Category Archive Health A – Z

There are three types of rectal prolapse

• Full-thickness – The full thickness of the wall of the rectum sticks out through the anus. This is the most common type of rectal prolapse. There can be a partial or complete protrusion.
• Mucosal – Only the lining of the anus (known as the mucosa) sticks out through the anus.
• Internal – The rectum folds in on itself but does not stick out through the anus.

Patients were considered to be constipated if they had two or fewer bowel actions per week or strained for more than 25% of the time spent defecating. Incontinence of feces was graded according to Park’s classification [rx] into: –

• Grade 4 = Incontinence for solid stool.
• Grade 3 = Incontinence for liquid and flatus.
• Grade 2 = Incontinence for flatus only.
• Grade 1 = Normal.

or

Rectal prolapse and internal rectal intussusception have been classified according to the size of the prolapsed section of the rectum, a function of rectal mobility from the sacrum and infolding of the rectum. This classification also takes into account sphincter relaxation:

• Grade I – nonrelaxation of the sphincter mechanism (anismus)
• Grade II – mild intussusception
• Grade III – moderate intussusception
• Grade IV – severe intussusception
• Grade V – rectal prolapse

Rectal internal mucosal prolapse has been graded according to the level of descent of the intussusceptum, which was predictive of symptom severity:^[rx]

• First-degree prolapse – is detectable below the anorectal ring on straining
• Second degree – when it reached the dentate line
• Third-degree – when it reached the anal verge

Pathogenesis of Procidentia

Etiologic factors: 1) congenital, 2) acquired.

• At the beginning of the century Moschcowitz (rx) described the anatomical basis for a rectal prolapse as a deficient pelvic floor through which the rectum herniates. This theory was that a redundant sigmoid colon lying within the deep pelvic sac, together with the resulting acute rectosigmoid junction, caused the patient to strain excessively to evacuate. Thus, the hypothesis continued, the eventual prolapse was the result of herniation through the weakened pelvic floor.
• A latter concept suggested that rectal prolapse was actually a circumferential 2° or 3° intussusception (rx). Complete circumferential intussusception usually starts 6–8 cm from the anal verge but can continue through the anal canal (rx).

Predisposing and associated anatomical and functional factors:

• Anatomical factors include female sex, redundant rectosigmoid, a deep pouch of Douglas, patulous anus (weak internal sphincter), diastasis of levator ani muscle (defects in the pelvic floor), lack of fixation of the rectum to the sacrum. Functional factors include poor bowel habits (chronic constipation), neurologic disease including congenital anomaly, cauda equina lesion, spinal cord injury, and senility.
• The majority of patients are women (rx) and peak occurrence is in the sixth decade of life. Rectal prolapse is relatively uncommon in men; moreover, they usually present when they are less than 50 years of age.

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get rectal prolapse; not having risk factors doesn’t mean that you will not get cancer. Talk to your doctor if you think you may be at risk for rectal prolapse

• Having a family history of colon or rectal prolapse in a first-degree relative (parent, sibling, or child).
• Having a personal history of rectal prolapse of the colon, rectum, or ovary.
• Having a personal history of high-risk adenomas (colorectal polyps that are 1 centimeter or larger in size or that have cells that look abnormal under a microscope).
• Having inherited changes in certain genes that increase the risk of familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary nonpolyposis colorectal cancer).
• Having a personal history of chronic ulcerative colitis or Crohn disease for 8 years or more.
• Having three or more alcoholic drinks per day.
• Smoking cigarettes.
• Being black.
• Being obese.

Older age is the main risk factor for most rectal prolapse. The chance of getting rectal prolapse increases as you get older.

Tests that examine the rectum and colon are used to detect (find) and diagnose rectal cancer

Tests used to diagnose rectal prolapse include the following:

• Physical exam and history – An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Digital rectal exam (DRE) – An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual. In women, the vagina may also be examined.
• Anal electromyography (EMG) – This test determines if nerve damage is the reason why the anal sphincters are not working properly. It also examines the coordination between the rectum and anal muscles.
• Anal manometry – This test studies the strength of the anal sphincter muscles. A short, thin tube, inserted up into the anus and rectum, is used to measure the sphincter tightness.
• Anal ultrasound – This test helps evaluate the shape and structure of the anal sphincter muscles and surrounding tissue. In this test, a small probe is inserted up into the anus and rectum to take images of the sphincters.
• Pudendal nerve terminal motor latency test – This test measures the function of the pudendal nerves, which are involved in bowel control.
• Proctography (also called defecography) – This test is done in the radiology department. In this test, an X-ray video is taken that shows how well the rectum is functioning. The video shows how much stool the rectum can hold, how well the rectum holds the stool, and how well the rectum releases the stool.
• Colonoscopy – A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
• Biopsy – The removal of cells or tissues so they can be viewed under a microscope to check for signs of rectal prolapse. Tumor tissue that is removed during the biopsy may be checked to see if the patient is likely to have the gene mutation that causes HNPCC. This may help to plan treatment. The following tests may be used:
• Reverse transcription-polymerase chain reaction (RT–PCR) test – A laboratory test in which the amount of a genetic substance called mRNA made by a specific gene is measured. An enzyme called reverse transcriptase is used to convert a specific piece of RNA into a matching piece of DNA, which can be amplified (made in large numbers) by another enzyme called DNA polymerase. The amplified DNA copies help tell whether a specific mRNA is being made by a gene. RT–PCR can be used to check the activation of certain genes that may indicate the presence of rectal prolapse cells. This test may be used to look for certain changes in a gene or chromosome, which may help diagnose rectal prolapse.
• Immunohistochemistry – A laboratory test that uses antibodies to check for certain antigens (markers) in a sample of a patient’s tissue. The antibodies are usually linked to an enzyme or a fluorescent dye. After the antibodies bind to a specific antigen in the tissue sample, the enzyme or dye is activated, and the antigen can then be seen under a microscope. This type of test is used to help diagnose cancer and to help tell one type of cancer from another type of cancer.
• Carcinoembryonic antigen (CEA) assay – A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both rectal prolapse and normal cells. When found in higher than normal amounts, it can be a sign of rectal prolapse or other conditions.
• Anorectal manometry – measures and assesses the anal sphincter (internal and external) and rectal pressure and its function. This method is used to evaluate patients with fecal incontinence and constipation. It can directly measure the luminal pressure, including the high-pressure zone, resting pressure, squeezing pressure, rectal sensation/compliance, and the anorectal inhibitory reflex.[rx]
• Defecating proctography/Defecography – A study using X-ray imaging to evaluate anatomic defects of the anorectal region and function of the puborectalis muscle. A contrast filled paste gets initially introduced to the rectum, and the patient is instructed to defecate in a series of stages (relaxation, contraction, tensing of the abdomen, and evacuation).[rx]
• Balloon capacity and compliance test – Evaluates the function of the rectum using a device (plastic catheter with a latex balloon attached), which is inserted into the rectum and gradually filled with warm water. During this process, the volume and pressure are measured.[rx]
• Balloon evacuation study – This test is similar to the balloon capacity and compliance test in which a catheter with a small balloon gets inserted into the rectum and filled with water. Different volumes of water get loaded inside the balloon, and the patient is instructed to evacuate the balloon. This procedure is done to evaluate the opening of the anal canal and to assess the relaxation of the pelvic floor.[rx]
• Pudendal nerve terminal motor latency – A probe designed to stimulate and record nerve activity is placed on the physician’s gloved finger, which is then inserted into the rectum to measure pudendal nerve activity (latency to contraction of the anal sphincter muscle). The pudendal nerve innervates the anal sphincter muscles; therefore, this test can be used to assess any injury to that nerve.
• Electromyography – A test to measure the ability of the puborectalis muscle and sphincter muscles to relax properly. An electrode is placed inside the rectum, and the activity of these muscles gets evaluated throughout a series of stages (relaxation, contraction, and evacuation).[rx]
• Endoanal Ultrasonography – The use of ultrasound imaging to examine rectal lesions, defects, or injuries to the surrounding tissues.[rx]
• Suction rectal biopsy – Gold standard for the diagnosis of Hirschsprung disease. A biopsy is taken two cm above the dentate line, and the absence of ganglion cells on histology confirms the diagnosis. Hypertrophic nerve fibers may be present in addition to this finding.[rx]
• Contrast enema – Used as one of the diagnostic methods for Hirschsprung disease. Useful for localization of the aganglionic segment by looking for a narrowed rectum. Diagnostic confirmation is via a rectal biopsy.[rx]

Treatment of Procidentia

• Activity – Typically, the child is encouraged to walk around as soon as possible.
• Diet –  Patients are started on liquids after their surgery then advanced to a general diet.
• Antibiotics –  To help prevent or treat an infection caused by bacteria.
• Anti-nausea medicine –  To control vomiting (throwing up).
• Pain medicine –  Pain medicine can include acetaminophen (Tylenol®), ibuprofen (Motrin®), or narcotics. These medicines can be given by vein or by mouth.
• Stool softeners –  Polyethylene glycol (Miralax), Docusate (Colace) or senna are among the medications used to avoid straining after surgery.

Therapy

• Management of rectal prolapse is surgical; over 100 different procedures have been described. The existence of so many surgical options is an attestation to the lack of uniform success associated with any one single procedure. Since no procedure is a panacea, the operation selected should be matched to the physiologic condition of the patient.

