Colorectal-anus short note by S.

Wichien (SNG KKU)

Anatomy Histology -mucosa -submucosa -inner cirint anal sphinc -outer long3 tenia coli -serosa Embryology -primitive gut derived from endoderm Midgut -small intestine, asc.colon, prox T.colon -SMA Hindgut -distal T.colon, des colon, rectum, prox.anus -IMA Distal anus -ectoderm -int pudendal A -dentate line use to divide Colon Landmark -3-5 feets -rectosigmoid=sacral promontary -caecum diameter 7.5-8.5 cm -sigmoid :narrowestmost to obstruct :extremely mobilemost vulvulus :diverticulitis -marginal A of Drummond -arch of Rioland SMA -ileocolicterminal ilium, asc.colon -rt colic aasc.colon -middle colicT.colon IMA -lt colic ades.colon -sigmoid brsigmoid colon -sup rectalprox rectum Watershed area 1.Griffith pointsplenic flexor 2.Sudak point Lymp drainage -network in m.mucosa Nerve -sympathetic (inhi)T6-12,L1-3 -parasym (stimu)vagus n, sacral n (S2-4) Anorectal Landmark -rectum 12-15 cm (lower 4-8 cm mid 8-12 cm upper 12-16 cm) -sx anal canal 2-4 cm -3 valve of Houston Peritoneal reflection -upperant+lateral -middleantpouch of douglas -lowerno peritoneum but have fascia :postwaldeyer fascia :antdenovillier fascia :lateral ligament Endopelvic fascia -visceral layer -parietal fasciapresacral fascia Dentate/pectinate line -longitudinal foldcolumn of Morgagni -anal crypt -above dentatecolumnar -dentatetransitional zone -below dentatesquamous Sphincter Internal sphincter -smooth m -sym & parasym External sphincter -3 group -subcu, superficial, deep group(puborectalis) -ext sphinc = inf rectal br of int pudendal n. Levator ani -puborectalis iliococcygeus pubococcygeus -int pudendal Artery -sup rectum = IMA -mid rectum = int illiac -inf rectum = int pudendalint iliac Lymphatic -upper/middle rectum = inf mesen LN -lower rectum = inf mesen LN, int iliac LN -anal canal :prox dentate = inf mesen, int iliac LN :distal dentate = inguinal LN Nerve plexus -sym (L1-3)hypogatric plexus -parasym (S2-4) Symp injretrograde ejacu & contract BD Parasymp injED & acute urinary retention

Colorectal-anus short note by S.Wichien (SNG KKU)

Physiology Fluid/elyte -90% water in ileum :absorb in colon -1000-2000cc/d -Na absorb via Na-K ATPase -can absorb Na 400 mEq/d -K absorb by passive diffusion -Cl absorb via Cl-HCO3 exchange -protein,urea --bact--ammonia -amonia to liver due to intraluminal pH -dec bact/pH>>dec absorb ammonia (lactulose administration ) Short chain fatty a. -acetate,butyrate,propionate -produce by bact ferment of carbo -energy for colonic mucosa,transport -lack of dietary,diversion fecal stream result in m.atrophy=Diversion colitis Microflora -bacteroides=most common anaerobe -e.coli=most common aerobe -breakdown carbo,prot -metabolism of bili,bile a,estro,chol -produce vit k -suppress patho organism--c.difficile -gas=n2,o2,co2,h2,methane (bact=h2,methane) Motility -not cyclic motor activity character of migratory motor complex in small b. -intermittent contraction S+S 1.Pain -abdominal pain -pelvic pain -anorectal pain :proctalgia fugax-levator spasm 2.LGIB -NG tube r/o UGIB -proctoscope r/o hemorrhoid -rbc scan detect bleeding 0.1 cc/hr If +ve :angiography to localized bleeding :vasopressin iv :angioembolization -if stable pt,rapid bowel preparation (4-6hr) to allow colonoscopy -colonoscopy identify cause bleeding, cautery or inject epi may control bl. -if persist bleeding = colectomy :segmental resection 3.constipation 4.diarrhea/IBS 5.incontinence -neurogenic -anatomic :procidentia :overflow inconti 2nd to impaction :trauma >>vg.delivery,sx

low amplitude

-short duration contraction -burst,move content ante/retrograde -delay colonic transit :absorp water,elyte

Hi amplitude

-mass movement Defecation -colonic mass movement -inc intraabdo/rectal p. -relax pelvic floor -rectum distend--reflex relax sphincter :rectoanal inhibitory reflex :no reflexHirschprung disease -sampling reflex :distinguish solid stool from liquid/gas -no defecateaccommadation reflex Continence -puborectalis--sling around distal R. -rectal wall compliance -ext/int sphincter -n=br of int pudendal n

Colorectal-anus short note by S.Wichien (SNG KKU)

Lower GI bleeding

Constipation Rome III criteria >=2/6, 3 mo Onset at least 6 mo No IBS criteria -straining -lumpy/hard stool -incomplete evacuation -anorectal obstruct sensation -manual evacuation -defecate <3/week Approach 1.BE/colonoscope -r/o mechanical obstruction 2.slow transit vs outlet obstruction

Ix Colonic fxn 1.colonic transit time -20 markers -dx if d5 > 5 marker 2.colonic manometry 3.colonic scintigraphy Anorectal fxn 1.anorectal manometry (gold std) -no RAIRHirschprung disease 2.balloon expulsion test -should < 5min 3.defecogram -rectocele/enterocele -intussusception -megarectum -rectal prolapsed 4.pudendal n terminal motor latency

Colorectal-anus short note by S.Wichien (SNG KKU)

Lab+imaging FOBT Advantage -non invasive -low cost -good sens c repeat testing Disadvantage -low spec -colonoscopy require for test+ve BE Advantage -entire colon -good sene in polyps >1cm Disadvantage -required bowel prep -less sens in <1cm -may miss lesion in sigmoid -colonoscopy if test +ve Endoanal/rectal ultrasound -dept of invasion in rectum -normal = 5 layer :mucosal surface,m.mucosa, submucosa,m.propia,perirectal fat -perirectal LN CT -extraluminal lesion -insensitive for detect intraluminal Positron emission tomography -PET -tissue c high level of anaerobic glycolysis(tumor) -F-fluorodeoxyglc(FDG) is tracer, metabolism of it = positron emission -as an adjunct to CT in staging -distinguish recurrent vs fibrosis Anoscope -anal c. -8 cm in length -rubber b.ligation,sclerotherapy Proctoscope -rectum,distal sigmoid -25 cm in length Sigmoidoscope -60 cm in length -see high as splenic flexor -enema is adequate for scope Advantage -bowel prep=enema only -exam most risk(sigmoid) Disadvantage -invasive -risk perforate -miss proximal lesion -colonoscopy if polyps identify Colonoscopy -100-160 cm in length -require oral bower preparation -require sedation -electrocautery not in absence bowel preparation=risk of explosion Advantage -entire colon -hi sens,spec Disadvantage -most invasive -require sedation/bowel prep -risk perforate CT colonography/ virtual colonoscopy Advantage -entire colon -noninvasive -sens as colonoscopy Disadvantage -require bowel prep -insen for small polyps -colonoscopy if test +ve -costly Pelvic floor ix Manometry -resting pressure = int sphincter (normal 40-80mmhg) -squeez pressure = ext sphincter (max p-resting p) (normal above resting pressure 2x) Neurophysiologic testing -assess pudendal n Rectal evacuation study -ballon expulsion test -video defecography

