Case 21- Colorectal Cancer Flashcards by pio monaghan

Sx CRC

Change in bowel habit, weight loss, PR bleeding, tenesmus, signs of anaemia, bowel obstruction, rectal mass

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Differentials for CRC

IBS, UC, Crohn’s disease, haemorrhoids, anal fissure, diverticula disease, gastroenteritis

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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

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Diverticulitis Sx

Let iliac fossa/ lower abdominal pain, tenderness and guarding, fever, diarrhoea, PR blood and mucus, nausea and vomiting, constipation

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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

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Hiatus hernia Sx

GORD Sx, epigastric or substernal pain, early satiety, retching

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Investigations for a hiatus hernia

FBC UE
CXR
OGD- ensure no malignancy

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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

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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

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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)

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Iron deficiency anaemia in over 50’s

2 week wait cancer referral for OGD and colonoscopy

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Investigations for diverticulitis

DRE and stool test
FBC UE LFT CRP
Colonoscopy (not during acute flare up- 6 weeks after)

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Management of diverticulitis

Dietary changes and mild analgesia

Severe- consider admission, antibiotics, analgesia, fluid resuscitation, may require surgery

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Classic signs of acute abdomen

Fever, tenderness, rigidity and guarding, rebound tenderness, absent bowel sounds in peritonitis, increased in SBO, abdominal distension

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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

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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

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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)