Colorectal Cancer
History of gastrectomy
- the colon and rectum (colorectal) are commonly
the most affected areas
- 3rd most common site of new cancer cases in US
- 150,000 new cases diagnosed annually
- 52,000 deaths from colorectal occur annually
- Lifetime risk of developing colorectal cancer is 1
out of 17
- Exact cause of colon is still unknown
Risk Factors:
1. Age- older than 85 years old
2. Family history of neoplasia-colon cancer and
polyps
-hereditary factors believe to contribute 20-
30% of colorectal cancer
- Family hx of colorectal cancer or
adenomatous polyps- most important risk factor
-people with one first-degree member with
colorectal cancer have increased risk approximately
2 times that of the general population.
- first degree relatives of patients with
adenomas also are at increased risk especially if the
adenoma was detected before age 60 years.
3. Previous colon cancer or adenomatous polyps
4. High consumption of alcohol
5. Cigarette smoking
6. Obesity – increased accumulation of fat-soluble
toxins and potentially carcinogenic hormones in the
fatty tissues.
7.
8. History of inflammatory bowel disease
Ulcerative colitis
- chronic inflammatory bowel disease that
affects the mucosa and submucosa of the
colon and rectum (terminal ileum), with
exacerbations and remissions; ulceration and
necrosis involves the entire colon;10-20
liquid stools/day (mixed with blood)
Crohn’s disease (regional enteritis)
- chronic, relapsing inflammatory disorder
affecting the GI tract, usually the terminal
ileum and ascending colon of the small
intestines; areas of involvement may be
separated by normal, unaffected segments
(skip areas); with continuous, episodic
diarrhea
9. High Fat, High CHON (↑beef), low fiber diet
- red meat
- increased free-radicals
10. Genital Cancer ( endometrial, ovarian and breast
CA)
* ADENOMA- benign epithelial tumor in which the
cells form recognizable glandular structures or in
which the cells are derived from glandular
epithelium
ALLELE – one or two or more alternative forms of a
gene at corresponding sites on homologous
chromosomes which determine alternative
characters of inheritance.
Pathophysiology :
Adenomatous polyp usually arising from the
epithelial lining of the intestines
↓
Loss of function of one or more tumor suppresor
genes
↓
Spontaneous mutation of one allele combined with
chromosomal instability
↓
Malignant transformation
↓
Invasion and destruction of normal tissues
extending into the surrounding tissues
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 ↓ b. urgency
migration to other parts of the body
(liver, peritoneum and lungs)
Clinical Findings:
Adenocarcinomas grow slowly and may be present
for several years before symptoms appear. These are
greatly determined by the
o location of the tumor
o stage of the disease
o function of the affected intestinal
segment
General Findings:
1. Change in bowel habits- most common
2. Colicky abdominal pain
3. Passage of blood in the stool- 2nd most
common
4. Unexplained anemia
5. Anorexia
6. Weight loss
Signs and Symptoms according to the location of
the tumor:
A. Right-sided colon CA
a. iron deficiency anemia manifested by
fatigue and weakness
b. obstruction is uncommon because the large
diameter of the right colon and the liquid
consistency of the fecal material.
B. Left-sided Colon CA
a. -lesions involves the colon circumferentially
because of its small diameter and its solid
fecal matter
b. -obstructive symptoms may develop
c. -colicky abdominal pain
d. -change in bowel habits
*constipation may alternate periods of
increase frequency and loose stools
*stools may be streaked with blood but
marked bleeding is unusual
C. Rectal CA
a. -tenesmus-ineffectual and painful straining
at stool or in urinating
