Colon MassColon Mass

GARCIA to GOSection B

45/ F severe colicky abdominal pain, 45/ F severe colicky abdominal pain, abdominal distentionabdominal distention

P.EP.E..Normosthenic not in any form of

distressHer vital signs are top normalChest and lungs are normalAbdomen is globularly distended,

with normal to hyperactive bowel sounds, soft, and nontender

Digital rectal examination is normal

Family HistoryFamily History(+)Colon cancer:

◦ Father at age 50 ◦ Father’s sister at age 52

(+) Abdominal Cancer:◦ Two of her cousins (alive and receiving

chemotherapy)Eldest of 4 siblings (40, 36, and 33

years old) and all of them are apparently well

Unaware of her grandparents’ medical history

What is your clinical What is your clinical working impression? working impression? Basis?Basis?

1. Obstruction◦Mass lesion

2. Irritable bowel Syndrome

Why Obstruction?Why Obstruction?Colicky abdominal painAbdominal distentionDue to causes within the bowel lumen,

within the wall of the bowel, or external to the bowel (such as compression, entrapment or volvulus).

Complicated by ◦ dehydration ◦ electrolyte abnormalities due to vomiting

Pain is felt lower in the abdomen and the spasms last longer

Why IBS?Why IBS?Functional bowel disorder Characterized by:

◦ chronic abdominal pain◦ discomfort◦ bloating◦ alteration of bowel habits in the absence of

any detectable organic causeMay begin life event or may begin at

onset of maturity without any other medical indicators

What are your immediate What are your immediate diagnostic and therapeutic diagnostic and therapeutic plans?plans?

Complete blood count◦ Abnormal levels may indicate bleeding

Fluid and electrolytes◦ Determine changes brought about by patient’s

vomiting and diarrheaPlain X-ray

◦ useful for detecting free intra-abdominal air , bowel gas patterns

Colonoscopy◦ for visualization of the entire colon and terminal

ileum◦ biopsy

Interpretation of the Interpretation of the Abdominal FilmsAbdominal Films

Comparison of large and small bowelobstruction featuresFeature Obstruction

Small bowel Large bowel Bowel diameter (cm) >3 and <5 >5Position of loops Central PeripheralNumber of loops Many FewFluid levels Many, short “Step Ladder” Few, long(on erect film)Bowel markings Valvaulae Haustra

(all the way across) (partially across)Large bowel gas No Yes

InterpretationInterpretationThere is a cut off point between

the transverse and descending colon due to obstruction

No volvulus seenNo diverticulumNo pneumoperitonium

What is your diagnosis What is your diagnosis now? Other now? Other considerations? Bases? considerations? Bases?

SMALL BOWEL OBSTRUCTION SMALL BOWEL OBSTRUCTION Abdominal pain

◦ Most small-bowel obstructions cause waves of cramping abdominal pain

◦ Pain occurs around the belly button (periumbilical area)

◦ If an obstruction goes on for a while, pain may decrease because the bowel stops contracting

◦ Continuous severe pain in one area can mean that the blockage has cut off the bowel's blood supply => This is called a bowel strangulation and requires emergency treatment

Vomiting

◦ Small-bowel obstructions usually cause vomiting

◦ Vomit is usually green if the obstruction is in the upper small intestine and brown if it is in the lower small intestine

Elimination problems

◦ Constipation and inability to pass gas are common signs of a bowel obstruction

◦ When the bowel is partially blocked, you may have diarrhea and pass some gas

◦ If you have a complete obstruction, you may have a bowel movement if there is stool below the obstruction

Bloating

◦ Blockages may cause bloating in the lower abdomen

◦ You may also hear gurgling sounds coming from your belly

◦ With a complete obstruction, your doctor may hear high-pitched sounds when listening with a stethoscope

◦ The sounds decrease as movement of the bowel slows

SMALL BOWEL SMALL BOWEL OBSTRUCTIONOBSTRUCTION

Pain tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes

Pain tends to be central and mid-abdominalVomiting occurs before constipationDepending on the level of obstruction, bowel

obstruction can present with abdominal pain, abdominal distension, vomiting, fecal vomiting, and constipation.

Obstruction may be due to causes within the:◦ bowel lumen◦ wall of the bowel◦ external to the bowel (such as compression, entrapment or

volvulus)

LARGE BOWEL LARGE BOWEL OBSTRUCTIONOBSTRUCTIONIn the large intestine,

obstructions are most often caused by cancer

. Other causes are severe constipation from a hard mass of stool and twisting or narrowing of the intestine that may occur because of diverticulitis or inflammatory bowel disease

LARGE BOWEL LARGE BOWEL OBSTRUCTIONOBSTRUCTION

Symptoms of large-bowel obstruction can include: A bloated abdomen Abdominal pain, which can be either vague and

mild, or sharp and severe, depending on the cause of the obstruction

Constipation at the time of obstruction, and possibly intermittent bouts of constipation for several months beforehand

If a colon tumor is the cause of the problem, a history of rectal bleeding (such as streaks of blood on the stool)

Diarrhea resulting from liquid stool leaking around a partial obstruction

Blockages caused by cancer may cause symptoms such as blood in the stool, weakness, weight loss, and lack of appetite.

