Rectum lecture 2 - PowerPoint Presentation

Slide1

Rectum lecture 2

Slide2

Partial Rectal

prolapse(Mucosal)

The mucous membrane and sub mucosa of the rectum protrude out side the anus 1-4 cm from .

it is evident that it is composed of no more than a double layer of mucous membrane

Slide3

Aetiology:

In infant

The absence of normal sacral curve predispose to rectal prolapse in infant.

In children :Start after of attack of diarrhea.Loss of fat in the ischo rectal fossa due to loss of weight. It may be associated with

cystic fibrosis .Neurological cause and mal development of pelvis .

In adult

Start as third degree hemorrhoid (

mucohaemorrhoidal

prolapse

)

In a female due to torn perineum.

In male, straining during micturition.

May fellow operation of fistula in ano ( damage large portion of muscle).

Slide4

Treatment :

Infant and young children :

Digital re position Submucosal

injection 5% phenol in almond oil. or banding by rubber band(If digital repositioning fails after a 6-week

trial)Adult :

Local

treatments

: Submucosal

injections of phenol in almond oil the application of rubber bands are sometimes successful in cases of mucosal prolapse.

Excision of prolapsed mucosa

:When

the prolapse is unilateral, the redundant mucosa can be excised

or

if circumferential, an (endoluminal stapling) technique.

Slide5

Complete Rectal prolapse

Complete rectal prolapse (

procendentia

) is Less common .Contain all layer of rectal wall .More common in the women, It is more than 4 cm and commonly as much as 10–15 cm in length

Examination between thumb and finger feels consist more than double layer. And thicker than mucosal prolapse

Some time part of peritoneal pouch contain small bowel with gurgle can be felt.

Slide6

Any prolapse over 5 cm in length will contain anteriorly, between its layers,

a pouch

of peritoneum. When large, the peritoneal pouch may contain

small intestine or bladder. The anal sphincter is characteristically

patulous and gapes widely on straining to

allow the

rectum to prolapse.

Complete

prolapse is uncommon

in children

but may occur as a result of malnutrition. In

adults,it

can occur at any age, but it is more common in the elderly .Women are affected six times more often than men. In approximately 50% of adults, fecal incontinence is also a feature. Complications of rectal prolapse include rectal ulceration and bleeding, incontinence and even incarceration with strangulationof the rectum

Slide7

Treatment

Perineal approach

: Thiersch operation, Delorme’s operation,

Altemeier’s procedureAbdominal approach : open and laparoscopic approach : Abdominal rectopexy,

Slide8

Slide9

Proctitis

The patient is usually middle-aged and complains of

defaecatory frequency

with the passage of loose motions, often

with blood

mixed in the

stools.

Inflammation

is sometimes

limited to

the rectum; in other cases, it is associated with a

similar condition in the colon (proctocolitis). The inflammation can be acute or chronic. Although the patient has a frequent, intense desire to defaecate, the amount of faeces passed at any time is small. Acute proctitis is usually accompanied by malaise and pyrexia.Sigmoidoscopic examination :shows inflamed mucous membrane without ulcer of the rectum extend 12.5 up to 15 cm from the anus .the mucosa above normal.

Slide10

Treatment in non specific 5-ASA

Prednisolone retention enema.

Oral steroid in resistant cases

Milk excluded from the diet.

Slide11

Ulcerative

proctocolitis

:This may be part of ulcerative colitis .

Proctitis due to crohn disease :The rectum can effected by the disease .Sigmoidoscopy revealed patchy ulceration rather confluent ,there may be fissuring rather ulceration; cobble stone appearance . Rectal

cronhs disease associated with severe perineal fistulation.Skip lesion also present .

Radiation

proctitis

Radiation therapy is used in the treatment of cervical,

prostate and

rectal cancers.

It

can produce acute radiation

proctitis with bleeding, pain, diarrhoea and defaecatory frequency.Most symptoms settle within a few weeks, but some patients develop chronic proctitis with symptoms appearing months or even decades after the radiation exposure.

Slide12

Proctitis due to specific infections

Clostridium

difficile :pseudomembranous colitis ,follow broad spectrum antibiotic

.Bacillary dysentery :acute purulent proctocolitis. dx swab from mucous membrane .proctoscopy painful

Amoebic dysentery: infection is chronic ,proctoscopy is not painful

Amoebic

granuloma

: Present

as mass in the

recto sigmoid

. The lesion is mistaken for a carcinoma .

Slide13

Tuberculous

Proctitis

:this is always associated with active pulmonary tuberculosis ,ulceration of the anus .Sub mucous rectal abscess raptured leave an ulcer with undermined edge .

Hypertrophic ulcer in the rectum is associated with Tuberculous peritonitis ,Tuberculous Salpingitis ..Dx by endoscopic biopsy .Gonococcal proctitis

:is sexual transmitted disease .in female direct spread from the vulva .In acute stage the mucosa id

hyperemic

with thick pus .

The

diagnosis

is established by bacteriological examination .

Treatment is specific for gonococcal infection .

