Rectal and Colon Diseases PDF

♦ grade IV - hemorrhoidal prolapse complete and present outside the act of defecation. This grade is most commonly associated with hemorrhoidal thrombophlebitis with mucosal ulceration. Repeated inflammations can lead to sclerosis of the varicose veins, resulting in a so-called ‫״‬he...

♦ grade IV - hemorrhoidal prolapse complete and present outside the act of defecation. This grade is most commonly associated with hemorrhoidal thrombophlebitis with mucosal ulceration. Repeated inflammations can lead to sclerosis of the varicose veins, resulting in a so-called ‫״‬hemorrhoidal scar‫״‬. Clinical trial Symptomatology - initially mild, represented only by: - anal itching, later followed by: - rectum lining the fecal bowl (it is secondary to stool and the blood is fresh); - glerosal discharge; - stinging pain after defecation; - sometimes anemia from repeated bleeding; Objectively - changes only occur in external or mixed hemorrhoids when the anal opening is marked by bluish swellings. The objective examination must necessarily be completed with rectal curettage, which will reveal soft masses inside the anal canal, anoscopy, rectoscopy, and irigography to exclude hemorrhoids secondary to an overlying neoplastic lesion. Evolution without treatment. The most common complications are: ♦ anal fissures; ♦ cryptitis, hemorrhages; ♦ hemorrhoidal thrombophlebitis; ♦ hemorrhoidal prolapse, which can progress to mucosal ulceration with hemorrhage and infection and malignancy; Treatment A.Profilactic avoiding a sedentary lifestyle, spices; constipation, rigorous local hygiene; B. Curative medical - consists of mild laxatives, decongestant and anti-inflammatory pomegranates and suppositories, as well as analgesics such as hemorzon, hemorsal, proctolog, troxevazin, etc. surgical - for complicated hemorrhoids, after a preliminary preparation of the colon consisting of a hydroelectrolytic diet for three to four days, laxatives and enema in the evening of the operation.  Hemorrhoidal thrombophlebitis is initially treated medically by: ♦ pain medicine; ♦ antibiotics; ♦ anticoagulant; ♦ sedatives and hydrolactosarate regimen; ♦ following surgical treatment 4-6 weeks after the acute process;  As surgical techniques can be practiced electroresection, sclerosing injections, transfixing ligation at the base of the hemorrhoidal bundles, resection operations of the type: ♦ Milligan-Morgan and ♦ Whithed-Vercescu operation. Anal fissure Definition - is a complication of hemorrhoidal varicose veins; - is a superficial, triangular or oval ulcer that develops on the wall of a hemorrhoidal vein; Etiopathogenesis - occurs most commonly between the ages of 40 and 60, in the following course: ♦ inflammation of the anal mucosa - which brings on; ♦ sphincter spasm that aggravates venous stasis in the hemorrhoid, causing: ♦ Mucosal ischemia with removal of the stifle, ♦ ulceration; This leaves the venous endothelium at the bottom of the fissure. The persistence of the inflammatory process determines the maintenance and accentuation of the sphincter spasm, which participates in this way in the chronicization of the local ulcerative phenomenon. Another mechanism to produce anal fissure is the mechanical aggression of an explosive constipation stool, which by its violence causes the rupture of the mucosa with consequent pain and the installation of the vicious circle.  Anatomopathologic - anal fissure is: - an oval or - triangular, often associating a sentinel hemorrhoid; Clinic - pain is the main symptom, sometimes violent in the form of burning, accompanied or not by: ♦ rectors and ♦ psychomotor restlessness; Objectively - sometimes sentinel hemorrhoid occurs, and rectal cough is impossible due to hypertonia of the anal sphincter. Investigations consisting of rectal cough, anoscopy, rectoscopy, can only be performed after infiltration of the anal sphincter with novocain.  Treatment - in recent fissures medical treatment consists of: ♦ pain medicine, ♦ anti-inflammatory, ♦ laxative, ♦ topical anti-inflammatory ointments or suppositories. In chronic fissures, treatment is surgical and consists of anal dilatation with excision of the fissure and minimal internal sphincterotomy under spinal anesthesia.  Ano-rectal discharge Acute or chronic. Acute suppurations can be: submucosal abscesses; intermuscular abscess; subcutaneous abscess; ischiorectal phlegmon; pelvirectal phlegmon (above the levator ani muscles) = pelvisubperitoneal suppuration;  Symptomatology ♦ perianal pain: - are common to all these infections; - they cause reflex constipation + acute urine retention. They often associate general signs of infection: - fever; - chills with: - alteration of general condition. They can evolve: - towards an intraanal or perianal fistulization that significantly blurs the symptoms; - concomitant with spontaneous pus discharge, either intraanal or perianal. Ischiorectal phlegmonomas (developed in the space between the anal elevators, anus and rectum and the subcutaneous fat): - may evolve into a horseshoe, i.e. also involve the contralateral ischiorectal space, by breaking the fibrous barriers separating them; or - can fistulize. Objective In superficial abscesses occur: - fluctuating swellings in the anus-rectal submucosa, or subcutaneous, small, relatively well demarcated, intensely painful spontaneously and on palpation. As a rule, rectal coughing is impossible, and any attempt is extraordinarily painful. In ischiorectal phlegmon, the bulging and redness of the integument is more extensive, involving the entire space between the anus and the ischial tuberosity.  