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Large Intestine, Colon, and Rectum

Dr. Marlow Esguerra June 30, 2015

and distally at the rectum, where the outer longitudinal
OUTLINE muscle layer is circumferential.
I. Large Intestine  In the distal rectum, the inner smooth muscle layer
A. Embryology coalesces to form the internal anal sphincter
B. Landmarks
 The intraperitoneal colon and proximal one-third of the
C. Blood Supply
D. Lymphatic Drainage
rectum are covered by serosa; the mid and lower rectum lack
E. Nerve Supply serosa.
II. Anus and Rectum
A. Anorectal Landmarks LANDMARKS
B. Anorectal Blood Supply
 The colon begins at the junction of the terminal ileum and
C. Lymphatic Drainage
D. Nerve Supply cecum and extends 3 to 5 feet to the rectum
III. General Surgical Considerations  The rectosigmoid junction is found at approximately the level
A. Resection of the sacral promontory
B. Colectomy o Level where teniae coli coalesces to form outer longitudinal
C. Proctocolectomy muscle layer of the rectum
D. Anterior Resection  The cecum is the widest diameter portion of the colon
E. Hartmann’s Procedure and Mucus Fistula
(normally 7.5–8.5 cm) and has the thinnest muscular wall
F. Abdominoperineal Resection
G. Anastomoses o Most vulnerable to perforation and least vulnerable
H. Ileostomy to obstruction
I. Colostomy  Ascending colon is retroperitoneal
IV. Large Intestine Diseases  Hepatic flexure marks the transition to the transverse colon
A. Inflammatory Bowel Disease  The mobile intraperitoneal transverse is tethered by the
i. Ulcerative Colitis gastrocolic ligament and colonic mesentery
ii. Crohn’s Disease
 The greater omentum is attached to the anterior/superior
B. Diverticular Disease
C. Neoplasms edge of the transverse colon
i. Adenocarcinoma  The splenic flexure marks the transition from the transverse
ii. Polyps colon to the descending colon
iii. Inherited Colorectal Carcinoma  The descending colon is relatively fixed to the
iv. Colorectal Cancer retroperitoneum
E. Benign Colorectal Conditions  The sigmoid colon is the narrowest part of the large intestine
i. Rectal Prolapse
and is extremely mobile
ii. Solitary Rectal Ulcer Syndrome
iii. Volvulus o Vulnerable to obstruction and volvulus
iv. Megacolon
v. Colonic Pseudo-obstruction (Ogilvie’s Syndrome) BLOOD SUPPLY
vi. Ischemic Colitis
ARTERY BRANCHING SUPPLIED PARTS
vii. Infectious Colitis
V. Anorectal Diseases VESSELS
A. Hemorrhoids Ileocolic artery Terminal ileum
B. Anal Fissure Superior
C. Anorectal Abscess Mesenteric Proximal ascending
D. Necrotizing Perianal and Perineal Infection Artery colon
E. Fistula In Ano
F. Rectovaginal Fistula
G. Perianal Dermatitis
Right colic artery Ascending colon
H. Sexually Transmitted Diseases (STDs) Middle colic artery Transverse colon
I. Pilonidal Disease Inferior Left colic artery Descending colon
J. Hidradenitis Suppurativa Mesenteric Sigmoidal branches Sigmoid colon
Artery Superior rectal artery Proximal
**This transcription was based mainly on Schwartz’s. rectum

LARGE INTESTINE
EMBRYOLOGY
 Begins developing during the fourth week of gestation
 The midgut and hindgut, which are derived from the
endoderm, contribute to the colon,
rectum, and anus
 The midgut develops into the small intestine, ascending
colon, and proximal transverse colon, and receives blood
supply from the superior mesenteric artery
 The hindgut develops into the distal transverse colon,
descending colon, rectum, and proximal anus, all of which
receive their blood supply from the inferior mesenteric
artery
 The distal anal canal is derived from ectoderm and
receives its blood supply from the internal pudendal
artery

ANATOMY
 The large intestine extends from the ileocecal valve to the
anus
 Divided anatomically and functionally into the colon,
rectum, and anal canal
 Five layers of colonic wall:
o Mucosa
o Submucosa
o Inner circular muscle
o Outer longitudinal muscle
o Serosa
 The outer longitudinal muscle is separated into three
teniae coli, which converge proximally at the appendix Fig 1. The large intestine and its’s blood supply

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 Large Intestines, Colon, and Rectum 1.04

LYMPHATIC DRAINAGE
 Originates in the muscularis mucosa
Lymph Location
nodes
Epicolic Bowel wall
Paracolic Inner margin of the bowel adjacent to
the arterial arcades
Intermediate Around the named mesenteric vessels
Main At the origin of the superior and inferior
mesenteric arteries

NERVE SUPPLY
 Sympathetic
o Arises from T6-12 and L1-3
 Parasympathetic
o Right and transverse colon is from the vagus nerve
o Left colon arise from sacral nerves S2-S4 to form the
nervi erigentes

ANUS AND RECTUM

Fig 3. Arterial supply to the rectum and anal canal.
ANORECTAL LANDMARKS
 The rectum is approximately 12 to 15 cm in length LYMPHATIC DRAINAGE
 Three distinct submucosal folds, the valves of Houston,
 Originates in the muscularis mucosa
extend into the rectal lumen
 The anatomic anal canal extends from the dentate or
Lymph nodes Drainage
pectinate line to the anal verge
 The dentate or pectinate line marks the transition point Inferior Upper to lower rectum; anal canal proximal
between columnar rectal mucosa and squamous anoderm mesenteric to dentate line
o Surrounded by longitudinal folds called columns of Internal iliac Lower rectum; anal canal proximal to
Morgagni dentate line
 The anal transition zone includes mucosa proximal to the Inguinal Anal canal distal to dentate line
dentate line
NERVE SUPPLY
 Sympathetic
o Arises from L1-3
 Parasympathetic
o Arises from S2-S4 to form the nervi erigentes
 The external anal sphincter and puborectalis muscles are
innervated by the inferior rectal branch of the internal
pudendal nerve
 The levator ani receives innervation from both the internal
pudendal nerve and direct branches of S3
to S5
 Sensory innervation to the anal canal is provided by the
inferior rectal branch of the pudendal nerve

PHYSIOLOGY
 The colon is a major site for water absorption and electrolyte
exchange
 Under normal circumstances, approximately 90% of the water
contained in ileal fluid is absorbed in the colon (1000–2000
mL/d), but up to 5000 mL of fluid can be absorbed daily
Fig 2. The lining of the anal canal
Colonic Microflora and Intestinal Gas
 In the distal rectum, the inner smooth muscle is thickened  Bacteriodes – Most common
and comprises the internal anal sphincter that is  E. coli – most numerous
surrounded by the subcutaneous, superficial, and deep  The gastrointestinal tract usually contains between 100 and
external sphincter 200 mL of gas, and 400 to 1200 mL/d are released as flatus
 The deep external anal sphincter is an extension of the
puborectalis muscle Motility- Contractions of low and high amplitude
 The puborectalis, iliococcygeus, and pubococcygeus
muscles form the levator ani muscle of the pelvic floor Defecation
 Complex, coordinated mechanism involving colonic mass
ANORECTAL VASCULAR SUPPLY movement, increased intra-abdominal and rectal pressure,
ARTERY SOURCE ARTERY SUPPLIED and relaxation of the pelvic floor
PARTS  Distention of the rectum causes a reflex relaxation of the
Superior rectal Inferior Upper rectum internal anal sphincter that allows the contents to make
artery mesenteric artery contact with the anal canal
Middle rectal Internal iliac Middle rectum o Sampling reflex- allows the sensory epithelium to
artery distinguish solid stool from liquid stool and gas
Inferior rectal Internal pudendal Distal rectum
artery CLINICAL EVALUATION OF THE LARGE INTESTINE
VEIN DRAINAGE DRAINED PARTS CLINICAL ASSESSMENT
Superior rectal Inferior Upper rectum  Important points in history taking
vein mesenteric o Past surgical procedures
Middle rectal Internal iliac Middle rectum o Anorectal surgery
vein o Obstetrical history
Inferior rectal Internal pudendal Distal rectum o Colorectal disease
vein > Internal iliac o Family hx of colorectal disease
Hemorrhoidal Drains to all rectal Submucosa, o Medications
plexus veins columns of  Physical exam, visual inspection of the anus and perineum
morgagni and careful digital rectal exam are essential

