Tumors and polyps of the bowel - PowerPoint Presentation

Slide1

Tumors and polyps of the bowelInflammatory bowel diseases

Gombošová Laura, MD, PhD

I.internal clinic University Hospital

Košice

Slide2

Tumors of the bowelTumors or polyps of the bowel are prostrusions to the lumen pedunculated,

sessile, semisessile

Polyps can be benign and

malignant

Slide3

Polyps and flat lesions – Paris classification

Slide4

Polyps – clinical signs and making diagnosisAsymptomatic – accidental finding during colonoscopyBleeding – occult, overt, massive

Sideropenic mikrocytic anemia, low iron and low

feritin

Abdomen pain

– big polyp with traction of the bowel wall

Ileus

– obstruction of the lumen with polyp

Tools for diagnosis

Endoscopy

– gastroscopy, colonoscopy, enteroscopy +

histologization

MR

alebo

CT

enterografia

Slide5

Polyps – clinical signs and making diagnosisAsymptomatic – accidental finding during colonoscopyBleeding – occult, overt, massive

Sideropenic mikrocytic anemia, low iron and low feritín

Abdomen pain

– big polyp with traction of the bowel wallIleus

– obstruction of the lumen with polyp

Tools for diagnosis

Endoscopy

– gastroscopy, colonoscopy, enteroscopy + histologization

MR

alebo

CT

enterografia

Slide6

Division of polypsEpitelial – adenomas (precancerous lesion), adenocarcinoma, neuroendocrinne tumors

N

onepitelial

– mesenchymal

(GIST

gastrointestinal stromal tumors)

lymphomas

from neuroectoderm – paraganglioma

hemangioma – vascular tumors

Secondary tumors

–

mestastasis from various malignancies

(cross growing lesions)

Polyposis

– a lot of polyps in GIT

FAP – familial adenomatous polyposis

Peutz-Jeghers sy, Gardner sy, Cowden sy, Turcot sy,

Slide7

Treatment – polypectomy Endoscopic procedure – electrogoaculation with polypectomy snareObligatory examinations: normal coagulation, level of platelets

Slide8

Treatment – polypectomy Endoscopic procedure – electrogoaculation with polypectomy snareObligatory examinations: normal coagulation, level of platelets

Slide9

Early cancer Malignancy localized to mucosa and submucosa – predominantly flat lesions in the right colon (without references of lymph node involvement)

Diagnosis

Endoscopy – white light

NBI – green blue light

Chromoendoscopy – dyeing of the mucosa

EUS

–

endoscopic ultrasound

Slide10

Early diagnosis increase 5-years survivalDiagnosis of malignancy in the I. stage – 80% survival

diagnosis in the I.stage – only 6% pts

Majority of pts are diagnosed in the IV

.

st

– 5% survival

Screening programs of an

early gastric cancer

Japan, Korea – diagnosis in 50% pacientov

Survival

intramucosal Ca - 99%

submucosal Ca - 96%

Y

ada T, et al. Diagnost Ther Endosc 2013

Slide11

Endoscopic mucosal resection and submucosal dissectionEMR

ESD

Therapy of early cancer

Slide12

Colorectal cancer

Slide13

Malignancies and deaths„Cancer is a fierce public health enemy“

The world

2016

– 8,9 mil death from malignanciesEurope

2012

– 1,3

mil death from

malignancies

Near half of them could be avoided

Every sixth death is from malignancy

26% of all deaths

immediately after cardiovascular deaths

(leading cause of deaths)

Slide14

Slide15

Globocan 2018Slovakia – the 1.position in Europe

in

incidence of CrCa

Slide16

Prevention of the cancersPrevention with screening can decrease the incidence of cancer

Effective screening is

with

50-60% of attendance

Screening have to be simple and low-cost

Slide17

Essence of the screeningDetection and removing of the precancerous lesions (polyps) and early cancerColorectal cancer is caused by:

70% adenomas

30% serrated adenomas - flat lesions

The size of polyps is importantUnder 5 mm – malignancy is rare, but detection is problematic

Slide18

Possibilities of the CrCa screeningColonoscopyStool test for occult bleeding – FIT fecal imunochemical test for hemoglobin detection

Stool test

for detection of fecal DNA

CT colonographySeptin 9 – blood test for detection of metylated tumor supresor gene mSEPT9(aberantly metylated DNA)

Slide19

Screening of the CrCaOportunistic

screening

–

GP invite the patients for screeningNational program screening –

programmed

invitation

for

examination

in the population in 50 y.

o

f age

Slovak

guidelines from

 

the 1.st

F

ebr 2018

Programmed population screening in 50.y

age with

common risk of CrCa

either

stool test every 2 years

or

screening colonoscopy every 10 years

Slide20

Population with increased risk for CrCaIndividual screening programsPositive family history for CrCa and adenomas of the large bowel

Familial adenomatous polyposis

Hereditary nonpolypous colorectal cancer - Lynch syndrome every 2 years

IBD

cancerophobia

Slide21

Screening and surveillanceScreening colonoscopy – detection of polyps and early cancers in asymptomatic peopleSurveillance

–

examinations

of patients after previous adenoma removal

Interval colonoscopy –

the next colonoscopy in interval between screening

colonoscopies (interval is every 7-10 years) – healthy people

Diagnostic colonoscopy

– examination of pts with symptoms

Slide22

Serrated adenomasMore in the right part of the large bowel30% of CrCa are transformed from them

Worse detectable

For

detection is

clean bowel needed

Slide23

Bowel preparation4 liters of cleansing liquid (polyetylenglykol, picosulfate, magnesium)Split dose

preparation of the bowel for better cleaning

2 liters in the

evening2 liters in the morning – 4 hours before examination

Boston scale classification

of the mucosa cleanness

Perfect 3+3+3 points – the whole bowel

Poor 0+0+0 points

Slide24

Colorectal cancerInfiltration of the whole bowel wallSpontaneous bleeding

Stages:

Asymptomatic

Symptomatic bleeding – occult or overt weakness - anemia

problematic bowel movement

paraneoplastic signs - DVT

weight losing

jaundice, liver involvement,

MTS

Slide25

Position of gastroenterologist in management of CrCaPrevention – screening and surveillanceMaking diagnosis

Endoscopic treatment of early cancer

EMR

ESD

Endoscopic treatment of advanced lesions

stenting of stenosis

stop bleeding

– diluted adrenalin injection to the tissue, argon plasma

coagulation, heat probe, laser coagulation

nutritional support, home parenteral nutrition

Slide26

Inflammatory bowel diseases

Slide27

IBD – inflammatory bowel diseasesImmune mediated diseases - dysregulated immune response to microbiota Increasing incidence

Etiology

Immune dysregulation

Genetic predispositionEnvironment – external and internal

Slide28

Inflammatory bowel diseasesCrohn´s disease CD – involvement of the whole GI tract and perianal region

Ulcerative colitis UC

– involvement only the large bowel

Indeterminate colitis 10%

Extraintestinal manifestations -

ocular, reumatological, dermatological, hepatological,

Slide29

EtiopathogenesisPathological immune response to microbial and antigenic stimuliMacrophages produce cytokines (IL1, 2, 6, TNF a, IFNγ

, others)

Cytokines bind to receptors – differentiation and activation of the

Th1 pathway (CD) and Th2

(UC)

Immune response disrupts an intestinal mucosa

– leads to the chronic inflammation

Slide30

Epidemiology2 peaks in incidence – in 15-40 years and in 65-70 yearsThe highest rate in developed countriesIncidence

0.5-24.5 cases

/

100.000 p.

y.

UC

0.1-16

cases

/100.

000

p.y.

