Diseases of Colon

Worrawit Wanitsuwan , MD.

Department of Surgery
Prince of Songkhla University.

Outline Content

Anatomy
Physiology
Diseases of colon
Diverticular disease
Massive Lower GI Bleeding
Acute colonic obstruction
Colon cancer

Transverse colon

Anatomy
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cecum

Sigmoid
colon

Anatomy

Histology : 4 layers
Teniae coli
Haustra coli

plicae semilunares

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Appendices epiploicae

Anatomy

Arterial blood supply

Superior mesenteric artery( SMA )
Inferior mesenteric artery( IMA )
Marginal artery of Drummond
Arc of Riolan

Anatomy

Lymphatic drainage
Epicolic group
Paracolic group
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Intermediate
group
Main group ( SMA IMA)

Anatomy

Nerve supply
Sympathetic :T7 T12 Supply Rt.colon
L1-L3 Supply Lt.colon and Rectum
inhibit peristalsis

Anatomy

Nerve supply
Parasympathetic : S 2-4 (Nervi ergentes)
Vagus nerve supply Right colon
Sacral nerve supply distal colon

Stimulate Peristalsis

Physiology

Normal colonic function

Absorb : water, sodium, chloride,
short-chain fatty acid, ammonia
Secrete : potassium, bicarbonate, mucus
Digest : carbohydrates, proteins

Physiology

Colonic microflora
Bacteroides : dominant bacteria
1011 - 1012 bacteria / gm. of feces
E.coli 108 1010 bacteria / gm. of feces
breakdown CHO, protein
produce Vit.K

Physiology

Colonic gas
N2 , O2 , CO2 , H2 , CH4
99% of all gas in gut
N2 , O2 : swallowing air
CO2 , H2 , CH4 : bacterial fermentation
* H2 , CH4 : Combustible gas
Adequate bowel cleansing
Polyethylene glycol No Burst

Physiology

Motility

Retrograde movement
Segmental contractions
Mass movement

Physiology
Factors that effect colonic motility
- Emotion
- Exercise
- Sleep
- Diet : Polysaccharide, cellulose
- Gut hormone : Cholecystokinin
- Drug : Morphine
- Neurogenic control

Diseases of Colon

Diverticulosis

Abnormal sac or pouch protruding from the

wall of hollow viscus organ

Diverticulum

Mesenteric site and

thickened colonic wall
Most common : sigmoid

colon

Diverticular Disease

Definitions
Diverticulum - outpouching from hollow organ
Diverticulosis - presence of diverticula
Diverticulitis - inflammation of diverticula
Diverticular disease presence of diverticula
with symptoms presentation
Complicated diverticular disease presence
diverticulum with perforation , fistula ,
obstruction or bleeding

Diverticular Disease

Epidemiology
Sex (M:F) as 2: 3
Age : More common with increasing age
< 40 incidence 2-29 %
> 60 incidence 60 %
> 80 incidence 70 %
95% in the sigmoid

Diverticular Disease

Pathogenesis
Increased intraluminal pressure + segmentation
Herniation of mucosa through muscular wall,
covered by serosa
Occur where vasa recta penetrate bowel wall
Weakness of colonic walls
Associated with low-fiber diet
Dense packed diverticulosis

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Colonoscopic view

Diverticulosis

Diverticulosis

Diverticulitis
Infection associated with diverticulum

Peridiverticulitis
LLQ pain, bowel habit change,
fever with chills
Tenderness over left lower abdomen
Tender mass at LLQ phlegmon or abscess
Abdominal distention : ileus, obstruction
Pelvic tenderness by DRE

Diverticulitis

Uncomplicated 85%
Complicated 15%
Abscess
Perforation
Fistula
Stricture/obstruction
(Bleeding)

Diverticulitis

Investigation

Limited sigmoidoscopy

CT abdomen

Ultrasonography
Contrast enema

Diverticulitis

CT Scan
Diagnostic of choice
Stages extent of extramural inflammation
Prognostic significance

Sensitivity 90-95%, specificity nearly 100%

Diverticulitis : Staging of severity

Diverticulitis - perforation of diverticulum

Spectrum/staging of inflammation
Hinchey stages - I-IV
I - Localized inflammation : MM < 5%
II - Pericolic abscess : MM < 5%
III - Purulent peritonitis : MM 13%
IV - feculent peritonitis : MM 43%

