 8. Anatomy
    • The rectosigmoid junction is found at approximately the level of the sacral promontory and is arbitrarily described as the point at which the three teniae coli coalesce to form the outer longitudinal smooth muscle layer of the rectum
  • 9. ARTERIAL SUPPLY MCA IMA SMA LCA SRA Sig. A ICA RCA
  • 10. Marginal artery of Drummond
  • 11. Blood Supply
    • The inferior mesenteric artery branches into the left colic artery , which supplies the descending colon, several sigmoidal branches , which supply the sigmoid colon , and the superior rectal artery , which supplies the proximal rectum .
    • The terminal branches of each artery form anastomoses with the terminal branches of the adjacent artery and communicate via the marginal artery of Drummond .
  • 12. Venous Drainage
    • Except for the inferior mesenteric vein , the veins of the colon parallel their corresponding arteries and bear the same terminology
    • The inferior mesenteric vein ascends in the retroperitoneal plane over the psoas muscle and continues posterior to the pancreas to join the splenic vein.
    • During a colectomy, this vein is often mobilized independently and ligated at the inferior edge of the pancreas.
  • 13. LYMPHATIC DRAINAGE
  • 14. lymphatic drainage
    • The lymphatic drainage of the colon originates in a network of lymphatics in the muscularis mucosa.
    • Lymphatic vessels and lymph nodes follow the regional arteries.
  • 15. lymphatic drainage
    • Lymph nodes are found on:
    • 1. The bowel wall (epicolic)
    • 2. Inner margin of the bowel adjacent to the
    • arterial arcades (paracolic)
    • 3. Around the named mesenteric vessels (intermediate)
    • 4. Origin of the superior and inferior mesenteric arteries (main).
  • 16. lymphatic drainage
    • The sentinel lymph nodes are the first one to four lymph nodes to drain a specific segment of the colon, and are thought to be the first site of metastasis in colon cancer. The utility of sentinel lymph node dissection and analysis in colon cancer remains controversial.
  • 17. Anorectal Landmarks
    • The rectum is approximately 12 to 15 cm in length. Three distinct submucosal folds:
    • 1.Valves of Houston , extend into the rectal lumen.
    • 2. Posteriorly, the presecral fascia separates the rectum from the presacral venous plexus and the pelvic nerves.
    • 3. At S4, the rectosacral fascia ( Waldeyer's fascia ) extends forward and downward and attaches to the fascia propria at the anorectal junction.
  • 18. ANORECTAL ANATOMY
    • Rectosigmoid (fusion of taenia coli) to anal canal
    • 3 distinct intraluminal curves (Valves of Houston)
    • - Proximal & distal curves convex to the right
    • - Middle curve marks the anterior peritoneal
    • reflection
    • - Posterior peritoneal reflection 12-15 cm from
    • anal verge
  • 19. Anorectal Landmarks
    • Anteriorly, Denonvilliers' fascia separates the rectum from the prostate and seminal vesicles in men and from the vagina in women
    • The lateral ligaments support the lower rectum.
    • The surgical anal canal measures 2 to 4 cm in length and is generally longer in men than in women. It begins at the anorectal junction and terminates at the anal verge .
  • 20. Anorectal Landmarks
    • The dentate or pectinate line marks the transition point between columnar rectal mucosa and squamous anoderm.
    • The 1 to 2 cm of mucosa just proximal to the dentate line shares histologic characteristics of columnar, cuboidal, and squamous epithelium and is referred to as the anal transition zone .
  • 21. Anorectal Landmarks
    • The dentate line is surrounded by longitudinal mucosal folds, known as the columns of Morgagni , into which the anal crypts empty. These crypts are the source of cryptoglandular abscesses
    • In the distal rectum, the inner smooth muscle is thickened and comprises the internal anal sphincter that is surrounded by the subcutaneous , superficial , and deep external sphincter .
  • 22. Anorectal Landmarks
    • The deep external anal sphincter is an extension of the puborectalis muscle .
    • Muscles that form the levator ani muscle of the pelvic floor:
    • 1. Puborectalis
    • 2. Iliococcygeus
    • 3. Pubococcygeus
  • 23. THE ANORECTUM VALVES OF HOUSTON DENTATE LINE ANAL SPHINCTERS ANAL VERGE HEMORRHOIDAL Plx.
  • 24. Anorectal Vascular Supply
    • The superior rectal artery arises from the terminal branch of the inferior mesenteric artery and supplies the upper rectum.
    • The middle rectal artery arises from the internal iliac ; the presence and size of these arteries are highly variable.
  • 25. Anorectal Vascular Supply
    • The inferior rectal artery arises from the internal pudendal artery , which is a branch of the internal iliac artery.
    • A rich network of collaterals connects the terminal arterioles of each of these arteries , thus making the rectum relatively resistant to ischemia
  • 26. ARTERIAL SUPPLY MCA IMA SMA LCA SRA Sig. A ICA RCA
  • 27. Anorectal Vascular Supply
    • The venous drainage of the rectum parallels the arterial supply.
    • The superior rectal vein drains into the portal system via the inferior mesenteric vein .
    • The middle rectal vein drains into the internal iliac vein.
    • The inferior rectal vein drains into the internal pudendal vein , and subsequently into the internal iliac vein .
  • 28. Anorectal Vascular Supply
    • A submucosal plexus deep to the columns of Morgagni forms the hemorrhoidal plexus and drains into all three veins.