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 Large Intestines, Colon, and Rectum
ENDOSCOPY
ANOSCOPY
 The anoscope is a useful instrument for examination of the
anal canal
 Used to visualize the anal canal
 Anoscopes are made in a variety of sizes and measure
approximately 8 cm in length
PROCTOSCOPY
 The rigid proctoscope is useful for examination of the
rectum and distal sigmoid colon and is occasionally used
therapeutically
FLEXIBLE SIGMOIDOSCOPY AND COLONOSCOPY
 Provides excellent visualization of the colon and rectum
 Sigmoidoscopes measure 60 cm in length; may allow
visualization as high as the splenic flexure
 Colonoscopes measure 100 to160 cm in length and are
capable of examining the entire colon and terminal ileum
 Both sigmoidoscopy and colonoscopy can be used
diagnostically and therapeutically
CAPSULE ENDOSCOPY
 Uses a small ingestible camera
 Images of the mucosa of the gastrointestinal tract are
captured, transmitted, and then downloaded to a computer
for viewing and analysis
 Used to detect small bowel lesions
IMAGING
PLAIN X-RAY
 Plain X-rays of the abdomen (supine, upright, and
diaphragmatic views) are useful for detecting:
o Free intra-abdominal air
o Bowel gas patterns suggestive of
small or large bowel obstruction
o Volvulus
CONTRAST STUDIES
 Useful for:
o Obstructive symptoms
o Delineating fistulous tracts
o Diagnosing small perforations or anastomotic leaks
CT SCAN
 Used primarily in the detection of extraluminal disease,
such as intra-abdominal abscesses and pericolic
inflammation, and in staging colorectal carcinoma
MAGNETIC RESONANCE IMAGING
 Use in colorectal disorders is in evaluation of pelvic lesions
 Helpful in the detection and delineation of complex fistulas
in ano
POSITRON EMMISION TOMOGRAPHY
 Used for imaging tissues with high levels of anaerobic
glycolysis, such as malignant tumors
ANGIOGRAPHY
 Occasionally used for the detection of bleeding within the
colon or small bowel
ENDORECTAL AND ENDOANAL ULTRASOUND
 Primarily used to evaluate the depth of invasion of
neoplastic lesions in the rectum
 Ultrasound can reliably differentiate most benign polyps
from invasive tumors based on the integrity of the
submucosal layer
 Endoanal ultrasound is used to evaluate the layers of the
anal canal
 Endoanal ultrasound is particularly useful for detecting
sphincter defects and for outlining complex anal fistulas
PHYSIOLOGIC AND PELVIC FLOOR INVESTIGATIONS
MANOMETRY
 Anorectal manometry is performed by placing a pressure-
sensitive catheter in the lower rectum. The catheter is then
withdrawn through the anal canal and pressures recorded
 Resting pressure in the anal canal reflects the function of
the internal anal sphincter (normal, 40–80 mmHg)
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 Squeeze pressure, defined as the maximum voluntary
contraction pressure minus the resting pressure, reflects
function of the external anal sphincter (normal, 40–80 mmHg
above resting pressure)
NEUROPHYSIOLOGY
 Neurophysiologic testing assesses function of the pudendal
nerves and recruitment of puborectalis muscle fibers
RECTAL EVALUATION STUDIES
 Balloon expulsion assesses a patient’s ability to expel an
intrarectal balloon
 Defecography is used to differentiate nonrelaxation of the
puborectalis, obstructed defecation, increased perineal
descent, rectal prolapse and intussusception, rectocele, and
enterocele
LABORATORY STUDIES
FECAL OCCULT BLOOD TESTING
 Used as a screening test for colonic neoplasms in
asymptomatic, average-risk individuals
 FOBT has been a nonspecific test for peroxidase contained in
hemoglobin; consequently, occult bleeding from any
gastrointestinal source will produce a positive result
 Many foods (red meat, some fruits and vegetables, and
vitamin C) will produce a false-positive result
 Any positive FOBT mandates further investigation,
usually by colonoscopy
STOOL STUDIES
 Helpful in evaluating the etiology of diarrhea
 Wet-mount examination reveals the presence of fecal
leukocytes, which may suggest colonic inflammation or the
presence of an invasive organism such as invasive
E. coli or Shigella species
 Stool cultures can detect pathogenic bacteria, ova, and/or
parasitesC. difficile colitis is diagnosed
by detecting bacterial toxin in the stool
 Steatorrhea may be diagnosed by adding Sudan red stain to a
stool sample
SERUM TESTS
 Preoperative studies generally include a complete blood count
and electrolyte panel
 The addition of coagulation studies, liver function tests, and
blood typing/cross-matching depends on the patient’s medical
condition and the proposed surgical procedure
TUMOR MARKERS
 Carcinoembryonic antigen (CEA) may be elevated in 60%
to 90% of patients with colorectal cancer
 CEA may be mildly elevated in patients who smoke
tobacco
 Other biochemical markers (ornithine decarboxylase,
urokinase) have been proposed, but none has yet proven
sensitive or specific for detection, staging, or predicting
prognosis of colorectal carcinoma
GENETIC TESTING
 Tests for mutations in:
o Adenomatous polyposis coli (APC) gene: FAP
o Mismatch repair genes: HNPCC
**Hindi nagdiscuss extensively ng general surgical
considerations si Doc. Lahat ng ito galling lang sa book. 
GENERAL SURGICAL CONSIDERATIONS
RESECTIONS
 The mesenteric clearance technique dictates the extent of
colonic resection and is determined by:
1. Nature of the primary pathology (malignant or benign)
2. Intent of the resection (curative or palliative)
3. Precise location(s) of the primary pathology
4. Condition of the mesentery (thin and soft or thick and
indurated)
 A proximal mesenteric ligation will eliminate the blood supply
to a greater length of colon and require a more extensive
“colectomy.”
 Curative resection of a colorectal cancer is best accomplished
by proximal mesenteric vessel ligation and radical mesenteric
clearance of the lymphatic drainage basin of the tumor site
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 Large Intestines, Colon, and Rectum 1.04

 Resection of a benign process does not require wide splenic flexure to well-perfused descending colon where the
mesenteric clearance ileocolic anastomosis can be performed safely.

EMERGENCY RESECTION TRANSVERSE COLECTOMY

 The bowel is almost always unprepared and the patient  Lesions in the mid and distal transverse colon may be
maybe unstable resected by ligating the middle colic vessels and resecting the
 Surgical principles still apply, and an attempt should be transverse colon, followed by a colocolonic anastomosis
made to resect the involved segment along with its  Extended right colectomy with anastomosis between the
lymphovascular supply terminal ileum and descending colon may be a safer
 Indications: anastomosis with equivalent functional result
1. Obstruction
2. Perforation LEFT COLECTOMY
3. Hemorrhage  For lesions or disease states confined to the distal transverse
 Right colon or proximal transverse colon (right or extended colon, splenic flexure, or descending colon
right colectomy)  The left branches of the middle colic vessels, the left colic
o Primary ileocolonic anastomosis as long as the remaining vessels, and the first branches of the sigmoid vessels are
bowel appears healthy and the patient is stable ligated
 Left-sided tumors  A colocolonic anastomosis can usually be performed.
o Traditional approach: Resection of the involved bowel
and end colostomy, with or without a mucus fistula
o New: Primary anastomosis without a bowel preparation
or with an on-table lavage, with or without a diverting
ileostomy (equally safe with traditional)
 Proximal colon appears unhealthy
o If there are: vascular compromise, serosal tears,
perforation
o Subtotal colectomy with a small bowel to rectosigmoid
anastomosis
 If the bowel appears compromised or if the patient is
unstable, malnourished, or immunosuppressed
o Resection and diversion (ileostomy or colostomy) is safe
and appropriate

MINIMALLY INVASIVE TECHNIQUES OF RESECTION

 Advantages:
o Improved cosmetic result
o Decreased postoperative pain
o Earlier return of bowel function
o Less immunosuppressive impact on the patient

COLECTOMY
ILEOCOLIC RESECTION
 A limited resection of the terminal ileum, cecum, and
appendix when these parts are affected
 Used in removing:
o Diseases such as ileocecal Crohn’s disease
o Benign lesions
o Incurable cancers
 If curable malignancy is suspected, more radical resections,
such as a right hemicolectomy are generally indicated
 The ileocolic vessels are ligated and divided
 A variable length of small intestine may be resected
depending on the disease process Fig 4. Terminology of types of colorectal resections:
 A primary anastomosis is created between the distal small AC Ileocecectomy; A+BD Ascending colectomy;
bowel and the ascending colon A+BF Right hemicolectomy; A+BG Extended right hemicolectomy;
 It is difficult to perform an anastomosis at or just proximal E+FG+H Transverse colectomy; GI Left hemicolectomy;
to the ileocecal valve; therefore, if the most distal ileum FI Extended left hemicolectomy; J+K Sigmoid colectomy;
needs to be resected, the cecum is also removed. A+BJ Subtotal colectomy; A+BK Total colectomy;
A+BL Total proctocolectomy.

RIGHT COLECTOMY
 Used to remove lesions or disease in the right colon
 Most appropriate operation for curative intent resection of
proximal colon carcinoma
 The ileocolic vessels, right colic vessels, and right branches
of the middle colic vessels are ligated and divided
 10 cm of terminal ileum are usually included in the
resection
 A primary ileal-transverse colon anastomosis is almost
always possible
EXTENDED RIGHT COLECTOMY
 Used for curative intent resection of lesions located at the
hepatic flexure or proximal transverse colon
 A standard right colectomy is extended to include ligation of
the middle colic vessels at their base
 The right colon and proximal transverse colon are resected,
and a primary anastomosis is created between the distal
ileum and distal transverse colon
o Such anastomosis relies on the marginal artery of
Drummond.
 If the blood supply to the distal transverse colon is
questionable, the resection is extended distally beyond the
EXTENDED LEFT COLECTOMY
 An option for removing lesions in the distal transverse colon
 The left colectomy is extended proximally to include the right
branches of the middle colic vessels
SIGMOID COLECTOMY
 Lesions in the sigmoid colon require ligation and division of
the sigmoid branches of the inferior mesenteric artery
 The entire sigmoid colon is resected to the level of the
peritoneal reflection
 Anastomosis is created between the descending colon and
upper rectum
 Full mobilization of the splenic flexure is often required to
create a tension-free anastomosis
TOTAL AND SUBTOTAL COLECTOMY
 Occasionally required for patients with:
o Fulminant colitis
o Attenuated FAP
o Synchronous colon carcinomas.
 The ileocolic vessels, right colic vessels, middle colic vessels,
and left colic vessels are ligated and divided