Diverticulitis

Treatment
Non-operative treatment No peritonitis

Bowel rest, intravenous fluid

Intravenous broad-spectrum antibiotics
Investigation 3 wk. later( colonoscopy, BE )
Abscess : Percutaneous drainage( PCD )

Operative treatment

Peritonitis
Recurrence

Special circumstances

Acute Diverticulitis
with
Immunocompromise
d
Can not exclude
malignancy
Diverticulum more
than 4 cm

Surgery

Acute Diverticulitis with

Right side diverticulitis
Young patients (< 40-50
years old )
Rectal Diverticulum

Conservative

Massive Lower GI bleeding

Incidence of GI bleeding

UGIB
40-50 episodes/100,000/year
mortality 6-10%

LGIB
20-27 episodes/100,000/year
mortality 4-10%

Lower GI bleeding

Any bleeding distal to the Ligament of Treitz

blood per rectum
Hematochezia
bright or maroon blood
10-15% cause from upper GI Bleeding

Melena
Stool occult blood

Lower GI bleeding

Melena : may be upper or lower source

> 200 mL blood in stomach, or
150 mL blood in cecum
Hematochezia : usually lower source; 11% from upper source.
> 100 mL blood in Lt colon, or
> 150 mL blood in Rt colon, or
> 1000 mL upper bleed ( orthostatic =/> 10 mmHg )

Lower GI bleeding

LGIB male > Female

Incidence in age > 80 :
In age > 30 years old
ratio as 200 : 1
Most common :
Colonic Diverticulosis

Cause of acute massive Lower GI bleeding

Cause

Prevalence

Upper GI tract
Peptic ulcer disease
Gastritis/duodenitis
Esophageal varices
Mallory-Weiss tear
Esophagitis
Gastric cancer
Dieulafoys lesion
Gastric arteriovenous malformations
Portal gastropathy

40-79%
5-30%
6-21%
3-15%
2-8%
2-3%
<1
<1
<1

Cause of acute massive Lower GI bleeding

Cause
Small bowel
Angiodysplasia
Jejunoileal diverticula
Meckels diverticulum
Neoplasms/lymphomas
(benign and malignant)
Enteritis/Crohns disease
Aortoduodenal fistula in patient
with synthetic vascular graft

Prevalence
70-80%

Cause of acute massive Lower GI bleeding

Cause
Large bowel
Diverticular disease
Arteriovenous malformations (Angiodysplasia)
Colitis (Ischemic colitis)
Colonic neoplasms /
post-polypectomy bleeding
Anorectal causes (Hemorrhoid)
Colonic tuberculosis

Prevalence
17-40%
2-30%
9-21%
11-14%
4-10%
-

Colonoscopy of Diverticula bleeding

Colonic
diverticula

Colonic
diverticula

Colonic
diverticula

(Non bleeding)

(bleeding)

(Non bleeding
visible vessel)

Colonoscopy of angiodysplasia
discrete (<5mm.)
hyperemic lesion
with frond-like or
scalloped edges

must not confused with

traumatic ecchymosis
(see on withdrawal the scope)

Internal Hemorrhoids !!!!

Internal hemorrhoids
Non bleeding

Internal
hemorrhoids
(bleeding)

Approach to LGIB

How severe?
high risk vs low risk

Where is the bleeding site?

upper, HBP
colon : Rt.side, Lt. side
anorectum

What is the cause?

angiodysplasia, diverticulosis,
inflammation&infection, cancer&polyps, others

Severity
BLEED criteria
(predicts outcome for any GI bleeding :UGIB&LGIB)

B
L
E
E
D

ongoing Bleeding
Low systolic blood pressure
Elevated prothrombin time
Erratic mental status
unstable comorbid Disease

Kollef MH Crit care Med 1997

odd ratio

Severity of
LGIB
252 Pts. with LGIB
(mean age 66 yr.)

123 Pts (49%) severe LGIB

24 factors were evaluated
7 factors were significant
risk

Lisa LS, Arch Intern Med.

