History

Fact Explanation
Bleeding per rectum Fresh blood may be found in hemorrohids, [8] anal fissures etc. Passage of formed stool mixed with blood is suggestive of an anorectal bleeding. Altered black blood is associated with right sided colonic malignancies. [7] Melena is black tarry stools, may be due to upper GI bleeding. Hemochezia is the passing of red blood via the rectum usually from the lower gastrointestinal tract, and usually associated with angiodysplasia like conditions.
Frequency and duration of bleeding [7] Bleeding per rectum which is persistent or intermittent is a common symptom in polyps. Acute onset may be due to diverticular disease, angiodysplasia, jejunoileal diverticula, meckel’s diverticulum, neoplasms/lymphomas, enteritis/Crohn’s disease. [1,2] Peptic ulcer disease, gastritis/duodenitis and esophageal varices are the causes of upper gastrointestinal causes for the acute rectal bleeding. Angiodysplasia, small bowel tumors, small bowel ulcers and erosions, crohn’s disease, small bowel diverticulosis, and radiation enteritis are causes for chronic intermittent bleeding. [7]
Pain Painless bleeding may be due to hemorrohids, [8] colorectal carcinoma, polps, diverticular disease and Bleeding will be painful in anal fissure which is a severe sharp pain occurring with straining on defecation and resolves within an hour after defecation. Strangulated hemorrhoids are usually associated with pain. [8]
Age [7] Diverticular disease, arteriovenous malformations, colorectal carcinoma [7] and polyps are known to be more common in elderly people. Meckel's diverticulitis, intussuseption is more common in infants and young children. Inflammatory bowel disease is common in the age between 20-40 years. Anal fissures and hemorrhoids are also common in young age group. [8]
Tenesmus [11] and sense incomplete evacuation of the rectum [7] Tenesmus is painful desira to defecate without passage of stools. Constipation may be chronic. [4] These symptoms are usually occurred in lower GI neoplasms.
Constipation [4] and diarrhoea Alternating constipation and diarrhoea is a feature of lower GI malignancies. Anal fissures [11] are more common in patients with history of constipation. Inflammatory bowel disease may also cause diarrhoea. [11]
Lump at anus Is due to the haemorrhoids. [8] Occasionally a polyp or rectal prolapse may be the cause.
Haematomesis Passage of blood with vomitus may be indicative of upper GI bleeding. Peptic ulcer disease [12] may occasionally presents with lower GI bleeding.
Abdomonal pain[4] Right sided colonic malignancies can cause right sided abdominal pain. Intestinal obstructuin by an annular growth also may be possible. [4,7]
History of radiation to abdomen and/or pelvis Radiation colitis may be due to radiation treatment. [13]
Extraintestinal features:uveitis, joint pain Associated features in autoimmune conditions like Inflammatory bowel disease.[11]
Shortness of breath on exertion, lethargy [6] Intermittent chronic blood loss may cause amaemia. [1] Low oxygen to the tissues due to the anaemia, causes lack of energy.
Diet [9] Increased fat in diet, high intake of red and processed meats,[10] highly refined grains and starches, and reduced fibre are known to increase the risk of colorectal carcinoma. Fiber [9] dilutes or adsorbs fecal carcinogens, modulates colonic transit time, alter bile acid metabolism, reduce colonic pH, or increase the production of short-chain fatty acids, by which it reduces the risk of colorectal cancers. [3]
References
  1. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  2. BAUM S, ATHANASOULIS CA, WALTMAN AC, GALDABINI J, SCHAPIRO RH, WARSHAW AL, OTTINGER LW. Angiodysplasia of the right colon: a cause of gastrointestinal bleeding. AJR Am J Roentgenol [online] 1977 Nov, 129(5):789-94 [viewed 11 August 2014] Available from: doi:10.2214/ajr.129.5.789
  3. CHAN AT, GIOVANNUCCI EL. Primary Prevention of Colorectal Cancer Gastroenterology [online] 2010 Jun, 138(6):2029-2043.e10 [viewed 28 August 2014] Available from: doi:10.1053/j.gastro.2010.01.057
  4. WOLPIN BM, MAYER RJ. Systemic Treatment of Colorectal Cancer Gastroenterology [online] 2008 May, 134(5):1296-1310 [viewed 28 August 2014] Available from: doi:10.1053/j.gastro.2008.02.098
  5. YAGNIK VD. Massive Rectal Bleeding: Rare Presentation of Circumferential Solitary Rectal Ulcer Syndrome Saudi J Gastroenterol [online] 2011, 17(4):298 [viewed 12 September 2014] Available from: doi:10.4103/1319-3767.82592
  6. KHANBHAI M, SHAH M, CANTANHEDE G, ILYAS S, RICHARDS T. The Problem of Anaemia in Patients with Colorectal Cancer ISRN Hematol [online] :547914 [viewed 12 September 2014] Available from: doi:10.1155/2014/547914
  7. STEBBING JF, NASH AG. Avoidable delay in the management of carcinoma of the right colon. Ann R Coll Surg Engl [online] 1995 Jan, 77(1):21-23 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502499
  8. SANCHEZ C, CHINN BT. Hemorrhoids Clin Colon Rectal Surg [online] 2011 Mar, 24(1):5-13 [viewed 12 September 2014] Available from: doi:10.1055/s-0031-1272818
  9. CHAN AT, GIOVANNUCCI EL. Primary Prevention of Colorectal Cancer Gastroenterology [online] 2010 Jun, 138(6):2029-2043.e10 [viewed 12 September 2014] Available from: doi:10.1053/j.gastro.2010.01.057
  10. PERICLEOUS M, MANDAIR D, CAPLIN ME. Diet and supplements and their impact on colorectal cancer J Gastrointest Oncol [online] 2013 Dec, 4(4):409-423 [viewed 12 September 2014] Available from: doi:10.3978/j.issn.2078-6891.2013.003
  11. STRINGER MD, RANDALL T, RUTTER DP, PICTON SV, PUNTIS JW. Appropriate investigation of inflammatory bowel disease in children. J R Soc Med [online] 1998 Nov, 91(11):589-591 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1296954
  12. PRABHU V, SHIVANI A. An Overview of History, Pathogenesis and Treatment of Perforated Peptic Ulcer Disease with Evaluation of Prognostic Scoring in Adults Ann Med Health Sci Res [online] 2014, 4(1):22-29 [viewed 12 September 2014] Available from: doi:10.4103/2141-9248.126604
  13. HABOUBI NY, KAFTAN SM, SCHOFIELD PF. Radiation colitis is another mimic of chronic inflammatory bowel disease. J Clin Pathol [online] 1992 Mar, 45(3):272 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC495505

