general surgery case presentation iii-b dr. erasmo
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GENERAL SURGERYCase Presentation
III-B Dr. Erasmo
Members: de Leon, Gemma de Mesa, Angelica
de Vera, Jestha dela Cruz, Ciara
Case: Colon Mass• Female 45 y/o• Moderate severe colicky
abdominal pain• Abdominal distention• Nausea – 2 days
Last month•Weight loss (15 lbs.)
3 weeks •Frequent episodes of watery stools alternating with hard, small caliber stools
24 hrs•Not passed any stool or gas
PTA•Vomited twice
HPI
Family History• Father died at 50 y/o – colon cancer• Aunt (father side) died at 52 – colon
cancer• Cousins diagnosed with some form
of abdominal cancer• Eldest of 4 (40, 36, and 33 y/o) – all
well
Physical Examination• Normosthenic female• vital signs - normal.• Chest and lungs -normal.• Abdomen • globularly distended• normal to hyperactive bowel sounds• soft, nontender.
• DRE - normal.
Clinical working impression
•Obstruction due to possible colon CA
Basis: Hx and PE• Chief complaint:
• Moderate severe colicky abdominal pain• Abdominal distention• Nausea – 2 days
• HPI• PTA, - vomited previously taken food twice. ‐• not passed any stool or gas in the last 24 hours. • frequent episodes of watery stools alternating with hard, small
caliber stools for the last 3 weeks. • lost 15 pounds in the last month.
• FH• Father died at 50 y/o – colon cancer• Aunt (father side) died at 52 – colon cancer• Cousins diagnosed with some form of abdominal cancer• Eldest of 4 (40, 36, and 33 y/o) – all well
Basis: Usual manifestation of Colon Cancer
obstruction• has not passed any stool or gas in the last 24 hours
Change in bowel habits• frequent episodes of watery stools alternating with hard, small
caliber stools for the last 3 weeks
blood streaked stools
Palpable abdominal mass
Basis: Other manifestation of Colon Cancer
Weight loss
Family history of colorectal cancer
Other GI symptoms
Rectal examination
Ancillary Tests• Double contrast Barium enema• Colonoscopy• CT Scan• MRI• Virtual colonoscopy
Double contrast barium enema
• colon is first filled with barium • the barium is drained out, leaving only a thin layer of
barium on the wall of the colon• colon is then filled with air • This provides a detailed view of the inner surface of
the colon, making it easier to see narrowed areas (strictures), diverticula, or inflammation.
• This technique can miss the (less common) flat polyp.
Colonoscopy• A lighted probe called a colonoscope is inserted into the rectum
and the entire colon to look for polyps and other abnormalities that may be caused by cancer.
• A colonoscopy has the advantage that if polyps are found during the procedure they can be immediately removed.
• Tissue can also be taken for biopsy.
CT SCAN• an x-ray test that produces detailed cross-sectional images of your body• Instead of taking one picture, like a regular x-ray, a CT scanner takes
many pictures as it rotates around you while you lie on a table.• A computer then combines these pictures into images of slices of the
part of your body being studied.• Unlike a regular x-ray, a CT scan creates detailed images of the soft
tissues in the body.• This test can help tell if colon cancer has spread into your liver or other
organs.
MRI• provide detailed images of soft tissues in the body• uses radio waves and strong magnets instead of x-rays• useful in looking at abnormal areas in the liver that might be due to
cancer spread• They can also help determine the extent of rectal cancers.• little more uncomfortable than CT scans• First, they take longer -- often up to an hour. • Second, you have to lie inside a narrow tube, which is confining and can
upset people with claustrophobia
VIRTUAL COLONOSCOPY• replaces X-ray films in the double contrast barium enema with a
special computed tomography scan • requires special workstation software in order for the radiologist to
interpret• This technique is approaching colonoscopy in sensitivity for polyps. • However, any polyps found must still be removed by standard
colonoscopy.
Therapeutic plans• • Surgery is the ONLY hope• Adjuvant chemotherapy for Colon CA
– Stage III disease– High risk Stage II disease
• Obstruction• High grade histology
What is your interpretation of Abdominal films?
Differentiating SBO from Paralytic Ileus
SBO Ileus
Pain Colicky Not a prominent feature
Abdominal distension Frequently prominent Sometimes not apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
Mechanical Obstruction of the lumen• Obturation of the lumen• Lesions extrinsic to bowel• Lesions of the bowel• Congenital• Traumatic• Neoplastic
Obstruction secondary to small bowel neoplasm• typically asymptomatic in its early stages, but more than 90% of
patients eventually develop symptoms as the disease progresses
Manifestations in the patient• nausea• vomiting• intestinal obstruction• abdominal pain• weight loss• distended abdomen
Characteristic features on abdominal flat and upright radiographs:• dilated bowel loops• air fluid levels proximal to the point
with little or no gas distally• air fluid levels are more pronounced
and a step ladder pattern is seen
Work-up
• Laboratory evaluation (cbc, serum electrolytes, blood chemistry, cardiopulmonary assessment)
• Contrast radiography• Enterocyclis• Abdominal CT scan• Upper GI series with small bowel follow through • Abdominal Ultrasound
Enterocyclis• Barium small bowel enema• Involves filling the small intestine with barium liquid while xray
images are being taken• 90 % sensitivity in detection of small bowel tumors• Test of choice
Abdominal CT scan• Has low sensivity in detecting mucosal and intramural lesions• Can demonstrate large tumors• Useful in staging intestinal malignancies
Contrast Enema and UGIS with small bowel follow through• Useful if diagnosis is uncertain or demonstrating partially
obstructing lesion• Ba enema is usually done first to rule out colonic obstruction
Abdominal Ultrasound
• May demonstrate larger tumors (>4cm)• Can differentuate between intramural, intraluminal and
extraluminal growth patterns
Initial Treatment• Aggressive fluid resuscitation (rehydrate,
correct elec abn, put foley catheter to monitor urine output)
• Nasogastric suction (to prevent aspiration and for decompression
• Administration of analgesia and antiemetic as indicated clinically
• Antibiotics• Early surgical consultation
.
Surgical excision of small bowel neoplasm• Primary treatment for cancer of the small intestine• For benign neoplasms: Exploratory laparotomy with excision of the
lesion• provides the safest and most direct method for lesion identification
and treatment.
• For malignant neoplasms: Surgical Resection• provides the only hope of cure for patients with small-bowel
adenocarcinomas.• others have have unresectable disease as a result of extensive local
disease or metastases to regional lymph nodes, the liver, or the peritoneum.
Chemotherapy and Radiotherapy• Useful if the cancer is widespread
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