The right colic flexure, also called the hepatic flexure, consists of a curve at the junction with the transverse colon. The anatomic relationships of the ascending colon include the right kidney and ureter, the duodenum, the liver, and the gallbladder. A poorly formed mesocolon can occasionally be observed. The ventral aspect is covered by the peritoneum, whereas the posterior surface is retroperitoneally fixed to the iliac fascia. The ascending colon is mainly involved in absorptive processes that eventually lead to feces formation. Cancers in the lower rectum (0вЂ“5В cm above the anal verge) may require preoperative chemoradiation therapy and/or abdominoperineal resection with a permanent colostomy. Adenocarcinomas in the middle and upper rectum are usually removed by anterior resection. Most colonic lesions can be resected with a primary anastomosis. For any cancers above the rectum, at least a 5В cm margin of grossly uninvolved tissue should be obtained and regional lymph nodes should be aggressively sampled. For distal colon cancers, left hemicolectomy is usually the procedure of choice. The transverse colon and both flexures are typically removed when cancers originate from anywhere between the ascending colon and the descending colon. In general, right hemicolectomy is performed for CRCs arising from the cecum, ascending colon, or hepatic flexure. The type of operation and extent of resection are dependent on multiple factors, including tumor location, size, and preoperative stage. Surgical excision is the mainstay of CRC treatment, especially when a curative outcome may be potentially achievable. Ahlquist, in Encyclopedia of Gastroenterology, 2004 Surgery

Routine blood tests, including sedimentation rate, should be normal. The patients may also have mucosal hyperalgesia to light touch via the sigmoidoscope. Sigmoidoscopic examination is usually normal but it is extremely difficult to proceed beyond the rectosigmoid junction, because of spasm and pain. Some patients are exquisitely tender on rectal examination. The patient will be tender over an area of the colon, most commonly the descending colon. On examination, there is usually a disparity between the severity of the patient's symptoms and his or her physical condition, since they look well. The Rome II Criteria are excellent for standardization of therapeutic trials and the discipline that they brought to the field but their very rigidity brings artificial constraints that will have to be reconsidered in the future ( Camilleri 1998). Recently at a second conference in Rome on IBS, the Rome II Criteria evolved ( Box 8.7). Cancer phobia is another frequent observation in these patients. They frequently have a past history of appendicectomy for вЂchronic appendicitisвЂ™. IBS may have been the cause of pelvic pain in 60% women attending gynaecological clinics, having dilatation and curettage for dysmenorrhoea, 40% having elective hysterectomy, compared to 32% of age-matched controls ( Crowell et al 1994). IBS pain is asociated with nausea without vomiting, dyspepsia, urinary symptoms, especially dysuria, gynaecological symptoms, especially dysmenorrhoea, and headache IBS symptoms may begin after an attack of gastroenteritis ( Gwee et al 1999). However, the patient's appetite is rarely affected, and therefore a history of significant weight loss (i.e., more than 3.5 kg) is unusual and should raise suspicions of an alternative diagnosis. In about half the patients pain is aggravated by eating and relieved by defecation. вЂMeteorismвЂ™ is due to вЂair trappingвЂ™ in which segmental accumulation of gas occurs.ДЄlterations of bowel habit, diarrhoea or constipation occur in up to 90% of the patients.

It varies from a dull ache to attacks of excruciating severity, lasting from minutes to several hours to all day, but it rarely prevents the patient from sleeping through the night. Laurence M Blendis, in Handbook of Pain Management, 2003 Clinical featuresДЄbdominal pain is predominantly periumbilical in children ( Milla et al 2001), whereas in adults it tends to occur over the surface markings of the colon with the commonest site in the left lower quadrant, less commonly the right or left upper quadrant over the hepatic or splenic flexures.

Hepatic flexture ultrasound