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GS36 General Surgery and Thoracic Surgery Other Conditions of the Large Intestine Toronto Notes 2019
Cecal Volvulus
AXR: Central cleft of “coffee bean” sign points to RLQ
Sigmoid Volvulus
AXR: Central cleft of “coffee bean” sign points to LLQ
Barium enema: “ace of spades” or “bird’s beak” sign
• rectalcancer
■ choice of operation depends on individual case; types of operations
◆ low anterior resection of rectum (LAR): curative procedure of choice if adequate distal margins (~2 cm); uses technique of total mesorectal excision
◆ abdominoperineal resection of rectum (APR): if adequate distal margins cannot be obtained; involves the removal of distal sigmoid colon, rectum, and anus – permanent end colostomy required
◆ transanal minimally invasive surgery (TAMIS)- local excision for select T1 lesions only
◆ palliative procedures involve proximal diversion with an ostomy for obstruction and radiation
for bleeding or pain ■ adjuvant therapy
◆ combined neoadjuvant chemoradiation therapy followed by post-operative adjuvant chemotherapy for stages II and III
Follow-Up
• currentlythereisnodatasurroundingoptimalfollow-up
• combinationofperiodicCTchest/abdomen/pelvis,carcinoembryonicantigen,andcolonoscopyis
recommended
• carcinoembryonicantigentomonitorforinitialresponsetotreatment,andforsurveillance(q6mo)
Other Conditions of the Large Intestine
Angiodysplasia
Definition
• vascularmalformation:focalsubmucosalvenousdilatationandtortuosity
Clinical Features
• mostfrequentlyinrightcolonofpatients>60yr
• bleedingtypicallyintermittent,rarelymassive,andnotusuallyhypotensive(melena,anemia,andoccult
blood positive stools)
Investigations
• colonoscopy:cherryredspots,branchingpatternfromcentralvessel
• angiography:early-fillingvein,vasculartuft,anddelayedemptyingvein;rarelyactivebleeding • RBCtechnetium-99scan
• bariumenemaiscontraindicated(obscuresotherx-rays,i.e.angiogram)
Treatment
• noneifasymptomatic
• cautery,righthemicolectomy,embolization,vasopressininfusion,sclerotherapy,bandligation,laser,
octreotide, and rarely segmental resection if other treatments fail
Volvulus
Definition
• rotationofsegmentofbowelaboutitsmesentericaxis
• sigmoid(65%),cecum(30%),transversecolon(3%),andsplenicflexure(2%)
• 5-10%oflargebowelobstruction;25%ofintestinalobstructionduringpregnancy
Risk Factors
• age(50%ofpatients>70yr:stretching/elongationofbowelwithageisapredisposingfactor) • highfibrediet(cancauseelongated/redundantcolon),chronicconstipation,laxative
abuse, pregnancy, bedridden, and institutionalization (less frequent evacuation of bowels)
Clinical Features
• symptomsduetobowelobstruction(seeLargeBowelObstruction,GS29)orintestinalischemia(see Intestinal Ischemia, GS23)
• colickyabdominalpain,persistenceofpainbetweenspasms,abdominaldistention,andvomiting
Investigations
• AXR(classicfindings):“omega”,“bentinner-tube”,“coffee-bean”signs
• barium/Gastrografin®enema:“aceofspades”(or“bird’sbeak”)appearanceduetofunnel-likeluminal
tapering of lower segment towards volvulus
• sigmoidoscopyorcolonoscopyasappropriate
• CT:“whirlpattern”ofmesentericvesselstwistingaboutthevolvulusaxis
Treatment
• initialsupportivemanagementsameasinitialmanagementforbowelobstruction(seeLargeBowel Obstruction, GS29)
• cecum
■ nonsurgical
◆ may attempt colonoscopic detorsion and decompression; successful 15-20% of cases