Tutorial 7 - Rectal bleed Flashcards
(Anatomy)
- Denate line
- Internal and external Haemorrhoid plexus
Denate line - halfway up internal sphincter (junction of squamous to columnar epithelium)
-no somatic pain on columnar epithelium (internal)
Internal haemorrhoid plexus - veins lie in submucosal layer above denate line
External haemorrhoid plexus - under skin in anal verge
Blood supply to Colon
(Look at diagram)
Why important?
Right (ascending) colon - Right colic artery (SMA)
Transverse - Marginal artery (SMA)
Left (descending) colon - left colic artery (IMA)
Sigmoid - Sigmoid arteries (IMA)
Rectum - Superior (IMA), middle (internal iliac) and inferior rectal arteries
Lymph nodes follow main colonic arteries - so need to resect blood supply with section of colon
Types of surgeries
- sigmoid colectomy
- left hemicolectomy
- transverse colectomy
- right hemicolectomy
- Anterior resection
(be familiar with these)
Hemicolectomy (one side of colon)
Anterior resection
Physical exam
Investigations
Posteriorly - feel puborectalis sling
-this pulls forward the junction of anus and rectum (if damaged - can cause faecal incontinence)
Main exam
- rectal exam (anus)
- proctoscope (rectum)
- Sigmoidoscope (colon)
Main investigations
- Barium enema (XRAY)
- CT
- Colonoscopy
Haemorrhoids
-Definition
Definition - dilated abnormal veins of the internal plexus mainly associated w constipation.
Haemorrhoids - internal
-Degree
External
1st - Bright blood after BM due to hard stool crushing veins (internal, no pain)
2nd - Varicosed veins have fallen out after BM . Feels like mass coming out, can push back in, no bleed.
3rd - Veins stay out after bowel motion, stays out. Soiling, tenderness, dull pain.
4th - large thrombosed mass protruding out of anus. Extreme pain
External - rupture of veins from external plexus (vigorous activity).
- Skin tag remains at site.
- Pain
Treatment Haemorrhoids
1st - increase fiber Injection (sclerosant)
Rubber band ligation
2nd - Injection
Rubber band
Surgery
3rd/4th -
Surgery (haemorrhoidectomy)
Anal fissure
Anal fistula
-tear below denate line
-often due to hard faecal mass passed.
Fistula - connection, normally after a burst abscess
Treatment -fissure
non surgical - gylcerol trinitrate, botulinum toxin (relax spincter)
-Pain relief
-Diet/stool bulker - metamucil
Surgical - subcutaenous sphincteroltomy
Adenocarcinoma
- Risk factors
- History
RF - FH, polyps, IBD, radiation
Hx - bleed, altered bowel habit, fatigue, weight loss
Exam - Abdo, PR
Inv - Sigmoidoscopy, biopsy
Adenocarcinoma of RECTUM!!
- Risk factors
- History
- Staging (next slide)
- Treatment
RF - FH, polyps, IBD, radiation Hx - bleed, altered bowel habit, fatigue, weight loss Exam - Abdo, PR Inv - Sigmoidoscopy, biopsy, MRI (stage) Tx - AR
(if puborectalis muscle involved, remove rectum and anal canal after chemo-radiation (permanent colostomy))
Staging adenocarcinom
-What inv for staging
MRI - to see resectability, pre-chemo/radiation needed
CT - distant mets
Colonoscopy - other cancer or polyps
Dukes Criteria for staging
A - confined to bowel wall (90%)
B - through bowel wall, no nodal involvement
C - thorough bowel wall ,nodal involvement (30%)
Proctitis
- Definition
- History
- Exam
- Investigation
- Management
Def - inflammation of rectal mucous (colitis of rectum)
-due to infection, or secondary to radiation therapy or IBD
Hx - loose stool, pus, mucus, blood
Exam - sigmoidoscopy
Inv - FBC, Stool culture,biopsy
Treatment
-supportive (pain relief)
-UC/Crohns - steroid enema
-Radiation - topical fomralin, argon plasma coagulation
Types of polyps - Colon
- 3 types
- whats worst?
- Genetic condition
Neoplastic polyps - tubular adenomas, tubulovillous adenomas, villous adenomas
- Villous = worse
- all polyps removed
Familial adenomatous polyposis, hereditary non-polyposis colorectal cancer
FAP - autosomal dominant, age 40
HNPCC - autosomal dominant, young cacner
Adenocarcinoma of Colon
RF - same as rectal
Hx - right sided - IDA, occult bleed, RIF mass, bowel obstruction
Left - alternating stool habits, blood in stool, obstruction of large bowel
Dx - barium enema, CT, colonoscopy
CT - staging (no MRI)
Tx - surgery w immediate anastomosis