    • HEMORRHOIDAL PLEXUS
    • - Subepithelial vascular cushion
    • a. INTERNAL H – above dentate line; insensate mucosa
    • b. EXTERNAL H – below dentate line; lined by richly innervated anoderm
  • 29. Anorectal Vascular Supply
    • Lymphatic drainage of the rectum parallels the vascular supply.
    • Lymphatic channels in the upper and middle rectum drain superiorly into the inferior mesenteric lymph nodes.
    • Lymphatic channels in the lower rectum drain both superiorly into the inferior mesenteric lymph nodes and laterally into the internal iliac lymph nodes.
  • 30. Anorectal Vascular Supply
    • The anal canal has a more complex pattern of lymphatic drainage.
    • 1. Proximal to the dentate line, lymph drains into both the inferior mesenteric lymph nodes and the internal iliac lymph nodes.
    • 2. Distal to the dentate line, lymph primarily drains into the inguinal lymph nodes, but can also drain into the inferior mesenteric lymph nodes and internal iliac lymph nodes.
  • 31. Anorectal Nerve Supply
    • Both sympathetic and parasympathetic nerves innervate the anorectum.
    • 1.Sympathetic nerve fibers from L1-L3 join the preaortic plexus whose nerve fibers then extend below the aorta to form the hypogastric plexus , which subsequently joins the parasympathetic fibers to form the pelvic plexus.
    • 2. Parasympathetic nerve fibers known as the nervi erigentes and originate from S2-S4. These fibers join the sympathetic fibers to form the pelvic plexus.
  • 32. Anorectal Nerve Supply
    • Sympathetic and parasympathetic fibers then supply the anorectum and adjacent urogenital organs.
  • 33. Anorectal Nerve Supply
    • The internal anal sphincter is innervated by sympathetic and parasympathetic nerve fibers; both types of fibers inhibit sphincter contraction.
    • The external anal sphincter and puborectalis muscles are innervated by the inferior rectal branch of the internal pudendal nerve .
  • 34. Anorectal Nerve Supply
    • The levator ani receives innervation from both the internal pudendal nerve and direct branches of S3 to S5.
    • Sensory innervation to the anal canal is provided by the inferior rectal branch of the pudendal nerve .
    • The rectum is relatively insensate , the anal canal below the dentate line is sensate.
  • 35. congenital anomalies
    • Perturbation of the embryologic development of the midgut and hindgut may result in anatomic abnormalities of the colon, rectum, and anus
    • Incomplete descent of the urogenital septum may result in imperforate anus and associated fistulas to the genitourinary tract
  • 36. Motility, Defecation, and Continence
    • Motility
    • Unlike the small intestine, the large intestine does not demonstrate cyclic motor activity characteristic of the migratory motor complex
    • Bursts of "rectal motor complexes" also have been described. In general, cholinergic activation increases colonic motility.
  • 37. Motility, Defecation, and Continence
    • Defecation
    • Defecation is a complex, coordinated mechanism involving:
    • 1. Colonic mass movement
    • 2. Increased intra-abdominal and rectal pressure
    • 3. Relaxation of the pelvic floor.
  • 38. Motility, Defecation, and Continence
    • Defecation
    • Distention of the rectum causes a reflex relaxation of the internal anal sphincter (the rectoanal inhibitory reflex) that allows the contents to make contact with the anal canal.
    • This "sampling reflex" allows the sensory epithelium to distinguish solid stool from liquid stool and gas. If defecation does not occur, the rectum relaxes and the urge to defecate passes (the accommodation response
  • 39. Motility, Defecation, and Continence
    • Defecation
    • Defecation proceeds
    • 1. By coordination of increasing intra-abdominal
    • pressure via the Valsalva maneuver
    • 2. Increased rectal contraction
    • 3. Relaxation of the puborectalis muscle
    • 4. Opening of the anal canal.
  • 40. Motility, Defecation, and Continence
    • Continence
    • The maintenance of fecal continence is at least as complex as the mechanism of defecation. Continence requires:
    • Adequate rectal wall compliance to accommodate the fecal bolus
    • Appropriate neurogenic control of the pelvic floor and sphincter mechanism
    • Functional internal and external sphincter muscles.
  • 41. Motility, Defecation, and Continence
    • Continence
    • 4. At rest, the puborectalis muscle creates a "sling" around the distal rectum, forming a relatively acute angle that distributes intraabdominal forces onto the pelvic floor.
    • 5. With defecation, this angle straightens, allowing downward force to be applied along the axis of the rectum and anal canal.
    • 6.The internal and external sphincters are tonically active at rest.
  • 42. Motility, Defecation, and Continence
    • Continence
    • . The internal sphincter is responsible for most of the resting, involuntary sphincter tone (resting pressure).
    • The external sphincter is responsible for most of the voluntary sphincter tone (squeeze pressure).
    • Branches of the pudendal nerve innervate both the internal and external sphincter
  • 43. Motility, Defecation, and Continence
    • Continence
    • Finally, the hemorrhoidal cushions may contribute to continence by mechanically blocking the anal canal. Thus, impaired continence may result from poor rectal compliance, injury to the internal and/or external sphincter or puborectalis, or nerve damage or neuropathy
  • 44. Clinical Evaluation
    • A complete history and physical examination is the starting point for evaluating any patient with suspected disease of the colon and rectum.
    • Special attention should be paid to the patient's past medical and surgical history to detect underlying conditions that might contribute to a gastrointestinal problem.