Examination

Fact Explanation
Pallor Anaemia is due to intermittent chronic blood loss [2], or malignancy induced inflammation. [4]
Low blood pressure [3] Sometimes bleeding may be massive; causing hypotension and shock. [3]
Tachycardia [3] Due to massive bleeding and shock. [3]
Lump at anus [6] May be there with haemorrhoids. [6]
Ejection systolic murmer at aortic area radiating to the neck [1] Some studies have shown that there is increased incidence of aortic stenosis among the patients with angiodysplasia and other vascular malformations. [1]
Digital rectal examination [3] DRE will reveal any polyps, groths, haemorrhoids and ulcers [3] in the anorectal region.
Abdominal mass Abdominal mass may be palpated in right sided colonic/caecal tumours. [5]
References
  1. BAUM S, ATHANASOULIS CA, WALTMAN AC, GALDABINI J, SCHAPIRO RH, WARSHAW AL, OTTINGER LW. Angiodysplasia of the right colon: a cause of gastrointestinal bleeding. AJR Am J Roentgenol [online] 1977 Nov, 129(5):789-94 [viewed 11 August 2014] Available from: doi:10.2214/ajr.129.5.789
  2. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  3. YAGNIK VD. Massive Rectal Bleeding: Rare Presentation of Circumferential Solitary Rectal Ulcer Syndrome Saudi J Gastroenterol [online] 2011, 17(4):298 [viewed 12 September 2014] Available from: doi:10.4103/1319-3767.82592
  4. KHANBHAI M, SHAH M, CANTANHEDE G, ILYAS S, RICHARDS T. The Problem of Anaemia in Patients with Colorectal Cancer ISRN Hematol [online] :547914 [viewed 12 September 2014] Available from: doi:10.1155/2014/547914
  5. STEBBING JF, NASH AG. Avoidable delay in the management of carcinoma of the right colon. Ann R Coll Surg Engl [online] 1995 Jan, 77(1):21-23 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502499
  6. SANCHEZ C, CHINN BT. Hemorrhoids Clin Colon Rectal Surg [online] 2011 Mar, 24(1):5-13 [viewed 12 September 2014] Available from: doi:10.1055/s-0031-1272818

