cme

1. CME:LGIB
Sindhu
Faiz

2. OUTLINE
1. Lower GI bleed
2. Colorectal cancer
3. Diverticular disease & IBD
4. Hemorrhoid and perianal fissures

3. 1. Lower GI bleed
• Refers to bleeding which occurs below the
ligament of Treitz.

4. Depending on site of bleeding
Small
intestine
Crohn’s ulcers
Meckel’s
diverticulum
Peutz-jehers
polyps
Large
bowel
Ulcerative
colitis
Carcinoma
colon
Diverticular
disease
Dysentery
Angiodysplasia
Anorectal
conditions
Prolapse
rectum
Fissure-in-ano
Fistula-in-ano
Injuries to the
rectum

5. Types
Source
• Small bowel bleed- 5%
• Colonic bleed- 95%
Clinical manifestation
• Melaena : passage of black tarry stools due to
slow bleeding or more proximal source of bleed.
• Haematochezia : passage of bright red stools with
or without clots.

6. COLORECTAL CARCINOMA
(CRC)

7. Epidemiology
• CRC is the most common cancer in Malaysia.
• Male > Female
• The incidence was highest in Chinese followed by Malay and
Indian.
• The most common presenting symptoms
– Altered bowel habit (41.7%)
– Blood in stool (35.5%)
– Abdominal pain (31.5%)
– Weight loss (31.0%)
– Anemia (9.8%)
– Intestinal obstruction (9.3%)
• Left-sided carcinoma is the commonest form.
• Majority of patients are at stage III and IV (54.36%) while only
8.4% are diagnosed at stage I according to TNM staging.

8. Pathology
Macroscopic Microscopic
• Schirrhous/annular (apple-core lesion)
• Tubular
• Ulcerated
• Cauliflower
• Adenocarcinoma –originating in the colonic
epithelium

9. Spread of Carcinoma
• Direct spread
– Retroperitoneal into the ureter, duodenum and posterior abdominal
wall muscles.
– Intraperitoneal into the small intestine, stomach, pelvic organs or the
anterior abdominal wall.
• Lymphatic
– Mesenteric nodes then to para aortic nodes to mediastinum and
supraclavicular nodes.
• Haematogeneous
– To liver (most common) followed by lungs, ovary, brain, kidney and
bone.
• Transcoelomic spread
– By way of cells dislodging from the serosa of the bowel or via the
superitoneal lymphatics and settling on other structures within the
peritoneal cavity (peritoneum and omentum).

10. Risk Factors
Non-modifiable Modifiable
• Increasing age (age > 50 years old)
• Genetic predisposition
• Personal history of CRC
• Family history of CRC
• Hereditary colorectal cancer syndrome
(HNPCC, FAP, MAP, juvenile polyposis and
Peutz-Jegher Syndrome)
• Inflammatory bowel disease
• ulcerative colitis
• Crohn’s disease
• Diet
• High in fat and red meat
• Preserved food (nitrosamines)
• Low fibre intake
• Smoking
• Alcohol
• Lack of physical exercise
Protective factor
- Aspirin and NSAIDS (30-50% risk reduction)
- Dietary calcium supplements and vitamin D.
- Hormonal replacement therapy.

12. Clinical Features

13. Physical Examination
• General
– Cachexia
– Pallor
– jaundice
– Supraclavicular nodes enlargement.
• Abdomen
– Abdominal mass
– Hepatomegaly
– Ascites
• Digital rectal examination
– Presence of mass (hard, non-tender, polypoid, irregular, contact
bleeding, fixation).
– Stool colour and consistency.
– Presence of blood/mucous.

