This is a powerpoint slideshow discussing some of the commonest disorders of colon; namely Hirschsprung's disease, Diverticular diseases of colon, ulcerative colitis, pseudomembranous colitis and ischemic colitis.

1. Colon
Prithwiraj Maiti

3. • Last part of the digestive system in most vertebrates.
• Length = 135 cm.
• Colon consists of four sections:
– Ascending colon,
– Transverse colon,
– Descending colon,
– Sigmoid colon.
• Proximal colon= (Ascending colon + Transverse colon).
• The cecum, colon, rectum and anal canal - the large
intestine.

4. • Wall– Mucosa
– Submucosa
– Inner circular muscle layer
– Outer longitudinal muscle layer

5. Identification of colon
 3 taenia coli.
 Appendices epiploicae: Small pocket of fat
filled peritoneum- except appendix, caecum
and rectum.
 Haustra: Sacculations between taeniae.

7. Endoscopic appearance of the caecum.
The characteristic trefoil appearance of
the confluence of the three taeniae is
usually obvious.
Endoscopic appearance of the
transverse colon. The characteristic
triangular appearance of the
haustrations when viewed
collectively is obvious.

8. Blood supply
Typical pericolic
arrangement of
arterial vasculature.

10. • Superior Mesenteric Artery (Caecum to splenic flexure)1. Right colic,
2. Middle colic.
3. Ileocolic.
• Inferior Mesenteric Artery (Descending and sigmoid colon)1. Left colic,
2. Sigmoid,
3. Superior rectal.
• Arc of Riolan: Anastotic arcade of SMA & IMA.
• Venous drainage: SMV- Portal vein, IMV-Spenic vein.

11. Lymphatic drainage
• Epicolic- Located in
colonic wall.
• Paracolic- Located
along the inner margin.
• Intermediate- Located
near mesenteric vessel.
• Principal- Located near
main mesenteric vessel.

12. Nerve supply
• Under autonomic nervous system.
• Parasympathetic- Vagi and pelvic nerves.
• Sympathetic- Superior and inferior mesenteric
ganglia.

13. HIRSCSPRUNG’S DISEASE/
CONGENITAL MEGA COLON
• Congenital, familial (10%).
• Absence of ganglion cells- Auerbach’s plexus
and Meissner’s plexus of colon.
• Always involve anus, internal sphincter &
rectum (partly/entirely).
• Gene mutation in chromosome 10
occasionally 13.

14. HIRSCSPRUNG’S DISEASE/
CONGENITAL MEGA COLON
Zones:
1. Distal immobile
spastic segment .i.e.
aganglionic zone.
2. Proximal middle
transitional zone.
3. More proximal
hypertrophied dilated
segment- Normal.

15. HIRSCSPRUNG’S DISEASE/
CONGENITAL MEGA COLON
Types:
1. Ultra short segment HD,
2. Short segment HD,
3. Long segment HD,
4. Total colonic HD.

16. HIRSCSPRUNG’S DISEASE/
CONGENITAL MEGA COLON
Clinical features
•
•
•
•
PresentationAcute, recurrent and chronic.
Male- 80%
Infant and children also adult (Down’s syndrome most
common association).
• 90% within 3 days of birth- fails to pass stool- After
introduction of finger tooth paste like stool- feature of
intestinal obstruction.
• Children- Goat pellet like stool, malnutrition, abdominal
distension– chronic type constipation-pass stool once in 3-4
days –
• PR- TIGHT SPHINCTER + EMPTY RECTUM- PASS LOT OF GAS
AND MECONIUM.

17. HD
Complication– Colitis,
– Intestinal obstruction,
– Growth retardation,
– Constipation,
– Perforation,
– Peritonitis,
– Septicaemia.

