1、Colon,Anorectum Disease,General Surgery The 2nd hospital of Shenyang Medical CollegeXu Daozhi,Parts of colon divided into cecum;ascending colon ;transverse colon;descending colon and sigmoid colon.average 150cm in length(120-200cm).diameter from cecum(7.5cm) to sigmoid colon(2.5cm).,Anatomy,Colon ha
2、ve three important anatomic landmarks: colic bands (teniae coli); haustra of colon; epiploic appendices (epiploicae appendices),Anatomy,Anatomy,the ileocecal valve: the terminal ileum empty into the cecum via the hepatic flexure and the splenic flexure rectum: up along with the sigmoid colon. down a
3、long with the anal canal.12 to 15cm in length. serve as a fecal reservoir. anal columns; anal valves and anal sinuses. anorectal line,Anatomy,anal canal: up is anorectal line, down is anus.1.5 to 2cm in length. the epithelium differ. the serrated dentate (or pectinate) line: demarcate rectum and ana
4、l canal (important anatomic landmarks) the importance show: upper is mucosa, autonomic nerve, no pain. below is skin, internal pudendal nerve, with keen pain.,Anatomy,blood supply differ: upper is superior rectal artery, inferior rectal artery. below is artery of anal canal. venous return differ: up
5、per is superior rectal plexus superior rectal vein portal vein. below is inferior rectal plexus vein of anal canal inferior vena cava. lymphatic return differ: upper is aorta abdominalis nearby or the internal iliac lymph node. below is inguinal lymph node or external iliac node. white line: intermu
6、scular groove.,Anatomy,rectum and anal canal musculature: the anal canal musculature with its sphincteric apparatus is the terminal muscular channel of the gastrointestinal tract. internal anal sphincter muscle is the continuation of the smooth circular layer of the rectum. external anal sphincter m
7、uscle is a continuous sheet of striated muscle constituting the pelvic floor. it divide into subcutaneous external anal sphincter muscle; superficial external anal sphincter muscle; deep external anal sphincter muscle. levator ani muscles: the puborectalis muscle; pubococcygeous muscle; illiococcyge
8、ous muscle. their fibers decussate medially form funnel-shaped.,Anatomy,anorectal ring: internal anal sphincter muscle; lower limb of longitudinal muscle of rectum; deep external anal sphincter muscle and proximal levator ani muscles (the puborectalis muscle). fecal incontinence. anorectal periphera
9、l clearance: comprise much adipose connective tissue. easily infect anal fistula. up levator ani muscles : pelvirectal clearance; retrorectal clearance. below levator ani muscles : ischiorectal clearance; perianal clearance.,Anatomy,arterial supply and venous and lymphatic drainage of colon; rectum
10、and anal canal: colon: right colon superior mesenteric artery (ileocolic artery; right colic artery; middle colic artery.) left colon inferior mesenteric artery (left colic artery and sigmoid artery). vein have the same name with artery,superior mesenteric vein inferior mesenteric vein,Anatomy,porta
11、l vein,Anatomy,colon lymphatic drainage: superior colic lymph nodes; paracolic lymph nodes; middle colic lymph nodes; central colic lymph nodes. colic nerve: parasympathetic nerve differ, right vagus; left pelvic nerve sympathetic nerve: superior mesenteric neuroplexus and inferior mesenteric neurop
12、lexus.,Anatomy,rectum and anal canal: artery:upper of pectinate line is superior rectal artery; inferior rectal artery and median sacral artery. below of pectinate line is anal canal artery. vein:upper of pectinate line is superior rectal plexus superior rectal vein inferior mesenteric vein portal v
13、ein. below of pectinate line is inferior rectal plexus inferior rectal vein and anal vein internal iliac vein and internal pudendal vein interior vena cava.,Anatomy,rectum and anal lymphatic drainage: most important path is superior rectal artery nearby inferior mesenteric artery. nearby inferior re
14、ctal artery internal iliac lymph nodes. down anal artery and internal pudendal artery internal iliac lymph nodes. below of pectinate line: downward pass through perineum and inner thigh inguinal lymph nodes external iliac lymph nodes. ischiorectal clearance nearby obturator artery internal iliac lym
15、ph nodes.,nerve：upper is autonomic nerve (sympathetic nerve and parasympathetic nerve) below is internal pudendal nerve,Anatomy,physiology,colonic major function: absorb water; gluscose;electrolyte and bile acid. store and transport soil. rectal major function: defecation; absorbtion and secretion.,
16、Anorectal examination,Posture anal inspection Rectal palpation Anoscope; sigmoidoscope; fibercoloscope examination X-ray;CT;MRI and rectal ultrasound endoscope examination Anorectal function examinatin,Rectal inspection: Digital examination of rectum: simple and important clinical examination ways.
