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Danny A. Portes , M.D.
Department of Medicine Veterans Memorial Medical Center
GENERAL OBJECTIVE :
To discuss a case of Adenocarcinoma of the colon presenting as intestinal obstruction
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.
• • • • • 82 y/o , male Married , RPV Roman Catholic Pangasinan Admitted for the 1st time on May 23, 2005
1 MONTH PTA
History of Present Illness
abdominal pain consultation done still with abdominal (+) vomiting (+) loss of appetite (+) weight loss no consultation nor medication taken
1 WEEK PTA pain
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
Past Medical History
(+) Hypertension x 20 years - on Amlodipine 5mg/tab, OD Hemorrhoidectomy - 1969
Personal / Social History
47 pack year smoker – stopped in 1969 alcoholic beverage drinker – stopped in 1969
Hypertension – paternal side
Review of Systems
(+) generalized body weakness (-) fever (-) cough, hemoptysis, DOB (-) chest pain, orthopnea, PND (-) palpitations, dyspnea (-) dysuria, frequency, urgency (-) bleeding episode (-) polyuria, polydipsia, polyphagia
Conscious , 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
• 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
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
DRE: no skin tags, no lesions, no fissures, good sphincteric tone, full rectal vault, (+) brownish hard stool on examining finger
82yo, male abdominal pain vomiting anorexia weight loss pallor slight tenderness on deep palpation at epigastric area and hypogastrium
T/C BPUD, Anemia 2° Hypertension, Stage 2, controlled
Biliary tract disease Chronic diverticulitis Colonic CA
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
Complete Blood Count
5-23 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
platelet 264 protime 264 Pro act 120 control MCV MCH 12.9 66 20
5-23 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
145 101 3.4
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
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
6-15 D. yellow sl turbid 1.015 6.5 neg neg 0-1 0-4 mod occ
7-15 yellow clear 1.015 7.5 neg neg 2-4 2-3
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
5-24 Gen adynamic ileus, OA thoraco lumbarspine 5-25 5-26 5-27
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
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
Abdominal Aorta: 5-23-05 - no sonographic evidence of abdominal aortic aneurysm
HBT, LGBPS, AA:
5-24-05 - normal liver, biliary tree, spleen - consider cholecystitis - non visualized pancreas and AA - minimal ascites noted
HBT, LGBPS, PAN: 6-17-05 - diffuse parenchymal liver disease
dilated intrahepatic duct sonographically normal gall bladder non visualized pancreas negative para-aortic node enlargement incident note of ascites and right basal pleural effusion
Whole Abdomen CT Scan
- Generalized ileus. Possibility of chronic partial intestinal obstruction likewise considered. - dilated gall bladder - OA changes of lumbar spine
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.
Course in the ward
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
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
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
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°
Surgery service Non surgical abdomen and concurred with the plan Suggestions : Endoscopy serum TPAG determination liquid diet if tolerated
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 & H Continue empiric antibiotic treatment and decompression BT of 2nd unit of PRBC referred back to Gastro service
5th hospital day
Still with abdominal pain localized in left hypogastrium (+) vomiting (-) fever – Increasing abdominal girth (37 inches) – Tenderness on deep palpation
CT scan of abdomen
– – – – Generalized ileus Consider Chronic partial intestinal obstruction Dilated gallbladder Osteoarthritic changes of lumbar spine
6th hospital day
Transfer of service
“E” lap done
– Left hemicolectomy with Devine’s colostomy and biopsy done
• 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
• 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
Course in the ward:
• He stayed at surgery service for two weeks. Antimicrobial coverage, hydration and nutritional build-up were provided.
Course in the ward:
• He was subsequently transferred to ONCOLOGY service. • On his 39th hospital day, he was discharged clinically improved and stable.
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
Neoplasm (60%) Volvulus (20%) Diverticular stricture (10%) Others (10%)
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
colicky abdominal pain, obstipation and
abdominal 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
diverticula are small mucosal pockets in
the 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.
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.
Management of Intestinal Obstruction
History and Physical Examination Laboratory Examinations Chest/Abdominal Radiographs - flat, upright and decubitus Contrast studies (single, double) Endoscopy
MRI CT colonoscopy/ Virtual colonography
Indications for colonoscopy: evaluation of potentially significant barium enema evaluation of lower GI bleed IBD therapeutic indications surveilance studies
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 to
physician discretion in individual cases”.
toxic, fulminant colitis perforation of abdominal viscus severe coagulopathy acute diverticulitis acute or recent MI patient refusal
American College of Physician
“ 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 perforation”
Sleisenger and Fordtran’s Edition 2002
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
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 & Fordtrans 7th Edition
Barium should be used cautiously or
not at all because it may inspissate at the site of stricture and exacerbate the blockage
Cameron’s Current Surgical Therapy 7th Edition
“ CT scan has an overall sensitivity of 98 % and specificity of 87 % in detecting colon cancer “
Robinson P , Brunett H , Nicholson DA Clinical Radiology Dec 2003
“ 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
“ 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)
“ CT scan as a routine preoperative diagnostic exam could cause MISDIAGNOSIS due to the following : Inadequate bowel preparation
Flat lesions > 10 mm - misinterpreted as feces Small polyps “
Barton JB , Langdale et al Am J of Surgey May 2004
“ MRI is superior to CT in staging Cancer
and in differentiating between scarring tissue and recurrence “ “ It’s 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
“ 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
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
Patients with partially obstructing
benign 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.
