4. CHIEF COMPLAINT
• Mr. Embong bin Othman, 70 years old Malay gentleman with
underlying hypertension and hyperlipidemia was electively admitted
to Hospital Tengku Ampuan Afzan for surgical intervention in view of
his per rectal bleeding for 5 months duration.
5. HISTORY OF PRESENTING ILLNESS
• He was apparently well until about 5 months ago when he suddenly
experienced per rectal bleeding during defecation.
• Bleeding was painless and he described it as fresh blood in bright red colour.
• Did not mixed with stool and usually came out in the beginning of defecation.
Sometimes, there were also presence of blood clot and mucus mixed with
blood.
• However, at this time he could not quantified the amount of blood coming
out.
• He claimed that this incident occurred once every five to six days.
• He denied any pain felt during defecation and the bleeding was not preceded
by any trauma. There was no history of per rectal bleeding before.
6. Cont.
• He also mentioned that there were changes in his bowel habit since 5
months ago whereby he usually defecated once a day but now it has
changed to about once every two days.
• The faeces normally soft and dark brown in colour. There was no
significant change in the odour of the stool.
• However, he did experience on and off constipation that making him
passing out hard, small and blackish faeces.
• Sometimes, he needed to take medication (stool softener) to ease the
defecation process.
7. Cont.
• Otherwise, he was able to pass flatus. There was no abdominal
distension, abdominal pain, nausea, vomiting, diarrhea and fever.
• There was no symptom of anemia such as lethargy, shortness of
breath, chest pain, palpitation, dizziness or syncopal attack.
8. Cont.
About 2 months ago
• when he noticed that the amount of blood came out during
defecation increase in the amount and frequency.
• He described the blood still as fresh blood not mixed with stool and
the bleeding was about two spoons for each episode of defecation.
• It was also associated with the feeling of incomplete evacuation and
bloating.
• He explained that the blood also came out when he passed flatus
thus requiring him to wear a pad per day.
9. Cont.
• He became easily lethargy but there was no other anemic symptom
such as shortness of breath, chest pain, dizziness and syncopal attack.
He noticed that he has lost weight around 7kg (from 70kg to 63kg)
within two months duration. However there was no loss of appetite.
• There was no passing out black tarry stool, vomit out blood, bowel
incontinence, perianal itchiness, any protrusion or swelling from anus.
No discolouration of skin or sclera, shortness of breath, chest pain,
hematuria, dysuria, bone or back pain, muscle weakness, headache,
vomiting or blurring vision.
10. Cont.
• Upon further questioning, he had no family history of malignancy.
• He has no previous history of colonic disease or inflammatory bowel
disease.
• He has adequate intake of water and high fibre diet.
• He was an ex-smoker which already stopped for 30 years and he
never takes alcohol.
11. Cont.
• Due to these problems, he then went to seek for medical attention at
Klinik Kesihatan Balok and he was given medication for haemorrhoid.
• As the per rectal bleeding still did not resolved, he later went to
private clinic and he was referred to SOPD HTAA whereby further
investigations, colonoscopy and CT scan were done.
• He was told to have colon cancer. Currently, he was electively
admitted to the ward for surgical intervention to remove the tumour.
12. What have been done?
COLONOSCOPY (24/2/2019)
• Reason: To inspect the internal lining of the colon for any polyps or abnormalities.
May also perform a biopsy to collect samples of tissues or cells for further
investigation.
Findings:
• 1.Polypoidal growth at 15 cm from anal verge with contact bleeding. Able to pass
scope through.
• 2.Single pedunculated polyp >1cm at descending colon 50 cm from anal verge.
• 3.Sessile polyp about 1cm at caecum.
• Clinical procedures: Multiple biopsy taken from rectal growth and cecal mass.
Polypectomy done for descending colon polyp.
Impression: Upper rectal cancer.
13. HISTOPATHOLOGY REPORT (29/2/2019)
• Specimen: cecal, descending, rectosigmoid
Gross:
A. Specimen labelled as caecal polyp biopsy consists of few pieces of
greyish tissue measuring 4mm in aggregate diameter. Submitted
entirely in 1 block
B. Specimen labelled as descending polyp biopsy consists of a polyp
measuring 10x20x5 mm in aggregate diameter. Submitted entirely in 1
block.
