Colonic Cancer. Presentation.. docdani_ph

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<p>Diagnostic and Management Approach of Intestinal Obstruction</p> <p>Danny A. Portes , M.D.Department of Medicine Veterans Memorial Medical Center</p> <p>GENERAL OBJECTIVE : To discuss a case of Adenocarcinoma of the colon presenting as intestinal obstruction</p> <p>SPECIFIC OBJECTIVES :1. To discuss diagnostic approach on intestinal obstruction. 2. To present differential diagnoses on intestinal obstruction. 3. To discuss the management approach of intestinal obstruction.</p> <p>General data 82 y/o , male Married , RPV Roman Catholic Pangasinan Admitted for the 1st time on May 23, 2005</p> <p>Chief Complaint</p> <p>Abdominal Pain</p> <p>1 MONTH PTA</p> <p>History of Present Illness</p> <p>abdominal pain consultation done still with abdominal (+) vomiting (+) loss of appetite (+) weight loss no consultation nor medication taken</p> <p>1 WEEK PTA pain</p> <p>1 DAY PTA persistence of above s/sx consultation done medication: Cotrimoxazole 800mg/tab Ranitidine 150 mg/tab tid Hyoscine N Butyl Bromide transferred to our institution</p> <p>ADMISSION</p> <p>Past Medical History (+) Hypertension x 20 years - on Amlodipine 5mg/tab, OD Hemorrhoidectomy - 1969</p> <p>Personal / Social History 47 pack year smoker stopped in 1969 alcoholic beverage drinker stopped in 1969</p> <p>Family History Hypertension paternal side</p> <p>Review of Systems (+) generalized body weakness (-) fever (-) cough, hemoptysis, DOB (-) chest pain, orthopnea, PND (-) palpitations, dyspnea (-) dysuria, frequency, urgency (-) bleeding episode (-) polyuria, polydipsia, polyphagia</p> <p>Physical ExaminationConscious , coherent , not in distress BP: 130/70 CR: 72bpm RR: 20 T:37 pale palpebral conjunctivae, anicteric sclerae,no nasoaural discharge, moist lips and buccal mucosa supple, no CLAD, no neck vein engorgement SCE, no lagging, nor retractions, resonant, no adventitious sounds Adynamic precordium, PMI at 5th ICS, LMCL NRRR, (-) murmur</p> <p> Flat, (-)scars, normoactive bowel sounds, (-) bruit, soft, tympanitic, with slight tenderness at the epigastric and hypogastric area on deep palpation, (-) hepatosplenomegaly, (-) palpable mass, (-) rebound tenderness Abdominal circumference= 34 inches</p> <p> Genitalia: no lesions no scrotal enlargement Extremities: grossly normal, full and equal pulses, no edema, no cyanosis Skin: dry skin, poor skin turgor, no active dermatoses, no jaundice</p> <p>DRE: no skin tags, no lesions, no fissures, good sphincteric tone, full rectal vault, (+) brownish hard stool on examining finger</p> <p>Salient Features 82yo, male abdominal pain vomiting anorexia weight loss pallor slight tenderness on deep palpation at epigastric area and hypogastrium</p> <p>Admitting Impression T/C BPUD, Anemia 2 Hypertension, Stage 2, controlled</p> <p>Differential Diagnosis Biliary tract disease Chronic diverticulitis Colonic CA</p> <p>Biliary Tract Disease nausea, vomiting and epigastric or RUQ abdominal pain that is steady or colicky post-prandial fullness, flatulence and fatty food intolerance jaundice</p> <p>Complete Blood Count5-23 Hgb Hct WBC seg 81 27 4.2 .78 5-28 116 37 5-30 148 46 15.7 .96 .04 6-15 115 37 8.4 .85 .15 .78 .22 7-7 112 36</p> <p>lymp .22</p> <p>retic</p> <p>16</p> <p>platelet 264 protime 264 Pro act 120 control MCV MCH 12.9 66 20</p> <p>MCHC 30</p> <p>Blood Chemistries5-23 BUN Crea Na Cl K FBS BUA HDL LDL 5.2 82 141 100 4.2 6.0 151 1.0 3.9 5-25 5-28 6-1 7-10 3.2 73 137 100 3.9</p> <p>145 101 3.4</p> <p>Mg Ca Phos sgot sgpt TC TG amylse glob alb TP 5.1 0.5 51 26 28 54 25 15 27 38 20 2.0</p> <p>5-26 color transprency sp gravity pH albumin sugar RBC PUS bacteria epith cells yellow sl turbid 1.010 7.0 neg neg 0-1 0-3 few few</p> <p>6-15 D. yellow sl turbid 1.015 6.5 neg neg 0-1 0-4 mod