Colorectal-anus short note by S.Wichien (SNG KKU)

Anal fissure -tear in anoderm distal to dentate line -related to trauma from passage hard stool or prolong diarrhea -cause spasm of int anal sphincter :pain--spasm--dec bl.supply :this cycle develop chronic fissure -major in posterior midline 10-15% in ant middle Sign/symptom -tearing pain c defecation -hematochezia:bl on toilet paper -anal spasm lasting several hours after bowel movement -seen by gently separate buttock -too tender on PR/proctoscope Tx Medical Tx--is effective in acute but only 50-60% in chronic fissure -bulk agent -stool softener -warm sitz baths -2%lidocain jelly -0.02%nitroglycerine ointment :improve bl.flow :but often severe headache -ca channel blocks :diltiazem,nifedipine -newer agent :arginine :topical bethanechol (muscarinic ago) -injection of botulinum toxin :inhi Ach release from presynap :cause temporary m.pararlsis :alternative to sx sphincterotomy Sx -in chronic fissure that fail medical lateral sphincterotomy -procedure of choice -divide 30% of internal sphincter fiber -open or closed technique -risk of incontinence (flatus) Anorectal abscess -Cryptoglandular infection -infect of anal glands -intersphincteric plane -ducts traverse int sphincter into crypts at level of dentate line Space -Perianal space -Intersphincteric space -Ischiorectal space -Pelvic/supralevator space Dx -severe anal pain -inc by walking,coughing,straining -fever,uri retention -life threatening abscess Treatment -drainage as soon as dx -ATB alone ineffective Perianal abscess -cruciate skin and subcu incision -no packing is necessary -sitz baths in nextday Ischorectal abscess -diffuse swelling in ischorectal fossa -incision in overlying skin -both=horseshoe abscess :drainage of deep postanal space :often require counterincision over one/both ischorectal space Intersphincteric abscess -difficult to dx -few perianal signs -pain deep and up inside anal area -posterior internal sphincterotomy Supralevator abscess -uncommon,difficult to dx -mimic intraabdo condition -PR=indurated bulging mass -identify origin of abscess prior to tx -if 2nd to extension of intersphincteric, should be drained through rectum -if from ischorectal,should be drained through ischorectal fossa -if from intraabdo ds,should drain via most direct route

Colorectal-anus short note by S.Wichien (SNG KKU)

Fistula in ano -50%of drainage of anorectal abscess -internal opening : infected crypt -external opening: site of prior drain -non-healing fistula should aware :crohn disease,malignancy,radiation, TB,actinomycosis,chlamydia Diagnosis -persist drainage from int/ext opening -indurated tract is often palpable Goodsall rules -determine locate of internal opening 1.external opening anteriorly -short-radial tract -except this rule if >3cm--post midline 2.external opening posteriorly -curve to post midline Type 1.intersphincteric fistula 2.transphincteric fistula 3.suprasphincteric fistula 4.extrasphincteric fistula:rare Complex fistula -hi transphincteric -suprasphincteric -extrasphincteric -ant fistula in female -multiple tract -recurrent fistula -asso incontinence -s/p XRT -crohn dz/ AIDS Treatment -locate int/ext opening -external opening usually visible -injection of hydrogen peroxide or dilute methylene blue may be helpful 1.Simple intersphincteric fistula -fistulotomy/curettage -wound healing by2nd intention 2.Transphincteric fistula :depend on location in sphincter <30% of sphincter -sphincterotomy -without signi risk of major incontine >30% of sphincter -initial placement of seton 3.Suprasphincteric fistula -seton placement 4.extrasphincter fistula -fistula outside sphinc--drain+open -1tract at level of dentate line :may opened if present -seton Failure to heal -require fecal diversion -may from malignancy,crohn,radiate -proctoscope assess rectal mucosa -bx can r/o malignancy Seton -drain placed through fistula -maintain drainage/induced fibrosis Cutting seton -suture or rubber band placed through fistula and intermittent tightened -tightening the seton results in fibrosis and gradual division of sphincter Noncutting seton -soft plastic drain,often vv loop -placed in to maintain drainage -tract may be laid open with less risk of incontinence because scarring prevent retraction of sphincter

Colorectal-anus short note by S.Wichien (SNG KKU)

Hemorrhoids -cushions of submucosa -contain venule, arteriole, smooth m. -3 hemorrhoidal cushion in left lateral, right ant, right post -fxn as continence mechanism -complete closure of anal canal External hemorrhoid -located distal to dentate line (anoderm) Thrombosed hemorrhoid Tx-24-72 hrsx, >72 hrsupportive Tx Skin tags -often confused c symp hemorrhoid -redundant fibrotic skin at anal verge -residual of thrombosed ext hemorr -Tx-only indicated for symptom relief Internal hemorrhoid -proximal to dentate line -covered by insensate anorectal mucosa -rarely pain, unless thrombosis/necrosis -may prolapsed, bleeding Grading 1st =may prolapse on straining 2nd=reduced spontaneous 3rd=require manaul reduction 4th=can't reduce,risk for strangulation Portal HT pt -Hemorrhoid = normal population -risk bleeding > normal population Hemorrhoid Tx Medical -bleeding 1st, 2nd degree -diet fiber, stool softener, water -avoid straining Rubber band ligation -persist bleeding 1st, 2nd, 3rd -pulled mucosa 1-2 cm proximal to dentate -1, 2 quadrants are banded -severe pain--placed distal to dentate c/p 1.urinary retention -1% of pt -ligate int sphincter 2.infection -necrotizing infection -rare but life threatening -severe pain, fever, chill, urine retention 3.bleeding -may 7-10 after rubber band -usually self limit -may require suture ligation Infared photocoagulation -small 1st,2nd degree -apply to apex of each hemorrhoid -coag underlying plexus -all 3 quadrant may be tx in same visit -large,prolapsed not effective Sclerotherapy -sclerosing agent :5-phenol in olive oil :sodium morrhuate :quinine urea -inject bleeding hemorrhoid -1st,2nd and some 3rd -1-3 ml of agent inject to submucosa Excision of thrombosed Ext Hemorrhoid -24-72 hr -elliptical excision under LA -usually loculated--I$D--ineffective -72hr--begin resorb--not excision Hemorrhoidectomy 1.Closed submu hemorrhoidectomy Park or Ferguson -prone/lithotomy -fansler anoscope -elliptical incision distal to anal verge and extended proximally -ligated apex of hemorrhoid plexus -resect hemorrhoid tissue -closure c running absorb suture -must identify fiber of int sphincter -avoid resect large area--stenosis 2.Open hemorrhoidectomy Milligan and Morgan -as above but wound are left open -allow to heal by 2nd intention 3.Whitehead hemorrhoidectomy -circumferential excision of H -proximal to dentate line -most don't use this method risk of ectropion (whitehead deform) 4.Stapled hemorrhoidectomy -alternative sx -remove short circum segment of rectal mucosa proximal to dentate line using circula staple -for large,bleeding int hemorrhoid -not in ext/combined hemorrhoid