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 Large Intestines, Colon, and Rectum
 The superior rectal vessels are preserved
 If sigmoid is desired to be preserved:
o Perform subtotal colectomy with ileosigmoid anastomosis
 Distal sigmoid vessels are left intact
 An anastomosis is created between the ileum and distal
sigmoid colon
 If the sigmoid is to be resected:
o Perform total abdominal colectomy with ileorectal
anastomosis
 Sigmoidal vessels are ligated and divided
 Ileum is anastomosed to the upper rectum
 If an anastomosis is contraindicated:
o End ileostomy is created
o Remaining sigmoid or rectum is managed either as a
mucus fistula or a Hartmann’s pouch
PROCTOCOLECTOMY
TOTAL PROCTOCOLECTOMY
 The entire colon, rectum, and anus are removed and the
ileum is brought to the skin as a Brooke ileostomy
RESTORATIVE PROCTOCOLECTOMY
(ILEAL POUCH-ANAL ANASTOMOSIS)
 Ileal Pouch – Anal anastomosis
 The entire colon and rectum are resected, but the anal
sphincter muscles and a variable portion of the distal anal
canal are preserved
 Bowel continuity is restored by anastomosis of an ileal
reservoir to the anal canal
 Most surgeons perform a proximal ileostomy to divert
succus from the newly created pouch in an attempt to
minimize the consequences of leak and sepsis, especially in
patients who are malnourished or immunosuppressed
 The ileostomy is then closed 6 to 12 weeks later, after a
contrast study confirms the integrity of the pouch.
 In low-risk patients, successful creation of an ileoanal
pouch without a diverting stoma is possible.
Fig 5. Ileal S-pouch anal anastomosis with temporary loop ileostomy.
ANTERIOR RESECTION
 Resection of the rectum from an abdominal approach to the
pelvis with no need for a perineal, sacral, or other incision
 There are 3 types: High anterior, low anterior and extended
low anterior resection
HIGHT ANTERIOR RESECTION
 Resection of the distal sigmoid colon and upper rectum
 Appropriate operation for benign lesions and disease at the
rectosigmoid junction such as diverticulitis
 Upper rectum is mobilized, but the pelvic peritoneum is not
divided and the rectum is not mobilized fully from the
concavity of the sacrum
 Inferior mesenteric artery is ligated at its base
 Inferior mesenteric vein (follows a different course than the
artery) is ligated separately
 A primary anastomosis (usually end-to-end) between the
colon and rectal stump with a short cuff of peritoneum
surrounding its anterior two thirds can be performed.
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LOW ANTERIOR RESECTION
 Used to remove lesions in the upper and mid rectum
 The rectosigmoid is mobilized
 The pelvic peritoneum is opened, and the inferior mesenteric
artery is ligated and divided either at its origin from the aorta
or just distal to the takeoff of the left colic artery
 The rectum is mobilized from the sacrum by sharp dissection
under direct view within the endopelvic fascial plane
 The dissection may be performed distally to the anorectal
ring, extending posteriorly through the rectosacral fascia to
the coccyx and anteriorly through Denonvilliers’ fascia to the
vagina in women or the seminal vesicles and prostate in men
 The rectum and accompanying mesorectum are divided at the
appropriate level, depending on the nature of the lesion
 A low rectal anastomosis usually requires mobilization of the
splenic flexure and ligation and division of the inferior
mesenteric vein just inferior to the pancreas
 Circular stapling devices have greatly facilitated the conduct
and improved the safety of the colon to extraperitoneal rectal
anastomosis.
EXTENDED LOW ANTERIOR RESECTION
 Necessary to remove lesions located in the distal rectum, but
several centimeters above the sphincter
 The rectum is fully mobilized to the level of the levator ani
muscle just as for a low anterior resection, but the anterior
dissection is extended along the rectovaginal septum in
women and distal to the seminal vesicles and prostate in men
 After resection at this level, a coloanal anastomosis can be
created using one of a variety of techniques.
o Traditionally: End-to-end stapled or hand-sewn
anastomosis
o New: Creation of a colon J-pouch or transverse coloplasty
to increase the capacity of the neorectal reservoir
o Because the risk of an anastomotic leak and subsequent
sepsis is higher when an anastomosis is created in the
distal rectum or anal canal, creation of a temporary
ileostomy should be considered in this setting.
 An anastomosis is feasible very low in the rectum or anal
canal but postoperative function may be poor
o Descending colon lacks the distensibility of the rectum and
the reservoir function may be compromised
o Pelvic radiation, prior anorectal surgery, and obstetrical
trauma may cause unsuspected sphincter damage
o A very low anastomosis may involve and compromise the
upper sphincter.
o Creation of a colon J-pouch or transverse coloplasty may
improve function
 A history of sphincter damage or any degree of incontinence
is a contraindication for a coloanal anastomosis
o End colostomy may be a more satisfactory option.
HARTMANN’S PROCEDURE AND MUCUS FISTULA
 A colon or rectal resection without an anastomosis in which a
colostomy or ileostomy is created and the distal colon or
rectum is left as a blind pouch
 Typically used when the left or sigmoid colon is resected and
the closed off rectum is left in the pelvis
 If the distal colon is long enough to reach the abdominal wall,
a mucus fistula can be created by opening the defunctioned
bowel and suturing the open lumen to the skin.
ABDOMINOPERINEAL RESECTION (APR)
 Removal of the entire rectum, anal canal, and anus with
construction of a permanent colostomy from the descending
or sigmoid colon
 The abdominal-pelvic portion of this operation proceeds in the
same fashion as described for an extended low anterior
resection
 The perineal dissection can be performed with the patient in:
o Lithotomy position (often by a second surgeon)
o Prone position after closure of the abdomen and creation of
the colostomy
 For cancer, the perineal dissection is designed to excise the
anal canal with a wide circumferential margin including a
cylindrical cuff of the levator muscle.
 Primary wound closure is usually successful, but a large
perineal defect, especially if preoperative radiation has
been used, may require a vascularized flap closure in some
patients
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 Large Intestines, Colon, and Rectum 1.04

 For benign disease, proctectomy may be performed using PERMANENT

an intersphincteric dissection between the internal and  Required after total proctocolectomy or in patients with
external sphincters obstruction.
o Minimizes the perineal wound (easier to close because  End ileostomy
the levator muscle remains intact) o Preferred configuration because a symmetric protruding
nipple can be fashioned more easily than with a loop
ANASTOMOSES ileostomy
 May be created between 2 segments of bowel
o Sub mucosal layer of the intestine COMPLICATIONS
 Provides strength; must be incorporated in the  Stoma necrosis
anastomosis o Occur in early post-op period
o At highest risk of leak and stricture: o Caused by skeletonizing the distal small bowel
 distal rectal or anal canal o Creating overly tight fascial defect
o Limited mucosal necrosis
ANASTOMOTIC CONFIGURATION o Above the fascia may be treated;
 End-to-End: 2 segments of bowel are roughly the same o Below the fascia requires surgical revision
caliber.  Stoma Retraction
o Often used in rectal resections may be used in o Occur early or late
colocolostomy and small bowel anastomoses. o May be exacerbated by obesity
 End-to-Side: used when one limb of bower is larger than o local revision may be necessary
the other. o Ileostomy output maintained at < 1500mL/d to avoid
o Most commonly occurs in chronic obstruction dehydration and electrolyte abnormalities
 Side-to-End: used when proximal bowel is of smaller o Bulk agents and opioids are useful (e.g., Lomotil, Imodium,
caliber than the distal bowel. tincture of opium
o Ileorectal anastomoses  Skin irritation due to poorly fitted stoma appliance
o Have less tenuous blood supply than End-to-End.  Parastomal hernia
 Side-to-Side: allows a large, well-vascularized connection o Less common after an ileostomy than after a colostomy
to be created on the anti-mesenteric side of two segments o Caused by poor appliance fitting, pain, obstruction, or
of intestine. strangulation.
o Commonly used in ileocolic and small bowel anastomoses  Prolapse
o Rare, late complication
ANASTOMOTIC TECHNIQUE o Associated with a parastomal hernia.
 Any anastomotic configurations may be created using hand-
sutured or stapled technique COLOSTOMY
 Most are created as End colostomies rather than loop
HAND-SUTURED TECHNIQUE colostomy
 Single layer: using running or interrupted stitches  Created mostly on the left side of the colon
 Double layer: consists of a continuous inner layer and an  Mucus Fistula
interrupted outer layer o The distal bowel may be brought through the abdominal
 Suture material: permanent or absorbable wall
 Hartmann’s pouch
o Distal bowel left intra-abdominally
STAPLED TECHNIQUE
 Linear cutting/stapling devices
COMPLICATIONS
o Uused to divide the bowel and to create side-to-side
anastomoses.  Colostomy necrosis
o Reinforced with interrupted sutures if desired. o Occur early postoperative period
 Circular cutting/stapling devices o Results from an impaired vascular supply
o Create end-to-end, end-to-side, or side-to-end  skeletonization of the distal colon
anastomoses.  tight fascial defect
o Useful for creating low rectal or anal canal anastomoses o limited suprafascial necrosis: treated expectantly
where the anatomy of the pelvis makes a hand-sewn o necrosis below the fascia: surgery
anastomosis technically difficult or impossible.  Retraction
 Leak test  Less problematic than with an ileostomy
o Instilling water or saline into the pelvis and insufflating  Stool is less irritating to the skin than succus entericus
the rectum with air via a proctoscope or alternatively  Obstruction
instilling methylene blue or betadine into the rectum to  Parastomal hernia
look for extravasation.  Most common late complication of a colostomy
 If symptomatic: requires repair
 Prolapse
ILEOSTOMY
 Occur rarely
TEMPORARY  More common with loop colostomy
 Used to protect an anastomosis at risk for leakage.  Dehydration – rare
o Low in the rectum  Skin irritation – less common
o Irradiated field
o Immuno-compromised FUNCTIONAL RESULTS
o Malnourished patient
 Excellent; following colonic resection and primary
o Emergency operation
anastomosis
 May experience diarrhea and bowel frequency
LOOP ILEOSTOMY  “The more distal the anastomosis, the greater the risk of
 A segment of distal ileum is brought through the defect in troublesome diarrhea”
the abdominal wall as a loop.  Ureteral stents
 Secured with or without an underlying rod  Used to udentify ureters intraoperatively and removed at
the end of the operation
DIVIDED LOOP
 Created by firing a linear cutting/stapler across the distal INFLAMMATORY BOWEL DISEASE
limb of the loop flush with the skin followed by maturation ETIOLOGY
of the proximal limb of the loop.  Diet and infection
 Prevents incomplete diversion that occasionally occurs with  Alcohol and oral contraceptives
a loop ileostomy  Smoking – etiology and exacerbation of Crohn’s Disease
 Flexible endoscopy exam & contrast enema (Gastrografin)  Autoimmune mechanism
 Recommended prior to closure to ensure that the anastomosis  Interaction between immune system, mucosal barrier of
has not leaked and is patent. the gut and a variety of infectious agent