C. Specimen labelled as rectosigmoid growth biopsy consists of
multiples pieces of strip whitish tissue measuring 6mm in aggregate
diameter. Submitted entirely in 1 block.
14. Micro:
• A.Sections show fragments of superficial colonic mucosa exhibiting
hyperplastic glands with numerous cryptitis. No crypt abscess, granuloma,
cellular dysplasia or malignant cells seen.
• B.Sections show polypoidal shape of colonic tissue exhibiting extensive low
grade dysplasia in many of the glands. No cryptitis, crypt abscess,
granuloma or malignant cells seen. The stalk margin is free of dysplasia.
• C.Levels show fragments of superficial colonic mucosa exhibiting infiltrating
malignant cells forming glands in some of the fragments. The malignant
cells are moderately pleomorphic, having hyperchromatic nuclei, visible
nuclei and moderate cytoplasm.
Interpretation:
A.Caecal polyp: Benign hyperplastic polyp
B.Descending polyp: Tubular adenoma with low grade dysplasia
C.Rectosigmoid growth: Adenocarcinoma
15. COMPUTED TOMOGRAPHY OF THORAX, ABDOMEN AND PELVIS with
contrast (9/3/2019)
Reason: To see evaluate the extant of cancer in the boy by detailed
images of the colon and rectum, as well as lungs, liver and other
organs. To help stage the cancer.
• Thorax: there is a small round well defined nodule abutting the
oblique fissure at the apical segment of the right lower lobe
measuring about 0.5 (L) x 0.6 (AP) x 0.3cm (CC) with HU 103: may
present a granuloma. No other lung nodule, mass or consolidation
seen. No pleural effusion. Heart size is prominent. No pericardial
effusion. Small hypodense thyroid nodules are seen. Prominent upper
thoracic paraspinal vessels are noted.
16. • Abdomen/pelvis:
• There are multiple filling defects in the rectum with poor bowel
preparation. Mild rectal wall thickening (0.7 cm) with intraluminal soft
tissue density is noted in the upper rectum at L5/S1 level which may
represent either faecal material or rectal mass (this is much higher in
the upper rectum and does not correlate well with clinical finding of
fungating mass 5cm from anal verge and inability to pass flexy scope.
No significant enhancement seen. There is thin streak of contrast
outlining the anal canal with smooth anal wall diameter of about
0.5cm. No appreciable mass seen at the anorectal junction or low
rectal region. The surrounding fat is not streaky. A 0.7 cm left iliac
node is noted. The fat plane with urinary bladder, seminal vesicle and
lateral pelvic wall is preserved. No bowel dilatation seen.
17. • Liver is homogenous with smooth liver margin. No focal liver lesion
seen. The biliary tree is not dilated. No focal lesion seen in the gall
bladder, spleen, pancreas and adrenals. Portal vein and IVC are
patent. There are small hypodense cysts in both kidneys; the largest
cyst is seen at the lower pole of the left kidney measuring 0.8 x 1.0
cm. no internal septation, wall calcification or enhance solid
component. No ascites. Degenerative changes are seen in the
visualized spine. No suspicious bone lesion seen.
Impression:
• 1.Poor bowel preparation with hardly any appreciable anal mass.
Suspicious intraluminal lesion at upper rectum needs correlation with
colonoscopy/HPE/MRI. No obvious local invasion or metastasis.
• 2.Solitary right lung nodule; possible granuloma. However suggest
follow up to exclude lung metastasis.
• Bilateral simple renal cysts (Bosniak I).
18. PAST MEDICAL AND SURGICAL HISTORY
• He was diagnosed with hypertension about 10 years ago and
hyperlipidemia 2 years ago during his regular health check-up.
Currently he is on medication for both disease and complied with the
medications. He attended follow-up at Klinik Kesihatan Balok every 3
months. His blood pressure reading ranging from 135-140/80-95
mmHg.
• Otherwise, he has no history of cancer before. No renal disease, TB,
asthma, tuberculosis, blood disorder or any history of heart or
respiratory disease. He never undergo surgery before.
19. DRUG HISTORY
• He is currently on medication for hypertension and hyperlidemia. He
was prescribed with Tablet Atenolol 50mg once daily and Tablet
Simvastatin 20 mg one daily. He claimed to be compliant to the drug.
