Cancer of Large intestine, CA colon, CA rectum

1. Dr. Danish Sagheer

2. HISTORY

3.  Tasleem Akhtar 50 y/o married female
resident of sargodha, presnted to E.R on 9th
jan 2022 with c/o:
 Post-prandial vomitting for last 7-8 days
 Severe pain in abdomen for last 4 days
 Absolute constipation for last 3 days

4.  Pt. was in USOH 8-10 days back when she
started experiencing vomitting episodes after
taking meals. Vomitting was sudden,
projectile, containing food particles,
aggravated upon taking meals and relieved
upon taking anti-emetics
 Vomitting was later associated with pain
abdomen and constipation

5.  Patient started experiencing generalized
abdominal pain 4 days back which started
from epigastric reigon and spread throughout
the abdomen.
 Pain was severe, colicky in nature, aggravated
upon taking meals and relieved upon
vomitting and on taking analgesics.

6.  Patient also complained of Obstipation for
last 3 days.
 She gave history of a similar episode of
Obstipation one week back which was
relieved by enema at a local hospital

7.  CVS: HTN -ve, IHD -ve
 RESP: Asthma -ve, COPD -ve, TB -ve
 CNS: CVA -ve , No other senile illnes
 RENAL: CKD -ve
 GIT: Hepatitis -ve, CLD -ve, NAFLD -ve

8.  Medical: Insignificant
 Surgical: Hx of Appendectomy 20 years ago

9.  Patient belong to a lower middle class family
 She lives in her own house having 6 rooms
with 12 people among which 2 are bread
earners
 Uses drinking water from a well and has no
pets
Allergies:
 No hx of any known allergies

10.  HTN, DM both parents
 No other hx of any familial disease
Personal history:
Normal sleep and appetite
No Addictions

11.  Upon GPE, a middle aged ladyof medium
hieght, moderately obese, lying in bed in
obvious discomcomfort, well oriented in time,
place and person
 Her vitals were
 B.P: 150/90, Pulse: 102/min
 Temp: 99F , R.R 16/min

12.  Jaundice –ve
 Anaemia –ve
 Cyanosis –ve
 Koilonychia –ve
 Palpable Lymph nodes –ve
 Edema -ve

13.  GIT:
Abdomen – Tender, Distended with sluggish
bowel sounds
Hernial orificies were normal
Upon DRE:
No impacted stool, hemmorhoids or fissure
seen. Normal mucosa

14.  CVS: S1+S2+0
 CNS: GCS: 15/15. No sensorimotor
neurological deficit
 RESP: Normal vesicular breathing. No added
sounds

15. Intestinal Obstruction??

16. CBC:
Hb: 14.7, TLC : 10700, PLT: 380000
LFTs:
Bilirubin: 0.9 , ALP: 234 U/L, ALT: 37U/L
RFTs and S/E:
Urea: 27, Creatinine: 0.7
Serum Na+ : 140, Serum K+: 3.9

17.  BSR : 94 mg/dl
 HbsAg: -ve
 Anti HCV: -ve
 HIV: -ve

18. >X-RAY Abdomen:
Multiple air fluids levels with dilated Gut
loops
 USG Abdomen:
Excessive gas shadows and Dilated gut loops
noted. Mild interloopal fluid was noted

19.  Done on 9th Jan
 Diffuse
circumferential wall
thickness of sigmoid
colon with segment
of strictural
narrowing.
 Retrogradely marked
dilatation of small
and large gut seen

20.  Admit
 NPO
 NG Intubation
 Foley’s cathertization
 Inf. 5% D/W 1000ml B.D
 Inf. R/L 1000ml O.D
 Inj. Metronidazole 500mg/100ml i/v TDS
 Inj. Tramal+ Gravinate

21.  On 13th jan, her exploratory laparotomy was
performed. Her per-op findings were:
 An Omental band near ileocecal junction
 Sigmoid stricuture and a hard fixed mass
involving sigmoid colon
 Enlarged mesenteric lymph nodes

22.  Omental band was released
 Tumor identified and 8-10cm of sigmoid colon was
resected along with it and sample was sent for
histopathology
 Proximal end was brought out as end colostomy and
dital stump was closed using silk suture (Hartman’s
Procedure)
 1 pelvic drain was placed
 Haemostasis secured and patient was sent back to
ward

24.  The large intestine
is approximately
1.5 mlong
 The large intestine
begins at the
ileocaecal valve and
extends to the
anus.