Without treatment these purulent collections can complicate with: - septicemia; - sepsis; - or fistulization; Treatment - is surgical; - as early as possible; - consists of wide incisions centered on the area of maximum fluctuation, with excision of the flayed tissues and drainage;  Usually a communication is sought between the perianal suppurative process and the anorectal region, which is initially caused by papillitis, with the establishment of a blind fistula, which is the source of infection of the perianal space. When this communication has been detected, it must be abolished, sometimes at the cost of a sphincterotomy. General treatment with antibiotics and treatment to increase anti-infective resistance by non-specific vaccination is done only to prevent further spread of the infectious process or its chronicization. Chronic suppuras They are generally the result of the chronicization of acute suppurations due to lack of treatment or inadequate treatment. The most common chronic suppurations are perianal fistulas. These are fibrous tracts between the anorectal cavity and the integument, with a lumen that allows secretions to drain. Etiopathogenesis - the most common causes are acute spontaneously or surgically discharged and chronically transformed suppurations, - less rarely, TB, actinomycosis. Sometimes they can be the first manifestation of Crohn's disease or ulcerative colitis. Anatomopathologic - they can be either with two orifices = complete fistula or with one orifice = blind fistula. According to the route and the anatomical structures they pass through we distinguish: subcutaneous fistulas; submucous fistulas, which may be subsphincteric, transsphincteric or extrasphincteric; ischiorectal fistulas that connect the rectum to the integument after passing through the ischiorectal fossa; Clinical - often some time after the onset of a perianal suppuration, spontaneously or incompletely surgically evacuated, the patient notices the presence of perianal purulent discharge, often intermittent. Objective - perianal there is a single or multiple fistulous orifice through which a purulent discharge is evacuated by compression of the rectal cough. The exploration can be done, instrumentally, by a buttoned stylet, by methyl blue injection or best radiologically by fistulography with a contrast substance such as lipiodol. Without treatment, this condition has no tendency to heal and has a debilitating and disabling character. Treatment prophylactic - correct treatment of anocutaneous infections; curative - in case of fistula institution, it is surgical and consists of: - either in excision of the fistulous tract - either in opening it and putting it‫ ״‬a flat‫״‬, with or without severing the internal sphincter, sometimes even the superficial external sphincter, but in one place so as not to cause anal incontinence. In complex fistulas, treatment is difficult, requiring repeated interventions, sometimes with questionable results.  Rectal prolapse is a form of rectorectal intussusception, with the upper rectum descending circumferentially through the anus. Rectal prolapse can be : ♦ propriuzis, when the anal canal remains in place, telescoping the upper rectum through it; ♦ mucosal rectal prolapse, in which, as the name implies, it is only the rectal mucosa that leaves its home;  Etiopathogenesis - is unknown, are incriminated: - biological factors (old age); - anatomical factors (an excessive mobility of the rectum as well as a particular laxity of the adjacent tissues); - mechanical factors, which incriminate elements that cause an increase in intra-abdominal pressure (chronic constipation, bronchitis, service providers with high physical exertion).  Clinic - Subjectively, the patient states that during the defecation act he found externalization of the anus, usually without pain or other alarming symptoms. - objective: these patients may be examined in lateral decubitus or genupupuptoral position when the patient is asked to do an abdominal press (to scream) and when found, anorectal prolapse in two or three cylinders. Rectal curettage, anuscopy, rectosigmoidoscopy, may reveal associated lesions that trigger the occurrence of prolapse (malignant tumors, rectocolonic polyposis or secondary polyps). Evolution without treatment - it progresses to ulceration of the anorectal mucosa with its infection, which can lead to disintegration. Treatment: - in children is conservative; - In adults, treatment is surgical and may use two types of intervention: anorectal resections or perineal tightening.  