15. Screening & Surveillance
• Faecal occult blood test
• Sigmoidoscopy
• Colonoscopy
• Colon Capsule endoscopy
• Computed Tomographic Colonography/ Virtual
colonoscopy
• CEA

16. Diagnostic and Radiological
Investigations for Staging
• Diagnostic investigation
– Colonoscopy ( first line investigation( diagnostic and
staging)
– Barium enema
– CT Colonography/ Virtual Colonoscopy
– Carcinoembryonic Antigen
• Radiological investigation
– CT TAP – accuracy in identifying CRC and nodal metastases
depends on the stages of tumour
– MRI – accurate assessment of rectal ca local spread
– Abdominal ultrasound - to evaluate abdominal organ
especially liver (hyperechoic liver mass).

17. Staging of tumour

18. Histopathology examination
• HPE of the resected colorectal specimen is
essential for patient’s management.
• Including the estimation of post-operative
outcome and the rationale for adjuvant
therapy.
• Adenocarcinoma is the most common type of
CRC.
• Signet-ring and mucin-producing carcinoma
have significant poor prognostic features.

19. Colorectal surgery
19

20. 20

21. 21

22. Pre-operative Preparation
1. Antibiotic prophylaxis
2. Bowel preparation ( low residue diet and
enemas )
22

23. 23

24. Standard operation for rectal
carcinoma
Abdominoperineal
resection of
rectum
Anterior resection
of rectum
Construction of J
pouch
Hartmann's
operation
24

25. 25

26. Management for Rectal Carcinoma
26
Stage of disease Treatment
T1 Involvement of submucosa, but no
penetration through muscularis propria
Local excision (AR or APR)
T2 Invasion into, but not penetration
through, muscularis propria
a) Local excision + adjuvant Chemo/RT OR
b) radical resection
T3 Penetration through muscularis propria
into subserosa (if present), or pericolic fat,
but not into peritoneal cavity or other
organs
Neoadjuvant chemo / RT before radical
resection
T4 Invasion of other organs or involvement
of free peritoneal cavity

27. Total Mesorectal Excision (TME)
• Presence of radial spread is
an important prognostic
indicator.
• TME is indicated as part of
low anterior resection for
patients with adenocarcinoma
of the middle and lower rectum
(gold standard) - reduce local
recurrence rates

28. Operative complication
Immediate < 24 h Damage to other organs eg. ureters
Early < 30 days Wound infection
Bleeding
Anastomosis breakdown/leak – faecal
peritonitis
Early stoma complications
Late>30 days Diarrhoea
Impotence( damage of pelvic nerves)
Adhesions(i/o)
Late stoma complications

29. Role of radiotherapy and chemotherapy :
• Adjuvant radiotherapy and chemotherapy  Duke C’s patient to increase
chance of prolonged survival.
• Neoadjuvant chemoradiotherapy is particularly relevant for rectal tumours
tethered in the pelvis by shrinking large tumour in order to make it
operable.
• This enables preservation of anal sphincter by downsizing the tumour.
• If rectal tumours extend through the bowel wall, particularly anteriorly, a
course of radiotherapy directly before surgery  reduce local pelvic
recurrence.
• Choice of chemotherapy in large bowel cancer  5-fluorouracil (5-FU) +
folinic acid
29

30. Follow up and Surveillance
• Follow-up strategies in post-surgery and/or
adjuvant treatment are:
• History, physical examination and CEA levels
every three to six months for five years.
• Surveillance colonoscopy at year one and every
three to five years.
• CT scan of thorax, abdomen and pelvis is
performed annually for three year. For high-risk
patients every six to 12 months for the first three
years.

31. DIVERTICULAR DISEASE
Congenital
All three layers of the bowel are
present in the wall of the diverticulum
(e.g. Meckel’s diverticulum).
Acquired
There is no muscularis layer
present in the diverticulum
(e.g. sigmoid diverticular disease)
Diverticula (hollow out-
pouchings)
31