2003

Approach to LGIB

How severe?
high risk vs low risk

Where is the bleeding site?

upper, HBP
colon : Rt.side, Lt. side
anorectum

What is the cause?

angiodysplasia, diverticulosis,
inflammation&infection, cancer&polyps, others

Site of bleeding

Knowing the site of bleeding is more

important than knowing the cause

Knowing site of bleeding

Hx
- age
- hematemesis
- bright red blood
- maroon blood
- melena

bedside examination
- PR
- NG tube lavage EGD scopy
- proctoscopy
- rigid sigmoidoscopy

investigation

- Colonoscopy
- Radionuclide scan
- Angiogram
- Barium enema
- MDCT
- Capsule enteroscopy

Colonoscopy

First Choice Investigation

identify bleeding site > 70%
electively or urgently
can perform tissue biopsy
can perform therapeutic procedure
injection, coagulation, band ligation,hemoclipping

Urgent colonoscopy
(within 6-12 hr.)

purge PEG bowel preparation

5-6 litre of PEG oral or NG feed within 3-4 hr.
1 hour later colonoscopy

not increasing rebleeding rate

not increasing septic complication
may recommend as initial diagnostic test
for most circumstance

Radionuclide scans

Technetium-99 (99Tc) sulfur colloid scan

short half-life and rapid elimination ,
scans can be taken for the few minutes
that the colloid is in circulation.

99mTc pertechnetatelabeled autologous red

blood cell scan (TRBC scan).
abdominal images can be obtained for
up to 24 hours, which is advantageous
in patients with intermittent bleeding.

TAGGED RBC SCAN

Bleeding in small bowel

Bleeding in Right side colon

Indication for angiogram

Indications
Identification of Gastrointestinal Bleeding site
Preoperative evaluation for occult GI Bleeding
Criteria may include
Early positive Tagged Red Cell Scan
Frequent blood transfusion required
Hemodynamic compromise

ANGIOGRAPHY
Advantages

accurate localization is

specificity - 100%
sensitivity

~ 47% (acute bleeding)

~ 30% (recurrent)

therapeutic intervention

Disadvantages
requires active bleeding
> 0.5 cc/min
invasive
complication of angiography
ischemia
infarction

ANGIODYSPLASIA

Dynamic enhanced helical CT scan

helical CT scan at 0.5 & 5 min. after iv. contrast
4 in 5 show pooling of contrast media (identify bleeding site)
less invasive
can perform within 15 min.
maybe useful in active LGIB

Multidetecter row computed tomography ( MDCT )

24/26 patients can identify point of bleeding
Adjunts with interventional angiogram or surgery
Yamaguchi T Abdom Imaging 2003
Jaeckle T,et al Eur Radiology 2008

Barium enema

No role in hematochezia or bloody stool

May effect to angiogram or colonoscopy
Last choice for diagnosis LGIB

Small bowel evaluation

Obscure Gastrointestinal bleeding

Small bowel tumor or abnormal vessel

Capsule endoscopy

Expensive and Need Expert

Sensivity about 92%

Diagnostic test for LGIB

Technique
Radionuclide
scan

Advantage
Noninvasive
High

sensitivity

Disadvantage
May

need to be done during active

bleeding
Does not localized site of bleeding

Accurate

Angiography

localization
Variable sensitivity
Does not require bowel prep.
Has to be perform during active
Can use catheter for vasopressin bleeding
infusion or embolization
Complication of angiography
Poor

Colonoscopy

visualization in unprepared
colon
Precise localization
Risks of sedation in acutely
Potential therapeutic intervention
bleeding patient
Variable sensitivity

Management of LGIB

Endoscopic management
Intervention angiography
Surgery

Management of LGIB

Endoscopic management
Intervention angiography
Surgery

Endoscopic management

Role in bleeding from diverticular

Clipping or injected under endoscopic
Unlocated and Recurrent Bleeding
May be further study

Management of LGIB

Endoscopic management
Intervention angiography
Surgery

Intervention angiography
Indication angiogram

Identification of Gastrointestinal Bleeding site

Preoperative evaluation for occult GI Bleeding

source

Criteria may include

Early positive Tagged Red Cell Scan

Frequent blood transfusion required
Hemodynamic compromise

Intervention angiography

Active bleeding
Superselective embolization
Methylene blue for Guide
Complication : Gangrene or peritonitis
Laparoscopic diagnosis : 48-72 hrs

