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COLORECTAL POLYPS

AND COLORECTAL
CARCINOMA

COLORECTAL POLYPS



Swelling arising from the colonic mucosa
Common finding in the large bowel
Prone to malignant changes
Any colorectal polyp must be considered
malignant until proved otherwise
Typically present with rectal bleeding or
anemia due to occult blood loss
Many polyps cause no symptoms and
found incidentally on barium enema
examination or colonoscopy

COLORECTAL POLYPS

Histopathologically- three patterns of
growth:
• tubular adenomas,
• villous adenomas,
• tubulo-villous adenomas

TUBULAR ADENOMAS

Small pedunculated or sessile lesions

The least potential for malignant changes

High risk in a rare familial disorder of
polyposis coli (adenomatous polyposis)

VILLOUS ADENOMAS


Usually sessile and frond-like lesions
Tend to secrete mucus
Main complaint- passing stool with
mucus
Symptomatic hypoK- emia may
develop
Great potential for malignant change

TUBULO-VILLOUS ADENOMAS



Intermediate forms between the first two
Include the majority of colonic polyps
Most are pedunculated, the stalk 1-10 cm.
Early malignant change- invasion through
the basement membrane into the muscularis
mucosa
Careful histological examination is essential

COLONIC POLYPS

May occur in any part of the colon
Majority of them arise in the rectum and
sigmoid colon
They tend to cause rectal bleeding (visible
or occult) and may undergo malignant
change
If rectal polyps are found, the entire colon
must be investigated- total colonoscopy
The larger the lesion the more likely it is to
be malignant

COLORECTAL POLYPS
DIAGNOSIS

Rectoscopy

Sigmoidoscopy

Colonoscopy

Barium enema

COLORECTAL POLYPS
MANAGEMENT

Polyps can be excised using diatermy
snare endoscopically
Pedunculated lesions<2 cm. can be
removed with ease
Larger polyps or sessile require
snaring in several pieces
If a malignant polyp has been
incompletely removed then bowel
excision is required

COLONIC POLYPS

PEDUNCULATED COLONIC
POLYP

SESSILE POLYP

PEDUNCULATED POLYP
ADENOCARCINOMA IN SITU

COLONIC POLYP
ADENOCARCINOMA IN SITU

MULTIPLE COLONIC POLYPS

BLEEDING COLONIC POLYP

SNARE POLYPECTOMY

BLEEDING POSTPOLYPECTOMY

ENDOSCOPIC VIEW

Inflammatory pseudopolyps

Can occur as a complication of
ulcerative colitis or Crohn's disease
of the colon.
They are completely harmless and
carry no risk of cancer but they can
be confused with adenomatous
polyps on examination.

Peutz-Jeghers syndrome

It is an autosomal dominant inherited disorder
characterized by intestinal hamartomatous polyps
in association with mucocutaneous melanocytic
macules.
Patients with Peutz-Jeghers syndrome (PJS) have
a 15-fold increased risk of developing intestinal
cancer compared with that of the general
population.
Such cancer locations includes gastrointestinal
and extraintestinal sites.

Facial photograph
of a patient with
Peutz-Jeghers
syndrome.
Note the
mucocutaneous
pigmentation

Photo of oral
pigmented lesion
from a patient
with PeutzJeghers
syndrome.

Peuts-Jeghers syndrome
gastroscopy

The gastrointestinal polyps found in
Peutz-Jeghers syndrome are typical
hamartomas.
Their histology is characterized by
extensive smooth muscle
arborization throughout the polyp.
Nevertheless, cancer may develop in
the gastrointestinal tract of patients
with Peutz-Jeghers syndrome (PJS)
with a higher frequency than in the
general population

COCAINE COLITIS.
44 year-old man, a frequent user of cocaine, who presented with
bloody diarrhea. Colonoscopy revealed a range of findings from areas
of congestion to sessile polyps to lesions resembling pedunculated
polyps. Stool cultures were all negative. Biopsies revealed mucosal
congestion and inflammation.

COLORECTAL CANCER
PATHOLOGY

Adenocarcinoma of the colon is
growing outside from the mucosa
and later ulcerate and invade the
muscular layer
Next invades the serosa and
surrounding structures
Stromal fibrosis causes narrowingbowel obstruction

COLORECTAL CANCER
PATHOLOGY



Lymphatic spread is sequential first to
mesenteric nodes and then paraaortic nodes
Large paraaortic nodes- duodenal obstruction
Large nodes compressing porta hepatis- jaundice
Hematogenous spread- to the liver, usually
follows lymphatic spread
By the time of diagnosis 25% of pts. already
have widespread metastases

COLORECTAL CANCER
CLINICAL PRESENTATION


Cecal cancer- occult bleeding- iron defficiency
anemia, palpable mass in RIF
Colorectal cancers ulcerate earlier- lower
digestive bleeding- hematochezia
Bowel obstruction, partial or total in stenotic
lesions, usually in the left colon
Bowel perforation- fecal peritonitis
Malignant fistula into the: stomach, bladder,
uterus, vagina, skin

COLORECTAL CANCER
SYMPTOMS AND SIGNS

Cecal tumor: anemia, diarrhea, palpable mass
Descending colon: rectal bleeding, change in
bowel habit, colicky pain, perforation
Rectal tumor: rectal bleeding, tenesmus, mucus
diarrhea
Compressing symptoms: jaundice, duodenal
obstruction, ureterohydronephrosis
Systemic effects: malaise, anorexia, weight loss