32. • Mainly in Sigmoid but can affect the whole colon
• But never the Rectum? Taeni coli has fused. The rectum has a complete
muscular coat and a wider lumen.
• Often asymptomatic (diverticulosis) and found incidentally, 10-30% -
symptomatic
• Risk factor
– Lack of dietary fiber
PATHOGENESIS
1. ↓ intraluminal diameter ⇨ ↑ intraluminal pressure by segmentation
movement ⇨ push mucosa through weak point ⇨ vasa recta penetrate
muscularis propria between the taenia coli
2. Disorder of motility
3. Degenerative changes in colonic wall - altered collagen structure with ageing
⇨ at the point of entry of terminal arteries, where serosa is weakest
32

33. CLINICAL FEATURES
• Depends on location of the affected diverticulum, the severity of
inflammatory process, and presence of complications
A. Mild cases : Abdominal distension, flatulence and a sensation of
heaviness in the lower abdomen
B. Diverticulitis:
– Persistent lower abdominal pain, usually in the left iliac fossa
– Pyrexia, tachycardia
– Diarrhoea or constipation
– The sigmoid colon may be tender and thickened on palpation
C. Rectal examination may reveal a tender mass (abscess)
D. Signs of peritonitis → indicate perforation
E. Painless, profuse haemorrhage (sigmoid: bright red with clots)
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34. COMPLICATIONS
• Pain and inflammation
Diverticulitis/ diverticular abscess
• most often contained leading to pericolic abscess formation but occasionally
leading to generalised peritonitis.
Perforation
• progressive fibrosis → fibrosis sigmoid and large bowel obstruction / loops of
small intestine can adhere to an inflamed sigmoid
Intestinal obstruction
• due to erosion of vessels adjacent to a diverticulum.
Haemorrhage
• occurs in 5% of cases, colovesical fistulation is most commonly seen.
• Recurrent UTI, pneumaturia or even faeces in the urine.
Fistula formation (colovesical, colovaginal, enterocolic,
colocutaneous)
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35. 35

36. HINCHEY CLASSIFICATION
for Staging of Complicated Diverticulitis
STAGING INVOLVEMENT
Stage I Pericolonic / mesenteric abscess <4cm
Stage II Large pelvic / retroperitoneal abscess
Stage III Small perforation causing purulent peritonitis
Stage IV Free rupture with faecal peritonitis
* need for surgery is reflected by degree of infective
complications
36

37. INVESTIGATIONS
Imaging
Chest X-ray
• tro perforation
Abdominal X-ray
• Ileus, air fluid level
within an abscess
Spiral CT
• Identifying bowel wall
thickening, abscess
formation and
extraluminal disease.
Colonoscopy
Demonstrate the necks of
diverticula within the bowel
lumen
Has significant risk of
endoscopic perforation in
narrowed area
Blood
FBC: Anemia,
leucocytosis
Urea & electrolytes
LFT: TRO other
causes of abdominal
pain
37

38. MANAGEMENT - conservative
• Advice for high-fibre diet and bulk-forming laxatives
• Acute diverticulitis
– Resuscitation and analgesia
– NBM
– IV broad spectrum antibiotics (augmentin / ciproflaxin / metronidazole) –
Stage 1- Abx ,nbm ,Iv fluids
– Stage 2 – drained percutenously
– Stage 3&4 – laparotomy
• After acute phase subsided (4-6weeks)
– Investigated by endoscopy, barium enema or CT virtual colonoscopy to
confirm the diagnosis and assess for complications.
– Colonoscopy and biopsy – exclude colon carcinoma
– Barium enema - only performed if the patient has strictures or an
excessively tortuous sigmoid colon
– The pericolic abscesses can be drained percutaneously. A diameter of 5 cm
is frequently regarded as the cut off between an abscess likely to settle with
antibiotics and one likely to require intervention.
38

39. Operative
procedures for
diverticular disease
The aim of
emergency surgery
is to control
peritoneal infection
Indications for
surgery:
• Generalised
peritonitis
• Failure to
respond to
optimum medical
management
39

40. 40

41. INFLAMMATORY
BOWEL DISEASE
Conditions characterized by the presence of idiopathic
intestinal inflammation
Ulcerative colitis and Crohn’s disease
- considered to be separate entities but in 10–15% of cases no
clear distinction can be made → Indeterminate colitis
Bailey & Love's Short Practice of
Surgery, 27th ed.
Essential Surgery Churchill Livingstone,
5th ed.
41