COLON CANCERCOLON CANCERAbout half of all large-bowel

obstructions are caused by colorectal cancer

Undiagnosed colon or rectal cancer may cause a gradual narrowing of the large intestine's inner passageway

Usually patients experience intermittent constipation for a while before the bowel finally becomes obstructed

Symptoms of colorectal cancer depend on the location of tumor in bowel and whether it has spread to elsewhere in the body (metastasis)

Symptoms and signs are divided into: ◦Local◦Constitutional (affecting the whole body) ◦Metastatic (caused by spread to other

organs)

LOCALTumor that is large enough to fill the entire lumen

of the bowel may cause bowel obstruction. This situation is characterized by constipation,

abdominal pain, abdominal distension and vomiting as seen in the patient

CONSTITUTIONAL If a tumor has caused chronic occult bleeding, iron

deficiency anemia may occurThis may be experienced as fatigue, palpitations

and noticed as pallor (pale appearance of the skin)Colorectal cancer may also lead to weight loss

generally due to a decreased appetite

METASTATICColorectal cancer most commonly

spreads to the liverThis may go unnoticed, but large

deposits in the liver may cause jaundice and abdominal pain (due to stretching of the capsule)

If the tumor deposit obstructs the bile duct, the jaundice may be accompanied by other features of biliary obstruction, such as pale stools

Work-upsWork-upsBiopsy 

◦ necessary to confirm the diagnosisColonoscopy

◦ inspects the entire length of your colon with a little camera

◦ detects colon cancer, ulcers, inflammation and other problems in the colon

◦ Localize the tumorCT scan

◦ Most accurate to detect metastasis in LN, liver

Virtual colonoscopy

ManagementManagementNasogastric suctionIV fluids

◦0.9% saline or lactated Ringer's solution for intravascular volume repletion

◦Urinary catheter to monitor fluid output◦Electrolyte replacement should be guided

by test results◦ In cases of repeated vomiting, serum Na

and K are likely to be depletedIV antibiotics if bowel ischemia is

suspected◦3rd generation cephalosporins

ManagementManagementSurgery to remove any obstructing

lesion◦Gallstone- enterotomy◦Prevent recurrence- repair of hernias,

removal of foreign bodies, lysis of the offending adhesions if any

◦Disseminated intraperitoneal cancer- bypassing the obstruction, either surgically or with endoscopically placed stents

◦Obstructing colon cancers- single-stage resection and anastomosis, diverting ileostomy and distal anastomosis, diverting colostomy with delayed resection

How did this finding How did this finding alter your previous alter your previous management plan?management plan?

A proctosigmoidoscopy is done 4 hours after admission and A proctosigmoidoscopy is done 4 hours after admission and reveals the following at the 18 cm level.reveals the following at the 18 cm level.Scope can not be inserted further. Biopsies are taken.Scope can not be inserted further. Biopsies are taken.

Optimum Treatment Optimum Treatment StrategyStrategySurgery is the ONLY hope for

CUREAdjuvant chemotherapy for Colon

CA◦Stage III disease◦High risk Stage II disease

Obstruction / Perforation High grade histology

What is/are your What is/are your objective/s in treatment? objective/s in treatment?

What do you think What do you think should be performed?should be performed?1. Colectomy2. Subtotal Colectomy3. Other types

- Right hemicolectomy and left hemicolectomy - Transverse colectomy - Sigmoidectomy - Total colectomy- Total proctocolectomy

ColectomyColectomy• Resection of any part of the colon entails mobilization &

ligation of the corresponding blood vessels.

• Lymphadenectomy: usually performed through excision of the fatty tissue adjacent to these vessels (mesocolon), in operations for colon cancer

• When the resection is complete, surgeon has the option of immediately restoring the bowel,– by stitching or stapling together both the cut ends

(primary anastomosis)– creating a colostomy

• Several factors are taken into account, including:– Circumstances of the operation (elective vs emergency); – Disease being treated; – Acute physiological state of the patient; – Impact of living with a colostomy, albeit temporarily; – Use of a specific preoperative regimen of low residue

diet and laxatives (so-called "bowel prep").

• An anastomosis carries the risk of dehiscence (breakdown of the stitches), – lead to contamination of the peritoneal cavity,

peritonitis, sepsis and death.

