Colon, rectum and anus

Dr. sigid djuniawan,spB

Anatomy

The Bodys Digestive System

Esophagus, Stomach, Small Intestine &

Large Intestine
1st 6 feet = large bowel or colon
Last 6 inches = rectum & anal
canal
The anal canal ends at the anus

cancer

Colorectal polyps
Hyperthrophic lymph folicles, submucosal lesion
Carcinoid tumor : at appendix (35-40%), rectum ( 15%), colon (10%)
Neoplastic mucosal lesion : tubular adenoma (60-80%), increase with
age, tubulovilous adenoma , vilous adenoma,
ADENOCARCINOMA SEQUENCE

DISTINGUISHING FEATURES
OF COLITIS-ASSOCIATED
COLORECTAL CANCER

MULTIPLE POLYPOSIS SYNDROME

Familial adenomatous polyposis : chromosome 5, rare,
Age start :25 yo, clinical : abdominal pain, diare, hematochezia,
anemia def iron

Signs & Symptoms

Change in bowel
habits
Blood in Stool

Bright red
Very dark red
Black/Tarry Stool

Diarrhea
Constipation
Does your bowel feel
like it emptied
completely?

General abdominal
discomfort

Gas pains
Bloating
Fullness
Cramps

Weight loss w/ no
explained reason
Constant tiredness
Vomiting (coffee
grounds)

Tests that examine

Rectum, Rectal Tissue, & Blood
Aids in diagnosing & preventing colon
cancer

Physical Exam

General Medical History

Includes self health habits

Past self illnesses
Various treatments used for previous issues
Family health history

If patient reports problems with respect to

signs and symptoms related to common
bowel change habits
Are symptoms affecting your everyday life?

Fecal occult blood test

Check stool for evidence of blood

Method
Small samples of stool are placed on
special cards and returned to the Dr. or
Lab for testing under a microscope

Potential harms
False-positive & false negative results
(uncommonserious

Digital Rectal Exam

The doctor or nurse inserts a

lubricated, GLOVED finger into the
rectum to feel for lumps or abnormal
areas.

Barium Enema

Barium is a liquid, that contains a

silver-white compound, inserted into
the rectum
The barium coats the lower GI tract
and a series of x-rays are taken of
the lower GI tract
AKA = a lower GI series

What does a Barium Enema do?

Detects
Ulcers
Narrowed areas (strictures)
Growth of the lining (polyps)
Small pouches in the wall of the
intestine

Diverticula

Cancer
abnormalities

How can one prepare for this test?

Colon must be completely empty

Prescribed laxatives or enema (pre-exam)

Special Diet to follow (2 days prior)

Clear liquids
Tea or coffee without milk or cream
Any juice without pulp (NO OJ or Tomato)
Broth
Carbonated beverages

Types of Barium Enemas

Single Column

Lie on side on Xray table

Enema tube inserted into rectum
Barium bag is delivered into colon
May feel urge to have a bowel movement.DONT
Though, a small balloon will keep it inside you
Take long deep breaths through mouthhelps relax
May be asked to turn & rotate to evenly coat all colon
Then the radiologist will take a number of X-ray
images from various angles

Air Contrast (Double contrast)

Similar to single-column
Big differenceAir is inflated with air
in addition to the barium to expand
and improve the quality of the
images
Polyps can be seen easier, among
other abnormalities

Results

Negative = no
abnormalities are
found
Positive =
abnormalities
found, such as
polyps.
If positive you may
be scheduled for
further testing.

Cons of Barium Enema

miss small polyps or sometimes even

small cancers
Biopsy and polyp removal cannot be
done during testing
you may need to follow up with a
colonoscopy
Preparing for the procedure
(emptying the colon) and the
procedure itself can be unpleasant

Sigmoidoscopy

Views the rectum and

sigmoid colon areas for
polyps, abnormalities, or
cancer
A sigmoidoscope is a thin
lighted tube is inserted
into rectum & up through
the sigmoid colon
May remove polyps or
tissue samples for biopsy

Procedure Detection

The cause of diarrhea, abdominal pain,

or constipation
Detect early signs of cancer in
descending (sigmoid) colon and rectum
can see bleeding, inflammation,
abnormal growths, and ulcers
not sufficient to detect polyps or cancer
in the ascending or transverse colon
(two-thirds of the colon).

