DEFINITION

Herniation of the mucosa through the muscular layers

of the bowel wall at sites where arterioles penetrate,
forming small outpouchings or diverticula.
Are generally numerous, collectively referred to as
diverticulosis.
Diverticulitis refers to the inflammation of diverticula.

INCIDENCE
> 50% of Americans over 70 years of age.
Men and women equally affected.
Sigmoid colon most commonly involved with
progressively decreasing frequency of involvement as
one proceeds proximally.

RISK FACTORS
1. Old age
2. Low-fiber diet

SIGNS AND
SYMPTOMS/Diverticulosis
1. 80% of patients are asymptomatic.
2. Massive, painless lower GI bleeding is classic
(notably absent in diverticulitis).

SIGNS AND SYMPTOMS/Diverticulitis

1. Persistent abdominal pain initially diffuse in nature
that often becomes localized to the left lower quadrant
(LLQ) with development of peritoneal signs.
2. LLQ and/or pelvic tenderness.
3. Ileus/abdominal distention.
4. Anorexia, nausea, vomiting, and change in bowel
habits (usually constipation).
5. Large bowel obstruction.
6. Fever.
7. Elevated WBC.

DIAGNOSIS/Diverticulosis
1. Characteristic history and physical exam
2. Confirmed by diverticula identified on CT/barium
enema and/or colonoscopy.
. Treatment:
1. High-fiber diet
2. Stool softeners.

DIAGNOSIS/Diverticulitis
1. Characteristic history and physical exam.
2. Elevated WBCs.
3. CT scan (test of choice):
A. Pericolonic inflammation
B. With or without abscess formation.
4. Barium enema and colonoscopy may induce perforation and are
contraindicated in the acute setting but should be obtained in
follow-up.
5. Abdominal x-ray:
A. Ileus
B. Distention
C. And/or free intraperitoneal air.

TREATMENT
Uncomplicated diverticulitis:
1. Outpatient management:
A. Clear liquid diet
B. PO antibiotics
C. And nonopioid analgesics with close follow-up.
2. Follow-up includes :
A. Colonoscopy
B. Dietary recommendations once acute infection has
subsided.

TREATMENT
3. If outpatient therapy fails, admit for:
A. IV antibiotics
B. IV hydration with bowel rest.
C. Nasogastric tube (NGT) is placed when there is
evidence of ileus or small bowel obstruction (SBO),
with nausea and vomiting.

TREATMENT
The Hinchey staging system is often used to describe the
severity of complicated diverticulitis:
1. Stage I includes colonic inflammation with an associated pericolic
abscess.
2. Stage II includes colonic inflammation with a retroperitoneal or
pelvic abscess.
3. Stage III is associated with purulent peritonitis.
4. Stage IV is associated with fecal peritonitis.
. Stage I and II are treated by:
1. IV antibiotics
2. CT-guided aspiration.

TREATMENT
If the abscess is inaccessible to drainage and not
responding to antibiotics, then it is treated
surgically:
1. Drainage with Hartmann pouch
2. Or sigmoid colectomy.
. Stage III and IV need operative management:
1. In the emergent setting, a Hartmanns procedure is
usually performed (i.e., resection with proximal
colostomy and distal pouch with reversal latertwostage procedure).

TREATMENT
2. If patient is very unstable, then a diverting colostomy
may be performed.
3. Elective resection of affected bowel must be
considered in the patient who has recurrent episodes
of diverticulitis requiring treatment.
4. All patients with diverticulitis must undergo a full
colonoscopy 46 weeks after the attack to rule out
malignancy, as sometimes colonic malignancy
presents as diverticulitis.

PROGNOSIS
One third of patients remain asymptomatic
One third have episodic pain
One third progress to have a recurrence.

DEFINITION
GI bleeding distal to the ligament of Treitz.
LGIB is considered massive when the patient requires 3 or
more units of blood within 24 hours.
Most common causes are diverticulosis and angiodysplasia.
Other causes include:
1. Cancer
2. IBD
3. Ischemic colitis
4. Hemorrhoids
. Anticoagulation treatment increases the risk for LGIB.

MANAGEMENT

INCIDENCE
Most commonly occurs in elderly patients
Much less common than small bowel obstruction.

