COLON, RECTUM, ANUS

Diverticular Disease of the Large

Bowel

Epidemiology

Incidence rises with age

33% general population by 45 years
66% general population by 85 years
Rare in patients < 40 years

Male: Female ratio is equal

Race
Disease of Western industrialized nations
??? diet

Pathogenesis

Pathology

More prevalent in countries with Usually multiple

low fiber intake
Much more common in
Colon depends on minimal
left colon than right
amount of bulk to propel
colon
contents towards rectum
90% occur in sigmoid
Low bulk increases contractions
Much more likely to be
and pressure causing herniation
right-sided if occurs in
Herniation usually at entry of
Asian patient
arteriae rectae along mesentery
Colonic wall is
and lateral tenia
thickened due to
Involve mucosa covered by serosa

hypertrophy of muscle
layer

Clinical Presentation

Most patients are asymptomatic unless a

complication develops
Morbidity and mortality of diverticula are
related to complications which include
inflammation and bleeding
Occur in 10-20% of patients with diverticular
disease during their lifetimes

Diverticulitis

Hemorrhage

Abscess or peridiverticular

inflammation initiated by the

rupture of a microscopic
mucosal abscess into the
mesentery or peritoneal cavity
Presents as LLQ pain, fever,
chills and obstipation or diarrhea
To contain the inflammation,
nearby viscera migrate toward
diverticulitis which include
omentum, small bowel, bladder,
uterus, fallopian tubes and
vagina
Infection may progress,
spontaneously resolve, fistulize,
or obstruct

Differential Diagnosis
Extracolonic Pathology
Appendicitis
Salpingitis
PIDHemorrhage
Lower GI
Perforated ulcer
Results
from rupture of small
Pancreatitis
that are
blood
Colonicvessels
Pathology
stretched
while
coursing
over
Perforated
Colonic
Cancer
thedome
IBD of the diverticula
Ischemic
bowelwith urge to
Sudden,
painless
Infectious colitis

defecate
Bright-red or wine colored
Amount is often massive and
tends to stop spontaneously

Evaluation and Management

Initial evaluation to include history & physical

examination
Abdominal pain steady, severe, & deep
Fever common
History of previous episodes, altered bowel habits
Pneumaturia, recurrent UTI, feculent vaginal
discharge
Obvious peritonitis

Laboratory Studies
Complete blood count: leukocytosis and/or a left shift in acute
diverticulitis
60% of patients may have a normal white blood cell count,
particularly elderly and immunocompromised patients.
Type and cross-match/coagulation profiles in patients with
lower GI bleeding or frank peritonitis.
Urinalysis/urine culture: identifies infections, hematuria &
colovesicular fistulas
Lipase/amylase/LFTs: Establish other etiologies particularly
important when patients present atypically (eg, steroid
therapy, elderly patients, those with diabetes) or relatively
late in the course of an inflammatory process with generalized
tenderness or frank peritonitis.

Radiographic Imaging
Plain radiographs: identifies signs of intestinal irritation
(ileus) and two thirds of visceral perforations (free air).
Identify volvulus, bowel obstruction, renal stones, and
occasionally intra-abdominal masses.

Ultrasonography: less sensitive and specific than other

modalities, and reliability is operator dependent.
Endoscopy: Useful to diagnose diverticular disease and to
establish the source of lower GI bleeding but is avoided
in acute diverticulitis because of the fear of perforation
and peritonitis.

Computed Tomography

Test of choice for acute

diverticulitis: diverticula, localized
colonic wall thickening (>5 mm),
abscesses, fistulas, and pericolic fat
inflammation and exclude other
pathologies.
Prognostic as well as the
presence of abscesses,
extraluminal air, or
extravasation of contrast
media is highly predictable
of failure of medical
treatment

Hinchey Grading System

I

Confined Pericolonic Abscess

II Distant Abscess
(Retroperitoneal/Pelvic)

III Generalized Peritonitis caused

by abscess rupture but no
communication with colonic lumen
IV Fecal Peritonitis

Management

IV Fluid Resuscitation
Invasive Monitoring if necessary
NPO
IV Antibiotics with Gram and anaerobic
coverage
Percutaneous drainage
In majority of patients, diverticulitis will
resolve with antibiotics alone

