ulcerative colitis and colon cancer

S V E T L A N A K L E Y M A N , M D ( P G Y 4 )

S U N Y D O W N S T A T E

8 / 2 9 / 2 0 1 3

Ulcerative Colitis and Colon Cancer

www.downstatesurgery.org

Case Presentation

67 year old male with a past medical history of HTN. The patient underwent a colonoscopy which demonstrated a lesion in the ascending colon and biopsy showed adenocarcinoma. The patient was referred for resection.

Medical history: HTN, Ulcerative Colitis? (questionable history given by patient of being diagnosed 20 years ago, however no documentation)


Medications: Valsartan

Allergies: NKDA

Surgeries: none

Social: no history of smoking, occasional glass of wine

Pre- op labs:

CBC 11.3/14.9/43/297

BMP 142/4.2/101/19/.79/119


Case Presentation

The patient underwent a laparoscopic right hemicolectomy.

Post operative course uneventful. Patient discharged on POD#3.

Pathology: Invasive adenocarcinoma ( 5.5 cm), invading the muscularis propria, well- differentiated, 24 negative lymph nodes. T2N0.


Outline

Introduction

Review of Ulcerative Colitis

Screening and Surveillance for cancer

Surgical options

Summary

Question


Introduction

Ulcerative Colitis is an inflammatory bowel disease affecting the mucosa of the colon and rectum.

Etiology is unknown

Male predominance

Typically begins in the teenage years or early adult hood with a second peak in the 40-60 age range.


Introduction

Regional differences: highest incidence in Northern Europe, United Kingdom, and North America

It has been shown to cluster in families. Studies have shown that 5-10% of people with UC have a family history.

Smoking may confer a protective benefit against UC.


Presenter

Presentation Notes

( smoking attenuates inflamation and prevents relapses)

Diagnosis of Ulcerative Colitis

Presenting Symptoms: bloody diarrhea, abdominal pain, fever

Patients with proctitis present with: urgency, frequency, and tenesmus

Patients with total colitis present with: anemia, fatigue, anorexia, and weight loss

80% of patients present with a mild attack of distal disease

10-20% present with an initial attack that will progress to fulminant colitis.


Presenter

Presentation Notes

Tenesmus: the feeling that you constantly need to pass stools despite having an empty colon

Endoscopic Features

A. Loss of normal vascular pattern B. Contact bleeding C. Granularity D. Ulceration and friability E. Colonic stricture


Presenter

Presentation Notes

The loss of mucosa leads to loss of normally visualized endoscopic vascular pattern E. Colonic strictures can occur in 5-12% of patients with chornic uc, usually benign, caused by hypertrophy of the muscularis. However in a patient with stricture important to rule out m alignancy

Pathological Features

UC is limited to the mucosa and submucosa of the colon and rectum.

The rectum is always involved and the disease presents in a continuous fashion from the rectum proximally.


Pathological Features

Gross Appearance - Hyperemic mucosa

- Friable mucosa

- Mucosal ulcerations

- Pseudopolyps

- Loss of mucosal folds

and haustra


Presenter

Presentation Notes

Mucosal ulcerations: superficial or full thickness of the mucosa Pseudopolyps are from regeneration of inflamed mucosa

Histological features

Early - Neutrophils fill and

expand the crypts of Lieberkuhn causing Crypt Abscesses

Late - Crypt abscesses coalesce,

superficial desquamation of epithelium leads to ulcers


Radiologic Features www.downstatesurgery.org

Presenter

Presentation Notes

Barium enema radiograph showing jagged ulcerative appearance of the mucosa Chronic ulcerative colitis, shortening and straighetning of the colon, as well as loss of haustrations , this is called “ lead pipe colon”

Ulcerative Colitis and Cancer Risk

Disease duration ** - 2% risk of cancer after 2 years, 8% after 20 years, 18% after 30 years

Extent of the disease ** - 1.7 fold increased risk of cancer in proctitis, 2.8 left- sided , 14.8 pancolitis

Primary Sclerosing Cholangitis

Young age at onset

Family History


Presenter

Presentation Notes

Mechanism that psc induces crc is unclear, hypothesized that alkterations in the bile salt pool and high concentratin of bile acids in the colon may be responsible for partial risk

Screening for Colorectal Cancer

A screening colonoscopy should be performed in UC patients to rule out neoplasia ( dysplasia/cancer) 8-10 years following onset of UC symptoms.

Risk of CRC becomes greater than that of general population 8-10 years after onset of symptoms.

In patients with primary sclerosing cholangitis (PSC) and UC, screening should begin at the time of PSC onset.


Presenter

Presentation Notes

This is important because at the time of Acute inflammation it is impossible to distinguish between dysplastic lesions or inflamatory lesions

Screening for Colorectal Cancer

Patients are classified based on anatomic extent of the disease.