18. HIRSCSPRUNG’S DISEASE/
CONGENITAL MEGA COLON
• M/t
• Diagnosis– History
– X ray abdomen
– Biopsy from all 3 zones- Starting from 2 cm above
dentate line- Full thickness rectal biopsy.
– Barium enema- Extent.
– Anorectal manometry- Absence of rectoanal reflex.
– Acetylcholenesterase staining- Hypertrophied nerve
bundle.

19. • D/d
– Total neuronal dysplasia,
– Acquired megacolon,
– ARM,
– Hypothyroidism,
– Meconium plug syndrome.

20. T/t -surgery
– Colostomy-nutritional supplement-definitive
procedure
– Excision of aganglionic segment
– Maintenance of continuity
– Closure of colostomy
Duhamel’s operation
Soave’s

21. DIVERTICULAR DISEASE OF COLON
• Acquired herniations of colonic mucosa through circular
muscles at the points where blood vessels penetrate.
• Raised intraluminal pressure results in pulsion diverticula.
• Most common- Sigmoid.
• Rectum not affected.
• Etiology– Low fibre diet,
– Female,
– Non-veg,
– NSAID, STEROID, immunocompromised;
– Smoking, alcohol;
– Long standing constipation.

22. DIVERTICULAR DISEASE OF COLON
Types
• Diverticulosis- Primary initial asymptomatic or
painful stage (muscular incoordination, increased
intraluminal pressure).
• Diverticulitis: Second stage with inflammation of
diverticula with pericolitis→ Persistent pain in
LIF, fever, loose stool recurrent constipation, tender
LIF, palpable thickened colon, P/R= tender mass.

23. DIVERTICULAR DISEASE OF COLON

24. Hinchey’s classification of diverticulitis

25. DIVERTICULAR DISEASE OF COLON
• Investigation– Barium enema- Saw teeth
appearance, Champagne glass sign
– Sigmoidoscopy- Not in acute stage
– Colonoscopy
– CT scan
• D/D
– CA colon, amebic colitis, ulcerative
colitis, ischaemic colitis, crohn’s disease, TB.

26. Diverticulitis Barium Enema
(showing spasm)

27. Treatment
• Medical
–
–
–
–
High fiber diet.
Antibiotic.
Bulk purgative- Avoid constipation.
Acute- Bowel rest, antispasmodic, antibiotic.
• Abscess-guided aspiration
• Surgery
– Resection anastomosis of sigmoid/ colostomyanastomosis.
– Reilly’s myotomy.

28. ULCERATIVE COLITIS
• Ulcerative colitis (Colitis ulcerosa, UC) is a form
of inflammatory bowel disease (IBD).
• Etiological factor:
– Western diet, red meat
– Defective mucin production in colonic mucosa and
mucosal immunological reaction
– Autoimmune factors
– Appendicectomy and smoking protects
– Familial
– Allergy to milk
– Psychological aspects- stress, life style, personality
disorders.

29. • Pathology– Multiple minute ulcer with proctitis and colitis→
–
–
–
–
–
–
Ulcer extend to deeper layer→
Spasm→
Stricture→
Pipe stem colon→
In between ulcer inflamed epithelium→
Pseudopolyp.

30. • Ulcerative colitis is normally continuous from the
rectum up the colon.
• Classification by the extent of involvement.
• Distal colitis, potentially treatable with enemas:
–
–
–
–
Proctitis: limited to the rectum.
Proctosigmoiditis: rectosigmoid colon,
Left-sided colitis: descending colon,
Extensive colitis: inflammation extending beyond the
reach of enemas:
– Pancolitis: Involvement of the entire colon, extending
from the rectum to the cecum, beyond which the
small intestine begins.

31. ULCERATIVE COLITIS
• Clinical features:
– Abdominal pain
– Diarrhea- watery, mucous or blood stained
– Loss of appetite
– Weight loss
– Weakness or fatigue
• Fulminant
• Chronic

32. Clinical grading
• Mild disease
–
–
–
–
–
<4 stools daily, with or without blood.
No systemic signs of toxicity.
Normal ESR/ CRP.
Mild abdominal pain or cramping. Tenesmus.
Rectal pain is uncommon.
• Moderate disease
–
–
–
–
–
–
>4 stools daily.
Minimal signs of toxicity.
Anemia (not requiring transfusions), weight loss.
Moderate abdominal pain,
Low grade fever, 38 to 39 °C (100 to 102°F).
ESR↑.