Preparation

Liquid diet
Most likely given an
enema preprocedure
Air is pumped into
colon to help
expand and see
more surface area
Duration is 10-20
minutes

Complications

Though very
uncommon
It is likely that
bleeding or a
puncture of the
colon could result
during procedure

Polyp...Removal

Colonoscopy

Procedure to look into entire length

of large intestine (colon) to detect
abnormalities
Preparation, procedure, & results
same as sigmoidoscopy
New virtual colonoscopy as
alternative procedure

Virtual or (CT) Colonography

a series of x-rays called computed

tomography to make a series of
pictures of the colon
Computer then puts these pictures
together to create a detailed image
that shows polyps, etc.

Prognosis (chances of recovery)

Depends on
Stage : in the inner lining of colon only,
whole colon? Spread to other places in body
Has it blocked or created a hole in the
colon?
Blood levels of carcinoembryonic antigen
(CEA); a substance in the blood that may
be increased when cancer is present, before
treatment begins.
Has cancer recurred?
Patients general health?

Treatment Options

Surgery (main treatment)

Radiation Therapy
Chemotherapy
Newer targeted therapies
Monoclonal antibodies

Depending on stage of cancer, it is likely

that 2-3 types of treatment may be
utilized at the same time or one after the
other

Surgery

Removal of cancer and normal area of

colon on either side, as well as nearby
lymph nodes
Then sewn back together
Colostomy (bag to catch the waste kept
outside the body)
If cancer is found early, a colonscope
can be used without cutting the
abdomen

Radiation Therapy

high-energy rays (such as x-rays) to kill or shrink

cancer cells
external radiation
internal or implant radiation; placed directly into
tumor
Radiation can also be used to ease symptoms of
advanced cancer such as intestinal blockage,
bleeding, or pain
Main uses is for those where cancer had attached
to an internal organ or the lining of the abdomen
can be aimed through the anus and reaches the
rectum without passing through the skin of the
abdomen

Chemotherapy

use of anticancer drugs injected into a vein or

given by mouth
treatment useful for cancers that have spread
to distant organs
increase the survival rate for patients with
some stages of colorectal cancer (will kill
normal cells also)
Side effects depend on amount, length, & type
of drugs given (i.e. diarrhea, nausea,
vomiting, loss of appetite & hair, mouth sores,
increased chance of infections, bruising &
bleeding after minor cuts or injuries & overall
increased fatigue

Risk Factors

Age 50 or older
Obesity (fat in waist area increases)
30%-40% of smokers diagnosed with cancer will die
A family history of cancer of the colon or rectum.
A personal history of cancer of the colon, rectum,
ovary, endometrium, or breast.
A history of polyps or ulcerative colitis (ulcers in the
lining of the large intestine) or Crohns disease.
Certain hereditary conditions, such as familial
adenomatous polyposis and hereditary nonpolyposis
colon cancer (HNPCC; Lynch Syndrome)
Heavy use of Alcohol has been linked to this cancer

Dietary Risk Factors

eat plenty of fruits, vegetables, and whole grain

foods
to limit high-fat foods (especially from animal
sources) and limit excessive alcohol consumption
studies suggest that taking a daily multivitamin
containing folic acid or folate can lower risk
Other studies suggest that getting more calcium
with supplements or low-fat dairy products can
help
Getting enough exercise is important as well 30
min of physical activity on 5+ days per week.

Survival Rates

9 of 10 people whose cancer is found &

treated at early stage (before spreading)
will live at least 5 years
Spread to nearby organs/lymph nodes=
5years 66% survival rate
Spread to lungs/liver= 5 year 9%
(5 yr is based on percentage of patients
that were alive 5 yrs after diagnosis.
Leaving out those who died of other
causes)

Modified Dukes Staging System

for Colorectal Cancer

Modified Dukes A The tumor penetrates into the mucosa

of the bowel wall but no further. Modified Dukes B B1:
tumor penetrates into, but not through the muscularis
propria (the muscular layer) of the bowel wall. B2: tumor
penetrates into and through the muscularis propria of the
bowel wall. Modified Dukes C C1: tumor penetrates into,
but not through the muscularis propria of the bowel wall;
there is pathologic evidence of colon cancer in the lymph
nodes. C2: tumor penetrates into and through the
muscularis propria of the bowel wall; there is pathologic
evidence of colon cancer in the lymph nodes. Modified
Dukes D The tumor, which has spread beyond the confines
of the lymph nodes (to organs such as the liver, lung or
bone).