Colorectal-anus short note by S.Wichien (SNG KKU)

Diverticular disease -acquired (major)false diverticula -congenitaltrue diverticula -75% asymptom, 25% symptom -75%diverticulitis, 25%bleeding Diverticulosis -diverticula without inflam -sigmoid=most common -lack of dietary fiber -most=asymptom Diverticulitis -10-25% of diverticulosis -lt side abdo.pain,leukocytosis,fever 1.uncomplicated diverticulitis -LLQ pain -CT:pericolic soft tissue stranding, colonic wall thickening,phlegmon -Rx=ATB -most=recovery without sx in 7-10 d -sigmoidoscope 4-6 wk after recovery r/o ca Sx--elective sx -sigmoid colectomy c 1anas (procedure of choice) -resect extend to rectum -recurrence if retain sigmoid colon Elective Sx I/C 1.>=2 episode 2.1 episode+young pt 3.1 episode+complicated diverticulitis 4.1episode+immunocompromise 2.complicated diverticulitis Hinchey staging system 1-colonic inflam c pericolic abscess 2-retroperitoneal or pelvis abscess 3-purulent peritonitis 4-fecal peritonitis Rx -abscess<2cm--iv ATB -larger--CT guide percu.drain--best Emergency laparotomy -can't percu.drain -free air / peritonitis Stage1,2 -sigmoid-colectomy c 1anas (one stage operation) Stage3,4 -sigmoid-colectomy c end colostomy c Hartman pouch (most common) Others -sigmoid-colectomy c 1anas +/on table lavage c prox.diversion (loop ileostomy) Obstruction -67% of diverticulitis -10% complete obstruction -sigmoid colectomy c end colostomy Fistula -5%of complete diverticulitis -1st--colovesical--most common 2nd--colovg,coloenteric Rare--colocutaneous -best Ix=CT with contrast 2 key point 1.defined anatomy of fistula 2.exclude other dx -DDx--malignancy,crohn,RTX induce -barium enema, CT, colonoscopy -Hx RTx--1st--should r/o recurrent ca Rx -resection of affected segment (usually 1repair) and simple repair of involved organ Hemorrhage -erosion of peridiverticula arteriole -may massive -elderly -80% spon.stop Rx -colonoscopy+epi injection/cautery -angiography--dx+therapeutic -laparotomy--segmental colectomy Giant colonic diverticula ->4cm -rare -antimesen of sigmoid colon -pain,nausea,constipation -Ix--BE -c/p--perforate,obstruct,volvulus Tx -should sx despite asymptom -symptomresection -asymptomdiverticulectomy

Colorectal-anus short note by S.Wichien (SNG KKU)

Diverticular disease (cont) Rt side diverticula -cecum, asc.colon -young pt -most--asymptomatic -ddx=appendicitis -dx in operating room Pre op Dx -good clinicalATB iv -not good ptrt hemicolectomy Intraop Dx -complicatedrt hemicolectomy -uncomplicatedappendectomy, ATB iv Pruritis ani Sx correctable -prolapsed hemorrhoid -ectropion -fissure -fistula -neoplasm Infection -fungus=candida,monilia -parasite=enterobius,scabies,louse -bact corynebac.minutissimum(erythrasma) treponema pallidum(syphylis) -virus=HPV Noninfectious -seborrhea -psoriasis -contact dermatitis -jx -DM Hidradenitis suppurative -infect of cuta.apocrine sweat gl. -infect gl.rupture>form subcu.sinus T -mimic complex fistula -stop at anal verge, because no apocrine gl.in anal canal Tx -I&D in acute abscess -unroof fistula,debride granulation Pilonidal dz -hair containing sinus/abscess -in intergluteal cleft -unknown etiology -cleft suct hair into midline when sit -ingrown hair=infect Tx acute -incised and drain midline w--heal poorly incision--lateral to gluteal cleft chronic -unroof tract -curetting base -marsupializing wound -free of hair Complex/recurrent sinus -more extensive resection -Z plasty/advancement flap/ Rotational flap STD Bacteria : proctitis -n.gonorrhea=most common -c.trachomatis -t.pallidum=chancre -h.ducreyi :chancroid :inguinal lymphadenopathy -donovania granulomatis :granuloma inguinale :red mass on perineum Parasite -e.histolytica :ulcer in GI mucosa -giardia lamblia Viral HIV HSV T.2 HPV -anogenital wart,condy.accuminata -asso AIN,sq.cell ca -HPV T.6,11--no ca -HPV T.16,18--ca Tx -topical podophyllin--small lesion -imiquimod (Aldara)--severe lesion -excision in large lesion + can r/o dysplasia

Colorectal-anus short note by S.Wichien (SNG KKU)

Megacolon -chronic dilate,elongate,hypertrophy -congenital vs acquire -asso chronic Mechanical or fxn obstr -exclude correctable mecha.obstr Congen. -Hirschprung dz -no GG cell in distal colon -failure of relaxation -fxn obstruction -resect aganglion segment -can later in childhood :ultrashort-srgment hirschprung dz Acquired Infection -T.cruzi (chagas dz) :destroy GG cell :megacolon/eso chronic constipation -from slow transit -med--anti cholinergic -neurologic--paraplegia Tx -diverting ileostomy or subtotal colectomy c ileorectal anas Colonic pseudo-obstruction -Ogilvie syndrome -fxn disorder -absent mech.obstruction -massive colon dilate (esp.rt and transverse colon) -common in hospitalized pt -narcotic,anticholi,bed rest comorbid -autonomic dysfxn -adynamic ileus Step Tx 1.conservative TxNG, rectal tube, elyte 2.Neostigmine (Achesterase inh) -s/e=bradycardia -not in CVS ds 3.colonoscopic decompression 4.Sx -gangreneresection -good caecumcecostomy Solitary rectal ulcer syndrome -asso internal intussusception -pain,bleeding,mucus d/c,obstruc -one or more ulcer in distal rectum -ant.wall 4-12 cm from AV

colitis cystica profunda

-nodule/mass in similar location -mucosal gland in submucosa Ix -bx r/o malignancy -colonoscopy /BE -defecogram r/o rectal intussusception Tx Nonsx -hi-fiber diet -defecation to avoid straining -laxative/enema Sx -as prolapsed -in symptomatic pt,fail med Typhlitis -neutropenic enterocolitis -life-threatening -abdo.pain/distend,fever, diarrhea()bloody),n/v -neutropenia -difficult dx due to lack inflam rxn -CT :dilate cecum c pericolic stranding :normal not r/o ds -perianal pain Rx -bowel rest -ATB -parenteral nutrition -granulocyte infusion -perforate >> sx