33. • Severe disease
–
–
–
–
> 6 bloody stools/ day.
Massive and significant bloody bowel movement.
Evidence of toxicity - fever, tachycardia, anemia.
Elevated ESR or CRP.
• Fulminant disease
–
–
–
–
–
–
–
>10 bowel movements/day.
Continuous bleeding.
Toxicity.
Abdominal tenderness and distension.
Blood transfusion requirement .
Colonic dilation (expansion).
Inflammation may extend beyond just the mucosal layer→
impaired colonic motility→ toxic megacolon.
– Serous membrane may involved → colonic perforation.
– Unless treated, fulminant disease will soon lead to death.

34. Extraintestinal features
Frequency: 6 - 47%.
• Aphthous ulcer of the mouth.
• Ophthalmic (involving the eyes):
– Iritis or uveitis, episcleritis.
• Musculoskeletal:
– Seronegative arthritis,
– Ankylosing spondylitis,
– Sacroiliitis.

35. •
•
•
•
•
Extraintestinal features
Cutaneous (related to the skin):
– Erythema nodosum- panniculitis inflammation of subcutaneous tissue involving
the lower extremities.
– Pyoderma gangrenosum, which is a painful
ulcerating lesion involving the skin.
Deep venous thrombosis and pulmonary
embolism.
Autoimmune hemolytic anemia.
Clubbing.
Primary sclerosing cholangitis.

36. Complication
• Pseudopolyposis, stricture, fistula, perforation, m
alignancy, toxic megacolon, haemorrhage, severe
malnutrition, cirrhosis.
• Toxic megacolon (megacolon toxicum):
–
–
–
–
Acute form of colonic distension.
Very dilated colon-megacolon> 6 cm.
Abdominal distension, fever, abdominal pain or shock.
Toxic megacolon is usually a complication of UC and
rarely of crohn's disease and some infections ex.:
Clostridium difficile, Entamoeba histolytica and
Shigella.
– Wall thinned out-immediate intervention.

37. ULCERATIVE COLITIS
• Factors involved for Carcinoma in UC
– Extent of involvement –more in total colonic
– Duration of disease- 5%-15yr, 25%-25yr, 35%30yr, 65%-40yr.
– Site of involvement- Left more.
– Sex - Equal in both sex.
– Carcinoma in UC are aggressive, poorly
differentiated, multicentric, synchronous
, infiltrative and schirrous.

38. ULCERATIVE COLITIS
•
•
•
•
Investigation
Barium enema
Blood and stool tests
Visual examination
– Sigmoidoscopy
– Colonoscopy

39. •
•
•
•
•
•
•
•
•
•
CBC-Hb↓; Platelet↑
Electrolyte- Hypokalemia, Hypomagnesemia.
Renal function tests- Pre-renal failure.
Liver function tests- Primary sclerosing cholangitis.
ESR↑
CRP↑
X-ray,
Barium enema,
Urinalysis.
Stool culture- Rule out parasites and infectious causes.

40. • Endoscopy- Best test for diagnosis.
• Full colonoscopy - If diagnosis is unclear.
• Flexible sigmoidoscopy- It is sufficient to support
the diagnosis.
• Endoscopic findings:
–
–
–
–
–
Loss of the vascular appearance of the colon.
Erythema and friability of the mucosa.
Superficial ulceration, which may be confluent, and
Pseudopolyps.
Rectum almost universally being involved. Rarely
perianal disease.

41. • Endoscopic image of a
bowel section (the
sigmoid colon) affected
with ulcerative colitis.
• The internal surface of
the colon is blotchy and
broken in places.