Transabdominal

• Transabdominal repairs involve rectal fixation, rectal resection or a combination of resection and fixation. Attachment of the rectum to the sacrum can be performed using foreign material or sutures although the lateral rectal attachments can be achieved to the sacral periosteum without foreign material.
• The primary advantages of a transabdominal procedure are the lower recurrence rates and the associated improvements in incontinence as well as the preservation of a rectal reservoir. Disadvantages are that they are a more invasive procedures and do have an associated risk of postoperative sexual dysfunction in males.

Perineal procedures

• Perineal procedures are associated with a higher recurrence rate than abdominal procedures. In addition, postoperative incontinence may be exacerbated (rx). However, the benefits are related to avoiding a laparotomy and include very low morbidity and negligible disability. These operations can be done under general, regional or occasionally local anesthesia.

Encirclement procedures

• These operations are no longer used as they fail to eliminate the prolapse or to improve incontinence. Moreover high rates of infection, implant extrusion and stenosis with associated prolapse incarceration have been noted.

The most common types of surgery

• Through the abdomen – This type of surgery can be done either with a large incision or using laparoscopy — this process uses small cuts and a camera attached to an instrument so the surgeon can see what needs to be done and if there are any additional issues that need to be fixed.
• Rectal repair – This approach may be used if you are older or have other medical problems. This type of surgery can involve the inner lining of the rectum or the portion of the rectum extending out of the anus.
• Altemeier procedure – In this procedure — also called a perineal proctosigmoidectomy — the portion of the rectum extending out of the anus is cut off (amputated) and the two ends are sewn back together. The remaining structures that help support the rectum are stitched back together in an attempt to provide better support.
• Delorme procedure – In this procedure, only the inner lining of the fallen rectum is removed. The outer layer is then folded and stitched and the cut edges of the inner lining are stitched together so that rectum is now inside the anal canal.
• Laparoscopic rectal prolapse surgery – Also done through the abdomen, this procedure uses several smaller incisions. The surgeon inserts special surgical tools and a tiny camera through the abdominal incisions to repair the rectal prolapse. An emerging robotic approach uses a robot to perform the operation.
• Rectal prolapse repair through the area around the anus (perineal rectosigmoidectomy) – During the more commonly performed form of this procedure (Altemeier procedure), the surgeon pulls the rectum through the anus, removes a portion of the rectum and sigmoid and attaches the remaining rectum to the large intestine (colon). This repair is typically reserved for those who are not candidates for open or laparoscopic repair

Home Care (“What do I need to do once my child goes home?”)

• Diet –  Your child may eat a normal diet after surgery. Avoid constipating foods such as dairy products, rice and bananas.
• Activity –  Your child should avoid strenuous activity and heavy lifting for the first 1-2 weeks after laparoscopic surgery, 4-6 weeks after open surgery.
• Wound care –  Surgical incisions should be kept clean and dry for a few days after surgery. Most of the time, the stitches used in children are absorbable and do not require removal. Your surgeon will give you specific guidance regarding wound care, including when your child can shower or bathe.
• Medicines – Medicines for pain such as acetaminophen (Tylenol®l) or ibuprofen (Motrin® or Advil®) or something stronger like a narcotic may be needed to help with pain for a few days after surgery. Stool softeners and laxatives are needed to help regular stooling after surgery, especially if narcotics are still needed for pain.
• What to call the doctor for – Call your doctor for worsening belly pain, fever, vomiting, diarrhea, problems with urination, or if the wounds are red or draining fluid.
• Follow-up care – Your child should follow up with his or her surgeon 2-3 weeks after surgery to ensure proper post-operative healing.

Long-Term Outcomes (“Are there future conditions to worry about?”)

• The long-term prognosis for children with rectal prolapse is good. More than 90 percent of children who experience rectal prolapse between nine months and three years of age will respond to medical treatment and will not require surgery.
• Children who develop rectal prolapse after the age of four are more likely to have underlying neurologic or muscular defects of the pelvis. These children are less likely to respond to medical treatments and should be seen early for surgical intervention.

References

There are three types of rectal prolapse

• Full-thickness – The full thickness of the wall of the rectum sticks out through the anus. This is the most common type of rectal prolapse. There can be a partial or complete protrusion.
• Mucosal – Only the lining of the anus (known as the mucosa) sticks out through the anus.
• Internal – The rectum folds in on itself but does not stick out through the anus.

Patients were considered to be constipated if they had two or fewer bowel actions per week or strained for more than 25% of the time spent defecating. Incontinence of feces was graded according to Park’s classification [rx] into: –

• Grade 4 = Incontinence for solid stool.
• Grade 3 = Incontinence for liquid and flatus.
• Grade 2 = Incontinence for flatus only.
• Grade 1 = Normal.

or

Rectal prolapse and internal rectal intussusception have been classified according to the size of the prolapsed section of the rectum, a function of rectal mobility from the sacrum and infolding of the rectum. This classification also takes into account sphincter relaxation:

• Grade I – nonrelaxation of the sphincter mechanism (anismus)
• Grade II – mild intussusception
• Grade III – moderate intussusception
• Grade IV – severe intussusception
• Grade V – rectal prolapse

Rectal internal mucosal prolapse has been graded according to the level of descent of the intussusceptum, which was predictive of symptom severity:^[rx]

• First-degree prolapse – is detectable below the anorectal ring on straining
• Second degree – when it reached the dentate line
• Third-degree – when it reached the anal verge

Pathogenesis of Rectal Prolapse

Etiologic factors: 1) congenital, 2) acquired.

• At the beginning of the century Moschcowitz (rx) described the anatomical basis for a rectal prolapse as a deficient pelvic floor through which the rectum herniates. This theory was that a redundant sigmoid colon lying within the deep pelvic sac, together with the resulting acute rectosigmoid junction, caused the patient to strain excessively to evacuate. Thus, the hypothesis continued, the eventual prolapse was the result of herniation through the weakened pelvic floor.
• A latter concept suggested that rectal prolapse was actually a circumferential 2° or 3° intussusception (rx). Complete circumferential intussusception usually starts 6–8 cm from the anal verge but can continue through the anal canal (rx).

Predisposing and associated anatomical and functional factors:

• Anatomical factors include female sex, redundant rectosigmoid, a deep pouch of Douglas, patulous anus (weak internal sphincter), diastasis of levator ani muscle (defects in the pelvic floor), lack of fixation of the rectum to the sacrum. Functional factors include poor bowel habits (chronic constipation), neurologic disease including congenital anomaly, cauda equina lesion, spinal cord injury, and senility.
• The majority of patients are women (rx) and peak occurrence is in the sixth decade of life. Rectal prolapse is relatively uncommon in men; moreover, they usually present when they are less than 50 years of age.

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get rectal prolapse; not having risk factors doesn’t mean that you will not get cancer. Talk to your doctor if you think you may be at risk for rectal prolapse

• Having a family history of colon or rectal prolapse in a first-degree relative (parent, sibling, or child).
• Having a personal history of rectal prolapse of the colon, rectum, or ovary.
• Having a personal history of high-risk adenomas (colorectal polyps that are 1 centimeter or larger in size or that have cells that look abnormal under a microscope).
• Having inherited changes in certain genes that increase the risk of familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary nonpolyposis colorectal cancer).
• Having a personal history of chronic ulcerative colitis or Crohn disease for 8 years or more.
• Having three or more alcoholic drinks per day.
• Smoking cigarettes.
• Being black.
• Being obese.

Older age is the main risk factor for most rectal prolapse. The chance of getting rectal prolapse increases as you get older.

Tests that examine the rectum and colon are used to detect (find) and diagnose rectal cancer

Tests used to diagnose rectal prolapse include the following:

• Physical exam and history – An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Digital rectal exam (DRE) – An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual. In women, the vagina may also be examined.
• Anal electromyography (EMG) – This test determines if nerve damage is the reason why the anal sphincters are not working properly. It also examines the coordination between the rectum and anal muscles.
• Anal manometry – This test studies the strength of the anal sphincter muscles. A short, thin tube, inserted up into the anus and rectum, is used to measure the sphincter tightness.
• Anal ultrasound – This test helps evaluate the shape and structure of the anal sphincter muscles and surrounding tissue. In this test, a small probe is inserted up into the anus and rectum to take images of the sphincters.
• Pudendal nerve terminal motor latency test – This test measures the function of the pudendal nerves, which are involved in bowel control.
• Proctography (also called defecography) – This test is done in the radiology department. In this test, an X-ray video is taken that shows how well the rectum is functioning. The video shows how much stool the rectum can hold, how well the rectum holds the stool, and how well the rectum releases the stool.
• Colonoscopy – A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
• Biopsy – The removal of cells or tissues so they can be viewed under a microscope to check for signs of rectal prolapse. Tumor tissue that is removed during the biopsy may be checked to see if the patient is likely to have the gene mutation that causes HNPCC. This may help to plan treatment. The following tests may be used:
• Reverse transcription-polymerase chain reaction (RT–PCR) test – A laboratory test in which the amount of a genetic substance called mRNA made by a specific gene is measured. An enzyme called reverse transcriptase is used to convert a specific piece of RNA into a matching piece of DNA, which can be amplified (made in large numbers) by another enzyme called DNA polymerase. The amplified DNA copies help tell whether a specific mRNA is being made by a gene. RT–PCR can be used to check the activation of certain genes that may indicate the presence of rectal prolapse cells. This test may be used to look for certain changes in a gene or chromosome, which may help diagnose rectal prolapse.
• Immunohistochemistry – A laboratory test that uses antibodies to check for certain antigens (markers) in a sample of a patient’s tissue. The antibodies are usually linked to an enzyme or a fluorescent dye. After the antibodies bind to a specific antigen in the tissue sample, the enzyme or dye is activated, and the antigen can then be seen under a microscope. This type of test is used to help diagnose cancer and to help tell one type of cancer from another type of cancer.
• Carcinoembryonic antigen (CEA) assay – A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both rectal prolapse and normal cells. When found in higher than normal amounts, it can be a sign of rectal prolapse or other conditions.
• Anorectal manometry – measures and assesses the anal sphincter (internal and external) and rectal pressure and its function. This method is used to evaluate patients with fecal incontinence and constipation. It can directly measure the luminal pressure, including the high-pressure zone, resting pressure, squeezing pressure, rectal sensation/compliance, and the anorectal inhibitory reflex.[rx]
• Defecating proctography/Defecography – A study using X-ray imaging to evaluate anatomic defects of the anorectal region and function of the puborectalis muscle. A contrast filled paste gets initially introduced to the rectum, and the patient is instructed to defecate in a series of stages (relaxation, contraction, tensing of the abdomen, and evacuation).[rx]
• Balloon capacity and compliance test – Evaluates the function of the rectum using a device (plastic catheter with a latex balloon attached), which is inserted into the rectum and gradually filled with warm water. During this process, the volume and pressure are measured.[rx]
• Balloon evacuation study – This test is similar to the balloon capacity and compliance test in which a catheter with a small balloon gets inserted into the rectum and filled with water. Different volumes of water get loaded inside the balloon, and the patient is instructed to evacuate the balloon. This procedure is done to evaluate the opening of the anal canal and to assess the relaxation of the pelvic floor.[rx]
• Pudendal nerve terminal motor latency – A probe designed to stimulate and record nerve activity is placed on the physician’s gloved finger, which is then inserted into the rectum to measure pudendal nerve activity (latency to contraction of the anal sphincter muscle). The pudendal nerve innervates the anal sphincter muscles; therefore, this test can be used to assess any injury to that nerve.
• Electromyography – A test to measure the ability of the puborectalis muscle and sphincter muscles to relax properly. An electrode is placed inside the rectum, and the activity of these muscles gets evaluated throughout a series of stages (relaxation, contraction, and evacuation).[rx]
• Endoanal Ultrasonography – The use of ultrasound imaging to examine rectal lesions, defects, or injuries to the surrounding tissues.[rx]
• Suction rectal biopsy – Gold standard for the diagnosis of Hirschsprung disease. A biopsy is taken two cm above the dentate line, and the absence of ganglion cells on histology confirms the diagnosis. Hypertrophic nerve fibers may be present in addition to this finding.[rx]
• Contrast enema – Used as one of the diagnostic methods for Hirschsprung disease. Useful for localization of the aganglionic segment by looking for a narrowed rectum. Diagnostic confirmation is via a rectal biopsy.[rx]

Treatment of Rectal Prolapse

• Activity – Typically, the child is encouraged to walk around as soon as possible.
• Diet –  Patients are started on liquids after their surgery then advanced to a general diet.
• Antibiotics –  To help prevent or treat an infection caused by bacteria.
• Anti-nausea medicine –  To control vomiting (throwing up).
• Pain medicine –  Pain medicine can include acetaminophen (Tylenol®), ibuprofen (Motrin®), or narcotics. These medicines can be given by vein or by mouth.
• Stool softeners –  Polyethylene glycol (Miralax), Docusate (Colace) or senna are among the medications used to avoid straining after surgery.

Therapy

• Management of rectal prolapse is surgical; over 100 different procedures have been described. The existence of so many surgical options is an attestation to the lack of uniform success associated with any one single procedure. Since no procedure is a panacea, the operation selected should be matched to the physiologic condition of the patient.

Transabdominal

• Transabdominal repairs involve rectal fixation, rectal resection or a combination of resection and fixation. Attachment of the rectum to the sacrum can be performed using foreign material or sutures although the lateral rectal attachments can be achieved to the sacral periosteum without foreign material.
• The primary advantages of a transabdominal procedure are the lower recurrence rates and the associated improvements in incontinence as well as the preservation of a rectal reservoir. Disadvantages are that they are a more invasive procedures and do have an associated risk of postoperative sexual dysfunction in males.

Perineal procedures

• Perineal procedures are associated with a higher recurrence rate than abdominal procedures. In addition, postoperative incontinence may be exacerbated (rx). However, the benefits are related to avoiding a laparotomy and include very low morbidity and negligible disability. These operations can be done under general, regional or occasionally local anesthesia.

Encirclement procedures

• These operations are no longer used as they fail to eliminate the prolapse or to improve incontinence. Moreover high rates of infection, implant extrusion and stenosis with associated prolapse incarceration have been noted.

The most common types of surgery

• Through the abdomen – This type of surgery can be done either with a large incision or using laparoscopy — this process uses small cuts and a camera attached to an instrument so the surgeon can see what needs to be done and if there are any additional issues that need to be fixed.
• Rectal repair – This approach may be used if you are older or have other medical problems. This type of surgery can involve the inner lining of the rectum or the portion of the rectum extending out of the anus.
• Altemeier procedure – In this procedure — also called a perineal proctosigmoidectomy — the portion of the rectum extending out of the anus is cut off (amputated) and the two ends are sewn back together. The remaining structures that help support the rectum are stitched back together in an attempt to provide better support.
• Delorme procedure – In this procedure, only the inner lining of the fallen rectum is removed. The outer layer is then folded and stitched and the cut edges of the inner lining are stitched together so that rectum is now inside the anal canal.
• Laparoscopic rectal prolapse surgery – Also done through the abdomen, this procedure uses several smaller incisions. The surgeon inserts special surgical tools and a tiny camera through the abdominal incisions to repair the rectal prolapse. An emerging robotic approach uses a robot to perform the operation.
• Rectal prolapse repair through the area around the anus (perineal rectosigmoidectomy) – During the more commonly performed form of this procedure (Altemeier procedure), the surgeon pulls the rectum through the anus, removes a portion of the rectum and sigmoid and attaches the remaining rectum to the large intestine (colon). This repair is typically reserved for those who are not candidates for open or laparoscopic repair

Home Care (“What do I need to do once my child goes home?”)

• Diet –  Your child may eat a normal diet after surgery. Avoid constipating foods such as dairy products, rice and bananas.
• Activity –  Your child should avoid strenuous activity and heavy lifting for the first 1-2 weeks after laparoscopic surgery, 4-6 weeks after open surgery.
• Wound care –  Surgical incisions should be kept clean and dry for a few days after surgery. Most of the time, the stitches used in children are absorbable and do not require removal. Your surgeon will give you specific guidance regarding wound care, including when your child can shower or bathe.
• Medicines – Medicines for pain such as acetaminophen (Tylenol®l) or ibuprofen (Motrin® or Advil®) or something stronger like a narcotic may be needed to help with pain for a few days after surgery. Stool softeners and laxatives are needed to help regular stooling after surgery, especially if narcotics are still needed for pain.
• What to call the doctor for – Call your doctor for worsening belly pain, fever, vomiting, diarrhea, problems with urination, or if the wounds are red or draining fluid.
• Follow-up care – Your child should follow up with his or her surgeon 2-3 weeks after surgery to ensure proper post-operative healing.

Long-Term Outcomes (“Are there future conditions to worry about?”)

• The long-term prognosis for children with rectal prolapse is good. More than 90 percent of children who experience rectal prolapse between nine months and three years of age will respond to medical treatment and will not require surgery.
• Children who develop rectal prolapse after the age of four are more likely to have underlying neurologic or muscular defects of the pelvis. These children are less likely to respond to medical treatments and should be seen early for surgical intervention.

References

There are three types of rectal prolapse:

• Full-thickness – The full thickness of the wall of the rectum sticks out through the anus. This is the most common type of rectal prolapse. There can be a partial or complete protrusion.
• Mucosal – Only the lining of the anus (known as the mucosa) sticks out through the anus.
• Internal – The rectum folds in on itself but does not stick out through the anus.

Patients were considered to be constipated if they had two or fewer bowel actions per week or strained for more than 25% of the time spent defecating. Incontinence of feces was graded according to Park’s classification [rx] into: –

• Grade 4 = Incontinence for solid stool.
• Grade 3 = Incontinence for liquid and flatus.
• Grade 2 = Incontinence for flatus only.
• Grade 1 = Normal.

or

Rectal prolapse and internal rectal intussusception have been classified according to the size of the prolapsed section of the rectum, a function of rectal mobility from the sacrum and infolding of the rectum. This classification also takes into account sphincter relaxation:

• Grade I – nonrelaxation of the sphincter mechanism (anismus)
• Grade II – mild intussusception
• Grade III – moderate intussusception
• Grade IV – severe intussusception
• Grade V – rectal prolapse

Rectal internal mucosal prolapse has been graded according to the level of descent of the intussusceptum, which was predictive of symptom severity:^[rx]

• First-degree prolapse – is detectable below the anorectal ring on straining
• Second degree – when it reached the dentate line
• Third-degree – when it reached the anal verge

Pathogenesis of Rectal Prolapse

Etiologic factors: 1) congenital, 2) acquired.

