Case 21- Colorectal Cancer Flashcards
Sx CRC
Change in bowel habit, weight loss, PR bleeding, tenesmus, signs of anaemia, bowel obstruction, rectal mass
Differentials for CRC
IBS, UC, Crohn’s disease, haemorrhoids, anal fissure, diverticula disease, gastroenteritis
Investigations for CRC
DRE
2 weeks wait pathway
FBC, UE (malnutrition, CT contrast), Ca (metastasis)LFT (hepatic metastasis), FIT (if not presented with blood in faeces)
Colonoscopy with biopsy (and OGD as it may be an upper GI bleed- melaena)
Staging CT scan (abdomen thorax pelvis)
Carcinoembryonic antigen (CEA)- useful for predicting relapse
Diverticulitis Sx
Let iliac fossa/ lower abdominal pain, tenderness and guarding, fever, diarrhoea, PR blood and mucus, nausea and vomiting, constipation
Diverticula disease investigations
DRE and stool test (rule out infection)
FBC, CRP, UE (contrast and malnutrition)
Abdominal CT with contrast
Colonoscopy- not during an acute episode. Wait 6 weeks for Sx to die down and then do it to rule out a malignancy/ assess extent of diverticulitis
Hiatus hernia Sx
GORD Sx, epigastric or substernal pain, early satiety, retching
Investigations for a hiatus hernia
FBC UE
CXR
OGD- ensure no malignancy
Acute abdomen
Ask about passing wind- bowel obstruction
Distension- bowel obstruction or fluid. Also pregnancy (may have noticed distension for a few weeks prior)
Bowel sounds- absent in peritonitis and ileus and increased in small bowel obstruction
Acute abdomen investigations
FBC, UE, LFT, CRP, serum amylase and lipase, BM, VBG (lactate), urinary pregnancy test, urine dipstick (UTI or pyelonephritis)
Erect CXR and supine AXR
CT scan of abdomen
Elderly patients and the acute abdomen
Always do a PR exam and look for hernias (strangulated)
AF- may have mesenteric ischaemia due to an embolus (signs of obstruction)
Iron deficiency anaemia in over 50’s
2 week wait cancer referral for OGD and colonoscopy
Investigations for diverticulitis
DRE and stool test
FBC UE LFT CRP
Colonoscopy (not during acute flare up- 6 weeks after)
Management of diverticulitis
Dietary changes and mild analgesia
Severe- consider admission, antibiotics, analgesia, fluid resuscitation, may require surgery
Classic signs of acute abdomen
Fever, tenderness, rigidity and guarding, rebound tenderness, absent bowel sounds in peritonitis, increased in SBO, abdominal distension
What is the most common form of inherited colon cancer?
HNPCC- autosomal dominant. Also at risk of endometrial cancer
Amsterdam criteria can aid diagnosis
MSH2/MLH1 gene mutations
What is FAP?
Autosomal dominant condition which leads to early onset polyp formation and carcinoma development- total colectomy with ileo anal pouch formed in 20’s
Also at risk of duodenal tumours
APC gene mutation
Location of CRC’s
Rectal-40% Sigmoid-30% Ascending colon and caecum-15% Transverse colon-10% Descending colon-5%
Type of resection for caecal, ascending or proximal transverse colon cancers
Right hemicolectomy
Type of resection for distal transverse or descending colon cancers
Left hemicolectomy
Type of resection for sigmoid colon cancers
High anterior resection
Type of resection for upper rectal cancer
Anterior resection (TME)
Type of resection for low rectal cancer
Anterior resection (low TME)
Type of resection for anal verge cancer
Abdomino perineal reaction of the rectum
Hartman’s procedure
Resection if sigmoid colon and end colostomy fashioned
Bowel perforation and stoma
In an emergency setting, if colonic tumour is associated with perforation, perform an end colostomy which can be reversed later
CRC referral guidelines
Urgent 2 ww
40+ with unexplained weight loss and abdominal pain
50+ with unexplained rectal bleeding
60+ with iron deficiency anaemia or change in bowel habit
Tests show occult blood in faeces
Consider 2 ww in
Rectal, anal, or abdominal mass
Patients less than 50 with rectal bleeding who have any of the following- abdominal pain, change in bowel habit, weight loss, iron deficiency anaemia
CRC screening
Every 2 years for all 60-74 year olds in England
Faecal immunochemical test (FIT) which measures faecal occult blood (FOB)- abnormal result, offered colonoscopy
NB- FIT recommended for people with new symptoms who don’t meet 2 week wait referral
Dukes classification
Extent of spread of colorectal cancer
A- confined to mucosa
B- invading bowel wall
C- lymph node metastases
D- distant metastases
Clinical features of haemorrhoids
Painless rectal bleeding
Pruritis
Pain- not significant unless piles or thrombosed
Soiling
Location: 3, 7, 11 o’clock position
External haemorrhoids
Below dentate line
Prone to thrombosis, can be painful
Internal haemorrhoids
Originate above dentate line
Don’t generally cause pain
Grading of internal haemorrhoids
1- do not prolapse out of the anal canal
2- prolapse on defecation but reduce spontaneously
3- manually reduced
4- can’t be reduced
Management of haemorrhoids
Stool softeners (increase dietary fibre and fluid intake)
Topical local anaesthetics and steroids
Rubber band ligation
Surgery is reserved for large symptomatic haemorrhoids that don’t respond to outpatient treatments
Investigations for acute abdomen
Bedside- observations, AE, abdominal examination, urine dip, pregnancy test
Bloods- FBC UE LFT CRP amylase lipase BM ABG
Imaging- erect CXR and AXR
Bowel cancer tumour marker
Carcinoembryonic antigen (CEA)- not useful in screening, but can be used for monitoring purposes post-surgery
Bowel cancer tumour marker
Carcinoembryonic antigen (CEA)- not useful in screening, but can be used for monitoring purposes post-surgery
Haemorrhoids vs anal fissure
Haemorrhoids cause painless bleeding, anal fissures cause painful bleeding
Anal fissure
Typically presents with painful rectal bleeding
Location: midline 6 (posterior midline 90%) & 12 o’clock position. Distal to the dentate line
Anal fistula
Usually form after previous ano-rectal abscess
Solitary rectal ulcer
Associated with chronic straining and constipation. Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)