Lymphogranuloma

inguinale :Is sexual transmitted disease ,but in female the mode of spread of infection from the cervix via lymphatic to the para rectal lymph nodes.Dx is suspected when there is inguinal lymph node enlargement .Proctoscopy the same for gonococcal infectionTreatment :oxytetracyclin ,streptomycin,co-trimoxazole.

Slide14

Proctitis

:due to

Primary syphilis:AIDS

Rectal bilharziasis : by Schistosoma mansoni common In Egypt .Proctitis

due to herbal enema :common in Africa (pepper ,bark, ginger )

Severe

proctitis

.proctoscopy complete gelatinous cast of the mucous membrane of the rectum

Treatment :streptomycin ,

morphine. Temporary

colostomy me be needed.

Slide15

Rectal evacuation disorder (RED)

Symptoms consist of a difficulty in

emptying despite

persistent straining and a feeling of incompleteness in the process.Rectal intussusception is often a component of RED whereby the rectal wall in folds on itself to produce an internal prolapse during straining

.Solitary rectal ulcer syndrome may also be another associated manifestation

of RED

. Classically, SRUS takes the form of an ulcer on

the anterior

wall of the rectum, situated around 8 cm from the

anal verge

. In this form, it can be mistaken for rectal

carcinoma or

inflammatory bowel disease,It may heal, leaving a polypoid appearance Histology will confirm the diagnosis

Slide16

The condition is difficult to treat. Symptomatic relief from bleeding and discharge may sometimes be

achieved by

controlling any associated straining with recoordination of defecation using biofeedback therapy.

Trans anal stapled resection of the intussusception (STARR procedure) or resuspension of the rectum by abdominal rectopexy may be beneficial. In rare cases, rectal excision may be required

Slide17

Benign tumor of the rectum

Rectal Polyp

In the rectum and sigmoid is the most common site ( adenomatous polyp) .

Polyps are described in terms of their appearance (pedunculated, sessile, flat) or histological composition (tubular

, villous, tubulovillous).Adenomatous type has the tendency to be malignant

sp

. Size >1 cm ,follow up increasing size ,sessile rather than

pedunculated

If more than one polyp ,total colonoscopy examination ,to exclude malignancy.(no rectal tumor removed until resection of the proximal part otherwise implantation tumor cell in the rectal

wound)

.

Most of then treated by endoscopic excision ,rarely rectal excision .

Slide18

Hyperplastic

polyps

These are small, pinkish, sessile polyps, 2–4 mm in diameterand frequently multiple. They are common and generally harmless

Tubular adenomasare

the most common type of polyp.

They

have the potential to

turn malignant

, particularly if over 1 cm in diameter.

Serrated

adenomas

They are typically

sessile lesions that have a distinct microscopic architecture and can give rise to cancers through an alternative ‘serrated’ pathway

Slide19

Hyperplastic polyps

Slide20

Villous adenoma

Frond like appearance

.Very

large size ,can occupy the whole rectum.High tendency to be malignant .Rarely, Presentation with profuse mucus discharge ,(potassium losing leading to dangerous electrolyte and fluid loss).

Treatment after excluding cancerous changes Sub mucous dissection per anum

Some time rectal excision

Recent trans anal endoscopic microsurgery

Slide21

Inflammatory polyp or pseudo polyp

Edematous polyp usually associated with colitis.

Slide22

Juvenile polyp

Bright red pedunculated (cherry tumor).

Common in infant and children.

Can cause bleeding ,pain or prolapseHistology :large mucous filled spaces covered by smooth surfaces of thin rectal wall of cuboidal epithelium

Slide23

Treatment of rectal polyps

All polyps should be biopsied or removed for

histological analysis to exclude cancer. A range of techniques can be used to

remove rectal polyps, dependent on their size and location.The majority of polyps less than 1 cm in size are benign and are amenable to endoscopic polypectomyPolyps greater than 1 cm in size have a 10% chance of harboring a malignancy.

Most polyps of 2 cm in size or less can be safely removed by endoscopic mucosal resection (EMR

)

Larger polyps

are more difficult to remove by EMR and may

require a

transanal

procedure, such as

transanal

endoscopic microsurgery (TEMS).

Slide24

.

Endometrioma

:The focus of the ectopic endometrial tissue produces either

a constricting lesion of the recto sigmoid or a tumour invading the rectum from the rectovaginal septumThe neoplasm is mistaken is carcinoma is tumor invading the recto sigmoid

or direct invasion from the rectovaginal septum.Sigmoidoscopy present with stricture with intact mucous membrane .Hormonal manipulation is the

first-line therapy

, but sometimes total abdominal hysterectomy

and bilateral

salpingo

-oophorectomy and even bowel

resection are required

Haemangioma

:Rare tumor In the lower part of the rectum .May cause fatal hemorrhageSelective angiography and embolization may be helpful, but excision of the rectum is sometimes required. Gastro intestinal stromal tumor :Smooth-muscle tumours of the rectum are rare. If the mitotic rate is high, and if there is variation in nuclear number, size