Colon, rectum and anus

Dr. sigid djuniawan,spB

Anatomy

The Bodys Digestive System

Esophagus, Stomach, Small Intestine &

Large Intestine 1st 6 feet = large bowel or colon Last 6 inches = rectum & anal canal The anal canal ends at the anus

cancer

Colorectal polyps
Hyperthrophic lymph folicles, submucosal lesion Carcinoid tumor : at appendix (35-40%), rectum ( 15%), colon (10%) Neoplastic mucosal lesion : tubular adenoma (60-80%), increase with age, tubulovilous adenoma , vilous adenoma, ADENOCARCINOMA SEQUENCE

DISTINGUISHING FEATURES OF COLITIS-ASSOCIATED COLORECTAL CANCER

MULTIPLE POLYPOSIS SYNDROME

Familial adenomatous polyposis : chromosome 5, rare, Age start :25 yo, clinical : abdominal pain, diare, hematochezia, anemia def iron

Signs & Symptoms

Change in bowel habits Blood in Stool

Bright red Very dark red Black/Tarry Stool

General abdominal discomfort

Gas pains Bloating Fullness Cramps

Diarrhea Constipation Does your bowel feel like it emptied completely?

Weight loss w/ no explained reason Constant tiredness Vomiting (coffee grounds)

Tests that examine

Rectum, Rectal Tissue, & Blood

Aids in diagnosing & preventing colon cancer

Physical Exam

General Medical History

Includes self health habits Past self illnesses Various treatments used for previous issues Family health history

If patient reports problems with respect to signs and symptoms related to common bowel change habits Are symptoms affecting your everyday life?

Fecal occult blood test

Check stool for evidence of blood Method

Small samples of stool are placed on special cards and returned to the Dr. or Lab for testing under a microscope

Potential harms
False-positive & false negative results (uncommonserious

Digital Rectal Exam

The doctor or nurse inserts a lubricated, GLOVED finger into the rectum to feel for lumps or abnormal areas.

Barium Enema

Barium is a liquid, that contains a silver-white compound, inserted into the rectum The barium coats the lower GI tract and a series of x-rays are taken of the lower GI tract AKA = a lower GI series

What does a Barium Enema do?

Detects
Ulcers Narrowed areas (strictures) Growth of the lining (polyps) Small pouches in the wall of the intestine

Diverticula

Cancer abnormalities

How can one prepare for this test?

Colon must be completely empty

Prescribed laxatives or enema (preexam)

Special Diet to follow (2 days prior)

Clear liquids Tea or coffee without milk or cream Any juice without pulp (NO OJ or Tomato) Broth Carbonated beverages

Types of Barium Enemas

Single Column
Lie on side on Xray table Enema tube inserted into rectum Barium bag is delivered into colon May feel urge to have a bowel movement.DONT Though, a small balloon will keep it inside you Take long deep breaths through mouthhelps relax May be asked to turn & rotate to evenly coat all colon Then the radiologist will take a number of X-ray images from various angles

Air Contrast (Double contrast)

Similar to single-column Big differenceAir is inflated with air in addition to the barium to expand and improve the quality of the images Polyps can be seen easier, among other abnormalities

Results

Negative = no abnormalities are found Positive = abnormalities found, such as polyps. If positive you may be scheduled for further testing.

Cons of Barium Enema

miss small polyps or sometimes even small cancers Biopsy and polyp removal cannot be done during testing you may need to follow up with a colonoscopy Preparing for the procedure (emptying the colon) and the procedure itself can be unpleasant

Sigmoidoscopy

Views the rectum and sigmoid colon areas for polyps, abnormalities, or cancer A sigmoidoscope is a thin lighted tube is inserted into rectum & up through the sigmoid colon May remove polyps or tissue samples for biopsy

Procedure Detection

The cause of diarrhea, abdominal pain, or constipation Detect early signs of cancer in descending (sigmoid) colon and rectum can see bleeding, inflammation, abnormal growths, and ulcers not sufficient to detect polyps or cancer in the ascending or transverse colon (two-thirds of the colon).