Extensive: UC proximal to the splenic flexure

Left Sided: UC in the descending colon up to the

splenic flexure

Proctosigmoiditis: disease limited to the rectum


Surveillance for Colorectal Cancer

If: Frequency of surveillance:

Negative screening colonoscopy Begin surveillance colonoscopies within 1-2 years

Negative surveillance colonoscopy Perform subsequent surveillance colonoscopies every 1-2 years

Two negative surveillance colonoscopies Perform subsequent surveillance colonoscopies every 1-3 years

Duration of UC > 20 years Perform surveillance every 1-2 years

Extensive Colitis and Left-sided Colitis:


Presenter

Presentation Notes

This is because the longer you have UC, the higher at risk you are for cancer


Proctosigmoiditis:

- Should be screened based on general CRC prevention measures

- If biopsies are positive proximal to 35 cm ( even though macroscopic disease is limited to the rectum), patients should follow UC type surveillance.

Primary Sclerosing Cholangitis:

- Patients should undergo yearly surveillance.


Presenter

Presentation Notes

Procto sigmoiditis : Little or no increased risk of CRC compared with population at large


Random Biopsies - Extensive disease: 4 quadrant biopsies every 10 cm

through the colon. - Less extensive disease: 4 quadrant biopsies from

proximal extent to every 10 cm distally

Chromoendoscopy - Targeted biopsies with methylene blue or indigo carmine - Done by appropriately trained endoscopists - Shown to be superior to random biopsies in detection rate

of neoplastic lesions


Presenter

Presentation Notes

Chromoendoscopy, or chromoscopy, refers to the top- ical application of stains or dyes at the time of endoscopy in an effort to enhance tissue characterization, differentia- tion, or diagnosis.


Abnormal findings on Colonoscopy - Indefinite for dysplasia - Low grade dysplasia (LGD) - High grade dysplasia (HGD) - Adenocarcinoma Additional considerations - Polyps - Dysplasia associated lesion or mass (DALM): lesion that

does not resemble typical adenoma with dysplasia in the surrounding mucosa



Finding: Management:

Indefinite for dysplasia

Follow up surveillance examination in 3-6 months

Low grade dysplasia Repeat examination in 3 months or Proctocolectomy * multifocal or repetitive LGD proctocolectomy*

High grade dysplasia Proctocolectomy

Adenocarcinoma Proctocolectomy

Polyps with dysplasia Polypectomy + 4 negative adjacent biopsies + no dysplasia anywhere in the colon 6 month follow up

Dysplasia associated lesion or mass Proctocolectomy


Surgical Management

Surgical options - Total proctocolectomy +

ileostomy

- Total proctocolectomy + Kock Pouch

- Total abdominal colectomy + ileorectal anastomosis

- Total proctocolectomy + ileal pouch anal anastomosis


Surgical Management

Definitions:

Total Proctocolectomy: Colon and Rectum are removed entirely

Total Abdominal Colectomy: Rectum is preserved


Total Proctocolectomy + Ileostomy

Historically was the gold standard, because the entire colon and rectum are removed with a low rate of complications

The disadvantages are having a permanent ileostomy,

and the potential for nerve injury during the perineal dissection

Best for: - Elderly patients - Patients with distal rectal cancer - Pre- operative poor anal sphincter function


Total Proctocolectomy + Ileostomy

Operation - Excision of the entire

colon, rectum, and anus

- Anal opening is sutured closed

- Creation of Brooke Ileostomy


Presenter

Presentation Notes

A brooke ileostomy:

Total Proctocolectomy and KOCK Pouch

Introduced by Nils Kock in the late 1960s, but has recently been falling out of favor.

It is a “continent ileostomy” that allows the patient to intubate the ostomy and empty it’s contents . This leads to improved quality of life and body image.

Disadvantages: high rate of complications and reoperations ( 35%) due to nipple valve failure

Best for: - Patients who have already undergone total proctocolectomy

and ileostomy, or those who have failed IPAA.


Total Proctocolectomy and KOCK Pouch

Operation

- Excision of the entire colon, rectum, and anus

- Anus sutured closed

- Creation of continent ileostomy


Presenter

Presentation Notes

-Kock pouch consists of an ilelal resevoir and nipple valve -the efferent limb of ileum is intussussepted and fixed into place with sutures -the pouch is then closed with sutures - The patient can then drain the contents of the pouch several times a day through the cutaneous stoma, by intubating it with a catheter

Total Abdominal Colectomy and Ileorectal Anastomosis

Non- definitive operation for selected patients with chronic ulcerative colitis

Less extensive operation, full continence maintained, no need for stoma, pelvic nerves not disturbed ( less risk of impotence/bladder dysfunction).

Disadvantages: the remaining rectum can develop persistent inflammation leading to an increased risk of maligancy

Best for: - Young patients who want to return to work or preserve their

fertility


Presenter

Presentation Notes

Approximately 20% of patients require subsequent proctectomy for uncontrollable proctitis or poor function the risk of rectal cancer is 5% ( 20 years) This operation is contraindicated in patients with anal spinter dysfunction, rectal disease, and rectal dysplasia/malignancy

Total Abdominal Colectomy and Ileorectal Anastomosis

Operation - The colon is mobilized

starting with the right colon

- The ileum is divided

- The rectum is divided at the sacral promontory

- Ileorectal anastomosis performed: hand- sewn/ stapled


Total Proctocoletomy and Ileal-Pouch Anal Anastamosis

The most common surgical treatment of patients with Ulcerative Colitis

Originally described in the 1940s but not used widely due to many post-operative issues.

