1. Colon Mass GARCIA to GO Section B

2. 45/ F severe colicky abdominal pain, abdominal distention 1Month PTA Lost 15 pounds 3 weeks PTA Frequent episodes of watery stool alternating with hard, small caliber stools 2 days PTA Nausea Abdominal pain Abdominal distention 1 day PTA Not passed any stool or gas in the last 24 hour Hours PTA Previously ‐ taken food twice Moderately severe colicky abdominal pain Abdominal distention

3. P.E. Normosthenic not in any form of distress Her vital signs are top normal Chest and lungs are normal Abdomen is globularly distended, with normal to hyperactive bowel sounds, soft, and nontender Digital rectal examination is normal

4. Family 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

5. What is your clinical working impression? Basis? 1. Obstruction ◦ Mass lesion 2. Irritable bowel Syndrome

6. Why Obstruction? Colicky abdominal pain Abdominal distention Due 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

7. Why IBS? Functional bowel disorder Characterized by: ◦ chronic abdominal pain ◦ discomfort ◦ bloating ◦ alteration of bowel habits in the absence of any detectable organic cause May begin life event or may begin at onset of maturity without any other medical indicators

8. What are your immediate diagnostic and therapeutic plans? Complete blood count ◦ Abnormal levels may indicate bleeding Fluid and electrolytes ◦ Determine changes brought about by patient’s vomiting and diarrhea Plain X-ray ◦ useful for detecting free intra-abdominal air, bowel gas patterns Colonoscopy ◦ for visualization of the entire colon and terminal ileum ◦ biopsy

9. Interpretation of the Abdominal Films Comparison of large and small bowel obstruction features Feature Obstruction Small bowelLarge bowel Bowel diameter (cm) >3 and 5 Position of loops Central Peripheral Number of loops Many Few Fluid 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

11. Interpretation There is a cut off point between the transverse and descending colon due to obstruction No volvulus seen No diverticulum No pneumoperitonium

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

13. 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

14. SMALL BOWEL OBSTRUCTION Pain tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes Pain tends to be central and mid-abdominal Vomiting occurs before constipation Depending 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)

15. LARGE BOWEL OBSTRUCTION In 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

16. LARGE BOWEL OBSTRUCTION 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.

17. COLON CANCER About 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

18. 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)

19. LOCAL Tumor 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 occur This 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

20. METASTATIC Colorectal cancer most commonly spreads to the liver This 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

21. Work-ups Biopsy ◦ necessary to confirm the diagnosis Colonoscopy ◦ inspects the entire length of your colon with a little camera ◦ detects colon cancer, ulcers, inflammation and other problems in the colon ◦ Localize the tumor CT scan ◦ Most accurate to detect metastasis in LN, liver Virtual colonoscopy

22. Management Nasogastric suction IV 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 depleted IV antibiotics if bowel ischemia is suspected ◦ 3 rd generation cephalosporins

23. Management Surgery 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

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

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

26. Optimum Treatment Strategy Surgery is the ONLY hope for CURE Adjuvant chemotherapy for Colon CA ◦ Stage III disease ◦ High risk Stage II disease  Obstruction / Perforation  High grade histology

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

28. What do you think should be performed? 1. Colectomy 2. Subtotal Colectomy 3. Other types - Right hemicolectomy and left hemicolectomy - Transverse colectomy - Sigmoidectomy - Total colectomy - Total proctocolectomy

29. Colectomy 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

30. 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

31. Subtotal colectomy Resection of part of the colon or a resection of all of the colon without complete resection of the rectum.

33. Other 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

34. How would you prepare the patient for surgery?

35. Colon cancer staging AJCC stageTNM stage TNM stage criteria for colorectal cancer[38][38] Stage 0Tis N0 M0 Tis: Tumor confined to mucosa; cancer-in-situ Stage IT1 N0 M0T1: Tumor invades submucosa Stage IT2 N0 M0T2: Tumor invades muscularis propria Stage II-AT3 N0 M0 T3: Tumor invades subserosa or beyond (without other organs involved) Stage II-BT4 N0 M0 T4: Tumor invades adjacent organs or perforates the visceral peritoneum Stage III-AT1-2 N1 M0 N1: Metastasis to 1 to 3 regional lymph nodes. T1 or T2. Stage III-BT3-4 N1 M0 N1: Metastasis to 1 to 3 regional lymph nodes. T3 or T4. Stage III-Cany T, N2 M0 N2: Metastasis to 4 or more regional lymph nodes. Any T. Stage IVany T, any N, M1 M1: Distant metastases present. Any T, any N.

36. Operability Cardiopulmonary status Co-morbid conditions ◦ Nutritional status ◦ Renal function ◦ Liver function

37. 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

38. What other considerations should you take into account prior to surgery? Previous colon resection Significant obesity Major illnesses ◦ Diabetes Mellitus

39. Considerations Proper staging of the disease Consider chemotherapy before laparotomy ◦ Highly vascularized area Consider metastases ◦ Liver metastases: remove during laparotomy

40. Further 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)

41. Further 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

42. Further Plans Other treatments have included the use of localized infusion of chemotherapeutic agents into the liver, the most common site of metastasis.

43. Follow 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

44. Physical Exam American 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

45. Blood test CEA ◦ 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.

46. Scans Computerized tomography (CT) of the chest and abdomen ◦ Annually for at least 3 years after resection of primary tumor Colonoscopy ◦ 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.