Indications for Surgery

Peritonitis
Closed loop obstruction secondary to bowel
adherence
Recurrent episodes of acute uncomplicated
diverticulitis
Emergency Surgery
7% mortality: Hartmann procedure
10-35% mortality: peritonitis

Surgical Considerations
Clearing of infection and bowel preparation are goals
before a resection should be attempted in 1 stage
If persistent soilage, needs sigmoidectomy with
colostomy and closure of rectal stump (Hartmann
procedure)
Reversal 8-12 weeks later

Extent of colonic resection is very important

Anastomoses after resection for diverticulitis have a high
incidence of complication
Ischemia secondary to tension from inadequate mobilization
Inclusion of diverticulum in anastomosis

Fistulas

Most common cause of fistulas is diverticulitis

in absence of tumor or Crohns disease
Indolent subacute diverticulitis may resolve by
releasing into neighboring viscus resulting in
fistula
Most common: colovesical (48%); colovaginal
(44%); colocutaneous (4%); colotubal (2%);
and coloenteric (2%)

Colorectal Cancer

Epidemiology
Second leading cause of cancer death in US - approx
148,000 cases/yr and 58,000 deaths
Equal lifetime risk between men and women

93% of cases dx over age 50. Five-year survival of

60%
Treatment costs over $6.5 billion per year
Among malignancies, second only to breast cancer at $6.6
billion per year

Epidemiology
Industrialized nations have the greatest risk

Geographic distribution of sporadic colon cancer

Pathogenesis
Adenoma to Carcinoma sequence:

Pathogenesis
Adenomatous polyps and adenocarcinoma are
epithelial tumors of the large intestine
Risk factors for polyps/adenomas to develop
into cancer:
Patient age (greatly increased after 50 yo, with
prevalence doubling until age 80)
Adenomas greater than 1 cm
Extensive villous patterns

Pathogenesis

Polyp/Cancer locations

CRC Risk Factors

Age: CRC incidence increases rapidly after 50
years of age
Adenomatous Polyps:
30% at 50 years, 40-50% at 60 years, and up to 65% at
70 years
Most importantly, the risk of HGD in a polyp is 80%
higher in an older person than younger person

CRC Risk Factors

Diet: Greatest association is between high fat
diet/red meat and CRC
High cholesterol, obesity linked to CRC
A prospective study of more than 760,000
people showed diets rich in vegetables and
high fiber grains demonstrated significant
protection against fatal CRC

Diet and Colon Cancer

Protective factors:
Fiber:
decreases fecal transit time by increasing stool bulk
Dilutes the concentration of other colonic constituents
which minimizes interactions btwn carcinogens and
colon epithelium
Reduces colonic pH and generates short chain fatty
acids

CRC Risk Factors

Other risk factors:

Other protective factors:

Hx of Ulcerative Colitis
Strep Bovis infection
Ureterosigmoidostomy
Dermatomyositis
Pelvic Irradiation
Smoking/ETOH consumption
Obesity

Exercise
NSAIDs/ASA
Folate
High calcium intake
Hormonal therapy
Selenium

CRC Risk Factors

Familial clustering present in 15% of all cases
of CRC
Increased risk 1.5-2.0 fold

Individuals with hx of adenomas are at three

to sixfold increased risk of metachronous
neoplasms

Genetic Sydromes
Familial adenomatous polyposis (FAP): an inherited
condition caused by a germline mutation on
chromosome 5 (APC gene)
Leads to hundreds to thousands of polyps
throughout the GI tract
Other findings include:
- duodenal adenomas
- fundic gland hyperplasia
- mandibular osteomas
- supernumerary teeth

Genetic Sydromes
Attenuated FAP: (<100 adenomas) and later
onset of CRC
Turcots Syndrome: familial predisposition for
colonic polyposis and CNS tumors
Gardners Syndrome: variant of FAP
Osteomas of the skull and long bones
(CHRPE) Congenital Hypertrophy of the Retinal
Pigmented Epithelium

