chapter 36: colorectal Flashcards
Colon secretes ____ and reabsorbs _____
colon secretes K and reabsorbs Na and water (mostly in right colon and cecum)
4 layers of the colon
mucosa (columnar epithelium) -> submucosa -> muscularis propria -> serosa
colonic layer: small interwoven inner muscle layer just below mucosa but above basement membrane
muscularis mucosa
colonic layer: circular layer of muscle
muscularis propria
retroperitoneal portions of colon
ascending, descending and sigmoid colon are all retroperitoneal
- peritoneum covers anterior upper and middle 1/3 of the rectum
transverse bands that form haustra
plicae semiliunares
3 bands that run longitudinally along colon. at rectosigmoid junction, these become broad and completely encircle the bowel
taenia coli
cm: dentate line from anal verge
2cm
cm: anal transition zone from anal verge
4 cm
vasculature: ascending and 2/3 of transverse colon
SMA (ileocolic, right and middle colic arteries)
vasculature: 1/3 transverse, descending colon, sigmoid colon, and upper portion of the rectum
IMA (left colic, sigmoid branches, superior rectal artery)
vascular: runs along colon margin, connecting SMA to IMA (provides collateral flow)
marginal artery
artery: short direct connection between SMA and IMA
Arc of Riolan
how is vascular supply distributed in the colon?
80% of blood flow goes to mucosa and submucosa
venous drainage of colon?
follows arterial except IMV, which goes to the splenic vein
what forms the portal vein?
splenic vein joins the SMV to form the portal vein behind the pancreas
what does superior rectal artery branch off of?
superior rectal artery - branch of IMA
what is the middle rectal artery a branch of?
branch of internal iliac
what contains the middle rectal arteries during low anterior resection [LAR] or abdominoperineal resection [APR]?
the lateral stalks
what is the inferior rectal artery a branch of?
branch of internal pudendal (which is a branch of the internal iliac).
where do superior and middle rectal veins drain?
superior and middle rectal veins drain into the IMV and eventually the portal vein.
where do inferior rectal veins drain?
inferior rectal veins drain into the internal iliac veins and eventually the caval system
major blood supply of the colon
SMA and IMA
drain to IMA nodal lymphatics
superior and middle rectum
drains primarily to IMA nodes, also to internal iliac nodes
lower rectum
does the bowel wall contain lymphatics?
bowel wall contains mucosal and submucosal lymphatics.
what are the watershed areas in the colon?
- splenic flexure (Griffith’s point)
- rectum (Sudak’s point)
watershed area: SMA and IMA junction
splenic flexure (Griffith’s point)
watershed area: superior rectal and middle rectal junction
rectum (sudak’s point)
more sensitive to ischemia: colon vs small bowel
colon more sensitive to ischemia than small bowel secondary to decreased collaterals
sphincter: is the continuation of the levator ani muscle (striated muscle)
- nerve: inferior rectal branch of internal pudendal nerve
external sphincter (puborectalis muscle) - under CNS (voluntary) control
- involuntary control
- is the continuation of the muscularis propria (smooth muscle)
- is normally contracted
internal sphincter
inner nerve plexus
meissner’s plexus
outer nerve plexus
auerbach’s plexus
parasympathetic to colon
pelvic splanchnic nerves
sympathetics to colon
lumbar and sacral plexus
from anal verge: anal canal
0 - 5 cm
from anal verge: rectum
5 - 15 cm
from anal verge: rectosigmoid junction
15 - 18 cm
marks the transition between anal canal and rectum
levator ani
mucus-secreting goblet cells
crypts of lieberkuhn
slow transit time; patients may need subtotal colectomy
colonic inertia
main nutrient of colonocytes
short-chain fatty acids
tx: stump pouchitis (diversion or disuse proctitis)
short-chain fatty acids
tx: infectious pouchitis
metronidazole (flagyl)
rectovesicular fascia in men; rectovaginal fascia in women
denonvilliers fascia (anterior)
rectosacral fascia
waldeyer’s fascia (posterior)
most common polyp; no cancer risk
hyperplastic polyps
most common (75%) intestinal neoplastic polyp (these are generally pedunculated)
tubular adenoma
polyp most likely to produce symptoms
- these are generally sessile and larger than tubular adenomas
villous adenoma
villous adenomas: percent that have cancer
50% of villous adenomas have cancer
polyps: characteristics of lesions with increased cancer risk
> 2cm
sessile
villous
polyps have ___ side predominance
polyps have left side predominance
what type of polyps can be removed endoscopically?
most pedunculated polyps can be removed endoscopically
management: if not able to get all of the polyp endoscopically (which usually occurs with sessile polyps)
need segmental resection
when is polypectomy adequate treatment for invasive carcinoma?