MESENTERIC CIRCULATION

ANGIOGRA
M

EMBOLIZATION

Management of LGIB

Endoscopic management
Intervention angiography
Surgery

Surgery for LGIB

10-20% need Sx
pre-op localization is very important
surgery without bleeding localization should be avoid
lithotomy position
directed segmental resection is preferred
subtotal colectomy if no bleeding site identified

Indication for operation in

Acute lower Gastrointestinal Hemorrhage
o

o
o

Greater than 1500 ml of blood transfused is necessary

to resuscitate the patient and bleeding continues
2,000 ml of blood is necessary to maintain
vital signs during a 24-hour peroid
Bleeding continues for 72 hours
Rebleeding (Signifficant) occurs within
one week of initial cessation

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Surgery for LGIB

LGIB 77 patients
Limited colon resection (LCR) 50 patients
Total or subtotal colon resection (TCR) 27 patients
Recurrent bleeding LCR > TCR
Complication : not different significant

Farner R,Am J surg 1999;178:587-

91

Outcome of blind resection

Procedure

Rebleed

Mortality

Right colectomy
(n=78)

19%

5%

Left colectomy
(n=92)

38%

32%

Total colectomy
(n=94)

2%

16%

Milewski Ann R Coll Surg Engl

1989

Option for Sx

Segmental resection
(know site of bleeding)

subtotal colectomy
(with ileorectal anastomosis or ileostomy)

blind segmental resection; eg. rt.hemicolectomy

(not recommend because high rebleed; 35-50%)

intraoperative colonoscopy
(not popular; may not helpful)

multiple enterotomy or divided colostomy

(usually unsuccessful)

severe hematochezia
initial evaluation and resuscitation
NG tube
aspiration

bile; no blood

all other
negativ
e
exam

colonoscopy
source
identif
y
Rx as
appropiate

negative
exam

bleeding
stop?

y
e
small bowel study
s

EGD

UGI
sourc
e

not
Rx as
possible
appropiate
due to
severity
n of
o bleedinarteriography
g(+ nuclear scan first)

Adapted from Zuccaro G, Am J Gastroenterol

1998

Colon cancer

Colon cancer

Etiology
Genetic predisposition
Environment factors
Premalignant conditions

Genetic predisposition
Colorectal cancer is a genetic disease
Familial Adenomatous Polyposis( FAP )

Autosomal dominant
Diagnosis
1. >100 adenomatous polyps in large bowel
2. Detection of colonic adenomas in member of FAP family

Familial adenomatous polyposis (FAP)

Develop cancer 100% in 10 year

Total proctocolectomy

Hereditary nonpolyposis colorectal cancer

Autosomal dominant inheritance pattern

Mismatch repaired gene
Polyps tend to be smaller than found in FAP
70 % CRC occur at the splenic flexure.
40% Synchronous or metachronous lesion
Pathologic : Poorly differentiation
Risk for extracolonic cancer :endometrium
ovary, stomach, small bowel, pancreas, brain

AMSTERDUM CRITERIA II
At least three relatives with an HNPCC-associated cancer
[ Colorectal cancer, cancer of the endometrium, small bowel,
ureter, or renal pelvis ]

Disease present in at least two successive generation

One individual first degree relative of the other two
Age at diagnosis < 50 years in one of the relatives
Familial adenomatous polyposis syndrome and the other
polyposis syndromes ruled out
Tumor should be verified by pathological examination

Environment factor

Premalignant conditions
Ulcerative colitis :

10 years
(Pancolitis)
after 20 years

2 % per year after

8 % per year
18 % per

year after 30 years

Crohns disease : 7% per year after 20
years

Colitis

Normal colon

Mild

Severe

ulcerative
colitis

ulcerative colitis

Colitis

Polyps

( gastrointestinal mucosa )

Adenoma

Occur throughout the entire bowel

Adenoma have malignant

potential

Genetic Progression to Carcinoma

Adenoma

Risk for adenoma turn to carcinoma

Polyps with Villous adenoma
Polyps with size > 2 cms
Polyps with duration after found polyps

Cancer screening

Detect Pre-cancerous leision or Early cancer

Non definite diagnosis
Recommended screening test
FOBT
Flexible sigmoidoscopy
Air contrast barium enema
Colonoscopy

