FISTULA IN ANO
TYPES
It is a track lined by granulation tissue which connects perianal skin superficially to anal canal; anorectum or rectum deeply.
It usually occurs in a pre-existing anorectal abscess which burst spontaneously.
CURLING ULCER
DEFINITION
They are acute ulcers which develop after major burns, presenting as pain in epigastric region, vomiting or haematemesis.
Curling’s ulcer occurs when burn injury is more than 35%.
It is observed in the body and fundus not in antrum and duodenum
TESTICULAR TUMOURS
PREVALANCE
99% of testicular tumours are malignant.
Life time prevalence of getting testicular tumour is 0.2%.
Very common in Scandinavia; least common inAfrica andAsia.
4 times common in whites than blacks.
REGIONAL ENTERITIS (Crohn’s Disease)
DEFINITION
It is a granulomatous, non-caseating (transmural) inflammatory condition of the ileum commonly and of the colon often.
It is independent of age, sex, socioeconomic status and geographic areas.
CARCINOMA RECTUM
It is common in females.
In 3% of cases, it occurs in multiple sites (syn chronous).
Usually originates from a pre-existing adenoma or papilloma (tubular polyp).
Any tumour within 15 cm proximal to the anal margin is called as rectal tumour/cancer.
More than 95% are adenocarcinoma.
VARICOCELE
It is dilatation and tortuosity of the pampiniform plexus of veins and so also the testicular veins.
Normally, there will be numerous plexus of veins (pampiniform) in the scrotum,
↓
which all join together to form about 4–8 veins in the inguinal canal.
FISTULA IN ANO
TYPES
It is a track lined by granulation tissue which connects perianal skin superficially to anal canal; anorectum or rectum deeply.
It usually occurs in a pre-existing anorectal abscess which burst spontaneously.
CURLING ULCER
DEFINITION
They are acute ulcers which develop after major burns, presenting as pain in epigastric region, vomiting or haematemesis.
Curling’s ulcer occurs when burn injury is more than 35%.
It is observed in the body and fundus not in antrum and duodenum
TESTICULAR TUMOURS
PREVALANCE
99% of testicular tumours are malignant.
Life time prevalence of getting testicular tumour is 0.2%.
Very common in Scandinavia; least common inAfrica andAsia.
4 times common in whites than blacks.
REGIONAL ENTERITIS (Crohn’s Disease)
DEFINITION
It is a granulomatous, non-caseating (transmural) inflammatory condition of the ileum commonly and of the colon often.
It is independent of age, sex, socioeconomic status and geographic areas.
CARCINOMA RECTUM
It is common in females.
In 3% of cases, it occurs in multiple sites (syn chronous).
Usually originates from a pre-existing adenoma or papilloma (tubular polyp).
Any tumour within 15 cm proximal to the anal margin is called as rectal tumour/cancer.
More than 95% are adenocarcinoma.
VARICOCELE
It is dilatation and tortuosity of the pampiniform plexus of veins and so also the testicular veins.
Normally, there will be numerous plexus of veins (pampiniform) in the scrotum,
↓
which all join together to form about 4–8 veins in the inguinal canal.
ULCERATIVE COLITIS
DEFINITION
It is an inflammatory condition of rectum & colon of unknown aetiology perhaps related to stress, westernized diet, autoimmune factor, familial tendency, allergic factor.
commonly starts in the rectum, spreads proximally to the colon & often into the ileum as back wash ileitis (5%).
ANORECTAL ABSCESS
AETIOLOGY
Most common causative organism is E. coli
Others are
Staphylococcus
Bacteroides
Streptococcus
B. proteus.
Commonly occurs due to infection of anal gland in perianal region.
INTUSSUSCEPTION (ISS)
DEFINITION
It is telescoping or invagination of one portion (segment) of bowel into the adjacent segment.
TYPES
1. Antegrade: Most common.
2. Retrograde: Rare (jejunogastric in gastrojejunostomy stoma).
STRICTURE URETHRA
CLASSIICATION -I
I: Aetiologically.
2. Congenital.
3. Inflammatory:
Post-gonococcal
is most common
Gonococcal stricture occurs one year after infection.
Retention develops only 10–15 years later.
HYDRONEPHROSIS (HN)
DEFINITION
It is an aseptic dilatation of pelvicalyceal system due to partial or intermittent obstruction to the outflow of urine.
AETIOLOGY
unilateral
bilateral.
