Anatomy of the colon:

- caecum –RIF, 6 cm. long- intraperit.

- ascending colon-13 cm.cecum-right
flexure, retroperitoneally
- transverse colon-38 cm. right to left colic
flexure, transverse mesocolon, intraperit.
- descending colon-25 cm.long,left flexure-
pelvic brim, retroperit.
- sigmoid colon- 35 cm.pelvic brim- S3,
mesocolon, intraperit.

1.
Colorectal cancer is a malignant tumor
arising from the inner wall of the large
intestine.
 2. Risk factors for colorectal cancer

include heredity, colon polyps, and long

standing ulcerative colitis.
 3. Most colorectal cancers develop from

polyps. Removal of colon polyps can

prevent colorectal cancer.
 4. Colon polyps and early cancer can have no
symptoms. Therefore regular screening is
important.
 5. Diagnosis of colorectal cancer can be made by
barium enema or by colonoscopy with biopsy
confirmation of cancer tissue.
 6. Treatment of colorectal cancer depends on the
location, size, and extent of cancer spread, as
well as the age and health of the patient.
 7. Surgery is the most common treatment for
colorectal cancer
 Early
stage- asymptomatic-silent
cancer

 Late stage- RIF pain, bowel

obstruction, weight loss, anorexia,
asthenia- chronic blood loss-anemia,
change in bowel habit, palpable lump
if large tumor.
 GA- thin and pale patient

 Abdomen:
◦ Distended or “full” in the RIF
◦ Palpable mass RIF; fixed or mobile
◦ Palpable liver-MTS
◦ Dullness over the mass
◦ NBS or hyperactive in bowel obstruction
◦ DRE-normal
 Frequent location: sigmoid colon, recto-
sigmoid junction

 Usually, small, annular, obstructive,

ulcerated

 Age>50 years old,

 Young adults- cancer on UC or familial

polyposis coli
 Symptoms: pain LIF, change in bowel habit
 GA- pale patient due to chronic blood loss

 Abdomen:
◦ Swelling LIF, ceacal distension if left colon
obstruction
◦ LIF palpable mass, mobile on sigmoid location
◦ Tender mass if pericolic inflamation - pericolic
abscess
◦ Hepatomegaly- liver MTS
◦ BS hyperactive- bowel obstruction
◦ DRE- color of feces, pelvic palpable mass.
 Sudden inability to micturate in the
presence of a painful bladder
 Hypogastric region severe pain
 The patient cannot pass urine inspite of a

desperate desire to do so
 Causes:
 Mechanichal: urethral stones, rupture of the

urethra, urethral stricture, prostatic

enlargement, paraphimosis
 Neurogenic: postop. retention, spinal cord

injury, anticholinergic drugs

 Symptoms: severe pain, feels like grossly
exaggerated desire to micturate
 The patient knows that his bladder is

overdistended
 Physical examination:

◦ distended bladder is palpable as a tense, dull,

rounded mass, arising out of the pelvis
◦ Pressure on the swelling exagerbates the p’s
desire to micturate
DRE- prostate or uterus is pushed backwards and
downwards
-you can not assess the size of the prostate gland
when the bladder is full
 Often the patient - always
an elderly gentleman with
gray hair and cataract -
arrives in severe agony
with a huge, distended
bladder due to acute
retention of urine.
  
 Carcinoma of the esophagus

 Reflux esophagitis

 Pyloric stenosis
Rarely produces any physical
signs apart from:
◦ - wasting and
◦ - perhaps a palpable
supraclavicular lymph node
 The main symptom is DYSPHAGIA

 Progressive dysphagia from solids to fluids

 Dysphagia= late symptom in the natural

history of the disease – 60% of
circumference is infiltrated with cancer
  Squamous cell carcinoma of the
esophagus is largely associated
with a poor prognosis.


 Direct invasion of adjacent

organs such as the aorta,
respiratory tract and lungs,

 and distant metastasis to other

organs such as the liver, lungs
and bone are commonly found in
advanced esophageal cancer
cases. I

  
  Examination of geographic areas of high incidence
have
 identified a number of environmental factors
strongly
 linked to the development of esophageal dysplasia
and
 squamous carcinoma
 
 In the United States and Europe alcohol and smoking

  In China nitrosamine containing foods, fungal

 contamination of foods and vitamin and essential
metal
 deficiency
  This 73 year old,
male presented
progressive
dysphagia for
 solid and liquid
and lost of weight
of 20 pounds.

 Endoscopy revealed
a large tumor.
 Esophageal cancer is a
treatable disease, but it is
rarely curable.

 The overall 5-year survival

rate in patients amenable to
definitive treatment ranges
from 5% to 30%.
 
 The occasional patient with
very early disease has a
better chance of survival.
 Patients with severe
dysplasia in distal esophageal
Barrett’s mucosa often have
in situ or even
 invasive cancer within the
dysplastic area.

 Following resection, these
 This 72 year-old man
with progressive
dysphagia
 (difficulty swallowing)
to solids, who was
found to have this
malign neoplasia.
  