Differential Diagnoses

Fact Explanation
Colonic polyps [11] Polyps are colonic mucosa overgrowths that carry < 1% risk of becoming malignant. Bleeding per rectum [11] which is persistent or intermittent is a common symptom in polyps. Inflammatory, juvenile, peutz-Jeghers, are the various types of polyps. Colonoscopy allow both diagnosis and the immediate therapeutic polypectomy. [4] Adenomatous and Peutz-Jeghers polyps need follow up with fibre optic colonoscopy for the recurrence and malignant changes. [5]
Haemorrhoids [13] This usually presents with painless rectal bleeding [13] with passage of mucous which is usually noticed during defecation. Person may notice a lump at anus which is manually or spontaneously reducible at the early stages and not reducible at later stages( stage 3) In advanced cases such as complicated with fibrosis, gangrene formation, necrosis and infections, it may cause pain. [13]
Colonic malignancies [7] Right-sided colonic bleeding [7] present with bright red blood in the case of massive bleeding is brisk. Otherwise it presents with dark altered blood or malena. Left-sided bleeding may be bright red. Intestinal obstruction can occur in colonic malignancies. Presentation would be abdominal pain, constipation, vomiting and abdominal distension. Loss of appetite and loss of weight and other features of dissemination of the malignancy may be present. [7] Right sided bleeding may be present with iron-deficiency anemia. [8]
Rectal malignancy Painless rectal bleeding may be associated with altered bowel habits [7] such as alternating constipation and diarrhoea, tenesmus [9] (pain during defecation) and sense of incomplete evacuation of the rectum. Loss of appetite and loss of weight [7] and other features of dissemination of the malignancy may be present.
Angiodysplasia [10] Angiodysplasia commonly affects the caecum and ascending colon less commonly located in the jejunum and/or ileum and the remainder are throughout the alimentary tract. [1] It is a significant cause of bleeding in the elderly people. [1] Degenerative pathology with aging is known to be associated. Lesions occur due to the intermittent partial chronic obstruction of the submucosal veins at the points where they penetrate the muscle layers of the colon. [2] Usually it will be altered blood with a maroon-colored stool.
Diverticular disease [3] Acute painless bleeding, with mild abdominal cramping due to the intraluminal blood and increased pressure [11] may be the presenting symptoms. Majority will have pain in the left lower quadrant, Fever may also present. May be recurrent. Sometimes bleeding may be massive causing hypotension and shock. Pneumaturia is a significant finding in colovesical fistula. [1] Perforated disease may have features of generalized peritonitis like tenderness, rebound tenderness, rigidity in the abdomen. Water-soluble contrast enema, CT scan, and ultrasound are the investigations done during the acute phase of diverticular disease. [11]
References
  1. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 11 August 2014] Available from: doi:10.4103/0256-4947.51786
  2. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  3. GALLAGHER HW. Diverticulitis and Rectal Bleeding Ulster Med J [online] 1954 Nov, 23(2):142 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC248019
  4. LATT TT, NICHOLL R, DOMIZIO P, WALKER-SMITH JA, WILLIAMS CB. Rectal bleeding and polyps. Arch Dis Child [online] 1993 Jul, 69(1):144-147 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1029431
  5. DEVLIN LA, PRICE JH, MORRISON PJ. Hereditary non-polyposis colon cancer. Ulster Med J [online] 2005 May, 74(1):14-21 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2475474
  6. RAWLS GH. Treatment of Colorectal Cancer J Natl Med Assoc [online] 1982 Aug, 74(8):809-812 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2552969
  7. STEBBING JF, NASH AG. Avoidable delay in the management of carcinoma of the right colon. Ann R Coll Surg Engl [online] 1995 Jan, 77(1):21-23 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502499
  8. KHANBHAI M, SHAH M, CANTANHEDE G, ILYAS S, RICHARDS T. The Problem of Anaemia in Patients with Colorectal Cancer ISRN Hematol [online] :547914 [viewed 12 September 2014] Available from: doi:10.1155/2014/547914
  9. STRINGER MD, RANDALL T, RUTTER DP, PICTON SV, PUNTIS JW. Appropriate investigation of inflammatory bowel disease in children. J R Soc Med [online] 1998 Nov, 91(11):589-591 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1296954
  10. BAUM S, ATHANASOULIS CA, WALTMAN AC, GALDABINI J, SCHAPIRO RH, WARSHAW AL, OTTINGER LW. Angiodysplasia of the right colon: a cause of gastrointestinal bleeding. AJR Am J Roentgenol [online] 1977 Nov, 129(5):789-94 [viewed 11 August 2014] Available from: doi:10.2214/ajr.129.5.789
  11. Diverticular disease of the colon. West J Med [online] 1981 Jun, 134(6):515-523 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1272839
  12. WAUGH JM, HARP RA, SPENCER RJ. The Surgical Management of Multiple Polyposis Ann Surg [online] 1964 Jan, 159(1):149-154 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1408485
  13. SANCHEZ C, CHINN BT. Hemorrhoids Clin Colon Rectal Surg [online] 2011 Mar, 24(1):5-13 [viewed 12 September 2014] Available from: doi:10.1055/s-0031-1272818