Preparation

Complications

Liquid diet Most likely given an enema preprocedure Air is pumped into colon to help expand and see more surface area Duration is 10-20 minutes

Though very uncommon It is likely that bleeding or a puncture of the colon could result during procedure

Polyp...Removal

Colonoscopy

Procedure to look into entire length of large intestine (colon) to detect abnormalities Preparation, procedure, & results same as sigmoidoscopy New virtual colonoscopy as alternative procedure

Virtual or (CT) Colonography

a series of x-rays called computed tomography to make a series of pictures of the colon Computer then puts these pictures together to create a detailed image that shows polyps, etc.

Prognosis (chances of recovery)

Depends on
Stage : in the inner lining of colon only, whole colon? Spread to other places in body Has it blocked or created a hole in the colon? Blood levels of carcinoembryonic antigen (CEA); a substance in the blood that may be increased when cancer is present, before treatment begins. Has cancer recurred? Patients general health?

Treatment Options

Surgery (main treatment) Radiation Therapy Chemotherapy Newer targeted therapies

Monoclonal antibodies

Depending on stage of cancer, it is likely that 2-3 types of treatment may be utilized at the same time or one after the other

Surgery

Removal of cancer and normal area of colon on either side, as well as nearby lymph nodes Then sewn back together Colostomy (bag to catch the waste kept outside the body) If cancer is found early, a colonscope can be used without cutting the abdomen

Radiation Therapy

high-energy rays (such as x-rays) to kill or shrink cancer cells external radiation internal or implant radiation; placed directly into tumor Radiation can also be used to ease symptoms of advanced cancer such as intestinal blockage, bleeding, or pain Main uses is for those where cancer had attached to an internal organ or the lining of the abdomen can be aimed through the anus and reaches the rectum without passing through the skin of the abdomen

use of anticancer drugs injected into a vein or given by mouth treatment useful for cancers that have spread to distant organs increase the survival rate for patients with some stages of colorectal cancer (will kill normal cells also) Side effects depend on amount, length, & type of drugs given (i.e. diarrhea, nausea, vomiting, loss of appetite & hair, mouth sores, increased chance of infections, bruising & bleeding after minor cuts or injuries & overall increased fatigue

Chemotherapy

Risk Factors

Age 50 or older Obesity (fat in waist area increases) 30%-40% of smokers diagnosed with cancer will die A family history of cancer of the colon or rectum. A personal history of cancer of the colon, rectum, ovary, endometrium, or breast. A history of polyps or ulcerative colitis (ulcers in the lining of the large intestine) or Crohns disease. Certain hereditary conditions, such as familial adenomatous polyposis and hereditary nonpolyposis colon cancer (HNPCC; Lynch Syndrome) Heavy use of Alcohol has been linked to this cancer

Dietary Risk Factors

eat plenty of fruits, vegetables, and whole grain foods to limit high-fat foods (especially from animal sources) and limit excessive alcohol consumption studies suggest that taking a daily multivitamin containing folic acid or folate can lower risk Other studies suggest that getting more calcium with supplements or low-fat dairy products can help Getting enough exercise is important as well 30 min of physical activity on 5+ days

Survival Rates

9 of 10 people whose cancer is found & treated at early stage (before spreading) will live at least 5 years Spread to nearby organs/lymph nodes= 5years 66% survival rate Spread to lungs/liver= 5 year 9% (5 yr is based on percentage of patients that were alive 5 yrs after diagnosis. Leaving out those who died of other causes)

Modified Dukes Staging System for Colorectal Cancer

Modified Dukes A The tumor penetrates into the mucosa of the bowel wall but no further. Modified Dukes B B1: tumor penetrates into, but not through the muscularis propria (the muscular layer) of the bowel wall. B2: tumor penetrates into and through the muscularis propria of the bowel wall. Modified Dukes C C1: tumor penetrates into, but not through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes. C2: tumor penetrates into and through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes. Modified Dukes D The tumor, which has spread beyond the confines of the lymph nodes (to organs such as the liver, lung or bone).