• At the beginning of the century Moschcowitz (rx) described the anatomical basis for a rectal prolapse as a deficient pelvic floor through which the rectum herniates. This theory was that a redundant sigmoid colon lying within the deep pelvic sac, together with the resulting acute rectosigmoid junction, caused the patient to strain excessively to evacuate. Thus, the hypothesis continued, the eventual prolapse was the result of herniation through the weakened pelvic floor.
• A latter concept suggested that rectal prolapse was actually a circumferential 2° or 3° intussusception (rx). Complete circumferential intussusception usually starts 6–8 cm from the anal verge but can continue through the anal canal (rx).

Predisposing and associated anatomical and functional factors:

• Anatomical factors include female sex, redundant rectosigmoid, a deep pouch of Douglas, patulous anus (weak internal sphincter), diastasis of levator ani muscle (defects in the pelvic floor), lack of fixation of the rectum to the sacrum. Functional factors include poor bowel habits (chronic constipation), neurologic disease including congenital anomaly, cauda equina lesion, spinal cord injury, and senility.
• The majority of patients are women (rx) and peak occurrence is in the sixth decade of life. Rectal prolapse is relatively uncommon in men; moreover, they usually present when they are less than 50 years of age.

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get rectal prolapse; not having risk factors doesn’t mean that you will not get cancer. Talk to your doctor if you think you may be at risk for rectal prolapse

• Having a family history of colon or rectal prolapse in a first-degree relative (parent, sibling, or child).
• Having a personal history of rectal prolapse of the colon, rectum, or ovary.
• Having a personal history of high-risk adenomas (colorectal polyps that are 1 centimeter or larger in size or that have cells that look abnormal under a microscope).
• Having inherited changes in certain genes that increase the risk of familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary nonpolyposis colorectal cancer).
• Having a personal history of chronic ulcerative colitis or Crohn disease for 8 years or more.
• Having three or more alcoholic drinks per day.
• Smoking cigarettes.
• Being black.
• Being obese.

Older age is the main risk factor for most rectal prolapse. The chance of getting rectal prolapse increases as you get older.

Tests that examine the rectum and colon are used to detect (find) and diagnose rectal cancer

Tests used to diagnose rectal prolapse include the following:

• Physical exam and history – An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Digital rectal exam (DRE) – An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual. In women, the vagina may also be examined.
• Anal electromyography (EMG) – This test determines if nerve damage is the reason why the anal sphincters are not working properly. It also examines the coordination between the rectum and anal muscles.
• Anal manometry – This test studies the strength of the anal sphincter muscles. A short, thin tube, inserted up into the anus and rectum, is used to measure the sphincter tightness.
• Anal ultrasound – This test helps evaluate the shape and structure of the anal sphincter muscles and surrounding tissue. In this test, a small probe is inserted up into the anus and rectum to take images of the sphincters.
• Pudendal nerve terminal motor latency test – This test measures the function of the pudendal nerves, which are involved in bowel control.
• Proctography (also called defecography) – This test is done in the radiology department. In this test, an X-ray video is taken that shows how well the rectum is functioning. The video shows how much stool the rectum can hold, how well the rectum holds the stool, and how well the rectum releases the stool.
• Colonoscopy – A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
• Biopsy – The removal of cells or tissues so they can be viewed under a microscope to check for signs of rectal prolapse. Tumor tissue that is removed during the biopsy may be checked to see if the patient is likely to have the gene mutation that causes HNPCC. This may help to plan treatment. The following tests may be used:
• Reverse transcription-polymerase chain reaction (RT–PCR) test – A laboratory test in which the amount of a genetic substance called mRNA made by a specific gene is measured. An enzyme called reverse transcriptase is used to convert a specific piece of RNA into a matching piece of DNA, which can be amplified (made in large numbers) by another enzyme called DNA polymerase. The amplified DNA copies help tell whether a specific mRNA is being made by a gene. RT–PCR can be used to check the activation of certain genes that may indicate the presence of rectal prolapse cells. This test may be used to look for certain changes in a gene or chromosome, which may help diagnose rectal prolapse.
• Immunohistochemistry – A laboratory test that uses antibodies to check for certain antigens (markers) in a sample of a patient’s tissue. The antibodies are usually linked to an enzyme or a fluorescent dye. After the antibodies bind to a specific antigen in the tissue sample, the enzyme or dye is activated, and the antigen can then be seen under a microscope. This type of test is used to help diagnose cancer and to help tell one type of cancer from another type of cancer.
• Carcinoembryonic antigen (CEA) assay – A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both rectal prolapse and normal cells. When found in higher than normal amounts, it can be a sign of rectal prolapse or other conditions.
• Anorectal manometry – measures and assesses the anal sphincter (internal and external) and rectal pressure and its function. This method is used to evaluate patients with fecal incontinence and constipation. It can directly measure the luminal pressure, including the high-pressure zone, resting pressure, squeezing pressure, rectal sensation/compliance, and the anorectal inhibitory reflex.[rx]
• Defecating proctography/Defecography – A study using X-ray imaging to evaluate anatomic defects of the anorectal region and function of the puborectalis muscle. A contrast filled paste gets initially introduced to the rectum, and the patient is instructed to defecate in a series of stages (relaxation, contraction, tensing of the abdomen, and evacuation).[rx]
• Balloon capacity and compliance test – Evaluates the function of the rectum using a device (plastic catheter with a latex balloon attached), which is inserted into the rectum and gradually filled with warm water. During this process, the volume and pressure are measured.[rx]
• Balloon evacuation study – This test is similar to the balloon capacity and compliance test in which a catheter with a small balloon gets inserted into the rectum and filled with water. Different volumes of water get loaded inside the balloon, and the patient is instructed to evacuate the balloon. This procedure is done to evaluate the opening of the anal canal and to assess the relaxation of the pelvic floor.[rx]
• Pudendal nerve terminal motor latency – A probe designed to stimulate and record nerve activity is placed on the physician’s gloved finger, which is then inserted into the rectum to measure pudendal nerve activity (latency to contraction of the anal sphincter muscle). The pudendal nerve innervates the anal sphincter muscles; therefore, this test can be used to assess any injury to that nerve.
• Electromyography – A test to measure the ability of the puborectalis muscle and sphincter muscles to relax properly. An electrode is placed inside the rectum, and the activity of these muscles gets evaluated throughout a series of stages (relaxation, contraction, and evacuation).[rx]
• Endoanal Ultrasonography – The use of ultrasound imaging to examine rectal lesions, defects, or injuries to the surrounding tissues.[rx]
• Suction rectal biopsy – Gold standard for the diagnosis of Hirschsprung disease. A biopsy is taken two cm above the dentate line, and the absence of ganglion cells on histology confirms the diagnosis. Hypertrophic nerve fibers may be present in addition to this finding.[rx]
• Contrast enema – Used as one of the diagnostic methods for Hirschsprung disease. Useful for localization of the aganglionic segment by looking for a narrowed rectum. Diagnostic confirmation is via a rectal biopsy.[rx]

Treatment of Rectal Prolapse

• Activity – Typically, the child is encouraged to walk around as soon as possible.
• Diet –  Patients are started on liquids after their surgery then advanced to a general diet.
• Antibiotics –  To help prevent or treat an infection caused by bacteria.
• Anti-nausea medicine –  To control vomiting (throwing up).
• Pain medicine –  Pain medicine can include acetaminophen (Tylenol®), ibuprofen (Motrin®), or narcotics. These medicines can be given by vein or by mouth.
• Stool softeners –  Polyethylene glycol (Miralax), Docusate (Colace) or senna are among the medications used to avoid straining after surgery.

Therapy

• Management of rectal prolapse is surgical; over 100 different procedures have been described. The existence of so many surgical options is an attestation to the lack of uniform success associated with any one single procedure. Since no procedure is a panacea, the operation selected should be matched to the physiologic condition of the patient.

Transabdominal

• Transabdominal repairs involve rectal fixation, rectal resection or a combination of resection and fixation. Attachment of the rectum to the sacrum can be performed using foreign material or sutures although the lateral rectal attachments can be achieved to the sacral periosteum without foreign material.
• The primary advantages of a transabdominal procedure are the lower recurrence rates and the associated improvements in incontinence as well as the preservation of a rectal reservoir. Disadvantages are that they are a more invasive procedures and do have an associated risk of postoperative sexual dysfunction in males.

Perineal procedures

• Perineal procedures are associated with a higher recurrence rate than abdominal procedures. In addition, postoperative incontinence may be exacerbated (rx). However, the benefits are related to avoiding a laparotomy and include very low morbidity and negligible disability. These operations can be done under general, regional or occasionally local anesthesia.

Encirclement procedures

• These operations are no longer used as they fail to eliminate the prolapse or to improve incontinence. Moreover high rates of infection, implant extrusion and stenosis with associated prolapse incarceration have been noted.