Investigations - for Diagnosis

Fact Explanation
Sigmoidoscopy This is the first line investigation in lower GI bleeding. [3] It usually examine upto splenic flexure of the colon. Intestinal growths, ulcers, polyps etc may be found on sigmoidoscopy. [3]
Colonoscopy This is an important diagnostic tools to evaluate acute lower gastrointestinal bleeding. Colonoscopy is more sensitive and accurate than sigmoidoscopy in diagnosis. These may be operator dependent. Active bleeding will limit the use of the investigation. It is also important as to exclude the other lesions in the colon before the hemicolectomy. [2]
Stool occult blood test Stool for occult blood is positive even in asymptomatic people. [2]
Angiography Clusters of small arteries during the arterial phase at the antimesenteric border, accumulation of vascular spaces and opacification of the bowel during the capillary phase, early opacification of the veins draining the caecum and ascending colon are the features for the diagnosis of angiodysplasia on angiography. [1]
Technetium-labeled red blood cell scintigraphy Is able to detect active gastrointestinal bleeding even at a low rate. [1]
References
  1. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  2. BAUM S, ATHANASOULIS CA, WALTMAN AC, GALDABINI J, SCHAPIRO RH, WARSHAW AL, OTTINGER LW. Angiodysplasia of the right colon: a cause of gastrointestinal bleeding. AJR Am J Roentgenol [online] 1977 Nov, 129(5):789-94 [viewed 11 August 2014] Available from: doi:10.2214/ajr.129.5.789
  3. STRINGER MD, RANDALL T, RUTTER DP, PICTON SV, PUNTIS JW. Appropriate investigation of inflammatory bowel disease in children. J R Soc Med [online] 1998 Nov, 91(11):589-591 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1296954

Investigations - Fitness for Management

Fact Explanation
Full blood count Chronic intermittent bleeding can cause iron deficiency anaemia, [1] which will manifest as low haemoglobin, reduced mean corpuscular volume [3] and mean corpuscular haemoglobin with microcytic anaemia and increased red cell distribution width. [1]
References
  1. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  2. KHANBHAI M, SHAH M, CANTANHEDE G, ILYAS S, RICHARDS T. The Problem of Anaemia in Patients with Colorectal Cancer ISRN Hematol [online] :547914 [viewed 12 September 2014] Available from: doi:10.1155/2014/547914
  3. KHANBHAI M, SHAH M, CANTANHEDE G, ILYAS S, RICHARDS T. The Problem of Anaemia in Patients with Colorectal Cancer ISRN Hematol [online] :547914 [viewed 12 September 2014] Available from: doi:10.1155/2014/547914

Investigations - Followup

Fact Explanation
Full blood count Chronic intermittent bleeding can cause iron deficiency anaemia, which will manifest as low haemoglobin. [1]
Colonoscopy Syndromes like heredetery non polyposis colorectal carcinoma (HNPCC) has a high risk of malignant transformation [5] and need regular follow up. It is recommended to screen every 2 yearly from the age of 25, and5 years younger than the earliest affected case in the family up to 75 years. [2]
References
  1. KHETERPAL S. Angiodysplasia: a review. J R Soc Med [online] 1991 Oct, 84(10):615-618 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295562
  2. DEVLIN LA, PRICE JH, MORRISON PJ. Hereditary non-polyposis colon cancer. Ulster Med J [online] 2005 May, 74(1):14-21 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2475474