Colorectal-anus short note by S.Wichien (SNG KKU)

Rectal prolapse -circum,full thickness protusion -1st degree/complete/procidentia -internal prolapse=intuss -female:male=6:1 -women:inc with age -men:unrelated with age Mucosal prolapse -partial thickness protusion -often asso hemorrhoid Tx--banding/hemorrhoidectomy Clinical -tenesmus -tissue protuding -incomplete evacuation -mucus d/c,leakage -fxn complaint--incontinence/constipa Ix -colonic transit study -anorectal manometry -colonoscope/BE--exclude ca/diverti Tx 1.Abdominal approach 1.Moschowitz repair -reduction of perineal hernia and closure of cul-de-sac 2.fixation of rectum 2.1 Ripsten and Well rectoplexy) -with prosthetic sling 2.2 suture rectoplexy 3.resection rectoplexy (Fryman Goldberg) -resection of redundant sigmoid colon may combine c rectal fixation 2.Peritoneal approach 1.Delorme procedure -mucosal resection+suture plication 2.Perineal rectosigmoidectomy or Altemeier procedure 3.2+levatoplasty 4.Thiersch operation -circular thightening Volvulus -twisted it mesentery -sigmoid 90% -caecum<20% -may reduce spontaneous -gut obstruction ,strangulate, gangrene,perforation -constipate--large redundant colon (chronic megacolon)--volvulus Clinical -acute bowel obstr -intermittent chronic volvulus Sigmoid volvulus X-ray -bent inner tube or coffee bean -BE=bird beak--(pathognomonic) Tx 1.not emer -resus -rectal tube to decompress -endoscopic detorsion :rigid proctoscope or flex.sigmoido/colonoscope -if suggest strangulate=sx -hi recurrent (40%) -elective sigmoidectomy 2.emer -gangrene,perforate -sx exploration -end colostomy (Hartman procedure) :safest operation Cecal volvulus -non-fixed of rt colon -rotate around ileocolic vv -early vascular compromise X-ray -kidney shape/air fill structure LUQ Tx -most can't endoscopic detorsion -rt hemicolectomy c 1ileocolic anas -simple torsion may cecoplexy :hi recurrence Transverse colon volvulus -rare -predispose--chronic consti--megaco -x-ray as sigmoid but BE show more proximal obstruction

Colorectal-anus short note by S.Wichien (SNG KKU)

Rectovaginal fistula -connect btw vagina and rectum/anal canal -proximal to dentate line 1.Low -rectum--close to dentate line -vagina--fourchette cause -common caused by OB inj -trauma from FB 2.Middle -vagina--between fourchette and cx cause -after sx resect of midrectal neoplasm -radiation inj -more severe OB inj -extension of undrain abscess 3.High -vagina--near cervix cause -operative -radiation inj complicated diverticulitis -may cause colovaginal fistula crohn dz -cause RV fistula all level -colovaginal, enterovaginal fistula Dx -pass flatus from vagina to -pass solid stool from vg -some degree of fecal incontinence -contaminate result in vaginitis -anoscope/vaginal speculum may dx -BE or vaginogram may identify -methylene blue into rectum while tampon in vagina may dx RV fistula Tx OB inj -50%heal spon--wait 3-6mo Cryptogl abscess -drainage allow spon closure low+mid rectovaginal fistula -endorectal advancement flap (best Tx) -healthy mucosa,submu,cir muscle if sphincter inj -overlapping sphincteroplasty -fecal diversion =rare hi fistula -best tx via trans-abdo pproach -bowel is resected -closed hole in Vg -omentum interposed Crohn -adequate drain of perianal sepsis -advancement flap may performed if spare from active dz Radiation -can't flap -bx--r/o ca

Colorectal-anus short note by S.Wichien (SNG KKU)

1.Ischemic colitis -intes colitis--most com=colon :splenic flexure -from low flow/small vv occlusion -rarely asso major a/v occlusion -splenic flexure=most site -rectum=spare(rich collateral br.) Risk factors -vascular dz -DM -vasculitis -hypoT -ligate IMA in aortic sx Ix Film -thumb printing (mucosal edema,submu.hmg) CT -nonspecific colonic wall thickening -pericolic fat stranding Angiography -not helpful -rare major a.occlusion Sigmoidoscope -dark,hmg mucosa -hi-risk to perforate -relative C/I BE -C/I in acute phase Tx -major can medical tx -rest bowel,broad ATB -correct low flow stage -colonoscopy after recovery :evaluate stricture :r/o other cause -fail med=sx exploration :resect necrotic bowel :avoid primary anas :may be 2nd look operation Sequele -stricture 10-15% -chronic segmental ischemia 15-20% 2.Infectious colitis 2.1 Pseudomembranous colitis -c.difficile -nosocromial diarrhea -give ATB=deplete normal flora :clindamycin -2 toxins :toxin A-enterotoxin :toxin B-cytotoxin -ulcer plaque,pseudomembranous Ix -stool c/s -immunoassay for toxins Tx -stop ATB -oral metro=1st line (10 d) -oral vanco=2nd line -vanco enema -recurrent=longer (up to 1 mo) Fulminant colitis -total colectomy c end ileostomy Others infectious colitis Common -e.coli,campylobacter jejuni,yersinia, samonella,shigella,gonorrhea -ameba,cryptosporidium,giadia -HIV,HSV,CMV Uncommon -TB,syphilis,actinomycosis -fungi 3.Radition proctitis -bleedingformalin packing -must sxcolostomy/ proctocolectomy

Colorectal-anus short note by S.Wichien (SNG KKU)