occ</p> <p>7-15 yellow clear 1.015 7.5 neg neg 2-4 2-3</p> <p> CEA: 6-24 1.18ng/ml ( 2.10-6.20) 12-L ECG Results: 5-23-05 - 1st degree AV block - CRBBB 6-5-05 - CRBBB</p> <p>Radiographic Report5-24 Gen adynamic ileus, OA thoraco lumbarspine 5-25 5-26 5-27</p> <p>Gen ileus, Gen ileus, Finding partial int partial int consistent obstruction obstruction with partial not ruled out, not ruled out, intestinal OA, TLS OA TLS obstruction, OA, TLS</p> <p> Chest ( A-P) 5-27-05 - No significant cardiopulmonary problems findings except for atheromatous aorta, OA, thoracis spine Lumbo-sacral - spurs on the bodies of the lumbar spine with intact disc space consistent with degenerative changes, lumbar instability</p> <p>Ultrasound Report Abdominal Aorta: 5-23-05 - no sonographic evidence of abdominal aortic aneurysm</p> <p> HBT, LGBPS, AA:5-24-05 - normal liver, biliary tree, spleen - consider cholecystitis - non visualized pancreas and AA - minimal ascites noted</p> <p> HBT, LGBPS, PAN: 6-17-05 - diffuse parenchymal liver diseasedilated intrahepatic duct sonographically normal gall bladder non visualized pancreas negative para-aortic node enlargement incident note of ascites and right basal pleural effusion</p> <p>Whole Abdomen CT Scan 5-27-05- Generalized ileus. Possibility of chronic partial intestinal obstruction likewise considered. - dilated gall bladder - OA changes of lumbar spine</p> <p>Histopathological Diagnosis Adenocarcinoma, low grade (Moderately Differentiated), 5x4 cm extending to the muscular and subserosal layer ASTLER COLLER STAGING, STAGE B2 T3MOMx, AJCC Remarks: all (0/8) lymph node and lines of resection are NEGATIVE for malignant cells.</p> <p>Course in the ward</p> <p>Admission Venoclysis done diet : low salt , low cholesterol Dx : CBC anemia 12 L ECG complete RBBB, 1st degree AV block Tx : Famotidine 20 mg IV q 8 Metoclopramide 10 mg IV prn AlMgOH 45 cc prn Amlodipine 5 mg/tab ISDN prn PRBC 2 u requested</p> <p>1st hospital day Vital signs were normal Occasional epigastric pain radiating to the hypogastric area 2 episodes of vomiting IMPRESSION: T/C Cholecystitis Dx: Ultrasound unremarkable Tx/Plan: Gastro service Surgery service</p> <p>2</p> <p>n d</p> <p>hospital day</p> <p> Still with crampy abdominal pain, vomiting Normal vital signs, abdominal girth= 36 inches IMPRESSION: T/C Acute Intestinal Obstruction Dx: Flat Plate of abdomen - Generalized adynamic ileus Serum amylase normal Serum electrolytes - normal UTZ of LGBPS normal Tx: NPO NGT inserted Blood transfusion 1 unit PRBC</p> <p>3rd hospital day Still with the same complaints Normal vital signs, abdominal girth = 36 inches Repeat flat plate done Generalized ileus Intestinal obstruction not ruled out GI service - continue decompression and start Empiric antibiotic therapy Cefuroxime 750 mg IV q8 Metronidazole 500 mg IV q8</p> <p> Surgery service Non surgical abdomen and concurred with the plan Suggestions : Endoscopy serum TPAG determination liquid diet if tolerated</p> <p>4th hospital day Still with crampy abdominal pain (+) nausea (-) vomiting Stable vital signs AC = 36 inches Repeat flat plate Partial Intestinal obstruction Post BT H &amp; H Continue empiric antibiotic treatment and decompression BT of 2nd unit of PRBC referred back to Gastro service</p> <p>5th hospital day Still with abdominal pain localized in left hypogastrium (+) vomiting (-) fever Increasing abdominal girth (37 inches) Tenderness on deep palpation</p> <p>CT scan of abdomen Generalized ileus Consider Chronic partial intestinal obstruction Dilated gallbladder Osteoarthritic changes of lumbar spine</p> <p>6th hospital day Transfer of service Surgery</p> <p>E lap done Left hemicolectomy with Devines colostomy and biopsy done</p> <p>Intraoperative findings 5 x 4 cms firm , constricting mass at the splenic flexure , markedly dilated bowels from LOT to mid transverse colon With serosal tears at 80 cm and 110 cm from LOT</p> <p>Histopathologic report Adenocarcinoma , low grade ( Moderately Differentiated ) extending to the muscular and subserosal layer ASTLER COLLER STAGING , STAGE B2 T3N0Mx , AJCC All (0/8)LN and lines of resection are NEGATIVE of malignant cells</p> <p>Course in the ward: He stayed at surgery service for two weeks. Antimicrobial coverage, hydration and nutritional build-up were provided.