25. Cancer effecting:
 Caecum
 Colon
 Rectum
 Anal canal and appendix are not considered
in the definition, and are treated as separate
entities

26.  Epidemiology
 Colorectal cancer is the second leading cause
of cancer-related deaths after lung cancer
 5-year survival rate : 55%.
 The most lethal GI malignant diseases in the
Western world.
 Is preventable and is highly curable if
detected early

28.  Early stages of colorectal cancer may have NO
signs or symptoms.
 If signs and symptoms are present, they may
include:
 Bleeding from the rectum or blood in the
stool
 Marked change in bowel habits
 Abdominal mass
 Abdominal cramps or pain
 Iron deficiency anemia that is not due to
other conditions

33. Lab INVESTIGATIONS:
CBC,
RFTS,
LFTS,
BSR,
Serum electrolytes
Stool R/E

34. Tumor markers:
Carcinoembryonic antigen (CEA)
CA 19-9
Can also be raised in
Not used to diagnose or screen colorectal
carcinoma. They’re rather used in pre-
diagnosed pts along with other investigations
Can also be used to monitor response to
treatment

35.  Double-contrast
barium enema
 described as
APPLE-CORE filling
defect

37.  If there is a
suspiscion of
colorectal carcinoma,
Biospy is taken
during colonoscopy
or flexible
simoidoscopy and
specimen is sent for
histopathalogy

38.  Chest X-ray: Mets in lungs
 Ultrasonography
 Contrast enhaced CT-Scan and MRI Scan
These investigations are helpful to identify
if tumor has spread into surrounding
structures and into distant abdominal visceras

41.  Dukes’ staging for colorectal cancer
 ●● A: invasion of but not breaching the muscularis
propria
 ●● B: breaching the muscularis propria but not
involving lymph nodes
 ●● C: lymph nodes involved.
D: Distant mets

42. Surgery is mainstay treatment of both palliative
and curative management of ca colon
It is necessary that tumor and 2 cm tumor free
margins should be resected
Following are various types of resections
depending upon the location of tumor:

43.  For carcinoma of
cecum and ascending
colon
 Cecum, ascending
colon, hepatic
flexure, proximal 3rd
of transverse colon is
resected
 Anastomosis is made
between ileum and
transverse colon

44.  Done for Ca of
hepatic flexure and
transverse colon
 Rt. Hemicolectomy+
whole of transverse
colon and splenic
flexure
 Anastomosis is made
between ileum and
descending colon

45.  Splenic flexure,
Descending colon and
sigmoid colon
 Distal 2/3rd of
transverse colon,
descending colon and
sigmoid colon are
removed and colorectal
anastomosis is created

46.  Tumor of upper 2/3rd is treated with Anterior
resection
 Tumor of distal 3rd is treated with
Abdominoperineal resection
 HARTMAN’S PROCEDURE: In this procedure
rectum is excised, distal stump is closed and
proximal stump is brought out as End
colostomy

47.  Advanced carcinoma of rectum which is fixed
and un-resectable is managed by palliative
procedures such as Colostomy to relieve the
obstruction and chemo/radiotherapy to
shrink the tumor

48.  Given in stage III and IV patients
 It has no survival benefits in stage 1 and II
 5-Fluorouracil in combination with Folinic
acid is most frequently used
 Neo adjuvant chemo is sometimes used in
non-operable cases to shrink the size of
tumor and make them operable

49.  Limited role in colorectal carcinoma
 Can be given pre-operatively or post op. to
reduce risk of local recurrence
Has also some role in combination therapy
with chemo as neo-adjuvant. Used to shrink
size of tumor preoperatively