Colitis

Ulcerative colitis
Diffuse inflamatory disease of mucosa colon and rectum Etiology : unknown, autoimunne respon,microba (chlamydia, cytomegalovirus, yersinia), Endoscopy : granulars superficial ulcers, thickened mucosa, superficial fissures, small pseudopolyps Clinical : bloody diarrhea, high fever, abdominal pain Therapy : corticosteroids and immunosupresive agent (azathioprine, cyclosporine, 6-mercaptopurine), sulfasalazine is profilactic effect (prostaglandin synthesis), surgical : children, fulminating acute colitis, obstruction, (11%), acute toxic megacolon (6-13%) total proctocolectomy with ileostomy

Polyps In Colitis

Chronic Ulcerative Colitis

Volvulus

Def : abnormal twisting or rotation about its mesentery Etiologi : occlusion of lumen at each end segmen vascular compromise Location : sigmoid (50%), cecal (20-40%),transverse colon , splenic flexure (gastrocolic, splenocolic, phrenocolic ligaments)

Chrons disease

Crohn's disease, also known as inflammatory bowel disease, regional enteritis, and Granulomatous ileocolitis disease is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms. It primarily causes abdominal pain, diarrhea (which may be bloody if inflammation is at its worst), vomiting, or weight loss,[1][2][3] but may also cause complications outside of the gastrointestinal tract such as skin rashes, arthritis, inflammation of the eye, tiredness, and lack of concentration.[1]

Crohn's disease can lead to several mechanical complications within the intestines, including obstruction, fistulae, and abscesses

Diverticulitis

Definition : saclike protrusion of colonic wall Congenital , aquired Age : 60 -65 yo Etiolofi : low fiber diets Location : caecum (2%), Colon descenden (94%) Clinical : bleeding Complication : abcess, fistula, obstruction Indication for surgery :
Absolute : complication of disease , persistent pain, clinical deteoritation Relative : chronis stricture, young patient, corticosteroid use, diverticulitis

Rectum

Surgery of rectum

Tumor at upper rectum V LAR, distal 2 cm, prox 5 cm 7-8 cm abdominoperineal resection > 12 cm LAR
Pathological staging (mod Astler and Collier) : TNM Post opertaive : monitoring CEA

Surgery for Rectal Cancer

Surgery is main treatment, along with a combination of radiation therapy Polypectomy, local excision, and local transanal resection) can be done with instruments placed into the anus, Stage I, II, & III rectal cancers, other types of surgery may be done A low anterior resection is used for cancers near the upper part of the rectum, close to where it connects with the colon. Abdominoperineal resection is done for cancers located close near the lower rectum-anal conjunction. After this surgery, a colostomy is needed

Pelvic Exenteration:
the surgeon removes the rectum as well as nearby organs such as the bladder, prostate, or uterus if the cancer has spread to these organs. A colostomy is needed after this operation. If the bladder is removed, a urostomy (opening to collect urine) is needed

Anus

Symptoms : bleeding, pain, discharge, change of bowel habits Disorders :

incontinence disordes, prolapse of the rectum hemorroids, fissura in ano, abcess, fistulo in ano, chrons disease neoplastic disorders : Bowens disease ( SCC), Pagets disease (intraepithelial adenocarcinoma), BCC,

Hemorhoid

HEMORHOID adalah pelebaran Vena di dalam pleksus HEMORHOIDALIS yg tidak merupakan keadaan patologik , hanya apabila homorhoid ini menyebabkan keluhan atau penyulit diperlukan tindakan.

HEMORHOID DIBEDAKAN :

HEMORHOID INTERNAL
Pelebaran pleksus vena hemorhoidalis superior di atas garis mukokutan dan ditutupi oleh mukosa. Merupakan bantalan vaskuler di dalam jaringan sub mukosa pada rektum sebelah bawah.

HEMORHOID EKSTERNAL
Merupakan pelebaran dan penonjolan pleksus hemorhoidalis inferior, terdapat di sebelah distal garis mukokutan di dalam jaringan di bawah epitel anus.