FISSURE IN ANO
It is an ulcer in the longitudinal axis of the lower anal canal.
It is superficial, small but distressing lesion.
Fissure ends above at the dentate line.
RUPTURE OF URETHRA (Anterior Urethra)
Usually, due to a fall astride a projecting object, like in sailing ships, cycling, over loose manhole cover, gymnasium.
REFLUX OESOPHGITIS
TYPES
Acute: Following burns, trauma, infection, peptic ulcer.
Chronic: Reflux of acid in sliding hernia, after gastric surgery. Reflux is quite common in pregnancy. Site is always in lower oesophagus
DIVERTICULAR DISEASE OF THE COLON
DEFINITION
They are acquired herniations of colonic mucosa through circular muscles at the points where blood vessels penetrate (points of least resistance).
EPISPADIAS
Here the urethra opens on the dorsum of the penis, proximal to the glans.
COMMON SITES
abdominopenile junction.
It is associated with a dorsal chordee, ectopia vesicae, urinary incontinence, separated pubic bones.
It is uncommon in females.
haemorrhoids are the most common tyoe of gastroenterological disease. it is a nutritive disease. here is a quick review on hemorrhoids, its pathophysiology, clinical features, classification, diagnosis and management.
PILES/HAEMORRHOIDS
DEFINIION
Piles = a ball or mass, Haemorrhoids = blood to ooze, Figs = a fruit (Anjoora).
The word ‘Haemorrhoids’ is derived from Greek word Haima (bleed) + Rhoos (flowering), means bleeding.
The pile is derived from the Latin word ‘Pila’ means Ball
ULCERATIVE COLITIS
DEFINITION
It is an inflammatory condition of rectum & colon of unknown aetiology perhaps related to stress, westernized diet, autoimmune factor, familial tendency, allergic factor.
commonly starts in the rectum, spreads proximally to the colon & often into the ileum as back wash ileitis (5%).
ANORECTAL ABSCESS
AETIOLOGY
Most common causative organism is E. coli
Others are
Staphylococcus
Bacteroides
Streptococcus
B. proteus.
Commonly occurs due to infection of anal gland in perianal region.
INTUSSUSCEPTION (ISS)
DEFINITION
It is telescoping or invagination of one portion (segment) of bowel into the adjacent segment.
TYPES
1. Antegrade: Most common.
2. Retrograde: Rare (jejunogastric in gastrojejunostomy stoma).
STRICTURE URETHRA
CLASSIICATION -I
I: Aetiologically.
2. Congenital.
3. Inflammatory:
Post-gonococcal
is most common
Gonococcal stricture occurs one year after infection.
Retention develops only 10–15 years later.
HYDRONEPHROSIS (HN)
DEFINITION
It is an aseptic dilatation of pelvicalyceal system due to partial or intermittent obstruction to the outflow of urine.
AETIOLOGY
unilateral
bilateral.
FISSURE IN ANO
It is an ulcer in the longitudinal axis of the lower anal canal.
It is superficial, small but distressing lesion.
Fissure ends above at the dentate line.
RUPTURE OF URETHRA (Anterior Urethra)
Usually, due to a fall astride a projecting object, like in sailing ships, cycling, over loose manhole cover, gymnasium.
REFLUX OESOPHGITIS
TYPES
Acute: Following burns, trauma, infection, peptic ulcer.
Chronic: Reflux of acid in sliding hernia, after gastric surgery. Reflux is quite common in pregnancy. Site is always in lower oesophagus
DIVERTICULAR DISEASE OF THE COLON
DEFINITION
They are acquired herniations of colonic mucosa through circular muscles at the points where blood vessels penetrate (points of least resistance).
EPISPADIAS
Here the urethra opens on the dorsum of the penis, proximal to the glans.
COMMON SITES
abdominopenile junction.
It is associated with a dorsal chordee, ectopia vesicae, urinary incontinence, separated pubic bones.
It is uncommon in females.
haemorrhoids are the most common tyoe of gastroenterological disease. it is a nutritive disease. here is a quick review on hemorrhoids, its pathophysiology, clinical features, classification, diagnosis and management.
PILES/HAEMORRHOIDS
DEFINIION
Piles = a ball or mass, Haemorrhoids = blood to ooze, Figs = a fruit (Anjoora).
The word ‘Haemorrhoids’ is derived from Greek word Haima (bleed) + Rhoos (flowering), means bleeding.
The pile is derived from the Latin word ‘Pila’ means Ball
There are marked variations in the incidence of gastric cancer worldwide.