Otherwise he did not take any other over the counter medications,
supplement or traditional drug. He denied of having any drug or food
allergy.
20. FAMILY HISTORY
• He is the youngest out of three siblings. His other two siblings died
around the age of 60 years old due to complication of Diabetes
Mellitus. His father and mother died around the age of 70 due to old
age. Nevertheless, there was no history of malignancies or other
chronic diseases running in his family.
21. SOCIAL HISTORY
• He is a retired civil servant (TLDM). He is married to a 63 year old
housewife and they have 5 children. His monthly income is around
RM1000 per month. He lives in their own village house at Balok with
total of 4 occupants (patient, his wife, two children). The house is
fully equipped with basic amenities. He is an ex-smoker and already
stopped about 30 years ago. He denied involve in high risk behaviour
such as alcohol, drug abuse and sexual promiscuity.
22. PHYSICAL EXAMINATION
GENERAL EXAMINATION
• Patient was lying comfortably on bed with one pillow. He was not in
pain and distress. He was alert, conscious and was well oriented to
time, place, and person. He is of medium built and tall. His hand was
warm and dry. There was no clubbing, koilonychias, leukonychia or
flapping tremor. There was no lymphadenopathy. He was pale but no
jaundice. Hydration status was fair. Oral hygiene was good. He had
branula insertion at the dorsum part of his right hand without any
active infusion. There was no bipedal edema or any dilated veins.
There was no spine tenderness or sacral edema.
23. Cont.
• Vital signs
• Blood pressure : 128/70 mmHg
• Pulse : 80 bpm with regular rhythm and good volume
• Respiratory rate : 19 breaths per minute
• Temperature : 37 °C
• Anthropometric measurements
• Weight: 63 kg
• Height: 170 cm
• BMI: 21.8 kg/m2 (normal)
24. ABDOMINAL EXAMINATION
• On inspection, the abdomen was symmetrical, not distended and moves with
respiration. The umbilicus was centrally located and inverted. There was no
surgical scar seen. No dilated veins or visible pulsation seen. Cough impulse
was negative.
• On superficial palpation, the abdomen was soft and non-tender. There was no
guarding or rebound tenderness. On deep palpation, no mass was palpable.
Liver and spleen were not palpable. Kidneys were not ballotable.
• On percussion, all the quadrants were resonant. Traube’s space was resonant.
Shifting dullness was negative indicating the absence of ascites.
• On auscultation, bowel sound was normal with 3 sounds per minute and
normal pitch. There was no aortic and renal bruit.
25. PER RECTAL EXAMINATION
• On inspection, there was no skin abnormality at the anus. No
anal fissure, ulcer, wart and no external haemorrhoid, masses or fecal
discharge noted.
• The anal canal was soft and non-tender. Anal tone was good.
There was no thickening of the wall. No mass palpable. Prostate was
not enlarged. Rectum was empty. No blood, mucus or feces noted on
the gloves.
27. SUMMARY
• Embong bin Othman, 70 years old Malay gentleman with underlying
hypertension and hyperlipidemia was electively admitted to HTAA for
surgical intervention following history of painless per rectal bleeding
for five months duration. The bleeding was associated with altered
bowel habits and constipation for 5 months duration and bloating,
tenesmus for 2 months prior to admission. He also has no loss of
appetite but he loss around 7 kg within 2 months. He has no other
anemic symptoms other than lethargy. Otherwise, there were no
metastatic symptoms, no fever and no bleeding tendencies. He is an
ex-smoker. He has no history of colonic disease or cancer runs in the
family.
29. • Enlarged, prolapsed anal cushion arising from arteriovenous
communications within connective tissue
30. Clinical features
• Bleeding
• outlet type,
• separated from the stool (evident
on wiping etc)
• Prolapse
• Aching/ dragging discomfort on
defecation.