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 Large Intestines, Colon, and Rectum
EXTRAINTESTINAL MANIFESTATIONS
 Liver - common site of extracolonic disease in inflammatory
bowel disease
o Fatty infiltration
 May be reversed by medical or surgical treatment of
colonic disease
 Cirrhosis – irreversible
 Arthritis
 Erythema nodosum
o Characteristic lesions are raised, red, and predominantly
on the lower legs
o Female > Male by 4x
 Ocular lesions
o Uveitis, iritis episcleritis, and conjunctivitis
o Occur in acute exacerbation
NON-OPERATIVE MANAGEMENT
 Focuses on decreasing inflammation and alleviating
symptoms
1. Salicylates – for mild to moderate
o Sulfasalazine (Azulfidine)
o 5-acetyl salicylic acid (5-ASA)
2. Antibiotics
o Decreases intraluminal bacterial load in Crohn’s disease
3. Corticosteroids
o Key component of treatment for an acute exacerbation of
either ulcerative colitis or Crohn’s disease
4. Immunomodulating agents
o Azathioprine and 6-mercatopurine (6-MP)
o Useful in patients who have failed salicylate therapy or
who are dependent on, or refractory to, corticosteroids
5. Biologic agents - inhibition of TNF-α
6. Nutrition
o Parenteral nutrition should be strongly considered early
in the course of therapy
ULCERATIVE COLITIS
 Mucosal process in which the colonic mucosa and
submucosa are infiltrated with inflammatory cells
 Mucosa is frequently friable and may possess multiple
inflammatory pseudopolyps
 Key feature: continuous involvement of rectum and colon
 It does not involve the small bowel
 Dynamic disease characterized by remissions and
exacerbations
 Onset may be insidious or abrupt
 Diagnosis
o Made endoscopically
o Proctoscopy
o Earliest manifestation: Mucosal edema
o Barium enema- used for chronic UC
INDICATION FOR SURGERY
 May be emergent or elective
EMERGENCY SURGERY
 Massive life-threatening hemorrhage
 Toxic megacolon
 Fulminant colitis who fail to respond rapidly to medical
therapy
ELECTIVE SURGERY
 Intractability despite maximal medical therapy
 High-risk development of major complications of medical
therapy such as aseptic necrosis of joints secondary to
chronic steroid use.
 Significant risk of developing colorectal carcinoma
OPERATIVE MANAGEMENT
EMERGENT OPERATION
 In patients with fulminant colitis or toxic megacolon
o Total abdominal colectomy with end ileostomy is preferred
than proctocolectomy
o Most patients improve dramatically after an abdominal
colectomy
o Avoids a difficult time-consuming pelvic dissection
especially in critically ill patients
 Loop ileostomy and decompressing colostomy if the patient is
too unstable to withstand colectomy
o Definitive surgery may be undertaken later when the
patient is stable
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1.04
 Ileal pouch anal reconstruction and other complex techniques
are contraindicated in emergent settings.
 Massive hemorrhage that include bleeding from the rectum
may necessitate proctectomy and either a permanent
ileostomy or ileal pouch anal anastomosis
ELECTIVE OPERATION
 Abdominal colectomy with ileorectal anastomosis is still
appropriate in patients with indeterminate colitis and rectal
sparing
 Total proctocolectomy with end ileostomy - GOLD STANDARD
for patients with chronic ulcerative colitis
o Removal of the entire affected intestine and avoids the
functional disturbances associated with ileal pouch-anal
reconstruction
o Most patients function well physically and psychologically
after the operation
 Total proctocolectomy with continent ileostomy (Kock’s
pouch)
o Developed to improve function and quality of life after
proctocolectomy
o But morbidity is high
o Restorative proctocolectomy with ileal pouch-anal
anastomosis - procedure of choice for patients who wish to
avoid a permanent ileostomy
CROHN’S DISEASE
 Characterized by exacerbations and remissions
 Transmural inflammatory process that may affect any portion
of the intestinal tract, from mouth to anus
o Most common site of involvement is the terminal ileum and
cecum>small intestines>colon and rectum
 Diagnosis may be made by colonoscopy or
esophagogastroduodenoscopy or by barium small bowel study
or enema, depending on which part is affected
 Can be caused by:
o Bacteria: M. paratuberculosis, L. monocytogenes
o Virus: Paramyxo and measles virus
 Characterized by deep serpiginous ulcers and a “cobblestone”
appearance
 Characteristic pathologic findings:
o Mucosal ulcerations
o Inflammatory cell infiltrate
o Non-caseating granulomas
 Skip lesions and rectal sparing (occurs in 40% of patients) -
Key in differentiating Crohn’s from UC
 Perianal and anal manifestations present as complex anal
fistulas and abscesses, anal ulcers, and large skin tags
INDICATIONS FOR SURGERY
 Unlike UC, which can be managed by resection of the affected
segment, Crohn’s disease, which can affect any part of the GI
tract, cannot be managed by removal of all of the intestine
at-risk.
o Surgery is only reserved for complications of the disease
 Crohn’s disease presents as an acute inflammatory process or
as a chronic fibrotic process.
o In the acute phase, it may present with intestinal
inflammation complicated by fistulas and/or by intra-
abdominal abscesses
o Maximal medical therapy must be given
 Anti-inflammatory medications, bed rest, and antibiotics
 Parenteral nutrition if the patient is malnourished
 Intra-abdominal abscesses can be drained
percutaneously with the use of CT scan guidance
 These will allow the condition to stabilize, nutrition to be
optimized, and inflammation to decrease before resection
is done
o Chronic fibrosis may result in strictures in the GIT
 Gradual fibrotic process
 Adjacent structures “wall off” the site of perforation =
perforation occurs very rarely
o Development of enteric and colonic internal fistulas to other
segments of the intestine and other viscera such as the
bladder, uterus, and vagina, or retroperitoneal sites
o Chronic strictures NEVER improve by medical therapy but
with resection or stricturoplasty
 Laparotomy for Crohn’s disease is done with a midline incision
because of the possible need of a stoma
o A stoma is required if the patient is hemodynamically
unstable, septic, malnourished, or taking high-dose
immunosuppressants, or in patients with extensive intra-
abdominal contamination
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 Large Intestines, Colon, and Rectum 1.04