    • If patients have had prior intestinal surgery, it is essential that one understand the resultant gastrointestinal anatomy
  • 45. Clinical Evaluation
    • In addition, family history of colorectal disease, especially inflammatory bowel disease, polyps, and colorectal cancer, is crucial.
    • Medication use must be detailed as many drugs cause gastrointestinal symptoms.
    • Before recommending operative intervention, the adequacy of medical treatment must be ascertained.
    • In addition to examining the abdomen, visual inspection of the anus and perineum and careful digital rectal exam are essential.
    • Endoscopy
  • 46. Clinical Evaluation
    • Endoscopy
    • Anoscopy
    • The anoscope is a useful instrument for examination of the anal canal. Anoscopes are made in a variety of sizes and measure approximately 8 cm in length. A larger anoscope provides better exposure for anal procedures such as rubber band ligation or sclerotherapy of hemorrhoids.
    • 2 . Proctoscopy
  • 47. Clinical Evaluation
    • Imaging
    • Plain X-Rays and Contrast Studies
    • Computed Tomography
    • Virtual Colonoscopy
    • Magnetic Resonance Imaging
    • Positron Emission Tomography
    • Angiography
    • Endorectal and Endoanal Ultrasound
  • 48. Clinical Evaluation
    • Physiologic and Pelvic Floor Investigations
    • Anorectal physiologic testing uses a variety of techniques to investigate the function of the pelvic floor. These techniques are useful in the evaluation of patients with incontinence, constipation, rectal prolapse, obstructed defecation, and other disorders of the pelvic floor
  • 49. Clinical Evaluation
    • Physiologic and Pelvic Floor Investigations
    • 1 . Manometry
    • 2. Neurophysiology
    • 3, Rectal Evacuation Studies
  • 50. Clinical Evaluation
    • Physiologic and Pelvic Floor Investigations
    • Manometry
    • Anorectal manometry is performed by placing a pressure-sensitive catheter in the lower rectum. The catheter is then withdrawn through the anal canal and pressures recorded.
  • 51. Clinical Evaluation
    • Physiologic and Pelvic Floor Investigations
    • Manometry
    • A balloon attached to the tip of the catheter also can be used to test anorectal sensation.
    • The resting pressure in the anal canal reflects the function of the internal anal sphincter (normal: 40 to 80 mm Hg )
  • 52. Clinical Evaluation
    • Physiologic and Pelvic Floor Investigations
    • Manometry
    • The squeeze pressure , defined as the maximum voluntary contraction pressure minus the resting pressure, reflects function of the external anal sphincter (normal: 40 to 80 mm Hg above resting pressure).
  • 53. Clinical Evaluation
    • Physiologic and Pelvic Floor Investigations
    • Manometry
    • The high-pressurezone estimates the length of the anal canal (normal: 2.0 to 4.0 cm).
    • The rectoanal inhibitory reflex can be detected by inflating a balloon in the distal rectum; absence of this reflex is characteristic of Hirschsprung's disease
  • 54. Clinical Evaluation
    • Physiologic and Pelvic Floor Investigations
    • Neurophysiology
    • Neurophysiologic testing assesses function of the pudendal nerves and recruitment of puborectalis muscle fibers. Pudendal nerve terminal motor latency measures the speed of transmission of a nerve impulse through the distal pudendal nerve fibers (normal: 1.8 to 2.2 msec);
  • 55. Clinical Evaluation
    • Physiologic and Pelvic Floor Investigations
    • Neurophysiology
    • Needle EMG has been used to map both the pudendal nerves and the anatomy of the internal and external sphincters. However, this examination is painful and poorly tolerated by most patients.
    • Needle EMG has largely been replaced by pudendal nerve motor-latency testing to assess pudendal nerve function and endoanal ultrasound to map the sphincters.
  • 56. Clinical Evaluation
    • Physiologic and Pelvic Floor Investigations
    • Rectal Evacuation Studies
    • Rectal evacuation studies include the balloon expulsion test and video defecography. Balloon expulsion assesses a patient's ability to expel an intrarectal balloon. Video defecography provides a more detailed assessment of defecation. In this test, barium paste is placed in the rectum and defecation is then recorded fluoroscopically.
  • 57. Clinical Evaluation
    • Physiologic and Pelvic Floor Investigations
    • Rectal Evacuation Studies
    • Defecography is used to differentiate nonrelaxation of the puborectalis, obstructed defecation, increased perineal descent, rectal prolapse and intussusception, rectocele, and enterocele. The addition of vaginal contrast and intraperitoneal contrast is useful in delineating complex disorders of the pelvic floor
  • 58. laboratory studies
    • 1. Fecal Occult Blood Testing
    • 2. Stool Studies
    • 3. Serum Tests
    • 4. Tumor Markers
    • 5. Genetic Testing
  • 59. laboratory studies
    • 1. Fecal Occult Blood Testing
    • Fecal occult blood testing (FOBT) is used as a screening test for colonic neoplasms in asymptomatic, average-risk individuals. The efficacy of this test is based upon serial testing because the majority of colorectal malignancies will bleed intermittently. FOBT has been a nonspecific test for peroxidase contained in hemoglobin
  • 60. laboratory studies
    • Stool Studies
    • Stool studies are often helpful in evaluating the etiology of diarrhea. Wet-mount examination reveals the presence of fecal leukocytes, which may suggest colonic inflammation or the presence of an invasive organism such as invasive E. coli or Shigella . Stool cultures can detect pathogenic bacteria, ova, and parasites. C. difficile colitis is diagnosed by detecting bacterial toxin in the stool. Steatorrhea may be diagnosed by adding Sudan red stain to a stool sample.