The UK it is approximately 15 per 100000 per year
The USA 10 per 100000 per year
Eastern Europe 40 per 100 000 per year.
It is more common in Japan—70 per 1,00,000 population.
Common in males 2:1.
Decrease incidence in western world (Western Europe and US)—last four decades.
CARCINOMA STOMACH
INCIDENCE
‘It is the captain of men of death’.
It is more common in Japan—70 per 1,00,000 population.
It is more common in males 2:1.
Decrease incidence in western world
A presentation on colon as pathology specimen. Identification of colon based on gross features. Anatomy, blood supply, lymphatics of Colon.
Brief description of colon cancer and colonic tuberculosis
RENAL CALCULUS AETIOLOGY
Males- radio-opaque gall stones
Females - Radiolucent gall stones
Diet:Vitamin A deficiency
it causes desquamation of epithelium
which acts as a nidus for stone formation.
Climate:
In hot climate urinary solutes will increase with decrease in colloids,
PARAPHIMOSIS
DEFINITION
Inability to place back (cover) the retracted prepucial skin over the glans is called as paraphimosis.
It causes ring like constriction proximal to the corona and prepuceal skin.
HYPOSPADIAS
DEFINITION
It is the most common congenital malformation of urethra wherein external meatus is situated proximal than normal, over the ventral (under) aspect of the penis.
BENIGN PROSTATE HYPERPLASIA (BPH)
AETIOLOGY
It is benign enlargement of prostate which occurs after 50 years, usually between 60 and 70 years.
BPH affects both glandular epithelium and connective tissue stroma.
It is involuntary hyperplasia due to disturbance of the ratio and quantity of circulating androgens and estrogens.
ORCHITIS
AETIOLOGY
It is an inflammation of the testis.
It is commonly associated with inflammation ofthe epididymis. Hence, called as epididymo-orchitis.
Orchitis is due to infection through blood, lymphatics or epididymis.
EPIDIDYMITIS,
CAUSES
Inflammation of epididymis is commonly associated with orchitis— epididymo-orchitis.
Nonspecific
viral like mumps.
Bacterial.
Filarial.
Tuberculosis
PERFORATED PEPTIC ULCER
PERFORATION
DEFINITION
It is the terminology used for perforation of duodenal ulcer or gastric ulcer or stomal ulcer.
Otherwise all clinical features and management are similar.
Perforation is common in duodenal ulcer
Mortality is more in gastric ulcer perforation and perforation in elderly
GASTRIC ULCER
AETIOLOGY
It occurs due to imbalance between protective and damaging factors of gastric mucosa.
Atrophic gastritis
duodenogastric bile reflux
gastric stasis
abnormalities in acid and pepsin secretion.
Acid becomes ulcerogenic even to normal gastric mucosa.
Congenital (infantile) hypertrophic pyloric stenosis by Dr.K.AmrithaAnilkumarDr. Amritha Anilkumar
CONGENITAL (INFANTILE) HYPERTROPHIC PYLORIC STENOSIS
DEFINITION
It is hypertrophy of musculature of pyloric antrum, especially the circular muscle fibres, causing primary failure of pylorus to relax.
Duodenum is normal.
PILONIDAL SINUS/DISEASE (Jeep Bottom; Driver’s Bottom)
Pilus—hair; Nidus—nest
It is epithelium lined tract, situated short distance behind the anus, containing hairs and unhealthy diseased granulation tissue.
It is due to penetration of hairs through the skin into subcutaneous tissue.
HIATUS HERNIA
DEFINITION
It is the most common type of diaphragmatic hernia
TYPES
Sliding hernia (85%).
Rolling hernia (10–12%).
Combined
SAINT’S TRIAD
Hiatus hernia
Diverticulosis
Gallstones .
ACHALASIA CARDIA (Cardiospasm)
DEFINITION
It is failure of relaxation of cardia (oesophago- gastric junction) due to disorganized oesophageal peristalsis, as a result of failure of integration of parasympathetic impulses causing functional obstruction
(Achalasia means failure to relax—Greek).
ACHALASIA CARDIA (Cardiospasm)
DEFINITION
It is failure of relaxation of cardia (oesophago- gastric junction) due to disorganized oesophageal peristalsis, as a result of failure of integration of parasympathetic impulses causing functional obstruction
(Achalasia means failure to relax—Greek).
HYDATID CYST
DEFINITION
Word meaning is ‘dew drop’ (Latin).