The most common types of surgery

• Through the abdomen – This type of surgery can be done either with a large incision or using laparoscopy — this process uses small cuts and a camera attached to an instrument so the surgeon can see what needs to be done and if there are any additional issues that need to be fixed.
• Rectal repair – This approach may be used if you are older or have other medical problems. This type of surgery can involve the inner lining of the rectum or the portion of the rectum extending out of the anus.
• Altemeier procedure – In this procedure — also called a perineal proctosigmoidectomy — the portion of the rectum extending out of the anus is cut off (amputated) and the two ends are sewn back together. The remaining structures that help support the rectum are stitched back together in an attempt to provide better support.
• Delorme procedure – In this procedure, only the inner lining of the fallen rectum is removed. The outer layer is then folded and stitched and the cut edges of the inner lining are stitched together so that rectum is now inside the anal canal.
• Laparoscopic rectal prolapse surgery – Also done through the abdomen, this procedure uses several smaller incisions. The surgeon inserts special surgical tools and a tiny camera through the abdominal incisions to repair the rectal prolapse. An emerging robotic approach uses a robot to perform the operation.
• Rectal prolapse repair through the area around the anus (perineal rectosigmoidectomy) – During the more commonly performed form of this procedure (Altemeier procedure), the surgeon pulls the rectum through the anus, removes a portion of the rectum and sigmoid and attaches the remaining rectum to the large intestine (colon). This repair is typically reserved for those who are not candidates for open or laparoscopic repair

Home Care (“What do I need to do once my child goes home?”)

• Diet –  Your child may eat a normal diet after surgery. Avoid constipating foods such as dairy products, rice and bananas.
• Activity –  Your child should avoid strenuous activity and heavy lifting for the first 1-2 weeks after laparoscopic surgery, 4-6 weeks after open surgery.
• Wound care –  Surgical incisions should be kept clean and dry for a few days after surgery. Most of the time, the stitches used in children are absorbable and do not require removal. Your surgeon will give you specific guidance regarding wound care, including when your child can shower or bathe.
• Medicines – Medicines for pain such as acetaminophen (Tylenol®l) or ibuprofen (Motrin® or Advil®) or something stronger like a narcotic may be needed to help with pain for a few days after surgery. Stool softeners and laxatives are needed to help regular stooling after surgery, especially if narcotics are still needed for pain.
• What to call the doctor for – Call your doctor for worsening belly pain, fever, vomiting, diarrhea, problems with urination, or if the wounds are red or draining fluid.
• Follow-up care – Your child should follow up with his or her surgeon 2-3 weeks after surgery to ensure proper post-operative healing.

Long-Term Outcomes (“Are there future conditions to worry about?”)

• The long-term prognosis for children with rectal prolapse is good. More than 90 percent of children who experience rectal prolapse between nine months and three years of age will respond to medical treatment and will not require surgery.
• Children who develop rectal prolapse after the age of four are more likely to have underlying neurologic or muscular defects of the pelvis. These children are less likely to respond to medical treatments and should be seen early for surgical intervention.

References

Incidence and Mortality

It is difficult to separate epidemiological considerations of rectal cancer from those of colon cancer because epidemiological studies often consider colon and rectal cancer (i.e., colorectal cancer) together.

Worldwide, colorectal cancer is the third most common form of cancer. In 2012, there were an estimated 1.36 million new cases of colorectal cancer and 694,000 deaths.[1]

Estimated new cases and deaths from rectal and colon cancer in the United States in 2020:[2]

• New cases of rectal cancer: 43,340.
• New cases of colon cancer: 104,610.
• Deaths: 53,200 (rectal and colon cancers combined).

Colorectal cancer affects men and women almost equally. Among all racial groups in the United States, African Americans have the highest sporadic colorectal cancer incidence and mortality rates.[3,4]

Anatomy

Anatomy of the lower gastrointestinal system.

The rectum is located within the pelvis, extending from the transitional mucosa of the anal dentate line to the sigmoid colon at the peritoneal reflection; by rigid sigmoidoscopy, the rectum measures between 10 cm and 15 cm from the anal verge.[5] The location of a rectal tumor is usually indicated by the distance between the anal verge, dentate line, or anorectal ring and the lower edge of the tumor, with measurements differing depending on the use of a rigid or flexible endoscope or digital examination.[6]

The distance of the tumor from the anal sphincter musculature has implications for the ability to perform sphincter-sparing surgery. The bony constraints of the pelvis limit surgical access to the rectum, which results in a lesser likelihood of attaining widely negative margins and a higher risk of local recurrence.[5]

Risk Factors

Increasing age is the most important risk factor for most cancers. Other risk factors for colorectal cancer include the following:

• Family history of colorectal cancer in a first-degree relative.[7]
• Personal history of colorectal adenomas, colorectal cancer, or ovarian cancer.[8–10]
• Hereditary conditions, including familial adenomatous polyposis (FAP) and Lynch syndrome (hereditary nonpolyposis colorectal cancer [HNPCC]).[11]
• Personal history of long-standing chronic ulcerative colitis or Crohn colitis.[12]
• Excessive alcohol use.[13]
• Cigarette smoking.[14]
• Race/ethnicity: African American.[15,16]
• Obesity.[17]

Screening

Evidence supports screening for rectal cancer as a part of routine care for all adults aged 50 years and older, especially for those with first-degree relatives with colorectal cancer, for the following reasons:

• Incidence of the disease in those 50 years and older.
• Ability to identify high-risk groups.
• Slow growth of primary lesions.
• Better survival of patients with early-stage lesions.
• Relative simplicity and accuracy of screening tests.

(Refer to the PDQ summary on Colorectal Cancer Screening for more information.)

Clinical Features

Similar to colon cancer, symptoms of rectal cancer may include the following:[18]

• Rectal bleeding.
• Change in bowel habits.
• Abdominal pain.
• Intestinal obstruction.
• Change in appetite.
• Weight loss.
• Weakness.

With the exception of obstructive symptoms, these symptoms do not necessarily correlate with the stage of disease or signify a particular diagnosis.[19]

Diagnostic Evaluation

The initial clinical evaluation may include the following:

• Physical exam and history.
• Digital rectal exam.
• Colonoscopy.
• Biopsy.
• Carcinoembryonic antigen (CEA) assay.
• Reverse-transcription polymerase chain reaction test.
• Immunohistochemistry.

Physical examination may reveal a palpable mass and bright blood in the rectum. Adenopathy, hepatomegaly, or pulmonary signs may be present with metastatic disease.[6] Laboratory examination may reveal iron-deficiency anemia and electrolyte and liver function abnormalities.

Prognostic Factors

The prognosis of patients with rectal cancer is related to several factors, including the following:[6,20–28]

• Tumor adherence to or invasion of adjacent organs.[20]
• Presence or absence of tumor involvement in the lymph nodes and the number of positive lymph nodes.[6,21–24]
• Presence or absence of distant metastases.[6,20]
• Perforation or obstruction of the bowel.[6,28]
• Presence or absence of high-risk pathologic features, including the following:[26,27,29]
• Positive surgical margins.
• Lymphovascular invasion.
• Perineural invasion.
• Poorly differentiated histology.
• Circumferential resection margin (CRM) or depth of penetration of the tumor through the bowel wall.[6,25,30] Measured in millimeters, CRM is defined as the retroperitoneal or peritoneal adventitial soft-tissue margin closest to the deepest penetration of tumor.

Only disease stage (designated by tumor [T], nodal status [N], and distant metastasis [M]) has been validated as a prognostic factor in multi-institutional prospective studies.[20–25] A major pooled analysis evaluating the impact of T and N stage and treatment on survival and relapse in patients with rectal cancer who are treated with adjuvant therapy has been published and confirms these findings.[31]

Follow-up After Treatment

The primary goals of postoperative surveillance programs for rectal cancer are:[43]

• To assess the efficacy of initial therapy.
• To detect new or metachronous malignancies.
• To detect potentially curable recurrent or metastatic cancers.

Routine, periodic studies following treatment for rectal cancer may lead to earlier identification and management of recurrent disease.[43–47] A statistically significant survival benefit has been demonstrated for more intensive follow-up protocols in two clinical trials. A meta-analysis that combined these two trials with four others reported a statistically significant improvement in survival for patients who were intensively followed.[43,48,49]

Guidelines for surveillance after initial treatment with curative intent for colorectal cancer vary between leading U.S. and European oncology societies, and optimal surveillance strategies remain uncertain.[50,51] Large, well-designed, prospective, multi-institutional, randomized studies are required to establish an evidence-based consensus for follow-up evaluation.

Epithelial Tumors

Adenoma

• Tubular.
• Villous.
• Tubulovillous.
• Serrated.

Carcinoma

• Adenocarcinoma.
• Mucinous adenocarcinoma.
• Signet-ring cell carcinoma.
• Small cell carcinoma.
• Adenosquamous carcinoma.
• Medullary carcinoma.
• Undifferentiated carcinoma.

Carcinoid (well-differentiated neuroendocrine neoplasm)

• Enterochromaffin-cell, serotonin-producing neoplasm.
• L-cell, glucagon-like peptide and pancreatic polypeptide/peptide YY–producing tumor.
• Others.

Intraepithelial neoplasia (dysplasia) associated with chronic inflammatory diseases

• Low-grade glandular intraepithelial neoplasia.
• High-grade glandular intraepithelial neoplasia.

Mixed carcinoma-adenocarcinoma

• Others.

Nonepithelial Tumors

• Lipoma.
• Leiomyoma.
• Gastrointestinal stromal tumor. (Refer to the PDQ summary on Gastrointestinal Stromal Tumors Treatment (Adult) for more information.)
• Leiomyosarcoma.
• Angiosarcoma.
• Kaposi sarcoma. (Refer to the PDQ summary on Kaposi Sarcoma Treatment for more information.)
• Melanoma. (Refer to the PDQ summary on Melanoma Treatment for more information.)
• Others.

Malignant lymphomas

• Marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type.
• Mantle cell lymphoma.
• Diffuse large B-cell lymphoma.
• Burkitt lymphoma.
• Burkitt-like/atypical Burkitt lymphoma.

