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Surgical treatment of the Colorectal Disease

Anatomy and Physiology

Bowel wall of colon: no villi in the colonic mucosa crypts of Lieberkuhn are the distinguishing histologic feature

Large intestine: mesenteric attachment 1. Ascending colon 2. Transverse colon 3. Descending colon 4. Sigmoid colon 5. Rectum

Valves and Sphincters of the Rectum and Anus

Three valves of the rectum stop feces from being passed with gas The anus has two sphincters:
Internal anal sphincter composed of smooth muscle External anal sphincter composed of skeletal muscle

These sphincters are closed except during defecation

Arterial vascular supply 1. Superior mesenteric artery ileocolic artery: appendix, cecum and proximal portion of ascending colon right colic artery: ascending colon and hepatic flexure middle colic artery: transverse colon 2. Inferior mesenteric artery left colic artery: splenic flexure and descending colon sigmoid & rectosigmoid arteries: sigmoid colon superior rectal artery: rectum Rectum superior rectal(hemorrhoid) artery: inferior mesenteric artery middle rectal(hemorrhoid) artery: internal iliac artery inferior rectal(hemorrhoid) artery: internal pudenal artery

Venous drainage Colon: portal venous system Rectum( middle and lower): 1. system venous system: internal iliac vein venous collaterals in the rectal submucosa 2. portal venous system inferior mesenteric vein Lower anal canal( below the pectinate line ): inferior rectal vein

Lymphatic Drainage 1.Lymphatic channels are located in the submucosa and muscularis mucosa,but not in the mucosa 2.Lymph vessel parallel the arterial supply of the colon nodes are located in the wall of the colon(epicolic) along the innermargin(paracolic) near mesenteric vessels(intermediate) around the main mesenteric arteries(main)

Innervation 1. Autonomic system: parasympathetic division 1. vagus nerve: lower GI tract to the level of the splenic flexure 2. nervi erigentes( plevic splanchnic nerve ): S2-S4 from splenic flexure to the pectinate line 3. motor innervation to the wall of the bowel sympathetic system 1. greater and lesser splanchnic nerves 2. blood vessel of the lower GI tract 2. Visceral afferent system parasympathetic nerves: afferent reflex arcs along the vagal & splanchnic pathways. sympathetic nerves: pain & pressure afferents along sympathetic pathways responsible for referred pain

Physiology 1. Absorption of water & electrolytes: major function Na,Cl and H2O are actively absorbed absorptive capacity 2L/day 2. Excretion mucosa secrete K and bicarbonate into the lumen 3. Motility: parasympathetic control via the vagus & plevic splanchnic nerve plexus ,transit time 5cm/hr, following meal chnage to 11cm/hr 4. Defecation reflex 5. Colonic gas swallowed air fermentation: hydrogen, methane,hydrogensulfide carbon dioxide

Functions of the Large Intestine

Other than digestion of enteric bacteria, no further digestion takes place Vitamins, water, and electrolytes are reclaimed Its major function is propulsion of fecal material toward the anus Though essential for comfort, the colon is not essential for life

Motility of the Large Intestine

Haustral contractions
Slow segmenting movements that move the contents of the colon Haustra sequentially contract as they are stimulated by distension

Presence of food in the stomach:

Activates the gastrocolic reflex Initiates peristalsis that forces contents toward the rectum

Distension of rectal walls caused by feces Stimulates contraction of the rectal walls Relaxes the internal anal sphincter Voluntary signals stimulate relaxation of the external anal sphincter and defecation occurs

Storage of feces 1/3 dry weight of feces consists of bacteria each gram of feces contains 1011 to 1012 bacteria, with anaerobes being 100 to 10000 times more prevelant than anerobes Bacteroides, an anaerobic bacteria, is the most common colonic organism Escherichia coli is the most common colonic aerobe

Human Colon Bacteria

>400 bacterial species in human colon Anaerobes greatly outnumber aerobes in colon by 1000 to 10,000-fold Important aerobes: Enterobacteria (E. coli), Streptococci, Staphylococci

Important anaerobes: Bacteroides, Bifidobacteria, Clostridia, Eubacteria, anaerobic Streptococci

Evaluation of the colon, rectum, and anus history physical examination radiographic studies flexibile endoscopy fecal occult blood determination anorectal physiologic studies endorectal ultrasound

History: provides the most important information in the evaluation bleeding hematochezia melena pain presence of an anal or perianal mass rectal discharge change in bowel habit incontinence history of cancer, both personal and family history of colorectal polyps and inflammatory bowel disease

Physical examination general examination anorectal examination: usually performed with the patient in the left lateral position inspection palpation anoscopy proctosigmoidoscopy

Fecal occult blood determination guaiac-impregnated paper daily loss of 20ml blood into the GI tract is required to consistently produce a positive fecal occult blood test
vitamin C (ascorbic acid) can cause false-negative results red meat, turnips, radishes, tomatoes, aspirin, nonsteroidal anti-inflammatory drugs, and iron may cause false-positive results

Flexible endoscopy flexible sigmoidoscopy colonoscopy

Anorectal physiologic studies Anorectal manometry provides information concerning anal sphincteric tone and the ability of the sphincter to contract document the presence of the normal rectosphincteric reflex, which is absent in Hirschsprungs disease Electromyography (pudenal nerve conduction velocity) may provide evidence of injury to the pudenal nerves that supply the anal sphincter

Endorectal ultrasound: relatively new test 1.The depth of invasion into the bowel wall by rectal cancer 2.The site of anal sphincter injury in the Incontinent patient 3.The path of complicated anal fistula

Radiographic studies barium enema water-soluble contrast enema computed tomography (CT) magnetic resonance imaging (MRI) defecography

Bowel preparation colon must be adequately cleansed before surgical resection or before studies feces must be removed from the bowel lumen; and, for surgery, the bacterial population must be reduced to minimize the risk of infection the type of preparation depends somewhat on specific requirements

Bowel preparation diet cathartics or laxatives enemas antibiotics

Diet solid food should be avoided for at least 24 hours and preferably 48 hours before the anticipated procedure clear liquids should be ingested to maintain adequate hydration IV fluids are occasionally required for patients with cardiac or renal disease Cathartics or laxatives: almost always required

Type of gastrointestinal bleeding hematemesis vomiting of blood,either bright red or resembling coffe grounds in appearance usually indicates a bleeding source proximal to the ligament of Treitz coffee-grounds hematemesis indicates that the blood has been in contact with gastric acid long enough to become converted from hemoglobin to methemoglobin hematochezia passage of bright red blood by rectum it does not specify the level within the GI tract melena passage of black, usually tarry stool it signifies a longer time within the GI tract than bright red blood, and it does not guarantee that the bleeding is from the upper tract currant-jelly stool blood mixed with stool and mucus this may originate from a Meckels diverticulum,particular in children

Lower Gastrointestinal Hemorrhage initial studies anorectal examination a bleeding site in the upper GI tract must be ruled out NG tube endoscopy a bleeding site in the lower GI tract must be located sigmoidoscopy anoscopy subsequent diagnostic tests depend upon whether the bleeding stops or continues 75% of the patients will spontaneously stop bleeding without intervention