Ulcerative colitis

Colitis

Diffuse inflamatory disease of mucosa colon and rectum

Etiology : unknown, autoimunne respon,microba (chlamydia,
cytomegalovirus, yersinia),
Endoscopy : granulars superficial ulcers, thickened mucosa, superficial
fissures, small pseudopolyps
Clinical : bloody diarrhea, high fever, abdominal pain
Therapy : corticosteroids and immunosupresive agent (azathioprine,
cyclosporine, 6-mercaptopurine), sulfasalazine is profilactic effect
(prostaglandin synthesis), surgical : children, fulminating acute colitis,
obstruction, (11%), acute toxic megacolon (6-13%) total
proctocolectomy with ileostomy

Polyps In Colitis

Chronic Ulcerative Colitis

Volvulus

Def : abnormal twisting or rotation about its mesentery

Etiologi : occlusion of lumen at each end segmen vascular
compromise
Location : sigmoid (50%), cecal (20-40%),transverse colon ,
splenic flexure (gastrocolic, splenocolic, phrenocolic ligaments)

Chrons disease

Crohn's disease, also known as

inflammatory bowel disease, regional
enteritis, and Granulomatous ileocolitis
disease is an inflammatory disease of the
intestines that may affect any part of the
gastrointestinal tract from mouth to anus,
causing a wide variety of symptoms. It
primarily causes abdominal pain, diarrhea
(which may be bloody if inflammation is at
its worst), vomiting, or weight loss,[1][2]
[3] but may also cause complications
outside of the gastrointestinal tract such as
skin rashes, arthritis,
inflammation of the eye, tiredness, and lack
of concentration.[1]

Crohn's disease can lead to

several mechanical complications
within the intestines, including
obstruction, fistulae, and
abscesses

Diverticulitis

Definition : saclike protrusion of colonic wall

Congenital , aquired
Age : 60 -65 yo
Etiolofi : low fiber diets
Location : caecum (2%), Colon descenden (94%)
Clinical : bleeding
Complication : abcess, fistula, obstruction
Indication for surgery :
Absolute : complication of disease , persistent pain, clinical
deteoritation
Relative : chronis stricture, young patient, corticosteroid use,
diverticulitis

Rectum

Surgery of rectum

Tumor at upper rectum V LAR, distal 2 cm, prox 5 cm

7-8 cm
abdominoperineal resection
> 12 cm
LAR
Pathological staging (mod Astler and Collier) : TNM
Post opertaive : monitoring CEA

Surgery for Rectal Cancer

Surgery is main treatment, along with a

combination of radiation therapy
Polypectomy, local excision, and local transanal
resection) can be done with instruments placed
into the anus,
Stage I, II, & III rectal cancers, other types of
surgery may be done
A low anterior resection is used for cancers near
the upper part of the rectum, close to where it
connects with the colon.
Abdominoperineal resection is done for cancers
located close near the lower rectum-anal
conjunction. After this surgery, a colostomy is
needed

Pelvic Exenteration:
the surgeon removes the rectum as
well as nearby organs such as the
bladder, prostate, or uterus if the cancer
has spread to these organs. A colostomy
is needed after this operation. If the
bladder is removed, a urostomy
(opening to collect urine) is needed

Anus

Symptoms : bleeding, pain, discharge, change of bowel habits

Disorders :

incontinence disordes, prolapse of the rectum

hemorroids, fissura in ano, abcess, fistulo in ano, chrons disease
neoplastic disorders : Bowens disease ( SCC), Pagets disease
(intraepithelial
adenocarcinoma), BCC,

Hemorhoid

HEMORHOID adalah pelebaran

Vena di dalam pleksus
HEMORHOIDALIS yg tidak
merupakan keadaan patologik ,
hanya apabila homorhoid ini
menyebabkan keluhan atau
penyulit diperlukan tindakan .

