Cutting Edge Leeds
Colorectal Carcinoma
Nicol, J
3rd Year Medical Student (2008)
History
- Sex: Male
- D.O.B.: 1924
- Age: 83
- Marital Status: Married
- Employment: Retired joiner
Mode of Admission
Self-referral via ambulance to St James's Hospital Accident & Emergency on 22/02/08.
Presenting Complaint
Patient c/o severe abdominal pain.
History of Presenting Complaint
Prior to admission, the patient had experienced blood-stained diarrhoea and nausea without associated vomiting. The patient stated that he experienced bouts of diarrhoea up to 10 times per day. The patient had recently lost his appetite and has been eating and drinking very little.
Previous Medical History
- 2000 Cystoscopy revealed benign prostatic hypertrophy.
- 2001 Sub-total colectomy following diagnosis of T3 N0 colorectal carcinoma.
- 2003 Left inginual hernia repair
- Hypothyroidism
- Parkinson's Disease
- Ischaemic Heart Disease
Family History
No family history of gastrointestinal or hepatobiliary disease.
Social History
Patient lives with his wife who does much of the shopping and cleaning around the house. No social support. 2 to 4 units of alcohol per week. Non-smoker. Never smoked.
Drug History
- Tramadol 50-100 mg QDS (opioid analgesic)
- Paracetamol 1 g QDS (NSAID)
- Oramorph 5-10 ml BD (opioid nalgesic)
- Co-codamol
- Thyroxine
- Allergies: None known
Examination
Patient appeared frail and unwell. Alert and orientated and had just finished eating his lunch.
Pulse Rate: 48 bpm (bradychardia)
Respiration Rate: 14
Blood Pressure: 125/47 (hypotensive)
Hands: Nil of Note. No asterixis
Eyes: Evidence of anaemia
Palpation of supraclavicular, parotid, submandibular and axillary lymph nodes revealed no obvious abnormalities.
Inspection of abdomen revealed no striae, spider naevae or obvious asymmetry.
Operation scar (subtotal colectomy)
Light palpation of 9 abdominal areas revealed extreme tenderness over LUQ.
AAA detected during percussion of abdomen
No bowel sounds detected upon auscultation.
Marked abdominal distention; percussion revealed shifting dullness (ascites ++).
A full examination would have included an examination of the external genitalia, inginual region and a digital rectal exam.
No ankle oedema.
Differential Diagnosis
Provisional diagnosis
Re-occurrence of colorectal carcinoma. Prior colorectal carcinoma is most common aetiology of re-occurrence.
Differential Diagnoses
Caecal volvulus, intussusception, Ogilvie syndrome sigmoid volvulus, bilateral inginual herniae.
Proposed Investigations
- Digital rectal exam
- Faecal occult blood
- Full blood count (assists in diagnosis of anaemia)
- Liver function test (establish if liver metastases present)
- Sigmoidoscopy (obtain biopsy)
- Prothrombin time
- Arterial blood gases
- Urea and Electrolytes (to establish presence of hypokalaemia)
- Abdominal X-Ray
- Chest X-Ray (establish if free air present under diaphragm if perforation present)
Management
Medical
- Analgesia
- Intravenous fluids
- Nasogastric tube
Surgical
If colorectal carcinoma confirmed by biopsy subsequent to sigmoidoscopy/colonoscopy: -
Vital to establish stage and grade of tumour and presence of any metastases to distant organs using Duke's classification.
If carcinoma is operable
- Intravenous urogram prior to surgery to establish possible bladder and ureteric involvement.
- Perioperatively, administration of suitable antibiotics.
- At surgery, resection of tumour with adequate margins to include regional lymph nodes.
- Resection of liver metastases (if present) possible only if less than 5 present.
- Right or left hemicolectomy dependent on site of tumour.
If carcinoma is inoperable
- Intraluminal stents for obstructing cancers
- Surgical bypass for obstructing cancers
- Open resection of tumour
- Palliative chemotherapy (5-Fluorouracil and/or Levamisole to palliate liver metastases).