In Greek it means ‘watery vesicle’.
Echinococcus means ‘hedge hog berry’ in Greek.
Caused by Echinococcus granulosus (EG), dog tape worm .
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
3. CARCINOMACOLON
DEFINITION
• It is commonly
adenocarcinoma.
• Veryrarely adenosquamous,
squamous carcinoma can
occur.
• Adenocarcinoma
COMMONSITES
• Sigmoid colonis the most
commonsite of malignancy
after rectum
• In caecum
4. AETIOLOGY
• Diet
Red meat and saturatedfat
(Cholesterol)
↓
increases the bile acid
concentration(acts as
cocarcinogen).
High fibre diet & Calcium
protects the colonagainst
cancer.
↓
It directlyacts on the colonic
mucosal cells
↓
to reduce their proliferative
potential
Diet withlack of fibre &
highfat increases the risk.
Dietaryvitamins A,C, E and
zinc reduces the risk.
• Genetic:
individuals with
adenoma colon
familial adenomatous
polyposis (FAP)
Gardner’s syndrome,
Turcot’s syndrome.
5. • Long standing ulcerative
colitis & Crohn’s disease
• Alcohol and cigarette
smoking increases the risk.
• Hereditary nonpolyposis
coloniccancer (HNCC)
• After cholecystectomy and
ileal resectionthere is
increasedbile salts and so
more prone for carcinoma
colon.
• Radiationincreases the
risk(mucinous type).
• Ureterosigmoidostomy
• Acromegaly
PATHOGENESIS
• Adenoma—carcinoma
sequence
• Most of the colonic
carcinoma develops from
polyp/adenoma pathway.
Normal epithelium
→initiation by 5q loss APC
gene → dysplasia
(hyperproliferative) →
DNA methylation→ early
adenoma → 12p activation
K ras → intermediate
adenoma
6. →18q loss DCC→ late
adenoma → actionby 17p loss
p53 →carcinoma → spread .
• 80% of colorectal cancer
arises fromloss of
heterozygosity (LOH)
pathway.
• LOH pathway
↓
APC gene defects (inFAP)
↓
K ras mutation altering the
cell cycle
↓
K ras binds to GTP(guanosine
triphosphate)
↓
hydrolyse to GDP which
inactivates G proteinnormally
↓
K ras mutation blocks GTP
hydrolyse
↓
leading intopermanently active
formof G protein causing
carcinoma
7. ↓
loss of DCCtumour suppressor
gene
↓
mutationof tumour suppressor
gene p53.
↓
LOH pathway is microsatellite
stable (MSS)and carries poor
prognosis compared with MSI.
• 20% of colorectal cancer
develops frommutation
fromRER (Replication Error
Repair) pathway
↓
whereinrepair mechanismof
DNA replication error is lost.
↓
It causes microsatellite regions of
genome to have repeated
sequences
8. ↓
leading intoerror and is called
as microsatellite instability
(MSI)
↓
In colon, it is seenin right side
growths & is associated with
better prognosis
• Colonic cancer may be:
Nonhereditary colon
cancer
• It can be sporadiccolon
cancer—60%.
• It canbe familial colon
cancer. Commonin
Ashkenazi– Jewish
population.
• Hereditary colon cancer
• FAP
• HNCC.
• PeutzJeghers syndrome—
2–3%risk of cancer colon.
• Cronkite—Canada
syndrome.
9. • Juvenilepolyposis
syndrome—it differs
fromisolated juvenile
polyps discussedearlier. It
is an autosomal dominant
condition
TYPES
• Patient can have de novo
multiple primary
carcinomas in different parts
of the colon at the same time,
i.e. synchro nous (5–10%)
• can present with growthin
different partsof the colon
in different periods, i.e. meta
chronous (10–20%).
• Gross types:
• Annular,
• Tubular
• ulcerative
• cauliflower like.
10. Annular (stenosing) type:
• It is more common on left
side.
• Here the growthspreads
roundthe internal wall and
so it oftenpresents with
intestinal obstruction.
Ulcerative type:
• It is common on right side
Proliferative type
• Common in right side.
• It is fleshy, bulky and
polypoid. It is less
malignant.
Histology (WHO)
• Adenocarcinoma—90%.
• Mucinous
adenocarcinoma—5–10%.
• Signet ring cell carcinoma.
• Small cell/oat cell
carcinoma—rare—
extremely poor prognosis.
• Squamous cell carcinoma.