National Comprehensive
Cancer Network (NCCN)

Screening for colorectal cancer

High risk group
1. Age > 50 years
2. Premalignant condition

UC > 10 years
Crohns disease with stricture
FAP
HNPCC
Previous history of colonic polyps

3. Family history of colorectal cancer or polyps

Colon cancer
Signs and Symptoms
Right colon

Do not change in bowel habit

Occult bleeding
Abdominal mass

Left colon

Lower abdominal pain

Bowel habit change
Obstruction

Colon cancer
Diagnosis
LFT : Increase ALP R/O liver metastasis
CXR : R/O pulmonary metastasis
BE : Demonstrate primary lesion and
synchronous lesion ( 3-5% )

Diagnosis
Carcinoembryonic antigen (CEA) test
Elevated in tumors of lung, breast, stomach,
pancreas, smoker, cirrhosis, pancreatitis,
renal failure and UC
- Not useful for screening
- Useful in F/U for detection tumor
recurrence or metastasis

Diagnosis
Colonoscopy : Most accurate
evaluted synchronous
carcinomas and polyps
CT abdomen : Extent of invasive of primary tumor
: Search for intraabdominal metastasis

Colon cancer

National Comprehensive Cancer Network (NCCN)

Cancer Stage Grouping

Stage 0: Tis, N0, M0:

The cancer is in the
earliest stage. It has not
grown beyond the inner
layer (mucosa) of the colon
or rectum. This stage is also
known as carcinoma in situ
or intramucosal carcinoma.

Cancer Stage Grouping

Stage I: T1, N0, M0, or T2, N0, M0:
The cancer has grown through the
mucosa into the submucosa or it may
also have grown into the muscularis
propria, but it has not spread into
nearby lymph nodes or distant sites.

Cancer Stage Grouping

Stage IIA: T3, N0, M0:

The cancer has grown through
the wall of the colon or rectum
into the outermost layers.

Stage IIB: T4, N0, M0:

The cancer has grown through
the wall of the colon or rectum
into other nearby tissues or
organs.

Cancer Stage Grouping

Stage IIIA: T1-2, N1, M0:
The cancer has spread to 1-3
nearby lymph nodes.
Stage IIIB: T3-4, N1, M0:
The cancer has grown through the
wall of the colon or rectum has
spread to 1-3 nearby lymph nodes.
Stage IIIC: Any T, N2, M0:
The cancer has spread to 4 or
more nearby lymph nodes

Cancer Stage Grouping

Stage IV: Any T, Any N, M1:
The cancer can be any T, any N,
but has spread to distant sites such
as the liver, lung, peritoneum (the
membrane lining the abdominal
cavity), or ovary.

Prognosis
Stage
Stage
Stage
Stage

I
II
III
IV

5 - year
survival
90 %
60 - 80 %
20 - 50 %
<5%

THERAPY FOR COLORECTAL

CANCER

Surgical therapy
Bowel margin > 5 cm
Extent of lymphatic resection
and vascular ligation
Adjacent organ invasion en bloc resection

ADJUVANT THERAPY FOR

COLON CANCER

Chemotherapy : Improve survival

Stage 3 ( N1) : clear

Stage 2 ( N0) : high risk of recurrence

High risk stage 2 : T4 lesion

: positive or closed margin
: perforation
: adherence
: LN < 12
: anuploid
: T3 + unfavorable histo
Radiation therapy : limit success

Long - term F/U

70 % recurrence in 2 years
90 % recurrence in 4 years

Surveillance

Physical examination
Lab investigation
( CBC , CEA , LFT , CXR )
Every 3 months for 2 years
Every 6 months for 2 years
After that once time / year

Surveillance

Colonoscopy
after surgery 3-6 months
Every years for 4 years
After that every 3-5 years

Acute colonic
obstruction


o
o
o

Acute colonic
Pathogenesis
obstruction
Hypovolumia
Bacterial translocation
Collagen degradation

What is your
differential
diagnosis?

Differential diagnosis

Malignancy
Volvulus
Diverticulitis
Psuedocolonic obstruction (Ogilvies syndrome)
Inflammatory bowel disease and infection
(Toxic megacolon)

Investigation

Acute abdomen series

Contrast enema
CT scan
Endoscopy

Acute abdomen series

Colonic & cecal dilatation, no rectal contents

Sigmoid volvulus

What finding should be obtained

from the X-ray?