• Colostomy is always safer, but places a societal, psychological and physical burden on the patient

Subtotal colectomySubtotal colectomyResection of part of the colon or

a resection of all of the colon without complete resection of the rectum.

Other typesOther types• Right hemicolectomy and left hemicolectomy

– resection of the ascending colon (right) and the descending colon (left), respectively.

– When part of the transverse colon is also resected, it may be referred to as an extended hemicolectomy

• Transverse colectomy is also possible, though uncommon. • Sigmoidectomy is a resection of the sigmoid colon, sometimes including

part or all of the rectum (proctosigmoidectomy).

– When a sigmoidectomy is followed by terminal colostomy and closure of the rectal stump, it is called a Hartmann operation;

– usually done out of impossibility to perform a "double-barrel" or Mikulicz colostomy, which is preferred because it makes "takedown" (reoperation to restore normal intestinal continuity by means of an anastomosis) considerably easier

• Total colectomy

– When the entire colon is removed

– also known as Lane's Operation• Total proctocolectomy

– Rectum is also removed

How would you How would you prepare the patient for prepare the patient for surgery?surgery?

Colon cancer staging Colon cancer staging AJCC stage TNM stage

TNM stage criteria for colorectal cancer[38]

Stage 0 Tis N0 M0Tis: Tumor confined to mucosa; cancer-in-situ

Stage I T1 N0 M0 T1: Tumor invades submucosa

Stage I T2 N0 M0 T2: Tumor invades muscularis propria

Stage II-A T3 N0 M0T3: Tumor invades subserosa or beyond (without other organs involved)

Stage II-B T4 N0 M0T4: Tumor invades adjacent organs or perforates the visceral peritoneum

Stage III-A T1-2 N1 M0N1: Metastasis to 1 to 3 regional lymph nodes. T1 or T2.

Stage III-B T3-4 N1 M0N1: Metastasis to 1 to 3 regional lymph nodes. T3 or T4.

Stage III-C any T, N2 M0N2: Metastasis to 4 or more regional lymph nodes. Any T.

Stage IV any T, any N, M1M1: Distant metastases present. Any T, any N.

OperabilityOperabilityCardiopulmonary statusCo-morbid conditions

◦Nutritional status◦Renal function◦Liver function

Pre-operative preparation Pre-operative preparation • subcutaneous heparin or low

molecular weight heparin– Patients undergoing surgery for

colorectal cancer are at risk of venous thrombo-embolism and wound and/or deep intra-abdominal sepsis

• graduated compression stockings • prophylactic antibiotics

(cephalosporin and metronidazole)– All patients should receive antibiotics

effective against both aerobes and anaerobes at induction of anaesthesia

• Mechanical bowel preparation

What other considerations What other considerations should you take into account should you take into account prior to surgery?prior to surgery?

Previous colon resectionSignificant obesityMajor illnesses

◦Diabetes Mellitus

ConsiderationsConsiderationsProper staging of the diseaseConsider chemotherapy before

laparotomy ◦Highly vascularized area

Consider metastases◦Liver metastases: remove during

laparotomy

Further PlansFurther Plans

Chemotherapy Used to reduce the likelihood of

metastasis developing, shrink tumor size, or slow tumor growth

In colon cancer, chemotherapy after surgery is usually only given if the cancer has spread to the lymph nodes (Stage III)

Further PlansFurther Plans

Radiotherapy Not used routinely in colon cancer,

as it could lead to radiation enteritis, and it is difficult to target specific portions of the colon

Indicated for pain relief and palliation targeted at metastatic tumor deposits if they compress vital structures and/or cause pain

Further PlansFurther PlansOther treatments have included

the use of localized infusion of chemotherapeutic agents into the liver, the most common site of metastasis.

Follow up after surgeryFollow up after surgery

Why?85% of colon cancer recurrences

occur within 3 years from after resection of primary tumor

Colon cancer resection (stage II and III) should undergo regular surveillance for at least 5 years following resection

Physical ExamPhysical ExamAmerican Society of Clinical Oncology

(2005) recommends physical examinations every 3-6 months for the first 3 years, every 6 months during years 4 and 5, and subsequently at the discretion of physician and based on individual risk assessment

Hidden occult blood

Blood testBlood testCEA

◦Every 3 months in patients with stage II or III disease for at least 3 years and every 6 months in years 4 and 5.

ScansScansComputerized tomography (CT) of the

chest and abdomen ◦ Annually for at least 3 years after resection

of primary tumorColonoscopy

◦ 3 months after◦ In the absence of high-risk pathology on

the first colonoscopy or increased susceptibility for colon cancer, follow-up colonoscopy should be performed at 3 years after surgery and then, if normal, once every 5 years thereafter.