• Pruritus (discharge in case of
constant prolapse)
• Irritation to perianal skin
Physical examination
• Lithotomy position
• Inspection- anal tag, bleeding,
prolapse
• Ask patient to strain
• Palpation- lumps at perianal
• DRE
31. Aetiology
• The underlying cause of stretching the fibroelastic support is
unknown
• Constipation
• Straining
• Pregnancy (hormonal effect induce tissue laxity+ pressure of baby’s
head + constipation)
32. Investigation
• Diagnostic
• Proctoscope
• Assess for internal haemorrhoid (position- 3,7,11 o clock, bleeding)
• Sigmoidoscope/ colonoscope
• Assessing other colon pathology- carcinoma
• Lab test
• Full blood count- Hb level
33. Management
• Conservative
• High fibre diet, drink plenty of water
• Medication
• Laxatives, stool softener (anucare, lactulose)
• Lidocaine gel
34. • Non operative management
• Aim: to cause fibrosis and shrinkage of the protruding
hemorrhoidal cushion, to prevent bleeding/ prolapse
• Rubber band ligation ( Barron’s bander)
• Can be done at outpatient department
• Risk of bleeding and pain postprocedure.
35. • Operative approach
Standard hemorhoidectomy
• Principle: total removal of hemorrhoidal
mass and securing the hemostasis of the
vessels.
• Either open (milligan-morgan)- NOW NOT
USED ANYMORE or closed (Ferguson)
37. • Linear ulcer below the dentate line, exposing internal sphincter as its
base, from anal transition zone to anal verge.
• Developed when anal mucosa is excessively stretched
• Successive bowel motion provoke further trauma, pain and anal
spasm, resulting in vicious cycle of pain and sphincter spasm, lead to
further trauma during defecation.
39. Clinical features
• Severe pain on defecation
• Burning, tearing, sharp in nature
• Pain to wipe anus, lasted 3-4 Hours
• Per rectal bleeding
• Minor, with some stain of mucus and blood
• Presence of skin tag: itchiness
40. Examination
• Inspection:
• hypertrophied anal papillae internally.
• sentinel pile (skin tag) at the lowermost extend of the ulcer.
• DRE and proctoscopy not recommended- pain
• Planned for colonoscopy to rule out other pathology at later date.
41. Management
• Non operative
• Mostly resolved spontaneously
• Aim: to alleviate the pain and anal spasm to break the vicious cycle
• Chemical sphincter relaxation (0.2% glyceryl trinitrate) cream 12 Hourly.
• Injection of botulinum toxin ( to reduce sphincter tone temporarily)
• 5% lignocaine gel for symptomatic relief.
42. • Operative
• For patient who are not respond to medical treatment and recurrence
• Lateral internal anal sphincterotomy (Notara’s procedure)
• Aim: lower the resting pressure of the internal anal sphincter, thus improves
blood supply and allow faster healing
46. Neoplastic
Base
Pedunculated Sessile
Tubular Villous Tubulovillous
• Majority; 75% • 10 %
• Accounts for 60% of
lesion larger than 2
cm
• Common site: rectum
• Small villous adenoma
<1cm) have 30% risk
of malignancy
• 15%
Epidemiology
• 40% of 50 years od age
• 70% of those aged 65
to 69 year old
48. Familial adenomatous polyposis
One of the most common single-gene disorders predisposing to cancer
Mutation of APC gene
Inherited in autosomal dominant trait or can be sporadic (25%)
Formation of multiple polyps
Usually develop during teenage years and early adulthood
> 90% chance of colorectal cancer by the third or fourth decade
Extra-colonic features
Investigations
Direct APC gene mutation analysis
Sigmoidoscopy and biopsy
Screen for associated tumors
Management: colectomy
Restorative proctocolectomy with ileo-anal pouch formation
Total colectomy with ileo-rectal anastamosis
49. EXTRA COLONIC FEATURES
GIT Gastric fundus: cystic gland polyps
Gastric antral and duodenal adenoma
Peri-ampullary cancer
Ileal adenoma (low risk of malignancy)
MSK and skin Craniofacial and long bone osteoma
Intra-abdominal desmoid tumor
Dermoid cyst
Eye Congenital hypertrophy of the retinal pigment epithelium
Endocrine Increased risk of papillary thyroid carcinoma in women
Rarely Hepatoblastoma
Ca Gallbladder, bile duct and pancreas
Brain tumors
50. Hamartomatous polyp
• Disorganized growth of tissue indigenous to the site
Juvenile Polyposis Syndrome
Rare
Can be single or multiple
Autosomal dominant genetic disorder
Presentation usually at around 10 year old
Risk for GI cancer: 9-68% (~50% in JPS families or documented gene mutation)