HEMORHOID DIBEDAKAN :

HEMORHOID INTERNAL
Pelebaran pleksus vena hemorhoidalis superior di
atas garis mukokutan dan ditutupi oleh mukosa.
Merupakan bantalan vaskuler di dalam jaringan sub
mukosa pada rektum sebelah bawah.

HEMORHOID EKSTERNAL
Merupakan pelebaran dan penonjolan pleksus
hemorhoidalis inferior, terdapat di sebelah distal
garis mukokutan di dalam jaringan di bawah epitel
anus.

POSISI HEMORHOID YANG

PALING SERING :
. Kanan Depan
. Kanan Belakang
. Kiri Lateral

PATOGENESIS

Tiga Teori :
1 TEORI MEKANIKAL :
1 Dasar
: Jaringan penunjang muskulo
fibroelastik
hemorhoid
interna, Parks ligamen yang
mengalami degeneratif kelemahan
abnormal dari jaringan
pergerakan
hemorhoid
peninggian tekanan intra
rektal peningkatan ukuran hemorhoid.

PATOGENESIS
2 TEORI HEMODINAMIK :
Dasar

: Mikrosirkuler anal kanal mengandung arterio

venus shunt yang cenderung akibat reaksi
hormonal atau rangsangan fisiologikal,
berdasarkan pemeriksaan mikroskop elektron
dan histologi.
3 SPINCTER ABNORMAL:
Dasar : Peningkatan aktivitas spincter, menyebabkan
peningkatan tekanan jaringan dalam analkanal.

Current etiologic, pathogenic, and

paathophysiological concepts of
hemorrhoidal disease

Pathophysiology of hemorrhoids:
hemorrhoids in place but mobile

Pathophysiolohy of hemorrhoids:
Prolapsed hemorrhoids

Normal arteriovenous shunt function:

Arteriovenous shunts closed,
precapillary sphincter opened

Arteriovenous shunt dysfunction:

opening of arteriovenous shunts,
contraction
of precapillary sphincter

FAKTOR RESIKO YANG DAPAT

MENYEBABKAN HEMORHOID :

Gangguan fungsi usus halus mis: diare, konstipasi

Gangguan pengosongan rektum
Kehamilan dan melahirkan
Pemakaian obat-obat lokal mis: enema,
supositoria, penggunaan laksan yang berlebihan
Oral kontraseptif
Iritasi mukosa anal kanal
Diet yang rendah serat
Alkohol

GAMBARAN KLINIK:
Nyeri
Perdarahan
Prolap hemorhoid
Discharge / Mucus
Pruritus

Examination in knee-elbow position

Examination in left lateral position

PEMERIKSAAN
Terdapat mucus pada
hemorhoid
yang prolap
2 Colok dubur
3 Anuskopi
4 Proktosigmoidoscopy
1

DIAGNOSA BANDING:
Karsinoma Kolorektum
Penyakit Divertikel
Prolap Rectum
Kolitis Ulserativa
Kondiloma Perianal
Lipatan kulit Sentinel pada garis
tengah dorsal

Macam Haemorhoid

Kelainan Anorektal

KOMPLIKASI
Trombosis melingkar nyeri
hebat
nekrose mukosa dan kulit
penutup
(jarang)
2
Emboli septik melalui sistem portal
abses hati
3
Anemia
1

Paska Haemorhoidektomi (komplikasi)

KLASIFIKASI
Hemorhoid interna dikelompokkan dlm 4 derajat:
DERAJAT I :
Perdarahan segar tanpa nyeri pada waktu
defekasi. Tidak ada prolap, pada
pemeriksaan anuskopi terlihat hemorhoid
yang menonjol ke dalam lumen.
DERAJAT II :
Menonjol melalui anal kanal saat
mengedan ringan, tetapi dapat masuk
kembali secara spontan.

KLASIFIKASI

DERAJAT III :
Menonjol saat mengedan dan harus
didorong kembali sesudah defekasi.

DERAJAT IV :
Menonjol keluar dan tidak dapat
didorong
masuk, biasanya timbul gejala
nyeri.

