Diseases of the Large Intestine / Colon Cancer

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:

  • Abdominal pain that starts as discomfort around the navel (epigastrium), then descends to the right abdominal area, right iliac fossa (may also be located in other areas of the abdomen depending on the position of the appendix)
  • Lack of appetite (anorexia), nausea, vomiting
  • Transit disorders (constipation or, more rarely, diarrhoea)
  • Moderate fever (between 37.5 °C and 38.5 °C); may also be absent

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 – non-invasive and atraumatic ultrasound-based imaging method, which may reveal collections around the cecum, or fluid in the abdominal cavity (in case of peritonitis) and may reveal an inflammatory pseudotumour in the right iliac fossa (appendiceal plastron); depending on the quality of the ultrasound machine/examiner’s experience, 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).

STOMACH DISEASE TREATMENT DIAGNOSIS – COLON CANCER

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 diverticula often occur due to a low-fibre diet, which will cause low-quantity, hard stools that require increased pressure to push through, forcing and causing 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:

  • Violent abdominal pain with altered general condition
  • Fever
  • Transit disorders
  • Feeling sick, vomiting

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) scan – 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, contrast substance 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 X-ray on the nude – radiological examination that may reveal pneumoperitoneum (in case of 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 the case of diverticular haemorrhages, limited resection of the affected segment will be indicated (if the source of bleeding has been diagnosed preoperatively by endoscopy or angio-CT).

STOMACH DISEASE TREATMENT DIAGNOSIS – COLON CANCER

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 tumours are cancerous tumours that develop in nearby tissues, contain cells that can rupture and reach the blood or lymphatic system, thus 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:

  • Transit disorders
  • Painful tenderness/discomfort in the right and lower abdomen (right iliac fossa)
  • Clinical signs of acute appendicitis if the tumour obstructs the lumen of the appendix
  • Occlusive/subocclusive syndrome – cessation of intestinal transit for faeces/gas – in locally advanced malignant tumours with caecal or small bowel invasion
  • Flushing (reddening of the face), wheezing, diarrhoea – in carcinoid tumours
  • Clinical signs of acute appendicitis if the tumour obstructs the lumen of the appendix

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) – makes 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; highlights the presence of the tumour 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 – minimally invasive exploration method – a surgical incision (cut) in the abdominal wall is made through a tube (laparoscope) into the abdomen, which allows 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:

  • Appendix removal

Appendectomy (if the tumour is in the appendix and oncological limits are ensured).

  • Right hemicolectomy

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.

STOMACH DISEASE TREATMENT DIAGNOSIS

Colorectal cancer (colon 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:

  • Small growths or polyps (pedunculated growths attached to the lining of the colon or rectum), which may undergo cancerous changes (malignant transformation) over time, giving rise to colorectal cancer (colon cancer)

  • Genetic/hereditary syndromes (Lynch syndrome – hereditary non-polyposis colorectal cancer (colon cancer), familial adenomatous polyposis – hereditary diseases in which the large intestine is covered by polyps)

  • Family medical history (hereditary history) people who have a first-degree relative with colorectal neoplasm have an increased risk of also developing the disease
  • Personal history/history of colorectal cancer or polyps
  • Age > 50 years
  • Inflammatory bowel disease (Crohn’s disease or ulcerative haemorrhagic colitis) with a long course (more than 10 years)
  • Radiotherapy of the abdomen and pelvis
  • Diet (high-fat, low-fibre diet)
  • Diabetes mellitus
  • Smoking and alcohol
  • Obesity
  • Sedentary lifestyle

Signs and symptoms – colon cancer

Colorectal cancer can give you the following signs and symptoms:

  • Changes in bowel movements, diarrhea/constipation, or changes in stool consistency lasting more than 4 weeks
  • Rectal bleeding/blood in stool, dark stools (melena)
  • Persistent abdominal discomfort in the form of cramping, bloating or pain
  • Feeling of incomplete defecation
  • Severe fatigue (tiredness)
  • Weight loss with no apparent cause

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)

Nuclear 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 material 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 located in the deep, inner layer (lining) of the colon/rectum, but does not extend beyond the wall of the colon/rectum.

Stage II
The cancer has invaded the wall of the colon/rectum without invading nearby lymph nodes.