17、may find: hemorrhoids; anal fistula; rectal polyp; anorectal cancer,Anorectal examination,Sigmoid volvulus,sigmoid mesentery as axle volvulus sigmoid colon is most commonly involved, occupy 65%-80%. cecum and transverse colon may occur. Old people(60y):young people=20:1,Ulcerative colitis (UC),UC is
18、 nonspecific inflammatory disease involving the mucosa of the colon and rectum. sigmoid and rectum often find. Macro-pathology: mucosal appearance varies with minimal friability; edema in the milder stage. bleeding; erosion and frank ulceration clinical manifestation: laxness with blood, stomachache
19、. indications for operations: include toxic megacolon. intractability extraintestinal symptom , dysplasia-carcinoma, massive bleeding, perforated ulcer treatment: removal of the colon and rectum.,Intestinal polyps and polyposis,A colorectal polyp is any mass projecting into the lumen of the bowel, i
20、t arise from the intestinal mucosa. gross appearance classified pedunculated or sessile. histologic appearance classified adenoma polyp (tubular adenoma and villous adenoma, or tubulovillous adenoma), inflammatory polyp, hamartomas. organic polyp polyps100polyposis. there is a 50% chance that a vill
21、ous adenoma greater than 2cm will contain a cancer. treatment usually remove polyp by colonoscopy. removed by a snare for pedunculated polyp, for sessile polyp ofen require segmental colectomy.,Colon cancer,common malignant tumor of gastrointestinal tract, 41-65years incidence high. commonly polyps
22、and polyposis cancer, adenoma cancer. etiology: much animal tallow, animal protein. lack of movement. heredity, precancerosis histology type: adenocarcinoma, mucoid carcinoma, undifferentiated carcinoma.,protruded type: commonly occur at right colon or cecum. infiltrating type: commonly occur at lef
23、t colon. ulcerative type: common type,*Gross pathology type,Clinical pathological stage,TNM stages: T: primary tumor. N: lymph node. M : metastasis0:TisN0M0.: T1N0M0 or T2N0M0.:T3N0M0 or T4N0M0.: anyTN1M0 or N2M0.: any TNM1. Prognosis: five survival rate: 93%; 80%; 60%; 8%. Metastasis: lymphatic met
24、astasis , hematogenous Metastasis, direct invasion, peritoneal implantation,Clinical manifestation,alterations in bowel habits and characteristics of feces. early findings. abdominal pain. abdominal discomfort. abdominal mass. intestinal obstruction. general symptoms: anemia, thin, fatigue, low feve
25、r.right colon cancer: general symptoms anemia, abdominal mass ,thin are major manifestation. left colon cancer: intestinal obstruction, constipation and diarrhea, hematochezia are major manifestation.,Diagnosis,*high risk group is 40 have any following one: first-degree relaties have history of colo
26、rectal cancer. have history of cancer, intestinal adenoma or intestinal polyps. the stool test positive for occult blood. have two fifth following manifestations: mucous bloody stool, chronic diarrhea, chronic constipation, chronic appendicitis, history of psychological trauma. fibercoloscope, CT, u
27、ltrasound, CEA.,radical colectomy:resection range include the segment of colon containing cancer, its mesentery and regional lymph node. radical right colectomy:apply to cecum, ascending colon, hepatic flexure of colon. radical transverse colectomy: apply to transverse colon. radical left colectomy:
28、 splenic flexures of colon. and descending colon. radical sigmoidectomy: sigmoid colon. operation of obstructing colon cancer: colostomy. chemotherapy of colon cancer.,Treatment,Anal fissure,Generally: an anal fissure is a liner ulcer of the lower half of the anal canal. located in the posterior com
29、missure in the midline or anterior midline. commonly young people. fissure away from this location should raise the possibility of associated Crohn disease, tuberculosis, ulcerative colitis.Etiology: maybe associated with the following factors： Anatomy External injury：defecation is the direct reason
30、 with the mechanical injury*Fissure triad：the fissure itself,hypertrophic anal papillathe sentinel pile.,Clinical Manifestation,Typical manifestation：pain,constipation and blood Pain cycle：defecation pain interval pain pain relieve sphincter contraction pain fissure constipation vicious cycle Blood：
31、cover the feces ，blood drop, rarely large amount of blood.,Diagnosis,typical clinical manifestations fissure triad：the fissure itselfhypertrophic anal papillathe sentinel pile. different diagnosis: crohn disease, ulcerative colitis, perianal tumor.,Treatment,Non-operative treatment Principle ：remove
32、 sphincterismus, relieve pain, help to defecate, stop vicious cycle, improve local cure.Specific measure：1.sitz baths with ：5000 KMnO42.stool softeners, bulking agents,take more water and food with abundant fibrin. 3.local anesthesia relax the internal sphincter and improve blood flow to the anorect
33、umOperative treatment ( Adaptation:conservative measures failed ) 1.fissure resection 2. internal anal sphincterotomy,Perianorectal abscess,General Consideration: Perianorectal abscess is most commonly acute inflammation of Perianorectal soft tissue Etiology: mostly because of the infection of the a