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
“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 & Fordtran’s GI and Liver Disease 7th Edition
“Operating in an urgent or emergent
fashion is associated with high operative mortality/morbidity”. A thorough knowledge of the cause of colonic obstruction is important for optimal patient’s outcome”.
Cameron’s Current Surgical Therapy
Current Concepts in Diagnoses and Management of Intestinal Obstruction
Virtual colonography/CT colonoscopy •
“ 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 >/=10 mm in size “
Gluecher TM , Fletcher JG . Europe J Cancer Nov. 2003
“ CT colonography is 98 % sensitive and 96 % specificity in detecting Colorectal Cancer “
Neri E., Giusti P., Battolla L Diagnostics and Interventional Radiology , Univ. Pisa , Rome June 2004
Angiography for diagnosis and treatment of colorectal cancer
Preoperative selective arterial angiography can help the diagnosis and locate primary tumors and to detect liver metastasis. At the same time arterial chemotherapy can be an important form of preoperative therapy.
Jin Gu, Ming Li, Guang Xu, Dept of Sx, Oncology School of Peking University, Beijing, Beijing China. Zhai-Li Dept of Surgery, Beijing Chaoyang Hospital
Carcinoma of the Colon
• 5-year survival is 90% when colorectal Ca is diagnosed at an early stage, less than 40% of cases are diagnosed when the cancer is still localized. • 3rd most common Ca in men and women. • about 60% present with obstructive symptoms
How is colon cancer diagnosed?
RISK FACTORS • > 40 y/o • High fat and low fiber diet • Sedentary lifestyle • Smoking • Alcohol use • Family history • IBD
• No obvious signs but could include
– Change in bowel frequency – Change in consistency – Rectal bleeding/ bloody stool – Unexplained weight loss – Fatigue – Persistent abdominal discomfort – Unexplained anemia
Probably Related - high fat and low fiber consumption Possibly Related - beer and ale consumption (esp Rectal Ca) - environmental carcinogen and mutagens Fecapentaenes ( from colonic bacteria ) Heterocyclic amines ( from charbroiled and fried meat and fish )
Environmental Factors Potentially Influencing Carcinogenesis in the Colon and Rectum
Probably Protective - high fiber consumption - physical activity and low body mass - Aspirin and NSAIDs - Calcium Possibly Protective - yellow green cruciferous vegetable - Vitamin A, C, E - HRT ( estrogen )
Average-Risk Sreening Guidelines
Flexible sigmoidoscopy Colonoscopy Double-contrast enema CEA and Serologic Tumor Markers Genetic Testing
Previous colorectal cancer Previous adenomas Female genital cancer Familial polyposis HNPCC Familial colon cancer
Surgery Chemotherapy Immunotargeted therapy and Immunotherapy Radiation therapy
History & Physical Examination Symptomatology Diagnostics Management and Intervention Prognosis
“Prompt investigation of the cause of abdominal pain, watchful monitoring of the patient’s clinical status with adequate history and physical examination as well as collaboration with different specialties are of prime importance to the diagnosis and appropriate management of our patient”.
THANK YOU! & GOOD MORNING
Small Intestinal Disease
Periumbilical region crampy and maybe associated with vomiting and changes in bowel movement constipation and inability to pass flatus high –pitched or musical bowel sounds
What is the most likely etiology of his abdominal pain?
A. PARIETAL B. VISCERAL A. ACUTE B. CHRONIC
What happens after treatment ? Follow up care
Follow up care 1st year after treatment 2nd -3rd year after treatment 4th – 5th year after treatment
Doctor’s visit Every 3- 6 mos Every 3-6 mos Every 6 mos Tumor markers Every 3 mos CT Yearly colonography Proctosigmoi- Yearly doscopy Every 3 mos Yearly yearly determined by doctor determined by doctor determined by doctor
What could have caused the misdiagnosis preoperatively ?
Differential Diagnosis of Colonic Obstruction
- cecal volvulus - sigmoid volvulus - transverse volvulus Subacute/Chronic onset - colon ca
Rectal ca Metastatic or extracolonic malignancy IBD Diverticulitis Ischemic bowel
Others - colonic pseudo-obstruction - Imperforate anus
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