This document provides information on the approach to colorectal cancer, including clinical presentation, risk factors, investigations, staging, screening, surgery, and complications. Key points include that changes in bowel habits and rectal bleeding are common symptoms. Risk factors include age, family history, and inflammatory bowel disease. Investigations include colonoscopy, CT scans, and serum CEA levels. Surgery involves removing the tumor and nearby lymph nodes, and may require temporary or permanent stomas. Complications can include anastomotic leaks, bleeding, and hernias.
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Approach to colorectal cancer
1. Approach to Colorectal Cancer
& a bit about stomas
Dr Elizabeth Brown
Elizabeth.brown25@nhs.net
2. Clinical Presentation
• Change in bowel habit
–
–
–
–
Loose stool
Frequent stool
Rectal bleeding
Tenesmus
• Rectal/abdominal mass
• Iron deficiency anaemia
• Screening
• Complications
– Bowel Obstruction
– Perforation
• Secondaries
– Liver metastases –
jaundice, ascites, hepatomegal
y
• General effects of cancer (likely
metastases)
– Anaemia
– Anorexia
– Weight loss
3. Tumours disobey the rules, but generally…
Left Colon
Rectal Bleeding
Change in bowel habit
More present with
obstruction
Right Colon
Anaemia
Mass
Pain
Usually no change in
bowel habit
Less present with
obstruction
Rectal Tumours
Tenesmus
‘Wet wind’
Rectal Bleeding
4. Risk factors for Colorectal Cancer
•
•
•
•
Increasing age
Colorectal polyps
Inflammatory bowel disease – UC
FHx
– FAP
– HNPCC
– Any first degree relative
•
•
•
•
Obesity
Diet
Smoking
Acromegaly
5. Factors that may lower risk of
Colorectal Cancer
• Diet rich in vegetables, garlic, milk, calcium
• Exercise
• Low dose aspirin & NSAIDS
6. Examination
•
General signs
– Anaemia
– Evidence of weight loss
•
Abdomen
– Evidence of obstruction
– Palpable mass
•
Digital rectal examination
– Rectal bleeding
– Palpable mass in rectum/pouch of Douglas
•
Evidence of spread
–
–
–
–
Hepatomegaly
Jaundice
Ascites
Supraclavicular lymphadenopathy
7. GP referrals for suspected LGI
Cancer:
• When are you going to make an urgent referral?
– Symptoms suggestive of LGI cancer
– Age ≥40yrs with rectal bleeding + change in bowel
habit for ≥ 6 weeks
– Age ≥60yrs with rectal bleeding without change in
bowel habit or anal symptoms for ≥ 6 weeks
– Age ≥60yrs with change in bowel habit for ≥ 6 weeks
– Any patient with RIF mass
– Any patient with rectal mass
– Iron deficiency anaemia <11 Males & <10 Females
8. • In borderline patients what important points
in the history might sway you to refer
urgently?
– Particularly if Hx of Ulcerative Colitis or if FHx
• What test can the GP do that will be useful to
the Colorectal specialist?
– Full Blood Count
10. Staging Investigations
• CT with contrast – Chest, Abdomen & Pelvis
– Probably the only staging investigation required
• If another suspicious lesion found on CT, perhaps follow
up with PET scan
• Liver mets best investigated by MRI
• If early rectal tumour (T1/T2) – endorectal USS (EUS)
11. Screening
• General population
– Faecal occult blood test (FOB)
– Age 60-73yrs
– 6 test cards every 2 years for FOB
– If FOB +ve…
• →Colonoscopy
• High risk groups (strong FHx or UC)
– Colonoscopy used for screening, not FOB
12. What is the role of serum CEA?
• Not for diagnosis of colorectal Ca
• Not for screening
• Useful for follow up – if CEA ↑ suggests
recurrence
How do we follow up patients postcolorectal cancer?