the simplest method, but which is suitable for elderly patients with associated hard tissues, is the Thiersch procedure, which consists of a suturing of the anus, initially with silver wire, today with a naylon 5 wire. Abdominal interventions involve direct or indirect rectopecs, which are now commonly performed laparoscopically.  RECTAL CANCER there are differences between rectal and colon cancers on: ▪ incidence by sex, ▪geographical distribution, ▪therapeutic sanction. currently rectal cancer = separate entity from colon cancer.  Epidemiology. is geographically unevenly distributed, -In France - first place -In Romania - first among digestive cancers -Common in Europe and the USA, less so in South America and Africa. with peak incidence in the seventh decade of life (60-69 years), more frequently in men than in women (3/2). Etiology. not known exactly, Favoring factors involved in rectal carcinogenesis. They can be grouped as : 1.environmental factors : ♦ with favorable effect in carcinogenesis : ▪ Red meat proteins, ▪ saturated fats, ▪alcohol, ▪ tuna. ♦ with protective effect : ▪ proteins from white fish meat, ▪ dietary fiber, ▪ eating fresh fruit and vegetables, ▪vitamins A, C, E. 2.local factors are encountered in patients: ♦cholecystectomized, due to consecutive bile acid elevation, ♦inflammatory type diseases: ▪ ulcero-hemorrhagic recto- colitis, ▪ Crohn's disease. 3.Genetic factors : ♦ Familial adenomatous familial polyposis from which hereditary polyposis rectal cancer later develops, ♦in the setting of Lynch 2 syndrome from which hereditary nonpolioposis cancer develops. Pathology. rectal cancers are usually well- circumscribed cancers, rarely present beyond macroscopic limits. Macroscopically, they can be classified into : Protuberant, exophytic or polypoid tumors Ulcerating tumors Infiltrative tumors Microscopically, rectal carcinomas are classified into : – Mucinous adenocarcinoma – Squamous cell carcinoma – Adeno-squamous carcinoma – Small cell carcinoma – Undifferentiated carcinoma Histologic grading is useful as : prognostic factor, in determining therapeutic behavior. Depending on the histologic grading, malignant tumors of the rectum are divided into three grades, as follows: Grade I or G 1 - differentiated tumors; Grade II or G 2 - moderately or poorly differentiated tumors; Grade III or G 3 - undifferentiated tumors. Stadialization. in the past a number of staging have been described as : ▪Dukes, ▪Astler-Coler, classifications that are currently used less and less. DUKES CLASSIFICATION: Stage A: localized mucosal tumor Stage B1: tumor reaching the muscle Stage B2: tumor invades the entire colon wall (no lymph node involvement) Stage C: tumor with locoregional lymph node entrapment. Stage D: distant organ metastases. TNM classification: T - primary tumor Tx - tumor cannot be assessed T0 - no evidence for primary tumor Tis - carcinoma in situ T1 - the tumor invades the submucosa T2 - tumor invades own muscle T3 - tumor invades the subserosum T4 - tumor perforates the visceral peritoneum or directly invades other organs or structures N - regional lymph nodules Nx - regional lymph nodes cannot be assessed N0 - no metastasized regional lymph node N1 - metastases in 1-3 pericolonic or perirectal lymph nodes N2 - metastases in 4 or more pericolonic or perirectal lymph nodes N3 - metastases in any lymph node along a vascular trunk M - distant metastases Mx - presence of distant metastases cannot be assessed M0 - no distant metastases M1 - distant metastasis. Status TNM 0-I TisT1-T2 No Mo II T3 N0 M0 T4 N0 M0 III T2 N1-3 M0 N>3 M0 T3-T4 N1-3 M0 N>3 M0 IV Tn Nn M1 Dukes classification correlated with TNM Dukes A T1, N0, M0 (stage I) T2, N0, M0 (stage I) Dukes B T3, N0, M0 (stage II) T4, N0, M0 (stage II) Dukes C T (any)N1, M0. T (any)N2, M0 (stage III) Dukes D T (any), M1 (stage IV) Clinical manifestations. Rectal cancer often progresses asymptomatically, the first manifestations are: ▪ changes in the rhythm of defecation (alternating constipation with diarrhea), ▪ bleeding expressed with the evacuation of the fecal bolus. in advanced stages the patient accuses: ▪ tenesmus, ▪hard, ▪ clinical manifestations of anemia due to blood loss.  the patient may present to the emergency department with occlusive manifestations; general signs that change the patient's status are: Weight loss Severe anemia Anorexia Jaundice - present in patients with liver metastases. Physical signs. rectal examination is done by rectal tact, the rectal contact only allows examination of the lower half of the rectum, the upper half can be examined at the same time as abdominal palpation, can only give information in large tumor formations. by digital examination can be determined: ▪ lower limit of the formation, ▪ in some cases also the upper limit, thus establishing the axial extent as well as the circumferential extent. Paraclinical investigations. their scope is: ▪confirmation of the primitive tumor, ▪ establish its headquarters, ▪ to assess local expansion, ▪existence of synchronous primary cancers, ▪association with other malignancies. The paraclinical investigations that are done are:  Radiologic investigations: – Simple abdominal X-ray: ▪ only useful in patients presenting to the emergency department for occlusion or perforation; – Barite enema ▪consists of barium