It continued to evolve into the 1980s and improved due to a better understanding of the anatomy of the anal sphincter complex.

Creation of an ileal-resevoir pouch further improved the technique.


Presenter

Presentation Notes

The theory was: since UC is a mucosal disease, the disease bearing rectal mucosa could be dissected down to the dentate line of the anus and the rectal muscular cuff and sphincter apparatus could be preserved

Pre-operative planning includes extensive patient counseling and anal manometry

Restores gastrointestinal continuity and patients are able to maintain continence, provides a good quality of life

Disadvantages: Two stage operation, post operative pouchitis, cuffitis




Operation - Removal of the Colon and Rectum

- Sparing of the pelvic nerves and

anal sphincter complex

- Construction of an ileal resevoir

- Ileal resevoir anal anastomosis * double stapled technique * hand sewn technique with mucosectomy

- Protective Ileostomy


Creation of an Ileal Resevoir



Presenter

Presentation Notes

Is the J pouch : a 2 loop pouch, easiest to construct, and has the same functional outcomes as the more complex pouch options the S pouch : a 3 loop pouch design, allows for 2-4 cm further reach than the j pouch, useful in patients with a short fat messentery and and narrow pelvis The w pouch: a 4 loop pouch, rarely used.

Double- Stapled IPAA to the Anal Transition zone



Presenter

Presentation Notes

There are two options: First I will go through the technique, and then I’ll discuss why we choose one or the other Pic 1: linear stapler applied at the intended level of distal rectal transsection, the tapler should rest on the anorectum, just below the superior border of the levator floor. the rectum is divided along the cephalad edge of the staples. Care is taken to minimize contmaination. Pic 2: Using an EEA stapler, the shaft transverses posterior to the staple line Pic 3: The shaft of the circular stapler is mated with the anvil emerging from the ileal pouch and the ends are approximated and the anastamosis is created

Mucosal Proctectomy and Hand–Sewn IPAA



Presenter

Presentation Notes

The mucosa is stripped from the underlying sphincters from the dentate line to the level of the anorectal transection using cautery Sutures are radially placed in the dentate line and the anastamosis is performed to the ileal pouch

Double Stapled Anastamosis vs. Mucosal Proctectomy

- Musocal proctectomy is more difficult and requires more experience

- Without mucosal proctectomy, there is still a risk of developing cancer in the anal transitional zone, and post operative surveillance is required.



Diverting Ileostomy: - Preferred because of the large number of suture and

staple lines involved in the anastamosis

- Closure performed 3 months after the initial operation

- Before closure, the integrity of the anastamosis is checked with pouch endoscopy and gastrograffin enema



Presenter

Presentation Notes

The temporary ileostomy is reversed 3 months after the initial operation, closre before that time is more difficult because of dense peri ileostomy adhesions A gastrograffin enema and pouch endoscopy is also performed before ileostomy closure to check for pouch and anastomotic integrity

Summary

Ulcerative colitis is a disease that affects the mucosa of the colon and rectum

Cancer risk is influenced by the extent of disease and disease duration

Screening and surveillance is important.

Once dysplasia or cancer has been diagnosed , surgical resection is the treatment of choice.

No role for limited resections in Ulcerative Colitis associated Colorectal cancer.


References

Greenfield, Lazar J., and Michael W. Mulholland. Greenfield's Surgery: Scientific Principles and Practice. Philadelphia, PA: Lippincott Williams & Wilkins, 2006. Print.

Maingot, Rodney, Michael Zinner, and Stanley W. Ashley. Maingot's Abdominal Operations. New York: McGraw-Hill Medical, 2007. Print.

Fischer, Josef E., and K. I. Bland. Mastery of Surgery. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2007. Print.

Itzkowitz, Steven H., and Daniel H. Present. "Consensus Conference: Colorectal Cancer Screening and Surveillance in Inflammatory Bowel Disease." Inflammatory Bowel Diseases 11.3 (2005): 314-21.

Lakatos, Peter-Laszlo. "Risk for Colorectal Cancer in Ulcerative Colitis: Changes, Causes and Management Strategies." World Journal of Gastroenterology 14.25 (2008): 3937.

Baik, Seung Hyuk, and Won Ho Kim. "A Comprehensive Review of Inflammatory Bowel Disease Focusing on Surgical Management." Journal of the Korean Society of Coloproctology 28.3 (2012): 121-31. Web.


Question

With regards to ulcerative colitis which of the following statements is true?

A. In at least one half of the patients, the entire colon is involved with skip areas.

B. The characteristic histologic finding of crypt abscesses is only seen in ulcerative colitis and not other inflammatory conditions.

C. The disease is most commonly a chronic relapsing one with a fulminant course seen in only 10-20% of patients.

D. Histologic demonstration of granulomas confirms diagnosis.

Answer: C


ulcerative colitis and colon cancer

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