only if the margin is sufficient (2mm), the carcinoma is not poorly differentiated, and no evidence of venous or lymphatic invasion is found.
polyps: basement membrane is intact (carcinoma in situ)
high-grade dysplasia
what is carcinoma in situ?
malignant cells are confined to the mucosa
polyps: into muscularis mucosa (CIS -> still has not gone thru the basement membrane)
intramucosal cancer
polyps: into submucosa (T1)
invasive cancer
colon cancer screening recommendations
at 50 for normal risk, at 40 (or 10 years before youngest case) for intermediate risk (e.g. family history of colon CA)
colon cancer screening options
1) colonoscopy q 10 years - or -
2) high-sensitivity FOBT q3 AND flex sig q5yrs - or -
3) high-sensitivity FOBT annually
Possible option: double contrast barium enema or CT colonography
what can cause a false-positive guaiac?
beef, vitamin C, iron, cimetidine
when do you not want to do colonoscopy?
recent MI, splenomegaly, pregnancy (if fluoroscopy planned)
management: polypectomy shows T1 lesion
polypectomy is adequate if margins are clear (2mm), is well differentiated, and has no vascular / lymphatic invasion; otherwise, need formal colon resection
tx: extensive low rectal villous adenomas with atypia
transanal excision (can try mucosectomy) as much of the polyp as possible. - NO APR unless cancer is present.
management: pathology shows T1 lesion after transanal excision of rectal polyp
transanal excision is adequate if margins are clear (2mm), it is well differentiated, and it has no vascular / lymphatic invasion
tx: pathology shows T2 lesion after transanal excision of rectal polyp
patient needs APR or LAR
2nd leading cause of CA death
colorectal cancer
symptoms of colorectal cancer
anemia, constipation, and bleeding
why are red meat and fat associated with colorectal cancer?
O2 radicals are thought to have a role
what infection is associated with colorectal cancer?
clostridium septicum infection
main gene mutations in colorectal cancer
APC, DCC, p53, and k-ras
most common site of primary colorectal cancer
sigmoid colon
most important prognostic factor for colorectal cancer
nodal status
- spreads to nodes first
primary sites of metastases in colorectal cancer
#1 liver #2 lung
how does colorectal cancer metastasize to liver?
portal vein
how does colorectal cancer metastasize to lung?
iliac vein
5 year survival rate for colorectal cancer with liver metastases
if resectable and leaves adequate liver function, patients have 35% 5-year survival (5-YS) rate
5 year survival rate for colorectal cancer with lung metastases
25% 5-YS rate in selected patients after resection
management: isolated liver or lung metastases in colorectal cancer
isolated liver or lung mets should be resected
rate of patients with drop metastases to ovaries in colorectal cancer
5%
why can rectal CA metastasize to spine directly?
via Batson’s plexus (venous)
does colon CA go to bone?
colon CA typically does not go to bone
surgery: colorectal CA growing into adjacent organs
can be resected en bloc with a portion of the adjacent organ (i.e., partial bladder resection)
colorectal ca prognosis: lymphocytic penetration
patients have an improved pronosis
colorectal ca prognosis: mucoepidermoid
worst prognosis
colorectal ca: good at assessing depth of invasion (sphincter involvement), recurrence, and presence of enlarged nodes
rectal ultrasound
mandatory in diagnosis of colorectal ca
need total colonoscopy to rule out synchronous lesions in patients with colorectal CA
colorectal ca: goals of resection
en bloc resection, adequate adenectomy
management of most right-sided colon CAs
can be treated with primary anastomosis without ostomy
management of rectal pain with rectal ca
patient needs APR
margins for colorectal cancer surgery
generally need 2-cm margins
colorectal ca: best method of picking up intrahepatic metastases
intraoperative ultrasound (U/S)
intraoperative ultraound
- resolution: conventional U/S
10 mm
intraoperative ultraound
- resolution: abdominal CT
5-10mm
intraoperative ultraound
- resolution: abdominal MRI
5-10mm (better resolution than CT)
intraoperative ultraound
- resolution: intraoperative U/S
3-5mm
permanent colostomy; anal canal is excised along with the rectum
abdominoperineal resection (APR)
potential complications of abdominoperineal resection (APR)
can have impotence and bladder dysfunction (injured pudendal nerves)
when is abdominoperineal resection indicated?
indicated for malignant lesions only (not benign tumors) that are not amenable to LAR
margins for abdominoperineal resection (APR)
need at least a 2-cm margin (2cm from levator ani muscles) for LAR, otherwise will need APR
risk of local recurrence: rectal CA vs colon CA
risk of local recurrence higher with rectal CA than with colon CA in general
produces complete response in some patients with rectal CA; preserves sphincter function in some
preoperative chemo-XRT
T? - into submucosa
T1
T? - into muscularis propria
T2