Colorectal Disorders and Diseases: An Infographic Guide

By Constantine P. Spanos

Colorectal Disorders and Diseases: An Infographic Guide provides a comprehensive and up-to-date overview of the most relevant diagnostic modalities, staging, classification systems and current therapeutic modalities for colorectal disorders and diseases. With coverage from incontinence, prolapse, anal fissures, and cancer, this reference offers a wide-ranging guide to colorectal disorders and diseases. The use of engaging infographics throughout provides an inviting “at-a-glace perspective of the subject, allowing users to retain a large amount of information without the need to scroll through large text or complex algorithms.

This is an important reference for clinicians, surgeons and medical students rotating in colorectal surgery as well as scientists that need a quick reference for research of colorectal issues including epidemiology, diagnosis and therapy.

• Provides in-depth coverage of mechanisms, helping users quickly recognize the indications that are connected to specific medical conditions
• Spans the epidemiology, diagnostic modalities, staging, classification systems, and therapy of colorectal diseases and disorders
• Presents Infographics with engaging visuals which allows users to retain a large amount of information without the need to scroll through large text or complex algorithms

• Language: English
• Publisher: Academic Press
• Release date: May 19, 2023
• ISBN: 9780443156496

Constantine P. Spanos

Constantine P. Spanos completed medical school in 1992, matriculating from the Aristotelian University School of Medicine. After an internship year at the Mayo Clinic in Rochester, Minnesota, he trained in General Surgery at Tufts Medical Center in Boston, Massachusetts. He then pursued fellowship training in Colon & Rectal Surgery at the University of Southern California in Los Angeles. Upon completion of his training, he returned to Greece where he is currently Associate Professor of Surgery at the Aristotelian University in Thessaloniki, Greece. He obtained his Master of Business Administration Degree (MBA) at the American College of Thessaloniki in 2018. He is currently certified (and recertified) by the American Board of Surgery and the American Board of Colon & Rectal Surgery and is an Associate Professor of Surgery at the Aristotelian University in Thessaloniki, Greece.

Book preview

Chapter 1: Anorectal examination

Abstract

The assessment and evaluation of disorders of the colon rectum and anus commences with a careful history and physical exam. Adjunctive laboratory, endoscopic and imaging investigations should follow, rather than precede the initial provider/patient encounter. Most working and differential diagnoses can be made with a careful history and physical examination. The nature of the disorders, as well as the physical exam may be a cause of significant apprehension for the patient. Therefore, healthcare providers must conduct themselves with utmost respect and professionalism when performing the examination. After taking the history, the exam commences with proper patient positioning and inspection. A digital anorectal exam follows in most cases. Anoscopy and/or rigid/flexible sigmoidoscopy can be performed in the office setting. The need for further diagnostic tests and procedures is discussed with the patient, and a plan for treatment formulated.

Keywords

History; Physical exam; Inspection; Digital anorectal exam; Anoscopy; Sigmoidoscopy

•The assessment and evaluation of disorders of the colon, rectum, and anus commences with a careful history and physical exam. Adjunctive laboratory, endoscopic and imaging investigations should follow (rather than precede) the initial provider/patient encounter. Most working (and differential) diagnoses can be made with a careful history and physical.

•Due to the nature of the subsequent physical examination and apprehension, which a patient may have regarding the proceedings, the provider should conduct the history and physical with the utmost professionalism and respect for the individual undergoing the exam.

•The patient’s chief complaint provides essential guidance pertaining to the diagnostic algorithm. Of note, the patient’s age and gender provide important context.

•The chief complaint may include one or a combination of the following:

oBleeding

oPain

oDischarge

oDiarrhea

oUrge

oTenesmus

oConstipation

oFecal incontinence

oA palpable lesion

oA reducible lesion

•Associated symptoms such as fever, nausea/vomiting, and weight loss should be duly noted.

•Prior SARS-CoV2 infection may lead to disorders of the GI tract.

•Bleeding is one of the most frequent complaints for initial evaluation by a colorectal surgeon.

•Timing, frequency, and chronicity of bleeding should be noted.

•Bleeding quantity (massive bleeding, intermittent bleeding, blood on toilet paper) and quality (bright red blood per rectum, blood mixed with stool/mucus, melena, maroon-colored stool) should be elicited.