42. ULCERATIVE COLITIS
Disease of the rectum and colon with extra-intestinal manifestations
42

43. • Crude incidence rates in Malaysia of ulcerative colitis
0.46 per 100,000 persons.
• Typically ulcerative colitis manifests in young adults (15-
40 years of age) and is more prevalent in males but onset
of disease after age 50 is also common
• Ulcerative colitis is usually limited to the mucosa and
submucosa .
• This chronic disease is associated with a significantly
elevated malignancy risk, of up to 0.5-1.0% per year after
10 years of disease.
43

44. • Usually begins in the rectum and can extend proximally to affect
entire colon
• Longitudinal mucosal continuity – ‘continuous lesion’
• Colonic inflammation:
• Diffuse
• Confluent and superficial
• Affect the mucosa and superficial submucosa
• ‘Pseudopolyposis’ occurs in ¼ of cases.
• Stricturing in UC is very unusual (unlike CD) - should prompt urgent
assessment, possibility of coexisting carcinoma
• Location: 40% - Rectum alone
40% - Left colon
20% - Total colitis
10% - Backwash ileitis : 30cm ileum affected
PATHOLOGY
44

45. • Crypt abscess
• Depletion if goblet cell mucin
• High grade dysplasia
HISTOLOGICAL
• Depends in large part on the extent of disease.
• Rectal bleed
• Tenesmus
• Mucous discharge
• Bloody diarrhea and urgency (colitis)
• In severe cases
• Anemia
• Hypoproteinaemia
• Electrolytes disturbances
• Extensive colitis – systemic illness involvement
• Malaise, fever, loss of appetite
• Children – may impaired the growth
SIGNS & SYMPTOMS
45

46. 46

47. Extra intestinal manifestations

48. INVESTIGATION
1. ENDOSCOPY & BIOPSY
• Flexible sigmoidoscopy/colonoscopy with
tissue biopsy
• to establish the extent of inflammation
• to distinguish between UC and Crohn’s
• to monitor the response to treatment
• to assess longstanding cases for malignant
change.
2. IMAGING
• Chest X-ray
• Risk of perforation
• Abdominal X-ray:
• severity of disease in acute setting
• CT abdomen:
• thickening of colonic wall
• Inflammatory stranding of colonic
wall mesentry
3. BLOOD INVESTIGATIONS
• FBC
• anemia, leucocytosis & thrombocytosis
• Renal profile
• hypokalaemia & dehydration – prolonged
diarhea
• LFT
• Hypoalbuminaemia - poor nutrional intake
• ESR & CRP
• Autoantibody assay: p-ANCA ↑ in UC, ASCA ↑ in CD
4. BACTERIOLOGY
• Stool specimens for
microbiological analysis to
rule out
• infective colitides
(Campylobacter)
• Clostridium difficile colitis
48

51. MANAGEMENT – MEDICAL
• For mild attack- more effective than steroids
• Given locally- suppositories or enema
Local corticosteroid or 5-aminosalicylic acid (5-
ASA) preparations
• For moderate to severe acute exacerbation
• Widespread anti-inflammatory action – oral or IV
Systemic corticosteroids
• Azathioprine and cyclosporin
• To maintain remission and as ‘steroid-sparing’ agents
Immunosuppressive drugs
• Eg: sulfasalazine, mesalazine, olsalazine
• Used long term as maintenance therapy.
Oral aminosalicyclate preparations
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52. INDICATION FOR SURGERY
Severe or fulminating disease failing to respond to medical
therapy
Chronic disease with anaemia, frequent stools, urgency and
tenesmus
Acute case – toxic megacolon/ perforation/ haemorrhage
Inability of the patient to tolerate medical therapy required
to control the disease
Neoplastic change: patients who have severe dysplasia or
carcinoma on review colonoscopy
Fail medical treatment – no symptoms improvement after 1
week intensive treatment
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54. SURGICAL
• Subtotal colectomy and ileostomy : Emergency – 1st line
• Proctocolectomy and permanent end ileostomy
– Removes all colon and rectum, removing any risk of colorectal
neoplasia or colitic symptoms + Permanent stoma
– Indicated – for patients, not candidates for restorative surgery
due to sphincter problems or patient preference.
• Restorative proctocolectomy with ileoanal pouch
– a pouch is made out of ileum as a substitute for the rectum
and sewn or stapled to the anal canal.
– This avoids a permanent stoma.
– Indicated - patients with adequate anal sphincters
54