POSISI HEMORHOID YANG PALING SERING :

. Kanan Depan . Kanan Belakang . Kiri Lateral

PATOGENESIS

Tiga Teori : 1 TEORI MEKANIKAL : 1 Dasar : Jaringan penunjang muskulo

fibroelastik hemorhoid interna, Parks ligamen yang mengalami degeneratif kelemahan abnormal dari jaringan pergerakan hemorhoid peninggian tekanan intra rektal peningkatan ukuran hemorhoid.

PATOGENESIS
2 TEORI HEMODINAMIK : : Mikrosirkuler anal kanal mengandung arterio venus shunt yang cenderung akibat reaksi hormonal atau rangsangan fisiologikal, berdasarkan pemeriksaan mikroskop elektron dan histologi. 3 SPINCTER ABNORMAL: Dasar : Peningkatan aktivitas spincter, menyebabkan peningkatan tekanan jaringan dalam analkanal. Dasar

Current etiologic, pathogenic, and paathophysiological concepts of hemorrhoidal disease

Pathophysiology of hemorrhoids:
hemorrhoids in place but mobile

Pathophysiolohy of hemorrhoids:
Prolapsed hemorrhoids

Normal arteriovenous shunt function: Arteriovenous shunts closed, precapillary sphincter opened

Arteriovenous shunt dysfunction: opening of arteriovenous shunts, contraction of precapillary sphincter

FAKTOR RESIKO YANG DAPAT MENYEBABKAN HEMORHOID :

Gangguan fungsi usus halus mis: diare, konstipasi Gangguan pengosongan rektum Kehamilan dan melahirkan Pemakaian obat-obat lokal mis: enema, supositoria, penggunaan laksan yang berlebihan Oral kontraseptif Iritasi mukosa anal kanal Diet yang rendah serat Alkohol

GAMBARAN KLINIK:
Nyeri Perdarahan Prolap hemorhoid Discharge / Mucus Pruritus

Examination in knee-elbow position

Examination in left lateral position

PEMERIKSAAN
Terdapat mucus pada hemorhoid yang prolap 2 Colok dubur 3 Anuskopi 4 Proktosigmoidoscopy
1

DIAGNOSA BANDING:
Karsinoma Kolorektum Penyakit Divertikel Prolap Rectum Kolitis Ulserativa Kondiloma Perianal Lipatan kulit Sentinel pada garis tengah dorsal

Macam Haemorhoid

Kelainan Anorektal

KOMPLIKASI
Trombosis melingkar nyeri hebat nekrose mukosa dan kulit penutup (jarang) 2 Emboli septik melalui sistem portal abses hati 3 Anemia
1

Paska Haemorhoidektomi (komplikasi)

KLASIFIKASI
Hemorhoid interna dikelompokkan dlm 4 derajat:

DERAJAT I : Perdarahan segar tanpa nyeri pada waktu defekasi. Tidak ada prolap, pada pemeriksaan anuskopi terlihat hemorhoid yang menonjol ke dalam lumen. DERAJAT II : Menonjol melalui anal kanal saat mengedan ringan, tetapi dapat masuk kembali secara spontan.

KLASIFIKASI

DERAJAT III :
Menonjol saat mengedan dan harus didorong kembali sesudah defekasi.

DERAJAT IV :
Menonjol keluar dan tidak dapat didorong masuk, biasanya timbul gejala nyeri.

Staging of hemorrhoids

PENANGGULANGAN
Secara umum B. Terapi obat-obatan C. Skeleroterapi D. Ligasi dengan gelang karet E . Bedah beku F . Infrared coagulasi G. Metode lain H. Hemorhoidektomi
A.