 Length of the romoved bowel should be minimized since the  True diverticula
patient may require multiple operations o Rare
 Bowel should be resected to an area with grossly normal o Congenital
margins o Involves all the layers of the intestine
 Frozen sections are not necessary  Sigmoid - MOST COMMON SITE
 Primary anastomosis can be created when the patient is
stable, adequate nutritionally, and taking a few UNCOMPLICATED DIVERTICULITIS
immunosuppressants  LLQ pain and tenderness
 Dx: Imaging - Barium enema, CT scan
ILEOCOLIC AND SMALL BOWEL CROHN’S DISEASE  Does not warrant immediate surgery
 Ileocolic Crohn’s disease occur in 41% of patients; while  Conservative therapy
the SI is involved in 35% of patients o Antibiotics
 Most common indications for surgery are internal fistulas, o Elective resection
abscesses, and obstruction
o Psoas abscesses may result from chronic ileocolic disease COMPLICATED DIVERTICULITIS
 Sepsis is controlled with drainage of abscesses and  Prone to rupture
antibiotics  Abscess, obstruction, diffuse peritonitis, fistulas may develop
 Extent of resection depend on affected segment of the  Hinchey staging system for complicated diverticulitis
intestine
 Parenteral nutrition is necessary in patients with chronic HINCHEY STAGING SYSTEM
obstruction
STAGE DESCRIPTION
 High recurrence rate after resection (50% within 10 years) I Inflammation with pericolic abscess; treated with
o Will require a second operation antibiotics, may not require surgery; can convert to
uncomplicated
CROHN’S COLITIS II Inflammation with retroperitoneal/pelvic abscess;
 Same treatment as toxic megacolon or fulminant colitis can also convert into uncomplicated
secondary to UC III Purulent peritonitis present
 Resuscitation and medical therapy with bowel rest, broad- IV Fecal peritonitis present; increased mortality due to
spectrum antibiotics, and parenteral corticosteroids sepsis
 Total abdominal colectomy with ileostomy is recommended
if there is no improvement NEOPLASMS
 Elective proctectomy is required for refractory Crohn’s ADENOCARCINOMA
proctitis
RISK FACTORS
 Ileorectal anastomosis may be appropriate once the patient
has recovered  Aging
 Intractability, complications of medical therapy, and risk or  Hereditary
development of malignancy are indications for surgery  Environmental/ dietary
o Segmental colectomy if the remaining colon or rectum o Smoking
appear normal and for isolated colonic strictures o Meat
o Crohn’s colitis pose the same risk for cancer as UC o Low fiber diet
 Inflammatory bowel diseases
ANAL AND PERIANAL CROHN’S DISEASE
POLYPS
 35% of patients
 Isolated anal Crohn’s disease is uncommon, therefore,  Majority of cancer evolves from adenomatous polyps -
evaluation of the remainder of the GIT for Crohn’s disease (adenoma-carcinoma sequence)
is important  Any projection from the surface regardless of histology
 Most common lesions are SKIN TAGS which are minimally  Can be classified as flat or sessile, and with stalk
symptomatic
 Fissures are also common CLASSIFICATION
o Deep and broad, better described as an anal ulcer  Neoplastic
o Multiple, located in a lateral position - indicative of  Hyperplastic
Crohn’s disease  Hamartomatous
 Abscesses and fistulas are common  Inflammatory - pseudopolyp, lymphomatous polyp
o Fistulas may have complex and multiple tracts
 Treatment focuses on alleviation of symptoms HAMARTOMATOUS POLYPS
o Skin tags are not removed unless extremely symptomatic  Usually not premalignant
o Fissures may respond to local or systemic therapy  Characteristic polyp of childhood but may occur at any age
o Sphincterectomy is contraindicated because of the risk of  Bleeding – common symptom
creating a chronic, nonhealing wound and the increased  Associated with PTEN mutation
risk of incontinence
o Control of sepsis, delineation of complex anatomy,
1. FAMILIAL JUVENILE POLYPOSIS
treatment of underlying mucosal disease, and sphincter
preservation are the goals for abscesses and fistulas  Hundreds of polyps in colon and rectum
 Abscesses can be drained  Tx: Total Proctolectomy – if rectum is carpeted with polyps
 Seton wire techinique for complex fistulas
o Proctectomy is the best option for highly symptomatic 2. PEUTZ-JEGHER SYNDROME
rectovaginal fistula in women  Polyposis of SI, to a lesser extent, colon & rectum
o Underlying proctitis can be treated with salicylate and/or  Characteristic melanin spots are often noted on the buccal
corticosteroid enemas mucosa and lips of these patients
 Low risk for malignancy
INDETERMINATE COLITIS  May cause obstruction and bleeding
 15% of patients manifest both UC and Crohn’s disease
 Endoscopy, barium enema, and biopsy may be unable to 3. CRONKITE-CANADA
differentiate from the two  GI polyposis associated with alopecia, cutaneous
 Same indications for surgery as UC pigmentation, and atrophy of the fingernails and toenails.
 Diarrhea - prominent symptom, and vomiting,
DIVERTICULAR DISEASE malabsorption, and protein-losing enteropathy may occur.
 Diverticulosis - Outpouching
 Diverticulitis - inflammation of the outpouching/diverticula 4. COWDEN SYNDROME
 False diverticula  Autosomal dominant disorder with hamartomas of all three
o Majority of patients embryonal cell layers
o Affects only the mucosa and the muscularis  Facial trichilemmomas, breast cancer, thyroid disease, and
o Prone to rupture of diverticula gastrointestinal polyps are typical of the syndrome

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 Large Intestines, Colon, and Rectum 1.04

INHERITED COLORECTAL CARCINOMA
A. FAMILIAL ADENOMATOUS POLYPOSIS (FAP)
 Genetic abnormality in FAP  mutation in the APC gene,
located on chromosome 5q
 Lifetime risk of colorectal CA in FAP patients is 100% by age
50 year
 Clinically, patients develop hundreds to thousands of
adenomatous polyps shortly after puberty.
 Flexible sigmoidoscopy of first-degree relatives of FAP is the
mainstay of screening.
 Associated with:
o Gardner’s syndrome – mandibular osteomas
o Turcot’s syndrome – CNS tumors
B. ATTENUATED FAP
 Present later in life with fewer polyps (usually 10–100)
 Only 30% are (+) for APC gene
C. HEREDITARY NONPOLYPOSIS COLON CA
HNPCC (LYNCH SYNDROME)
 Genetic defects - arise from errors in mismatch repair
 Approximately 70% will develop colorectal CA
 Macroscopically - Tumor may take one of four forms
o Type 1 – Annular
o Type 2 – Tubular
o Type 3 – Acinar
o Type 4 – Cauliflower (is the least malignant form)
STAGING
 TNM Staging system
 Stage I
o Includes adenoCAs that are invasive through the muscularis
mucosa but are confined to the submucosa (T1) or the
muscularis propria (T2) in the absence of nodal metastases.
 Stage II
o Consists of tumors that invade through the bowel wall into
the subserosa or nonperitonealized pericolic or perirectal
tissues (T3) or into other organs or tissues or through the
visceral peritoneum (T4) without nodal metastases.
 Stage III
o Includes any T stage with nodal metastases
 Stage IV
o Denotes distant metastases.

COLORECTAL CA
CLINICAL PRESENTATION
 Nonspecific and generally develop when the cancer is locally
advanced.
 Classic first symptoms: change in bowel habits and rectal
bleeding
 left-sided tumors are more likely to cause obstruction than
are right-sided tumors
o Because of the caliber of the bowel and the consistency
of the stool
 Rectal tumors may cause bleeding, tenesmus, and pain
 Patients may be asymptomatic and/or present with
unexplained anemia, weight loss, or poor appetite

 CA of the LEFT side of the colon:

o Pain
o Alteration of bowel habit
o Palpable lump
o Distension
 CA of the SIGMOID
o Pain
o Tenesmus
o Bladder symptoms
o Anemia
 CA of the CECUM and ASCENDING colon:
o Lump in the right iliac fossa
o Acute appendicitis
o Intermittent obstruction
 May present with features of metastasis
o Palpable liver
o Ascites
o Jaundice

PREDISPOSING FACTORS
 Low-fibre containing diet
 Smoked fish
 High content of refined carbohydrate in diet
 Red meat
 Less intake of micronutrients esp Selenium
TREATMENT
ROUTES OF SPREAD AND NATURAL HISTORY  Preoperative chemoradiation therapy may delay recurrence.
 Spreading  Salvage surgery
o Local o For patients who have local recurrence
o Lymphatic o Recurrence after colon cancer resection usually occurs at
o Hematogenous the local site within the abdomen or in the liver or lungs
 Colon and Rectal CA may arise in the mucosa  Adjuvant therapy should be administered prior to salvage
 Regional lymph node involvement is the most common form surgery
of spread of colorectal carcinoma  For patients who has not received chemotherapy and
 The T stage (depth of invasion) is the single most radiation
significant predictor of lymph node spread.  Negative margin is in question
 LIVER- most common site of distant metastasis from o The addition of intraoperative radiation therapy (usually
colorectal cancer brachytherapy) can help improve local control
o These metastases arise from hematogenous spread via
the portal venous system MINIMALLY INVASIVE TECHNIQUES FOR RESECTION
 Laparoscopic colectomy for cancer
PATHOLOGY  shown oncologic equivalence between open and
 Microscopically laparoscopic techniques
o Columnar cell CA originating in the colonic epithelium

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 Large Intestines, Colon, and Rectum 1.04

BENIGN COLORECTAL CONDITIONS NONOPERATIVE THERAPY

RECTAL PROLAPSE  High-fiber diet
 Rectal prolapse refers to a circumferential, full-thickness  Defecation training to avoid straining
protrusion of the rectum through the anus
o Has also been called “first-degree” prolapse, “complete” SURGICAL MANAGEMENT
prolapse, or procidentia  Abdominal or perineal repair of prolapse
 Far more common among women, with a female-to-male  Reserved for highly symptomatic patients who have failed all
ratio of 6:1 medical interventions
o Prolapse becomes more prevalent with age in women and
peaks in the seventh decade of life VOLVULUS
o In men, prevalence is unrelated to age.  Occurs when an air-filled segment of the colon twists about
 Internal prolapse its mesentery
o Rectal wall intussuscepts but does not protrude and is  Sigmoid colon is involved in up to 90% of cases
probably more accurately described as internal  May reduce spontaneously
intussusception.  Commonly produces bowel obstruction
 Mucosal prolapse o Can progress to strangulation, gangrene, and perforation
o Partial-thickness protrusion often associated with  Chronic constipation may produce a chronic megacolon that
hemorrhoidal disease predisposes to volvulus
o Treated with banding or hemorrhoidectomy  Symptoms -> acute bowel obstruction
 Symptoms include o Abdominal distention
o Tenesmus o Nausea
o A sensation of tissue protruding from the anus that may or o Vomiting
may not spontaneously reduce  Fever and leukocytosis
o Sensation of incomplete evacuation o Gangrene and/or perforation

PRIMARY THERAPY FOR RECTAL PROLAPSE SIGMOID VOLVULUS

 Abdominal operations have taken three major approaches:
 Reduction of the perineal hernia and closure of the cul-de-sac
(Moschowitz repair
 Fixation of the rectum, either with a prosthetic sling (Ripsten
and Wells rectopexy) or by suture rectopexy
 Resection of redundant sigmoid colon
 Differentiated from cecal or transverse colon volvulus ->
plain X-rays of the abdomen
 Bent inner tube or coffee bean appearance
 Convexity of the loop -> right upper quadrant
 Gastrografin enema -> bird’s beak
 The presence of necrotic mucosa, ulceration, or dark blood
o Suggest strangulation
o Is an indication for operation

