Colorectal Problems In Primary Care

Transcription

1 Colorectal Problems In Primary Care Lincoln Israel General and Colorectal Surgeon Middlemore Hospital Middlemore Hospital Mercy Hospital Auckland Colorectal Centre (Gilgit Rd Specialist Centre) Manukau Health Trust (Manukau Super Clinic) Common Presenting Symptoms Rectal Bleeding Local Anorectal Symptoms Abdominal Pain Change In Bowel Habit Over-riding riding concern Exclusion of Malignancy Rectal Bleeding Causes Ano-rectal Problems Haemorrhoids Fissure in ano Anal Cancer Bleeding from Rectum/Colon Polyps Cancers Colitis/Proctitis Massive -Upper GI Bleed -Diverticular disease -Angiodysplasia Colitis/Proctitis inflammatory bowel disease 1

2 Rectal Bleeding An extremely common symptom Who do we investigate? History Alarm Symptoms History Amount/ Volume/ Frequency? Is blood anorectal in origin (outlet type) or more proximal Colour Mixed in with stool/ on toilet paper/coating stool Associated symptoms Change in bowel habit Weight loss/anorexia Rectal Bleeding Family History Carcinoma Familial conditions (HNPCC, FAP) 1x 1 st degree relative >55yr RR = 2 counsel as per average risk 1 st degree < 55, or 2x 1 st degree any age RR = 4-64 Syndromes Familial Adenomatous Polyposis - Hereditary Non Polyposis Colorectal Carcinoma Inflammatory Bowel Disease Examination General Exam/ Abdo exam Rectal Bleeding Examination of the ano rectum Digital Exam If you don t t put your finger in it you put your foot in it One UK series: 36% of patients presenting with rectal bleeding from f a colorectal cancer had a palpable rectal mass Proctoscopy -? Required in General practice Rigid Sigmoidoscopy 2

3 Rectal Bleeding Risk of cancer in patient with rectal bleeding over 40 yrs old ~ 3-5% 3 With bleeding and a change in bowel habit double the risk Change in bowel habit to looseness or increased frequency is more concerning than constipation Rectal Bleeding Who to Refer/Investigate-Guidelines: Australian (NHMRC) 2005 In symptomatic patients over 40 years, referral to a specialist should be considered and consideration of full examination of the colon with colonoscopy should be considered In all patients proctosigmoidoscopy is recommended as this enables haemorrhoids to be identified. Failure of symptoms to settle should lead to full colonoscopic evaluation American Society Of Colorectal Surgeons: Indications for complete colon evaluation Age > 50 yrs if no complete evaluation within 10 years >40 yrs with a positive family history for a 1 st degree relative with colorectal cancer Iron deficiency anaemia Iron Deficiency Australian Guidelines (NHMRC) 2005 There is always a cause. In non menstruating patients gastrointestinal bleeding is the most common cause. Investigation must include full colonic evaluation Always Do A Rectal Exam 3

4 Practicalities in NZ Public Patients Consider referral of all to General Surgery/Colorectal Clinic (Priority- See within 6 weeks) Long waits for colonoscopy in public may delay cancer diagnosis?avoid referral young pts e.g <35yrs outlet bleeding, minimal or resolved symptoms no danger signs At clinic all will receive proctosigmoidoscopy Most >50 yrs or any worrying symptoms will then be referred for full colonic evaluation Private Patients Refer to surgeon or consider direct referral for colonoscopy >50yrs (as minimal wait in private) (?40yrs) If not for colonoscopy need proctosigmoidoscopy Once cancer excluded can treat symptoms on their merits Common Anorectal Diseases Haemorrhoids Anal Fissures Pruritis Ani Perianal Sepsis Pilonidal Disease Haemorrhoids Internal (True)Haemorrhoids One of the oldest afflictions known to man Described in ancient Egyptian papyrus, Later Hippocrates Normally 3 Vascular cushions lying above the dentate line under the anal mucosa Haemorrhoids are secondary to hypertrophy and congestion of these anal cushions Mucousal prolapse Primary venous problem Causes - minimal evidence Defaecatory habits Low fibre,, constipation 4

