colon lecture John R Pender, M.D. Dept. of Surgery BSOM, East Carolina University

Patient 58 y/o with wt loss and abd pain 58 y/o with wt loss and abd pain

symptoms Wt loss Wt loss Change in caliber of stools Change in caliber of stools Blood in stool/ FOBT (fecal occult blood test) Blood in stool/ FOBT (fecal occult blood test) Anemia Anemia Abd pain Abd pain constipation constipation

Work up H&P H&P CEA (carcinoembryonic antigen) CEA (carcinoembryonic antigen) CBC CBC CXR CXR Colonoscopy Colonoscopy CT scan abd/pelvis CT scan abd/pelvis

Polyps Sessile vs pedunculated Sessile vs pedunculated Hyperplastic Hyperplastic Adenoma Adenoma Malignant Malignant –Villous –tubulovillous

Follow up after polypectomy Q 6 months for first year, 3 and 5 years. Q 6 months for first year, 3 and 5 years. Once clear at five years, repeat Q 5 years Once clear at five years, repeat Q 5 years HNPCC (hereditary nonpolyposis col ca) HNPCC (hereditary nonpolyposis col ca) –Average # polyps ~80% cancer by 45% FAP (familial adenomatous polyposis) FAP (familial adenomatous polyposis) –Cancer by age 40 ~100% –5% cancer by age 20

CHEMO? 5-FU and leucovorin 5-FU and leucovorin Stage III (+/- poorly differentiated stage II) Stage III (+/- poorly differentiated stage II) –colon Sage II and III Sage II and III –rectal ca

XRT Not for colon Not for colon Only helps with local control in rectal cancer if T3 or greater Only helps with local control in rectal cancer if T3 or greater Does not improve survival Does not improve survival

Post operative surveillance

Patient 60y.o. with BRBPR 60y.o. with BRBPR –What do you do

GI BLEED

Patient 45 y/o with left LQ pain, fever 45 y/o with left LQ pain, fever –What do you do

w/u CBC CBC U/A U/A AAS AAS CT CT Contrast enema Contrast enema

Diverticular Disease

Management Iv fluid Iv fluid antibiotics antibiotics npo npo Resuscitation Resuscitation Antibiotics Antibiotics Hartmann’s procedure Hartmann’s procedure –Blind rectal pouch&colostomy Operation Operation –free air –obstruction –Abscess –Uncontrolled sepsis

Indications for Surgery Perforation Perforation Fistula Fistula Abscess Abscess Obstruction Obstruction Age < 40 Age < 40

Patient 30 y/o with anal pain 30 y/o with anal pain –What do you do? –Examine pt.

Differential of Anal pain Hemorrhoids Hemorrhoids abscess abscess Fissure Fissure Fistula-in-ano Fistula-in-ano Codyloma Codyloma Puritis ani Puritis ani Cancer Cancer FB FB

Hemorrhoid TX First and second degree/ thrombosed First and second degree/ thrombosed –Sitz bath –Bulk laxative –topical analgesia Acute thrombosed, third/fourth degree Acute thrombosed, third/fourth degree –Hemorrhoidectomy

hemorrhoidectomy

Fissure cycle of sphincter spasm cycle of sphincter spasm Nitrates, Botox, digital stretch Nitrates, Botox, digital stretch Bulky laxative Bulky laxative Water Water Sitz baths Sitz baths

Fistula

Patient 23 y/o with R LQ pain, fever what else do you want know? bowel habits

operation You operate for presumed appendicitis and find an inflamed cecum and terminal ileum with creeping fat. You operate for presumed appendicitis and find an inflamed cecum and terminal ileum with creeping fat. –What do you do?

Inflammatory bowel diseases Crohn’s Crohn’s –Mouth to anus –Skip areas –Perianal –Granulomatous/full thickness –Fistula, stricture –Extraintesatinal dz Ulcerative Colitis Ulcerative Colitis –COLON AND RECTUM ONLY –Toxic megacolon –Rectal bleeding –Higher risk of colon cancer

Indications for surgery Obstruction Obstruction Bleeding Bleeding Abscess/perforation Abscess/perforation cancer cancer Fistula Fistula Megacolon unresponsive Megacolon unresponsive Unresponsive/intolerance to medical management Unresponsive/intolerance to medical management

Associated SX Erythema nodosum Erythema nodosum Pyoderma gangrenosum Pyoderma gangrenosum Aphthous ulcers Aphthous ulcers Episcleritis Episcleritis Ankylosing spondylitis Ankylosing spondylitis Sclerosing cholangitis Sclerosing cholangitis

Patient 80 y/o nursing home pt with distend abdomen, feculent emesis, obstipation 80 y/o nursing home pt with distend abdomen, feculent emesis, obstipation –What do you do?

w/u IVF IVF NG NG AAS AAS CBC, ect CBC, ect

Differential of colonic obstruction Cancer Cancer Adhesions Adhesions Hernia Hernia Volvulus Volvulus Ogilvie’s pseudo-obstruction Ogilvie’s pseudo-obstruction