Case 21 - Bowel Cancer

Question 1

What is an acute anal fissure?

Answer 1

A break/tear in the skin of the anal canal associated with severe pain when passing hard faces

Sometimes blood is observed on toilet paper or toilet

Question 2

What is the common presentation of bowel cancer? (Red Flags)

Answer 2

Rectal bleeding 
Change in bowel habit in person over 60 years
Abdominal rectal mass
Iron deficiency anaemia 
Unexplained weight loss
Family history of bowel cancer

Question 3

What are the differentials for bowel cancer?

Answer 3

Anal fissure
Haemorrhoids
IBD
IBS

Question 4

List some of the common causes for fresh blood in stools

Answer 4

Haemorrhoids
Acute anal fissure (following trauma or severe constipation)
Colorectal cancer
Acute proctitis - inflammation of rectum
IBD

Question 5

What investigations are done in a suspected colorectal cancer?

Answer 5

FBC - look for microcytic anaemia
Colonoscopy
CT scan - look for mets

Question 6

Where do colorectal cancers commonly spread to?

Answer 6

Liver, lung, bone

Question 7

How is colorectal cancer classified?

Answer 7

Dukes staging:
A - limited to muscularis mucosa 
B - extension through muscularis mucosa
C - involvement of regional lymph nodes
D - metastatic spread

Question 8

What is the difference between an anterior resection and an abdominal perineal (AP) resection?

Answer 8

Anterior resection - surgery for low sigmoid or high rectal tumours (involving the sphincter)

Abdominal Perineal (AP) resection - for tumours in lower rectum

Question 9

What is an iliostomy and a colostomy?

Answer 9

Operations where a stoma is created

A stoma is an artificial opening into a hollow organ

Question 10

What is a hemicoloctomy?

Answer 10

Removal of part of the colon

Right hemicolocetomy - removal for cecal, ascending or proximal transverse tumours
Left hemicoloctomy - removal for distal transverse or descending colon

Question 11

What is the colorectal cancer national screening programme?

Answer 11

Offers screening every 2 years to all men and women ages 60-69

They receive a faecal occult blood home test kit - sample 3 separate bowl motions and return for analysis

Patients which test positive will undergo colonoscopy

Question 12

What is a polyp?

Answer 12

A lump that appears above the mucosa in the colon. They can be pre malignant

Question 13

What are the two genetic forms of colorectal cancer?

Answer 13

FAP - familial adenomatous polyposis

HNPCC - hereditary non-polyposis colorectal cancer

Question 14

What is diverticular disease?

Answer 14

Outpouchings of the colonic mucosa and submucosa through inherent weakness in the outer muscle layers

Question 15

What are the risk factors for diverticular disease?

Answer 15

Chronic constipation
Low fibre diet 
Increasing age 
Smoking 
Long term use of ibuprofen or aspirin 
Family history

Question 16

What are the frequent complications of colonic diverticuli?

Answer 16

Diverticulitis - infection in the diverticular
Bleeding - occult or overt
Perforation (note this can be very serious due to leakage of faeces giving rise to faecal peritonitis)
Abscess formation

Question 17

What is an acute abdomen?

Answer 17

A condition of severe abdominal pain, usually requiring emergency surgery

Caused by acute disease or injury to internal organs

Question 18

What are the classic signs of acute abdomen?

Answer 18

Fever
Tenderness
Rigidity and guarding
Rebound tenderness
Absent bowel sounds - in peritonitis
Increased bowel sounds - in small bowel obstruction
Abdominal distention - due to bowel obstruction and filling with gas or fluid

Question 19

What must you always do in a women of child bearing age presenting with an acute abdomen?

Answer 19

Pregnancy test

Don’t want to miss ectopic pregnancy

Question 20

What is rossvigs sign?

Answer 20

Palpation the left iliac fossa and see if you get pain on the right side

Question 21

What are the differentials for constipation?

Answer 21

Opiates

Bowl obstruction - adhesions, Volvulus, cancers, strictures, hernias

Question 22

What are the typically symptoms of appendicitis?

Answer 22

Dull pain near the naval that becomes sharp as it moves to the lower right abdomen

Loss of appetite, associated with nausea and vomitting

Question 23

What should be considered thinking about acute abdomen in the elderly?

Answer 23

They tend to show less specific signs and symptoms
A serious pathology is more likely
Morbidity and mortality in older patients presenting with acute abdominal pain are high
Aortic aneurysm and bowel ischaemia are more prevalent - don’t forget to examine them

Question 24

What investigations should be done in acute abdomen?

Answer 24

FBC, U&E, LFTs, CRP
Serum amylase 
Serum glucose
Blood gas, including lactate measurement 
Pregnancy test in women (always!)
Urine dipstick 
Erect chest x ray (if perforation is suspected)
Supine abdominal X ray 
USS
CT abdomen

Question 25

What are the different cause of mechanical obstruction in the bowel?

Answer 25

Adhesions - following surgery
Cancer
Intussusception - typically at iliocecal valve
Hernias - bowl bulges into the abdominal wall
Volvulus - twisting of the bowel

Question 26

What are the main complications of bowel obstruction?

Answer 26

Bowel ischemia
Perforation
Sepsis