Sclerotherapy equipment

Injection sclerotherapy

Sclerotherapy technique

Rubber and ligator with its cone

engabling fitting of a rubber band

Cryode with its nitrous oxid cylindeer and pressure adjuster

Infrared coagulation apparatus

Indikasi metode pengobatan berbagai derajat hemorhoid Derajat Hemorhoid Pengobatan

I Terapi obat-obatan Sklerosing metode Foto coagulasi Bipolar coagulasi diatermi Terapi obat-obatan Ligasi gelang karet Heater probe Sklerosing metode Ligasi gelang karet Operasi Terapi obat-obatan Operasi Terapi obat-obatan

II

III

IV

PILIHAN TERAPI
TRADITIONAL
MODERN

I0
II0 III0 IV0

MEDICAL MEDICAL OFFICE PRACTICE SURGICAL

I0

II0

SURGICAL

III0
IV0

PARADIGMA BARU
1. DIAGNOSA HEMORRHOID INTERNA HARUS DILENGKAPI PEMERIKSAAN PROKTOSKOPI 2. TENTUKAN : LETAK, JUMLAH DAN BESARNYA MASING- MASING BENJOLAN (PENTING UNTUK EVALUASI PROKTOSKOPI) 3. DERAJAT 3 : BISA DIBAGI MENJADI 3A DAN 3B

PARADIGMA BARU
DERAJAT 3A : SEPERTI KRITERIA 3 TETAPI BILA BENJOLAN 2
: SEPERTI KRITERIA 3 BILA BENJOLANNYA >2 ATAU

DERAJAT 3B SIRKULER

DERAJAT 3B

: BIASANYA AKAN TURUN KE DERAJAT 4.

PARADIGMA BARU : KONSERVATIF ----> TRIO

1. PENGATURAN DIET --> BAB LUNAK 2. OBAT-OBAT PER-ORAL 3. SUPPOSITORIA.

PARADIGMA BARU : PENGATURAN DIET

1. MINUM AIR PUTIH 1 - 1 LITER/HARI
2. BUAH-BUAHAN : PEPAYA, PISANG

3. SAYURAN
4. LARANGAN MAKAN.

LARANGAN MAKAN
1. DAGING KAMBING

2. PEDAS
3. DURIAN 4. NANAS 5. CUKAK 6. SALAK

7. NANGKA
LAMANYA SAMPAI 6 MINGGU (1 BULAN)

PARADIGMA BARU
1. PENGOBATAN KONSERVATIF SELAMA 6 MINGGU 2. GEJALA HILANG SEMBUH. TIDAK BERARTI

3. SEMUA GEJALA RATA-RATA HILANG DALAM SEMINGGU PERTAMA BEROBAT. 4. EVALUASI HARUS DENGAN PROKTOSKOPI MINIMAL 2 MINGGU SEKALI 3 X BERTURUT-TURUT.

HEMORHOID EKSTERNAL YANG MENGALAMI TROMBOSIS :

1. Rendam duduk menggunakan larutan hangat, salep yang mengandung analgetik. 2. Istirahat di tempat tidur, untuk mempercepat berkurangnya pembengkakan. 3. Kurang dari 48 jam dapat ditolong : segera mengeluarkan trombus atau eksisi lengkap dengan anastesi lokal.

KESIMPULAN

Hemorhoid suatu keadaan normal dari anatomi manusia, jika mengalami perubahan diperlukan tindakan. Dengan bertambahnya usia terjadi perubahan hemorhoid yang membesar dan turun dalam lumen anal kanal. Vena-vena menjadi tegang dan perubahan ini meningkat setelah dekade ke-3 dalam kehidupan. Dengan meningkatnya pengetahuan struktur anatomi dan prevalensi penyakit, akan memudahkan cara pencegahan dan pengobatan simptomatis penyakit ini.

