Appendix, Colon, Rectum and Anus

• Colon secrets: potassium

• Colon reabsorbs: Na and water.

• Branches of SMA includes:

a. Ileocolic artery (cecal and appendicular branches)
b. Right colic artery
c. Middle colic artery
• Watershed areas:
a. Splenic flexure (Griffith’s point) = SMA and IMA Junction
b. Rectum (Sudeck’s point) = Superior rectal and middle rectal
artery junction
• Colon more sensitive to ischemia than small bowel due to poor
collaterals.
• Rectal lateral stalks contain —> Middle rectal arteries.
• The internal anal sphincter is supplied by pelvic splanchnic nerves.
(Autonomic nervous system)
• The external anal sphincter is innervated by somatic nervous system
(Inferior rectal branch of the pudendal nerve).
• The two diseases that do NOT get better in patients with Ulcerative
colitis after colectomy are:
a. Sclerosing cholangitis
b. Ankylosing spondylitis
• Any dysplasia with UC is an indication for procto-colectomy.
• UC pts with low grade dysplasia in the upper rectum —> Total
procto-colectomy and J pouch formation (Ileal-anal anastomosis)
• Prophylactic colectomy in UC indicated in:
a. Toxic megacolon worsening after 72 hours
b. Perforation
c. Low grade dysplasia on biopsy
• Ogilvie's Syndrome:
a. Acute dilation of the colon in absence of a mechanical
obstruction, seen in severely ill or postoperative patients.
 (Tx: IVF, Bowel rest, +- Neostigmine) if failed —>
Decompressive colonoscopy.
• The most distal rectal tumor extent which would still allow a 2 cm
margin is about 2 cm from the proximal anal canal.
• Post low anterior resection for rectal CA, fluid collection near
anastomosis —> Percutaneous drainage and antibiotics. If Showed
small leak only give antibiotics only.
• Tx of Diverticulitis:
A) uncomplicated diverticulitis —> Conservative management with
broad spectrum oral antibiotics using ciprofloxacin plus
metronidazole.
B) If abscess there —> Percutaneous drain.
C) If perforation —> Sigmoid resection (Until normal rectum) and
diverting ileostomy, abdominal washout
• Diverticula:
a. True diverticulum: Affects all layers of intestinal wall. E.g.
Meckel diverticulum. Usually, congenital.
b. False diverticulum/ Pseudodiverticulum: involves only
mucosa and submucosa. Acquired. Most common type of
GI diverticula.
• Most of LOWE RGI Diverticula are --> False diverticula.
• Most common cause of Colo vesicle fistula is —> Diverticulitis.
• Best test for colo-vesicle fistula —> Cystoscopy.
• Direct invasion of CRC of another structure requires en bloc
resection, even if you must perform a whiple to get en bloc
resection.
• CEA is useful to detect colon CA recurrence and for following
response to treatment! NOT FOR SCREENING
• Laparoscopic vs open resection for colon CA is associated with
longer operative time.
• FAP develops in puberty. Undergo screening early in teens. Total
procto-colectomy indicated at age 20.
• APC gene mutation in 14 years old boy undergo sigmoidoscopy and
adenomatous polyp were found —> observation with delayed
surgery.
Familial Juvenile Polyposis:
• Hamartomata's polyps form.
• Annual upper and lower endoscopy recommended
• Autosomal Dominant.
• Small risk of CA
• Colectomy only indicated for adenomatous changes in
hamartomata's polyp
• In case of polypectomy from his left colon, during the procedure you
see omental fat —> Primary repair is indicated for free perforation
following colonoscopy.

