Gen Surg: colorectal cancer

Question 1

What are red flag symptoms for Colorectal cancer?

Answer 1

Change in bowel habit, rectal bleeding, weight loss, iron deficiency anaemia, tenesmus

Question 3

A patient comes in and has unexplained microcytic anaemia and weight loss. What is your next investigation?

Answer 3

Colonoscopy/lower GI tract investigation as could have colorectal cancer.

If in GP - would want to do FIT - before referral

Question 4

Patient presents with lower Gi bleed. What are the your differentials?

Answer 4

Chrons, UC, haemorrhoids, anal fissure, colorectal cancer, anal cancer, diverticula disease, colonic polyps.

Question 5

What is the significance of polyps in the colon?

Answer 5

10% progressive from benign adenomas to invasive adenocarcinoma

Question 6

What is the APC gene?

Answer 6

It is present in FAP (familial Adenomatous polyposis) and is a tumour suppressor gene, results in the growth of polyps

Question 7

What is the HNPCC gene and what condition does it give you?

Answer 7

It is a mismatch repair gene, giving you Lynch syndrome and increases your chance of colorectal cancer

Question 8

What are the risk factors for colorectal cancer?

Answer 8

Male, increasing age, family hx, low fibre diet, increased processed meat intake, smoking, alcohol excess

Question 9

How does colorectal cancer present?

Answer 9

Weight loss, change in bowel habit, PR bleeding, abdominal pain, iron deficiency anaemia.

Question 10

How does presentation of colorectal cancer differ on location?

Answer 10

Right sided (ascending colon)- FUNGATING, change in bowel habit happens later on, abdo pain, iron deficiency anaemia, palpable mass in the R iliac fossa- presents later at diagnosis

Left sided (descending colon)- STENOSING, change in bowel habit early on, rectal bleeding, palpable mass in the LIF, tenesmus, presents earlier

Question 11

When would you refer via 2 WW with suspected colorectal cancer?

Answer 11

40 years or more with unexplained weight loss and abdo pain
50 years or more with unexplained rectal bleeding
60 years or more with iron deficiency anaemia or change in bowel habit

Question 12

What lab investigations would you do for a suspected colorectal cancer?

Answer 12

FBC, LFTs and Clotting
May show a microcytic (iron deficiency anaemia)

Question 13

What is your first line investigation for a suspected colorectal cancer?

Answer 13

Colonoscopy with biopsy
If unable to do a colonoscopy, CT colonography

Question 14

What is the role of alternative imaging (CT, MRI etc.) in colorectal cancer?

Answer 14

CT TAP, once diagnosed for staging and distant mets
MRI rectum for rectal tumours- to see tumour depth
Endo-anal ultrasound for T1/2 rectal tumours to determine suitability for trans-anal resection

Question 15

How do you approach management of colorectal cancer

Answer 15

Discussion with the MDT

Very small tumours may be suitable for endoscopic resection

Surgery is the main curative treatment

R.Sided tumour- right hemicolectomy
L.Sided tumour- left hemicolectomy
Sigmoid colon tumour- Sigmoidectomy
High Rectal tumour- Anterior resection with loop ileostomy
Low Rectal tumour- Abdominoperineal resection

CHEMO- used Neo-adjuvant or adjuvant, usually in patients with advanced disease
RADIOTHERAPY-used more in rectal cancer

Question 16

What is the aim of palliation in colorectal cancer?

Answer 16

Reduce cancer growth and focus on symptom control

Question 17

How can R sided colorectal malignancy present?

Answer 17

Abdo pain, iron deficiency anaemia, palpable mass in the RIF, present later than L sided

Question 18

How can L sided colorectal malignancy present?

Answer 18

Rectal bleeding, change in bowel habits, tenesmus, palpable mass in the LIF or on PR exam.

Question 19

What is involved in a colonostomy?

Answer 19

Colon is brought to the surface of the skin. Located in the LIF. contents are more solid as water is reabsorbed in LI. Flat to the skin.

Question 20

What is involved in a Ileostomy?

Answer 20

Ileum brought to the skin, located at RIF. Spout created as contents are liquid.

Question 21

Describe a loop stoma

Answer 21

Loop of bowel is taken through the abdo wall - proximal and distal ends are left open. . Temporary colostomy to allow distal portion of the bowel and anastomosis to heal after surgery. Usually reversed 6-8weeks later.

Question 22

Name four complications of a stoma

Answer 22

Local skin irritation,
Parastomal hernia
Psycho-social impact
High output = dehydration and malnutrition
Stenosis
Obstruction
Retraction
Prolapse

Question 23

Describe the Hartmann’s procedure

Answer 23

A sigmoid colectomy, proximal colon used to form a temporary end colostomy. The distal bowel is sewn over as a rectal stump. This is used in an emergency (i.e. bowel obstruction, ischaemia, toxic megacolon, or perforation

Question 24

What is the most likely operation in a patient with a loop ileostomy and an anus?

Answer 24

In a loop ileostomy 2 bowel ends are visible. The patient is likely to have had an anterior resection (for high rectal cancer >5cm from anus) with formation of a temporary loop ileostomy (to allow for healing of the distal anastomosis).

Question 25

What are the early complications of a stoma?

Answer 25

mechanical and functional

Early mechanical - bowel ischaemia/necrosis, bowel retraction, and para-stomal abscess formation.

Early functional -poor stoma function and high output stoma.

Question 26

What are the late complications of stoma?

Answer 26

mechanical, functional and psychosocial.

Late mechanical - para-stomal hernia formation, bowel stenosis and prolapse, adhesion formation leading to bowel obstruction, and para-stomal dermatitis.

Late functional -bowel dysmotility (leading to constipation/diarrhoea) and malabsorption (e.g. if the terminal ileum is removed this can cause B12 deficiency).

Psychosocia -difficulties with body image and sexual activity.

Question 27

What is the best initial management for patients with high output stomas (4 points)?

Answer 27

Restrict oral hypotonic fluid intake, advise dextrose-saline solution, prescribe oral loperamide and omeprazole