Management
o Colonoscopic surveillance from age 15-18 year old until 35 year old
o Prophylactic colectomy
51. Hyperplastic polyps
Usually <5mm
Found mainly in the rectum and often on the crest of mucosal folds
Polyps tend to be pale, flat-topped, sessile plaques
Histology: crypts are elongated, dilated and lined by columnar epithelium that has a
sawtooth pattern
Occur in increasing numbers with age (present in 75% of people over 40 year old)
No malignant potential
MUTYH-associated polyposis
Gene involved in DNA base excision repair
Presence of colorectal hyperplastic polyposis in association with adenomatous polyps
Autosomal recessive
Management
• Colonoscopic surveillance
• Prophylactic colectomy with ileorectal anastamosis
52. Inflammatory polyps
Benign lymphoid polyp
Definition Reactive hyperplasia of mucosa associated
lymphoid tissue which resemble polyp
Site Most common in colon around the
ileocecal valve due to the presence of
abundant lymphoid tissue (prominent
Peyer patches) in this region
Pathology Round, smooth and sessile tumor
53. Pseudopolyposis
Associated with IBD
The repeated cycle of ulceration, alternating with
the deposition of granulation tissue during the
healing phase, results in the development of
raised areas of inflamed tissue that resemble
polyps.
However, these lesions are not neoplastic (i.e.,
true polyps), but inflammatory tissue, and are
called pseudopolyps.
No malignant potential.
55. Definition
• Solitary = single / stand alone
• Rectal = rectum
• Ulcer = discontinuity of an epithelial tissue characterized by
destruction of the surface epithelium and granulating base
• Syndrome = is a set of medical signs and symptoms that are
correlated with each other and, often, with a particular disease or
disorder
“ is the sign and symptoms that produce from single
discontinuity of an epithelial tissue in the rectum “
56. Aetiology Behavioral +/- psychological overlay
Associated with introspective and anxious personality
Patients with this condition spend an inordinate amount of time in
the toilet attempting to defaecate
Pathophysiology Paradoxical contraction of the puborectalis muscle
Chronic constipation
Attempts at manual disimpaction of hard stools
Which will then cause localized ischemic injury or prolapse of the distal
rectal mucosa
Epidemiology Peak age group: 20-40 year old
Clinical features Rectal bleeding, copious mucus discharge, prolonged excessive straining,
perineal and abdominal pain, tenesmus, constipation, and rarely, rectal
prolapse
57. Investigation Proctoscopy + biopsy
Visualizing the anterior ulcer in the low rectum
Typical features of submucosal fibrosis, hypertrophy of the muscularis
mucosae and overlying ulceration
Management Behavioral modification
Laxative
Biofeedback therapy
Surgical
Anterior or posterior rectopexy
Low anterior resection
59. Diverticula
• Out-pouching that form along the hollow structure in the body.
• Commonly occur in large intestine – colonic diverticulosis
60.
61.
62.
63. Colonic Diverticulosis
• Colonic diverticulosis is extremely common in developed countries, being
apparent to some extent in > 60% of people over the age of 70 years.
• In most cases it is asymptomatic, often being noted incidentally on investigation
for symptoms that are not due to the disease itself.
• Symptomatic diverticular disease can be classified as uncomplicated or
complicated.
64. • Diverticulosis is an acquired condition linked with a low-fibre diet.
• Although the whole colon can be affected, the sigmoid colon is most commonly
involved, related to the high intraluminal pressure at this site caused by a low-
residue diet
65. Clinical features
• Colonic diverticulae may give rise to intermittent lower abdominal/left iliac fossa pain
• Altered bowel habit
• Urgency of defaecation
• Episodic rectal bleeding.
• The sigmoid colon may be tender on examination
67. 2) Abdominal CT (either as CT colonography or plain CT abdominal)
• provides an assessment of the degree of surrounding inflammation and/or
abscess formation, in addition to extent of the diverticular changes
3) Colonoscopy
• reveals the ostia of diverticulae and may show surrounding inflammation.
68. Management
• Uncomplicated diverticular change, patients should be advised to
take:
• high-fibre diet
• Supplemented by bran or a bulk laxative such as methylcellulose.