 Cancer of the
esophagus remains a
devastating
disease because it is
usually not detected
until it has progressed
to an advanced
incurable stage.
 Patients are able to locate the level of
obstruction
 Extension of the tumor into the tracheo-

bronchial tree- fistula formation:

◦ - Stridor
◦ - Coughing
◦ - Choking
◦ - Aspiration pneumonia

Distant metastasis- liver, lung, peritoneum

 Regurgitation of gastric contents into the
lower esophagus:

◦ Incompetent lower esophageal sphincter

◦ Slinding hiatus hernia

 Factors that decrease the LOS pressure:
 Alcohol
 Cigarette smoking
 Morphine
 Estrogen therapy
 Fatty foods
 Presence of a NG tube
 Main symptom-heartburn-retrosternal
burning sensation
 Associated symptom- dysphagia-

inflammation- fibrous stenosis

 Relationship of pain to posture of the

patient:
 Bending
 Stooping
 Heavy lifting
 Tight clothes
 All forces acid up into the esophagus
 Gastric outlet obstruction:

 Chronic complication- 5% of GDU

 Neo-nates-congenital HT pyloric stenosis

 Adults- carcinoma of the gastric antrum

 Main symptom- vomiting
 The vomit is large in volume, not bile-

stained containing undigested foof

 Associated symptom- epigastric discomfort

 Signs:

◦ epigastric distension,
◦ visible peristalsis,
◦ succusion splash
 Infections in food

 Ulcerative colitis

 Crohn’s disease

 Cholera

 Rectal villous tumor

 Inflammatory bowel disease
 Main symptom: diarrhea
 Ulcerative colitis
 - loose bloodstained stools
 - frequency-up to 20 stools/day
 - preceded by cramping abdo. pain
 - urgency to defecate- the worst symptom
 Crohn’s disease:
 Diarrhea is watery with mucus
 Abdo. pain is colicky in nature
 Progressive inflammation- muscle paralysis-
dilatation- toxic megacolon

 Diarrhea
 - dehydration
 - electrolyte disturbance
 - anemia due to bloody diarhhea
 Toxic megacolon- colonic perforation- fatal

peritonitis
 is a disorder characterized by diffuse mucosal
inflammation limited to the colon.
 UC is usually a chronic disease which involves
the rectum and may extend proximally in a
symmetrical, circumferential, and uninterrupted
pattern to involve parts or all of the large
intestine.
 The hallmark clinical symptom is bloody
diarrhea often with prominent symptoms of
rectal urgency and tenesmus (painful straining
at stool).

 The clinical course is marked by exacerbations

and remissions, which may occur
spontaneously or in response to treatment
changes or intercurrent illnesses.
 Inflammatory bowel disease (IBD)
is a general term that covers two
disorders:
 Ulcerative colitis
 Crohn's
 Some evidence suggests that
they are part of a biologic
continuum, but at this time they
are considered distinct disorders
with somewhat different
treatment options.
 The basic distinctions are location
and severity.
 As many as 10% of patients with
IBD have features and symptoms
that match the criteria for both
disorders, at least in the early
stages. (This is called
indeterminate colitis.)
 Plain radiograph of the
abdomen show moderate
dilation of the colon with loss
of haustration in the
descending colon.

 Thickening of the wall of the

colon indicating edema is also
visible .
 Affects any part of the digestive system
 Inflammation involves the whole thickness

 Complications:
◦ Stenosis
◦ Fistula formation
◦ Abscess formation
 Crohn’s disease is a chronic
inflammatory disease of the
intestines that can affect the
digestive system from the
mouth to the anus. The most
commonly affected areas
tend to be in the small and
the large intestines.
Terminal ileitis (inflammation
that affects the end of the
small intestine (terminal
ileum), the part of the small
intestine closest to the colon
 Acute inflammation of the peritoneal serosa

 Acute peritonitis
 - localized
 - generalized
 If you can not determine the cause of
peritonitis you must decide whether the
patient needs a laparotomy
Two circumstances in which a
laparotomy is essential
1. If there is evidence of ischemic bowel caused by strangulation or
vascular occlusion

2. If there is an unexplained general peritonitis where lapatomy is

needed to make the diagnosis
 - Increasing tachycardia
 - Pyrexia
 - Tenderness and guarding
 - Rebound tenderness
 - Localized pain during distant palpation
 - Absence of the bowel sounds
 Causes in relation with the age:
 Neo-nates: congenital pyloric stenosis
 6-9 months: intussusception
 Teenagers: intussusception of Meckel’s

diverticulum
 Young adult: hernia, adhesions, Crohn’s

stenosis, bowel tumors

 Elderly: bowel tumors, diverticulitis,sigmoid

volvulus
 A segment of bowel which becomes
invaginated into the bowel immediately
distal to it

 The invaginated segment progressively

elongates as it is propelled distally by
peristalsis

 Ileo-cecal invagination is the most common

variety
 A huge sigmoid loop, heavy with faeces that
becomes twisted on its mesenteric pedicle
to produce a close loop obstruction

 Venous infarction with perforation and

faecal peritonitis might appear unless
emergent surgical intervention is decided
 Is there intestinal obstruction ??
◦ Obstruction: colicky pain, vomiting, abdominal
distention and absolute constipation

 Is the bowel strangulated??

◦ Strangulation: pain, tenderness, guarding and
rebound tenderness
 It is a true colic

 There are severe gripping exacerbations

mixed with periods of little or no pain

 Small bowel colic is felt in the central

abdomen

 Large bowel colic in the lower third of the

abdomen
 The nature of the vomitus depends upon
the level of the obstruction:

◦ Pyloric stenosis- vomitus is watery and acid

◦ High small-bowel obstruction- greenish bile-

stained vomit

◦ Middle small bowel obstruction- brown vomit,

thick and foul smelling as the obstruction persists
 The lower down the gut the obstruction, the
more bowels is available to distend and the
greater the distention
 High obstruction is not associated with

much distention, particularly if the patient

vomits frequently
 Obstruction in the left colon- distention

extends into the small bowel if the ileo-

cecal valve is incompetent
 If the valve remains closed, the caecum

becomes grossly distended-visible

assymetry
 Complete obstruction with bowel below it
empty- absolute constipation