Diseases of the Large Intestine / Colon Cancer
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Acute appendicitis
Acute appendicitis is inflammation of the vermiform appendix, a rudimentary segment of the large intestine, which is tubular in shape, resembling a thumbstick, a few centimetres long, located in the right and lower abdomen. It is one of the most common causes of abdominal pain in both adults and children.
Causes
Appendicitis occurs as a result of obstruction of the appendix lumen (most commonly by faecal matter, intestinal parasites or undigested food debris), which will lead to increased mucus secretion and multiplication of bacteria at this level, resulting in increased tension in the appendix walls. Without prompt treatment, necrosis and even perforation of the appendix can occur, which can have negative consequences for the patient’s health.
Signs and symptoms – acute appendicitis
Acute appendicitis may give you the following symptoms:
If complications occur, the pain worsens and spreads throughout the abdomen and fever increases (in case of perforation and/or peritonitis).
Diagnosis – acute appendicitis
The diagnosis of acute appendicitis is most often established on the basis of the above symptoms and the patient’s clinical/physical examination (pain on palpation in the right iliac fossa, signs of peritoneal irritation). Paraclinical investigations (laboratory tests, imaging methods) may be necessary in some cases to differentiate acute appendicitis from other conditions with similar symptoms.
– Abdominal ultrasound – a non-invasive and atraumatic ultrasound-based imaging method that may reveal collections around the cecum, or fluid in the abdominal cavity (in case of peritonitis) and may reveal an inflammatory pseudotumor in the right iliac fossa (appendiceal plastron); depending on the quality of the ultrasound scanner/experience of the examiner, the inflamed appendix may be revealed
– Thoraco-abdominal computed tomography (CT) – takes a series of detailed images of certain regions of the body, these images are taken from different planes; for better highlighting of the region explored, contrast material is used. May show the presence of inflamed appendix, pericecal or other pathological collections in the abdominal cavity, or other intra-abdominal pathology
– Blood tests – CBC (leukocytosis with neutrophilia), increased C-reactive protein
Treatment – acute appendicitis
In most cases the treatment of acute appendicitis consists of surgical removal of the inflamed appendix, an operation called appendectomy. Appendectomy can be performed laparoscopically (most commonly, in over 90% of cases, when the inflamed appendix is removed through small incisions of a few mm) or by the classic, open approach, which involves making a 4-6 cm oblique incision in the abdominal area corresponding to the location of the appendix (recommended if appendicitis is accompanied by complications – perforation of the appendix with spread of infection in the abdomen, peritonitis, or formation of an appendiceal abscess – a purulent collection around the appendix).
Colonic diverticulitis
Diverticula are saccular structures that form at the folds of the colon’s lining. The presence of more than one diverticulum is called diverticulosis, and if the diverticula become inflamed, a disease called diverticulitis occurs.
These diverticuli often occur due to a low-fiber diet, which will cause low-quantity and hard stool, requiring increased pressure to push it out, forcing and causing the diverticular pouches to protrude through the colon wall.
Signs and symptoms – colonic diverticulitis
Symptomatology may differ, depending on the stage of the disease: acute uncomplicated/complicated diverticulitis (perforation, local abscess, haemorrhage), chronic symptomatic diverticulitis (stenosis, fistula). You may experience the following symptoms:
Making the diagnosis – colonic diverticulitis
The diagnosis of acute appendicitis is most often established on the basis of the above symptoms and the patient’s clinical/physical examination (pain on palpation in the right iliac fossa, signs of peritoneal irritation). Paraclinical investigations (laboratory tests, imaging methods) may be necessary in some cases to differentiate acute appendicitis from other conditions with similar symptoms.
– Physical/objective examination – bloating (abdominal distention), pain on palpation in the left and lower abdomen (left iliac fossa), palpation of a pseudotumoural formation (inflammatory block/abscess); in case of acute diverticulitis presence of signs of generalized peritoneal irritation
– Rectal Cough – a routine examination in which the doctor digitally examines the anal region and rectum and may identify an area of thrusting in the pelvis with pain there
The choice of diagnostic imaging investigations is made according to the severity of diverticular disease, based on clinical criteria.