COLORECTAL CANCER

Premalignant conditions
• Poliposis coli- genetic familial disorder
• Ulcerative colitis- inflammatory bowel
disease

PHYSICAL EXAMINATION

General examination- features
suggesting malignant disease:
• Obvious weight loss
• Palor of the skin
• Abdominal distention
• Hepatomegaly
• Abdominal mass

PHYSICAL EXAMINATION

Rectal examination:
• Finger can reach lesions as far as the its
length 7-9 cm
• Palpable fixed mass in Douglas pouchsigmoid tumor dropped retrorectally
• The glove inspected for blood and
mucus

COLORECTAL CANCER
INVESTIGATIONS






Rectosigmoidoscopy- about 50% of
colorectal cancer lie within reach of the
rigid sigmoidoscope- biopsy
Barium enema- synchronous tumors
Colonoscopy
Abdominal CT- staging
Urography- ureterohydronephrosos
Barium meal- duodenal compression
Plain abdominal X ray- bowel obstruction

RESECTED ILEOCOLON
CECAL CANCER

COLONIC CANCER

ULCERATED COLON
CANCER

STENOTIC COLON CANCER

ULCERATED RECTAL
CANCER

BARIUM ENEMA
TRANSVERSE COLON CANCER

BARIUM ENEMA
CECAL CANCER

BARIUM ENEMA
RECTAL CANCER

RECTAL CANCER

ENDOSCOPIC ULTRASOUND

RECTAL CANCER

STENOTIC COLON CANCER

SIGMOID STENOTIC CANCER
LIVER AND PERITONEAL MTS

COLORECTAL CANCER
MANAGEMENT

Surgical resection is the only curative
therapeutic modality
Radio/chemotherapy- neoadjuvant or
adjuvant treatment
Radio/chemo neoadjuvant therapydecreases locoregional recurrences in
rectal cancer
Adjuvant chemotherapy- useful for
colon cancer

COLORECTAL CANCER
MANAGEMENT

Loco-regional recurrence= tumor regrowth at the anastomosis or within
operative area
Loco-regional recurrence may develop
from either retained microscopic
tissue in the lateral margins of
resection or microscopic positive
nodes left in the mesorectum

COLORECTAL CANCER
PROGNOSTIC FACTORS


Age (young or very old)
Histological type (coloid type is
worse)
Vascular and lymphatic invasion
Histological grade (poor
differentiated)
The degree of wall invasion (Dukes
classification)

STAGING- DUKES
CLASSIFICATION


After histological examination of the
resected specimen
Dukes A- tu.confined to the bowel wall
Dukes B- tu. spread into the extrarectal or
extracolic tissues, no+ lymph nodes
Dukes C- tu. spread extrarectally or
extracolic with + lymph nodes
Dukes D- distant metastases

SURVIVAL RATES

½ of the pts. are incurable at
presentation
¼ of the pts. with radical surgery are
alive and well at 5 years
Very few pts. surviving 5 years die
later of recurrent disease

COLORECTAL CANCER
OPERATIONS

The principles of tumor resection:
• The affected segment of bowel resected with a
margin of normal tissue
• The precise lines of resection are determined by
the distribution of mesenteric blood vessels
• No touch, isolation technique
• The mesentry resected with its lymph nodes
• The cut ends of bowel can be rejoined at the
same operation

COLORECTAL CANCER
OPERATIONS

Right colon tu.- right colectomy with ileocolic
anastomosis
Transverse colon tu. Segmental colectomy with
colo-colic anastomosis
Left colon tu.- left colectomy with colorectal
anastomosis
Upper rectal tu.- anterior resection of the rectum
with colorectal anastomosis
Low rectal tu.- abdominoperineal resection of the
rectum with definitive left colostomy
Stenotic recto-sigmoid tu.-Hartmann op.=
rectosigmoidectomy, closure of the rectal stump,
left colostomy

ADVANCED DISEASE


Palliative resection when distant metastases are
present- survival within 1 year
If liver metastases are confined in a lobelobectomy can be associated to bowel resection if
the pt. is relatively fit.
Bone metastases- local radiotherapy
Unresectable right colon cancer- ileotransverso.
by-pass
Unresectable left colon cancer- transversosigmoidostomy
Unresectable rectosigmoid cancer- loop
colostomy

FAMILIAL POLIPOSIS COLI



It is a rare autosomal dominant
disorder
Multiple colorectal polyps
Rectal bleeding/ change in bowel habit
The treatment- colorectal removal with
ileoanal anastomosis, or
panproctocolectomy with definitive
ileostomy

POLIPOSIS COLI

POLIPOSIS COLI

COMPLICATIONS OF LARGE
BOWEL SURGERY


Wound infection and dehiscence
Intraperitoneal abscess
Peritonitis
• Causes:- fecal spillage intraoperative

- anastomotic leak

EARLY COMPLICATIONS


Wound infection
Intra-abdominal abscess
Stoma problems

LATE COMPLICATIONS

Diarrhea due to short bowel
Small bowel obstruction- adhesions,
fibrous band, internal herniation,
kinking
Abdominoperineal resectionhypogastric plexus damagedmicturition problems and impotence

STOMAS
INDICATIONS



CANCER SURGERY
ULCERATIVE COLITIS
FAMILIAL POLIPOSIS
DIVERTICULITIS

STOMAS

PERMANENT STOMAS
TEMPORARY STOMAS:
- BOWEL OBSTRUCTION,
- PROTECTIVE STOMAS,
- UNPREPARED BOWEL

STOMA TYPES


CECOSTOMY
LOOP COLOSTOMY
END COLOSTOMY