View
214
Download
0
Category
Tags:
Preview:
Citation preview
colon lecturecolon lecture
John R Pender, M.D.John R Pender, M.D.
Dept. of SurgeryDept. of Surgery
BSOM, East Carolina BSOM, East Carolina UniversityUniversity
PatientPatient
58 y/o with wt loss and abd pain58 y/o with wt loss and abd pain
symptomssymptoms
Wt lossWt loss Change in caliber of stoolsChange in caliber of stools Blood in stool/ FOBT (fecal occult Blood in stool/ FOBT (fecal occult
blood test)blood test) AnemiaAnemia Abd painAbd pain constipationconstipation
Work upWork up
H&PH&P CEA (carcinoembryonic antigen)CEA (carcinoembryonic antigen) CBCCBC CXRCXR ColonoscopyColonoscopy CT scan abd/pelvisCT scan abd/pelvis
PolypsPolyps
Sessile vs pedunculatedSessile vs pedunculated HyperplasticHyperplastic AdenomaAdenoma MalignantMalignant
– VillousVillous– tubulovilloustubulovillous
Follow up after Follow up after polypectomypolypectomy
Q 6 months for first year, then @ 3 and 5 Q 6 months for first year, then @ 3 and 5 years. years.
Once clear at five years, repeat Q 5 yearsOnce clear at five years, repeat Q 5 years HNPCC (hereditary nonpolyposis col ca)HNPCC (hereditary nonpolyposis col ca)
– Average # polyps ~80% cancer by 45%Average # polyps ~80% cancer by 45% FAP (familial adenomatous polyposis)FAP (familial adenomatous polyposis)
– Cancer by age 40 ~100%Cancer by age 40 ~100%– 5% cancer by age 205% cancer by age 20
CHEMO?CHEMO?
5-FU and leucovorin5-FU and leucovorin Stage III (+/- poorly differentiated Stage III (+/- poorly differentiated
stage II)stage II)– coloncolon
Sage II and III Sage II and III – rectal carectal ca
XRTXRT
Not for colonNot for colon Only helps with local control in Only helps with local control in
rectal cancer if T3 or greaterrectal cancer if T3 or greater Does not improve survivalDoes not improve survival
Post operative Post operative surveillancesurveillance
PatientPatient
60y.o. with BRBPR60y.o. with BRBPR– What do you doWhat do you do
GI BLEEDGI BLEED
PatientPatient
45 y/o with left LQ pain, fever45 y/o with left LQ pain, fever– What do you doWhat do you do
w/uw/u
CBC CBC U/AU/A AASAAS CT CT Contrast enemaContrast enema
Diverticular DiseaseDiverticular Disease
ManagementManagement
Iv fluidIv fluid antibioticsantibiotics nponpo
Resuscitation Resuscitation AntibioticsAntibiotics Hartmann’s Hartmann’s
procedure procedure – Blind rectal Blind rectal
pouch&colostomypouch&colostomy OperationOperation
– free air free air – obstructionobstruction– AbscessAbscess– Uncontrolled sepsisUncontrolled sepsis
Indications for SurgeryIndications for Surgery
PerforationPerforation FistulaFistula AbscessAbscess ObstructionObstruction Age < 40Age < 40
PatientPatient
30 y/o with anal pain30 y/o with anal pain– What do you do? What do you do? – Examine pt.Examine pt.
Differential of Anal Differential of Anal painpain HemorrhoidsHemorrhoids abscessabscess FissureFissure Fistula-in-anoFistula-in-ano CodylomaCodyloma Puritis aniPuritis ani CancerCancer FBFB
Hemorrhoid TXHemorrhoid TX
First and second degree/ First and second degree/ thrombosedthrombosed– Sitz bathSitz bath– Bulk laxativeBulk laxative– topical analgesiatopical analgesia
Acute thrombosed, third/fourth Acute thrombosed, third/fourth degreedegree– HemorrhoidectomyHemorrhoidectomy
hemorrhoidectomyhemorrhoidectomy
FissureFissure
cycle of sphincter spasmcycle of sphincter spasm Nitrates, Botox, digital stretchNitrates, Botox, digital stretch Bulky laxativeBulky laxative WaterWater Sitz bathsSitz baths
FistulaFistula
PatientPatient
23 y/o with R LQ pain, fever23 y/o with R LQ pain, fever
what else do you want know?what else do you want know?
bowel habitsbowel habits
operationoperation
You operate for presumed You operate for presumed appendicitis and find an inflamed appendicitis and find an inflamed cecum and terminal ileum with cecum and terminal ileum with creeping fatcreeping fat..– What do you do?What do you do?
Inflammatory bowel Inflammatory bowel diseasesdiseases
Crohn’sCrohn’s– Mouth to anusMouth to anus– Skip areasSkip areas– Perianal Perianal – Granulomatous/Granulomatous/
full thicknessfull thickness– Fistula, strictureFistula, stricture– Extraintesatinal Extraintesatinal
dz dz
Ulcerative ColitisUlcerative Colitis– COLON AND COLON AND
RECTUM ONLYRECTUM ONLY– Toxic megacolonToxic megacolon– Rectal bleedingRectal bleeding– Higher risk of Higher risk of
colon cancercolon cancer
Indications for surgeryIndications for surgery
ObstructionObstruction BleedingBleeding Abscess/perforationAbscess/perforation cancercancer FistulaFistula Megacolon unresponsive Megacolon unresponsive Unresponsive/intolerance to medical Unresponsive/intolerance to medical
managementmanagement
Associated SXAssociated SX
Erythema nodosumErythema nodosum Pyoderma gangrenosumPyoderma gangrenosum Aphthous ulcersAphthous ulcers EpiscleritisEpiscleritis Ankylosing spondylitisAnkylosing spondylitis Sclerosing cholangitisSclerosing cholangitis
PatientPatient
80 y/o nursing home pt with 80 y/o nursing home pt with distend abdomen, feculent distend abdomen, feculent emesis, obstipationemesis, obstipation– What do you do?What do you do?
w/uw/u
IVFIVF NGNG AASAAS CBC, ectCBC, ect
DifferentialDifferentialof of colonic colonic obstructionobstruction CancerCancer AdhesionsAdhesions HerniaHernia VolvulusVolvulus Ogilvie’s pseudo-obstructionOgilvie’s pseudo-obstruction
Recommended