CD

P

revalence

for

IBD

is 396 cases per

100

000

persons

annually

CD

319 cases per 100 000 in Europe

UC

505 cases per 100 000 in Europe

Slide31

The basic differences between CD and UCCDTerminal ileum – the most common involvementInvolve the whole GI tract

Skip lesion on the mucosa

Perianal fistulas and absceses

Diarrhea and bloody stools don´t beSmoldering course

UC

Involves only the large bowel

Always involves the rectum

Bloody diarrhea

Without fistulas and abscesses

Slide32

Patient with CD – various clinical pictureDiagnosis is made often lateAsymptomatic course

– the first sign can be perforation, surgery for „acute appendicitis”

Weight losing, fatique, weakness

Sporadic abdomen painOligoarthritis, erythema nodosum, sporadic diarrhea

Anemia,

sideropenia

– young men

Perianal fistulas, without diarrhea

Indirect signs of the stenosis of the terminal ileum: constipation, stomach pain, nausea, vomiting

Slide33

Course of CD and timing of the treatmentWindow of opportunity

Pariente B, et al. Inflamm Bow Dis, 2011

Slide34

CD - involvement

1%

4%

30%

40-70%

25%

10-15%

perianal fistulas, abscesses

Slide35

Patient with CDTypical clinical signsAbdomenache

Diarrhea

Weight losing

AnemiaPerianal fistulas

Nontypical signs

Weakness

Obstipation

Fever

Erythema nodosum

Monoarthritis

Sideropenia

Slide36

Forms of CD

Luminal

–

ulcerations on the mucosaFistulazing/

penetrating

–

enteroenteral, enterocutaneous, enterovaginal, e-vesical

Stenotic

–

stenosis of the terminal ileum, small bowel, rectum

Perianal

–

fistulas, abscesses

Combinations

...

Late diagnosis, late therapy

– intestinal insuficiency and failure

Slide37

Perianal fistulas

Slide38

CD – perianal form

absces

s

kin tags

Slide39

Advanced CDExtensive involvement of the small bowel malabsorption, malnutrition, hypoproteinemia, edemas, low B12, low calcium, low glucose

Presence of complications

– stenosis, fistulas, abscesses

acute abdomen – ileus, spontaneus perforation

Slide40

UC - involvementTypical signs of UC

Bloody liquid stool

Mucus stool

Abdomen crampsWeight loosingFever

Slide41

UC – acute severe colitisLifethreatening conditionBleeding, anemia Hb under 80g/lTachycardia, hypotension

Fever

Leucocytosis, sepsis, septic shock

Failure of the large bowel – exsudation of proteins to the stoolToxic megacolonComplex management on ICU

Need for acute proctocolectomy is often

Slide42

UC – acute severe colitisLifethreatening conditionBleeding, anemia Hb under 80g/lTachycardia, hypotension

Fever

Leucocytosis, sepsis, septic shock

Failure of the large bowel – exsudation of proteins to the stoolToxic megacolonComplex management on ICU

Need for acute proctocolectomy is often

Slide43

Patient with bloody stoolDif. dg. of the enterorhagia

Colorectal cancer

Haemoroids

NSAID colitisIschemic colitisBleeding from diverticula

Hypocoagulation conditions

Angiodysplasia

Each

patient

with enterorhagia have to be examined with colonoscopy

Slide44

Diagnosis – blood laboratory studiesAnaemia MalnutritionHigh

inflammatory response – CRP, leukocytes, platelets, fibrinogen, D-dimer

Low

iron, feritin, B12, folate

albumin, total proteins

Immunology

ASCA + .. in CD (anti saccharomyces cerevisiae Ab)

p-ANCA+ ..

i

n UC (

anti-neutrophil cytoplasmic Ab)

Slide45

Diagnosis – stool laboratory studiesMicrobiology – excluding of Salmonela sp., pathogenic E.coli, Campylobacter jejuni

Toxin A/B –

Clostridium difficile

Faecal calprotectin

Noninvasive marker of bowel inflamm

Sensitivity 97%

Specificity 67%

The use

Dif dg - inflammation or not

Follow up of IBD – remission, relaps

Slide46

Diagnosis – imagine studies in CDUltrasound – the basic checking of the abdomen measuring of the bowel wall thickness – terminal ileum