– Abdominal ultrasound – a non-invasive, atraumatic ultrasound-based imaging method that can reveal thickening of the bowel wall and/or collections in the abdominal cavity
– Thoraco-abdominal computed tomography (CT) – takes a series of detailed images of certain regions of the body, these images are taken from different planes; for better highlighting of the region explored, contrast material is used. Can highlight diverticula, specifying their location and size, the presence of stenosis, fistulas, perforations (extravasation of contrast material outside the digestive lumen), active haemorrhages, intra-abdominal collections (abscesses, peritonitis)
– Abdominal plain abdominal X-ray – radiological examination that may reveal pneumoperitoneum (in case of a digestive perforation)
– Fistulography (Rx or MRI) – imaging examination that allows visualization of a fistula
– Blood tests – take a series of detailed images of certain regions of the body, these images are taken from different planes; contrast material is used to better highlight the region being explored. Can highlight diverticula, specifying their location and size, the presence of stenosis, fistulas, perforations (extravasation of contrast material outside the digestive lumen), active haemorrhages, intra-abdominal collections (abscesses, peritonitis)
Treatment – colonic diverticulitis
Most of the time, diverticulitis, if it is a mild form, can be treated with antibiotics and a liquid diet. In severe forms, surgical treatment may be required for complicated acute diverticulitis.
In case of diverticular perforation with abscess formation depending on the size of the abscess, drainage of the collection (ultrasound/CT guided or surgical) is indicated. In the case of abscesses > 4 cm of first intention percutaneous drainage is indicated. In case of failure of the percutaneous approach, surgical evacuation of the abscess (by laparotomy or laparoscopy) is indicated. In patients with purulent or faecal peritonitis, emergency surgery is required, consisting of extensive lavage of the peritoneal cavity and Hartmann’s operation (removal of the affected colon, with or without restoration of digestive continuity by suturing the ends of the colon or rectum either manually or mechanically). When it is not possible to restore digestive continuity, a stoma is performed, which involves making an incision in the abdominal wall with suturing of the end of the free bowel at this level, the faeces being removed to the outside and collected in a special plastic container. The stoma is temporary (until the bowel heals), the digestive continuity is restored later, in another operating time.
When the patient presents with acute occlusive abdomen (inflammatory stenosis), resection of the affected digestive segment is required and depending on the quality of tissues proximal and distal to the resection site, per primam anastomosis or Hartmann operation is chosen, followed by reoperation in transit at 3 months.
In diverticular bleeding, limited resection of the affected segment (if the source of bleeding has been diagnosed preoperatively by endoscopy or angio-CT) is indicated.
Appendix tumours (benign and malignant)
Benign tumours are non-cancerous tumours, they remain in one place and do not spread to other parts of the body. Also after they are removed they do not reappear. Even if they are not cancerous, they can cause symptoms by putting pressure on surrounding structures. Pre-cancerous (pre-malignant) tumours are benign tumours containing abnormal cells that have the potential to turn into cancer if left untreated.
In contrast, malignant tumors are cancerous tumors that develop in nearby tissues, contain cells that can break off and end up in the blood or lymphatic system, spreading to lymph nodes and other distant regions of the body.
Signs and symptoms – appendix tumors
Benign tumours of the caecal appendix are often asymptomatic, being diagnosed incidentally when examinations are performed for other diseases/symptoms or incidentally in case of surgery for another diagnosis. Malignant tumours of the appendix include carcinoid tumours, adenocarcinomas and appendiceal mucoceles:
If symptoms are present, they are non-specific in both benign and malignant tumours:
Diagnosis – appendiceal tumours
– Physical/objective examination – palpable tumour in right iliac fossa, painful tenderness/discomfort on palpation in right iliac fossa, signs of acute appendicitis
If you have the above symptoms, the following tests and procedures should be carried out to establish the diagnosis:
– Abdominal ultrasound – a non-invasive, atraumatic ultrasound-based imaging method that can reveal a tumour formation in the right iliac fossa
– Computed tomography (CT) – produces a series of detailed images of certain regions of the body, these images are taken from different planes; contrast is used to better highlight the region being explored; highlights the presence of tumor formation in the right iliac fossa, indicated when abdominal ultrasound is inconclusive
– Lower digestive endoscopy/colonoscopy – involves insertion of a tube with a camera at the end, the tube is inserted through the anus, ascends into the colon to the last part of the small intestine
– Biopsy – a manoeuvre performed during upper endoscopy, in which the doctor removes a piece of tissue from the suspicious-looking area of the colon/rectum, which is then examined under a microscope.