Colon injury Tx depend on 1.size perforation 2.duration of time since inj 3.condition of pt 4D 1.debridement 2.prox.fecal diversion 3.distal rectal washout 4.presacral drain placement 1.Prenetrating colorectal inj 1.1 Primary repair -hemodynamic stable -minimal contaminate C/I -shock -inj>2 organs -mesen.vascular damage -extensive fecal contaminate Relative C/I ->6hr 1.2 Ostomy (fecal diversion) Inj factor -hi-velocity bullet/blast/crush inj Pt factor -tumor/XRT/age/med condition -local FB -impaire bl.supply -mesen.vv damage -shock/hmg>1000cc ->2organ inj ->6hr 2.Blunt colorectal inj -less than penetrating inj -colon perforate -shear inj to mesentery -crush inj :debride nonviable tissue :prox.fecal diversion :distal rectal washout :+/-presacral drain placement 3.Iatrogenic inj 1.intraop -pelvic operation -must early recognition -little conta=primary repair -delay=sig.peritonitis,sepsis :fecal diversion :repeat exploration 2.BE -rare -above petitoneal reflection=sx -extraperitoneal rectum=NOM 3.colonoscopy -perforation -<1%of procedure Tx depend on 1.size perforation 2.duration of time since inj 3.condition of pt -signi contaminate/delay dx/unstable pt prox.diversion+/-resection Anal sphincter injury cause -obstetric traummost common -hemorrhoidectomy -sphincterotomy -abscess drainage -fistulotomy -penetrating/blunt inj Ix -anal manometry -electromyography(EMG) -endoanal u/s Surgical repair A wrap around sphincteroplasty -most common -mobilize divided sphincter m. -reapproximate without tension Postanal intersphincteric levatorplasty -levator ani m.is approximate to restore anorectal angle -puborectalis/ext sphincter are tighten with suture Gracilis m.transposition -sig.loss sphincter m. -fail prior procedure Artificial anal sphincter -inflate silastic cuff Sacral n.stimulation

Colorectal-anus short note by S.Wichien (SNG KKU)

Polyps 1.Neoplastic polyps -adenomatous polyps -dysplastic -risk ca--size + type of polyps Size--polyps<1cm--rare ca Type -Tubular adenoma - ca 5% -Villous adenoma - ca 40% -tubulovillous - ca 22% -serrated polyp-ca 10% :adenomatous+hyperplastic polyp :BRAF mutation Malignant polyp Size>2cm Margin<2mm Kudo3 Haggitt4 Haggitt 0-Tis-mucosa 1-mm into submuhead 2-neck 3-stalk 4-below stalk (LN 12-25%) Kudo Sm1-upper 1/3 submu Sm2-middle 1/3 submu Sm3-lower 1/3 submu Tx -snare excision--pedunculate P -saline lift+piecemeal snare--sessile P Surveillance s/p endo Tx -scope 3 moq 6 mo*2 yrq 2yr 2.Hamatomatous polyps -juvenile polyps -not usually premalignancy -childhood -common symptom :bleeding,intussus,obstruction A.familial juvenile polyposis -AD -100 polyps in colon,rectum -may ca -anaul screening age 10-12 yr Tx -spare rectum :total colectomy c ileorectal anastomosis -total proctocolectomy,ileal pouch, anal reconstruction B.Peut-Jeghers synd -polyposis small bowel,colon,rectum -melanin spot on buccal mucosa,lips -may ca Sx--symptom,develop adenomatous C.Cronkite-Canada synd -GI polyposis c alopecia, cutaneous pigmentation, atrophy fingernail/toenail -diarrhea,n/v,malabsorp -prot-losing enteropathy -sx for c/p--obstruction D.Cowden synd -AD -harmartomatous -facial trichilemmomas,breast ca, thyroid dz,GI polyps = typical synd 3.Inflammatory polyps -pseudopolyps -inflam bowel dz -amebic/ischemic/schisto colitis -not ca -but can't distinguished adenomatous polyps,so should be removed 4.Hyperplastic polyps -usually <5mm -hyperplasia ,without dysplasia -large polyps >2cm--slightly risk ca

Colorectal-anus short note by S.Wichien (SNG KKU)

Pre-op evaluation -colonoscopy :synchronous lesion :up to 5% of pt -PR -proctoscope c bx -endorectal u/s -CXR -abdo./pelvis CT -obstructive symp :avoid mech.bowel preparation -PET -CEA = follow up Pre-op preparation 1.Bowel preparation -mechanical bowel preparation :polyethylene glycol (PEG) solution :sodium phosphate solution :drink large volume -antibiotic prophylaxis :neomycin 1 gm :erythromycin 1 gm/metro 500mg 2.stomal planning -consult enterostomal(ET)nurse -educated -stoma siting : pre-op mark 3.ureteral stent -identify ureter intraop -inflam/phlegmon inc risk of ureter inj during mobllize sigmoid colon Anastomoses -highest risk of leak/stricture in :distal rectal or anal canal :irradiated/disease bowel Configuration End to end -same caliber -colocolostomy,small bowel anasto End to side -one limb of bowel larger than other -in chronic obstruction Side to end -prox.bowel smaller than distal -ileorectal anastomosis -less bl.supply than end to end Side to side -antimesen of two segment -ileocolic,small bowel anas Technique Hand suture -single layer :running or interrupt -double layer :inner=continue :outer=interrupt -permanent or absorb suture Stapled technique -linear cutter stapling device :end to end anastomosis -circular stapling device :end to end,end to side,side to end -useful in low rectal/anal canal anas that hand sew difficult due to pelvis

Colorectal-anus short note by S.Wichien (SNG KKU)

Colectomy Ileocolic resection -resect terminal ilium,cecum,appendix -ileocolic crohn dz -benign lesion or incurable ca -if curable ca,more radical resection, such as rt hemicolectomy -ligated ileocolic vv -1anastomosis between distal small bowel and ascending colon Rt colectomy -for curative intent resection of proximal colon ca -ligated ileocolic,rt colic, rt br of middle colic vv -10 cm of terminal ilium are resected -primary ileal transverse colon anas Extend rt colectomy -for curative intent resection of hepatic flexure/prox transverse colon -ligate middle colic vv at their base -rt colon,prox tv colon are resected -primary anas at ilium-distal tv colon Transverse colectomy -lesion in mid,distal tv colon -ligate middle colic vv -colocolonic anastomosis Lt colectomy -lesion confined to distal tv colon, splenic flexure,descending colon -ligated lt br of middle colic vv, lt colic vv,1st br sigmoid vv -colocolonic anastomosis Extended lt colectomy -lesion in distal tv colon -lt colectomy+extend include rt br of middle colic Sigmoid colectomy -sigmoid lesion -ligated sigmoid br of IMA -resected to level of peritoneal reflect -anas at descending c./upper rectum -full mobilization of splenic flexure to Total Colectomy -fulminant colitis -FAP -peserved sup rectal a. -ileorectal anastomosis -if anas is contraindicate,an end ileostomy is created and remaining sigmoid or rectum as mucus fistula or hartmann pouch Subtotal colectomy -distal sigmoid vv are left -anas ilium-distal sigmoid colon Proctocolectomy Total protocolectomy -colon,rectum,anus are removed -ileum to skin=ileostomy Restorative proctolectomy -ileal pouch anal anastomosis -preserve anal sphincter m,anal canal -anastomose of ileal reservoir to anus neorectum by anastomosis of terminal ileum aligns to J,S,W

