A 67-year-old man presents to the ED with a 2-month history of nausea, emesis, 20-lb weight loss, and worsening diarrhea until 4 days ago, when he stopped passing flatus and having bowel movements. A CT scan shows a large obstructing right colon mass that may be involving the omentum with two liver lesions. What should be resected in this case?
The objective in treatment of carcinoma of the colon is to remove the primary tumor along with its lymphovascular supply. Because the lymphatics of the colon accompany the main arterial supply, the length of bowel resected depends on which vessels are supplying the segment involved with the cancer. Any adjacent organ or tissue, such as the omentum, that has been invaded should be resected en bloc with the tumor. If all of the tumor cannot be removed, a palliative procedure should be considered, although it important to note that "debulking" is rarely effective in colorectal adenocarcinoma. If the metastatic disease is low volume (isolated or potentially resectable liver lesions) and the resection of the primary tumor is straightforward (segmental abdominal colectomy), it is probably reasonable to proceed with resection. On the other hand, if the metastatic disease is high volume (carcinomatosis), especially if the primary tumor is minimally symptomatic, the operation should be aborted in order to facilitate early systemic chemotherapy.
A 30-year-old man presents to the ED after a witnessed syncopal episode. He has been having bloody diarrhea and intermittent crampy abdominal pain for the past 3 months. A week later he has a colonoscopy and is found to have ulcerative colitis based on colonoscopy findings and mucosal biopsies. Which feature of listed below is NOT seen in ulcerative colitis?
Ulcerative colitis is a mucosal process in which the colonic mucosa and submucosa are infiltrated with inflammatory cells. The mucosa may be atrophic, and crypt abscesses are common. In long-standing ulcerative colitis, the colon may be foreshortened and the mucosa replaced by scar. Ulcerative colitis does not involve the small intestine, but the terminal ileum may demonstrate inflammatory changes ("backwash ileitis"). A key feature of ulcerative colitis is the continuous involvement of the rectum and colon; rectal sparing or skip lesions suggest a diagnosis of Crohn disease.
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