• Undifferentiated carcinoma
11. Duke’s histological grading of
carcinoma colon (nowmodified
Morson-Dawson)
• Grade I—low grade.
• Grade II—average grade.
• Grade III—highgrade.
• Grade IV—anaplastic.
Carcinoma confined to
muscularis mucosadoes not
metastasize.
Sessile MalignantPolyp
• InvasionSm 1: Submucosal
invasion into upper 1/3rd
(superficial/ inner)
• Sm 2: Submucosal invasion
into middle 1/3rd (inner
2/3rd)
• Sm3: Submucosal invasion
lower 1/3rd(deep).
12. SPREAD
• Direct spread:
• Locallyit can invade the
bladder, obstruct ureter
and so cause
hydronephrosis.
• Canperforate and cause
peritonitis/pericolic
abscess/faecal fistula.
• Growth may get
adherent to psoas
muscle posteriorly.
• Carcinoma sigmoid
colon caninfiltrateand
cause colovesical or
colovaginal fistula.
• It can infiltrate ureter,
ovary, uterus etc. It can
cause pericolicabscess
or abscess in lateral
abdominal wall.
13. • Lymphatic spread:
• Growththrough
lymphatics spreads to
pericolic, epicolic,
intermediate and
principal group of
lymph nodes. Groups of
lymph nodes draining
colon
• N1: Nodes immediately
adjacentto bowel wall.
• N2: Nodes along
ileocolic/right
colic/middle colic/ left
colic/ sigmoidarteries.
• N3: Nodes near the
originof SMA and IMA.
• Nodal spreadin
carcinoma colon is
sequential fromN1 →
N2 → N3
14. TNMCLASSIFICATION- Blood
spread
• 40%of carcinoma colon
spreads to liver via portal
veins.
• Secondaries may be either
solitaryor multiple, present
as liver with hard,
umbilicatednodules.
• Rarelyit spreads to bone,
lung, skin.
TNMstaging of colorectal cancer
Tumour—T
• Tx – Primary tumour
cannot be assessed
• T0 – No evidence of tumour
• Tis – Carcinoma in situ—
intraepithelial/invasioninto
lamina propria
• T1 – Invasion into
submucosa
• T2 – Invasion into
muscularis propria
• T3 – Invasion into
pericolorectal tissues/fat
15. • T4a – Invasionintosurface
of the visceral peritoneum
T4b – Direct Invasion or
adherent to adjacent
structures/organs
Regional nodes—N
• Nx – Nodes cannot be
assessed
• N0 – No nodal spread
• N1 – Regional nodes 1–3
involved –
• N1a – 1 regional node
• N1b – 2 to 3 regional
nodes
• N1c – Tumour deposits
in serosa/mesentery/
nonperitonealised
pericolic or perirectal
tissues without regional
nodes
16. • N2 – Regional nodes 4 or
more involved
• N2a – 4-6 regional nodes
• N2b – 7 or more regional
nodes .
Distant metastases—M
• M0 – No distantspread
• M1 – Distant spread present
• M1a – Spread confined
to one organ or site—
liver/lung/ovary/
nonregional nodes;
• M1b – Spread to more
than one organor
site/peritoneum.
17. Histological grade—G
• Gx – Grade cannot be
assessed
• G1 – Well differentiated
• G2 – Moderately
differentiated
• G3 – Poorly differentiated
• G4 – Undifferentiated
CLINICALFEATURES
• Occurs usually after 50
years.
• Familial type can present in
younger age group.
• loss of appetite& weight
• Anaemia
• abdominal discomfort and
mass per abdomen.
• 20% - acuteintestinal
obstruction.
• 20% of colonic/colorectal
cancer has stageIV
disease at the time of first
presentation
18. • Right sided growth
commonly presents with
• Anaemia
• palpable mass in the
rightiliacfossa, which is
not moving
• with respiration
• Mobile
• Nontender
• hard, well-localised with
impairedresonant note.
• Carcinoma caecum
occasionallypresents
• Acuteappendicitis/
• intusscepion with
intestional
obstruction
19. • Left sided growth presents
• colicky pain
• alteredbowel habits
(alternating
constipationand
diarrhoea)
• palpable lump
• distensionof
abdomendue to sub
acute/chronic
obstruction.
• Later may presentlike
• complete colonic
obstruction
• Tenesmus, with passage
of blood and mucus
• with alternate
constipation&
diarrhoea, is common.