  • 61. laboratory studies
    • Serum Tests
    • Specific laboratory tests that should be performed will be dictated by the clinical scenario. Preoperative studies generally include a complete blood count and electrolyte panel. The addition of coagulation studies, liver function tests, and blood typing/cross-matching depends upon the patient's medical condition and the proposed surgical procedure
  • 62. laboratory studies
    • Tumor Markers
    • Carcinoembryonic antigen (CEA) may be elevated in 60 to 90% of patients with colorectal cancer. Despite this, CEA is not an effective screening tool for this malignancy. Many practitioners follow serial CEA levels after curative-intent surgery in order to detect early recurrence of colorectal cancer. However, this tumor marker is nonspecific, and no survival benefit has yet been proven .
  • 63. laboratory studies
    • Tumor Markers
    • Other biochemical markers (ornithine decarboxylase, urokinase) have been proposed, but none has yet proven sensitive or specific for detection, staging, or predicting prognosis of colorectal carcinoma
  • 64. laboratory studies
    • Genetic Testing
    • Although familial colorectal cancer syndromes, such as familial adenomatous polyposis (FAP) and hereditary nonpolyposis colon cancer (HNPCC) are rare, information about the specific genetic abnormalities underlying these disorders has led to significant interest in the role of genetic testing for colorectal cancer.
  • 65. laboratory studies
    • Genetic Testing
    • Tests for mutations in the adenomatous polyposis coli (APC) gene responsible for FAP, and in mismatch repair genes responsible for HNPCC, are commercially available and extremely accurate in families with known mutations. Although many of these mutations are also present in sporadic colorectal cancer, the accuracy of genetic testing in average-risk individuals is considerably lower.
  • 66. laboratory studies
    • Genetic Testing
    • These tests are not recommended for screening. Because of the potential psychosocial implications of genetic testing, it is strongly recommended that professional genetic counselors be involved in the care of any patient considering these tests.
  • 67. evaluation of common symptoms
    • Abdominal Pain
    • Abdominal pain is a nonspecific symptom with a myriad of causes. Abdominal pain related to the colon and rectum can result from obstruction (either inflammatory or neoplastic), inflammation, perforation, or ischemia. Plain x-rays and judicious use of contrast studies and/or a CT scan can often confirm the diagnosis. Gentle retrograde contrast studies (barium or Gastrografin enema) may be useful in delineating the degree of colonic obstruction.
  • 68. evaluation of common symptoms
    • Abdominal Pain
    • Sigmoidoscopy and/or colonoscopy performed by an experienced endoscopist can assist in the diagnosis of ischemic colitis, infectious colitis, and inflammatory bowel disease.
    • However, if perforation is suspected, colonoscopy and/or sigmoidoscopy are generally contraindicated.
  • 69. evaluation of common symptoms
    • Abdominal Pain
    • .
    • Evaluation and treatment of abdominal pain from a colorectal source should follow the usual surgical principles of a thorough history and physical examination, appropriate diagnostic tests, resuscitation, and appropriately timed surgical intervention
  • 70. evaluation of common symptoms
    • Pelvic Pain
    • Pelvic pain can originate from the distal colon and rectum or from adjacent urogenital structures. Tenesmus may result from proctitis or from a rectal or retrorectal mass. Cyclical pain associated with menses, especially when accompanied by rectal bleeding, suggests a diagnosis of endometriosis. Pelvic inflammatory disease also can produce significant abdominal and pelvic pain.
  • 71. evaluation of common symptoms
    • Pelvic Pain
    • The extension of a peridiverticular abscess or periappendiceal abscess into the pelvis may also cause pain. CT scan and/or MRI may be useful in differentiating these diseases. Proctoscopy (if tolerated) also can be helpful. Occasionally, laparoscopy will yield a diagnosis.
  • 72. evaluation of common symptoms
    • Anorectal Pain
    • Anorectal pain is most often secondary to an anal fissure or perirectal abscess and/or fistula. Physical examination can usually differentiate these conditions. Other, less common causes of anorectal pain include anal canal neoplasms, perianal skin infection, and dermatologic conditions. Proctalgia fugax results from levator spasm and may present without any other anorectal findings.
  • 73. evaluation of common symptoms
    • Anorectal Pain
    • Physical exam is critical in evaluating patients with anorectal pain. If a patient is too tender to examine in the office, an examination under anesthesia is necessary. MRI may be helpful in select cases where the etiology of pain is elusive.
  • 74. evaluation of common symptoms
    • Lower Gastrointestinal Bleeding
    • The first goal in evaluating and treating a patient with gastrointestinal hemorrhage is adequate resuscitation.
    • The principles of ensuring a patent airway, supporting ventilation, and optimizing hemodynamic parameters apply and coagulopathy and/or thrombocytopenia should be corrected.
  • 75. evaluation of common symptoms
    • Lower Gastrointestinal Bleeding
    • The second goal is to identify the source of hemorrhage. Because the most common source of gastrointestinal hemorrhage is esophageal, gastric, or duodenal, nasogastric aspiration should always be performed; return of bile suggests that the source of bleeding is distal to the ligament of Treitz. If aspiration reveals blood or nonbile secretions, or if symptoms suggest an upper intestinal source, esophagogastroduodenoscopy is performed.
