1. BY
DR.SEFEEN SAIF ATTYA
SOHAG TEACHING HOSPITAL

2.  The large intestine extends from the ileocecal valve to
the anus. It is divided anatomically and functionally
into the colon, rectum, and anal canal.
 The wall of the colon and rectum comprise five
distinct layers: mucosa, submucosa, inner circular
muscle, outer longitudinal muscle, and serosa.
 In the colon, the outer longitudinal muscle is
separated into three teniae coli,
 In the distal rectum, the inner smooth-muscle layer
coalesces to form the internal anal sphincter.

3.  The rectosigmoid junction is found at approximately
the level of the sacral promontory and is arbitrarily
described as the point at which the three teniae coli
coalesce to form the outer longitudinal smooth
muscle layer of the rectum.
 The cecum is the widest diameter portion of the colon
(normally 7.5 to 8.5 cm) and has the thinnest muscular
wall. As a result, the cecum is most vulnerable to
perforation and least vulnerable to obstruction.
 The ascending colon is usually fixed to the
retroperitoneum.The hepatic flexure marks the
transition to the transverse colon.

4.  The intraperitoneal transverse colon is relatively mobile
The splenic flexure marks the transition from the
transverse colon to the descending colon.
 The attachments between the splenic flexure and the
spleen (the lienocolic ligament) can be short and dense,
making mobilization of this flexure during colectomy
challenging.
 The descending colon is relatively fixed to the
retroperitoneum.
 The sigmoid colon is the narrowest part of the large
intestine and is extremely mobile,This mobility explains
why volvulus is most common in the sigmoid colon.The
narrow caliber of the sigmoid colon makes this segment of
the large intestine the most vulnerable to obstruction

5.  The great majority (75%) of colorectal cancers
are sporadic and without identifiable risk factors
other than increased age
 Previous cholecystectomy and gastric surgery
confer some increased risk
 High risk groups include patients with :
Ureterosigmoid urinary diversion
Extensive colitis
Colorectal adenoma
Previous colorectal cancer
Strong family history of colorectal cancer
Familial adenomatous polyposis

6.  80 % of Patients with colorectal cancer
present electively with symptoms of several
months duration
 Earlier diagnosis of symptomatic colorectal
cancer is therefore possible but requires
greater public awareness of the nature of
colorectal cancer , its presenting features and
potential curability

7.  Altered bowel habit
 Bleeding per rectum
 Abdominal pain
 Tenesmus
 Palpable abdominal or rectal mass
 Iron deficiency anaemia

8.  This is specially common in cancers of left
colon or rectum
 Patients may complain of recent or increasing
constipation , passage of small –caliber
stools or diarrhoea
 Altered bowel habit may be caused by IBS or
diverticular disease but colorectal cancer
needs to be excluded

9.  Passage of small or moderate amounts of
blood mixed through the motion is suspicious
for colorectal carcinoma
 In rectal cancer the bleeding may be
indistinguishable from that caused by
haemorrhoids-which may of course ,coexisits
with cancer
 The likelihood of colorectal cancer is 10% in
patients aged >40 years who present with
recent-onset rectal bleeding

10.  Colorectal cancer may present with a dull
,poorly localized or suprapubic pain
 Carcinoma of the right colon sometimes
causes postprandial pain (provoked by the
gastrocolic reflex)
 Direct spread of the tumor into the adjacent
structures may cause constant , well localized
abdominal ,sacral or thigh pain

11.  This is an irresistable ,uncomfortable or
painful urge to defaecate ,often with passage
of only a small volume of stool ,blood or
mucus and followed by a sense of incomplete
evacuation
 Tenesmus suggests rectal carcinoma
,although it may also be caused by proctitis
or infective colitis

12.  Physical examination is often normal
,findings may include
Abdominal fullness
Hepatomegaly
Rectal examination is essential ;75% of
rectal cancers are felt as a mass ,ulcer or
stricture
Stool should be tested for ocult blood
Iron-deficiency anaemia

13.  Recent onset iron-deficiency anaemia should
prompt a search for a source of blood in the
gastrointestinal tract particularly the colorectum
 Bleeding may be intermittent , and occult blood
testing may be negative
 Positive faecal occult blood tests should initially
be followed by colonoscopy rather than upper GI
endoscopy
 Iron-deficiency anaemia is more commonly due
to colorectal cancer than upper GI lesion

14.  20% of patients have distant metastases at
the time of diagnosis ,such patients may
present in diverse ways including
Cachexia
Jaundice
Ascites
Pathological fractures
Weight loss

