Escolar Documentos
Profissional Documentos
Cultura Documentos
low amplitude
-short duration contraction -burst,move content ante/retrograde -delay colonic transit :absorp water,elyte
Hi amplitude
-mass movement Defecation -colonic mass movement -inc intraabdo/rectal p. -relax pelvic floor -rectum distend--reflex relax sphincter :rectoanal inhibitory reflex :no reflexHirschprung disease -sampling reflex :distinguish solid stool from liquid/gas -no defecateaccommadation reflex Continence -puborectalis--sling around distal R. -rectal wall compliance -ext/int sphincter -n=br of int pudendal n
Constipation Rome III criteria >=2/6, 3 mo Onset at least 6 mo No IBS criteria -straining -lumpy/hard stool -incomplete evacuation -anorectal obstruct sensation -manual evacuation -defecate <3/week Approach 1.BE/colonoscope -r/o mechanical obstruction 2.slow transit vs outlet obstruction
Ix Colonic fxn 1.colonic transit time -20 markers -dx if d5 > 5 marker 2.colonic manometry 3.colonic scintigraphy Anorectal fxn 1.anorectal manometry (gold std) -no RAIRHirschprung disease 2.balloon expulsion test -should < 5min 3.defecogram -rectocele/enterocele -intussusception -megarectum -rectal prolapsed 4.pudendal n terminal motor latency
-nodule/mass in similar location -mucosal gland in submucosa Ix -bx r/o malignancy -colonoscopy /BE -defecogram r/o rectal intussusception Tx Nonsx -hi-fiber diet -defecation to avoid straining -laxative/enema Sx -as prolapsed -in symptomatic pt,fail med Typhlitis -neutropenic enterocolitis -life-threatening -abdo.pain/distend,fever, diarrhea()bloody),n/v -neutropenia -difficult dx due to lack inflam rxn -CT :dilate cecum c pericolic stranding :normal not r/o ds -perianal pain Rx -bowel rest -ATB -parenteral nutrition -granulocyte infusion -perforate >> sx
-most perform proximal ileostomy to divert succus from create pouch to minimize leak and sepsis -ileostomy closed 6-12 wk later Procedure in colorectal obstruction 1.colonic obstruction Rt side/ prox transverse colon 1.low risk pt1ileocolic anastomosis 2.hi risk ptresection+ostomy Lt side colon 1.resection without anastomosis -proximal colostomy+Hartmann 2.resection+on table lavage+1anasto 3.subtotal colectomy+1anasto -caecal perforate -synchronous lesion -massive distend colon 4.3 stage -colostomyresectionanastomosis 5.colonic stent -C/Iperforate/<4cm from AV/rt side 2.Rectal obstruction Upper+middle rectum -stent or transverse colostomyCCRT/LAR Lower rectum -sigmoid colostomyCCRTSx
(Brooke technique)
1.Ileostomy Temporary ileostomy -protect anastomosis for leakage -loop ileostomy -with or without rod -divided loop prevent incomplete diversion that occur c loop ileostomy -advantage=closure can be accomplished without laparotomy,handsewn or stapled anastomosis can be created and return bowel to peritoneal cavity Permanent ileostomy -require after total proctocolectomy or in pt c obstruction -end ileostomy :Brooke end ileostomy :Continent ileostomy (by Kock) internal ileal reservoir nipple valve construct :continence m.
Ca rectum.Tx -more difficult to resect neg margin -because anatomic limit of pelvis -local recurrence higher than colon Local tx distal 10 cm of rectum can transanal Transanal excision -noncircum,benign,villous adenoma -can T1,some T2 -can't LN--may understage pt Transanal Endoscopic microsx(TEM) -higher lesion(up to 15cm) Ablative technique -electrocautery,radiation -disvantage=no patho specimen Radical resection -remove involve segment, lymphovascular supply -2cm distal margin Total mesorectal excision(TME) -sharp dissection anatomic plane -complete resection rectal mesentery -upper rectum/rectosigmoid :partial mesorectal excision :5cm distal tumor=adequate -extensive involvement of pelvic organ may require pelvic exenteration :APR :en bolc resection (ureter,BD,prostate or uterus/vg) :colostomy,ileal conduit :sacrectomy upto S2-3 jxn
stage0 (Tis N0 M0) -Transanal excision -1 cm margin stage1 (T1-2 N0 M0) -localized rectal ca -local excision:local recur hi(20-40%) -radical resection:recommend -in refuse radical sx :local excision :adjuvant chemoradiation :improve local recurrence stage2 (T3-4 N0 M0) -localized rectal ca 1.preop staging 2.CCRT 4-6 wk 3.Sx distal margin 2 cm TME margin 2mm ANP sphincter preserve if >= pelvic floor 1 cm 4.post op CRRT stage 2a, LN +ve stage3 (anyT N1 M0) -node metas -chemoradiation pre or post op for node+ve rectal ca -neoadjuvant>>sx stage4 (M1) -palliative procedure -avoid morbid procedure -intraluminal stent -diverting colostomy