Clinical features

Signs and symptoms

Some patients are asymptomatic, especially when their neoplasm is identified by screening or surveillance. Haemato-chezia and anaemia are common presenting features due to bleeding from the tumour. Many patients experience change in bowel habit; in the right colon, the fluid faeces can pass exophytic masses, whereas in the left colon the solid faeces are more often halted by annular tumours so that constipation is more common. There may be associated abdominal distension. Rectosigmoid lesions can produce tenesmus. Other symptoms include fever, malaise, weight loss, and abdominal pain. Some patients present with the complications of obstruction or perforation.

Imaging

Modern imaging techniques permit non-invasive detection and clinical staging. Conventional barium enema detects large tumours, while air-contrast radiography improves the visualization of less advanced lesions. Cross-sectional imaging by CT, MRI imaging and transrectal ultra-sonography permit some assessment of the depth of local tumour invasion and the

Fig. 6.06 A Endoscopic view of two small flat adenomas highlighted with indigo-carmine to show the abnormal tubular pit pattern. B Magnifying video endoscopy of a tubulovillous adenoma highlighted with indigo-carmine to show cribriform pattern. C Histological section of a flat elevated tubular adenoma showing low-grade intraepithelial neoplasia. D Stereomicroscopic view with indigo-carmine dye spray of a depressed adenoma with high-grade intraepithelial neoplasia containing very small round pits.

Fig. 6.06 A Endoscopic view of two small flat adenomas highlighted with indigo-carmine to show the abnormal tubular pit pattern. B Magnifying video endoscopy of a tubulovillous adenoma highlighted with indigo-carmine to show cribriform pattern. C Histological section of a flat elevated tubular adenoma showing low-grade intraepithelial neoplasia. D Stereomicroscopic view with indigo-carmine dye spray of a depressed adenoma with high-grade intraepithelial neoplasia containing very small round pits.

presence of regional and distant metastases {2202}. Scintigraphy and positron emission tomography are also used.

Endoscopy

The development of endoscopy has had a major impact on diagnosis and treat ment. Colonoscopy allows observation of the mucosal surface of the entire large bowel with biopsy of identified lesions. Chromoendoscopy employing dyes to improve visualization of non-protruding lesions and magnification, have been developed. The flat neoplastic lesions

Aif i M

Aif i M

Fig. 6.07 A Small adenocarcinoma invading muscularis propria, arising in a depressed adenoma. B Early adenocarcinoma invading submucosa, arising in a flat adenoma.

Fig. 6.07 A Small adenocarcinoma invading muscularis propria, arising in a depressed adenoma. B Early adenocarcinoma invading submucosa, arising in a flat adenoma.

Fig. 6.08 Advanced colorectal carcinomas. A Small depressed invasive carcinoma (arrow) with a nearby protruding adenoma, B Advanced colorectal carcinoma, depressed type. C Cross section of adenocarcinoma with extension into the submucosa (pT1).

have been designated by Japanese gas-troenterologists as 'type II', with three subtypes: IIa, 'en plateau' elevated; IIb, completely flat; and 11c, 'en plateau' depressed. The depressed lesions have, despite a smaller diameter, a poor prognosis with prompt penetration in the sub-mucosa. The pit pattern of the surface at magnification 100 allows a reliable prediction of histology. Therapeutic endo-scopy, including snare polypectomy and endoscopic mucosectomy, can be used to remove colorectal neoplasms, especially adenomas, and carcinomas with minimal submucosal invasion. Protruded neoplasms can usually be resected by snare polypectomy. Superficial lesions (flat and depressed) and some protruded

Fig. 6.09 Small ulcerating adenocarcinoma of colon producing a depressed lesion.
Fig. 6.10 Well differentiated adenocarcinoma arising in Crohn disease, invading wall beneath intraepithelial neoplasia.

lesions may be removed by endoscopic mucosal resection {2121, 2122, 1164}.

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Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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