15.  None of the features of colorectal cancer are
pathognomonic
 Diagnosis is most likely to be delayed when symptoms are
ascribed to benign disease such as haemorrhoids or IBS
 Most usually the diagnosis will be made by a combination
colonoscopy and barium enema ,these approaches are
complementary
 Double contrast Barium enema does not examine the
anorectum adequately
 Colonoscopy is more sensitive than barium enema in
detecting colorectal cancer , but depends crucially on the
endoscopist’s skill in visualising the entire length of the
colon

16. Barium
enema study
showing
stenosing
(apple core)
carcinoma of
the colon

17.  Barium enema.
showing irregular
filling defect in the
caecum
 Diagnosis :
Cancer caecum

18. •Barium enema.
•Irregular long
stricture of the right
colon.
•Diagnosis :
Cancer right colon.

19.  Barium enema.
 Cancer
transverse colon
with
intussusception.

20.  Barium enema.
 Describe
Irregular filling
defect & stricture
with shouldering
on both sides
(Apple core
appearance).
 Diagnosis:
Cancer sigmoid.

21.  Barium enema.
 Describe
Irregular filling
defect & stricture
with shouldering
on both sides
(Apple core
appearance).
 Diagnosis:
Cancer sigmoid.

22.  Barium enema.
 Describe
Irregular filling
defect & stricture
with shouldering
on both sides
(Apple core
appearance).
 Diagnosis:
Cancer
rectosigmoid.

23.  The indications to reinvestigate a patient
with persistent or recurrent symptoms will
depend on their nature and the doctor’s
confidence in the quality and interpretation
of previous investigations

24.  Colorectal cancer is managed by a
multidisplinary team to optimise cure and
outcome
 Treatment of colorectal cancer may include a
combination of operative resection ,
radiotherapy and chemotherapy as well as
evolving techniques

25.  The primary treatment for potentially curable cancer
colon is segmental resection with restoration of
intestinal continuity
 Surgical resection is the treatment of choice for
potentially curable rectal cancer
Carcinoma of the upper rectum is treated by high
anterior resection generally without a stoma
Carcinoma of the mid and lower rectum is increasingly
treated by low anterior resection with total
mesorectal excision (TME) to minimise local recrrence
rates
Leak rates are higher after this operation , so a
temporary defunctioning stoma is often employed

26.  The lowest rectal tumours are treated by
abdominoperineal resection with permanent
stoma where the sphincters must be removed
to ensure a safe margin of clearance
 Postoperative chemotherapy gives an absolute
increase in five-year survival of approximately
6% in patients with involved nodes
 The benefit of chemotherapy when nodes are
not involved is being investigated

27.  A small proportion of patients with rectal
cancer are suitable for local resection using
either a conventional transanal technique or
a microsurgical technique
 these procedures are usually restricted to
small tumours that are judged to have a very
low potential for nodal metastases

28.  Laparoscopic resection
 Transanal endoscopic microsurgery
 Intraoperative radiotherapy
 Neoadjuvant chemotherapy to downstage
tumours
 immunotherapy

29.  20% Of patients with colorectal cancer
present with a complication of colorectal
cancer including
-Intestinal obstruction
-Perforation and peritonitis
-Profuse bleeding per rectum
 Surgical management will be directed to
relieving the life threatening crisis and
performing an adequate surgical resection of
the tumour

30. Patients with advanced or recurrent disease are
assised to determine whether this is unifocal
or multifocal
Locally advanced disease without distant
metastases may be amenable to wide
resection perhaps including adjacent organs
Single sites of distant metastases (hepatic for
example) may be amenable to radical
resection

31.  Patients with disseminated or unresectable disease
cannot be cured however several interventions are
available that may improve palliation
Useful palliative procedures :
 Resection of primary , surgical bypass or stoma
formation
 Stenting of colonic strictures
 Laser ablation of rectal tumours
 Radiotherapy to primary tumours / local recurrence
 Laser or radiofrequency ablation for hepatic deposits
 Radiotherapy to painful bone deposits
 chemotherapy

32.  80% of patients with colorectal cancer present
electively ,often with of several month duration ,
the cardinal features are: altered bowel habit ;
bleeding per rectum ; abdominal pain ;
tenesmus; palpable abdominal or rectal mass
and iron deficiency anaemia
 Early stage disease , in which cancer is localised
within the bowel wall , is curable in more than
80% of patients , unfortunately ,55% of patients
present late with evidence of lymphatic or
distant metastases

33.  Rectal examination is essential , 75% of rectal
cancers are palpable as a mass , ulcer or
stricture
 Patients with suspected diagnosis of
colorectal cancer should undergo rapid
access colonoscopy and barium enema

34. THANK
YOU