  • 76. evaluation of common symptoms
    • Lower Gastrointestinal Bleeding
    • Anoscopy and/or limited proctoscopy can identify hemorrhoidal bleeding.
    • A technetium-99 ( 99m Tc)-tagged red blood cell (RBC) scan is extremely sensitive and is able to detect as little as 0.1 mL/h of bleeding; however, localization is imprecise.
    • If the 99m Tc-tagged RBC scan is positive, angiography can then be employed to localize bleeding
  • 77. evaluation of common symptoms
    • Lower Gastrointestinal Bleeding
    • Infusion of vasopressin or angioembolization may be therapeutic. Alternatively, a catheter can be left in the bleeding vessel to allow localization at the time of laparotomy. If the patient is hemodynamically stable, a rapid bowel preparation (over 4 to 6 hours) can be performed to allow colonoscopy.
  • 78. evaluation of common symptoms
    • Lower Gastrointestinal Bleeding.
    • Colonoscopy may identify the cause of the bleeding, and cautery or injection of epinephrine into the bleeding site may be used to control hemorrhage. Colectomy may be required if bleeding persists despite these interventions
  • 79. evaluation of common symptoms
    • Lower Gastrointestinal Bleeding.
    • Intraoperative colonoscopy and/or enteroscopy may assist in localizing bleeding. If colectomy is required, a segmental resection is preferred if the bleeding source can be localized. "Blind" subtotal colectomy may very rarely be required in a patient who is hemodynamically unstable with ongoing colonic hemorrhage of unknown source. It is crucial to irrigate rectum & examine the mucosa by proctoscopy to ensure source of bleeding is not distal to the resection margin
  • 80. evaluation of common symptoms
    • Lower Gastrointestinal Bleeding.
    • Intraoperative colonoscopy and/or enteroscopy may assist in localizing bleeding. If colectomy is required, a segmental resection is preferred if the bleeding source can be localized. "Blind" subtotal colectomy may very rarely be required in a patient who is hemodynamically unstable with ongoing colonic hemorrhage of unknown source. It is crucial to irrigate rectum & examine the mucosa by proctoscopy to ensure source of bleeding is not distal to the resection margin
  • 81. evaluation of common symptoms
    • Lower Gastrointestinal Bleeding.
    • Occult blood loss from the gastrointestinal tract may manifest as iron-deficiency anemia or may be detected with fecal occult blood testing. Because colon neoplasms bleed intermittently and rarely present with rapid hemorrhage, the presence of occult fecal blood should always prompt a colonoscopy. Unexplained iron-deficiency anemia is also an indication for colonoscopy.
  • 82. evaluation of common symptoms
    • Lower Gastrointestinal Bleeding.
    • Hematochezia is commonly caused by hemorrhoids or fissure.
    • Sharp, knife-like pain and bright-red rectal bleeding with bowel movements suggest the diagnosis of fissure.
  • 83. evaluation of common symptoms
    • Constipation and Obstructed Defecation
    • Constipation is an extremely common complaint, affecting more than 4 million people in the United States. Despite the prevalence of this problem, there is lack of agreement about an appropriate definition of constipation.
    • Patients may describe infrequent bowel movements, hard stools, or excessive straining. A careful history of these symptoms often clarifies the nature of the problem.
  • 84. evaluation of common symptoms
    • Constipation and Obstructed Defecation
    • Constipation has a myriad of causes.
    • 1.Underlying metabolic
    • 2.Pharmacologic
    • 3.Endocrine
    • 4.Psychologic
    • 5.Neurologic causes often contribute to the problem
  • 85. evaluation of common symptoms
    • Constipation and Obstructed Defecation
    • A stricture or mass lesion should be excluded by colonoscopy or barium enema. After these causes have been excluded
    • Evaluation focuses upon differentiating slow-transit constipation from outlet obstruction . Transit studies, in which radiopaque markers are swallowed and followed radiographically, are useful for diagnosing slow-transit constipation.
  • 86. evaluation of common symptoms
    • Constipation and Obstructed Defecation
    • Anorectal manometry and electromyography can detect nonrelaxation of the puborectalis, which contributes to outlet obstruction. The absence of an anorectal inhibitory reflex suggests Hirschsprung's disease and may prompt a rectal mucosal biopsy.
    • Defecography can identify rectal prolapse, intussusception, rectocele, or enterocele
  • 87. evaluation of common symptoms
    • Constipation and Obstructed Defecation
    • Medical management is the mainstay of therapy for constipation and includes fiber, increased fluid intake, and laxatives. Outlet obstruction from nonrelaxation of the puborectalis often responds to biofeedback. 7 Surgery to correct rectocele and rectal prolapse has a variable effect on symptoms of constipation, but can be successful in selected patients.
  • 88. evaluation of common symptoms
    • Constipation and Obstructed Defecation
    • Subtotal colectomy is considered only for patients with severe slow-transit constipation (colonic inertia) refractory to maximal medical interventions. While this operation almost always increases bowel movement frequency, complaints of diarrhea, incontinence, and abdominal pain are not infrequent, and patients should be carefully selected.
  • 89. evaluation of common symptoms
    • Diarrhea and Irritable Bowel Syndrome
    • Diarrhea is also a common complaint and is usually a self-limited symptom of infectious gastroenteritis. If diarrhea is chronic or is accompanied by bleeding or abdominal pain, further investigation is warranted.
  • 90. evaluation of common symptoms
    • Diarrhea and Irritable Bowel Syndrome.
