2. Basic science/Anatomy
• Fuel – SCFA (butyrate)
• 1st branch SMA – inferior pancreaticoduodenal
• Replaced RHA – Off SMA travels POSTERIOR
to portal vein – 12% incidence
• Watershed areas:
• Griffith’s = Splenic flexure
• Sudek’s = Recto-sigmoid junction
• Colon ABSORBS (Na and H2O) and Secretes
(K)
3. Ischemic Colitis
• Most are idiopathic
• High suspicion after aortic surgery
• Affects watershed regions first
• Dx: colonoscopy/flex sigmoidoscopy
• May need need surgical resection with second
look
• Rectal sparing due to IMA and iliac collaterals
4. Clostridium Difficile
• RF: Antibiotic use (classically clindamycin) and
immunocompromised
• Tx: oral metronidazole, oral vancomycin
• IV metronidazole
• Vancomycin emema
• Fecal transplant
• Subtotal colectomy
5. Lower GI Bleeding
• MC cause (after upper GI source) is diverticular
disease
• Vasa recta – arterial bleeding
• 50-90% from right side
• Angiodysplasia
• MC in elderly
• Right side
• Venous
• Aortic stenosis
• Heyde syndrome triad: aortic stenosis, coagulopathy, anemia
d/t bleeding from intestinal angiodysplasia
6. Lower GI Bleeding
• Indications for surgery:
• Transfusion of 4U PRBC in 24 hours
• Persistent bleeding after 72 hours
• Re-bleeding within one week
• Localization studies
• Angiography: 1-1.5cc/min
• Tagged RBC Scan: 0.1-0.5cc/min
• Capsule endoscopy
• Tech99 Meckel scan
• Push endoscopy
• No segmental resection without previous localization
7. Lower GI Bleeding
• Unstable despite resuscitation
• R/O UGI bleed (NGT) and hemorrhoids (anoscopy)
• On-table angiography for localization segmental
resection
• Total abdominal colectomy if unable to localize
8. Ogilvie Syndrome
• Non-obstructive colonic dilation
• Elderly, debilitated, recent surgery (ortho total
joints), trauma, narcotic use
• Conservative Tx:
• bowel rest
• electrolyte correction (K, Mg)
• stop narcotics and anticholinergics
9. Ogilvie Syndrome
• Neostigmine after conservative management
• Increased acetylcholine activity
• 90% success rate (significant emotional event)
• Contraindicated: cardiovascular disease, severe
asthma, beta-blocker use
• Must have atropine at bedside for bradycardia
• Cecum >10-12 cm
• Cecostomy tube
• Subtotal colectomy with end ileostomy
10. Sigmoid Volvulus
• MC of colonic volvulus
• Bedridden, institutionalized neuro/psych patient
• Abd XR points toward RUQ (away from volvulus)
• Bent inner tube sign
• Coffee bean sign
• Barium enema reveals sigmoid bird’s beak
• Flexible sigmoidoscopy to reduce/detorse
• Then prep
• Then elective sigmoidectomy as long as pt stays hemodynamically stable and no recurrence in
meantime
• No sigmoidopexy because reccurence is too high
• If at any time perforation, peritonitis, gangrene, or failure of detorsion need surgery
• Do not detorse if evidence of ischemia – will release inflammatory cytokines
12. Cecal Volvulus
• Similar presentation but less common
• Abd XR points toward LUQ (away from volvulus)
• Bent inner tube sign
• Coffee bean sign
• Barium enema shows bird’s beak
• Right hemicolectomy
• Cecopexy if poor candidates or due to cecal bascule
14. Diverticular Disease
• False diverticula – 90% in sigmoid (Western)
• >50% of people will get this
• Complicated Diverticulitis = Hinchey scale
• I: Confined pericolic abscess/inflammation
• II: Distant abscess (pelvic or retroperitoneal)
• III: Purulent peritonitis (surgical diagnosis)
• IV: Feculant peritonitis (surgical diagnosis)
• Treatment
• Uncomplicated: oral antibiotic to cover E.coli and anaerobes
• Complicated:
• Hinchey I-II: IV abx, IV fluids, NPO, perc drain abscess >4cm
• Elective resection in 6-12 weeks
• Hinchey III-IV: Surgical resection (Hartmann’s, primary anastomosis with/without diversion)
15. Diverticular Disease
• Elective Sigmoidectomy
• Resect all inflammed bowel and anastamose with rectum
• Do not removed non-inflamed diverticula
• Colovesicular fistula is the most common
• Pneumaturia, UTI, colonic resection with fistula closure
• Colovaginal fistula
• Hysterectomy, colonic resection with fistula closure and
vaginal defect repair
16. Familial Adenomatous
Polyposis