Staging Evaluation

Clinical evaluation and staging procedures may include the following:

• Digital-rectal examination (DRE): DRE and/or rectovaginal exam and rigid proctoscopy to determine if sphincter-saving surgery is possible.[1,2,5]
• Colonoscopy: Complete colonoscopy to rule out cancers elsewhere in the bowel.[5]
• Computed tomography (CT): Pan-body CT scan to rule out metastatic disease.[5]
• Magnetic resonance imaging (MRI): MRI of the abdomen and pelvis to determine the depth of penetration and the potential for achieving negative circumferential (radial) margins and to identify locoregional nodal metastases and distant metastatic disease. MRI may be particularly helpful in determining sacral involvement in local recurrence.[1]
• Endorectal ultrasound: Endorectal ultrasound with a rigid probe or a flexible scope for stenotic lesions to determine the depth of penetration and identify locoregional nodal metastases.[2,4]
• Positron emission tomography (PET): PET to image distant metastatic disease.[1]
• Carcinoembryonic antigen (CEA): Measurement of the serum CEA level for prognostic assessment and the determination of response to therapy.[6,7]

AJCC Stage Groupings and TNM Definitions

The AJCC has designated staging by TNM (tumor, node, metastasis) classification to define rectal cancer.[11] The same classification is used for both clinical and pathologic staging.[11] Treatment decisions are made with reference to the TNM classification system, rather than the older Dukes or Modified Astler-Coller classification schema.

Cancers staged using this staging system include adenocarcinomas, high-grade neuroendocrine carcinomas, and squamous carcinomas of the colon and rectum. Cancers not staged using this staging system include these histopathologic types of cancer: appendiceal carcinomas, anal carcinomas, well-differentiated neuroendocrine tumors (carcinoids).[11]

Primary Surgical Therapy

The primary treatment for patients with rectal cancer is surgical resection of the primary tumor. The surgical approach to treatment varies according to the following:

• Tumor location.
• Stage of disease.
• Presence or absence of high-risk features (i.e., positive margins, lymphovascular invasion, perineural invasion, and poorly differentiated histology).

Types of surgical resection include the following:[1–3]

• Polypectomy for select T1 cancers.
• Transanal local excision and transanal endoscopic microsurgery for select clinically staged T1/T2 N0 rectal cancers.
• Total mesorectal excision with autonomic nerve preservation techniques via low-anterior resection.
• Total mesorectal excision via abdominoperineal resection for patients who are not candidates for sphincter-preservation, leaving patients with a permanent end-colostomy.

Polypectomy alone may be used in certain instances (T1) in which polyps with invasive cancer can be completely resected with clear margins and have favorable histologic features.[4,5]

Local excision of clinical T1 tumors is an acceptable surgical technique for appropriately selected patients. For all other tumors, a mesorectal excision is the treatment of choice. Very select patients with T2 tumors may be candidates for local excision. Local failure rates in the range of 4% to 8% after rectal resection with appropriate mesorectal excision (total mesorectal excision for low/middle rectal tumors and mesorectal excision at least 5 cm below the tumor for high rectal tumors) have been reported.[6–10]

For patients with advanced cancers of the mid- to upper rectum, low-anterior resection followed by the creation of a colorectal anastomosis may be the treatment of choice. For locally advanced rectal cancers for which radical resection is indicated, however, total mesorectal excision with autonomic nerve preservation techniques via low-anterior resection is preferable to abdominoperineal resection.[1,2]

The low incidence of local relapse after meticulous mesorectal excision has led some investigators to question the routine use of adjuvant radiation therapy. Because of an increased tendency for first failure in locoregional sites only, the impact of perioperative radiation therapy is greater in rectal cancer than in colon cancer.[11]

Chemoradiation Therapy

Standard Treatment Options for Stage 0 Rectal Cancer

Stage 0 rectal cancer or carcinoma in situ is the most superficial of all rectal lesions and is limited to the mucosa without invasion of the lamina propria.

Standard treatment options for stage 0 rectal cancer include the following:

1. Polypectomy or surgery.

Standard Treatment Options for Stage I Rectal Cancer

Stage I tumors extend beneath the mucosa into the submucosa (T1) or into, but not through, the bowel muscle wall (T2). Because of its localized nature at presentation, stage I rectal cancer has a high cure rate.

Standard treatment options for stage I rectal cancer include the following:

1. Surgery with or without chemoradiation therapy.

Standard Treatment Options for Stages II and III Rectal Cancer

Standard treatment options for stages II and III rectal cancer include the following:

• Surgery.
• Preoperative chemoradiation therapy.
• Short-course preoperative radiation therapy followed by surgery and chemotherapy.
• Postoperative chemoradiation therapy.
• Primary chemoradiation therapy followed by intensive surveillance for complete clinical responders.

Chemotherapy Regimens of Colorectal Carcinoma

Many academic oncologists suggest that LV/5-FU/oxaliplatin (FOLFOX) be considered the standard for adjuvant chemotherapy in rectal cancer. However, there are no data about rectal cancer to support this consideration. FOLFOX has become the standard arm in the latest Intergroup study evaluating adjuvant chemotherapy in rectal cancer. An Eastern Cooperative Oncology Group trial (ECOG-E5202 [NCT00217737]) randomly assigned patients with stage II or III rectal cancer who received preoperative or postoperative chemoradiation therapy to receive 6 months of FOLFOX with or without bevacizumab, but this trial closed because of poor accrual; no efficacy data are available.

Metastatic and Recurrent Rectal Cancer

Standard treatment options for stage IV and recurrent rectal cancer include the following:

• Surgery with or without chemotherapy or radiation therapy.
• First-line chemotherapy and targeted therapy.
• Second-line chemotherapy.
• Palliative therapy.

Treatment of Liver Metastasis

Approximately 15% to 25% of colorectal cancer patients will present with liver metastases at diagnosis, and another 25% to 50% will develop metachronous hepatic metastasis after resection of the primary tumor.[67–69] Although only a small proportion of patients with liver metastasis are candidates for surgical resection, advances in tumor ablation techniques and in both regional and systemic chemotherapy administration provide a number of treatment options. These include the following:

• Surgery.
• Neoadjuvant chemotherapy.
• Local ablation.
• Adjuvant chemotherapy.
• Intra-arterial chemotherapy after liver resection.

Diagnosis of Rectal Cancer

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. Talk to your doctor if you think you may be at risk for colorectal cancer.

• Having a family history of colon or rectal cancer in a first-degree relative (parent, sibling, or child).
• Having a personal history of cancer of the colon, rectum, or ovary.
• Having a personal history of high-risk adenomas (colorectal polyps that are 1 centimeter or larger in size or that have cells that look abnormal under a microscope).
• Having inherited changes in certain genes that increase the risk of familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary nonpolyposis colorectal cancer).
• Having a personal history of chronic ulcerative colitis or Crohn disease for 8 years or more.
• Having three or more alcoholic drinks per day.
• Smoking cigarettes.
• Being black.
• Being obese.

Older age is a main risk factor for most cancers. The chance of getting cancer increases as you get older.

Tests that examine the rectum and colon are used to detect (find) and diagnose rectal cancer.

Tests used to diagnose rectal cancer include the following:

• Physical exam and history – An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Digital rectal exam (DRE) – An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual. In women, the vagina may also be examined.
• Colonoscopy – A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
• Biopsy – The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. Tumor tissue that is removed during the biopsy may be checked to see if the patient is likely to have the gene mutation that causes HNPCC. This may help to plan treatment. The following tests may be used:
• Reverse transcription-polymerase chain reaction (RT–PCR) test – A laboratory test in which the amount of a genetic substance called mRNA made by a specific gene is measured. An enzyme called reverse transcriptase is used to convert a specific piece of RNA into a matching piece of DNA, which can be amplified (made in large numbers) by another enzyme called DNA polymerase. The amplified DNA copies help tell whether a specific mRNA is being made by a gene. RT–PCR can be used to check the activation of certain genes that may indicate the presence of cancer cells. This test may be used to look for certain changes in a gene or chromosome, which may help diagnose cancer.
• Immunohistochemistry – A laboratory test that uses antibodies to check for certain antigens (markers) in a sample of a patient’s tissue. The antibodies are usually linked to an enzyme or a fluorescent dye. After the antibodies bind to a specific antigen in the tissue sample, the enzyme or dye is activated, and the antigen can then be seen under a microscope. This type of test is used to help diagnose cancer and to help tell one type of cancer from another type of cancer.
• Carcinoembryonic antigen (CEA) assay – A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both cancer cells and normal cells. When found in higher than normal amounts, it can be a sign of rectal cancer or other conditions.
• Anorectal manometry – measures and assesses the anal sphincter (internal and external) and rectal pressure and its function. This method is used to evaluate patients with fecal incontinence and constipation. It can directly measure the luminal pressure, including the high-pressure zone, resting pressure, squeezing pressure, rectal sensation/compliance, and the anorectal inhibitory reflex.[rx]
• Defecating proctography/Defecography – A study using X-ray imaging to evaluate anatomic defects of the anorectal region and function of the puborectalis muscle. A contrast filled paste gets initially introduced to the rectum, and the patient is instructed to defecate in a series of stages (relaxation, contraction, tensing of the abdomen, and evacuation).[rx]
• Balloon capacity and compliance test – Evaluates the function of the rectum using a device (plastic catheter with a latex balloon attached), which is inserted into the rectum and gradually filled with warm water. During this process, the volume and pressure are measured.[rx]
• Balloon evacuation study – This test is similar to the balloon capacity and compliance test in which a catheter with a small balloon gets inserted into the rectum and filled with water. Different volumes of water get loaded inside the balloon, and the patient is instructed to evacuate the balloon. This procedure is done to evaluate the opening of the anal canal and to assess the relaxation of the pelvic floor.[rx]
• Pudendal nerve terminal motor latency – A probe designed to stimulate and record nerve activity is placed on the physician’s gloved finger, which is then inserted into the rectum to measure pudendal nerve activity (latency to contraction of the anal sphincter muscle). The pudendal nerve innervates the anal sphincter muscles; therefore, this test can be used to assess any injury to that nerve.
• Electromyography – A test to measure the ability of the puborectalis muscle and sphincter muscles to relax properly. An electrode is placed inside the rectum, and the activity of these muscles gets evaluated throughout a series of stages (relaxation, contraction, and evacuation).[rx]
• Endoanal Ultrasonography – The use of ultrasound imaging to examine rectal lesions, defects, or injuries to the surrounding tissues.[rx]
• Suction rectal biopsy – Gold standard for the diagnosis of Hirschsprung disease. A biopsy is taken two cm above the dentate line, and the absence of ganglion cells on histology confirms the diagnosis. Hypertrophic nerve fibers may be present in addition to this finding.[rx]
• Contrast enema – Used as one of the diagnostic methods for Hirschsprung disease. Useful for localization of the aganglionic segment by looking for a narrowed rectum. Diagnostic confirmation is via a rectal biopsy.[rx]