SIGNS AND SYMPTOMS

1. Abdominal distention
2. Cramping abdominal pain
3. Nausea
4. Vomiting
5. Obstipation
6. High-pitched bowel sounds.

DIAGNOSIS
1. Supine and upright abdominal films:
A. Distended proximal colon
B. Air fluid levels
C. And no distal rectal air.
2. Establish 8- to 12-hour history of obstipation
3. Passage of some gas or stool indicates partial small
bowel obstruction, a nonoperative condition.
4. Barium enema: May be necessary to distinguish
between ileus and pseudo-obstruction.

TREATMENT
1. Correction of fluid and electrolyte abnormalities.
2. Nasogastric tube for intestinal decompression (as
gastric emptying is reflexly inhibited).
3. Broad-spectrum IV antibiotics (e.g., cefoxitin).
4. Relieve obstruction surgically (colonic obstruction is a
surgical emergency since a nasogastric tube will not
decompress the colon).

DEFINITION
Rotation of a segment of intestine about its mesenteric
axis
Characteristically occurs in the sigmoid colon (75% of
cases) or cecum (25%).

INCIDENCE
More than 50% of cases occur in patients over 65.

RISK FACTORS
1. Elderly (especially institutionalized patients).
2. Chronic constipation.
3. Pyschotropic drugs.
4. Hypermobile cecum secondary to incomplete fixation
during intrauterine development (cecal volvulus).

SIGNS AND SYMPTOMS

See Large Bowel Obstruction.

DIAGNOSIS
1. Clinical presentation.
2. Abdominal films: Markedly dilated sigmoid colon or
cecum with a kidney bean appearance.
3. Barium enema: Characteristic birds beak at areas of
colonic narrowing.

TREATMENT
Cecal volvulus:
1. Right hemicolectomy if vascular compromise
2. Cecopexy otherwise adequate (suturing the right colon to the
parietal peritoneum).
. Sigmoid volvulus:
1. Sigmoidoscopy with rectal tube insertion to decompress the
volvulus.
2. Emergent laparotomy if sigmoidoscopy fails or if strangulation
or perforation is suspected.
3. Elective resection in same hospital admission to prevent
recurrence (nearly 50% of cases recur after nonoperative
reduction).

DEFINITION
Massive colonic dilation without evidence of
mechanical obstruction.

INCIDENCE
More common in older, institutionalized patients.

RISK FACTORS
1. Severe infection
2. Recent surgery
3. Trauma

SIGNS AND SYMPTOMS

1. Marked abdominal distention
2. Mild abdominal pain
3. Decreased or absent bowel sounds.

DIAGNOSIS
1. Abdominal radiograph with massive colonic distention.
2. Exclude mechanical cause for obstruction with watersoluble contrast enema and/or colonoscopy.

TREATMENT
1. NGT and rectal tube for proximal and distal decompression,
respectively.
2. Correction of electrolyte abnormalities.
3. Discontinue narcotics, anticholinergics, or other offending
medications.
4. Consider pharmacologic decompression with neostigmine (a
cholinesterase inhibitor).
5. If peritoneal signs develop, the patient should undergo
prompt exploratory laparotomy to treat possible perforation.
6. Refractory cases may need total colectomy.

Hemorrhoids
Prolapse of the submucosal veins located in the left
lateral, right anterior, and right posterior quadrants of
the anal canal.
Classified by type of epithelium:
1. Internal if covered by columnar mucosa (above
dentate line)
2. External if covered by anoderm (below dentate line)
3. And mixed if both types of epithelia are involved.
. Incidence: Male = female.

Hemorrhoids
Risk factors:
1. Constipation
2. Pregnancy
3. Increased pelvic pressure (ascites, tumors)
4. Portal hypertension.
. Diagnosis:
1. Clinical history
2. Physical exam
3. Visualize with anoscope.

Anal Fissure
Painful linear tears in the anal mucosa below the
dentate line
Induced by constipation or excessive diarrhea.

SIGNS AND SYMPTOMS

1. Pain with defecation.
2. Bright red blood on toilet tissue.
3. Markedly increased sphincter tone and extreme pain
on digital examination.
4. Visible tear upon gentle lateral retraction of anal
tissue.

DIAGNOSIS
1. History
2. Physical exam.

TREATMENT
1. Sitz baths.
2. Fiber supplements, bulking agents.
3. Increased fluid intake.
4. If nonsurgical therapy fails, options include:
A. lateral internal sphincterotomy
B. Or forceful anal dilation.

Anorectal Abscess
Obstruction of anal crypts with resultant bacterial
overgrowth and abscess formation within the
intersphincteric space.

RISK FACTORS
1. Constipation/diarrhea
2. IBD.
3. Immunocompromise.
4. History of recent surgery or trauma.
5. History of colorectal carcinoma.
6. History of previous anorectal abscess.