Stage III
The cancer invaded nearby lymph nodes, but did not invade other areas of the body.

Stage IV
The cancer has spread to distant organs, such as 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.

  • Appendix removal

Appendectomy (if the tumour is in the appendix and oncological limits are ensured).

  • Endoscopic treatment

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.

  • Surgical treatment

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.

  • Chemotherapy

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.

  • Radiotherapy

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.

  • Radiochemotherapy

It involves combining chemotherapy with radiotherapy to increase their effectiveness.

  • Biological therapy/immunotherapy

It uses substances produced by the body or synthesised in the laboratory to strengthen the immune system in its fight against cancer.

STOMACH DISEASE TREATMENT DIAGNOSIS – COLON CANCER PICTURES

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:

  • Crampy abdominal pain
  • Diarrhoea chairs
  • Blood in stool/dark/black stool (melena), in case of chronic GI bleeding; hematochezia – loss of blood through the rectum
  • Weight loss
  • Asthenia/ fatigue, altered general condition
  • Febrile syndrome
  • Perianal pain with pathological discharge from the perianal area (in case of Crohn’s disease with perianal localization)
  • Severe lower gastrointestinal bleeding in advanced stages of disease
  • Acute surgical abdomen through colonic perforation
  • Intestinal obstruction by colonic strictures
  • fulminant colitis manifested by multiple, explosive, hemorrhagic stools, fever >38.5, systemic toxicity, dehydration, electrolyte imbalances, greatly altered general condition with hemodynamic instability
  • Fecaluria – excretion of faecal matter through urine, in case of perianal manifestation of the disease, with recto-vaginal fistula

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, ascends into the colon up to the level of the last part of the small intestine; it is the investigation of choice, which allows direct evidence of the mucosa (with the typical appearance of cobblestones, inflamed areas alternating with healthy areas)

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) – an imaging method that produces a series of detailed images of certain regions of the body, these images are taken from different planes; for better highlighting of the explored region, contrast material is used; it can highlight the extension of inflammatory disease in the digestive tract (thickening of the colonic wall), with a role in the differential diagnosis with ulcerative haemorrhagic colitis; it can also highlight 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.

  • Conservative treatment/ medication

Steroids (anti-inflammatory drugs most often used in the treatment of moderate or severe acute pustules), azathioprine, anti-TNF therapy.

  • Surgical treatment indicated in the following situations:

– 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.
– Intestinal obstruction caused by strictures/stenosis in the colon.
– Failure of properly managed drug treatment.
– Acute intestinal perforation with generalized or chronic peritonitis with formation of fistulae (entero-colic, entero-colic, entero-colic), abscesses or phlegmons; 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 GI bleeding – with haemodynamic instability (failure of conservative and endoscopic treatment); depending on the identification of the source of 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 therapy treatment (worsening under treatment, hypotension) or in case of occurrence of specific complications such as imminent perforation; total resection of the colon (total colectomy) with formation of a terminal stoma (terminal ileostomy) is indicated.

STOMACH DISEASE TREATMENT DIAGNOSIS

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

  • Multiple diarrhoeal stools with mucus, pus and blood accompanied by the feeling of incomplete stool and the need to go to the toilet urgently, but without having a stool
  • Abdominal pain, with spontaneous tenderness or tenderness on palpation
  • Asthenia, adynamia
  • Atypical symptoms such as red eyes, joint pain, skin lesions, irritability or depression

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

  • Conservative treatment/medication

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.

  • Surgical treatment – required in the following situations

– Symptoms/disease that do not respond to correctly managed conservative treatment/medication
– fulminant colitis/toxic megacolon
– Perforation
– Haemorrhage
– Extracolonic complications (primary sclerosing cholangitis, nodal oedema, arthritis, ophthalmologic pathology) that do not remit under conservative treatment and influence quality of life
– Suspicion of 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 which will replace the rectum is connected to the anal canal
– When patients present a cancerous transformation of ulcerative haemorrhagic rectocolitis in the lower rectum or when the muscles that control faecal retention (anal sphincter) are affected, total proctocolectomy with a definitive terminal ileostomy is indicated

STOMACH DISEASE TREATMENT DIAGNOSIS
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Diagnostic and Treatment Location

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