c. recurrent hematochezia- passage of bloody
stools
d. - a mass may be palpable in the abdomen
Assessment and Diagnostic Findings :
A. Inspection of the colon:
1. Colonoscopy – diagnostic procedure of choice in
patients with a clinical history suggestive of
colon cancer or in patients with an
abnormality suspicious for cancer detected
on radiographic imaging
- colonoscopy with biopsy or
cytology smears to identify malignancy and
staging
2. CT colonography ( or virtual colonoscopy )
-computer-assisted image reconstruction and
rapid helical CT, 2 and 3-dimensional views
can be generated of the colon lumen that
simulate the view of colonoscopy
- no sedation, no IV contrast
-requires similar bowel cleansing regimen as
colonoscopy as well as the insufflation of air
into the colon through a rectal tube, which
may be associated with discomfort
-abnormalities identified requires
assessment by colonoscopy
- favorable for those who are unable or
unwilling to undergo coloscopy.
3. Flexible sigmoidoscopy- a 60-cm flexible
sigmoidoscope permits visualization of the
rectosigmoid and the descending colon
4. Barium enema
- detect for obstruction
5. Fecal Occult Blood testing- determine bleeding
- two slides must be prepared from 3
consecutive bowel movements
- patients should abstain from aspirin and
NSAIDS (prolonged regular use of aspirin (at least
325 mg twice weekly) and NSAIDS- 30-50%
decrease in colorectal cancer), red meat, poultry,
fish adn vegetables with peroxide activity (eg.
Turnips, horseraddish) for 72 hours.
B. Imaging
1. CT scan- may demonstrate distal
metastases in other organcs
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CLASS
A Tumor limited to muscular mucosa
and submucosa
B1 Tumor extends to the mucosa
B2 Tumor extends through entire bowel
wall into serosa or pericolic fat, no
nodal involvement
C1 Positive nodes, tumor is limited to the
bowel wall
C2 Positive nodes, tumor extends through
entire bowel wall
D Advanced and metastasis to the liver,
lung or bone
*Hepatic metastases
-Direct palpation of the liver during
intraoperative assessment
-UTZ
Laboratory Findings:
1. Fecal DNA Assay
-commercially available for screening of
colorectal neoplasia. The test analyzes fecal DNA
for point mutations in the genes, instability and a
marker for abnormal apoptosis
2. Carcinoembronic antigen (CEA)
- may be reliable prognostic indicator but
not a highly reliable indicator in diagnosing
colon cancer
-should be measured in all clients with
proved colorectal cancer
-preoperative CEA level > 5 ng/dl is a poor
prognostic indicator
- after complete surgical resection, CEA
levels should normalize
- persistently elevated levels suggest the
presence of persistent disease and warant
further evaluation.
3. CBC- anemia detection
4. Liver function tests- if metastatic activity reached
the liver
Staging of Colorectal Cancer
Dukes’ Classification-Modified Staging System
The TNM (Tumor, nodal involvement, metastasis)
classification may be used to describe the anatomic
extent of the primary tumor, depending on:
1. Size, invasion depth and surface
spread
2. Extent of nodal involvement
3. Presence or absence of metastasis
*The HIGHER the score in each category, the worse
the disease and the prognosis.
Management :
A. Adjuvant therapy
(Chemotherapy can be given as adjuvant
(preventive) after surgery or in advanced stage of
cancer)
o Class B and C
5-flourouracil (5-FU; Adrucil)
Pelvic Irradiation
o Class C (non-metastasized)
5-flourouracil (5-FU; Adrucil)
leucovorin calcium (Welcovorin)
o Other agents:
oxaliplatin (Eloxatin)
capecitabine (Xeloda)
mitomycin
o Radiation therapy
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B. Surgical Management
1. Laparoscopic colotomy with polypectomy