• Surveillance Colonoscopies
13. Dukes’ Classification
- A – Tumour confined to mucosa & submucosa
- >90% 5 year survival
- B – Invasion of muscle wall
- ~65% 5 year survival
- C – Regional Lymph Nodes involved
- ~30% 5 year survival
- D – Distant spread e.g. liver, bladder
14. Spread of colorectal cancer
• Local
– Bladder & ureters
•
– Small bowel &
stomach
– Uterus/vagina or
•
prostate
– Abdominal/Pelvic wall
• Lymphatics
– Mesenteric LNs
– Groin LNs (rectal CA)
– Supraclavicular LNs
Blood
– Portal vein → Liver
– Lungs
Transcoelomic
– Peritoneal seedings
15. Surgery for bowel cancer
• Principles:
– Ideally empty bowel
• Enemas & laxatives
– Remove the tumour
• Wide resection of growth
– Lymphadenectomy
• Regional LNs
– Neo-adjuvant chemotherapy
• Rectal Ca T1 or T2 only
• Not colonic tumours
• Aim to downsize tumour before surgery
23. Anastomotic breakdown/Anastomotic
leak:
• High morbidity & mortality
–
–
–
–
–
–
–
–
Can be subtle or obvious
Fever
Oliguria
Ileus
Raised WCC & CRP
Peritonitis
Drain/wound – enteric contents
Usually non-specific examination unless peritonitic
• NEEDS URGENT CT ABDOMEN & PELVIS
• Small abscess/localised collection – CT guided drainage
with broad spectrum antibiotics
• IF GENERALISED PERITONITIS: NEEDS LAPAROTOMY
24. Stomas
• Temporary stoma
– Primary resection with proximal diversion
– To decompress dilated colon before resection of
obstructing lesion
– Free perforation with peritonitis
– Faecal contamination (unprepared bowel)
– Poor nutrition – low albumin
– For reversal procedure in future with anastomosis
• Permanent stoma
– AP resections
– Ileostomy after subtotal colectomy (although ileorectal
anastomosis is an option)
25. • A stoma is…
– …surgically created communication between a
hollow viscus and the skin or external
environment
– Ileostomies, Colostomies, Urostomies, technically
a tracheostomy…
28. Loop Ileostomy
• 2 openings when examine stoma
• Ileum brought to surface & antimesenteric
boder opened
• Rod is used to stop the opened bowel loop
falling back inside
• Simple to reverse so used for temporary
diversion
• Loop ileostomies preferable to loop
colostomies as better blood supply
29. Early complications of stomas
• Bleeding
– unlikely to have large bleed
– some blood in stoma bag
acceptable
• Ischaemia & necrosis
– Dusky stoma colour
– Needs resiting
• Retraction
– Risk of faecal peritonitis
– Back to theatre
• Obstruction
– Due to oedema or hard stool
– Examine stoma with gloves
• High output ileostomy
– Severe dehydration
– Electrolyte disturbances
• Parastomal dermatitis
– Leaking ileostomy
30. Late complications of stomas
• Parastomal hernia
– Stoma/bowel obstruction
– Strangulation
– Stoma may need resiting
•
•
•
•
•
Prolapse
Stenosis of stomal orifice
Stomal diarrhoea
Psychological problems
Underlying disease e.g. Crohn’s peristomal
fistulae
Editor's Notes
Tenesmus = sensation of incomplete emptyingWet wind – passing wind & mucus
Sigmoid tumour may prolapse down into the rectovaginal pouch so can palpate mass anteriorly on DRE
Urgent referrals by GP…2 week wait to local colorectal servicesChange in bowel habit = change to looser stools or more frequent stoolshttp://guidance.nice.org.uk/CG27/NICEGuidance/pdf/English
Colonoscopy is TOO MUCH for some patients to cope withIf comorbities prevent then patient should have flexible sigmoidoscopy followed by a barium enema.Ct colonography depending on local servicesAlternative investigations if comorbidities prevent colonoscopy
SupraclavicularLNs via thoracic duct
Cancer research uk – colorectal cancer – surgical resections = good diagrams
crucial for the prevention of mortality.1,3,4,5,6,7 The signs and symptoms can be subtle or obvious and include the presence of fever, oliguria, ileus, diarrhea, leukocytosis, and peritonitis. Once suspicion is raised, if the anastomosis is in the low pelvis, one can consider a digital rectal examination with the intent of feeling any defect or a mass. Otherwise, physical examination is generally nonspecific except in the setting of enteric contents draining from the wound or a drain. Water-soluble contrast enema, traditionally the first test used to evaluate a higher anastomosis, has been largely supplanted by a computed tomographic (CT) scan. A CT scan of the abdomen and pelvis can be done with intravenous, oral, or rectal contrast material and is particularly useful if a concomitant abscess is suspected. This can be not only diagnostic but also therapeutic, as if an abscess is found, it can often be drained percutaneously.
No nerve endings, patients must be careful not to injure it as won’t be able to feel the damageWhen perforation of uninvolved colon proximal to an obstructing tumor has occurred, whenever possible, resection of the tumor following the oncological principles outlined above should be performed in addition to resection of the perforated segment. In most instances, an ostomy will provide effective fecal diversion and allow for patient recovery until the acute peritonitis has resolved. If the perforation occurs at the site of the tumor but is contained by adjacent structures, resection should ideally incorporate the adjacent structures en bloc. In cases of free perforation with peritonitis, the involved segment should be resected and proximal fecal diversion constructed. A primary anastomosis (with/without proximal diversion) may be considered in selected patients with minimal contamination, healthy tissue quality, and clinical stability.ObstructionThe management of patients with an obstructing cancer should be individualized but may include a definitive surgical resection with primary anastomosis. Grade of Recommendation: 1BOptions for the treatment of obstructing tumors depend on the site of obstruction and the presence of proximal colonic distention with fecal load. Options for treatment may include resection with or without anastomosis (e.g., Hartmann resection), resection of the distended bowel (e.g., subtotal/total colectomy), or temporary relief of obstruction and fecal load (e.g., preoperative stenting as a bridge to resection).