5 Haemorrhoids - Symptoms Bleeding outlet. May be profuse splattering pan Can lead to anaemia Prolapse (often misinterpreted by patient. Often just skin tags) Discomfort secondary to congested prolapsed cushions. Rarely painful unless prolapsed and thrombosed Discharge and pruritis- secondary to mucousal prolapse Acute Thrombosis (Strangulation) Haemorrhoid - Management Defaecatory advice (Minimal evidence) Avoid straining (BM every day, completion of defaecation) Avoid delay of defaecation (holding on) Dietary advice Topical Applications Rarely assessed critically Usually contain topical anaesthetic and steroid Lubricant action to stop cushions rubbing together Some symptomatic relief (?anitis anitis) ) will not have any effect on anatomical pathology. Anusol &Ultraproct (Cinchocaine, Fluocortolone) Only fully subsidised (ointment or suppository) avoid prolonged use Haemorrhoids Invasive Treatment Mucousal fixation techniques Injection sclerotherapy ~70% satisfaction Banding ~80% satisfaction 24hrs discomfort Small risk haemorrhage at days Operative Treatment Only required in approx 5-10% 5 of patients Grade IV haemorrhoids or failed banding Standard Haemorrhoidectomy painful++ ~90-95% 95% complete relief of symptoms New Technique Stapled Haemorrhoidopexy No cuts on skin less pain Concerns: Efficacy,??Chronic pain 5

6 Perianal Haematoma External Haemorrhoids NOT true haemorrhoids Rupture of veins in the external venous plexus (or thrombosis within these veins) Treatment if seen within 72 hrs may incise and drain under LA Usually symptomatic treatment symptoms resolve in days May resolve to leave skin tags Anal Fissures Symptoms PAIN & bleeding Acute usually settle Chronic -Internal sphincter hypertonicity/spasm Leads to ischaemic ulcer in watershed midline Beware IBD, STD syphylis, HIV, malignancy, perianal abscess Treatment Stool softeners: Metamucil, Lactulose Relax internal sphincter GTN paste (0.2%) Rectogesic Apply BD to TDS for 6 weeks 50-80% cure ~30% recurrence at 2 years Headaches in up to 50% Wear a glove when applying Botox: Expensive, Cure in 60-80% Operation Lateral Sphincterotomy Cure 95-98% 98% Risk = Incontinence Pruritis Ani A very common problem Often Idiopathic Causes Anorectal Lesions Haemorrhoids,, fissures,mucousal mucousal/rectal prolapse, incontinence, proctitis,, skin tags Primary Skin Diseases e.g.psoriasis, lichen planus Hypersenstivity (Esp to local Preparations) Infections- esp fungal, threadworm, herpes 6

7 Treatment Of Idiopathic Pruritis Ani Avoid Excessive anal hygene hygene Trauma from rubbing with toilet tissue Soaps Use toilet wipes unscented Stop all steroid/local anaesthetic creams Use zinc based barrier cream only Underwear - cotton Abscesses and Perianal Fistula Most arise from infections in the anal glands/crypts - The cryptoglandular theory Rarely associated with inflammatory bowel disease After drainage of abscess in theory ~10% risk of fistula Classification and treatment based upon relationship to sphincter mechanism Intersphincteric Transphincteric Supra/extra sphicteric Pilonidal Disease Generally accepted as acquired disease secondary to hair invasion into skin of midline natal cleft Pathogenesis Hair type, Force, Skin vulnerability Can Occur in other regions Presentation Abscess ~25% subsequently require definitive treatment after I & D Chronic sepsis Natural History Ongoing problems rare after age 45 Definitive Surgical options Excision +/- closure primarily or with rotational flaps All operations complicated by difficult wound healing (20-40%) and recurrence (1-10%) 10%) 7

8 Colorectal Cancer The second most common cause of cancer registration and death in NZ 1 in 20 lifetime risk In 2002: 2588 registrations, 1135 deaths We lead the world! NZ Australia UK USA Incidence per 100,00 Mortality per 100,00 Male Female Male Female Colorectal Cancer Overall Survival ~50% (~20% have metastases at presentation) Dukes Staging 5Year Survival Dukes A 88% Contained within wall of bowel Dukes B 70% Through wall Dukes C 43% Lymph node metastases Dukes D 7% Distant Metastases Chemotherapy: Dukes C bad prognostic Dukes B Improves survival with absolute benefit of ~10-15% 15% (i.e Dukes C C survival 40-50% 50% 50-65%) Management Of Liver Metastases Synchronous or subsequent metastases may be suitable for liver resection ~30% 5 year survival if resectable Colorectal Cancer Screening As colorectal cancer is so common in NZ why not? Report Of The Colorectal Cancer Screening Advisory Group November 2006 (Update from report 1998) 2 international population based RCTs of guaiac based faecal occult blood testing (only test with quality evidence): Each Group Age Range Age Participation at 1 st screening Follow Up Sensitivity Colonoscopy Rate CRC mortality reduction Absolute Risk Reduction Funen Denmark 31, FOBT every 2 yrs 67% 10 yrs 50% 4.3% 18% 16 Per 100,000 Nottingham UK 76, FOBT every 2 years 53% 7.8% 53.6% 4% 15% 10 per 100,000 8