- a technique combining colonoscopy and

laparoscopy to remove polyps without the
need for segmental resections. B:Endo-GIA 60 mm stapling with careful
-The procedure is facilitated through an preservation of colonic lumen with incorporation of
abdominal opening to allow for the the entirety of the defect and area of coagulation
colonoscope to be entered towards the necrosis.
bowel. The proximal bowel is cross-clamped
and the colonoscope passed to the involved
portion of the colon to facilitate the removal
of the polyp. The serosal surface is
monitored for any indications of
transluminal injury, and the area is repaired
if needed. All polyps undergo immediate
frozen section analysis. If the pathologic
evaluation indicates malignancy then a
segmental resection may be performed,
otherwise the patients are decompressed and
fed within a short time before discharge.

Operative Images Demonstrating Findings and

Stapling Technique.
C: Final staple line showing colonic lumen integrity.

 A: Anterior cecal perforation with surrounding
circumferential area of necrosis and endoscopically
placed clips (white arrows).
2. Laparoscopic colectomy
Minimally invasive or laparoscopic surgery involves
using multiple trocars (thin tubes) placed through 3
to 5 small incisions. These incisions are usually less
than 0.5 cm (less than ¼ inch). Carbon dioxide gas is
then used to slowly inflate the abdomen. A thin
telescope is placed through one of the trocars. This
allows the surgical team to view the inside of the
abdomen on a TV monitor. Specialized instruments
are placed through the other trocars to perform the
operation. For colon surgery, one of the incisions is
enlarged to remove the piece of colon. This larger
incision can also be made initially, allowing one
hand to be placed within the abdomen along with the
camera and long instruments to assist with the
operation. The procedure is performed under general
anesthesia.

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 2. Dissection is performed with specially constructed
thin instruments that are placed into the abdomen
through small incisions, referred to as ports.  A
miniature magnifying video camera is inserted into
the abdomen, and the surgeon and assistants view
the procedure on monitors in the operating room
(Figure 2). 

1. Minimally invasive surgery involves insufflating

the abdomen with carbon dioxide gas, which pushes
the abdominal wall away from the intestine and
allows the surgeon to work (figure 1).

3. A small incision, often less than one-third the

length normally required in open colectomy, is
utilized to remove the specimen at the end of the
procedure (Figure 3).

(A) In open surgery for colorectal cancer, a midline

incision is often used. 

The specimen is removed by enlarging one of the

 (B) In laparoscopic colorectal surgery multiple incisions. 
small incision are used for instruments and camera. 

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Possible surgical procedures:
1. Segmental resection with anastomosis
2. Abdominoperineal resection with permanent
sigmoid colostomy
3. Temporary colostomy followed by
segmental resection and anastomosis and
subsequent reanastomosis of the colostomy
4. Construction of a coloanal reservoir
Collaborative problems and potential complication
in patient with colorectal cancer:
1. Intraperitoneal infection
2. Complete large bowel obstruction
3. GI bleeding
4. Bowel perforation
5. Peritonitis, abscess, and sepsis
Planning Goals:
1. Attainment of optimal level of nutrition
2. Maintenance of F/E balance
3. Reducing anxiety
4. Learning about the DX, surgical procedure, and
self-care after discharge
5. Maintenance of optimal tissue healing
6. Protection of the peristomal skin
7. Learning how to irrigate the colostomy and
change the appliance
8. Expressing the feelings and concerns about the
colostomy and the impact on self
9.Avoidance of complication
Nursing Interventions:
1. preparing the patient for surgery
2. Providing emotional support
3. Providing post-operative care
4. Maintaining optimal nutrition
-Diet is individualized as long as it is
nutritionally sound and does not cause diarrhea or
constipation
- A complete nutritional assessment is
important for the patient with colostomy: avoid
foods that cause excessive odor and gas (cabbage
family, eggs, asparagus, fish ,beans, and high
cellulose products such as peanuts. Help client to
identify foods or fluids that may cause diarrhea
(fruits, high-fiber foods, soda, coffee, tea or
carbonated beverages.
-Increase fluid intake of at least 2 liters per
day.
5. Providing wound care
- Frequently examine the abdominal
dressing during the first 24 hours after surgery to
detect signs of hemorrhage
-Monitor V/S to detect possibility of
infectious process to occur.
- check for stoma color (pink or red), slight
edema or swelling, small amount of oozing
discharge and bleeding (if bright red or beyond trace
amounts)
6. Monitoring and managing complications
-frequently assess abdomen, including
bowel sounds and abdominal girth to detect bowel
obstruction
- Check V/S to monitor possibility of
occurring infectious process
- prevent pneumonia and atelectasis:
Frequent turning Q 2 hours, deep breathing,
coughing and early ambulation
7. Removing and applying the colostomy appliance
 Transverse colostomy- effluent is soft and
unformed and irritating to the skin
 Descending/ sigmoid colostomy- solid, less
irritating to the skin
8. Irrigating the colostomy
- regulating the passage of fecal material is
achieved by irrigating the colostomy or allowing the
bowel to evacuate naturally without irrigations.
- Irrigate the stoma at a regular time, there is
less gas and retention of the irrigant.
9. Supporting a positive body image
- encourage to verbalize feelings and
concerns about altered body image and to discuss
the surgery and the stoma (if created)
10. Discussing sexuality issues
-Alternative sexual positions are
recommended, as well as alternative methods of
stimulation to satisfy sexual drives
11. Promoting home and community-based care
-patient education and discharge planning