PERIANAL FISTULA

LAB/SMF BEDAH SEKSI BEDAH DIGESTIV

PENDAHULUAN
~ FISTULA ANI / FISTULA IN ANO ~ CHRONIS RESIDIF. ~ FISTULA : PENGHUBUNG ANORECTAL - LUAR ~ Th/ TIDAK ADEKUAT ~ PEMBEDAHAN

~ MEMAHAMI ANATOMI, KLASSIFIKASI & TEKNIK

ANATOMI ANORECTUM

PATHOGENESIS

KLASSIFIKASI : 1. MILLIGAN MORGAN (1934) 2. PARKS (1976)

TUJUAN : ARAH & LETAK FISTULA

TINDAKAN PEMBEDAHAN

MILLIGAN-MORGAN 1934

Subcutan

Anorectal

Low Anal

High Inter

Muscular
High Anal

KLASIFIKASI PARK (1976)

SIMPLE LOW

HIGH BLIND - OPEN RECTUM

NO PERINEAL

SUPRALEVATOR ABSCESS

PELVIC EXTENSION

INTERSPHINCTERIC

TRANSSPHINCTERIC

UNCOMPLICATED

HIGH BLIND TRACK

SUPRASPHINCTERIC

EXTRASPHINCTERIC

GOODSALS RULE
12

LINEA DENTATA

ANORECTAL RING

ANAL ORIFICE

GAMBARAN KLINIS :

~ RIWAYAT PERIANAL ABSCESS ~ CHRONIS RESIDIF ~ TERASA BASAH, PUS / CAIRAN

~ PRURITUS

PEMERIKSAAN FISIK
~ INSPEKSI LUBANG LUAR

PEMERIKSAAN FISIK
~ PALPASI (PERKIRAKAN ARAH)

PEMERIKSAAN FISIK
~ RT & SONDAGE

PEMERIKSAAN FISIK
~ RECTOSCOPY

PEMERIKSAAN PENUNJANG
~ ZAT WARNA , PERHIDROL ~ FISTULOGRAFI ~ ENDORECTAL SONOGRAFI ~ CT SCAN FISTULOGRAFI

~ THORAX PA
~ BARIUM ENEMA ~ LABORATORIUM

PEMBEDAHAN
~ SATU-SATUNYA TERAPI KARENA : ~ RISIKO SEPSIS OK ANORECTAL ABSCESS ~ PERLUASAN TIDAK TERDETEKSI SECARA FISIK ~ RECURENT (CHRONIS RESIDIF)

~ PRINSIP : MEMBUANG FISTEL BESERTA CABANGNYA TANPA MENIMBULKAN INCONTINENSIA.

~ PREOPERATIF :

TEKNIK OPERASI
1. LAYING OPEN TECHNIQUE ~ UNTUK FISTEL LETAK RENDAH ~ BUKA SAL.FISTEL DARI LUBANG LUAR S/D DALAM LALU FISTULOTOMY /

FISTULECTOMY / DGN SKIN GRAFT.

TEKNIK OPERASI
2. KOMBINASI LAYING OPEN + SETON
~ UNTUK FISTEL LETAK TINGGI DGN INTERNAL OPENING ~ SETELAH FISTULOTOMY, PASANG SETON ~ > 1 MINGGU BUKA SBG GUIDE

TEKNIK OPERASI
3. EKSISI FISTEL + MUCOSAL ADVANCEMENT FLAP 4. RE-ROUTING TECHNIQUE

POST OPERASI
~ CEGAH PENYEMBUHAN PREMATUR DARI
LUKA KULIT LUAR SEBELUM LUKA DALAM SEMBUH (DARI DALAM KELUAR) ~ WAKTU CUKUP LAMA

KOMPLIKASI POST OPERASI

~ RETENSIO URINE, PERDARAHAN, INCONTINEN FISTEL REKUREN, ANAL STENOSIS

~ SEPSIS

KEKAMBUHAN
~ TIDAK SELURUHNYA TERANGKAT ~ SALAH DIAGNOSIS (TBC FISTULA)

~ PERAWATAN POST OP KURANG BAIK

KESIMPULAN
1. SANGAT PENTING UNTUK MENGETAHUI TIPE FISTEL DAN MEMAHAMI ANATOMI SEBELUM TINDAKAN PEMBEDAHAN. 2. PRINSIP PEMBEDAHAN FISTEL.

3. CARA PEMBEDAHAN SESUAIKAN DENGAN

LETAK FISTEL (TINGGI / RENDAH). 4. PERAWATAN POST OP MEMEGANG PERANAN SANGAT PENTING.