Genetic Sydromes
Hereditary nonpolyposis colorectal cancer (HNPCC)
syndrome: also called Lynch syndrome:
characterized by proximal cancer in 3rd and 4th
decade of life
Also associated with extracolonic cancers- (uterus,
ovaries, stomach, small bowel and bile duct)
Mutations in DNA mismatch repair genes (MLH1,
MSH2)

HNPCC

Amsterdam Criteria for Dx of HNPCC

1. > 3 relatives with HNPCC related cancers
2. > 1 case is a first-degree relative of 2 other
cases
3. > 2 successive generations affected
4. > 1 case diagnosed before age 50 years

Genetic Sydromes
Other Genetic Diseases linked to CRC:

Muir-Torre Syndrome
Peutz-Jeghers Syndrome
Tuberous Sclerosis
Juvenile Polyposis Sydrome
Cowden disease
Cronkhite-Canada Syndrome

Screening
Annual Fecal Occult Blood Test (FOBT)
Flexible Sigmoidoscopy every 5 years
Annual FOBT + Flexible Sigmoidoscopy every 5 years
Colonoscopy every 10 years

Double Contrast Barium Enema (DCBE) every 5 years

FOBT
Uses the peroxidase activity of hemoglobin to cause
a change in a reagent
Consume diets high in fiber, restrict red meat
consumption, vitamin C, and NSAID drugs for several
days prior to testing
The sensitivity of fecal occult blood testing ranges
from 3092% with a specificity of 98%

Flexible Sigmoidoscopy
Colonoscope inserted to the descending colon
60% of all neoplasms are within this distributiontherefore, flex sigmoidoscopy along with FOBT
provides an effective screening tool
Minimal prep and no sedation required; office
procedure performed by internists, fam med docs,
NPs
Perforation risk: 1-2/10,000

Colonoscopy
Gold standard for CRC screening
Risk of complications: 0.10.3% risk of hemorrhage
and perforation
Allows for mucosal biopsy, polypectomy, tattooing,
accurate localization and flushing/suctioning
Sensitivity of colonoscopy for the detection of polyps
greater than or equal to 1 cm and tumors is greater
than 95%

Colonoscopy

Chemoprevention
COX-II inhibitors
Estrogens
Ursodeoxycholic Acid

Adenocarcinoma

TNM and Dukes Staging for CRC

Treatment
Primary treatment for early colon cancer is
surgery. For rectal cancer, total mesorectal
excision
In tumors that are > T3 or > N1, preoperative
chemo is recommended
Radiation is useful in rectal cancer, not colon
cancer

CRC Treatment
Common chemotherapeutic regimen includes
5-fluorouracil, leucovorin, oxaliplatin
Other agents include bevacizumab,
cetuximab,irinotecan, capecitabine

PERI-ANAL
PAIN, MASSES &
DISCHARGES

DIGITAL RECTAL EXAMINATION

Uncomfortable but not painful

Urge to defecate &/or to pass out flatus
Adequate lubrication
Keep patient assured & relax
Peri-anal area & anal verge
Anal canal, tightness, ano-rectal ring(internal
sphincter)
Distal rectum
Contents of rectal vault

Anoscopy
Adequate lubrication
Visualize anal canal (anoderm, dentate line,
anal crypt, column of Morgagni)
Hemorrhoidal plexus

When anorectal examination including DRE

and Anoscopy causes undue pain,

DO EXAMINATIONS
UNDER ANESTHESIA

Thrombosed External Hemorhoids

:
COMPLAINTS
Sudden pain
Recent diarrhea
Long history of small anal mass/es
Painful anal mass
+/- fever

Thrombosed External Hemorhoids

Anesthesia
I & D or Excision
Hygiene
Analgesic
Hot Sitz bath

Internal hemorrhoids
st
nd
- 1 or 2 degree
Complaints:
Blood streaked stools
Blood drips into toilet bowl just after
defecation
Blood on tissue paper
Mucoid discharge/ soiling

Internal hemorrhoids
- 1st or 2nd degree
High fiber diet
Increase oral fluids
Improve defecation habits to avoid straining
..when necessary
- Rubber band ligation
- Infrared photocoagulation
- sclerotherapy

