1. POLIPI
COLONICI Definitie. Clasificare. Polipii colonici reprezinta leziuni supradenivelate (protruzive), bine delimitate, dezvoltate la nivelul mucoasei colonice. Importanta clinica a acestor leziuni este deosebita, deoarece sunt considerate leziuni precanceroase, raspunzatoare pentru aparitia majoritatii cancerelor colorectale. Identificarea si rezectia endoscopica a acestor leziuni, precum si supravegherea ulterioara a pacientilor scad sau chiar inlatura riscul individual de cancer colorectal. Aspectul polipilor colonici este variabil ca forma, dimensiuni si localizare. Pot fi sesili, cu o baza larga de implantare sau pediculati, avand un pedicul (“piciorus”) care uneste capul polipului de peretele colonic. In functie de dimensiune, pot fi mici (sub 5 mm), medii (5-15 mm) si mari (peste 15 mm), acestia din urma prezentand un risc crescut de transformare maligna. Polipii pot aparea oriunde la nivelul colonului, avand insa o predispozitie pentru colonul stang (decendent, sigmoid) in 70% din cazuri. De aceea, rectosigmoidoscopia flexibila reprezinta o metoda excelenta si cost-eficienta pentru depistarea acestor leziuni. Substratul histologic al polipilor colonici este variat, determinand diferente in ceea ce priveste istoria naturala, evolutia si prognosticul. Schematic, polipii pot fi “adenomatosi” (tubulari, vilosi sau tubulo-vilosi), caracterizati prin atipii glandulare variabile si potential evolutiv catre cancerul colorectal, si “non-adenomatosi” (hiperplazici), cu consecinte clinice minore. De aceea, abordarea corecta a acestor leziuni porneste intotdeauna de la examenul anatomo-patologic (microscopic). Transformarea polipilor adenomatosi in cancer este un proces imprevizibil, cu o durata variabila (intre 2 si 10 ani), riscul crescand cu marimea, tipul histologic, numarul polipilor, varsta pacientului. Malignizarea este doar una din posibilele cai de evolutie ale unui polip, si se caracterizeaza prin acumularea de mutatii genetice succesive in celulele glandulare epiteliale. Incidenta polipilor colonici in studiile endoscopice creste cu varsta, de la 10% la 45 ani pana la 40-50% la persoane peste 55-60 ani. Dintre acestia, peste 75% sunt adenoame, in special cei cu dimensiuni de peste 5 mm. Diagnostic. De cele mai multe ori, polipii colonici sunt diagnosticati intamplator in cadrul examenelor colonoscopice, fiind asimptomatici. Uneori, polipii mari, de peste 10 mm, situati distal se pot manifesta prin sangerare (rectoragii), ceea ce trebuie sa reprezinte un semn de alarma. De aceea, colonoscopia este obligatorie in orice sangerare rectala, pentru precizarea diagnosticului. Colonoscopia, spre deosebire de alte metode, ofera posibilitatea descrierii amanuntite a polipului, oferind detalii asupra localizarii, dimensiunilor, formei, aspectului mucoasei si permite in acelasi timp prelevarea de biopsii pentru examenul microscopic. Modificarile tranzitului intestinal (diaree si/sau constipatie) pot apare in cazul polipilor voluminosi, localizati distal. Tratament. Polipectomia endoscopica (indepartarea polipilor in cursul colonoscopiei) reprezinta metoda optima pentru tratamentul polipilor rectocolonici. Leziunile polipoide trebuie excizate complet si recuperate pentru examenul histologic. De asemenea este necesara examinarea endoscopica a intregului colon pentru a depista eventuale leziuni asociate. Ulterior, este necesara supravegherea colonoscopica a pacientilor la 1 an postpolipectomie iar apoi individualizat in functie de caracteristicile polipilor excizati. In Clinicile Proctomed, rectosigmoidoscopiile se efectueaza cu aparatura de ultima generatie, de catre medici gastroenterologi cu experienta in endoscopia digestiva diagnostica si terapeutica. O analiza interna retrospectiva pe un numar de 700 de pacienti investigati si tratati in clinica noastra a aratat ca rectosigmoidoscopia flexibila este o procedura diagnostica sigura si eficienta, cu minim disconfort pentru pacient. Au fost diagnosticati 74 pacienti cu polipi colonici (10.5%), dintre care 19 aveau polipi multipli. Un numar total de 98 polipi au fost depistati si biopsiati, iar un procent important au fost excizati endoscopic. De asemenea 8 pacienti (1.15%) au fost