– Diagnostic laparoscopy – a minimally invasive method of exploration – through a surgical incision (cut) in the abdominal wall, a tube (laparoscope) is inserted into the abdomen, allowing direct visualization of the intra-abdominal organs and is performed when, in the case of a painful right iliac fossa syndrome, the investigations listed above do not resolve the diagnosis
– Blood tests – haemolucogram (leukocytosis in case of inflammation of the appendix)
Treatment – appendix tumors
Surgical treatment:
Appendectomy (if the tumour is in the appendix and oncological limits are ensured).
Removal of the entire right colon (in case of tumours with extension to the cecum or where oncological safety margins cannot be ensured by appendectomy), with restoration of digestive continuity by suturing the transverse colon with the small intestine. When it is not possible to restore digestive continuity, for various reasons (poor biological condition of the patient, advanced cancer) a stoma is performed, which involves making an incision in the abdominal wall with suturing of the end of the free bowel at this level, the faecal material being removed outside and collected in a special plastic container. The stoma may be temporary (until the bowel heals), with restoration of digestive continuity at a later operative time, or it may be permanent when the entire colon or rectum is resected or the patient’s condition does not allow reintegration into transit.
Colorectal cancer
Colorectal cancer is cancer that affects the large intestine (colon) or rectum, with similar symptoms.
There are several factors that increase a person’s risk of developing colon cancer, such as:
Signs and symptoms – colon cancer
Colorectal cancer can give you the following signs and symptoms:
Diagnosis – colon cancer
If you have the above symptoms, you will need to undergo the following tests and procedures to establish a diagnosis of colon cancer:
– Rectal Cough – is a routine examination in which the doctor digitally examines the anal region and rectum and can easily identify: active bleeding occurring there, rectal pain at the time of coughing or a tumour formation
– Blood tests – haemolucogram – red blood cell count, white blood cell count, platelet count, haemoglobin-oxygen carrying protein and blood biochemistry
– Occult bleeding test – which identifies microscopic bleeding of intestinal cause, the test is performed by examining the stool
– Lower digestive endoscopy/colonoscopy – involves insertion of a tube with a camera at the end, the tube is inserted through the anus, ascends into the colon to the last part of the small intestine
– Biopsy – a manoeuvre performed during lower endoscopy, in which the doctor removes a piece of tissue from a suspicious-looking area of the colon/rectum, which is then examined under a microscope.
– Computed tomography (CT) – takes a series of detailed images of certain regions of the body, these images are taken from different planes; for a better highlighting of the explored region the contrast substance is used
To determine the extent of colorectal cancer/stage of the disease, it is necessary to perform additional investigations such as:
– Assay of serological tumour markers – CAE (carcinoembryonic antigen)
– Abdominal ultrasound – a non-invasive, atraumatic ultrasound-based imaging method that involves visualization of intra-abdominal organs, indicated when secondary liver determinations are suspected
– Radiography of the chest, chest organs and bones
– Computed Tomography (CT)
– Magnetic resonance imaging (MRI) – an imaging method that uses a magnetic field and radiofrequency pulses to visualize images of various organs and tissues of the human body; contrast agents may also be used for better visualization
The staging of colorectal cancer helps to determine the therapeutic course of treatment.
Colorectal cancer studies – colon cancer
Stage I
Colon cancer is localized in the deep, inner layer (lining) of the colon/rectum, but does not extend beyond the colon/rectum wall.
Stage II
The cancer has invaded the wall of the colon/rectum without invading nearby lymph nodes.
Stage III
The cancer has invaded nearby lymph nodes but not other areas of the body.
Stage IV
The cancer has spread to distant, non-cancerous organs – for example the liver or lungs.