SIGNS AND SYMPTOMS

1. Rectal pain, often of sudden onset
2. With associated fever
3. Chills
4. Malaise
5. Leukocytosis
6. Tender perianal swelling with erythema and warmth of
overlying skin.

TREATMENT
Surgical drainage.

Anorectal Fistulas
Tissue tracts (abnormal connections between two
areas) originating in the glands of the anal canal at the
dentate line that are usually the chronic sequelae of
anorectal infections, particularly abscesses.

CLASSIFICATION OF ANORECTAL
FISTULAS
1. Intersphincteric (most common): Fistula tract stays
within intersphincteric plane.
2. Transsphincteric: Fistula connects the intersphincteric
plane with the ischiorectal fossa by perforating the external
sphincter.
3. Suprasphincteric: Similar to transsphincteric, but the
fistula loops above the external sphincter to penetrate the
levator ani muscles.
4. Extrasphincteric: Fistula passes from rectum to perineal
skin without penetrating sphincteric complex.

SIGNS AND SYMPTOMS

Recurrent or persistent perianal drainage that becomes
painful when one of the tracts becomes occluded.

DIAGNOSIS
1. Bidigital rectal exam.
2. Anoscopy.
3. If the internal opening cannot be identified by direct
probing, it should be identified by probing the external
opening or by injecting a mixture of methylene blue
and peroxide into the tract.

TREATMENT
1. Intraoperative unroofing of the entire fistula tract
2. With or without placement of setons (heavy suture
looped through the tract to keep it patent for drainage
and to stimulate fibrosis).

Pilonidal Disease
Definition: A cystic inflammatory process generally
occurring at or near the cranial edge of the gluteal cleft.
Incidence: Most commonly seen in young men in their
late teens to the third decade.

SIGNS AND SYMPTOMS

1. Can present acutely as an abscess (fluctuant mass)
2. Or chronically as a draining sinus with pain at the top
of the gluteal cleft.

TREATMENT
1. Incision and drainage under local anesthesia
2. With removal of involved hairs.

ANAL CANCER
Neoplasms of the anorectal region
That are classified into:
1. Tumors of the perianal skin (anal margin carcinomas)
2. Tumors of the anal canal.
. INCIDENCE:
. Rare (12% of all colon cancers).

RISK FACTORS
1. Human papillomavirus (HPV)
2. Human immunodeficiency virus (HIV)
3. Cigarette smoking
4. Multiple sexual partners
5. Anal intercourse
6. Immunosuppressed state

SIGNS AND SYMPTOMS

1. Often asymptomatic
2. Can present with anal bleeding
3. Lump
4. Itching
5. An irregular nodule that is palpable or visible
externally (anal margin tumor)
6. Or a hard, ulcerating mass that occupies a portion of
the anal canal (anal canal tumor).

DIAGNOSIS
Surgical biopsy with histopathologic evaluation.
Histology:
Anal margin tumors include:
1. Squamous and basal cell carcinomas
2. Pagets disease
3. Bowens disease.
. Anal canal tumors are usually:
1. Epidermoid (squamous cell carcinoma or transitional
cell/ cloacogenic carcinoma)
2. Or malignant melanoma.

DIAGNOSIS
Clinical staging: Involves:
1. History
2. Physical exam
3. Proctocolonoscopy
4. Abdominal or pelvic CT or MRI
5. CXR
6. Liver function tests.

TREATMENT
Epidermoid carcinoma of anal canal:
1. Chemoradiation is mainstay 5-FU, mitomycin C, and
3,000 cGy external beam radiation (Nigro protocol)
surgery is reserved for recurrence.
. Anal canal tumors:
1. Local excision not an option
2. Combined chemotherapy (5-FU and mitomycin C) with
radiation often successful
3. APR only if follow-up biopsy indicates residual tumor.

TREATMENT
Other anal margin tumors:
1. Wide local excision alone
2. Or in combination with radiation and/or chemotherapy
is successful in 80% of cases without abdominalperineal resection (APR) if tumor is small and not
deeply invasive.

PROGNOSIS
Anal margin tumors: 80% overall 5-year survival.
Anal canal tumors:
1. Epidermoid carcinoma: 50% overall 5-year survival.
2. Malignant melanoma: 1015% 5-year survival.