•Is there blood present with/without defecation?

•Is bleeding associated with anorectal or abdominal pain?

•Is there a palpable lesion present?

•Pain is a major chief complaint. Presence of anal and/or abdominal pain should be elucidated.

•Is the pain intermittent or continuous? Is it associated with defecation or not? Is there a palpable lesion present? Is there fever associated with pain. Is there discharge present?

•Regarding abdominal pain, the presence of nausea/vomiting, weight loss, rectal bleeding, and association with meals should be noted.

•The past medical history may reveal relevant information; previous disorders of the anus, colon, and rectum as well as surgery may facilitate the diagnosis. The endoscopic history (of both the upper and lower gastrointestinal tract) is extremely important. A detailed review of the patient’s medications may reveal drugs which exacerbate signs and symptoms such as bleeding, diarrhea, and constipation. Urinary symptomatology is relevant.

•Social, sexual, and dietary histories include inquiry regarding smoking, drug use, alcohol consumption, sexual practices (including anoreceptive intercourse), fiber, caffeine, and water intake. A history of HPV/HIV should be elicited as well. In females, the obstetrical history may reveal eventful delivery, perineal tears, and episiotomy complications.

•The family history is especially important. A history of colorectal cancer (age, number of relatives affected, degree of relation), polyposis, other malignancies (e.g., gynecological) as well as inflammatory bowel disease may put the patient at higher risk for developing these disorders; consultation regarding screening endoscopy may change as a result.

•The initial office exam usually consists of inspection, digital anorectal examination, and anoscopy. Some colorectal surgeons may perform rigid or flexible sigmoidoscopy in the office routinely.

•Prior to physical examination, the provider should explain to the patient the exact sequence and nature of the exam, and why it will be done. A thoughtful provider may explain what the patient will expect to feel during the examination.

•Inspection is the first step. Optimal exposure of the perianal area, anal verge, perineum, and genitalia is essential. Common positions to successfully achieve this are the prone-jackknife, knee-chest, and lateral decubitus position, with the knees flexed. Lighting must be optimal.

•Inspection may reveal normal anatomy, skin tags, external hemorrhoidal thrombi, prolapsed internal hemorrhoids, rectal prolapse, scars from previous surgery, anal fissure, condylomata, and inflammation. Abscess and external fistula openings may be observed. Soiling of the perianal area/anal verge should be noted. A gaping anus may be a sign of fecal incontinence. Suspicious signs of perianal Crohn’s (multiple fistula openings/fissures, edematous tags, and abscess) may manifest.

•The digital anorectal examination is conducted using a well-lubricated, gloved finger. First, palpate the anal verge for tenderness, masses, fistula tracts. Purulent (±bloody) discharge may be elicited at this point. Then, gently and gradually insert the finger in the anal canal. A basic assessment of resting and squeeze pressure can be made. Circumferential palpation may reveal major sphincter defects, anal/rectal masses, internal fistula openings, abscess, rectovaginal fistula, and enlarged prostate. Higher up, the puborectalis can be assessed for defects, as well as failure to contract/relax. In females, a vaginal exam may be appropriate to assess the presence of a rectocele, enterocele, or uterine prolapse.

•Anoscopy is conducted with a lighted, well-lubricated anoscope. A circumferential anoscopic examination of the anal canal may assist in grading of internal hemorrhoids, assessing mucosal inflammation, and examination of anal fissure, hypertrophic anal papilla as well as internal openings of anal fistula/anovaginal fistula. Condylomata may also be observed.

•Many colorectal surgeons perform routine rigid/flexible sigmoidoscopy in prepared patients. A full bowel prep is not necessary; a simple enema prior to the office visit is sufficient.

•The rigid sigmoidoscope reaches up to 30 cm from the anal verge; a flexible sigmoidoscope is 60 cm in length. Evaluation of rectal bleeding, neoplasia, inflammatory bowel disease (IBD), radiation proctitis, as well as assessment of anastomoses (recurrence of neoplasia/stenosis) can be achieved. The rigid sigmoidoscope is quite accurate in assessing accurate distance of a lesion from the anal verge (i.e., in treatment planning for rectal cancer).