    • Bloody diarrhea and pain are characteristic of colitis; etiology can be an infection:
    • 1.Invasive E. Coli
    • 2. Shigella
    • 3.Salmonella
    • 4. Campylobacter
    • 5.Entamoeba histolytica
    • 6.C. Difficile
  • 91. evaluation of common symptoms
    • Diarrhea and Irritable Bowel Syndrome.
    • Inflammatory bowel disease (ulcerative colitis or Crohn's colitis), or ischemia.
    • Stool wet-mount and culture can often diagnose infection.
    • Sigmoidoscopy or colonoscopy can be helpful in diagnosing inflammatory bowel disease or ischemia. However, if the patient has abdominal tenderness, particularly with peritoneal signs, or any other evidence of perforation, endoscopy is contraindicated.
  • 92. evaluation of common symptoms
    • Diarrhea and Irritable Bowel Syndrome.
    • Rarely, carcinoid syndrome and islet cell tumors (vasoactive intestinal peptide-secreting tumor [VIPoma], somatostatinoma, gastrinoma) present with this symptom.
    • Large villous lesions may cause secretory diarrhea.
    • Collagenous colitis can cause diarrhea without any obvious mucosal abnormality.
  • 93. evaluation of common symptoms
    • Diarrhea and Irritable Bowel Syndrome.
    • Along with stool cultures, tests for malabsorption, and metabolic investigations, colonoscopy can be invaluable in differentiating these causes. Biopsies should be taken even if the colonic mucosa appears grossly normal
  • 94. evaluation of common symptoms
    • Diarrhea and Irritable Bowel Syndrome.
    • Irritable bowel syndrome is a particularly troubling constellation of symptoms consisting
    • 1. Crampy abdominal pain
    • 2. Bloating
    • 3. Constipation
    • 4. Urgent diarrhea.
  • 95. evaluation of common symptoms
    • Diarrhea and Irritable Bowel Syndrome.
    • Irritable bowel syndrome
    • Work-up reveals no underlying anatomic or physiologic abnormality.
    • Once other disorders have been excluded, dietary restrictions and avoidance of caffeine, alcohol, and tobacco may help to alleviate symptoms.
    • Antispasmodics and bulking agents may be helpful
  • 96. evaluation of common symptoms
    • Incontinence
    • The incidence of fecal incontinence has been estimated to occur in 10 to 13 individuals per 1000 people older than age 65 years. Incontinence ranges in severity from
    • occasional leakage of gas and liquid stool to
    • daily loss of solid stool.
  • 97. evaluation of common symptoms
    • Incontinence
    • The underlying cause of incontinence is often multifactorial and diarrhea is often contributory. In general, causes of incontinence can be classified
    • as neurogenic
    • anatomic .
    • Neurogenic causes include diseases of the central nervous system and spinal cord along with pudendal nerve injury.
  • 98. evaluation of common symptoms
    • Incontinence.
    • Anatomic causes include
    • 1. congenital abnormalities
    • 2. procidentia
    • overflow incontinence secondary to impaction or neoplasm,
  • 99. evaluation of common symptoms
    • Incontinence.
    • trauma.
    • The most common traumatic cause of incontinence is injury to the anal sphincter during vaginal delivery.
    • Other causes include
    • Anorectal surgery,
    • Impalement,
    • Pelvic fracture.
  • 100. evaluation of common symptoms
    • After a thorough medical evaluation to detect underlying conditions that might contribute to incontinence, evaluation focuses on:
    • 1. Assessment of anal sphincter & pudendal nerves. Pudendal nerve terminal motor latency testing m ay detect neuropathy. Anal manometry can detect low resting and squeeze pressures. Defecograph y can detect rectal prolapse. Endoanal ultrasound is invaluable in diagnosing sphincter defects
  • 101. evaluation of common symptoms
    • Therapy depends upon underlying abnormality.
    • 1.Diarrhea should be treated medically. Even in the absence of frank diarrhea
    • 2.Addition of dietary fiber may improve continence.
    • 3.Some patients may respond to biofeedback.
  • 102. evaluation of common symptoms
    • Therapy depends upon underlying abnormality.
    • 4.Many patients with a sphincter defect are candidates for an overlapping sphincteroplasty.
    • 5.Innovative technologies such as sacral nerve stimulation or artificial bowel sphincter are proving useful in patients who fail other interventions
  • 103. General Surgical Considerations
    • Anterior Resection
    • High Anterior Resection
    • Low Anterior Resection
    • Extended Low Anterior Resection
    • Hartmann's Procedure and Mucus Fistula
    • Abdominoperineal Resection
  • 104. POLYPS
    • Neoplastic-Tubular, villous, tubulovillous
    • Hamartomatous- juvenile, Peutz-Jeghers
    • Hyperlastic - <5mm- >2cm
    • Inflammatory- pseudopolyp
    • Polyps less than 1 cm - 1-10%
    • 1 to 2 cm – 7 -10%
    • 2 cm – 35 -50%
  • 105. RECTAL POLYPS SESSILE PEDUNCULATED
  • 106. CASE: MULTIPLE COLORECTAL POLYPS CLINICAL PRESENTATION BARIUM ENEMA
  • 107. CASE: MULTIPLE COLORECTAL POLYPS LOCATION OF COLORECTAL POLYPS
  • 108.