9 Colorectal Cancer - Screening Conclusions Of Advisory Group for NZ The only test with quality evidence available is guaiac based FOBT mortality benefit modest Mortality reduction from other types of screening (flexible sigmoidoscopy,, colonoscopy) will not be known for many years Currently NZ does not have the capacity to offer a screening programme Colonoscopic follow up for +ve+ FOBT is not feasible in NZ already significant delays for symptomatic patients (in pts waited >6 months) Significant delays for surveillance of those at increased risk In pts waited >6months To support screening programme would require an increase in colonoscopic capacity of % Colorectal Cancer - Screening Pilot study in Australia 45% participation rate Cost per QALY in Australia estimated at A$17,000 (1996 costs) Cost Compares favourably to breast and cervical cancer screening (not including additional set-up cost of colonoscopy services) Conclusion Of Advisory Group A feasibilty study using FOBTi should be considered an essential pre-requisite requisite to a decision regarding a pilot study (particularly in relationship to the provision of colonoscopy) Rectal Cancer Recognized over last 2 decades that surgical technique and specialization can have major impact on cancer recurrence (Total Mesorectal Excision) (local recurrence rates of 30% decreased to 4-10% 4 specialisation) Also may require preoperative radiation Australian NHMRC guidelines Elective surgery for rectal cancer should be carried out by a surgeon who has undergone a period of special exposure to this form of surgery during surgical training and who has maintained satisfactory tory experience in the surgical management 9

10 CT Colonography (Virtual Colonoscopy) 1 st described 1994 at the annual meeting of the Society of Gastrointestinal Radiologists fly through video accompanied by the sounds of Wagner s Ride of the Valkyries first commercially available CTC product. Bowel preparation still required. Recent interest in faecal tagging ging of retained stool. Imaging software digitally removes tagged stool Rectal tube inserted colon is insufflated to the maximum tolerable volume the patient can withstand. CT Colonography Sensitivity lesions >10mm 90-95% 95% Lesions 6-9mm % Advances in CT technology may enhance sensitivity further If find a lesion patient will still require colonoscopy Perforations have been reported Not sensitive enough yet for screening? Impact of radiation dose Incidental findings (Up to 10% may be problematic) Applications unable to complete colonoscopy Symptomatic patients Alternative to barium enema Enhanced Recovery Programmes Dogma of post Op care following colorectal resection now being challenged Bowel prep Nil By Mouth Fluid loading Mobilisation Gastric/Urinary/Peritoneal Drainage Length of stay post resection days Enhanced Recovery / Fast Track 10

11 Enhanced Recovery Programmes Multimodal Optimization of perioperative care Comprehensiveatient Information/ expectations. Pre-Op carbohydrate loading, up to hrs pre-op Decreases post op stress response,protein loss, insulin resistance Analgesia Epidurals vs opiods Limit post-op op fluids (GI oedema) Discharge planning Nursing enthusiasm Fast-Track at Counties Manukau 45 patients Mean age : 71 Median day-stay 4 days (3-34) for all patients Manukau (Manukau Surgical Centre) Laparoscopic Colorectal Surgery What has taken colorectal surgery so long? 1. Movement around wide abdominal regions repositioning of ports, instruments, personnel & patient 2. Major vascular division 3. Formation of anastomosis 4. Handling of bowel and risk of inadvertent injury 5. Removal of large specimen bigger hole 6.?? Oncological Safety Advantages Of Laparoscopic Resection 1. Less Invasive 2. Reduced Post-Op Pain 3. Earlier return of Gastro-intestinal function 4. Shorter Hospital Stay 5. Earlier return to full activity 6. Cosmesis 11