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?

History, Mr. Gunnerson Consider the following:

• Characterization of Symptoms:

• Temporal sequence• Alleviating /

Exacerbating factors:

• Associated signs/ symptoms:• Pertinent PMH• ROS• MEDS• Relevant Family Hx• Relevant Social Hx.

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

What is your Differential Diagnosis?

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

HEENT: no adenopathy, no bruits

Genital-rectal: testicles symmetrical, firm prostate, no discrete mass, guaiac + brown stool,

Chest: CTA Skin/Soft Tissue: No inguinal adenopathy

CV: RRR without murmur Neuromuscular: no focal deficits

Abd: obese, distended, no appreciable organomegaly, Tympanic,mild lower abdominal tenderness, no mass

Remaining Exam findings non-contributory

Differential DiagnosisWould you like to update your differential?

What next?

1.Imaging?2.Labs ?3.Endoscopy?4.OR?5.Other?

Colonoscopy

GUNNERSON

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

CT Scan: Abd/Pelvis CT Scan: Chest ?

PA/Lat Chest MRI ?

Bone Scan ? PET SCAN ?

Obstruction Series/Acute Abdominal Series etc. ?

OTHER:

Justify your additional evaluation

CT Scan Mr. Gunnerson

CT Scan Findings

Sigmoid lesion with some adjacent soft tissue change

CT otherwise negative/ No liver lesions identified

Chest X-Ray Mr. Gunnerson

Laboratory

What would you obtain?

Mr. Gunnerson

CBC: Hb/Hematocrit

WBC

Electrolytes

LFT’s Amylase /Lipase

PT/PTT/ Platelets Urinalysis

PSA Type and Crossmatch

CEA Type and Screen

List all labs ordered for your particular patient

Labs Mr. Gunnerson

CBC: Hb 11.0Hematocrit 34

WBC 8.0

CEA: 8.2

Electrolytes : Normal PSA: 4

LFT’s: Normal

PT/PTT: Normal

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?

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

What Stage is Mr. Gunnerson’s Cancer?

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:

Liver Metastases noted on original exploration

What if Mr. Gunnerson presented withAcute perforation ?

What if Mr. Gunnerson presented with:Complete Obstruction?

A large right sided cecal mass?

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?

Chest X-Ray

CT Scan of Chest

OTHER?

Bone scan ? Pet Scan? CT scans?

What if Mr. Gunnerson presented withMultiple Synchronous Lesions ?

QUESTIONS ??????

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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