42. Histologic Appearance
Biopsy sample (H&E stain)
– Disease confined to mucosa and sub mucosa.
– Increase in substance P in nerve fibers.
– Decreased goblet cell mucin.
– Marked lymphocytic infiltration (blue/purple) of
the intestinal mucosa and architectural distortion
of the crypts.
– Inflammation of crypts (cryptitis), frank crypt
abscesses and hemorrhage or inflammatory cells
in the lamina propria.

43. ULCERATIVE COLITIS

44. D/D
• Crohn's disease
• Infectious colitis- detected on stool cultures
• Pseudomembranous colitis, or Clostridium
difficile-associated colitis,
• Ischemic colitis• Radiation colitis- previous pelvic radiotherapy
• Chemical colitis- harsh chemicals into the
colon from an enema or other procedure.

45. ULCERATIVE COLITIS: TREATMENT
•
•
•
•
General:
Correction of Hb, fluid, electrolyte, nutrition.
Sedative, tranquiliser, psychological counseling.
Drugs:
– Sulfasalazine/salazopyrine- 2-4 gm/day- induce remissionactive disease.
– 5ASA (5-Amino Salicylic Acid/Mesalamine)- Oral/retention
enema.
– Steroid- In refractory case-oral prednisolon 60mg/d
tapering in 4 weeks.
– IV hydrocortisone.
– Immunmodulators- Azathioprine , 6 mercaptopurine
(6MP), Cyclosporin.

46. ULCERATIVE COLITIS
• Indication for surgery–
–
–
–
–
–
–
–
–
–
–
Intractability
Toxic dilatation
Perforation
Haemorrhage
Risk of malignant transformation
Onset at early age
Progressive disease
Steroid dependency- persistent active disease
Malignancy
Severe extraintestinal feature
Growth retardation in children

47. Differentiating features
Crohn’s disease
Terminal ileum involvement Commonly
Ulcerative colitis
Seldom
Colon involvement
Usually
Always
Rectum involvement
Seldom
Usually
Involvement around
the anus
Common
Seldom
Bile duct involvement
No increase in rate of primary
sclerosing cholangitis
Higher rate
Distribution of Disease
Patchy areas of inflammation (Skip
lesions)
Continuous area of inflammation
Endoscopy
Deep geographic and serpiginous
(snake-like) ulcer
Continuous ulcer
May be transmural
Shallow, mucosal
Common
Seldom
Depth of inflammation
Stenosis
Granulomas on biopsy
May have non-necrotizing non-peri- Non-peri-intestinal crypt granulomas
intestinal crypt granuloma
not seen

48. ISCHAEMIC COLITIS
•
•
•
•
•
Splenic flexure- watershed area- blood supply precarious.
Female.
Aged patient.
Atherosclerosis ,emboli, vasculitis.
Types (Marston’s classification)– Gangrenous- Full thickness.
– Stricture- Muscular layer.
– Transient- Mucosal involvement.

49. • Clinical features:
– Pain LIF, LHC.
– Vomiting , diarrhoea.
– Blood in stool.
• Inv– Plain x ray- Thumb print sign
– CT
• T/t
• Conservative-fail-surgery

50. The arrow is pointing to thumbprinting in a patient with ischemic colitis.
Thumbprinting is a nonspecific finding of mucosal edema, which may be found with
inflammatory bowel disease, pseudomembranous colitis, or ischemic bowel. As the
edema worsens, the haustral markings may disappear completely, leaving a hoselike
appearance to the colon. Narrowing and stricturing are other common findings.

51. PSEUDOMEMBRANOUS COLITIS
• Toxin of Clostridium difficile– After antibiotic therapy.
– Immunocompromised.
• Diarrhoea, toxemia, perforation, haemorrhage.
• Mortality 30%.
• Investigations:
– Stool cytotoxin assay,
– ELISA,
– Colonoscopy.
• T/T
– Vancomycin,
– Metronidazole.

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