• Autosomal dominant, APC gene, 1000’s polyps
• 100% CA at age 50
• Annual screening at 10-12 y/o
• Prophylactic proctocolectomy at 20 y/o
• Sooner if villous or HGD
• Need total proctocolectomy, rectal mucosectomy, IPAA
• New Dx = colo, metastatic w/u, EGD, genetic testing
• Post-Op: Do NOT need yearly colonoscopy – just
yearly EGD and flex sigmoidoscopy
17. Familial Adenomatous
Polyposis
• FAP-associated tumors
• Desmoid – most common
• Duodenal adenocarcinoma
• Medulloblastoma (Turcot- CNS tumors)
• Hepatoblastoma
• Osteoma (Gardner- sebaceous cysts, osteomas)
• Thyroid
• Adrenal
• Death is from desmoid or duodenal carcinoma
• Bi-annual EGD after 25 y/o
18. Desmoid
• Occur at surgical sites from prior surgery
• Benign, rapid growth
• Treatment
• COX-2 – Sulindac
• Tamoxifen
• Imantinib
• Resection with negative margins (abdominal wall)
19. HNPCC/Lynch Syndrome
• Autosomal dominant; mismatch repair, microsatellite
instability
• Type I: Colon only
• Type II: Colon and other
• Fewer polyps(<100)
• Predilection for RIGHT sided colon carcinoma
• Associated with endometrial, ovarian, gastric, and small
bowel
• All get subtotal colectomy for cancer/dysplasia
diagnosis
• Consider TAH-BSO
20. HNPCC/Lynch
• Amsterdam Criteria (3:2:1)
• Three affected (one first-generation), two generations affected, one
diagnosed before 50 y/o
• Revised Bethesda Criteria for testing for MSI
• <50 y/o
• Colon and HNPCC associated cancer
• Evidence of MSI <60 y/o
• Colon cancer or HNPCC related cancer in first degree relative (<50)
• Colon cancer or HNPCC related cancer in 2 or more 1st-2nd relatives
(regardless of age)
• Colonoscopy yearly at age 20-25
• Screen for everything else at age 35 (CA-125, annual transvaginal
U/S, endometrial biopsy
21. Peutz-Jeghers Syndrome
• Autosomal Dominant
• Benign intestinal hamartomas and
mucocutaneous pigmentation
• General increased risk of cancer
• No prophylactic surgery
22. Familial Juvenile
Polyposis
• Autosomal Dominant
• Benign hamartomas and mucin-filled polyps
• Hamartomas are not pre-malignant
• Overall increased colon cancer risk
26. Ulcerative Colitis
• Surgery if – toxic megacolon, perforation,
dysplasia, medical failure, prolonged steroids,
FTT, cancer
• Emergent surgery = TPC w/ end ileostomy
• Elective surgery = TPC w/ rectal mucosectomy
and IPAA or APR with end ileostomy (divert)
• Take down IPAA if 1) CA 2) refractory pouchitis 3)
incontinence
• Pouchitis – flagyl (MC complication after IPAA)
27. Ulcerative Colitis
• CA risk 1% per year
• Start surveillance at 10 yrs post Dx w/
colonoscopy and random biopsies
• FHX, young age, left-sided, PSC – resect @ 20yrs
28. Colon Cancer
• Scope at 50yo or 40 if fam Hx or 10yrs prior
• APC (TSG); K-ras (Oncg); DCC (TSG)-P53 (TSG)
• CEA – not for screening
• For progression, recurrence, chemo response
• Strep bovis, strep galollyticus, clost. Septicum
• Colonoscopy and CT and TRUS (best for T&N)
29. Colon Cancer
• T – 0)intra mucosal, HGD, in-situ 1)sub mucosa 2)into muscle 3)through
muscle/into sub serosa* 4) through serosa/other organs
• N – 1) 1-3nodes 2) >4 nodes ++ (need 12 nodes)
• M – mets
• Stage 1) into muscle no nodes
• Stage 2) past muscle no nodes*
• Stage 3) NODES a- into muscle b- past muscle c->4n++
• Stage 4) mets ++
• (* = Neo-adjuvant for rectal)
• (++ = post op chemo for colon CA)
31. Colon Cancer
• Surgery after polypectomy
• Positive margin; deep stalk invasion
• Unclear margin
• Polyps >3cm
• Angiolymphatic invasion
• Grade 3 histology
32. Colon Cancer
• Colon CA 4-5 cm margins
• 2012 society of colorectal surgeons
• Rectal CA 2 cm margins
• Extension into other organs – En Bloc
resection
33. Colon Cancer
• Colon CA
• Stage 1 – formal resection and done
• Stage 2 – formal resection and chemo if <12 nodes,
LV invasion, perf, obstruction, or CEA
• Stage 3 – resect and chemo
• Stage 4 – resect and chemo (bevacizamab,
cituximab )
• Rectal CA
• Same but Stage 2 gets neo-adjuvant
34. Colon Cancer
• Anal Canal – dentate line to levator ani muscles
• Need 2 cm margin PROXIMAL to levator ani
• if 2 cm from levator ani muscles then can perform
LAR for rectal CA
