Pictures Of Malignant Tumors In The Rectem

Fig. 9.34a In an early phase of ulcerative colitis the residual islands of relatively normal mucosa appear as pseudopolyps. b This advanced ulcerative colitis reaches from the rectum to the splenic flexure of the colon, producing the typical aspect of a "rigid tube."

I Radiation Stenosis of the Rectum

I Radiation Stenosis of the Rectum

Malignant Tumor Rectal
Fig. 9.35 This woman had a pelvic malignant tumor and underwent radiation therapy. Now the rectum in the presacral region is fibrotic and stenosed.

I Tapeworm in the Colon

Ulcerative Colitis Stool Pattern
Fig. 9.36 The two parallel lines within the bowel lumen (arrows) indicate the outer wall of the worm. The contrast medium between them is in the bowel of the tapeworm: bowel in bowel, so to say.

Ulcerative colitis: Ulcerative colitis is different from Crohn disease in that it has a different pattern of intestinal involvement. It begins in the rectum and progresses proxi-mally in a continuous fashion (Fig. 9.34). Fistulas are hardly ever seen. Up to 10 % of all patients per year develop colon cancer, typically after several years of disease, which is why a total colectomy is often performed. Nowadays colorectal surgeons can preserve the patient's anal sphincter and build a new rectal pouch from small bowel, so that the patients can have a fairly normal life even without their colon and without the need for any external appliances.

Radiation colitis: Radiation colitis may develop after radiation therapy has been given to the abdomen and pelvis, for example, in pelvic tumors. Ulcerations and a bowel wall swelling arise that may ultimately result in a segmental bowel stenosis (Fig. 9.35).

I The Ultimate Bleed

I The Ultimate Bleed

Radiation Colitis Radiology

Fig. 9.37 a-c Arteriography of the mesenteric vessels is the modality of choice if the hemorrhage necessitates the infusion of packed red cells. The arterial phase (a) shows contrast extravasation into a jejunal loop (arrow). A later image after the clearance of vascular contrast demonstrates a persistent con trast depot in this location (b), which illustrates the force of the bleed. After several embolization coils have been deployed into the major feeding vessels, the bleeding is stopped

Fig. 9.37 a-c Arteriography of the mesenteric vessels is the modality of choice if the hemorrhage necessitates the infusion of packed red cells. The arterial phase (a) shows contrast extravasation into a jejunal loop (arrow). A later image after the clearance of vascular contrast demonstrates a persistent con trast depot in this location (b), which illustrates the force of the bleed. After several embolization coils have been deployed into the major feeding vessels, the bleeding is stopped

Parasitosis of the colon: Parasites, for example, tapeworms (Fig. 9.36), may set up shop in the bowel as well and need to be considered in the differential diagnosis, especially if the patient has recently traveled to an endemic area or enjoys raw food.

• Diagnosis: Paul has checked the whole list of differential diagnoses, but the appearance, the patient's age, and sheer probability have led him to come to a straightforward conclusion: This is a sigmoid cancer that has led to a partial obstruction of the sigmoid colon. Diverticulitis could certainly produce a similar appearance, but the symptoms do not fit and other diverticula cannot be found. Llewellyn calls Mrs. Herbgarden's primary care physician. He arranges an urgent appointment for her in the surgical clinic during this conversation. Mrs. Herbgarden will visit her physician the next morning to find out about the result of the study and the treatment options. Dr. Llewellyn takes a little time to tell Paul about the diagnostic handling of more intense and acute bleeds into the gastrointestinal lumen. "If endoscopy is impossible or does not yield any results, radiology comes into the picture. Basically it is the small and large bowel that need to be looked at in that setting. Angiography is the modality for really strong bleeds [Fig. 9.37a-c]. But if the patient does not require infusions of blood at the time of the intervention, chances are low of detecting the source of bleeding with a catheter-based contrast injection into a blood vessel: in that case don't even try an angiogram! On the other hand, if you find it you can embolize it right away! In lower intensity bleeds, nuclear medicine is your only chance: a blood pool scan will show bleeds of as little as 0.1 ml per minute. And you can image the patient over and over again in the first 24 hours after injection without giving more drug, so you can wait until they bleed again and then hunt for the source [Fig. 9.37d, e]."

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