•Colonoscopy requires full bowel preparation and is used for:

oScreening and surveillance of neoplasia/IBD

oDiagnosis of neoplasia, IBD, lower gastrointestinal bleeding

oAnastomotic assessment

oTreatment of bleeding, stenting of stenosis/strictures

•Disorders of the colon, rectum, and anus belong to the realm of abdominal disorders; therefore, a thorough and careful abdominal examination is essential.

•Inspect for distention, jaundice, pallor (anemia), and abdominal scars.

•Palpate for hernia defects, masses, tenderness, hepatomegaly, ascites, and lymphadenopathy.

•Laboratory exams include CBC, electrolytes, liver function tests; carcinoembryonic antigen is used when indicated. A hemoccult stool test is part of a routine exam as well.

•Specialized lab tests include the fecal immunochemical test (FIT). Annual FIT may be a screening option for patients, who are unable/unwilling to undergo colonoscopy. The sensitivity for colorectal cancer (CRC) is 74%; colonoscopy is recommended after a positive FIT.

•The multitarget stool DNA test combines markers for hemoglobin and DNA mutations/epigenetic changes and methylation. The respective sensitivity/specificity for detecting CRC is 92.3%/86.6% and is superior to FIT (Fig. 1).

Fig. 1 Fundamentals of anorectal examination and assessment.

Further reading

[1] Billingham R.P., Isler J.T., Kimmins M.H., Nelson J.M., Schweitzer J., Murphy M.M. The diagnosis and management of common anorectal disorders. Curr Prob Surg. 2004;41(7):586–645.

[2] Patel N.D., Steele S.R., Steinhagen E. Anorectal examination. In: Steele S.R., Maykel J.A., Wexner S.D., eds. Clinical decision making in colorectal surgery. 2nd ed. Cham: Springer International Publishing; 2020:3–6.

[3] Davids J.S., Maykel J.A. Preoperative assessment of colorectal patients. In: Steele S.R., Hull T.L., Read T.E., Saclarides T.J., Senagore A.J., Whitlow C.B., eds. The ASCRS textbook of colon and rectal surgery. 3rd ed. Cham: Springer International Publishing; 2016:93–106.

Chapter 2: Colorectal radiology

Abstract

Imaging plays a very important role in the evaluation of colorectal diseases and disorders. Prior to the advent of endoscopy, plain films and contrast studies were the primary modality for the diagnosis of most colorectal diseases. Currently, a variety of imaging studies are available for diagnosis and treatment of colorectal disorders and diseases. These include plain radiographs, intestinal contrast studies, computed tomography, magnetic resonance tomography, ultrasound, and nuclear medicine imaging. Interventional radiology also plays an important role, such as angiography and CT-guided interventional procedures.

Keywords

Radiology; Plain films; Contrast studies; Computed tomography; Magnetic resonance imaging; Nuclear medical imaging; Ultrasound; Interventional radiology

•Imaging plays a very important role in the evaluation of colorectal diseases and disorders. Prior to the advent of endoscopy, imaging in the form of plain films and contrast studies was the primary modality for the diagnosis of most colorectal diseases. Tumors, colonic obstruction, inflammatory bowel disease, and functional disorders such as constipation and incontinence were diagnosed this way.

•Currently, a variety of imaging studies are available for the diagnosis and treatment of colorectal disorders and diseases. These include plain radiographs, colonic contrast studies, computed tomography, magnetic resonance tomography, ultrasound, and nuclear medicine imaging. Interventional radiology such as angiography and CT-guided interventional procedures also plays an important role.

•Plain films are the initial modality used for acute problems:

◦A bowel obstruction may present with air-fluid levels and/or small bowel/colonic distention

◦Intestinal ischemia may present with bowel wall thickening/thumbprinting

◦Foreign bodies are relatively easy to detect with plain films

◦Perforation presents with free intraperitoneal air

•Colonic contrast studies are still frequently used. Water-soluble studies are better for acute inflammatory processes and lower neoplasms; they may be therapeutic in partial colonic obstructions. Barium studies provide greater mucosal detail; this is useful in the diagnosis of smaller neoplasms and inflammatory bowel disease. Air insufflation (double-contrast) improves resolution. However, a partial colonic obstruction may become complete when thick barium is used. Several conditions are diagnosed with colonic contrast