• Bladder symptoms may
warn colovesical fistula.
• Features of pericolic
abscess/obstruction
/perforation/ peritonitis
maybe the first
presentation
20. • Closedloop obstruction can
occur in transverse colon
growth(stricture type
causing block) with
competent ileocaecal valve.
• Enormouslydilated right
sided colonis prone for
• stercoral ulcer
• Perforation& faecal
peritonitis.
• Enlargedliver with multiple
umbilicatedhard
secondaries
• Ascites
• rectovesical secondaries
• palpable left supraclavicular
lymph nodes are other
presentations.
• Faecal strength of
Streptococcus bovisbacteria
increases many fold in
patients with coloniccancer
compared to individuals
without coloniccancer
21. INVESTIGATION
• Bariumenema
• Shows irregular filling
defect and ‘apple core’
lesion (inleft sided
carcinoma)
• It also helps in finding
colonicpolyps (air-
contrast barium
enema).
• Colonoscopy and biopsy
confirms the diagnosis.
Virtual colonoscopy (CT
colonography) is also useful to
visualize entirecolon
22. • CT scanabdomenand
pelvis—to see local spread,
invasion, size and extent,
stage, nodal status and liver
secondaries.
• Left supraclavicular lymph
nodeif palpable, its FNAC
may clinchthe histological
diagnosis.
• Hb%, PCV, haematocrit,
ESR. Look for occult blood in
stool is the initial test for
anaemia.
• LFT—mainlyenzyme
studies like alkaline phos
phatase
• SGPT.
• US
• secondaries in liver
• Peritoneum
• lymph nodestatus
• rectovesical secondaries.
• CEA(carcinoembryonic
antigen):
• It is a cell surface
glycoprotein
-- discovered by
Gold and Freedman
23. SURGERY
Right-sidedearly growth:
• Right radical hemicolec
tomy with ileo-transverse
anastomosis is done.
• Structures removedare
terminal 6 cm of ileum,
caecumand appendix,
ascending colon, 1/3 of
transversecolon, lymph
nodes (epicolic, paracolic,
intermediate).
• In inoperable rightsided
growth, ileotransverse
anastomosis is done as a by-
pass procedure.
24. Transverse colon growth:
• An extended right
hemicolectomyis the
procedure done for
transversecolon growth
Left-sided early growth:
• Left radical
hemicolectomyis done,
where in left ½ of
transversecolon and des
cending colon is removed
along withlymph nodes.
• Left-sided stenosing type
of growthcan present
with acuteintestinal
obstruction, in which case
initially colostomyis done
25. • Oftengrowthin the
transverseor left sided
colon, whichis stenosing or
obstructive type, can cause
closed loop obstruction
Multiple synchronous primaries
in the colon:
• Total abdominal colectomy
with ileorectal anastomosis
is done
• Surgical treatment of liver
secondaries:
• In solitaryliver secondary,
segmental hepaticresection
is useful
• Adjuvant Therapy
Chemotherapy
26. Indications for chemotherapy
• Positive nodes.
• T4 lesions.
• Venous (microscopic)
spread.
• Signet cell type.
• Poorlydifferentiated
tumour/aneuploidy.
• Changes in CEAlevel.
• Postoperative
chemotheraphy
• Radiotherapy (RT)
• Usually there is no role for
RT as tumour is
radioresistant.
27. • It is often usedin locally
advancedtumour,
infiltrating the psoas major
muscle or lateral abdominal
wall, left sided colonic
growth.
COMPLICATION
• Intestinal obstruction ™
• Closedloop obstruction ™
• Perforation& peritonitis ™
• Vesicocolicfistula ™
• Invasionof ureter ™
• Pericolic abscesss
PROGNOSIS
• Site—left sidedtumours
has got better prognosis as
theypresent early.
• Type—colloid carcinoma
has got poorer prognosis.
• Size of the tumour.
• Lymph nodes status:
Number of lymph nodes
involved decides the
prognosis.
• Liver secondaries has poor
prognosis.
• Age of the patient.
28. • Associateddiseases like HIV.
• Stage of the tumour.
• Presence of complications
• perforation
• peritonitis.
• On the whole, it is a
curable malignancy with
proper surgeryand
adjuvant therapy.
5 yearsurvival is:
• Stage I – 90%.
• Stage II – 75%.
• Stage III – 50%.
• Stage IV – less than 5%.
REFERENCE
1. SRB's Manual of Surgery
by SriramBhat M
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das