Peutz-Jegphers Syndrome:
• These patients are higher risk for extra-intestinal malignancies.
• MC ca in these patients are breast Cancer
• These patients form GI tract hamartomatous polyps
• Bowel obstruction is the MC presentation
 • Villous adenomas are villians because they have the highest of
malignant potential.
• The most effective study for a patient with massive lower GI
bleeding is —> Colonoscopy.
• Hemostatic resuscitation:
1. PRBCS
2. PLATELETS
3. FFP
In 1:1:1 ratio
• The MCC of GI bleeding not apparent on upper and lower endoscopy
(Obscure GI bleeding) —> Small bowel AVM (Angiodysplasia)
• Ischemic colitis:
o Seen in hospitalized patients with hypoxia.
o Seen in watershed areas are vulnerable.
o TX: IVF and antibiotics.
• Leaks after surgery:
• Different causes of leak through abdominal wounds:
1. Stool after appendectomy stump blow-out
2. Enterotomy or anastomosis sucus leakage after small bowel
resection
3. Urine leak after APR
• Complications:
1. Peritonitis
2. Sepsis
 3. Necrotizing fasciitis
4. Shock
5. Death
• Managment:
1. <7 Days —> Reoperation. Includes: simple washout and placement of
drains to revising an anastomosis or staple line or resection.
2. >/ 7 days —> Adhesions become an issue and reoperation is not
advised. At this point leak is called FISTULA. TX: CT scan.
• Large amounts of pink salmon-colored drainage along with bulge
under the incision is consistent with fascial dehiscence.
Rexpolartion and placement of retention sutures is indicted.

• Erectile dysfunction post LAR is due to —> Pelvic splanchnic plexus

(parasympathetic)
• Retrograde ejaculation following LAR is due to —> Hypogastric
plexus (Sympathetic)
• Ejaculatory failure following LAR due to —> Pudendal nerve injury
(Sympathetic)
• Dysuria and frequency occurring late after LAR due to —> Pelvic
splanchnic plexus.(Parasympathetic, causes bladder problems)
• The recommended screening in patients with HNPCC -->
Transvaginal US and endometrial aspiration biopsy at age 35.

Rectum and Anus

• Separates the rectum from the sacral venous plexus --> Waldeyer's
fascia
• Separates the rectum from prostate in men and vagina in women --
> Denovillier's fascia
• Separates the rectum from the bladder--> Rectovesicle fascia
• Marks the transition between rectum and anal canal --> Levator ani
• Marks the transition form columnar to stratified squamous
epithelium --> Dentate line
• Denetate line —> Transition from columnar to stratified squamous
epithelium.
• Anus arterial blood supply —> Inferior rectal artery.
• Anus venous drainage:
o Above dentate line —> Internal Hemorrhoid plexus
o Below dentate line —> External hemorrhoid plexus
• External anal sphincter is the continuation of the puborectalis
muscle
• Internal anal sphincter is the continuation of the muscularis propria
• Central tendon separates the vagina and external sphincter
• The pudendal nerve (S2–S4) innervates the external anal sphincter.
Injury to this nerve (e.g., during childbirth) can cause fecal
incontinence and perianal sensory loss.
• The recto-vesicle fascia separates the rectum from the bladder.
• The levator ani marks the transition between rectum and anal
canal.
• The dentate line marks the transition from columnar to stratitied
squamous epithelium

• Anal canal tumors (above the dentate line) tend to drain to the
internal iliac and inguinal nodes. E.g. anal canal squamous cell
cancer.
• Melanosis Coli:
• Benign hyperpigmentation of the colonic mucosa caused by
anthraquinone abuse (Laxative use)
• Resolves after it is discontinued.
• Asymptomatic fistulas in crohns can remain dormant for long
period, avoid operating on them as healing is poor and
complications are high.
• Best therapy for trans-sphincteric fistula that is refractory to
draining seton stitch —> Endo-rectal advancement flaps avoids anal
incontinence risk.
• Concerning (for CA, IBD, STDS) fistulas:
1. Fistula recurrence
2. Multiple sinus tracts emanating from a fistula
3. An associated mass.
• The type of fistula has lowest risk of anal incontinence with
fistulotomy —> Extra-sphincteric.
• Thrombosed external hemorrhoid (Present with tender bluish-purple
mass) treatment:
• <72 hrs of Symptoms —> Elliptical excision
• >72 hrs of symptoms —> lance open only
• Strangulated quaternary hemorrhoids should be resected to prevent
necrosis with an urgent hemorrhoidectomy with 3 quadrant
resection.
• Anal fissure:
o treatment:
• Conservative (First line!)
1. Dietary improvement includes fibers
and water.
2. Stool softeners e.g. docusate
3. Anti-inflammatory and analgesic
creams e.g. nitrate
4. Sitz baths
5. Topical vasodilator e.g. calcium channel
blocker gel - nifedipine or GTN ointment
o Sites:
• Most common —> posterior
• Most common in crohns, tb, syphilis, HIV —>
Lateral
• Interim
• Outpatient procedures —> BTX into internal anal sphincter
• Surgical intervention (If conservative treatment failed)
• Anal fissure that should raise susicpoins of anal Ca or IBD or STD —>
Lateral fissuers.
• Most serious complication of lateral internal subcutaneous
sphincterotomy is —> Anal incontinence.
• Surgical options for rectal prolapse (Procidentia):
• Altemeier procedure (perineal rectosigmoidectomy): for elderly and
frail patients.
• LAR (Recto-sigmoid resection with pexy of the residual colon,
laparoscopic or open): for young and fit patients.
• The MCC of solitary rectal ulcer syndrome —> Internal
intussusception!
• Parastomal hernia:
 • Occurs 50% in patients with ileostomy/colostomy.
• Asymptomatic parastomal hernias can be managed conservatively
with a stoma belt (ostomy belt), which reduces the hernia.
• Symptomatic or large parastomal hernias (which hinder the proper
application of the stoma bags, causing leakage of bowel contents
and skin erosion) need to be surgically repaired (primary suture or
mesh repair) or the stoma site should be relocated.
• Post-vaginal delivery anal incontinence (Damage to external anal
sphincter/ type of abdomino-perioneal descent), if refractory to
medical tx —> anterior sphincteroplasty 2-3 months after medical
therapy.
• MCC of anorecto-vaginal fistula —> Obstetrical trauma.
• Tx of Anal Canal Squamous Cell Carcinoma:
o Nigro Protocol (Consists of 5-FU and Mitomycin plus
radiotherapy).
o Surgery IS NOT initial tx of choice
o Positive inguinal nodes confer a worse

