Investigations;

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Investigations

• 1- Sigmoidoscopy should be performed in all cases
  where blood mucous have been passed.

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• 2- Colonoscopy, either short (60 cm) flexible
  colonoscopyis done which need minimal bowel
  preparation (by immediate disposable enema) or by
  using total colonoscopy which need complete bowel
  preparation has the advantage of picking up the
  primary carcinoma the synchronous lesions of
  the colon if present.

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• 3- Radiography, barium enema shows a constant,
  irregular filling defect but negative X-ray
  finding will not exclude small carcinoma of the
  colon in patients with high suspicion of the
  disease.

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CT examination Contrast enhanced axial scans An
intraluminal, bulging soft tissue mass is visible
in the ventral wall of the ascending colon (upper
pictures-arrows). Distally the lumen is narrowed,
the circular thickening of the mucosal wall is
irregular, the adjacent fat is infiltrated (lower
pictures - arrows (
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• Colonography An 'apple-core' lesion of the colon
  is visible as a well-demarcated, circular, 1.5 cm
  long, irregular narrowing (arrow).

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• Barium enema A 6 cm long section of the
  recto-sigmoid region has irregular contour,
  narrowed lumen (1 cm) and filling defect (arrow).

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Enterography Multiple narrowing of the terminal
ileum is visible (arrow). The tumor involves the
cecum and the ascending colon (double arrow).
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• 4- Exfoliative cytology, is of valuable help in
  diagnosis of carcinoma colon cases when endoscopy
  is not available, this need good careful
  bowel preparation, here after 5-10 min. the
  returned fluid is collected centrifuged the
  sediment is prepared stained examined.

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Treatment

• Preoperative preparation
• I- when there is no intestinal obstruction,
• The patient should receive blood to correct the
  anemia.
• Mechanical preparation to cleans the bowel by
  using

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1. Strong purgatives.
2. Whole bowel irrigation.
3. Enemas or combination of the above

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• 3- High caloric low residue diet.
• 4- Chemical preparation, by using metronidazole
  (flagyl) to deal with anaerobic microorganisms in
  conjunction with gentamycin or by using third
  generation cephalosporins.

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• II- When there is intestinal obstruction a
  preliminary drainage of the intestine proximal to
  the obstruction must be performed especially in
  cases of Lt. Side colonic cancer.
• In cases of Rt. Side lesions a primary resection
  end to end ileo-colic anastomosis is done.

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Tests of operability at opening the peritoneal
cavity the operability should be seen at first by

1. Palpating the liver for secondary metastasis.
2. Neoplastic implantation in the peritoneum
   especially the pelvic peritoneum.

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• 3- Variant groups of lymph nodes that drains the
  involved segment, although their enlargement will
  not necessarily mean neoplastic invasion.
• 4- Fixity of the tumor to the underlying
  structures.

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• The operations to be described are designated to
  remove both the primary lesion as well as the
  loco-regional lymph nodes.

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Types of operations

1. Rt. Hemicolectomy treats carcinoma of the cecum
   or the ascending colon.
2. Carcinoma of the hepatic flexure, the resection
   here is extended Rt. Hemcolectomy to involve the
   transverse colon splenic flexure also.

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• 3- Carcinoma of transverse colon, by excision of
  transverse colon both flexures together with
  greater omentum is the operation of choice.
• 4- Carcinoma of the splenic flexure or descending
  colon is treated by removing the transverse colon
  the segment involved by tumor.
• 5- Carcinoma of pelvic colon, treated by Lt.
  Hemicolectomy.

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• With each type of the above operation the
  continuity of the bowel is restored by end to end
  anastomosis putting drain down to the site of
  anastomosis.

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Post-operative care includes

1. Administration of antibiotics.
2. Free fluids are not given by mouth after
   anastomosis until flatus is passed.

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• In cases of inoperable carcinoma of the colon,
  a proximal colostomy is done in case of tumor of
  pelvic or descending colon, while ileo-transverse
  
• Anastomosis is done to by pass the obstructive
  tumor in case of carcinoma of ascending colon or
  the cecum.