</p> <p>Course in the ward: He was subsequently transferred to ONCOLOGY service. On his 39th hospital day, he was discharged clinically improved and stable.</p> <p>DISCUSSION</p> <p>Intestinal Obstruction By location small bowel (proximal/distal) - large bowel By mechanism mechanical or non-mechanical ( adynamic, paralytic ileus, pseudo-obstruction) By pathophysiology simple, closed loop, strangulated</p> <p>Colonic Obstruction Neoplasm (60%) Volvulus (20%) Diverticular stricture (10%) Others (10%)</p> <p>Volvulus 20-50% of all intestinal obstruction abnormal twisting of a segment of bowel on itself along its longitudinal axis closed loop obstruction is often produced sigmoid and cecum are the most frequent sites transverse colon, splenic flexure</p> <p> colicky abdominal pain, obstipation andabdominal distention bent-inner tube ( sigmoid volvulus) or omega loop sign kidney-bean shaped ( cecum) these classical radiographic findings are seen in 40%-60% of cases operative distortion/colonoscopic distortion</p> <p>Diverticulitis diverticula are small mucosal pockets inthe wall of the colon obstruction of the neck of the diverticulum may result in the distention secondary to mucus secretion and overgrowth of normal colonic bacteria ultimately leading to perforation.</p> <p> pain maybe intermittent or constant frequently associated with a change in bowel habits hematochezia is rare anorexia, nausea and vomiting may occur recurrent attacks can result in the formation of scar tissue, leading to narrowing and obstruction of the colonic lumen.</p> <p>Management of Intestinal Obstruction</p> <p>Evaluations History and Physical Examination Laboratory Examinations Chest/Abdominal Radiographs - flat, upright and decubitus Contrast studies (single, double) Endoscopy</p> <p> Computed Tomography MRI CT colonoscopy/ Virtual colonography</p> <p>ColonoscopyIndications for colonoscopy: evaluation of potentially significant barium enema evaluation of lower GI bleed IBD therapeutic indications surveilance studies</p> <p> removal of colon polyp work up of iron deficiency anemia discretionary follow-up of colonic lesions of unknown significance diagnosis and localization of lower GI bleed prior to possible electrocauterization or surgery These indications are not all-inclusive and are subject tophysician discretion in individual cases.</p> <p>Contraindications: toxic, fulminant colitis perforation of abdominal viscus severe coagulopathy acute diverticulitis acute or recent MI patient refusalAmerican College of Physician</p> <p> Although colonoscopy maybe useful in patients with partial colonic obstruction, it has little role in the initial evaluation of patients suspected of having complete obstruction. The insufflation of air or CO2 through endoscope may exacerbate colonic distention and precipitate perforationSleisenger and Fordtrans Edition 2002</p> <p>7TH</p> <p>Contrast Studies Perform if the diagnosis of large bowel obstruction is suspected but not proven If differentiation b/w obstipation and obstruction is required If localization is required for surgical intervention</p> <p>Contrast Studies The reflux of barium above an obstructing colon may promote the development of complete obstruction The use of water soluble contrast media obviates the risk of barium impaction at the site of obstruction and barium peritonitis in the case of