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Basic Science – “Large Bowel”
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Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Dec 17, 2015

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Domenic Long
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Page 1: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Basic Science – “Large Bowel”

Page 2: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Anatomy

Right colon Transverse colon Left colon

Descending Sigmoid

Rectum What defines the

transition between the sigmoid colon and rectum?

Page 3: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon - Anatomy

What are the layers of the bowel wall?

What comprises the tenia?

Page 4: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon – Arterial Supply & Lymphatic Drainage

Page 5: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Rectum - Anatomy

Page 6: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Rectum – Venous and Lymphatic Drainage

Page 7: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon - Physiology What is the primary role of the colon?

Fluid absorption900ml of waterBile acidsSodium (active transport)

Page 8: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colonic transit R colon: segmental propulsive &

retropulsive contractions for “mixing”

L colon: mostly propulsive contractions “Mass movements”: large peristaltic

contractions (1-3/day) that move contents about 1/3 the length of the colon

Page 9: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Defecation Distention of the rectum triggers

the rectoanal inhibitory reflex (RAIR): External anal sphincter voluntarily

relaxed Rectum / Distal colon contract Pelvic floor relaxes (straightening of

rectosigmoid angle)

Page 10: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Diverticular Disease

True or false diverticula?

Page 11: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Acute Diverticulitis (simple) Symptoms

LLQ abdominal pain/fever/leukocytosis

Radiologic evaluation CT scan

Treatment Bowel rest & IV ABX

Duration of both?

Page 12: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Acute Diverticulitis (simple) Management after resolutions of

symptoms: BE or Colonoscopy 6-8 wks later Discussion re: surgical intervention

What are the proximal and distal margins in an elective resection for diverticulosis?

Page 13: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Complicated Diverticulitis Perforation

Abscess/Phlegmon/Peritonitis Obstruction

Acute inflammation vs. fibrosis Fistula

Colovesical/Colovaginal Bleeding

Page 14: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Complicated Diverticulitis - Management

Perforation With contained abscess With peritonitis

Obstruction Acute Chronic

Fistula Bleeding

Page 15: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Ulcerative Colitis Inflammatory condition of the

colon and rectum limited to the mucosa and submucosa

Etiology: unknown Age of onset: Bimodal distribution

Page 16: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Ulcerative Colitis Disease begins at the dentate line

and move proximally without skip areas 75% confined to proctosigmoiditis

Symptoms: Numerous bloody bowel movements

“no blood, no UC” Abdominal pain and cramps Tenesmus, fecal urgency & incontinence

Page 17: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Ulcerative Colitis – Endoscopic Findings

Page 18: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Ulcerative colitis – Medical Management

Tailored to disease severity Mild –Moderate disease

Sulfasalazine and its derivatives (mesalamine based compounds)

Immunosuppressives (6-MP, Azathioprine)

Severe disease Corticosteroids Cyclosporine A

Page 19: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Ulcerative colitis – Indications for surgery

ElectiveIntractability

Dysplasia, malignancy or malignancy prophylaxis

Complications of medications (usually steroids)

EmergencyToxic colitis

Hemorrhage

Acute exacerbation unresponsive to medical Tx

Page 20: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Ulcerative Colitis – Surgical options

Emergency Subtotal colectomy with end-

ileostomy Elective

Proctocolectomy + End ileostomy IPAA Koch pouch

Page 21: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Ulcerative colitis -IPAA

Page 22: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Crohns Disease Inflammatory condition of the GI

tract of unknown etiology Bimodal distribution “mouth to anus” Skip areas Transmural Non-caseating granulomas

Page 23: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Crohns Disease - symptoms

Crampy abdominal pain Watery diarrhea Fecal urgency and tenesmus

Page 24: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Crohns Colitis – Endoscopic features Skip areas – often with rectal sparing “cobblestone” appearance Serpigenous ulcerations

Page 25: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Crohns disease -Treatment Medical management is the

mainstay of Crohns disease: Mild / Moderate disease: 5-ASA

compounds Severe disease: Steroids

6-Mp and Azathioprine for maintenance

Page 26: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Crohns disease - complications

Abscess Fistula Perforation Toxic colitis

Obstruction Colonic stricture = malignancy

Page 27: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Crohns Disease - Surgery

Goal: To palliate the symptoms Location and extent of disease

determine operative procedure in Crohns colitis: Segmental resection vs.

proctocolectomy

Page 28: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Large Bowel Obstruction Etiology:

Colon cancer (Left-sided)

Volvulus (cecal & sigmoid)

Diverticulosis

Page 29: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Large Bowel Obstruction - Presentation

Symptoms Obstipation, abdominal pain and

distention, +/- emesis Physical Exam

Abdominal distention, tenderness,

Page 30: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Large Bowel Obstruction - Management

Resuscitation X-Rays…

Plain films Retrograde GGE CT scan

…vs. Endoscopy

Page 31: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

What is this?

Page 32: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Large Bowel Obstruction - Management

Sigmoid Volvulus Cecal volvulus Malignancy (Left side)

Hartmann procedure

Resection/ on-table lavage/ primary anastomosis

Subtotal + anastomosis

? Stent

Page 33: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon cancer – Inherited

Familial adenomatous polyposis Autosomal Dominant (APC gene: 5q21) Scattered polyps to “carpeted” 100% lifetime risk of developing cancer without

surgery Extraintestinal manifestations (Gardner’s syndrome)

Desmoids/CHRPE/periampullary ca/epidermal cysts

Page 34: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon cancer – Inherited FAP – Surgical treatment

Proctocolectomy with End ileostomy IPAA

Subtotal colectomy / IRA +/- Sulindac

Page 35: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon cancer – Inherited HNPCC (Lynch Syndrome)

Autosomal dominant Germline mutation in DNA mismatch repair genes

(hMLH1, hMSH2) Scattered polyps with tendency toward proximal

lesions 80% lifetime risk of developing colon cancer Amsterdam criteria Extracolonic malignancies

Endometrial/Ovarian/GUSurgical management: Subtotal / IRA

Page 36: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon cancer - polyps Non-neoplastic

Hyperplastic Juvenile Inflammatory

Neoplastic potential Villous adenoma Tubular adenoma Tubulovillous

adenoma

Which has the highest malignant potential?

Page 37: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon cancer – Sporadic

Adenoma to carcinoma:

Page 38: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Cancer in a polyp…

Page 39: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon cancer - presentation Bleeding Anemia Guaiac + Obstruction Screening

Page 40: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon cancer – pre-op evaluation

Family history! CEA Colonoscopy

Tissue for diagnosis Evaluate remainder of colon

Abdominal/Pelvic CT scan ? PET scan

Page 41: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.
Page 42: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon cancer - staging

Page 43: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon cancer – adjuvant therapy

Stage III 5-FU / Leucovorin based

? Stage II with adverse features Poorly differentiated LVI Obstruction/Perforation

Page 44: Basic Science – “Large Bowel”. Anatomy Right colon Transverse colon Left colon Descending Sigmoid Rectum What defines the transition between the sigmoid.

Colon cancer - surveillance

No survival benefit with aggressive surveillance strategies!