Colorectal Polyps
MORPHOLOGY:
Can be classified into:
1. Sessile (flat)
2. Pedunculated (on a stalk).
. HISTOLOGIC TYPES:
1. Inflammatory (pseudopolyp): Seen in UC.
2. Lymphoid: Mucosal bumps containing intramucosal
lymphoid tissue; no malignant potential.

Colorectal Polyps
3. Hyperplastic: Overgrowth of normal tissue; no
malignant potential.
4. Adenomatous: Premalignant;
. Are classified (in order of increasing malignant
potential) as:
A. Tubular (75%)
B. Tubulovillous (15%)
C. Villous (10%).
5. Hamartomatous: Normal tissue arranged in abnormal
configuration; juvenile polyps, Peutz-Jeghers polyps.

Colorectal Polyps
INCIDENCE:
30-40 % of individuals over 60 in the United States.
SIGNS AND SYMPTOMS:
1. Asymptomatic (most common)
2. Melena
3. Hematochezia
4. Mucus
5. Change in bowel habits

Colorectal Polyps
DIAGNOSIS:
Flexible endoscopy (sigmoidoscopy or colonoscopy).
TREATMENT:
1. Attempt colonoscopic resection if :
A. Pedunculated
B. Well or moderately well differentiated
C. No venous or lymphatic invasion
D. Invades only into stalk
E. Margins negative.

Colorectal Polyps
2. Otherwise, a segmental colon resection is indicated.

Polyposis Syndromes

INCIDENCE
Second most common cause of cancer deaths overall
(behind lung cancer).
130,000 new cases and 55,000 deaths each year.
Incidence increases with increasing age starting at age
40 and peaks at 6079 years of age.
See Table 10-5 for screening recommendations from
the U.S. Preventative Services Task Force.

RISK FACTORS
1. Age > 50.
2. Personal history of resected colon cancer or
adenomas.
3. Family history of colon cancer or adenomas.
4. Low-fiber, high-fat diet.
5. Inherited colorectal cancer syndrome (familial
adenomatous polyposis [FAP], hereditary nonpolyposis
colon cancer [HNPCC]).
6. Long-standing UC or Crohns disease.

Adenoma-Carcinoma Sequence
Normal hyper proliferative early adenoma
intermediate adenoma late adenoma carcinoma (
metastatic disease).
1. APC gene loss or mutation
2. Loss of DNA methylation
3. Ras (gene) mutation
4. Loss of DCC gene
5. Loss of p53 gene

SIGNS AND SYMPTOMS

1. Typically asymptomatic for a long period of time
2. Symptoms, if present, depend on location and size.
3. Right-sided cancers:
A. Occult bleeding with melena
B. Anemia
C. Weakness
4. Left-sided cancers:
A. Rectal bleeding
B. Obstructive symptoms
C. Change in bowel habits and/or stool caliber.
5. Both: Weight loss, anorexia.

DIAGNOSIS
Colon cancer:
1. Flexible sigmoidoscopy or colonoscopy (need to evaluate
entire colon and rectum to look for synchronous lesions).
. Rectal cancer:
1. Digital rectal exam
2. Proctoscopy/colonoscopy
3. Barium enema
4. Also consider transrectal ultrasound (TRUS), CT, or
magnetic resonance imaging (MRI) to assess depth of
local tumor invasion and local lymph node status.

STAGING AND PROGNOSIS

Dukes System (old system):
A. Limited to wall
B. Through wall of bowel but not to lymph nodes
C. Metastatic to regional lymph nodes
D. Distant mets

STAGING AND PROGNOSIS

TNM System (more current system):
T1: Invasion of submucosa
T2: Invasion of muscularis propria
T3: Invasion of subserosa, or nonperitonealized pericolic or
perirectal tissues
T4: Invasion of visceral peritoneum/direct invasion of other
organs
N0: No nodal disease
N1: 13 pericolic or perirectal lymph nodes
N2: 4 or more lymph nodes
M0: No evidence of distant mets
M1: Distant mets

TREATMENT
Surgical resection (see Table 10-6 and Figure 105):
Goal is to remove primary tumor along with
lymphatic's draining involved bowel.
In rectal cancer, the circumferential radial margin
(CRM) is crucial to local recurrence.
Total mesorectal excision (TME) reduces the rates of
local recurrence.
Adjuvant treatment:
Stage III: 5-fluorouracil (5-FU)-based chemotherapy.

TREATMENT
Rectal cancer: Preop radiation using 5-FU as a
radiosensitizer (this sequence is called neoadjuvant
therapy because it occurs prior to the definitive surgical
treatment.