Fig 6. Transabdominal proctopexy for rectal prolapse. The fully mobilized

rectum is sutured to the presacral fascia. A. Anterior view. B. Lateral
view. If desired, a sigmoid colectomy can be performed concomitantly to
resect the redundant colon

 Resection Rectopexy
o Resection is combined with rectal fixation Fig 7. Sigmoid volvulus: (A) Illustration and (B) Gastrografin enema
 Tightening The Anus With A Variety Of Prosthetic Materials: showing “bird-beak” sign (arrow).
o Delome Procedure
 Reefing the rectal mucosa MANAGEMENT
o Perineal rectosigmoidectomy or Altemeier procedure  The initial management -> resuscitation followed by
 Resecting the prolapsed bowel from the perineum endoscopic detorsion
 Abdominal rectopexy (with or without sigmoid resection)  Detorsion
o The most durable repair o Accomplished by using a rigid proctoscope
o Recurrence occurring in less than 10% of patients o But a flexible sigmoidoscope or colonoscope may also be
 Perineal rectosigmoidectomy effective
o Avoids an abdominal operation  Rectal tube
o May be preferable in high-risk patients o Maintain decompression
o Higher recurrence rate  Elective sigmoid colectomy
 Reefing the rectal mucosa is effective for patients with limited o Should be performed after the patient has been stabilized
prolapse. and undergone an adequate bowel preparation
o To prevent recurrence
SOLITARY RECTAL ULCER SYNDROME  Hartmann’s procedure
 Commonly associated with internal intussusception o Dead bowel
 One or more ulcers are present in the distal rectum o Laparotomy
 Usually on the anterior wall o Sigmoid colectomy with end colostomy
 Nodules may be found in a similar location o Safest operation to perform

DIAGNOSIS CECAL VOLVULUS

 Anorectal manometry  Results from nonfixation of the right colon
 Defecography  Rotation occurs around the ileocolic blood vessels
 Colonoscopy or barium enema  Plain X-rays of the abdomen -> kidney-shaped, air-filled
 Biopsy of an ulcer or mass is mandatory structure in the left upper quadrant
o To exclude malignancy or infection due to cytomegalovirus  Gastrografin enema
(CMV) o Confirms obstruction at the level of the volvulus
 Cecal volvulus can almost never be detorsed endoscopically

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 Large Intestines, Colon, and Rectum 1.04

MANAGEMENT o Intravenous neostigmine

 Surgical exploration is necessary
 Right hemicolectomy with a primary ileocolic anastomosis
o Prevents recurrence
 Simple detorsion or detorsion and cecopexy
o High rate of recurrence
 Extremely effective in decompressing the dilated colon
 Low rate of recurrence (20%)
 May produce transient but profound bradycardia
 It is crucial to exclude mechanical obstruction prior to medical
or endoscopic treatment

TRANSVERSE COLON VOLVULUS ISCHEMIC COLITIS

 Predisposing factors  Intestinal ischemia occurs most commonly in the colon
o Nonfixation of the colon and chronic constipation with  Most colonic ischemia appears to result from low flow and/or
megacolon small vessel occlusion
 The radiographic appearance of  Risk factors include:
o Resembles sigmoid volvulus o Vascular disease
 Gastrografin enema -> reveal a more proximal obstruction o Diabetes mellitus
o Vasculitis
o Hypotension
MANAGEMENT
o Tobacco use
 Colonoscopic detorsion o Ligation of the inferior mesenteric artery during aortic
o Occasionally successful surgery
 Emergent exploration and resection  Thrombosis or embolism may cause ischemia
 Splenic flexure
MEGACOLON o Most common site of ischemic colitis
 Chronically dilated, elongated, hypertrophied large bowel  The rectum is relatively spared because of its rich collateral
 Usually related to chronic mechanical or functional circulation
obstruction  Mild Cases
 Degree of megacolon is related to the duration of o Diarrhea (usually bloody) without abdominal pain
obstruction  More Severe Ischemia
o Intense abdominal pain
CONGENITAL MEGACOLON o Tenderness
 Hirschsprung’s disease o Fever
 Results from the failure of migration of neural crest cells to o Leukocytosis
the distal large intestine  Fullthickness necrosis and perforation
 Absence of ganglion cells in the distal colon results in a o Peritonitis and/or systemic toxicity
failure of relaxation and causes a functional obstruction
 Ultrashort-segment Hirschsprung’s disease DIAGNOSIS
o Presents later in adulthood  Based on the clinical history and physical examination
o Results if an extremely short segment of the bowel is  Plain films
affected o May reveal thumb printing
o Results from mucosal edema and submucosal hemorrhage
MANAGEMENT  CT Scan
 Surgical resection of the aganglionic segment is curative o Nonspecific colonic wall thickening
o Pericolic fat stranding
ACQUIRED MEGACOLON  Angiography
o Usually not helpful because major arterial occlusion is rare
 Result from infection or chronic constipation
 Sigmoidoscopy
 Infection Trypanosoma cruzi (Chagas’ disease)
o Dark, hemorrhagic mucosa
o Destroys ganglion cells and produces both megacolon
o Risk of precipitating perforation is high
and megaesophagus
o Contraindicated in any patient with significant abdominal
 Chronic constipation from slow transit or secondary to:
tenderness
o Medications
 Contrast studies (Gastrografin or barium enema)
 Anticholinergic medications
o Contraindicated during the acute phase of ischemic colitis
o Neurologic disorders
 Paraplegia
 Poliomyelitis MANAGEMENT
 Amyotrophic lateral sclerosis  Bowel rest and broad-spectrum antibiotics are the mainstay
 Multiple sclerosis of therapy
 Hemodynamic parameters should be optimized
MANAGEMENT  Long-term sequelae include
o Stricture (10%–15%)
 Diverting ileostomy
o Chronic segmental ischemia (15%–20%)
 Subtotal colectomy with an ileorectal anastomosis
 Colonoscopy should be performed after recovery
o Evaluate strictures and to rule out other diagnoses such as
COLONIC PSEUDO-OBSTRUCTION inflammatory bowel disease or malignancy
(OGILVIE’S SYNDROME)  Indications for surgical exploration
 Is a functional disorder in which the colon becomes o Failure to improve after 2 to 3 days of medical
massively dilated in the absence of mechanical obstruction management
 Most commonly occurs in hospitalized patients and is o Progression of symptoms
associated with the use of narcotics, bed rest, and o Deterioration in clinical condition
comorbid disease o All necrotic bowel should be resected
 Result from autonomic dysfunction and severe adynamic o Primary anastomosis should be avoided
ileus o Repeated exploration may be necessary

DIAGNOSIS INFECTIOUS COLITIS

 Presence of massive dilatation of the colon (usually right PSEUDOMEMBRANOUS COLITIS
and transverse colon) in the absence of a mechanical  Caused by C. difficile
obstruction  Leading cause of nosocomially acquired diarrhea.
 Ranges from watery diarrhea to fulminant, life-threatening
MANAGEMENT colitis.
 Cessation of narcotics, anticholinergics, or other  Clindamycin
medications that may contribute to ileus o Was the first antimicrobial agent associated with C. difficile
 Strict bowel rest colitis
 Intravenous hydration o Almost any antibiotic may cause this disease
 Colonoscopic decompression  Risk:
o Up to 40% of patients recur o Immunosuppression

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 Large Intestines, Colon, and Rectum 1.04