-J puch is simplest=most used

-most perform proximal ileostomy to divert succus from create pouch to minimize leak and sepsis -ileostomy closed 6-12 wk later Procedure in colorectal obstruction 1.colonic obstruction Rt side/ prox transverse colon 1.low risk pt1ileocolic anastomosis 2.hi risk ptresection+ostomy Lt side colon 1.resection without anastomosis -proximal colostomy+Hartmann 2.resection+on table lavage+1anasto 3.subtotal colectomy+1anasto -caecal perforate -synchronous lesion -massive distend colon 4.3 stage -colostomyresectionanastomosis 5.colonic stent -C/Iperforate/<4cm from AV/rt side 2.Rectal obstruction Upper+middle rectum -stent or transverse colostomyCCRT/LAR Lower rectum -sigmoid colostomyCCRTSx

create tension free anastomosis

Colorectal-anus short note by S.Wichien (SNG KKU)

Anterior resection -resect rectum from abdo approach High AR -resect distal sigmoid, upper rectum -mobilize rectum, not fully from sacrum -ligated IMA at its base -ligated IMV -1anastomosisend to end Low AR -lesion at upper/mid rectum -mobilize rectosigmoid -open pelvic peritoneum -mobilize rectum from sacrum -dissection anorectal ring -Post : through rectosacral fascia Ant : through Denonvilliers fascia to vagina in women or seminal vesicle and prostate in men -anastomosis require mobilize of splenic flexexure Extend low AR -lesion in distal rectum -but several cm above sphincter -moblize rectum as low AR -but ant dissection is extended along rectovaginal septum in women distal seminal vesicle/prostate in men - when risk of leakage is hi should perform temporary ileostomy -post operative fxn may be poor des colon lack distensibility reservoir fxn may compromise colon J-pouch or coloplasty =Improve fxn -Hx of sphincter damage or incontinence is relative C/I for coloanal anastomosis End colostomy should perform Pouchitis -inflam affect both ileoanal pouch and continent ileostomy reservoir -incidence 30-55% -diarrhea,hematoczia,abdo.pain,fever -dx=endo+bx -ddx=infection,undx crohn dz -etiology=unknown -fecal stasis -ATB=metro+/-ciprofloxacin -some develop chronic pouchitis salicylate/steroid enema pouch excision APR -abdomioperineal resection -remove entire rectum,anal,anus -permanent colostomy -procedure as extend low AR -peritoneal dissection :2nd surgeon :excise anal c. c wide circum margin TME -sharp dissection under vision -outside mesorectal fascia -down to pelvic floor -identified and preserve symp+parasymp -adequate mesorectal excision= 5cm margin Step 1.plane behind rot of pedicle package 2.plane ant to ANS 3.hi ligation IMA=prox to left middle colic A IMV=inf of pancreas 4.dissect Holy plane postlatant 5.divide lateral ligament 15% in lateral ligament 6.anterior dissection include peritoneal reflection+Denoviller ANS sparing TME -sup hypogastric plexusejaculation dysfxn -inf hypogastric plexusED&urine retention

Colorectal-anus short note by S.Wichien (SNG KKU)

Ostomy -temporary vs permanent -end on vs loop -located in rectus m.to minimize risk of parastromal hernia -pt can see,easily manipulate -abdo should flat to prevent leak -circular skin incision -subcu.dissected to ant rectal sheath -sheath is incised in cruciate fashion -separated m. -incised post sheath -size of defect depend on bowel size -should be as small as possible, without compromise bl.supply -usually width of 2-3 finger -closed incision and dress prior maturing stoma to avoid contaminate -3-4 interrupt absorb suture are placed through edge of bowel then through serosa then through dermis Complication -stoma necrosis (early post op) :tight fascial defect or :skeletonizing the distal small bowel -stoma retraction :in obesity -skin irritation -obstruction -parastomal hernia :less than colostomy :resiting the stoma to contralat side -prolapse :rare,late c/p :asso parastomal hernia -Continent ileostomy = valve slippage 2.Colostomy -most as End colostomy > loop colos -loop colostomy >>more prolapse -most = in left side -mature by Brooke fashion -distal bowel as :mucus fistula :Hartman pouch -closure of colostomy require laparotomy : end to end anas Complication -colostomy necrosis :skeletonize distal colon :tight fascial defect Tx :suprafascia--expectant :below fascia--sx -retraction -obstruction -parastomal hernia -prolapse -less skin irritation than ileostomy -less dehydrate than ileostomy

(Brooke technique)

1.Ileostomy Temporary ileostomy -protect anastomosis for leakage -loop ileostomy -with or without rod -divided loop prevent incomplete diversion that occur c loop ileostomy -advantage=closure can be accomplished without laparotomy,handsewn or stapled anastomosis can be created and return bowel to peritoneal cavity Permanent ileostomy -require after total proctocolectomy or in pt c obstruction -end ileostomy :Brooke end ileostomy :Continent ileostomy (by Kock) internal ileal reservoir nipple valve construct :continence m.

:most common late c/p

Colorectal-anus short note by S.Wichien (SNG KKU)

Adenocarcinoma Incidence -most common malignancy in GI -men=female -adenoma-carcinoma sequence Risk factor 1.aging > 50yr 2.hereditary -80%sporadic 20%fam.hx -APC gene defect 3.environments -animal fat diet,low fiber -hi-sat or polyunsaturated fat -alcohol -vit A,E,C,ca,selenium=dec risk 4.inflammatory bowel -10yr--inc 2% 20yr--inc 8% 30yr--inc 18% 5.other -smoking,ureterosigmoidotomy acromegaly,pelvis irradiation Genetic defect Normal epi>>APC>>dysplastic epi>>early adenoma>>K-ras>>intermediate adenoma>>DCC/DPC4>>late adenoma>>p53>>carcinoma>>other change>>metas APC-tumor suppressor gene K-ras-proto-oncogene DCC-tumor suppressor gene p53-tumor suppressor gene Genetic pw--2 major pw 1.LOH pw--80% -chromosome deletion and tumor aneuploidy 2.RER pw--20% -Replication Error pw -missmatch repair pw -asso microsatellite instability--MSI Familial colorectal ca Risk of ca -no fam.hx 6% -one 1st degree 12% -two 1st degree 35% Spreading 1.Regional LN -most common -node metas inc with tumor size, poorly diff, dept of invade, lymphovas invade -dept of invasion (T) :most signi predictor of LN spreading :Tis = no node metas :T1,2 = node metas 5-20% :T3,4 = node metas >50% -number of node asso.distant ds ->=4 node : poor prog -upper rectum :along sup.rectal vv to IMA -lower rectum :middle rectal vv :inf rectal vv to int illiac node 2.Hematogenous -most common = liver -via portal venous system -risk of hepatic metas :tumor size/ tumor grade -pulmo.metas rarely occur in isolate Staging T1-invade submucosa T2-invade mucularis propia T3-invade into pericolorectal tissue T4a-visceral peritoneum, T4b-invade organ N1-1-3 LN N1a-1, N1b-2-3 N1c-no LN but tumor in subsero/mesen N2->=4 LN N2a-4-6, N2b->=7 M1a-1 organ, M1b->=2 organ