• The treatment of appendicitis is surgical and requires removal of

the inflamed appendix, except in cases of appendiceal perforation in
which treatment can vary (Drainage and antibiotic treatment).
• Appendiceal abscess:
o Clinical features:
• Tender mass in RLQ in an acutely ill patient (i.e.,
high grade fever, possible paralytic ileus,
leukocytosis, signs of sepsis)
o Treatment;
• Non operative management of acute appendicits.
• Abscess <4cm: Antibiotic therapy alone

Hemorrhoids classification and management:

Class Description

Grade 1 •Hemorrhoids do not prolapse, reversible, often bleed

Grade 2 •Prolapse when straining but spontaneously reduce at

rest

Grade 3 •Prolapse when straining; only reducible mannualy

Grade 4 •Irreducibleprolapse; may be strangulated and

thrombosed with possible ulceration

• Genes associated with Colon cancer:

1. APC (Adenomatous polyposis coli) tumor suppressor gene
2. K-ras- proto-oncogene
3. DCC (Deleted in colorectal carcinoma) - Tumor suppressor gene
 4. P53- Gene

• Oglivie’s syndrome:
o Pseudo obstruction of colon associated with opiate use,
bedridden, older patients, recent surgery, infection or
trauma.
o Massively dilated colon when can perforate
o Tx:
• Decompression
Colonscopic decompression if enema
unsuccessful of if patient has
significant cecal dilation
• Enema
• IV neostigmine

Screening Guidelines for Colorectal Cancer:

• Case of RLQ abdominal pain after lifting heavy object, o/e

irreducible with -ve cough impuse and not changing with
contracting the abdominal muscle —> Rectus sheath hematoma.
o Forthergill’s sign:
• A palpable adominal mass that remains
unchanged with contract of the recuts muscles
and is classically associated with rectuss sheath
hematoma

• Sigmoid Volvulus:
o Abdominal x-ray will show:
 • Bent inner Tube Sign
• Coffee bean apperance

o Gastrografin enema will show:

• Birds beak sign (tapered colon)
o Tx: (If no signs of gangrene or peritonitis)
• Resuscitation, NPO
• Endoscopic detorsion (By rigid Proctoscope)
If patient stable —> Decompress with
colonoscopy or sigmoidoscopy
If unstable —> for for OR for sigmoidectomy
• Patient with epigastric pain for 6 hours and high amylase and WBC
ct showed intraperitoneal air but not contrast extravasation, next
step —> Diagnostic Laparoscopy

• The initial radiological test for patient suspecting pancreatitis —>

US

• Diagnositc and management algorithm for GI bleeding:

• Patient with ulcerative colitis and low grade dysplasia in the upper
rectum should undergo --> Total procto-colectomy and J pouch
formation (Ileal-anal anastomosis)