• Stimulant laxatives and purgatives are to be avoided.
• Antispasmodics, such as propantheline or mebeverine, may be useful if there
is smooth muscle spasm and colicky pain.
• Surgical resection of the affected segment may be indicated if there are
persistent symptoms, or when carcinoma cannot be excluded by radiology or
colonoscopy
69. Complicated Diverticular Disease
INFLAMMATION
Peri-diverticulitis
Clinical features:
• Pyrexia, leucocytosis, nausea and vomiting
• Pain and tenderness in the left iliac fossa are almost universal and a mass may be palpable.
Investigation:
• CT scanning with or without gentle rectal contrast
• Colonoscopy or flexible sigmoidoscopy and biopsy of inflamed segments
• Not usually necessary in the acute phase of illness and best left until the acute inflammation settles
Treatment:
• Treatment comprises fasting, bed rest, IV fluids and broad-spectrum antibiotics, such as a cephalosporin or gentamicin,
along with metronidazole.
• Failure of antibiotic suggests the development of pericolic abscess
• Surgical resection and peritoneal toilet combined with abscess drainage may be required.
• In the absence of rapid improvement within 36–48 hours, IV and oral contrast-enhanced CT should be undertaken.
• The presence of an abscess indicates the need for surgical resection
70. INFLAMMATION
Pericolic abscess → Purulent peritonitis → Faecal peritonitis
Clinical features
• The patient is usually profoundly ill
• Septic shock, dehydration
• Marked abdominal pain, tenderness and distension
Management
• Intravenous broad-spectrum antibiotics and vigorous preoperative resuscitation are essential
• Followed by resection of the affected bowel and peritoneal lavage
• If peritoneal contamination is severe and there is poor bowel perfusion of the gut, a colostomy may be
preferable.
• The most common approach is to bring the end of the proximal colon through the abdominal wall and
close the rectal stump (Hartmann's procedure).
• The distal end may be exteriorized as a mucous fistula
• Continuity can be restored once the patient has recovered, but this should not be for at least 3 months
The mortality of perforated diverticular disease is 10–20% but may be as high as 50% in the elderly with faecal
peritonitis.
71. OBSTRUCTION
• Fibrotic stricture
• Adherent small bowel loops
FISTULA
• Colovesical fistula
• Clinical features:
• Usually complains of dysuria
• Passage of cloudy urine, with
• Bubbling on micturition (pneumaturia).
• Investigation:
• The diagnosis may be confirmed by barium enema
• Cystoscopy is frequently performed
• CT may reveal air in the bladder and show the fistulous tract itself
• Treatment:
• Resection of the affected segment, usually a sigmoid colectomy, with synchronous repair of the bladder.
• Colovaginal fistula
• Enterocolic fistula
72. BLEEDING
• Massive lower GI haemorrhage
• Chronic intermittent blood loss
• Anaemia
• It may present with persistent fresh rectal bleeding or massive haemorrhage.
• Differential diagnosis includes:
• angiodysplasia (which frequently co-exists with diverticular disease)
• Haemorrhoids
• Polypoid colorectal tumours
• Fulminant inflammatory bowel disease
• Investigation:
• Colonoscopy seldom allows the bleeding site to be identified
• CT angiography
• Angiography may be helpful – the bleeding must be at the rate of 1 ml/min to be visible.
• Management:
• It may be possible to embolize the bleeding vessel using gel foam
• In some cases of unremitting torrential haemorrhage, operation has to be undertaken when a source of
bleeding has not been localized
• On-table lavage and colonoscopy may be helpful in allowing a segmental resection of the affected bowel
• In some cases, a blind total colectomy and ileorectal anastomosis may be required.
73. Angiodysplasia
• Angiodysplasia is an important cause of massive lower gastrointestinal haemorrhage, and may co-
exist with diverticular disease
• The acquired submucosal arteriovenous malformations commonly affect the caecum and
sigmoid colon
• The diagnosis may be secured by visualization of a bleeding point at colonoscopy.
• Bleeding angiodysplastic lesions can be treated by angiographic embolization, by laser treatment
or injection sclerotherapy at colonoscopy, or by resection at emergency laparotomy.