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

• The stage of the cancer (whether it affects the inner lining of the rectum only, involves the whole rectum, or has spread to lymph nodes, nearby organs, or other places in the body).
• Whether the tumor has spread into or through the bowel wall.
• Where the cancer is found in the rectum.
• Whether the bowel is blocked or has a hole in it.
• Whether all of the tumor can be removed by surgery.
• The patient’s general health.
• Whether the cancer has just been diagnosed or has recurred (come back).

After rectal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the rectum or to other parts of the body.

The process used to find out whether cancer has spread within the rectum or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.

The following tests and procedures may be used in the staging process:

• Chest x-ray – An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

• Colonoscopy – A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue). abnormal areas, or cancer. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.

  

• CT scan (CAT scan) – A procedure that makes a series of detailed pictures of areas inside the body, such as the abdomen, pelvis, or chest, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• MRI (magnetic resonance imaging) – A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• PET scan (positron emission tomography scan) – A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
• Endorectal ultrasound – A procedure used to examine the rectum and nearby organs. An ultrasound transducer (probe) is inserted into the rectum and used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The doctor can identify tumors by looking at the sonogram. This procedure is also called transrectal ultrasound.

The following stages are used for rectal cancer:

Stage III

Stage III rectal cancer is divided into stages IIIA, IIIB, and IIIC.

Stage IIIA rectal cancer. Cancer has spread through the mucosa of the rectum wall to the submucosa and may have spread to the muscle layer, and has spread to one to three nearby lymph nodes or tissues near the lymph nodes. OR, cancer has spread through the mucosa to the submucosa and four to six nearby lymph nodes.

In stage IIIA, cancer has spread:

• through the mucosa (innermost layer) of the rectum wall to the submucosa (layer of tissue next to the mucosa) or to the muscle layer of the rectum wall. Cancer has spread to one to three nearby lymph nodes or cancer cells have formed in tissue near the lymph nodes; or
• through the mucosa (innermost layer) of the rectum wall to the submucosa (layer of tissue next to the mucosa). Cancer has spread to four to six nearby lymph nodes.

Stage IIIB rectal cancer. Cancer has spread through the muscle layer of the rectum wall to the serosa or has spread through the serosa but not to nearby organs; cancer has spread to one to three nearby lymph nodes or to tissues near the lymph nodes. OR, cancer has spread to the muscle layer or to the serosa, and to four to six nearby lymph nodes. OR, cancer has spread through the mucosa to the submucosa and may have spread to the muscle layer; cancer has spread to seven or more nearby lymph nodes.

In stage IIIB, cancer has spread:

• through the muscle layer of the rectum wall to the serosa (outermost layer) of the rectum wall or has spread through the serosa to the tissue that lines the organs in the abdomen (visceral peritoneum). Cancer has spread to one to three nearby lymph nodes or cancer cells have formed in tissue near the lymph nodes; or
• to the muscle layer or to the serosa (outermost layer) of the rectum wall. Cancer has spread to four to six nearby lymph nodes; or
• through the mucosa (innermost layer) of the rectum wall to the submucosa (layer of tissue next to the mucosa) or to the muscle layer of the rectum wall. Cancer has spread to seven or more nearby lymph nodes.

Stage IIIC rectal cancer. Cancer has spread through the serosa of the rectum wall but not to nearby organs; cancer has spread to four to six nearby lymph nodes. OR, cancer has spread through the muscle layer to the serosa or has spread through the serosa but not to nearby organs; cancer has spread to seven or more nearby lymph nodes. OR, cancer has spread through the serosa to nearby organs and to one or more nearby lymph nodes or to tissues near the lymph nodes.

In stage IIIC, cancer has spread:

• through the serosa (outermost layer) of the rectum wall to the tissue that lines the organs in the abdomen (visceral peritoneum). Cancer has spread to four to six nearby lymph nodes; or
• through the muscle layer of the rectum wall to the serosa (outermost layer) of the rectum wall or has spread through the serosa to the tissue that lines the organs in the abdomen (visceral peritoneum). Cancer has spread to seven or more nearby lymph nodes; or
• through the serosa (outermost layer) of the rectum wall to nearby organs. Cancer has spread to one or more nearby lymph nodes or cancer cells have formed in tissue near the lymph nodes.

Stage IV

Stage IV rectal cancer is divided into stages IVA, IVB, and IVC.

Stage IV rectal cancer. The cancer has spread through the blood and lymph nodes to other parts of the body, such as the lung, liver, abdominal wall, or ovary.

• Stage IVA – Cancer has spread to one area or organ that is not near the rectum, such as the liver, lung, ovary, or a distant lymph node.
• Stage IVB – cancer has spread to more than one area or organ that is not near the rectum, such as the liver, lung, ovary, or a distant lymph node.
• Stage IVC – Cancer has spread to the tissue that lines the wall of the abdomen and may have spread to other areas or organs.

Treatment of Rectal Cancer

Six types of standard treatment are used

Surgery

Surgery is the most common treatment for all stages of rectal cancer. The cancer is removed using one of the following types of surgery:

• Polypectomy – If the cancer is found in a polyp (a small piece of bulging tissue), the polyp is often removed during a colonoscopy.
• Local excision – If the cancer is found on the inside surface of the rectum and has not spread into the wall of the rectum, cancer and a small amount of surrounding healthy tissue is removed.
• Resection – If cancer has spread into the wall of the rectum, the section of the rectum with cancer and nearby healthy tissue is removed. Sometimes the tissue between the rectum and the abdominal wall is also removed. The lymph nodes near the rectum are removed and checked under a microscope for signs of cancer.
• Radiofrequency ablation – The use of a special probe with tiny electrodes that kill cancer cells. Sometimes the probe is inserted directly through the skin and only local anesthesia is needed. In other cases, the probe is inserted through an incision in the abdomen. This is done in the hospital with general anesthesia.
• Cryosurgery – A treatment that uses an instrument to freeze and destroy abnormal tissue. This type of treatment is also called cryotherapy.
• Pelvic exenteration – If cancer has spread to other organs near the rectum, the lower colon, rectum, and bladder are removed. In women, the cervix, vagina, ovaries, and nearby lymph nodes may be removed. In men, the prostate may be removed. Artificial openings (stoma) are made for urine and stool to flow from the body to a collection bag.

After the cancer is removed, the surgeon will either

• do an anastomosis (sew the healthy parts of the rectum together, sew the remaining rectum to the colon, or sew the colon to the anus);

  

  Resection of the rectum with anastomosis. The rectum and part of the colon are removed, and then the colon and anus are joined.

  or

• make a stoma (an opening) from the rectum to the outside of the body for waste to pass through. This procedure is done if the cancer is too close to the anus and is called a colostomy. A bag is placed around the stoma to collect the waste. Sometimes the colostomy is needed only until the rectum has healed, and then it can be reversed. If the entire rectum is removed, however, the colostomy may be permanent.
• Radiation therapy and/or chemotherapy may be given before surgery to shrink the tumor, make it easier to remove cancer, and help with bowel control after surgery. Treatment is given before surgery is called neoadjuvant therapy. After all, cancer that can be seen at the time of the surgery is removed, some patients may be given radiation therapy and/or chemotherapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that cancer will come back, is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy:

• External radiation therapy uses a machine outside the body to send radiation toward the cancer.
• Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

The way radiation therapy is given depends on the type and stage of the cancer being treated. External radiation therapy is used to treat rectal cancer.