Investigations - Screening/Staging

Fact Explanation
Echocardiogram Some patients have the underlying cardiac disorders that can cause low perfusion and ischaemia of the walls of intestines. [1]
CT scan, MRI scan To stage the disease in colorectal carcinoma. [2]
Carcinoembryonic antigen (CEA) [4] Plasma level of carcinoembryonic antigen (CEA) is measured preoperatively in a suspected case of colorectal malignancy. [3] It may also be elevated in other conditions like gastric carcinoma, pancreatic carcinoma, lung carcinoma, breast carcinoma, and medullary thyroid carcinoma, as well as some non-neoplastic conditions like ulcerative colitis, pancreatitis, cirrhosis, COPD, Crohn's disease. [3]
References
  1. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 11 August 2014] Available from: doi:10.4103/0256-4947.51786
  2. WOLPIN BM, MAYER RJ. Systemic Treatment of Colorectal Cancer Gastroenterology [online] 2008 May, 134(5):1296-1310 [viewed 28 August 2014] Available from: doi:10.1053/j.gastro.2008.02.098
  3. HOLYOKE D, REYNOSO G, CHU TM. Carcinoembryonic antigen (CEA) in patients with carcinoma of the digestive tract. Ann Surg [online] 1972 Oct, 176(4):559-564 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1355453
  4. NEVILLE AM, NERY R, HALL RR, TURBERVILLE C, LAURENCE DJ. Aspects of the structure and clinical role of the carcinoembryonic antigen (CEA) and related macromolecules with particular reference to urothelial carcinoma. Br J Cancer Suppl [online] 1973 Aug:198-207 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2149056

Management - General Measures

Fact Explanation
Resuscitation Patients can present with acute massive gastrointestinal haemorrhage needing resuscitation. [5] Special attention should be focused on circulation due to the massive blood loss. Volume resuscitation may be needed.
Management of anaemia [6] Anaemia can be due to chronic intermittent blood loss from gastrointestinal tract, malignancy induced inflammation and underlying comorbidities. [6] If significant anaemia present with clinical features they need to get treatment and if needed even blood transfusion.[6]
Pre op angiography Selective angiography is recommended for the preoperative localization of bleeding sites. [1]
Reducing the risk of colorectal carcinoma Clinical trials have shown that aspirin in doses as low as 325 mg per day reduces risk of colorectal carcinoma. [3] Reduction of fat in diet is also an important measure. Avoidance of smoking and heavy alcohol use, prevention of weight gain, and the maintenance of a reasonable level of physical activity are known to lower the risks of colorectal cancer. [4]
Management and prevention of constipation Constipation can be an aetiology for various diseases. [5] Therefore simple measures like maintaining adequate fluid intake, eating fresh vegetables, fruits and green leaves, adequate fibre intake and maintaining proper toilet habits are important. [4]
References
  1. BAUM S, ATHANASOULIS CA, WALTMAN AC, GALDABINI J, SCHAPIRO RH, WARSHAW AL, OTTINGER LW. Angiodysplasia of the right colon: a cause of gastrointestinal bleeding. AJR Am J Roentgenol [online] 1977 Nov, 129(5):789-94 [viewed 11 August 2014] Available from: doi:10.2214/ajr.129.5.789
  2. AL-MEHAIDIB A, ALNASSAR S, ALSHAMRANI AS. Gastrointestinal angiodysplasia in three Saudi children Ann Saudi Med [online] 2009, 29(3):223-226 [viewed 11 August 2014] Available from: doi:10.4103/0256-4947.51786
  3. GARCIA-ALBENIZ X, CHAN AT. Aspirin for the prevention of colorectal cancer Best Pract Res Clin Gastroenterol [online] 2011 Aug, 25(0):461-472 [viewed 28 August 2014] Available from: doi:10.1016/j.bpg.2011.10.015
  4. LLOYD M. Consensus on prevention and treatment of colorectal cancer: implications for general practice. Br J Gen Pract [online] 1990 Dec, 40(341):483-484 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371441
  5. YAGNIK VD. Massive Rectal Bleeding: Rare Presentation of Circumferential Solitary Rectal Ulcer Syndrome Saudi J Gastroenterol [online] 2011, 17(4):298 [viewed 12 September 2014] Available from: doi:10.4103/1319-3767.82592
  6. KHANBHAI M, SHAH M, CANTANHEDE G, ILYAS S, RICHARDS T. The Problem of Anaemia in Patients with Colorectal Cancer ISRN Hematol [online] :547914 [viewed 12 September 2014] Available from: doi:10.1155/2014/547914