    • Familial polyposis of the colon is most often
    • associated with which of the following
    • conditions
    • A. Carcinoma of the pancreas
    • B. Carcinoma of the colon
    • C. Granulomatous disease of the colon
    • D. Pneumatosis cystoides intestinales
    • E. Sigmoid volvulus
  • 109. CASE: POST- SURGICAL RESECTION
  • 110. INFLAMMATORY BOWEL DISEASE
    • ULCERATIVE COLITIS
    • Rare in Filipinos
    • Common in caucasians esp. in Jews
    • Non-specific, idiopathic mucosal inflammation of the colon and the rectum
  • 111. INFLAMMATORY BOWEL DISEASE
    • ULCERATIVE COLITIS
    • Usually begins at the rectum moving proximally by direct extension (mucosa and submucosa)
    • inflammation stops at the ileocolic junction
    • Bloody mucoid diarrhea , abdominal pain, tenesmus, fever
  • 112. INFLAMMATORY BOWEL DISEASE
    • ULCERATIVE COLITIS
    • Treatment:
    • Sulfasalazine -4g/day relapse rate 9%/yr.
    • Rowasa- topical enema of 5-ASA.
    • steroids , azathioprine, cyclosporine, 6-mercaptopurine, tacrolimus.
    • Total abdominal colectomy with end ileostomy.
  • 113. INFLAMMATORY BOWEL DISEASE
    • Crohn’s disease
    • Nonspecific, transmural inflammation
    • exacerbation/remission
    • Mouth to anus, bloody diarrhea
    • Extraintestinal manifestation
    • Skip lesion , rectal sparing(40%)
    • Terminal ileum and cecum (41%), SI(35%)
    • Fistula,abscess,obstruction,stricture
  • 114. ANORECTAL DISEASES
    • Hemorrhoids
    • Ischiorectal Abscess
    • Fistula in ano
    • Fissure in ano
    • Warts
    • Fournier’s gangrene
    • Foreign Body
  • 115.  
  • 116. Right Anterior Right Posterior Left Lateral 3 MAJOR PILES
  • 117. HEMORRHOIDAL DISEASE A P L R Primary Locations 3-7-11 o’clock positons (Left Lateral, Right Anterior and Right Posterior)
  • 118. HEMORRHOIDAL DISEASE
    • Submucosal cushion contains venules, arterioles, smooth muscle fibers.
    • Part of continence mechanism.
    • Excessive straing, increase abdominal pressure, hard stools.
    • Bleeding, thrombosis, prolapse.
    • External hemorrhoids distal to dentate line
    • Internal hemorrhoids proximal to dentate line
  • 119. HEMORRHOIDAL DISEASE
    • Grading :
    • First degree – bulge into anal canal ,prolapse beyond dentate line
    • Second degree- prolapse through anus, reduce spontaneously
    • Third degree- require manual reduction
    • Fourth degree- cannot be reduced, prone to strangulation
  • 120. Retrograde View from Colonoscopy Hemorrhoids
  • 121. Hemorrhoids: Management
    • Medical
    • Diet
    • Sitz Bath
    • Suppositories
    • Surgical
    • Milligan Morgan
    • Rubber Band Ligation
    • Harmonic Scalpel
  • 122. Hemorrhoidectomy Rubber Band Ligation Harmonic Scalpel
  • 123. Hemorrhoidectomy Stapler Technique Ferguson or Excision
  • 124. Anorectal Abscess and F i stula
    • What is an anal fistula?
    • An abnormal communication between anal canal &skin
    • What is the assoc. bet. Abscess/Fistula?
    • Approx. 50% of abscess occur secondary to anal fistula. Abscess is the acute sign .
  • 125. Anorectal Abscess and F i stula
    • What is the P/E in anorectal abscess?
    • Inflamed and tender perianal swelling
    • Treatment for anorectal abscess/fistula?
    • I & D “asap” for abscess.
    • Elective surgery for fistula.
  • 126. Salmon Goodsalls rule: Anterior - straight tracts Posterior- curved tracts Exception: > 3cm curved Fistula in Ano
  • 127. Fistula in Ano
  • 128. COMPLICATED FISTULA IN ANO
  • 129. Anal Fissure
    • Anal fissure
    • Linear ulcer (anal canal) dentate to anus
    • Symptoms of anal fissure
    • Bleeding / anal pain during / after BM
    • Physical findings
    • Split in anal canal, posterior midline,
    • sentinel pile, DRE extremely painful
  • 130. Fissure in Ano
  • 131. Anal Fissure
    • Treatment of acute anal fissure
    • High fiber diet, wheat bran, steroid cream
    • Treatment of chronic anal fissure
    • Lateral internal sphincterotomy
  • 132. Incidence of Cancer-Philippines
    • Male
    • Lungs
    • Liver
    • Colon/Rectum
    • Stomach
    • 5. Prostate
    • Female
    • Breast
    • Cervix /Uterus
    • Colon/ Rectum
    • Lungs
    • Thyroid
    • Ovary
    • Liver
  • 133. Colorectal Carcinoma
    • Colon Cancer
    • 3rd most common type /Filipino Male
    • (11.5 per 100,000)
    • Male : female ratio = 1.21
    • Incidence in the Philippines is lower than those elsewhere with the exception of Thailand
    • Incidence among Filipino migrants to the USA is higher than those observed in the Philippines
  • 134. Colorectal Carcinoma
    • Colon Cancer- Global
    • Highest among western countries
    • 15% of all malignancies
    • Age related- 7 th decade; <40y/o (5%)
    • Rectum(30%) sigmoid(28%),cecum(13%),transverse (11%),ascending/descending(9%).