Short-course preoperative radiation therapy is used in some types of rectal cancer. This treatment uses fewer and lower doses of radiation than the standard treatment, followed by surgery several days after the last dose.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly in the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

Chemoembolization of the hepatic artery is a type of regional chemotherapy that may be used to treat cancer that has spread to the liver. This is done by blocking the hepatic artery (the main artery that supplies blood to the liver) and injecting anticancer drugs between the blockage and the liver. The liver’s arteries then carry the drugs into the liver. Only a small amount of the drug reaches other parts of the body. The blockage may be temporary or permanent, depending on what is used to block the artery. The liver continues to receive some blood from the hepatic portal vein, which carries blood from the stomach and intestine.

The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Active surveillance

Active surveillance is closely following a patient’s condition without giving any treatment unless there are changes in test results. It is used to find early signs that the condition is getting worse. Inactive surveillance, patients are given certain exams and tests to check if the cancer is growing. When cancer begins to grow, treatment is given to cure cancer. Tests include the following:

• Digital rectal exam.
• MRI.
• Endoscopy.
• Sigmoidoscopy.
• CT scan.
• Carcinoembryonic antigen (CEA) assay.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells.

Types of targeted therapies used in the treatment of rectal cancer include the following

• Monoclonal antibodies – Monoclonal antibody therapy is a type of targeted therapy being used for the treatment of rectal cancer. Monoclonal antibody therapy uses antibodies made in the laboratory from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells.

There are different types of monoclonal antibody therapy

• Vascular endothelial growth factor (VEGF) inhibitor therapy – Cancer cells make a substance called VEGF, which causes new blood vessels to form (angiogenesis) and helps the cancer grow. VEGF inhibitors block VEGF and stop new blood vessels from forming. This may kill cancer cells because they need new blood vessels to grow. Bevacizumab and ramucirumab are VEGF inhibitors and angiogenesis inhibitors.
• Epidermal growth factor receptor (EGFR) inhibitor therapy – EGFRs are proteins found on the surface of certain cells, including cancer cells. Epidermal growth factor attaches to the EGFR on the surface of the cell and causes the cells to grow and divide. EGFR inhibitors block the receptor and stop the epidermal growth factor from attaching to the cancer cell. This stops the cancer cell from growing and dividing. Cetuximab and panitumumab are EGFR inhibitors.
• Angiogenesis inhibitors – Angiogenesis inhibitors stop the growth of new blood vessels that tumors need to grow
• Ziv-aflibercept – is a vascular endothelial growth factor trap that blocks an enzyme needed for the growth of new blood vessels in tumors.
• Regorafenib – is used to treat colorectal cancer that has spread to other parts of the body and has not gotten better with other treatment. It blocks the action of certain proteins, including vascular endothelial growth factor. This may help keep cancer cells from growing and may kill them. It may also prevent the growth of new blood vessels that tumors need to grow.

Immunotherapy

Immunotherapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or biologic therapy.

Immune checkpoint inhibitor therapy is a type of immunotherapy:

• Immune checkpoint inhibitor therapy: PD-1 is a protein on the surface of T cells that helps keep the body’s immune responses in check. When PD-1 attaches to another protein called PDL-1 on a cancer cell, it stops the T cell from killing the cancer cell. PD-1 inhibitors attach to PDL-1 and allow the T cells to kill cancer cells. Pembrolizumab is a type of immune checkpoint inhibitor.

Treatment Options by Stage

For information about the treatments listed below, see the Treatment Option Overview section.

Stage 0 (Carcinoma in Situ)

Treatment of stage 0 may include the following:

• Simple polypectomy.
• Local excision.
• Resection (when the tumor is too large to remove by local excision).

Use our clinical trial search to find NCI-supported cancer clinical trials that are accepting patients. You can search for trials based on the type of cancer, the age of the patient, and where the trials are being done. General information about clinical trials is also available.

Stage I Rectal Cancer

Treatment of stage I rectal cancer may include the following:

• Local excision.
• Resection.
• Resection with radiation therapy and chemotherapy after surgery.

Use our clinical trial search to find NCI-supported cancer clinical trials that are accepting patients. You can search for trials based on the type of cancer, the age of the patient, and where the trials are being done. General information about clinical trials is also available.

Stages II and III Rectal Cancer

Treatment of stage II and stage III rectal cancer may include the following:

• Surgery.
• Chemotherapy combined with radiation therapy, followed by surgery.
• Short-course radiation therapy followed by surgery and chemotherapy.
• Resection followed by chemotherapy combined with radiation therapy.
• Chemotherapy combined with radiation therapy, followed by active surveillance. Surgery may be done if the cancer recurs (comes back).
• A clinical trial of a new treatment.

Use our clinical trial search to find NCI-supported cancer clinical trials that are accepting patients. You can search for trials based on the type of cancer, the age of the patient, and where the trials are being done. General information about clinical trials is also available.

Stage IV and Recurrent Rectal Cancer

Treatment of stage IV and recurrent rectal cancer may include the following:

• Surgery with or without chemotherapy or radiation therapy.
• Systemic chemotherapy with or without targeted therapy (angiogenesis inhibitor).
• Systemic chemotherapy with or without immunotherapy (immune checkpoint inhibitor therapy).
• Chemotherapy to control the growth of the tumor.
• Radiation therapy, chemotherapy, or a combination of both, as palliative therapy to relieve symptoms and improve the quality of life.
• Placement of a stent to help keep the rectum open if it is partly blocked by the tumor, as palliative therapy to relieve symptoms and improve the quality of life.
• Immunotherapy.
• Clinical trials of chemotherapy and/or targeted therapy.

Treatment of rectal cancer that has spread to other organs depends on where the cancer has spread.

• Treatment for areas of cancer that have spread to the liver includes the following:
• Surgery to remove the tumor. Chemotherapy may be given before surgery, to shrink the tumor.
• Cryosurgery or radiofrequency ablation.
• Chemoembolization and/or systemic chemotherapy.
• A clinical trial of chemoembolization combined with radiation therapy to the tumors in the liver.

Drugs Approved for Colon and Rectum Cancer

• Avastin (Bevacizumab)
• Bevacizumab
• Camptosar (Irinotecan Hydrochloride)
• Capecitabine
• Cetuximab
• Cyramza (Ramucirumab)
• Eloxatin (Oxaliplatin)
• Erbitux (Cetuximab)
• 5-FU (Fluorouracil Injection)
• Fluorouracil Injection
• Ipilimumab
• Irinotecan Hydrochloride
• Keytruda (Pembrolizumab)
• Leucovorin Calcium
• Lonsurf (Trifluridine and Tipiracil Hydrochloride)
• Mvasi (Bevacizumab)
• Nivolumab
• Opdivo (Nivolumab)
• Oxaliplatin
• Panitumumab
• Pembrolizumab
• Ramucirumab
• Regorafenib
• Stivarga (Regorafenib)
• Trifluridine and Tipiracil Hydrochloride
• Vectibix (Panitumumab)
• Xeloda (Capecitabine)
• Yervoy (Ipilimumab)
• Zaltrap (Ziv-Aflibercept)
• Ziv-Aflibercept

Drug Combinations Used in Colon Cancer

• CAPOX
• FOLFIRI
• FOLFIRI-BEVACIZUMAB
• FOLFIRI-CETUXIMAB
• FOLFOX
• FU-LV
• XELIRI
• XELOX

Drugs Approved for Rectal Cancer

• Avastin (Bevacizumab)
• Bevacizumab
• Camptosar (Irinotecan Hydrochloride)
• Capecitabine
• Cetuximab
• Cyramza (Ramucirumab)
• Eloxatin (Oxaliplatin)
• Erbitux (Cetuximab)
• 5-FU (Fluorouracil Injection)
• Fluorouracil Injection
• Ipilimumab
• Irinotecan Hydrochloride
• Keytruda (Pembrolizumab)
• Leucovorin Calcium
• Lonsurf (Trifluridine and Tipiracil Hydrochloride)
• Mvasi (Bevacizumab)
• Nivolumab
• Opdivo (Nivolumab)
• Oxaliplatin
• Panitumumab
• Pembrolizumab
• Ramucirumab
• Regorafenib
• Stivarga (Regorafenib)
• Trifluridine and Tipiracil Hydrochloride
• Vectibix (Panitumumab)
• Xeloda (Capecitabine)
• Yervoy (Ipilimumab)
• Zaltrap (Ziv-Aflibercept)
• Ziv-Aflibercept

Drug Combinations Used in Rectal Cancer

• CAPOX
• FOLFIRI
• FOLFIRI-BEVACIZUMAB
• FOLFIRI-CETUXIMAB
• FOLFOX
• FU-LV
• XELIRI
• XELOX

Drugs Approved for Gastroenteropancreatic Neuroendocrine Tumors

• Afinitor (Everolimus)
• Everolimus
• Lanreotide Acetate
• Somatuline Depot (Lanreotide Acetate)

To Learn More About Rectal Cancer

For more information from the National Cancer Institute about rectal cancer, see the following:

• Colorectal Cancer Home Page
• Colorectal Cancer Prevention
• Colorectal Cancer Screening
• Tests to Detect Colorectal Cancer and Polyps
• Childhood Colorectal Cancer Treatment
• Cryosurgery in Cancer Treatment
• Drugs Approved for Colon and Rectal Cancer
• Targeted Cancer Therapies
• Genetic Testing for Inherited Cancer Susceptibility Syndromes

For general cancer information and other resources from the National Cancer Institute, see the following:

• About Cancer
• Staging
• Chemotherapy and You: Support for People With Cancer
• Radiation Therapy and You: Support for People With Cancer
• Coping with Cancer
• Questions to Ask Your Doctor about Cancer
• For Survivors and Caregivers

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