Anatomy of large intestine

• Extends from ileo-caecal valve to the anus

• Divided anatomically & functionally into colon, rectum & anus
• The wall comprises 5 distinct layers-mucosa submucosa, inner
circular m.outer longitudinal m. & serosa
• Outer longitudinal m.separeted into 3 teniae coli
• The caecum is the widest & thinnest –vulnerable to perforation
• Mid gut- SI, ascending colon & proximal transverse colon—blood
supply by SMA
• Hind gut- distal transverse colon, descending ,rectum & proximal
anus –blood supply by IMA
 Colon vascular supply
• SMA. –branches into
– Ileocolic a. which supply the terminal ileum &
proximal ascending colon
– Rt.colic a. supplies the ascending colon
– Middle colic a. supplies the transverse colon
• IMA--Lt.colic a. ,several sigmoidal a.& sup. Rectal a.
 Colon lymphatic drainage
• Originate in a net work of lymphatics in the
muscularis mucosa
• LV & LN follow the regional arteries
• LN can be classified as –
.epi colic- on the bowel wall
.para colic – adj. to arterial arcades
.intermediate –named mesentric V.
.main – at the origin of SMA & IMA
SENTINEL LN –the 1st 1-4 LNS to drain the
specific segment of the colon
 Colorectal Carcinoma
• Most common abdominal visceral malignancy
women- second to breast ca
men -third, Lung, prostate
• Sex -both sexes are affected
rectal ca- men
colonic -women
• Usually after sixth decade
_ Not strictly disease of old age
_ 10% occur before 40 years
_Familial and hereditary type-third decade
• Relatively un common in Africa&Asia
More common in Urban setup.
Distribution of CRC
 Etiology( Risk factors)
• Environmental Factor
– Diet :High fiber diet with low fat diet is said to be more protective than fat
free diet
– Minor diet-Selenium, Vit A, Vit E , Caroteinoids
they decrease the free oxygen radicals at the mucosal surface and
decrease the risk of ca
– Other carcinogens Alcohol, Bile acid, Ionizing radiation
• Age –more than 50 years
• Pre malignant condition
Ulcerative colitis
Crohn’s disease
FAP
HNPCC
Previous hx of colonic polyp
• Family Hx of colorectal ca/polyp
• Long term immune suppression-small cell ca
 Pathology and Path physiology
• Predominantly –mucosal adenocarcinoma
-Connective tissue sarcoma
-Carcinoid tumor
-Lymphoma
-M.melanoma
• Histologically- well ,moderately& poorly
differentiated
• Grossly –Annular _circumferential…left
• -Polyploidy ……right
• -ulcerative
 Adenocarcinoma
Spread
• Arises in the colonic mucosa ` then invades the
muscularis mucosa…lymphatics in the submucosa …
regional LN….LN along the segmental arterial
supply and venous drainage
• Direct spread to adjacent structures (bladder,
ovaries,vagina)
• Transcelomic spread…cul de sac, blummer’s shelf
• Hematogenous spread…from the submucosal vein …
portal vein…liver
systemic vein….lung ,brain ,adrenal gland, kidneys.
Hematogenous spread is generally associated with
poor prognosis.
 Staging …..
• Duke's staging
– Duke`sA - tumor confined to bowel wall(T1-3)
– Duke`sB- tumor involving or through serosa,not extending
to LN(T4)
– Duke`sC –Lymph node involved
– Duke's D –Distant metastasis
 TNM Staging System
• T1 - tumor invading the submucosa
• T2- tumor invading muscularis propria
• T3-tumor invades through muscularis propria in
to the serosa or nonperitonized pericolic or
perirectal tissue
• T4-tumor out side the serosa.