55. 55

56. CROHN’S DISEASE
Chronic full-thickness inflammatory process that can affect any part of the
GI tract from the lips to the anal margin
56

57. • Incidence of 0.2 per 100 000 recorded in Malaysia
• Rare in Asian population, most common in North
America and Northern Europe
• Slightly more common in women than in men
• Common in younger age : 60% patients aged below
25 years old.
• Smoking increases the relative risk of CD three-fold
• 10% of patients have a first-degree relative with the
disease
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58. PATHOLOGY
• The terminal ileum is most commonly involved (65%)
• Perianal lesions are common, affecting up to 50–75% of
patients.
• Fibrotic thickening of the intestinal wall with narrowing of the
lumen and fat wrapping
• Dilated bowel just proximal to the stricture & deep mucosal
ulcerations.
• Cobblestone appearance- criss-cross of deep fissured ulcers
• Transmural inflammation- inflammation involves entire
thickness of bowel wall
– Adhesions
– Perforation
– Fistulae
• ‘Skip’ lesions
58

59. CLINICAL FEATURES
• CD more commonly presents with features of chronicity
i. abdominal colicky pain, which may be postprandial
ii. mild diarrhoea extending over many months occurring in
bouts
iii. palpable tender mass in the right iliac fossa- omentum
wrapped around terminal ileum
iv. Intermittent fevers, secondary anaemia and weight loss are
common
v. chronic obstructive symptoms
• For Colon: symptoms of colitis and proctitis as described for UC.
– Toxic megacolon is much less common
• Perianal problems
i. Bluish perianal skin
ii. Superficial ulcers (painless); Deep cavitating ulcers (painful)
iii. Risk of fistula
59

60. INVESTIGATIONS
LABORATORY
FBC (anemia)
fall in serum
albumin,
magnesium, zinc
and selenium
ESR & CRP (disease
activity)
ENDOSCOPY
Colonoscopic
examination with
biopsies
• areas of normal mucosa
in between areas of
inflammation
• Irregular and ulcerated,
with a mucopurulent
exudate
• Stricturing, biopsy TRO
malignancy
OGDS – upper GI
involvement
IMAGING
High-resolution ultrasound
• Demonstrate inflamed and
thickened bowel loops
• fluid collections and abscesses
Computed tomography (CT)
scans with oral contrast
• can demonstrate fistulae, intra-
abdominal abscesses
• bowel thickening or dilatation
Magnetic resonance imaging
• assessing complex perianal
disease
• investigating the small bowel
60

62. MANAGEMENT – MEDICAL
• TPN
Nutritional support
• induce remission in 70–80% of cases
• used in short courses only and tapered when a response has been achieved
• should not be used for maintenance therapy
Steroids
• Induce & maintain remission (sulfasalazine, mesalazine)
Aminosalicylates (5-ASA agents)
• in perianal disease
Antibiotics (Metronidazole and ciprofloxacin)
• Monoclonal antibody therapy
• targeting TNF-alpha and other key pro-inflammatory mediators
• Infliximab
Immunomodulatory agents (Azathioprine & Cyclosporin)
62