Staging of hemorrhoids

PENANGGULANGAN
umum
B . Terapi obat-obatan
C . Skeleroterapi
D . Ligasi dengan gelang karet
E . Bedah beku
F . Infrared coagulasi
G . Metode lain
H . Hemorhoidektomi
A

. Secara

Sclerotherapy equipment

Injection sclerotherapy

Sclerotherapy technique

Rubber and ligator with its cone

engabling fitting of a rubber band

Cryode with its nitrous oxid cylindeer

and pressure adjuster

Infrared coagulation apparatus

Indikasi metode pengobatan berbagai derajat

Derajat Hemorhoid hemorhoid
Pengobatan
I

II

III
IV

Terapi obat-obatan
Sklerosing metode
Foto coagulasi
Bipolar coagulasi diatermi
Terapi obat-obatan
Ligasi gelang karet
Heater probe
Sklerosing metode
Ligasi gelang karet
Operasi
Terapi obat-obatan
Operasi
Terapi obat-obatan

PILIHAN TERAPI
TRADITIONAL

MEDICAL

I0
II0
III0
IV0

MODERN

MEDICAL

SURGICAL

OFFICE
PRACTICE
SURGICAL

I0

II0
III0
IV0

PARADIGMA BARU
1. DIAGNOSA HEMORRHOID INTERNA HARUS
DILENGKAPI PEMERIKSAAN PROKTOSKOPI
2. TENTUKAN : LETAK, JUMLAH DAN BESARNYA
MASING- MASING BENJOLAN
(PENTING UNTUK EVALUASI
PROKTOSKOPI)
3. DERAJAT 3 : BISA DIBAGI MENJADI 3A DAN 3B

PARADIGMA BARU
DERAJAT 3A

: SEPERTI KRITERIA 3 TETAPI

BILA BENJOLAN 2

DERAJAT 3B

: SEPERTI KRITERIA 3 BILA

BENJOLANNYA >2 ATAU SIRKULER

DERAJAT 3B

: BIASANYA AKAN TURUN KE

DERAJAT 4.

PARADIGMA BARU :
KONSERVATIF ----> TRIO
1. PENGATURAN DIET --> BAB
LUNAK
2. OBAT-OBAT PER-ORAL
3. SUPPOSITORIA.

PARADIGMA BARU :
PENGATURAN DIET
1. MINUM AIR PUTIH 1 - 1 LITER/HARI
2. BUAH-BUAHAN : PEPAYA, PISANG
3. SAYURAN
4. LARANGAN MAKAN.

LARANGAN MAKAN
1. DAGING KAMBING
2. PEDAS
3. DURIAN
4. NANAS
5. CUKAK
6. SALAK
7. NANGKA
LAMANYA SAMPAI 6 MINGGU (1 BULAN)

PARADIGMA BARU
1. PENGOBATAN KONSERVATIF SELAMA 6
MINGGU
2. GEJALA
HILANG
SEMBUH.

TIDAK

BERARTI

3. SEMUA GEJALA RATA-RATA HILANG

DALAM SEMINGGU PERTAMA BEROBAT.
4. EVALUASI
HARUS
DENGAN
PROKTOSKOPI MINIMAL 2 MINGGU
SEKALI 3 X BERTURUT-TURUT.

HEMORHOID EKSTERNAL YANG

MENGALAMI TROMBOSIS :
1. Rendam duduk menggunakan larutan hangat,
salep yang mengandung analgetik.
2. Istirahat di tempat tidur, untuk mempercepat
berkurangnya pembengkakan.
3. Kurang dari 48 jam dapat ditolong : segera
mengeluarkan trombus atau eksisi lengkap
dengan anastesi lokal.

KESIMPULAN

Hemorhoid suatu keadaan normal dari anatomi

manusia, jika mengalami perubahan diperlukan
tindakan.
Dengan
bertambahnya
usia
terjadi
perubahan
hemorhoid yang membesar dan turun dalam lumen
anal kanal.
Vena-vena menjadi tegang dan perubahan ini
meningkat setelah dekade ke-3 dalam kehidupan.
Dengan meningkatnya pengetahuan struktur anatomi
dan prevalensi penyakit, akan memudahkan cara
pencegahan dan pengobatan simptomatis penyakit ini.