*node is single most important prog.factor

Colorectal-anus short note by S.Wichien (SNG KKU)

Ca colon.Tx Pre-op -Colonoscopy :synchronous lesion--5% of pt -endorectal u/s :assess T N -CT chest/abdo/pelvis -CEA Objection -remove 1tumor along with its lympovascular supply :lymph along a. :bowel resection depends on vv are supplying segment involved with ca -resect adjacent organ :omentum -if can't remove all tumor :palliative procedure Stage 0 (TisN0M0) -no node metas -completely remove endoscopic -follow colonoscopy Stage1 (T1 N0 M0) (malignant polpys) Pedunculate polyps -in head polyp--can endoscopic tx -lymphovas.invasion,poorly diff, tumor within 1mm msrgin, invade submu :segmental colectomy Stage1 and 2 (T1-3 N0 M0) (localized colon ca) -major=cure c sx -adjuvant CMT for select pt c stage2 :young pt,tumor c hi-risk histo.finding Stage3 (anyT N1 M0) (LN metastasis ) -recommend adjuvant CMT -5-FU base regimen c leucovorin Stage4 (anyT anyN M1) (distant metas) -all require adjuvant CMT -can't cure by sx -palliative Follow up -most recur within 2yr -colonoscopy within 12 mo if normal,repeat q 3-5 yr -CEA q 2-3 mo for 2 yr -CT scan in CEA elevate,not routine Screening Average risk -50yr -annual FOBT -flex.sigmoidoscope q 5yr or BE q 5 yr or Colonoscopy q 10 yr Adenomatous polyps -50yr -colonoscopy at 1st dx then in 3yr Colorectal ca -at dx -pre tx colonoscope then 12 mo after curative resection then colonoscopy after 3yr then q 5yr FAP -10-12yr -annual flex.sigmoidoscope -EGD q 1-3yr after polyps appear Attenuated FAP -20yr -annual flex.sigmoidoscope -EGD q 1-3yr after polyps appear HNPCC -20-25yr -colonoscopy q 1-2 yr -endometrial aspi.bx q 1-2yr Fam.colorectal.ca (1st degree relative) -40 yr or 10 yr before the age of youngest affect -colonoscopy q 5yr Surveillance Hx+PE+CEA -q 3 mo * 2 yr -q 6 mo until 5 yr Colonoscope -135 yr -if no pre-opshould s/p sx 3-6 mo CT scan -q 1yr * 3 yr

Colorectal-anus short note by S.Wichien (SNG KKU)

Ca rectum.Tx -more difficult to resect neg margin -because anatomic limit of pelvis -local recurrence higher than colon Local tx distal 10 cm of rectum can transanal Transanal excision -noncircum,benign,villous adenoma -can T1,some T2 -can't LN--may understage pt Transanal Endoscopic microsx(TEM) -higher lesion(up to 15cm) Ablative technique -electrocautery,radiation -disvantage=no patho specimen Radical resection -remove involve segment, lymphovascular supply -2cm distal margin Total mesorectal excision(TME) -sharp dissection anatomic plane -complete resection rectal mesentery -upper rectum/rectosigmoid :partial mesorectal excision :5cm distal tumor=adequate -extensive involvement of pelvic organ may require pelvic exenteration :APR :en bolc resection (ureter,BD,prostate or uterus/vg) :colostomy,ileal conduit :sacrectomy upto S2-3 jxn

stage0 (Tis N0 M0) -Transanal excision -1 cm margin stage1 (T1-2 N0 M0) -localized rectal ca -local excision:local recur hi(20-40%) -radical resection:recommend -in refuse radical sx :local excision :adjuvant chemoradiation :improve local recurrence stage2 (T3-4 N0 M0) -localized rectal ca 1.preop staging 2.CCRT 4-6 wk 3.Sx distal margin 2 cm TME margin 2mm ANP sphincter preserve if >= pelvic floor 1 cm 4.post op CRRT stage 2a, LN +ve stage3 (anyT N1 M0) -node metas -chemoradiation pre or post op for node+ve rectal ca -neoadjuvant>>sx stage4 (M1) -palliative procedure -avoid morbid procedure -intraluminal stent -diverting colostomy

Colorectal-anus short note by S.Wichien (SNG KKU)

CA rectum Sx 1.Sphincter saving procedure Procedure 1.AR -intraperito colorectal anastomosis 2.LAR -extraperito colorectal anastomosis 3.ultralow AR -just above pelvic floor 4.intersphincteric resection -divide full thickness of IAS -1-2cm distal from tumor +/- frozen section -coloanal anstomosis Reconstruction 1.end to end -loss rectal reservoir -LAR syndtrenesmus, frequency, inconti 2.colonic J pouch -6-8 cm pouch -dec LAR synd 3.coloplasty Protective ileostomy I/C 1.pre op XRT/ CMT 2.ultralow anastomosis 3.incoplete donut ring 4.malnutrition, immunosup, pelvic abscess 2.APR I/C 1.tumor invade ext sphincter/ pelvic floor 2.sphincter incompetence 3.poor colonic vasculariztion 3.local excision I/C -T1, well diff, no LVI -N0 -mobile -< 3cm -<30% circum ->3mm margin Complication s/p rectum Sx 1.ureter injury Mechanism of inj 1.hi ligation of IMA1repair 2.sigmoid mobilization1repair/Boari flap 3.anterolat dissectionre implant Suspect in intraop -iv indigo carmine/ methylene blue -post op RP 2.urethral inj -dissection APR -dont dissect across transverse perineal m -Tx1repair over foleyretain 2-4 wk 3.anastomosis leakage Prevention -good blood supply -tension free anastomosis -complete donut ring -air test Free leakage Tx -take down anastomosishartmann -1anasto+diverting ostomy+pelvic drain (low contaminate+small defect) Contained leakage or abscess Tx -small abscessATB iv -large abscessPCD -continue leakagePCD+diversion ostomy 4.anastomosis bleeding -staple > handsewn 5.post op ileus -open sx > 5 d -lap sx > 3 d Tx -enhanced recovery program -peripheral opioid antagonist :Alvimopam (approve 15 dose) :12 mcg o 30 min pre op :12 mcg o bid * 7 d