Management - Specific Treatments

Fact Explanation
Management of colorectal carcinoma Surgery is the most important part in the treatment of rectal cancer. [4] Stage T1 and T2 local excision is possible. Local excision combine with pre- or postoperative radio-chemotherapy gives the good the outcome. Transanal endoscopic microsurgery (TEM), is a new technique that provides a locally curative operation. [6] High ligation of the interior mesenteric artery, will be beneficial. Minimum margin of mesorectum should be 5 cm. There are main 2 types of surgical options available: Abdominoperineal resection (APR) and anterior resection. [1] Anterior resection is a sphincter-sparing operation that gaining the popularity. Abdominoperineal resection (APR) does not preserve the sphincters. Intravenous Fluorouracil, oral fluoropyrimidines, angiogenesis Inhibitors, epidermal Growth Factor Receptor Inhibitors in isolation[3] or as combined treatment is used as systemic therapy for the colorectal cancers. [3]
Management of polyps [10] HNPCC is an autosomal dominant condition with a mutation in DNA mismatch repair genes. [2] This condition has a high chance of developing colorectal carcinomas. Prophylactic colectomy will be needed in high risk people. [10] Single staged subtotal colectomy with ileosigmoidostomy is the treatment for multiple polyps. [10]
Management of haemorrohids [5] Constipation or other causative factors needs to be corrected. [5] Sitz baths are used to reduce swelling and sphincter spasm. [5] Injection sclerotherapy, band ligation and surgical treatment are the other options available.
Management of angiodysplasia Conservative approach is suitable for the hemodynamically stable patients as bleeding can stop spontaneously in the majority of patients.[1] Surgery is the management option with highest cure rate. It is done when the endoscopic ablation is not suitable or if life-threatening hemorrhage occurs. Right hemicolectomy or if relevant total colectomy is done.
Management of diverticular disease [7] Endoscopic therapy, includes epinephrine injection, thermal application, or band ligation. [7]
Treatment of radiation proctits [8] Argon plasma coagulation [9] , formalin application, sucralfate enemas, and hyperbaric oxygen therapy is used to treat radiation proctits. However endoscopic therapies are now becoming the treatment of choice in chronic radiation proctitis. [8]
References
  1. PERRY WB, CONNAUGHTON JC. Abdominoperineal Resection: How Is It Done and What Are the Results? Clin Colon Rectal Surg [online] 2007 Aug, 20(3):213-220 [viewed 28 August 2014] Available from: doi:10.1055/s-2007-984865
  2. DEVLIN LA, PRICE JH, MORRISON PJ. Hereditary non-polyposis colon cancer. Ulster Med J [online] 2005 May, 74(1):14-21 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2475474
  3. WOLPIN BM, MAYER RJ. Systemic Treatment of Colorectal Cancer Gastroenterology [online] 2008 May, 134(5):1296-1310 [viewed 28 August 2014] Available from: doi:10.1053/j.gastro.2008.02.098
  4. BOLTON JS, VAUTHEY JN, SAUTER ER. Colorectal Cancer: Surgical Management of Recurrent and Metastatic Disease J Natl Med Assoc [online] 1988 May, 80(5):561-564 [viewed 28 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2625769
  5. SANCHEZ C, CHINN BT. Hemorrhoids Clin Colon Rectal Surg [online] 2011 Mar, 24(1):5-13 [viewed 12 September 2014] Available from: doi:10.1055/s-0031-1272818
  6. RAWLS GH. Treatment of Colorectal Cancer J Natl Med Assoc [online] 1982 Aug, 74(8):809-812 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2552969
  7. Diverticular disease of the colon. West J Med [online] 1981 Jun, 134(6):515-523 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1272839
  8. RUSTAGI T, MASHIMO H. Endoscopic management of chronic radiation proctitis World J Gastroenterol [online] 2011 Nov 7, 17(41):4554-4562 [viewed 12 September 2014] Available from: doi:10.3748/wjg.v17.i41.4554
  9. ZHOU C, ADLER DC, BECKER L, CHEN Y, TSAI TH, FIGUEIREDO M, SCHMITT JM, FUJIMOTO JG, MASHIMO H. Effective Treatment of Chronic Radiation Proctitis Using Radiofrequency Ablation Therap Adv Gastroenterol [online] 2009 May, 2(3):149-156 [viewed 12 September 2014] Available from: doi:10.1177/1756283X08103341
  10. WAUGH JM, HARP RA, SPENCER RJ. The Surgical Management of Multiple Polyposis Ann Surg [online] 1964 Jan, 159(1):149-154 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1408485