• N1 -1-3 pericolic or perirectal LN

• N2 ->4 pericolic or perirectal LN
• N3 -metastasis in any LN along the named
vascular trunk
 Staging …..
• Mo –no distant metastasis
• M1 _distant metastasis

• Stage I –T1/No/Mo or T2/No/Mo

• Stage II –T3/No/Mo or T4/No/Mo
• Stage III _Any T/N1/Mo or Any T/N2 orN3/Mo
• Stage IV _Any T/Any N/M1

• This provides more detailed pathologic information, and can

be converted easily to the simpler Duke’s system.
– Stage I -----Duke’s A
– Stage II.----Duke’s B
– Stage III----Duke’s C
– Stage IV---Duke’s D
 Prognosis
• Staging is most important for prognosis.
• Stage I disease has 95-100% five years survival
• Stage II---40-60% five years survival
• LN involvement ---30%
• Liver involvement ---5-10%
85% die within 1 year.
• Age -Those which occur <40 years have bad prognosis
• Poor histologic differentiation
Excessive mucin producing tumor
Signet ring cell tumor
• Venous or perineural invasion
• Bowel perforation
• Elevated CEA
 Signs and Symptoms
• Has wide range of clinical presentation.
• Depends on the location of tumor
• 20% of the ca occur in the ceacum and Rt side
of colon
• 70% occur distal to splenic flexure
• -_45% occur at or below the rectosigmoid
level
• Change of bowel habit
• Abdominal pain
• Rectal bleeding
• Iron deficiency anemia
 Sub acute presentations
• Rt side Usually silent, don't cause change in
bowel habit except those large mucin
producing tumor ,which may produce
diarrhea.
• Acute appendicitis in elderly
• Ileal obstruction
• Signs of Anemia ,fatigue ,palpitation
• intermittent
• Weight lose, Fever of unknown origin
• As lead point for intussusception in adult.
 Left side colonic ca
• Lower abdominal pain---relieved by bowel
motion
• Change of bowel habit
• Passage of mucus
• Tenesmus
• Abdominal/ rectal pain
• ↓the caliber of stool
• Pass bright red blood per rectum
• Mass in the left iliac fossa
• Ascites. Jaundice,peruritis or chest x-ray
picture of lung lesion
 Acute presentation
• Significant proportion of pt

• Obstruction
• Perforation

• Obstruction—complete obstruction occurs in 10% of

pts but it is real emergency
• If the obstruction is not relieved it leads to
perforation ---fecal peritonitis and sepsis
• Perforation can occur at site of tumor
• Some times it perforates to adjacent structures like
bladder,vagina or small bowel
• If it perforate posteriorly psoas abscess.
 Diagnosis and Evaluation of Colorectal ca
• Hx and P/E are important tool for Dx.
• PDE
• Definitive Dx is usually made by
• flexible sigmoidoscope 60-75%
• colonoscopy 100%
• Important for Biopsy and to estimate distance
• Barium enema .synchronous lesions 3-5%
• Other tests are important to evaluate the
extent of the disease and to search for
metastasis.
 Routine investigations
• Hct
• Chest x-ray
• U/S
• CT scan of the abdomen to assess the extent of primary
tumor and to search for metastasis to intra abdominal
organ.
• LFT Late event
• CEA -if the tumor does not penetrate the bowel wall its
level does not raise
-it is non specific lung ca,breast ca, pancreas and
stomach ca., Smokers, Cirrhosis, pancreatits and renal
failure.
- high correlation with tumor metastasis and
recurrence
• Transanal US to assess depth of rectal ca
• Imaging of the upper Urinary tract---IVP
 Treatment Principle
 Preoperative pt preparation
• Psychological preparation for
possibility of colostomy & site of colostomy
Rx complications…Impotency
• Bowel preparation
it decrease risk of wound infection and
intraabdomenal abscess.
by mechanical cleansing and antibiotics(E coli and
B fragilis)
• Heparin
 The definitive management is surgery
• Adjuvant Chemotherapy
– Colorectal ca is said to be resistant to
Chemotherapy.
– It is effective only,Post operatively when the
tumor burden is small
– 5 FU and Levamisole or
– 5 FU and Leucovorin
– Decreases cancer recurrence by 39% and cancer
related death by 32%