Internal hemorrhoids
- 2nd degree; 3rd degree; 4th degree
Complaints:
Comes out during straining & defecation but
spontaneously goes in after..or
.must be pushed in..or
.irreducible
+/- blood streaked stools
+/- blood dripping after defecation
Pain
Mass protrudes thru anus on straining but suddenly
now is permanent
Alcohol drinking binge or diarrhea
Pain, itch, soiling

Internal hemorrhoids
MEDICAL
- High fiber diet
- Stool softeners
- Increase oral fluid intake
- Improve defecation habits
SURGICAL
- Rubber band ligation
- Infrared photocoagulation
- Sclerotheraphy
- Excision (hemorrhoidectomy)

Inflamed Internal Hemorrhoids

Complaints:

Masses felt on the anus

Aggravated by straining/defecation
+/- bleeding, soiling
Multigravida & multipara

Treatment

Hot sitz bath

Oral & local anti-inflammatory & analgesics
High fiber diet & stool softeners
Increased oral fluids
Excision once edema subsides

Thrombosed Internal Hemorrhoids

Complaints:
Sudden painful mass
Long history of mass coming out the anus
usually during defecation but spontaneously
goes in
+/- bleeding during defecation
+/- fever

Thrombosed internal hemorrhoids

Analgesic
Hot sitz bath
Anesthesia
Excision
Stool softener/ high fiber diet

Peri-anal skin irritation

Complaints:
Burning pain around anus
Soiling of underwear

Peri-anal skin irritation

Due to poor hygiene

Akin to diaper rash
Wash area with soap & water
Keep area dry

Complaints:

Sudden, very painful peri-anal bulge

+/- fever
+/- urinary retention
Often cannot tolerate DRE

Anorectal & Cryptoglandular abscess

-perianal
-ischiorectal
-deep postanal
-supralevator
-intersphincteric
-Forniers gangrene

Adequate incision & drainage upon diagnosis;

debridement; fistulotomy
Antibiotics as indicated
Hot sitz bath
Frequent daily cleansing

Anal fissure
-acute
-chronic

Complaints:
Spastic anal pain most severe during periods
of anxiety, passage of feces &/or flatus
High strung person ( O- C)
Poor defecating habits (irregular, incomplete)
= hard stools

Anal fissure
-acute
-chronic
MEDICAL:
- fiber diet
- Stool softeners
- Hot sitz bath
- relax
- Local analgesic; botulinum toxin

SURGICAL:
- LEFT LATERAL INTERNAL SPHINCTEROTOMY ( open or
closed)

Herpes proctitis
Complaints:
Severe peri-anal pain
Tenesmus
Anal sex
Vesicles
contagious

Herpes proctitis

Viral culture
Symptomatic treatment
Abstinence
hygiene

Rectal prolapse
Complete evaluation of terminal colon,
rectum & anus
Anal sphincter function
Surgical procedures: perineal vs abdominal

Anal Carcinoma
Complaints:
Masses on anal canal, anal verge &/or perianal skin
+/- pain
+/- discharge

CARCINOMA
- epidermoid
- basal cell
- melanoma

Excisional biopsy
Wide local sphincter saving excision, APR
RADIOTHERAPY
CHEMOTHERAPY

- CONDYLOMA ACUMINATA (Anogenital warts)

- Syphilis
- Sebaceous cyst
- Hydradenitis suppurativa

Histopathology
Treatment of all affected contacts
Local conservative treatment

Pilonidal disease
Complaints:
Whitish, thick fluid, hairs
Midline pit, coccyx
Since birth
When no discharge, mass develops
Treatment:
I & D for abscess
Tractotomy, curettage for sinus tract

Rectal or anal carcinoma

Histopathology
Stool softener
SURGICAL EXCICION
- Wide local excision APR
RADIOTHERAPY
-neoadjuvant
- Adjuvant
CHEMOTHERAPY
- Neoadjuvant
- adjuvant

Fistula in ano
Complaints:
Painful fluctuant mass spontaneously
ruptured
Peri-anal skin opening
Purulent, fecaloid material comes out
sometimes no discharge, painful & fluctuant

Fistula in ano
Fistulotomy/ fistulectomy
Seton
Biopsy to rule out chronic inflammatory
disease (TB, Crohns)