PERIANAL FISTULA

LAB/SMF BEDAH SEKSI BEDAH DIGESTIV

PENDAHULUAN
~ FISTULA ANI / FISTULA IN ANO
~ CHRONIS RESIDIF.
~ FISTULA : PENGHUBUNG ANORECTAL - LUAR
~ Th/ TIDAK ADEKUAT
~ PEMBEDAHAN
~ MEMAHAMI ANATOMI, KLASSIFIKASI & TEKNIK

ANATOMI ANORECTUM

PATHOGENESIS

KLASSIFIKASI :
1. MILLIGAN MORGAN (1934)
2. PARKS (1976)

TUJUAN : ARAH & LETAK FISTULA

TINDAKAN PEMBEDAHAN

MILLIGAN-MORGAN 1934

Subcutan

Anorectal

Low Anal

High Inter
Muscular

High Anal

KLASIFIKASI PARK (1976)

SIMPLE LOW

HIGH BLIND - OPEN RECTUM

SUPRALEVATOR ABSCESS

NO PERINEAL

PELVIC EXTENSION

INTERSPHINCTERIC

TRANSSPHINCTERIC

UNCOMPLICATED

SUPRASPHINCTERIC

HIGH BLIND TRACK

EXTRASPHINCTERIC

GOODSALS RULE
12

ANORECTAL
RING

LINEA DENTATA

ANAL ORIFICE

GAMBARAN KLINIS :

~ RIWAYAT PERIANAL ABSCESS

~ CHRONIS RESIDIF
~ TERASA BASAH, PUS / CAIRAN
~ PRURITUS

PEMERIKSAAN FISIK
~ INSPEKSI LUBANG LUAR

PEMERIKSAAN FISIK
~ PALPASI (PERKIRAKAN ARAH)

PEMERIKSAAN FISIK
~ RT & SONDAGE

PEMERIKSAAN FISIK
~ RECTOSCOPY

PEMERIKSAAN PENUNJANG
~ ZAT WARNA , PERHIDROL
~ FISTULOGRAFI
~ ENDORECTAL SONOGRAFI
~ CT SCAN FISTULOGRAFI
~ THORAX PA
~ BARIUM ENEMA
~ LABORATORIUM

PEMBEDAHAN
~ SATU-SATUNYA TERAPI KARENA :
~ RISIKO SEPSIS OK ANORECTAL ABSCESS
~ PERLUASAN TIDAK TERDETEKSI SECARA FISIK
~ RECURENT (CHRONIS RESIDIF)

~ PRINSIP : MEMBUANG FISTEL BESERTA

CABANGNYA TANPA MENIMBULKAN
INCONTINENSIA.

~ PREOPERATIF :

TEKNIK OPERASI
1. LAYING OPEN TECHNIQUE
~ UNTUK FISTEL LETAK RENDAH
~ BUKA SAL.FISTEL DARI LUBANG LUAR
S/D DALAM LALU FISTULOTOMY /
FISTULECTOMY / DGN SKIN GRAFT.

TEKNIK OPERASI
2. KOMBINASI LAYING OPEN + SETON
~ UNTUK FISTEL LETAK TINGGI DGN
INTERNAL OPENING
~ SETELAH FISTULOTOMY, PASANG
SETON
~ > 1 MINGGU BUKA SBG GUIDE

TEKNIK OPERASI
3. EKSISI FISTEL + MUCOSAL ADVANCEMENT FLAP
4. RE-ROUTING TECHNIQUE

POST OPERASI
~ CEGAH PENYEMBUHAN PREMATUR DARI
LUKA KULIT LUAR SEBELUM LUKA DALAM
SEMBUH (DARI DALAM KELUAR)
~ WAKTU CUKUP LAMA

KOMPLIKASI POST OPERASI

~ RETENSIO URINE, PERDARAHAN, INCONTINEN
FISTEL REKUREN, ANAL STENOSIS
~ SEPSIS

KEKAMBUHAN
~ TIDAK SELURUHNYA TERANGKAT
~ SALAH DIAGNOSIS (TBC FISTULA)
~ PERAWATAN POST OP KURANG BAIK

KESIMPULAN
1. SANGAT PENTING UNTUK MENGETAHUI TIPE
FISTEL DAN MEMAHAMI ANATOMI SEBELUM
TINDAKAN PEMBEDAHAN.
2. PRINSIP PEMBEDAHAN FISTEL.
3. CARA PEMBEDAHAN SESUAIKAN DENGAN
LETAK FISTEL (TINGGI / RENDAH).
4. PERAWATAN POST OP MEMEGANG PERANAN
SANGAT PENTING.