examination of the large intestine, ▪the most sensitive technique being the double- contrast technique, by insufflation of air after the rectal mucosa has been coated with barium; – Computer tomography ▪use more for: -metastatic determinations, -local extension grade, -has low sensitivity in the diagnosis of primary tumor Endoscopic investigations: – Rectoscopy ▪ examination with rigid rectoscope, ▪ allows direct evaluation of the rectum with biological sampling – Fiber-optic colonoscopy ▪ne permit: full visualization of the colonic frame, determining possible synchronous rectal and colonic formations Endosonography - is indicated in rectal cancer without stenosis. In women, transvaginal endosonography can be used even in the case of a stenotic rectal tumor. - it accurately shows the parietal extension of the tumor, invasion of neighboring organs and metastatic adenopathy - is essential for pretherapeutic staging Hydrosonography - is indicated in stenosing colorectal cancers with inconclusive irigography or endoscopy - ultrasonographic examination is performed after water has been introduced into the colic - it could be used as a screening method being non-invasive and inexpensive Ultrasound: – Intra-rectal ultrasound ▪does not allow the extent of local invasion to be determined by detailed examination of the rectal wall and surrounding tissues – Abdominal ultrasound ▪is mostly used to diagnose possible metastases. Tumor markers: are mainly used in post-operative monitoring in a proven rectal cancer patient, represents the most accurate way to detect relapse, the value of these markers may increase several months before the onset of symptoms. for the digestive tract the most used markers are: ▪ carcinoembryonic antigen (CAE), ▪antigen carbohydrate CA-19-9.  DIFFERENTIAL DIAGNOSIS Hemorrhoidal disease and anal fissure Boala Crohn Rectocolita ulcerohemorrhagic Diverticuloza colonic Colita ischemic and radicular colitis Angiodisplazia colonic Colonul irritable Treatment of rectal cancer: is achieved by several therapeutic methods can be applied alone or in combination, are represented by: ▪ surgical treatment, ▪radiotherapeutic, ▪chemotherapeutic. Surgical treatment represents the main treatment method for rectal cancer. surgery can be performed: ▪both scheduled, ▪even in an emergency. scheduled surgical treatment can be done: ▪ Radical-vis in radical-vis surgery, ▪paleactive-surgical intervention is not for oncologic targeting curative (radical) interventions aim to: ▪ablation of the tumor rectum, the mesorectum, ▪ regional lymph nodes. these operations can be applied only in case of early detection, i.e. in the first two stages. depending on the site of the tumor the operations that can be performed are: Abdomino-perineal amputation of the rectum - mainly practiced in low rectal cancers; High anterior resection - mainly used for tumors located at the recto-sigmoid junction, known as the "Dixon procedure"; Abdomino-transphincter resection ; Transanal resection. any of the listed procedures must fulfill the following anatomical keys: ▪metorectal removal, ▪ Dilaceration of the constituent lamellae of the Denonvilliers fascia, ▪section of the lateral ligaments and middle rectal arteries, ▪ respect for the pelvic nerve plexuses.  in advanced stages (>2), surgery: ▪ no longer propose curative intentions, ▪It turns into palliative surgery, ▪ aim to prevent possible complications and increase patient comfort; ▪excision of the tumor rectum should always be attempted because in this way bowel obstruction is prevented and the patient's suffering is decreased.  local surgery (per anum procedures): ▪ is performed in patients unsuitable for major surgery, ▪ for those who refuse radical surgery. ▪ only under certain conditions, namely: -low tumors, -mobile lesion with exophytic appearance, -up to approx. 3 cm in size, -without invasion of the rectal wall (mobile on deep planes) -with well-differentiated histologic character. local techniques include: ▪electrocoagulation of the tumor, ▪ cryotherapy, ▪Contact ▪Contact ▪Contact ▪ Contact details, ▪local focus, ▪ laser therapy. Radiotherapy can be applied as radiation therapy: radical ▪ used when the tumor is small (less than 5 cm in diameter) ▪ Complete sterilization can be achieved in about 50% of cases; palliative ▪used when rectal cancers are in advanced stages ▪is to: – decrease of the patient's symptoms in the sense of reducing bleeding, pain, – of tumor conversion can transform an unresectable formation into an extirpable one; adjuvant ▪is used to sterilize tumor material remaining after surgical treatment. due to surgery that changes the vascularization of the tissues they become radioresistant and for this reason the protocol in the treatment of rectal cancer provides that radiation therapy is performed before surgery. Chemotherapy. the response of the digestive tract to chiomyotherapy is disappointing, The only antitumor agent that has shown some efficacy is 5-FU (5 fluorouracil). as unwanted effects of chemotherapy have occurred: ▪ stomatitis, ▪diarhea, ▪ hematologic toxicity. chemotherapy in the treatment of rectal cancer is less adjuvant than radiotherapy.