Approach to Colorectal Cancer

General surg 

History

CA, Benign polyps, diverticular ds, IBD, angiodysplasia, infection, thyroid, bleeding tendency, nerve?

presented with

associated symp:

lower GI bleed?

anaemia only?

alter bowel habit?

• bleed: 
•  > exophytic polyps- CA
• benign growth
• IBD
• angiodysplasia
• bleeding tendency
• haemorrhoid (dropping post defecation)

• anaemia: occult bloood- CA

IO s/s: colic, distension, consti, vomit

• > distal CA... others Crohn? or pain cause cannot BO- not consti
• continence flatus (complete IO)
• constipation with intermittent outfolw diarrhoe (incomplete IO)
• laxative not useful

(pseudo obstruction: no bowel sound, PR distended rectum (old, unfit, trauma, stroke, electrolyte imba, post procedure, peritonitis, sick))

LOW/ LOA: CA (LOW only?- malabsp in IBD)

mucus secreting: causing hypokalaemia

tenesmus

perianal pain: fissure, abscess, fistula, strangulated haemorrhoids, CA-( sacral plexus invasion)

CA risk:  old, constipation, diet (low fiber, high carb, high fat), alcohol, FH, UC, PMH several ca esp HNPCC

(smoking is risk of mortality after colorectal ca)

• family history (FAP/HNPCC/ peutz) ask age (>45yo- risk 1/50, <45yo- risk 1/10)
• HNPCC- associated with other ca (for own interest only: stomach, hepatobiliary, uro, ovarian, uterus, brain, skin)
• AD microsatellite mutation (3 family member in 2 generation, 1 <50 yo)
• FAP- AD, 40yo malignant changes, screen: retina pigment layer hypertrophy
• Peutz-Jeghers-AD, hyperpigmented freakles at hand, feet , mouth, genitalia (for own interes onlyt: ca SI, LI, stomach, pancreas, testis, breast)

presentation of diverticular ds and colon CA is so similar that need Ix to diff it (colonoscopy, gastrograffin enema, CT)

complication check:

psychosocial include what impression towards ca and family support

perforation: peritonitis, pericolic abscess

fistula: colovesicle (fecal urine, UTI)

gastrocolic

to skin

adhesion

stricture- also Crohn

malabsp

anaemia: fainted...

distal mets: liver, lungs

local invasion: bladder, ureter, uterus, peritoneal seedling (carcinomatosis peritonei), pelvic wall, sacral plexus

LN: peritoneal along thoracic duct causing compress duodenum and ureter, portal hepatis.

      Virchow's node in late

PE

sign,or associated sign of certain syn, complication check, risk check

anaemia sign

bruises, jaundice

retinal pigment layer hypertrophy (refer ophthalmologist fundoscopic)

pigmentation of oral mucosa- peutz

LN virchow's 

any surgical scar before?eg.- HNPCC (endometrium), peutz

**stoma describe**

hepatomegaly

obstructing I/O- active bowel, distension, peristalsis visible, toxic

peritonitis?- silent bowel, generalise tender, rebound tender

abd mass/ pain?

PR- no anal opening?? (ant resec), describe mass, distance from anal verge, ant/ post/ circumference, invade and attachment to surrounding tissue (fix), anal tone (sphincter)

respi: crep, pleural effusion

bone tender, urine, lower limb

Ix

AXR IO-  with/without competency of caecal valve (emergency in competenc valve)

gastrograffin enema (apple core)

**faecal occult blood** 

sigmoidoscopy + biopsy, histo

colonoscopy +biopsy, histo (>100 polyps= FAP)

DUKES: (good enough)

A- bowel wall 90% 5 yrs survival

B- Extend tru bowel wall 60%

C- Regional LN 30%

D- Mets 10%

or

TNM staging 

T0

Tis-in-situ

T1- lamina propria/submucosa

T2- muscularis mucosa

T3- subserosal/ non peritoneal perimuscular

T4- invade other organ/struc

N0

N1- 1-3 pericolic n

N2- >=4 pericoloc n

N3- any node of vessel

M0

M1-mets

FBC and cross match: anaemia, transfuse (if suspected sever blood loss, tell 1st)

staging: CT TAP, PET scan, liver u/s + LFT, local spread use transrectal u/s and MRI

baseline tumour marker CEA

preop biochemical assessment ( RP, LFT, Coag, ECG, CXR), vital sign, dietary (fasting), antibiotic prophylaxis cefuroxime + metronidazole)

ops:

principally 5cm clearence of margin but if lower down- 2cm and inter-sphincter resection to preserve sphincter

R or L hemicolectomy or sigmoid colectomy

for rectal ca: APR or Ant resection + mesorectal resection (low)

adjuvant chemo and radiotherapy to increase prolong survival in Duke's B, C, D or TNM 3, 4

neoadjuvant only in rectal tumour:

1. chemoradiotherapy (long): (chemo- radio- chemo) to sensitized radio and to downgrade it and preserve sphincter. T>=T3 or N1

2. radiotherapy (short): to reduce local recurrent in all rectal ca

very ill just stent or stoma to release obstruction

post ops:

multidisiplinary approach: vital sign- bleed, pain management, clean ops site, stomal care, physiotherapy, mobility prvnt DVT, dietetics, counsel self stoma and wound care, prvnt any sepsis, do distal loopogram look for (anastomotic leak, anastomotic stricture and fistula), monitor CEA after tx, complete scope postop and f/up 3/12

aspirin (NSAIDS) and cox 2 inhibitor said to be a protective factor.

• proximal: polypoidal exophytic mass along ascen colon and caecum

     diarrhoea (ascend colon diameter large and faecal is fluid)

     >occult bleed

     IDA

     RIF mass

• distal: annular, encircling, constrictive > sigmoid or rectal

     constipation

     use laxative not effective (mayb can pass out little stool still not finish)

     >visible bleed  IDA

     LIF pain

     low rectal  feel tenesmus (mass stimulate rectum to expel the mass)

stoma: important topic

area

colour of stoma bag content

barrel

sproud

caliber

complication check

PR- any anus

• type of stoma
• hv to diff ilio/colo
• indication- permenant; temporary:- emergency, defunctioning, bowel rest
• what complication- 

early:

haemorrhage

ischaemia

high output in ilio (hypoK, Dehydrate)

retraction

obs 2 ot adhesion

late:

prolapse

parastomal hernia

peristomal excoriation (ilio)

stricture

psychogenic