Mechanical or functional obstruction.

Level of obstruction.
Complete or incomplete obstruction.
Closed loop obstruction or not.
Competency of IC valve.
Complication of obstruction.

Investigation

Contrast enema
Exclude from Colonic
pseudo-obstruction
Water soluble single
contrast enema better
Evaluated site of
decompress obstruction
: Sens 84% and spec 72%

Investigation

CT scan
Identified point obstruction
Cause of obstruction
Staging and metastatic disease
Other cause of obstruction :
diverticulitis or intussusceptions

Investigation

Endoscopy (Sigmoidoscopy,Colonoscopy)
Location
Biopsy
Diagnosis : Benign stricture

Decompression ; by tube and stent success rate 96%

Synchronous lesion

Preoperative management

NPO / NG tube suction for decompression

IV fluid resuscitation
Foleys catheter and monitor urine output
Broad spectrum IV antibiotic
and DVT prophylaxis

Patient should be taken to

surgery as soon as patient stable

Malignant colonic obstruction

Obstructing colorectal cancer

10-30% of CRC patients present

with colonic obstruction
Occur in left side 70%
Overall mortality rate 15-20%
Morbidity rate 40-50%

Predictive factors for

postoperative mortality

Age > 70 years

ASA III-IV
Damage of proximal colon
and/or associated peritonitis
Preoperative renal failure
( Serum Cr > 1.36 mg%)

Management of Malignant colonic

obstruction

Operative & Non-operative

management

Management
Non operative management :
( without signs of perforation,peritonitis or close loop obstruction )

Bridging for elective surgery

Palliative treatment

Decompression tubes

Laser therapy
Self-expanding metal stents
(SEMS)

Stabilization and Prepare before surgery

Self-expanding metal stents (SEMS)

Contraindication in
- Suspect perforation
- Tumor below 4 cms from anal verge

Surgical management

Right & Left side management

Obstructing lesions to the right side or proximal

transverse colon
Right or extended right hemicolectomy

Lesion obstructing the distal transverse or left

colon or sigmoid colon
Left hemicolectomy or sigmoidectomy with
colostomy and mucous fistula or Hartmanns pouch

Obstructing lesion at left side colon with

perforation of cecum
Subtotal colectomy with primary anastomosis

Volvulus
Twisting of an air-filled
segment of bowel about
its narrow mesentery
Sigmoid, cecum,
transverse colon

Sigmoid volvulus

90% of all volvulus

Older, neurogenic disorders
Redundant sigmoid colon
narrow-based mesocolon
90% have features of LBO

Sigmoid volvulus
Investigation
Plain abdomen
Inverted U-shaped

Sigmoid volvulus

Investigation
Water-soluble
contrast enema
Birds beak
deformity

Sigmoid volvulus

Treatment
Peritonitis : Emergency operation

- sigmoid resection +/- colostomy

- sigmoidopexy

No peritonitis : - Rigid sigmoidoscopy

- Rectal tube decompression
- Elective sigmoid resection

Volvulus
Cecal volvulus
: Plain film
: Emergency Rt. hemicolectomy
Transverse colon volvulus
: + Colonoscopic detortion
: Emergency resection

OGILVIES SYNDROME

Acute colonic pseudoobstruction

Colonic
obstruction without

mechanical obstruction
Etiology : Unknown
: Related with secretin,
glucagon
: Underlying disease
Plain film

Water soluble contrast enema

Acute colonic pseudo-obstruction

OGILVIES SYNDROME
Rx 1. NPO + hydration
2. Stop narcotic drug
3. Fail colonoscopy 1-2 times
4. Fail iv neostigmine
5. Fail explore : cecostomy or resection

Diverticulitis associated with obstruction

Exclude other causes

Surgery is main treatment
Surgical options
Resection with primary anastomosis
Resection with on-table lavage with primary anastomosis
Hartmans operation
Colostomy, resection with primary anastomosis

Diverticulitis associated with obstruction

Others topic

Inflammatory bowel disease

Polyps
FAP & HNPCC
Ischemic colitis
Toxic megacolon
Type of colostomy etc.

Thank you all for your times