o Medical comorbidities ANORECTAL DISEASES

o Prolonged hospitalization
HEMORRHOIDS
o Nursing home residence
 Cushions of submucosal tissue containing venules, arterioles,
o Bowel surgery increase the risk
and smooth muscle fibers that are located in the anal canal
 The pathogenic result from production of two toxins:
 Three hemorrhoidal cushions
o Toxin A (an enterotoxin)
o Left lateral
o Toxin B (a cytotoxin)
o Right anterior
o Right posterior positions
DIAGNOSIS  Function of Hemorrhoids
 Culturing the organism from the stool o Part of the continence mechanism
 Detection of one or both toxins (either by cytotoxic assays o Aid in complete closure of the anal canal at rest
or by immunoassays) has proven to be more rapid,  Prolapse of hemorrhoid tissue is caused by increase venous
sensitive, and specific engorgement of the hemorrhoidal plexus:
 May also be made endoscopically by detection of o Excessive straining
characteristic: o Increased abdominal pressure
o Ulcers o Hard stools
o Plaques  Symtoms/Result:
o Pseudomembranes o Bleeding
o Thrombosis
MANAGEMENT o Symptomatic hemorrhoidal prolapse
 Immediate cessation of the offending antimicrobial agent
 Patients with mild disease EXTERNAL HEMORRHOIDS
o Diarrhea but no fever or abdominal pain  Located distal to the dentate line and are covered with
o May be treated as outpatients with a 10-day course of anoderm
oral metronidazole  The anoderm is richly innervated and thrombosis of an
o Oral vancomycin external hemorrhoid may cause significant pain
 Second-line agent used in patients allergic to  External hemorrhoids should not be ligated or excised without
metronidazole or in patients with recurrent disease. adequate local anesthetic
 More severe diarrhea associated with dehydration and/or  Skin tag
fever and abdominal pain o A redundant fibrotic skin at the anal verge, often persisting
o Bowel rest as the residua of a thrombosed external hemorrhoid
o Intravenous hydration o Often confused with symptomatic hemorrhoids.
o Oral metronidazole or vancomycin  External hemorrhoids and skin tags may cause itching and
 Proctosigmoiditis difficulty with hygiene if they are large
o Vancomycin enemas  Treatment of external hemorrhoids and skin tags is only
 Recurrent colitis indicated for symptomatic relief
o Occurs in up to 20% of patients
o Longer course of oral metronidazole or vancomycin (up to
INTERNAL HEMORRHOIDS
1 month)
 Located proximal to the dentate line and covered by insensate
o Rifaximin
anorectal mucosa
o Reintroduction of normal flora by ingestion of probiotics
 May prolapse or bleed, but rarely become painful unless they
or stool
develop thrombosis and necrosis (usually related to severe
 Fulminant colitis
prolapse, incarceration, and/or strangulation)
o Characterized by septicemia and/or evidence of
 Internal hemorrhoids are graded according to the extent of
perforation
prolapse.
o Requires emergent laparotomy
o First degree
o A total abdominal colectomy with end ileostomy may be
 Hemorrhoids bulge into the anal canal and may prolapse
lifesaving
beyond the dentate line on straining
o Second-degree
OTHER INFECTIOUS COLITIDES  Hemorrhoids prolapse through the anus but reduce
 Common bacterial infections include : spontaneously.
o Enterotoxic E. coli o Third-degree
o Campylobacter jejuni  Hemorrhoids prolapse through the anal canal and require
o Yersinia enterocolitica manual reduction
o Salmonella typhi o Fourth-degree
o Shigella  Hemorrhoids prolapse but cannot be reduced and are at
o N. gonorrhoeae risk for strangulation.
 Less common
o Mycobacterium tuberculosis
COMBINED INTERNAL AND EXTERNAL HEMORRHOIDS
o Mycobacterium bovis
 Located in the dentate line and have characteristics of both
o Actinomycosis israelii
internal and external hemorrhoids.
o Treponema pallidum (syphilis)
 Hemorrhoidectomy is often required for large, symptomatic,
 Parasitic infections: Amebiasis, Cryptosporidiosis, Giardiasis
combined hemorrhoids.
 Fungal infections
o Extremely rare in otherwise healthy individuals.
o Candida species and Histoplasmosis POSTPARTUM HEMORRHOIDS
 Viral Infection: HIV, Herpes simplex viruses, CMV  Straining during labor  edema, thrombosis, and/or
 Most symptoms are nonspecific : strangulation
o Consist of diarrhea (with or without bleeding)  Hemorrhoidectomy is the treatment of choice, especially if the
o Crampy abdominal pain patient has had chronic hemorrhoidal symptoms
o Malaise
RECTAL VARICES
DIAGNOSIS  May occur and may cause hemorrhage
 Made by identification of a pathogen in the stool by  Best treated by lowering portal venous pressure
microscopy or culture  Surgical hemorrhoidectomy should be avoided in these
 Serum immunoassay patients because of the risk of massive, difficult-to-control
o Amebiasis variceal bleeding
o HIV
o CMV TREATMENT
 Endoscopy with biopsy may be required  Mainly non-surgical
 Bleeding from 1st and 2nd degree hemorrhoids
TREATMENT o Dietary fiber
 Specific treatment to the causative agent o Stool softener