Colorectal-anus short note by S.Wichien (SNG KKU)

Anal tumor -uncommon -2%of colorectal malignant Divided into 1.anal canal -puborectalis to AV -lymph drainage :sup.rectalIM node :middle,inf.rectalint.illiac node 2.anal margin -distal to dentate line -5 cm around AV -lymph drainage :inguinal node :if 1are blocksup.rectal Anal intraepi.neoplasia (AIN) -bowen ds -hi-grade squa. intraepi lesion--HSIL -sq.cell ca in situ -precursor to invasive sq.cell ca -plaque like lesion -as CIN : acetic acid,Lugol solution -asso HPV 16,18 -asso HIV,homosexual men -hi-reso anoscopy--abnor telangiec Tx -resection or ablation -hi recurrent,require closed f/u :pap smear q 3-6 mo Epidermoid carcinoma 1.sq.cell ca 2.cloacogenic ca 3.transitional ca 4.basaloid ca -slow growing -anal/perianal mass -pain,bleeding -inguinal node=poor prog Tx SCC of anal canal -non keratinized -Nigro protocol (5FU,MMC,3000cGy) > APR SCC of anal margin -keratinized -as sq.cell ca in skin -WLE 2 cm Verrucous ca -Buschke-Lowenstein tumor or Giant condyloma accuminata -aggressive of condy.accuminata (HPV 6,11) -not metas -Tx of choice--wide local excision Basal cell ca -rara of anus -as skin -raise,pearly edge,central ulcer -slow growing tumor -rare metas -wide local excision -large lesion=radical resection,RTX Adenocarcinoma -extremely rare -spread from lower rectal ca -may from anal gland/chronic fistula -Tx of choiceAPR+WLE of perineum Paget dz -adenocarcinoma in situ -apocrine gland -plaque like -indistinguish from Bowen dz -paget cell -asso synchronous GI adenoca complete assess GI tract -wide local excision 1 cm Melanoma -rare -1-2% of melanoma -S-100 -5yr survive <10% -at dxoften deep invade, metastasis -Tx of choice WLE

Colorectal-anus short note by S.Wichien (SNG KKU)

Rare colorectal tumor Carcinoid -25% in rectum -risk malignancy inc with size -tumor>2cm :60% have metas -less vasoactive in other location -have syndrome--have liver metas -in prox.colon :less common :more likely to be malignancy -med=somatostatin(octreotide),INF Small -locally resect Large/invade muscular -more radicak sx Carcinoid carcinoma -adenocarcinoid -both carcinoid and adenoca -hx=more closely adenoca -common regional/systemic metas -tx as adenoca Lipoma -most common in submucosa -benign -<2cm=rarely cause bleed,obstr,intus -small asymp=not sx -larger :colonoscopic resection :colotomy c enucleation Lymphoma -10%of GI lymphoma -rare in colon/rectum -cecum is most involve (spread from terminal ileum) -bleeding,obstruction -Tx of choice = bowel resection -adjuvant cmt upon stage Leiomyoma -smooth m.tumor -most common in upper GI -most=asymp -large lesion=bleed,obstruct -difficult to distinguished from leiomyosarcoma,should resect ->5cm--radical resection, (because risk of malignancy) Leiomyosarcoma -rare in GI -rectum is most common -radical resection Retrorectal tumor -presacral tumor -ant--rectum post--presacral fascia lateral--endopelvic fascia -upper 2/3 of rectum and sacrum -contain embryologic remnant (neuroectoderm,notocord,hindgut) -most common=congenital -lower back/pelvic/leg pain -GI symptom -PR=palpable lesion -MRI pelvis=most sense/spec -myelogram in CNS involve -bx not indicate,if lesion resectable :infection,seeding Cyst -dermoid/epidermoid--ectoderm -enterogeneous cyst--primitive gut -ant meningocele/myelomeningocele :scimitar sign = pathognomonic (sacrum c round, concave border without bony destruction) Solid -teratoma--germ cell -chordoma--notochord :most common malig in this region :bony destruction -neurofibroma,neurilemoma ependymoma,ganglioneuroma -osteoma,bone cyst osteogenic sarcoma ewing sarcoma,giant cell T chondromyxosarcoma Tx -sx resection Hi-lesion--transabdo approach Low-lesion--transacral

Colorectal-anus short note by S.Wichien (SNG KKU)

Familial Adenomatous Polyposis -1% of colorectal adenoca -AD -APC gene mutation -APC gene testing (+ve in 75%) -located on chrom 5q -risk ca 100% by age 50 yr Screening -flex.sigmoidoscope :1st degree relative--age 10-15 yr :q 2 yr until 34 yr :q 3 yr until 44 yr :then 3-5 yr -EGD :at 25-30yr q 1-3yr :adenoma anywhere in GI :duodenum >> periampullary ca Rx 4 factors affect choice of Sx -age -severity of symptom -extend of rectal polyposis -location of ca,desmoid tumor 1.total abdo.colectomy -ileorectal anastomosis -surveillance rectum 2.total proctocolectomy -end ileostomy (Brooke) or continent ileostomy (Kock) -large abandon--success of 1 3.restorative proctocolectomy -ileal pouch anal anastomosis +/- temporary ileostomy Med -admin cox-2 inh (celecoxib,sulindac) may slow develop polyps Extraintes manifestation -congen.hypertrophy of retinal pigment epithelium -desmoid -epidermal cyst -mandibular osteoma (Garder synd) -CNS tumor (Turcot synd) FAP attenuated (AFAP) -polyps < 100 -later in life age -APC mutationAD (30% of pt) -MYH mutationAR -10-100 polyps--dominant rt colon ->50%--ca clon--average 50yr -duodenal polyposis Tx -total colectomy+IRA -if have rectal lesionsnare+follow colono HNPCC (Lynch syndrome) -Hereditary Nonpolyposis Colon Ca -AD -error in mismatch repair -develop ca at early age--40-45 yr -not Ca 100% as FAP -synchronous lesion = 40 Lynchs syndrome 1=only colon 2=GI/KUB/Gyne 3=skin lesion 4=Turcot syndrome Extracolonic malignancy -endometrial--most common -ovarian, panc, stomach, smb, biliary, uro 3-2-1-0 rules Amsterdam criteria ->=3 relative dx--HNPCC one of whom is 1st degree relative -at least 2 generations -at least 1--dx <50yr -no FAP Screening -screening colonoscopy 20-25yr or 10yr younger than youngest age at diagnosis in family -hi risk of endometrial ca :TVS or endometrial aspiration bx :after 25-35yr Sx -total colectomy+IRA 40% risk of develop 2colon ca in adenoma/colon ca anaul proctoscope >> risk ca rectum -prophylactic hysterectomy c BSO in complete childbearing