Longitudinal section

Transversal

section

Slide47

CD - Inflammed terminal ileum and inflammatory hypervascularisation – colour doppler

Slide48

Endoscopic imagineCD

UC

Slide49

UC

Slide50

Extraintestinal manifestations of IBDImmune mediated inflammation of other tissues in the bodyHoming of activated T lymphocytes to tissues

Skin

Reumatological

– joints, tendons, muscles, bonesOphtalmologicalHepatobiliary systemHematological system

Slide51

Skin EIM - Erythema nodosum10-15% pts with IBDMore often in women with CD

Can be the first sign of the disease

It depends on IBD activity

Good response to therapy, corticosteroids, antiTNF,

Histologization is not necessary, skin lesion is clear

Histological finding – nonspecific focal panniculitis (inflammation of the fat tissue)

Harbord M, et al. JCC 2015, Guidelines of EIM

Slide52

Erythema nodosum

Slide53

Pyoderma gangrenosum2-5 % pts with IBD

Independent

on the disease activity

50% patients with PG have

IBD,

malignancy, arthritis, polyarthritis, systemic diseasese

Histologization is recommended

– for differential diagnosis of the skin malignancy, lymphoma, necrotising vasculitis,

necrobiosis lipoidica, art/ven

ulcerations

Histological finding

– acute neutrofil dermatosis

Harbord M, et al. JCC 2015, Guidelines of

EIM

Slide54

Pyoderma gangrenosum

Slide55

Reumatological EIMSeronegative spondylarthritis ankylosing spondylitis HLA B27 pozit

enteropatitic arthritis (mono, oligoarthritis)

entezitis, bursitisArthralgias

Osteoporosis

Myalgias

(but also in malnutrition and weight losing, corticosteroids, antiTNF therapy)

Harbord M, et al. JCC 2015, Guidelines of EIM

Slide56

Oftalmological EIM 10% pts with IBDUveitis, HLA B27 pozit – inflammation of the front eye segment (iris, corpus ciliare and

chorioidea)

K

eratitisEpiscleritisDry eye

Retinitis

Optic neuritis

Irwin MS, et al. Crohn Colitis foundation 2015

Harbord M, et al. JCC 2015, Guidelines of EIM

Slide57

Staging of IBD and therapyBefore therapy staging of IBD is needed – mild, moderate and severe CD and UC– relaps and remission

Scoring indexes

Complex indexes CDAI, UCDAI, Mayo score, Harvey Bradshaw index

Endoscopic indexes – the part of complex indexes

CD

– clinical manifestation neednot correlate with endoscopic finding

Patient in clinical remission – without diarrhea and pain can have endoscopic lesions on the

mucosa

Slide58

Treatment – individual personal approachConventional – mesalasin, corticosteroids, azatioprin, MTX, cyklosporin antibiotics, unabsorbable rifaximin for microbiota modulation

Biological

– monoclonal antibodies IgG against cytokines

for moderate and severe forms of IBD (failure of conventional th)

antiTNF

–

infliximab, adalimumab, golimumab

Anti-integrín –

vedolizumab

Anti IL12 a 23

–

ustekinumab

FMT

–

fecal microbial transplantation

– resistant forms of UC

Nutritional therapy

enteral and home parenteral feeding (temporary, permanent)

Slide59

Surgical treatment of CDStenosisAbscessesEnteroenteral fistulasEnterocutanneous fistulas

Rectovaginal fistulas

Perianal fistulas, abscesses

Slide60

Surgical treatment of UCProctocolectomyIPAA – ileoanalpouch anastomosis – neorectum

Indications for surgery

Chronic active

UC with morfological changes of the bowel – bleeding, dysplasias, cancerAcute severe colitis – toxic megacolon, exsudative bowel with severe malnutrition