neoplasm of large intestine
DESCRIPTION
This preparetion was prepared for Prof. Feroze Quder on the eve of 21st Feb for a class for the undergraduate medical students.TRANSCRIPT
Prof. Feroze Prof. Feroze QuaderQuaderDept. of SurgeryBegum Khaleda Zia Medical College
Polyp:
A grape-like protrusion of tissue into the bowel lumen.
a)Sessile: flat on the mucosal surface
a)Pedunculated: Has a stalk b)Epithelial or submucosal c)Non-Neoplastic Polypsd)Neoplastic Polyps
Non-neoplastic Polyp
a) Hyperplastic polyps
b) Juvenile Polyps c) Peutz-Jegher
Polyps (Syndrome)
Peutz-Jegher’s syndrome
Neoplastic Polyp (adenoma)
a) Tubular adenomab) Villous Adenomac) Tubulovillous
adenoma
Tubular Adenoma Villous
It is a general neoplastic disorder of the intestine.
Affected area: Mainly large bowel.
Other : Stomach, duodenum & small intestine
The most important thing about adenomatous polyposis coli is that colorectal cancer develops before age 40 in nearly all untreated patients.
It is inherited as a Mendelian dominant . The
gene responsible (APC gene) has now been identified on the short arm of chromosome 5.
Males & females are equally affected.
Symptomatic patients:
Loose stoolLower abdominal painWeight lossDiarrhoeaPassage of blood &Mucus.
Asymptomatic patients:
Usually are diagnosed during screening or incidentally.
Clinical features
Clinical features…
Polyps are usually visible on sigmoidoscopy by the age of 15 years and will almost always be visible by the age of 30.
Carcinoma of the large bowel occurs 10-20 years after the onsent of the polyposis.
Some extra-cortical manifestations
Benign
Endocrine adenomeOsteomaEpidermoid cystHypertrophic retinal pigmentationMedulloblastoma
Malignant
Duodenal carcinomaDesmoid tumorBile duct, pancreatic carcinoma Carcinoma stomach
Treatment
Restorative proctocolectomy with an ileoanal anastomosis:(Now-a- days more frequently used)
Indicated specially in cases
• With serious rectal involvement with polyps• Who are likely to be poor at attending for follow up• With an established cancer of the rectum or sigmoid.
Treatment
Colectomy with ileorectal anastomosis :
was practiced in past as usual operation because it avoids an ileostomy
in a young patient.
Treatment
Restorative proctocolectomy with an ileoanal anastomosis:(Now-a- days more frequently used)
Indicated specially in cases
• With serious rectal involvement with polyps• Who are likely to be poor at attending for follow up• With an established cancer of the rectum or sigmoid.
DietLow fibre containing dietSmoked fishHigh content of refined carbohydrate in Diet red meat Less intake of micronutrients specially Selenium
deficiency.
Predisposing Factors
Pathology
Microscopically
The neoplasm is a columnar cell Carcinoma originating in the colonic epithelium.
Macroscopically
The tumor may take one of four forms . Type 4 is the least malignant form.
Pathology
Types of growth
Spreading
• Local spreading• Lymphatic apreading• Hematogenous spreading
Staging
Dukes’ classification A Confined to bowel wall.
B Through the bowel wall but not involving the free
Peritoneal serosal surface .
C Lymph nodes involved. D advanced local disease or metastasis to liver.
CARCINOMA COLONClinical Feature
Carcinoma of the left side of the colon:
PainAlteration of bowel habitPalpable lumpDistension
CARCINOMA COLONClinical Feature…
Carcinoma of the sigmoid:
PainTenesmusBladder symptoms
CARCINOMA COLONClinical Feature
Carcinoma of the transverse colon:
Palpable lumpAnaemiaLassitude
CARCINOMA COLONClinical Feature
Carcinoma of the caecum and ascending colon:
AnemiaLump in right iliac fossaAcute appendicitisIntermittent obstruction
CARCINOMA COLONClinical Feature
May present with features of metastasis
• Palpable Liver• Jaundice• Ascites
CARCINOMA COLONInvestigations
Diagnostic:
EndoscopySigmoidescopyColonscopy
With tissue biopsy
Investigations
Radiology
Double contrast barium enemaShows Irregular filling defect
Ultra-sonographyLiver metastasis
CT ScanLocal invasion specially in Pelvis
Treatment
Preoperative preparation:
General : Correction of anaemia by blood Correction of nutritional imbalance Correction of electrolyte imbalance Resuscitation
if there is - intestinal Obstruction, perforation
Treatment
Special preparation:
Bowel preparation by Dietary restriction to fluids for 2 days before
operation. Laxative Enema prophylatic antibiotic
Treatment
Operation:
Laparotomy is done The tumor is assessed for resectibility by
checking involvement in Liver Peritoneum Local lymph nodes Tumor itself for Mobility
Treatment…
In case of operable cases: Operations are done to remove the primary
tumor and the draining lymph nodes. Removal of the portion of colon surrounding the
tumor area depends on site of original of tumor.
Carcinoma of the caecum/ascending colon. Right hemicolectomy
Carcinoma of the hepatic flexure: resection will be extended correspondingly
Treatment…
In case of operable cases: Carcinoma of transverse colon: ▪ Excision of transverse colon & the two flexures
together with the transverse mesocolon and the two flexures together with the transverse mesocolon and the greater omentum followed by end – to – end anastomosis.
▪ Alternative is an extended right hemicolectomy. Carcinoma of the splenic flexure or descending
colon:▪ Resection from right colon to descending colon.
Sometimes removal of colon upto the ileum, with an ileorectal anastomosis.
Treatment
In case of inoperable cases:
Palliative procedure is done:
Transverse colostomy if growth in upper part left colon
Left Illiac fossa colostomy for Pelvic colonic growth
By-pass Illio-colic anastomosis for ascending colon-growth