Treatment – colon cancer
Depending on the stage of your cancer and your clinical condition, there are several treatment options, such as endoscopic, surgical and/or oncological treatment.
Appendectomy (if the tumour is in the appendix and oncological limits are ensured).
If the cancer is located in a small polyp, but not beyond it, at an early stage, it may be resected during colonoscopy; in the case of large polyps, it may also be necessary to resect part of the lining of the colon/rectum, called a mucosal endoscopic resection.
Also called partial colectomy – this procedure involves the removal of a part of the colon containing the tumour formation and a portion of healthy tissue on either side of the cancer + resection of the affected lymph nodes (lymphadenectomy). Depending on the stage of the cancer and the conditions in which the operation was performed (emergency or scheduled), the surgeon will restore or not the digestive continuity by suturing the ends of the colon or rectum either by manual or mechanical suturing. When it is not possible to restore digestive continuity, for various reasons (poor biological condition of the patient, advanced cancer) a stoma is performed, which involves making an incision in the abdominal wall with suturing of the end of the free bowel at this level, the faecal material being removed outside and collected in a special plastic container. The stoma may be temporary (until the bowel heals), with restoration of digestive continuity at a later operative time, or it may be permanent when the entire colon or rectum is resected or the patient’s condition does not allow reintegration into transit.
Anti-tumour treatment, which uses certain drugs to destroy cancer cells; it can be administered before surgical treatment (neoadjuvant chemotherapy) with the aim of reducing the size of the tumour formation so that it can subsequently be surgically removed, or it can be administered after surgical treatment (adjuvant chemotherapy) with the aim of destroying cancer cells that may have already spread in the body; chemotherapy can also be used as the sole treatment of colorectal cancer in advanced stages to relieve symptoms.
Anti-tumour treatment, which uses high-intensity X-rays or other types of radiation that are capable of destroying malignant cells; it can be, as with chemotherapy, of two types: neoadjuvant or adjuvant.
It involves combining chemotherapy with radiotherapy to increase their effectiveness.
It uses substances produced by the body or synthesised in the laboratory to strengthen the immune system in its fight against cancer.
Inflammatory diseases: Crohn’s disease of the large intestine
Crohn’s disease is a chronic inflammatory disease that presents as ulcerative lesions located in the wall of the digestive tract, which can lead to complications such as fistulas or stenosis (narrowing of the intestinal lumen). It can theoretically affect any segment from the oesophagus to the anus, but with localisation mainly in the last portion of the small intestine (terminal ileitis) and the colon.
Signs and symptoms – Chron’s disease of the large intestine
If you have Crohn’s disease you may experience the following symptoms:
Making the diagnosis – Chron’s disease of the large intestine
The following investigations are required to establish the diagnosis of Crohn’s disease in the colon:
– Lower digestive endoscopy/colonoscopy – involves the insertion of a tube with a camera at the end, the tube is inserted through the anus, it ascends into the colon up to the last part of the small intestine; it is the investigation of choice, which allows direct visualization of the mucosa (with typical appearance of paving stones, inflamed areas, alternating with healthy areas)
– Biopsy – a manoeuvre performed during lower endoscopy, in which the doctor removes a piece of tissue from a suspicious-looking area of the colon/rectum, which is then examined under a microscope.
– Computed tomography (CT) – an imaging method that produces a series of detailed images of certain regions of the body, these images are taken from different planes; contrast is used to better highlight the region being explored; it can show the extent of inflammatory disease in the digestive tract (thickening of the colonic wall), which may be used in the differential diagnosis with ulcerative ulcerative colitis; it can also show the presence of intra-abdominal abscesses
– Coproparasitological examination – examination of faecal material to exclude the origin of other infectious or parasitic causes
– Blood tests – immunology (specific antibodies): pANCA (perinuclear cytoplasmic antineutrophil antibodies), SSCAs (anti Saccharomyces cerevisiae antibodies); haemolucogram (leukocytosis)
Treatment – Chron’s disease of the large intestine
Treatment in Crohn’s disease aims to control inflammation, control nutritional deficiencies and relieve symptoms.
