Altered Bowel Function Linda Barney, MD Wright State University Christopher Brandt, MD Case Western Reserve University
Mr. Gunnerson. • Mr. Gunnerson is a 62-year-old male who is seen by his PCP in the office for abdominal distension and progressive constipation.
History What other points of the history do you want to know?
Characterization of Symptoms: Temporal sequence Alleviating / Exacerbating factors: Associated signs/ symptoms: Pertinent PMH ROS MEDS Relevant Family Hx Relevant Social Hx. History, Mr. GunnersonConsider the following:
History Mr. Gunnerson • Characterization of Symptoms: decreasing caliber and frequency of BM’s • Temporal sequence: 3months of abdominal distension, • Alleviating / Exacerbating factors: No improvement with laxatives • Associated signs/symptoms: 10lb wt. loss No nausea/vomiting • PMH : HTN, Obesity Prostate CA treated with RT • MEDS:Atenolol, ASA • Relevant Family Hx. Brother w/ polyps
Differential DiagnosisBased on History and Presentation • Constipation • Colorectal neoplasm • Diverticular disease • Recurrent prostate cancer • IBD • Stricture
Physical Examination What specifically would you look for?
Physical Examination, Mr. Gunnerson • Vital Signs: Afeb, BP 180/85 • Appearance: NAD Relevant Exam findings for a problem focused assessment
Differential DiagnosisWould you like to update your differential?
What next? • Imaging? • Labs ? • Endoscopy? • OR? • Other?
Colonoscopy Findings • Colonoscopy is done and reveals a near obstructing lesion at 25cms. The proximal colon is surveyed to cecum without additional lesions. • Biopsy reveals adenocarcinoma What further studies would you want at this time?
Studies Ordered Mr. Gunnerson Justify your additional evaluation
CT Scan Findings • Sigmoid lesion with some adjacent soft tissue change • CT otherwise negative/ No liver lesions identified
Laboratory What would you obtain?
Mr. Gunnerson List all labs ordered for your particular patient
Lab Results Discussion • What labs are relevant at this particular point in his work-up? • How would you interpret the findings listed? • Are there other tests that might contribute to his peri-operative course?
Interventions at this point? • Plan elective sigmoid colectomy • Discuss surgical approach options • Open Vs. Laparoscopic • Discuss preoperative preparation • Discuss treatment risks, potential complications and alternatives
Intra-op Mr. Gunnerson Liver inspection & US revealed no evidence of metastases
Post op Management • Discuss routine post op course • Discuss most common complications
Pathology • 4 cm circumferential Adenocarcinoma penetrating through muscularis propria • 3 of 21 lymph nodes positive for metastatic adenocarcinoma
Mr. Gunnerson’s Tumor Stage • Tumor = T3 • Nodes= N1 • Mets= Mo • Stage III / Duke’s C
Colon Cancer Staging • Describe the staging systems for colorectal carcinoma and implications for treatment and prognosis • Outline further treatment options and follow-up care
Post-operative visit • When seen in follow-up Mr. Gunnerson notes that his older brother with a history of polyps alerted him that their father also had polyps before his accidental death at age 51. • Mr. Gunnerson has 3 healthy sons age ( 36, 34,& 31) • What would you advise him regarding their risk assessment and follow-up?
Alternative Scenarios What if Mr. Gunnerson presented with:
What if Mr. Gunnerson presented witha Rising CEA 2 years post-op? How would you work this up?
What if Mr. Gunnerson was found on work-up to have: Liver Metastases?
Where else might colon CA spread and which studies might be utilized to evaluate for metastases?
OTHER? • Bone scan ? • Pet Scan? • CT scans?
Summary • Colon CA can present with an array of symptoms or as occult disease • Colonoscopy is the most definitive diagnostic modality • Laparoscopic and open surgical options are available • Adjuvant treatment options may influence prognosis • Screening and long-term follow-up guidelines are important to disease management
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