unrecognized perforation.Sleisenger &amp; Fordtrans 7th Edition</p> <p> Barium should be used cautiously ornot at all because it may inspissate at the site of stricture and exacerbate the blockageCamerons Current Surgical Therapy 7th Edition</p> <p> CT scan has an overall sensitivity of 98 % and specificity of 87 % in detecting colon cancer </p> <p>Robinson P , Brunett H , Nicholson DA Clinical Radiology Dec 2003</p> <p> Overall sensitivity was 71.7% on plain film And 83.0% on CT.Efficacy of abdominal plain film and CT in bowel obstruction Nippon Igaku Hoshesen Gakkai Zasshi, Mar 2002 Dept of Radiology, St Martin University</p> <p> CT had high sensitivity (93%), specificity (99%) and accuracy (94%) in diagnosing the presence of obstruction. The comparable sensitivity, specificity and accuracy were, respectively, (83%), (98%), (84%) for US and (77%), (70%) and (80%) for plain radiography. The level of obstruction was correctly predicted in 93% on CT, 70% on US and 60% on plain films.Comparative evaluation of plain films, ultrasound and CT in the diagnosis of Intestinal obstruction. Suri, Gupta, Sudhakar, Venkataramu, Sood, Wig Dept of Radiodiagnosis, Post Grad Inst of Medical Education And Research, Chandigarh, India ( 2001)</p> <p> CT scan as a routine preoperative diagnostic exam could cause MISDIAGNOSIS due to the following : Inadequate bowel preparation Flat lesions &gt; 10 mm - misinterpreted as feces Small polyps Barton JB , Langdale et al Am J of Surgey May 2004</p> <p> MRI is superior to CT in staging Cancerand in differentiating between scarring tissue and recurrence Its 91 % sensitive and 100 % specific It has 100% positive predictive value and 89% negative predictive value with an accuracy of 95 % Hock D. , Cancer Journal May 2003</p> <p> MRI is superior in sensitivity , specificity and accuracy to CT scan in determining extent of tumor Pema PJ , Bennett WF Journal of Computer assisted Tomography March-April 2004</p> <p>Treatment and Outcome Resuscitation and Initial management- restoration of intravascular volume - correction of electrolyte abnormalities - nasogastric decompression Subsequent therapeutic decision depend primarily on the presence of complete or partial obstruction or evidenced of strangulation</p> <p> Patients with partially obstructingbenign or malignant strictures w/o evidenced of peritonitis may undergo semi-elective resection. Complete colonic obstruction necessitates emergency operative decompression. Self-expanding metallic endoprostheses or endoluminal colonic wall stents.</p> <p>The goals of operative management in complete colonic obstruction are threefold : (a) to quickly decompress the obstructed colon (b) to definitely treat the obstructing lesion (c) to re-established the intestinal continuity</p> <p>The competency of ileocecal valve is of great importance to the pathophysiology of colonic obstruction. The necessity for emergency operation is dictated by the presence of complete colonic obstruction and not by the measurement of cecal diameter.Sleisenger &amp; Fordtrans GI and Liver Disease 7th Edition</p> <p>Operating in an urgent or emergent</p> <p>fashion is associated with high operative mortality/morbidity. A thorough knowledge of the cause of colonic obstruction is important for optimal patients outcome.7TH Edition</p> <p>Camerons Current Surgical Therapy</p> <p>Current Concepts in Diagnoses and Management of Intestinal Obstruction</p> <p>Virtual colonography/CT colonoscopy </p> <p>Current concepts CT colonography /Virtual colonoscopy promises to become a 1 screening method for colorectal Cancer New rapidly developing non invasive CT technique to detect polyps and cancers &gt;/=10 mm in size Gluecher TM , Fletcher JG . Europe J Cancer Nov. 2003</p> <p> CT colonography is 98 % sensitive and 96 % specificity in detecting Colorec...</p>