Steroids (anti-inflammatory drugs most often used in the treatment of moderate or severe acute pustules), azathioprine, anti-TNF therapy.
– Failure of properly managed drug treatment.
– Progression of the disease despite treatment (high doses of corticosteroids, monoclonal antibodies) without therapeutic response for 3-6 months.
– Bowel obstruction caused by strictures/stenosis in the colon.
– Failure of properly managed drug treatment.
– Acute intestinal perforation with generalized or chronic peritonitis with the formation of fistulae (entero-colic, entero-colico-vesical), abscesses or phlegmo; in case of intra-abdominal abscesses, antibiotic treatment and percutaneous image-guided drainage of the purulent collection is indicated; in case of failure of minimally invasive treatment, surgical drainage is indicated. In the case of an ileocolic fistula (between the small bowel and colon, most commonly between the sigmoid bowel and colon / small bowel and bladder) fistula dissection and ileocolic resection and suturing of the remaining fistulous orifice is performed.
– Lower gastrointestinal bleeding – with hemodynamic instability (failure of conservative and endoscopic treatment); depending on the identification of the source of the bleeding, segmental colonic resection or total colectomy is chosen if the source cannot be identified.
– Fulminant colitis/ toxic megacolon – in patients who do not respond to intensive care treatment (worsening under treatment, hypotension) or in case of specific complications such as impending perforation; total resection of the colon (total colectomy) with formation of a terminal stoma (terminal ileostomy) is indicated.
Ulcerative haemorrhagic colitis (HUSCR)
HUS is an inflammatory disease that affects the lining of the colon (large intestine) and rectum which becomes inflamed and ulcerates. Most commonly, the inflammation is localized to the rectum, but it can progress to affect the colon and in some cases the entire colon.
Signs and symptoms – ulcerative colitis
Making the diagnosis – ulcerative colitis
The following investigations are required to establish the diagnosis of HUSR:
– Lower digestive endoscopy/colonoscopy – involves insertion of a tube with a camera at the end, the tube is inserted through the anus, ascends into the colon to the last part of the small intestine; establishes the diagnosis, assesses the extent of the disease, and is useful in differential diagnosis with other benign and malignant pathologies
– Biopsy – a manoeuvre performed during lower endoscopy, in which the doctor removes a piece of tissue from the suspicious-looking area of the colon/rectum, which is then examined under a microscope.
– Computed tomography (CT) – imaging method that produces a series of detailed images of certain regions of the body, these images are taken from different planes; for a better highlighting of the explored region, a contrast substance is used; when toxic megacolon or complications (perforations, peritonitis) are suspected
– Abdominal ultrasound – a non-invasive, atraumatic ultrasound-based imaging method that can show dilatation of the digestive lumen and thickening of the colonic wall, intra-abdominal collections
– Stool coproparasitological examination – stool analysis – differential diagnosis with other enterocolitis
– Laboratory tests – immunology – (specific antibodies): pANCA (perinuclear cytoplasmic antineutrophil antibodies)
Treatment – ulcerative haemorrhagic colitis
In the vast majority of patients, the disease can be controlled by drug treatment: steroids (anti-inflammatory drugs most often used in the treatment of moderate or severe acute flares), azathioprine, anti-TNF therapy.
– Symptoms/disease that do not respond to correctly managed conservative treatment/medication
– Fulminant colitis/toxic megacolon
– Perforation
– Hemorrhage
– Extracolonic complications (primary sclerosing cholangitis, edema nodosa, arthritis, ophthalmologic pathology) that do not remit under conservative treatment and affect quality of life
– Suspected malignancy
There are several types of surgery that may be indicated for these patients:
– Restorative proctocolectomy with ileal reservoir and ileoanal anastomosis – which involves complete excision of the rectum and colon, after which a reservoir is constructed from the last portion of the small intestine and this reservoir that will replace the rectum is connected to the anal canal
– When patients present with a cancerous transformation of ulcerative ulcerative ulcerative colitis in the lower rectum or when the muscles that control fecal retention (anal sphincter) are affected, total proctocolectomy with a definitive terminal ileostomy is indicated
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