    • Calcium supplement- (RTC) protective.
  • 135.
    • RISK FACTORS
    • Familial Adenomatous polyposis
    • Inflammatory bowel disease
    • Familial Cancer Syndromes
    • Family History
    • Adenomatous polyps
    • Diet
    Colorectal Carcinoma
  • 136. Distribution of Cancer : Left side total = 81 %
  • 137. narrowing
  • 138. Modified Dukes’ Classification
    • Stage A- CA confined to wall of bowel
    • Stage B- CA spread to pericolonic tissues
    • Stage C- Mets. present in lymph nodes
    • Stage D- Omental implant; peritoneal seeding; metastasis beyond the confines
    • of surgical resection
  • 139. Colorectal Cancer Dukes' Classification / Survival(5 years)
    • Dukes’ A 83 %
    • B 57%
    • C 31 %
    • D 0%
  • 140. Survival By TNM
    • Stage I T1-2NOMO,75-90%
    • Stage II T3-4NOMO,54-65%
    • Stage III anyTN1-3MO <50
    • Stage IV 0-5%
  • 141. Colorectal Cancer-Screening
    • FOBT
    • - low specificity, low sensitivity
    • - test repeated annually >50y/o
    • Flexible sigmoidoscope
    • - repeat every 5 years,safe.
    • DCBE
    • - sensitivity 50%-80%(<1cm polyps) , 70-90%(>1cm); 55-85% Duke’s A & B.
    • Colonoscopy
    • - cecum visualized in 98.6%
  • 142. Colorectal Cancer-Screening
    • Guidelines Common to Most Organizations :
    • 50 years or more
    • - Annual FOBT
    • - Flexible Sigmoidoscopy
    • - DCBE q 6 years
  • 143. Colorectal Cancer-Screening
    • Guidelines Common to Most Organizations :
    • 1 st degree relative w/ cancer/adenoma
    • - Flex Sig ,DCBE or colonoscopy q 5 years at 50 years old
    • - relative Dx < 55 y/o, colonoscopy done at 50
  • 144. Proctosigmoidoscopy
  • 145. Colonoscopy
  • 146.
    • Screening for HNPCC* and FAP*
    • Genetic consult
    • Annual colonoscopy from age 25
    • * Hereditary Non Polyposis Cancer/Colon
    • (Lynch Syndrome I - 5 to 10 %)
    • * Familial Adenomatous Polyposis
    Colorectal Carcinoma / Screening
  • 147.  
  • 148. Synchronous and Metachronous CA
    • Synchronous Carcinoma - two or more sites of cancer .
    • Metachronous Carcinoma - another cancer found two or more years after
  • 149. Colorectal CA-Clinical Presentation
    • Rectal bleeding
    • Change/bowel habits
    • Tenesmus / fatigue
  • 150. Colorectal CA Clinical Presentation
    • Persistent narrowing of stools
    • Feeling / incomplete emptying after b.m.
    • Unexplained weight loss/Anemia
  • 151.
    • An elderly woman is admitted with weakness
    • anemia, weight loss, and a palpable abdominal
    • mass. She has colonic carcinoma. The most
    • likely anatomic site would be:
    • A. Rectum
    • B. Sigmoid colon
    • C. Left colon
    • D. Transverse colon
    • E. Cecum
  • 152. RECTAL CANCER
    • Rectal bleeding ( bright red)
    • Altered bowel habits( incomplete
    • evacuation and unproductive
    • urge to defecate)
    • Rectal mass
  • 153.  
  • 154. TNM Staging of Colorectal Cancer
    • Definition of TNM
    • Primary Tumor (T)
    • Tx Cannot be assessed
    • Tis Carcinoma in situ
    • T1 Tumor invades submucosa
    • T2 Tumor invades Muscularis propia
    • T3 thru muscularis propia to serosa
    • T4 directly invades other organs
    • or perforates
  • 155.
    • Regional Lymph Nodes(N)
    • NX cannot be assessed
    • NO no lymph node metastasis
    • N1 Metastasis in one to three
    • N2 Metastasis in four or more
    • N3 any lymph node along named
    • vascular trunk
  • 156.
    • Distant Metastasis ( M )
    • MX Cannot be assessed
    • MO No distant metastasis
    • M1 Distant Metastasis
  • 157. Colorectal Cancer
    • Stage Groupings (TNM)
    • Stage O T1sNOMO N/A
    • I T1NOMO Stage A
    • T2NOMO Stage B1
    • II T3NOMO Stage B2
    • T4NOMO Stage B3
    • III Any TN1MO Stage C
    • IV Any T AnyNM1 Stage D
  • 158. Colorectal Cancer
    • Stage II – High Risk Group
    • - tumor fixation
    • - tumor perforation
    • - complete obstruction
    • - poor histologic grades
  • 159.
    • CEA
    • for prognostication
    • not for diagnosis or screening
    • rising titer postop indicates
    • recurrence
  • 160. Is there any role for surgery in patients with liver metastasis? In highly selected patients with less than four metastasis and no evidence of any other disease ( no local recurrence or further metastasis )
  • 161.
    • 5 year survival is 25 to 30 % in patients who undergo a successful resection
    • 100 % of patients die within 2 years with untreated liver metastasis
  • 162. Colostomy
  • 163.
    • Squamous type
    • Treatment
      • Nigro Protocol
        • 5FU chemotherapy
        • Radiotherapy
    ANAL CANCER
  • 164. THANK YOU!!!