34、nal glands some for perianal skin injure,infection, anal fissure, internal hemorrhoids.,Clinical Manifestation,Perianal Abscessmost common;severe and continuous throbbing pain that worsen with ambulation and straining;few patients with fever, urinary retention and sepsis;swelling and discharge are n
35、oted less frequently. Ischiorectal abscess continuous swelling pain and become throbbing pain that worsen with ambulation and straining. Sometime with urinary retention, and rectal tenesmus systemic infection is significant。erythematous mass ,obvious red and fluctuant。If dont drain in time , spread
36、into the perirectal skin and cause the high level fistula,Clinical Manifestation,Pelvirectal abscessInfected by the rectitis, rectal ulcer, or rectal injure.In early stage, the systemic infection is obvious, but the local symptoms is not, and often misdiagnosed awareness of defecation increase, urin
37、ary retention .Palpate the mass in the rectal wall, tenderness and fluctuant.Ultrasonography by anus or pelvic CT is useful for diagnosis,Treatment,Non-operative treatment （1）antibiotic （2）sit baths （3）local physical therapy （4）stool softeners,bulking agentsOperative treatment: Accurate diagnosis, d
38、rained surgically。 Attentions： （1）right location （2）“cut” choice （3）drain radically （4）prevention of fistula （5）cultivation of pus,Anal fistula,General consideration the fistula is composed by the internal entrance ，external entrance and the fistula canal 。The internal entrance locate at the low rec
39、tum or anus, one number，the external entrance locate at the perianal skin, one or more . Etiology Most fistulas derive from sepsis originating in the glands of the anal canal at the dentate line. Peri-anorectal abscess .Some occur as a result of obstetric injury ,crohns disease , diverticulitis , ra
40、diation and so on.,Classification,according to the level Low level fistula：fistula locate under deep of the external sphincter High level fistula：fistula locate above deep of the external sphincter according to the number of entrance Simple fistula Complicated fistula * according to the relationship
41、 between fistula and sphincter Inter-sphincter fistula Trans-sphincter fistula Supra-sphincter fistula Extro-sphincter fistula,Clinical manifestation,Acute chronic recurring abscess or chronic draining sinus over the sacrococcygeal or perianal region. Pain, tenderness, purulent,blood, mucinous excre
42、tion drainage,.general symptoms (fever, chill, weak). above sypmtoms repeated outbreak,Treatment,blockage ways: biological protein glue. operation:1 fistula dissection :low level fistula.2 secton division3 fistulectomy,Etiology:unclear 1 anal cushion theory 2 varicosity theory 3 perianal infection (
43、spicy food/drink alcohol)*Internal hemorrhoid：3、7、11(lithotomy position) 1 painless interval bleeding after defecation 2 internal hemorrhoid protrusion,Hemorrhoid,Clinical manifestation,Classification：1 internal hemorrhoidI painless bleeding,without protrusionII protrusion with defecation spontaneou
44、s reduction, bleeding；III protrusion, spontaneous of with bowel movement, requiring manual reduction , occasionally bleeding；IV permanently prolapsed, irreducible, occasionally bleeding 2 external hemorrhoids:Discomfort anus、wet nastiness，perianal-pruritus ,sometime severe pain if thrombosis 3 compl
45、icated hemorrhoid Internal hemorrhoid develop to III degree, then become the mixed hemorrhoid,Diagnose and Differential diagnosis,Diagnosis: anorectal inspection, anoscope Differential diagnosis：rectal cancer;rectal polyps ;rectal prolapse ,Treatment,* three principles: (1) no treatment without symp
46、toms.(2)lighten or remove symptoms for with symptoms.(3)conservative treatment is first. General treatment: change habitual food and defecation, sit bath and softeners Injection therapy Rubber band ligation,Treatment,doppler-guided hemorrhoidal artery ligation Surgical treatment: (1) simple hemorrho
47、idectomy(2) external thrombus hemorrhoidectomy(3)Procedure for prolapse and hemorrhoid（PPH）,Rectal Cancer,common enteron malignant tumor *about rectal cancer have three epidemiology characteristic in china:(1)rectal cancercolon cancer.(2)low rectal cancer occupy 60%-75%.(3)young people(30years)occup
48、y 10%-15%. etiology: unclear Histology type Adenocarcinoma: 75%85%, tubular, papillary, mucinous, signet-ring cell. Adenosquamous carcinoma Undifferentiated : bad prognosis.Others: melanoma . Two or above two histology type,Pathology,*Gross type ulcerative type: 50% low differentiated, early metasta
49、ses protruded type: good prognosis infiltrating type:low differentiated, early metastases, bad prognosis,Diffusion and metastasis,Direct diffusionLymph metastasis (main way)Blood metastasisPlant metastasis,Clinical manifestation,rectal irritation :constipation and diarrhea, tenesmus, the feeling of
50、incomplete evacuation after a bowel movement,Alternating rectal pain. Symptoms with narrow intestinal cavity cancer ruptured and infection symptom *frequency of Rectal Cancer symptom: hematochezia 80%-90%,feces frequent 60%-70%,feces thin 40%, mucous stool 35%, anal pain 20%. Tenesmus20%, constipation10%.,
