Diseases of Large Bowel. Diverticulosis of the Colon I. Diverticula of the colon are acquired herniations of colonic mucosa protruding through the.

Diseases Diseases ofof

Large BowelLarge Bowel

Diverticulosis of the Colon I.

Diverticula of the colon are acquired Diverticula of the colon are acquired herniations of colonic mucosa herniations of colonic mucosa protruding through the circular muscle protruding through the circular muscle and the wall of large bowel.and the wall of large bowel.

Localisation -Localisation - usually in the left part of usually in the left part of the large bowel ( sigmoid colon is the large bowel ( sigmoid colon is involved in 90% cases), but they can involved in 90% cases), but they can occur everywhere in large boweloccur everywhere in large bowel

Ethiology -Ethiology - muscular incoordination and muscular incoordination and hypertrophy resulting in increasing hypertrophy resulting in increasing segmentation and intraluminal pressure.segmentation and intraluminal pressure.

Diverticulosis of the Colon II.

FrequencyFrequency of the disease is increasing of the disease is increasing with the age.with the age.

Clinical featuresClinical features - the disease is very - the disease is very often asymptomatic, or there are some often asymptomatic, or there are some non specific symptoms due to disordered non specific symptoms due to disordered colonic function ( f.e. distension, colonic function ( f.e. distension, flatulence ) flatulence )

But the symptoms of the complications But the symptoms of the complications are usually very serious.are usually very serious.

Diverticulosis of the Colon III.

DiagnosisDiagnosis

clinical examinationclinical examination X-ray picture with barium enemaX-ray picture with barium enema UltrasonographyUltrasonography ColonoscopyColonoscopy Cystoscopy, gynecological Cystoscopy, gynecological

examinationexamination

Diverticulosis of the Colon IV.

Complications:Complications:

inflammation ( diverticulitis )inflammation ( diverticulitis ) perforationperforation bleedingbleeding postinflammatory stenosispostinflammatory stenosis obstructionobstruction fistula with the surrounding organs fistula with the surrounding organs ( urinary bladder, vagina ) ( urinary bladder, vagina )

Diverticulosis of the Colon V.

TreatmentTreatment

antibiotics, bed rest, liquid diet, antibiotics, bed rest, liquid diet, spasmolytics ( acute attack of diverticulitis )spasmolytics ( acute attack of diverticulitis )

operation – 10% patients require operationoperation – 10% patients require operation

one stage resectionone stage resection

two stage procedures - colostomy two stage procedures - colostomy

- exteriorisation of the affected bowel- exteriorisation of the affected bowel

- - Hartman´s procedureHartman´s procedure

- fistulas – resection of the bowel and - fistulas – resection of the bowel and

closure of the fistula closure of the fistula

Ulcerative Colitis I.

Aethiology is inknown – possibly is Aethiology is inknown – possibly is linked with emotional stress, maybe linked with emotional stress, maybe it is auto-immune disease, secondary it is auto-immune disease, secondary infection maybe plays some role.infection maybe plays some role.

young peopleyoung people Pathology – in 95% cases the disease Pathology – in 95% cases the disease

starts in rectum and spreads starts in rectum and spreads proximally.proximally.

the disease is characterised by the disease is characterised by appearance of multiple ulcers, appearance of multiple ulcers, sometimes they are discrete sometimes they are discrete sometimes there is a lot of ulcers.sometimes there is a lot of ulcers.

Ulcerative Colitis II.

Clinical featuresClinical features : watery diarhoe occuring : watery diarhoe occuring day and night,day and night, rectal discharge of rectal discharge of

mucusmucus pain, bleedingpain, bleeding 2 types : 1. fulminating type 5% - 2 types : 1. fulminating type 5% - temperature, diarhoe temperature, diarhoe

containing containing blood mucus and pusblood mucus and pus 2. chronic type 95%2. chronic type 95%

Ulcerative Colitis III. Treatment :Treatment : medicaments medicaments

(antibiotics,corticosteroids, imunossupresive (antibiotics,corticosteroids, imunossupresive drugs , drugs ,

Remicade ? )Remicade ? )

Indications for surgical treatment:Indications for surgical treatment: 1. to save life ( perforation, toxic 1. to save life ( perforation, toxic

megacolon )megacolon ) 2. local complications, general 2. local complications, general complications ( liver changes, skin lesions, complications ( liver changes, skin lesions, renal disease, sclerosis cholangitis)renal disease, sclerosis cholangitis) 3. risk of carcinoma3. risk of carcinoma

The method of choice is The method of choice is restorative proctocolectomyrestorative proctocolectomy

Toxic megacolon I.Toxic megacolon I. CClinical term for an acute toxic colitis with linical term for an acute toxic colitis with

nonobstructive colonic dilatation larger nonobstructive colonic dilatation larger than 6 cm and signs of systemic toxicitythan 6 cm and signs of systemic toxicity

The dilatation can be either total or The dilatation can be either total or segmental. segmental.

- - potentially lethal conditionpotentially lethal condition

TheThe inflammation extending beyond the inflammation extending beyond the mucosa into the smooth-muscle layers mucosa into the smooth-muscle layers and serosa.and serosa.

Toxic megacolon II.Toxic megacolon II.