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 Large Intestines, Colon, and Rectum
o Increased fluid intake
o Avoidance of straining
 Associated pruritus often may improve with improved
hygiene
 Rubber band ligation
o Used in persistent bleeding from 1st, 2nd and selected 3rd-
degree hemorrhoids
 3rd and 4th degree internal hemorrhoids:
o Harmonic cutter
o Stapler technique
o Ferguson technique
ANAL FISSURE
 Tear from the dentate line up to the anal verge lined by
skin
 Seen in young and middle age groups
 Manifests as burning/tearing pain and hematochezia
 Location:
o Majority occur in the posterior midline
o 10-15% occur in the anterior midline.
o Less than 1% occur off midline
 If the diagnosis is in doubt or there is suspicion of another
cause for the perianal pain such as abscess or fistula, an
examination under anesthesia may be necessary.
ETIOLOGY
 Passage of large hard stool
 Secondary to Crohn’s disease, Ulcerative colitis, HIV,
Syphilis, Tuberculosis or Leukemia
TREATMENT
 Therapy focuses on breaking the cycle of pain, spasm, and
ischemia responsible for development of fissure in ano
 First-line therapy to minimize anal trauma:
o Bulk agents
o Stool softeners
o Warm sitz baths
 Addition of 2% lidocaine jelly or other analgesic creams can
provide additional symptomatic relief
 Nitroglycerin ointment has been used locally to improve
blood flow but often causes severe headaches
 Both oral and topical calcium channel blockers (diltiazem
and nifedipine) have also been used to heal fissures and
may have fewer side effects than topical nitrates.
 Newer agents, such as arginine (a nitric oxide donor) and
topical bethanechol (a muscarinic agonist) can be used
 Medical therapy is effective in most acute fissures, but will
heal only approximately 50% of chronic fissures.
 Botulinum toxin (Botox)
o Causes temporary muscle paralysis by preventing
acetylcholine release from presynaptic nerve terminals
o Injection of botulinum toxin is used in some centers as
an alternative to surgical sphincterotomy for chronic
fissure.
 Surgical therapy
o Traditionally recommended for chronic fissures that have
failed medical therapy
o Lateral internal sphincterotomy
 Procedure of choice
 Aims to decrease spasm of the internal sphincter by
dividing a portion of the muscle
 Approximately 30% of the internal sphincter fibers are
divided laterally by using either an open or closed
technique
 Healing is achieved in more than 95% of patients using
this technique
 Most patients experience immediate pain relief
ANORECTAL ABSCESS
 The majority of anorectal suppurative disease results from
infections of the anal glands (cryptoglandular infection)
found in the intersphincteric plane
 Infection of an anal gland results in the formation of an
abscess that enlarges and spreads along one of several
planes in the perianal and perirectal spaces
 5 potential spaces
o Perianal space
 Surrounds the anus and laterally becomes continuous
with the fat of the buttocks
o Intersphincteric space
 Separates the internal and external anal sphincters
 Continuous with the perianal space distally and extends
cephalad into the rectal wall
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o Ischiorectal space (ischiorectal fossa)
 Located lateral and posterior to the anus and is bounded
medially by the external sphincter, laterally by the
ischium, superiorly by the levator ani, and inferiorly by
the transverse septum
 Contains the inferior rectal vessels and lymphatics.
o Deep postanal space
 This space is fromed by the two ischiorectal spaces
connecting posteriorly above the anococcygeal ligament
but below the levator ani muscle
o Supralevator space
 Lie above the levator ani on either side of the rectum and
communicate posteriorly
 Perianal abscess
o Most common manifestation and appears as a painful
swelling at the anal verge
 Ischiorectal abscess
o Spread through the external sphincter below the level of
the puborectalis
 Intersphincteric abscesses
o Occur in the intersphincteric space and are difficult to
diagnose because there are no apparent sign of swelling or
induration in the perianal area
o A clue is deep seated tenderness when circum-anal
pressure is applied above the dentate line
o Often requires an examination under anesthesia
o Drainage is thru the anal canal lining or thru the internal
sphincteric muscle
 Pelvic and Supralevator abscesses
o Uncommon and may result from extension of an
intersphincteric or ischiorectal abscess upward or extension
of an intraperitoneal abscess downward
o Mimic acute intra-abdominal condition
ETIOLOGY
 Infection of anal gland
 Organisms (fecal, cutaneous flora)
o E. coli
o Clostridium difficile
o Bacteroides fragilis
o Staphylococcus
o Streptococcus
TREATMENT
 Drainage and antibiotics
 Good hygiene
 Warm Sitz bath
NECROTIZING PERIANAL AND PERINEAL INFECTION
 Necrotizing soft tissue infection of the perineum is a rare, but
lethal, condition.
 Most of these infections are polymicrobial and synergistic
 Immunocompromised patients and diabetic patients are at
increased risk.
ETIOLOGY
 Undrained or inadequately drained cryptoglandular abscess
 Urogenital infection
 Postoperatively (e.g., after hemorrhoidectomy)
MANIFESTATIONS
 Necrotic skin, bullae, or crepitus.
 Signs of systemic toxicity and may be hemodynamically
unstable
TREATMENT
 Surgical débridement of all nonviable tissue is required to
treat all necrotizing soft tissue infections
 Broad-spectrum antibiotics
 Colostomy may be required if extensive resection of the
sphincter is required or if stool contamination of the perineum
makes wound management difficult.
 Despite early recognition and adequate surgical therapy, the
mortality of necrotizing perineal soft tissue infections remains
approximately 50%.
FISTULA IN ANO
DIAGNOSIS
 Patients present with persistent drainage from the internal
and/or external openings
 Indurated tract is often palpable
 External opening is easily identifiable
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 Large Intestines, Colon, and Rectum
 Goodsall’s rule can be used in determining the location of
the internal opening
Fig 8. Goodsall’s rule to identify the internal opening of fistulas in ano.
 Anterior external opening connect to the internal opening
by a short, radial tract
 Posterior external opening track in a curvilinear fashion to
the posterior midline
 Exception: often if an anterior external opening is greater
than 3 cm from the anal margin, it tracks to the posterior
midline
Fistulas are categorized based on their relationship to the
anal sphincter complex. Usual operative procedures to
correct the fistula are depicted on the right side of the drawings.
Fig 9. Intersphincteric fistula - distal internal sphincter and
intersphincteric space to an external opening near the anal verge
Fig 10. Transsphincteric fistula - results from an ischiorectal abscess
and extends through both the internal and external sphincters
Fig 11. Suprasphincteric fistula - from the intersphincteric plane and
tracks up and around the entire external sphincter
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Fig 12. Extrasphincteric fistula - from the rectal wall and tracks
around both sphincters to exit laterally, usually in the ischiorectal fossa
TREATMENT
 Goal of treatment: eradication of sepsis without sacrificing
continence
 External opening is usually visible as a red elevation of
granulation tissue with or without concurrent drainage
 Injection of hydrogen peroxide or dilute methylene blue
may be helpful to identify the internal opening
 Care must be taken to avoid creating an artificial internal
opening (thus often converting a simple fistula into a
complex fistula)
 Intersphincteric fistulas - often treated by fistulotomy
(opening the fistulous tract), curettage, and healing by
secondary intention (Figure A above)
 “Horseshoe” fistulas usually have an internal opening in the
posterior midline and extend anteriorly and laterally to one
or both ischiorectal spaces by way of the deep postanal
space
 Transsphincteric fistula - tx depends on its location in the
sphincter complex
o Fistulas that include < 30% of the sphincter muscles –
sphincterotomy: w/o significant risk of major
incontinence (Fig B)
o High transsphincteric fistulas encircle a greater amount of
muscle - more safely treated by a seton
 Suprasphincteric fistulas are usually treated with seton
placement (C)
 Extrasphincteric fistulas - tx depends on the anatomy and
its etiology
o Portion of the fistula outside the sphincter should be
opened and drained
o A primary tract at the level of the dentate line may also
be opened if present
o Liberal use of drains and setons is helpful
o Failure to heal may require fecal diversion (D)
 Complex and/or nonhealing fistulas may result from
Crohn’s disease, malignancy, radiation proctitis, or unusual
infection
o Proctoscopy - to assess the health of the rectal mucosa
 Biopsies of the fistula tract - to rule out malignancy
Seton - drain placed through a fistula to maintain drainage
and/or induce fibrosis
 Cutting setons consist of a suture or a rubber band that is
placed through the fistula and intermittently tightened in the
office
o Tightening the seton results in fibrosis and gradual division
of the sphincter, thus eliminating the fistula while
maintaining continuity of the sphincter
 Noncutting seton - soft plastic drain (often a vessel loop)
placed in the fistula to maintain drainage
o Tract may subsequently be laid open with less risk of
incontinence because scarring prevents retraction of the
sphincter
o Alternatively, the seton may be left in place for chronic
drainage
 Higher fistulas may be treated by an endorectal
advancement flap
 Fibrin glue and collagen-based plugs also have been used to
treat persistent fistulas
 Recent technique: ligation of the intersphincteric fistula
tract (LIFT)
o Fistula is identified in the intersphincteric plane (usually
by a lacrimal probe), divided, and the two ends ligated
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 Large Intestines, Colon, and Rectum
RECTOVAGINAL FISTULA
 A connection between the vagina and the rectum or anal
canal proximal to the dentate line
 Low (rectal opening close to the dentate line and vaginal
opening in the fourchette)
o Commonly caused by obstetric injuries or trauma from a
foreign body
 Middle (vaginal opening between the fourchette and cervix)
o May result from more severe obstetric injury, after
surgical resection of a midrectal neoplasm, radiation
injury, or extension of an undrained abscess
 High (vaginal opening near the cervix)
o Result from operative or radiation injury
 Complicated diverticulitis may cause a colovaginal fistula
 Crohn’s disease can cause rectovaginal fistulas at all levels,
as well as colovaginal and enterovaginal fistulas
DIAGNOSIS
 Symptoms varying from the sensation of passing flatus
from the vagina to the passage of solid stool from the
vagina; some degree of fecal incontinence
 Contamination may result in vaginitis
 Occasionally, a barium enema or vaginogram may identify
these fistulas
 Endorectal ultrasound may also be useful
 In prone position, installation of methylene blue into the
rectum while a tampon is in the vagina may confirm a small
fistula
TREATMENT
 Depends on the size, location, etiology, and condition of
surrounding tissues
 Up to 50% of fistulas caused by obstetric injury heal
spontaneously; wait 3 to 6 months before doing surgical
repair in these patients
 If caused by a cryptoglandular abscess, drainage of the
abscess may allow spontaneous closure
 Low and mid-rectovaginal fistulas are usually best treated
with an endorectal advancement flap
o Advancement of healthy mucosa, submucosa, and
circular muscle over the rectal opening (the high-
pressure side of the fistula) to promote healing
o If a sphincter injury is present, an overlapping
sphincteroplasty is performed concurrently
 High rectovaginal, colovaginal, and enterovaginal fistulas
are treated via a transabdominal approach
o The diseased tissue, which caused the fistula, is resected
and the hole in the vagina closed
o Healthy tissue, such as omentum or muscle, frequently is
interposed between the bowel anastomosis and the
vagina to prevent recurrence
 Rectovaginal fistulas caused by Crohn’s disease, radiation
injury, or malignancy almost never heal spontaneously
 Fistulas caused by malignancy should be treated with
resection of the tumor
 Because differentiating radiation damage from malignancy
can be extremely difficult, all fistulas resulting from
radiation should be biopsied to rule out the presence of
cancer
PERIANAL DERMATITIS
PRURITUS ANI
 Severe perianal itching
 Surgically correctable (anatomic) causes include prolapsing
hemorrhoids, ectropion, fissure, fistula, and neoplasms
 Infections:
 Fungus (Candida species and Epidermophyton organisms)
 Parasites (Enterobius vermicularis [pinworms], Pediculus
pubis [lice], and Sarcoptes scabiei [scabies])
 Bacteria (Corynebacterium minutissimum [erythrasma] and
T. pallidum [syphilis])
 Viruses (HPV [condyloma acuminata])
 Antibiotic use may also cause itching, usually by
precipitating fungal infection
 Noninfectious, dermatologic: seborrhea, psoriasis, and
contact dermatitis
 Majority is idiopathic and probably related to local hygiene,
neurogenic, or psychogenic causes
 Treatment focuses on removal of irritants, improving
perianal hygiene, dietary adjustments, and avoiding
scratching
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NONPRURITIC LESIONS
 Leprosy, amebiasis, actinomycosis, and lymphogranuloma
venereum produce characteristic perianal lesions
 Neoplasms such as squamous intraepithelial lesions,
Paget’s disease, and invasive carcinomas may also appear
first in the perianal skin
 Biopsy
STDs
 Bacterial: N. gonorrhoeae, Chlamydia trachomatis, T.
pallidum (painless chancre), Haemophilus ducreyi (painful
chancroid), Donovania granulomatis, Campylobacter or
Shigella may also be sexually transmitted
 Parasitic: Entamoeba histolytica, Giardia lamblia
 Viral: HIV, HSV, HPV
o HSV
 Proctitis is usually caused by type 2 herpes simplex
virus and less commonly by type 1
o HPV
 Causes condyloma acuminata (anogenital warts) and is
associated with squamous intraepithelial lesions and
squamous cell carcinoma
 HPV types 16 and 18 predispose to malignancy and
cause flat dysplasia in skin unaffected by warts
 HPV types 6 and 11 cause warts, but do not appear to
cause malignant degeneration
PILONIDAL DISEASE
 Pilonidal disease (cyst, infection) consists of a hair-
containing sinus or abscess occurring in the intergluteal
cleft
 Speculated that the cleft creates a suction that draws hair
into the midline pits when a patients sits
 These ingrown hairs may then become infected and present
acutely as an abscess in the sacrococcygeal region
 Once an acute episode has resolved, recurrence is common
 An acute abscess should be incised and drained as soon as
the diagnosis is made
HIDRADENITIS SUPPURATIVA
 Infection of the cutaneous apocrine sweat glands
 Glands rupture and form subcutaneous sinus tracts
 Mimics complex anal fistula disease, but stops at the anal
verge because there are no apocrine glands in the anal
canal
 Treatment: incision and drainage, and unroofing of all
chronically inflamed fistulas and débridement of granulation
tissue
----t4P0wZ n4 ph0wZ----
Sample Quiz:
1. Gene mutation in FAP?
2. Disease related with mutation on mismatch repair genes?
3. Non-surgical management for hemorrhoids?
4. Main manifestation of anal fissures?
5. Disease with a count of polyps around 10-100?
6. GI polyposis associated with alopecia, cutaneous pigmentation, and
atrophy of the fingernails and toenails?
7. The recommended treatment safer for high transsphincteric fistulas:
a. Sphincterotomy
b. Fistulotomy
c. Seton placement
d. LIFT
8. Treatment of a rectovaginal fistula due to cryptoglandular abscess:
a. Wait 3 to 6 months first before doing surgical repair
b. Endorectal advancement flap
c. Proctoscopy first to assess the health of the rectal mucosa
d. Drainage of the abscess to allow spontaneous closure
9. Surgical treatment for Fistula In Ano
10. Resection of the rectum from an abdominal approach to the pelvis
with no need for a perineal, sacral, or other incision
Answers:
1. APC (Adenomatous Polyposis Coli)
2. HNPCC (Hereditary Non-Polyposis Colon Cancer)
3. Stool softener, intake of dietary fiber, increased fluid intake, avoidance
of straining, Sitz bath
4. Tearing pain
5. Attenuated FAP
6. Cronkite Canada
7. C
8. D
9. Seton technique
10. Anterior resection
Page 15 of 15