diagnosticati cu cancer colo-rectal si ulterior evaluati si tratati in clinici universitare. Nu au fost inregistrate incidente in cursul rectosigmoidoscopiei. In concluzie, colonoscopia ramane metoda ideala pantru identificarea si indepartarea polipilor colorectali, avand o excelenta sensibilitate si specificitate, si reducandu-se astfel considerabil riscul de aparitie a cancerului colo-rectal. postat: 07.07.2007 2. THE IMPORTANCE OF THE ENDOSCOPIC INVESTIGATION – RECTOSIGMOIDOSCOPY, COLONOSCOPY For the patient with non-neoplasic proctological affections (the hemorrhoidal disease, the anal crack, the perianal fistula, abscess)The patient with proctological affections goes to the doctor for external bleeding through the anal channel (red blood, which accompanies or not the stool), anoperianale pains with various degrees of intensity (discomfort, poignancy, pain), hemorrhoidal prolaps (reducible or irreducible). The doctor, after a discussion with the patient, (anamnesis and the affections’ history) and after the clinical exam, (which includes in this case the rectal handle and the anuscopia) establishes a stage diagnostic. This has to be followed by subsequent investigations (pozitive diagnostic) and each of the patient’s symptoms have to be analyzed according the affection that generate it (different diagnostic with other affections). It is important to put a different diagnostic according all the signs and symptoms which made the patient go to a doctor. The bleeding with red blood through the anal channel can have as a starting point a proctological affection (hemorrhoids, anal cracks), excluding an affection with hemorrhagical situated on the rectum or on the left colon. In this case it is indicated a recosigmoidoscopy which can discover affections like: adenoids or the colonic poliposis, colonic diverticulosis, colon cancer, colon inflammable diseases (the Crohn disease, undetermined colitis), angiodisplasic lesions. The elimination of semi digested blood, cherry-coloured blood, can have as cause o lesion situated upper on the colon (transversal colon or upward colon), this time a total colonoscopy is necessary (with the visualization of the whole colic frame). Taking into consideration the gravity of the affections below we can find an explanation for the introduction of the endoscopical investigations in the diagnostical proceedings for the perianal affections and the patient should accept this investigation if he/she is adviced to undertake it, understanding its purpose. There are patients with hemorrhoidal disease which go to a proctologist because of the increase of the symptoms caused by the transit disturbances. The alternation, constipation – diarrhoea is a high suggestive symptom for a stenotising colonic affection being indicated as investigation the total colonoscopy or the barium enema. The presence of imperious stools or the emission of mucus through anus are not symptoms which can accompany the proctological affections , but they can be caused by the presence of some adenoids or some vilous tumours, easily to be diagnosed when the patient undertakes a endoscopical investigation. In many cases, the anoperianal affections can be manifestations of other diseases that can be diagnosed at that moment or, rarely, foregoing the beginning of another affection (e.g. perianal fistule in the Crohn disease). The anoperianal or hypogastric pain (usually a symptom in the proctological diseases) can be caused by the lesions situated on the rectum or sigmoid - tumors, inflammable diseases, diverticulitis – affections that can be easily discovered if the patient accepts an rectosigmoidoscopy investigation. You do not have to neglect the possibility that a pelvin abscess is actually a abcedata tumor, easily emphasized through an rectoscopic exam. In the same time, the therapeutical possibilities offered now by the endoscopice investigations are of great importance, in many cases a classical surgery being avoided in this manner. We hope that this exposal will make easier to be accepted an investigation with a higher degree of aggressiveness, but with higher benefits, through the understanding of its role by the patient. postat: 10.03.2007 |
