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 Peutz-
Jeghers
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 narrowing-
bowel 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 pouch-
sigmoid 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 therapy-
decreases locoregional recurrences in
rectal cancer
 Adjuvant chemotherapy- useful for
colon cancer
 COLORECTAL CANCER
MANAGEMENT
 Loco-regional recurrence= tumor re-
growth 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 lobe-
lobectomy 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- transverso-
sigmoidostomy
 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 resection-
hypogastric plexus damaged-
micturition 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