SSymptoms:ymptoms:

High feverHigh fever Abdominal pain and tendernessAbdominal pain and tenderness TachycardiaTachycardia DehydrationDehydration

Mortality : Mortality : 5 – 10 %5 – 10 %

Toxic megacolon III.Toxic megacolon III.

Three Three main goals:main goals:

1. 1. reduce colonic distension to prevent reduce colonic distension to prevent perforation perforation

2. 2. correct fluid and electrolyte disturbancescorrect fluid and electrolyte disturbances

3. 3. treat toxemia and precipitating factorstreat toxemia and precipitating factors

Conservative treatment: fluid replacement, Conservative treatment: fluid replacement, antibiotics, steroids, remicade, nasogastric antibiotics, steroids, remicade, nasogastric tube, bowel resttube, bowel rest

Surgical treatment : subtotal or total colectomy.Surgical treatment : subtotal or total colectomy.

Tumors of Large BowelTumors of Large Bowel

A. Benign tumors

B. Malignant tumors

Benign tumors I.

2 types2 types - tubular adenoma - - tubular adenoma - pedunculatedpedunculated

villous adenoma - sessilevillous adenoma - sessile

They have malignant potential ,so they They have malignant potential ,so they should be removed.should be removed.

Malignancy depends on size and type Malignancy depends on size and type

of adenoma.of adenoma. More dangerous are large and villous More dangerous are large and villous

adenomas adenomas

Benign tumors II.

ComplicationsComplications - bleeding, - bleeding,

- diarrhoe, hypokalaemia - diarrhoe, hypokalaemia

/ villous // villous /

Treatment Treatment - fibre endoscopic removal - fibre endoscopic removal

- operation - partial colon - operation - partial colon

resection (very large polyps )resection (very large polyps )

Familial adenomatous polyposis Familial adenomatous polyposis (FAP)(FAP)

hereditary disease . hereditary disease .

The gene for FAP is on the long arm The gene for FAP is on the long arm

of chromosome 5 and is called the APC of chromosome 5 and is called the APC gene.gene.

There are a lot of polyps / hundreds/ at There are a lot of polyps / hundreds/ at the colon and rectal mucosathe colon and rectal mucosa

very strong malignant potentialvery strong malignant potential

Diagnosis : colonoscopy, genetic testsDiagnosis : colonoscopy, genetic tests

Familial adenomatous polyposis Familial adenomatous polyposis II.II.

TreatmentTreatment is surgical is surgical

1. colectomy + ileo-rectal anastomosis1. colectomy + ileo-rectal anastomosis

2. total colectomy with permanent 2. total colectomy with permanent ileostomyileostomy

( cancer )( cancer )

3. 3. „ restorative proctocolectomy“„ restorative proctocolectomy“

- proctocolectomy with ileal pouch – - proctocolectomy with ileal pouch – anal anal

anastomosisanastomosis

Carcinoma of the Colon I. Colon carcinoma originating in the Colon carcinoma originating in the

epithelial cells of the colonepithelial cells of the colon M : W = 3 : 2M : W = 3 : 2 25 % of cases present as emergencies 25 % of cases present as emergencies

with intestinal obstruction or perforation with intestinal obstruction or perforation and peritonitisand peritonitis

The spread of carcinoma – local spread The spread of carcinoma – local spread ( penetration through intestinal wall( penetration through intestinal wall to surrounding organs )to surrounding organs ) lymphatic spread to regional or distant lymphatic spread to regional or distant lymphonodeslymphonodes spread by the blood-stream to liverspread by the blood-stream to liver

Carcinoma of the Colon II.

Typing, Grading, StagingTyping, Grading, Staging Typing Typing - the type of tumor – - the type of tumor – adenocarcinoma - 90%adenocarcinoma - 90% „ „Signet ring cell “ Signet ring cell “

carcinomacarcinoma GradingGrading - well differential carcinoma well differential carcinoma - moderate differential- moderate differential - poor differential- poor differential StagingStaging - spread of the carcinoma spread of the carcinoma Dukes classificationDukes classification TNM classificationTNM classification

Carcinoma of the Colon III.

Clinical FeaturesClinical Features carcinoma of the left side (75% cases): carcinoma of the left side (75% cases):

pain, alteration of bowel habit pain, alteration of bowel habit ( irregularity ), palpable tumor, bleeding( irregularity ), palpable tumor, bleeding

carcinoma of the right side : aneamia, carcinoma of the right side : aneamia, the presence of a mass in the right iliac the presence of a mass in the right iliac fossafossa

DiagnosisDiagnosis endoscopy - sigmoidoscopy, colonoscopyendoscopy - sigmoidoscopy, colonoscopy radiography with the barium enemaradiography with the barium enema ultrasonographyultrasonography CTCT

Carcinoma of the Colon IV.

ComplicationsComplications - obstruction - obstruction

- perforation with stercoral peritonitis- perforation with stercoral peritonitis

- bleeding - bleeding

TreatmentTreatment - operation - operation

A. radical A. radical

B. paliative : intestinal by-pass, B. paliative : intestinal by-pass,

colostomycolostomy

Clasic or laparoscopic proceduresClasic or laparoscopic procedures

Right side Right side hemicolectomyhemicolectomy

Left side hemicolectomyLeft side hemicolectomy

Resection of rectumResection of rectum

Abdominoperineal Abdominoperineal rescetion of rectumrescetion of rectum