63. SURGICAL TREATMENT
• 70% of patients with CD will require a bowel
resection within 10 years
• 40% will require a further resection in the decade
following
• Fundamental principle: to preserve healthy gut and
to maintain adequate function
• Surgery doesn’t cure CD, recurrence is common
63

64. 1. Ileocaecal resection
2. Segmental resection of short segments of small or large
bowel strictures
3. Colectomy and ileorectal anastomosis
 for colonic CD with rectal sparing and a normal anus.
4. Subtotal colectomy and ileostomy
5. Temporary loop ileostomy
6. Proctectomy and proctocolectomy
7. Strictureplasty
64

65. Essential Surgery Churchill Livingstone, 5th ed.
65

66. 66

67. HAEMORRHOIDS
• Is symptomatic enlargement and distal
displacement of normal anal cushions located
at 3, 7 and 11 o’clock position
• Pathophysiology – degeneration of supporting
fibroelastic tissue and smooth muscle
• Common when
– increase intraabdominal pressure : eg: pregnancy,
constipation, straining
67

68. 68

69. SYMPTOMS AND SIGNS
HISTORY
• bright-red, painless bleeding -> not mixed with stool -> OUTLET TYPE BLEEDING
• mucous discharge -> pruritus
• Haemorrhoidal prolapse -> staining underwear with mucus and faecal fluid
• pain only on prolapse – may indicated thrombosed, strangulated haemorrhoid
EXAMINATION
• DRE – assess sphincter tone, exclude anal condition
• Palpable piles – 3rd or 4th degree piles
UPON EXAMINATION USING PROCTOSCOPY, RIGID SIGMOIDOSCOPY
- dilatation of anal cushion
- Thrombosed – oedematous, congested purplish mass
- Strangulated – necrotic, ulceration
69

70. Internal haemorrhoid External haemorrhoid
70

71. 71

72. MANAGEMENT
CONSERVATIVE AND PREVENTION
- Lifestyle modification - High fiber diet, increase oral fluid, good defecation habit
- Replacing prolapse digitally after defaecation
- Creams, suppository and other topical medication – symptomatic relief only
NON – SURGICAL INTERVENTION – For first degree failed conservative treatment and
2nd degree
- Rubber band ligation (Barron’s Bander)
- Submucosal Injection of sclerosant(sclerotherapy) -> 5% phenol in almond oil
SURGICAL INTERVENTION
- Haemorrhaidectomy – 3rd degree/ other intervention failed
- Stapled haemorrhoidopexy
- Haemorrhoidal artery ligation operation - HALO
72

73. 73

74. PERIANAL FISSURE / FISSURE-IN-
ANO
- Painful linear tear in distal anal canal extended to
but not beyond dentate line
- Long term can involve full thickness of anal
mucosa
- Aetiology
- Stretching of anal mucosa (strained evacuation of
hard stool)
- Birth trauma
- Anal sex
- Inflammatory bowel disease
74

75. Symptoms
• Fissure is concealed
by anal spasm
• Small skin tag
(sentinel pile)
Signs
• Pain on defaecation
• Bright-red bleeding
• Mucous discharge
• Constipation
• Itchiness
75

76. Management
• Conservative and medical treatment
- normalization bowel habit
• high fibre diet
• increase water intake
• stool softener
- topical application
• GTN (relax sphincter spasm)
• Injection of botulinum toxin
• Surgical approach
– Lateral internal anal sphincterotomy - definitive
management
76

77. References
In Burnand, K. G., & In Browse, N. L. (2015). Browse's
introduction to the symptoms & signs of surgical disease.
In Williams, N. S., In O'Connell, P. R., & In McCaskie, A. W.
(2018). Bailey & Love's short practice of surgery.
Ramachandran, M., & Gladman, M. A. (2010). Clinical cases and
OSCEs in surgery. Edinburgh: Churchill Livingstone.
Essential Surgery: Problems, Diagnosis and Management, 5th
edition.
Principles & Practice of Surgery, 6th Edition.
CPG Management of Colorectal Carcinoma, 2017. MOH.
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