Colorectal Carcinoma differential diagnosis, investigations, treatment

1. CBD:
Colorectal Carcinoma
Cohort 8A Batch 3 Group 1 Presenters:
1. Abdulrahman Naji Ahmed SUKD1503969
2. Chin Yi Min SUKD1600903
3. Nadia Eka Wulan Sari SUKD1701864
4. Adnan Hadi Abdurabu SUKD1503968

2. Scenario 1
A 70-year-old patient is presenting with
vomiting, constipation and abdominal pain.
A CT abdomen has revealed a lesion in the
rectosigmoid junction suspicious of
malignancy.
Discuss with the patient the diagnosis and
management.

3. Scenario 2
A 70-year-old patient is presenting with
vomiting, constipation and abdominal pain.
A CT abdomen has revealed a lesion in the
hepatic flexure of transverese colon
suspicious of malignancy.
Discuss with the patient the diagnosis and
management.

4. Table of contents
Differential Diagnosis Possible Diagnosis
Comparison on Left & Right Colon Carcinoma
On presentation,
Investigation &
Management
01 02
03

5. Differential
Diagnosis
01
a

6. Colorectal Cancer
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● the majority of colorectal cancers occur in people older than 50
● Symptoms:
❖ A persistent change in your bowel habits, including diarrhea or
constipation or a change in the consistency of your stool
❖ Rectal bleeding
❖ Persistent abdominal discomfort, such as cramps, gas or pain
❖ Tenesmus
❖ Weakness or fatigue
❖ Unexplained weight loss

7. Bowel Obstruction
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
Bowel obstruction is one of the most frequent emergencies in general
surgery, commonly affecting elderly patients.
Symptoms:
❖ Crampy abdominal pain that comes and goes
❖ Loss of appetite
❖ Constipation
❖ Vomiting
❖ Inability to have a bowel movement or pass gas.
❖ Swelling of the abdomen

8. Diverticular Disease
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● Diverticula are small bulges or pockets that can develop in the lining of
the intestine as the patient get older
● Symptoms:
❖ Abdominal pain, usually in the lower left side, that tends to come
and go and gets worse during or shortly after eating.
❖ constipation, diarrhoea, or both
❖ occasionally, blood in the stool
● If your diverticula become infected and inflamed (diverticulitis),
Patient may suddenly:
❖ get constant, more severe abdominal pain
❖ have a high temperature
❖ have diarrhoea or constipation
❖ get mucus or blood in the stool, or rectal bleeding
❖ Nausea or vomiting

9. Intussusception
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● Intussusception is a rare phenomenon in adults and usually presents
with bowel obstruction
● adult intussusception is seldom idiopathic and frequently associated
with secondary causes such as benign and malignant tumors
● Symptoms:
❖ Intermittent abdominal pain is considered to be the most
common symptom, presenting in 70-100% of cases
❖ Nausea
❖ Vomiting
❖ Constipation
❖ Melena
❖ Weight loss
❖ Fever

10. Bowel polyps
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● Bowel polyps are very common, affecting around 1 in 4 people aged 50
or over.
● They're slightly more common in men.
● Symptoms:
❖ Some people develop just 1 polyp, while others may have a few.
❖ Small amount of mucus
❖ Rectal bleeding
❖ Change in bowel habit (diarrhoea or constipation)
❖ abdominal pain
❖ Unexplained iron deficiency anemia or weight loss.

11. Possible
Diagnosis
02
Yimin, a, Adnan

12. Bowel Obstruction 2ْ
Colorectal Cancer
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● Colorectal cancer is the single most common cause of large intestinal
obstruction.
● The age of the patient is 70 y/o which increase the probability that the
CT scan to be positive of malignancy.
● The CT scan shows a lesion in the rectosigmoid junction with
suspicion of malignancy, this may indicate a colorectal cancer, and the
symptoms (Abdominal pain, Vomiting, and constipation) the patient
has seems to be intestinal obstruction which is a complication of the
cancer.

13. Comparison
on Left &
Right Colon
Carcinoma
03
Yimin, a, Adnan

14. Presentation
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● Usually
asymptomatic
● Vague abdominal
discomfort
● Rectal bleeding
● Alternating
diarrhea &
constipation
● Narrow,
ribbonlike stool

15. Mercury is the closest planet to the Sun and
the smallest one in the Solar System
Right Colonic Carcinoma Left Colonic Carcinoma
Elderly; more in women Found in Younger; more in men
Exophytic lesion Annular invasive lesion
Peritoneal Mets Liver & lungs
Larger Tumour
size
Small
Higher TNM
staging
Lower
Overall worse Prognosi
s
Overall better

16. Mercury is the closest planet to the Sun and
the smallest one in the Solar System
Right Colon CA Left Colon CA Rectal CA
Exophytic lesion Annular invasive
lesion
Ulcerative lesion
Loss of weight,
weakness
Loss of weight, loss of appetite
Rarely obstruction Constipation,
altered bowel habit,
abdominal pain,
decrease stool caliber,
Tenesmes,
altered bowel habit,
intestinal obstruction,
urgency
Occult bleeding Painless rectal bleed Painless rectal bleed
Iron deficiency
anaemia
Bright red blood per
rectum, large bowel
obstruction
Palpable mass at DRE
Bright red blood per
rectum

17. Investigtions
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
1. Sigmoidoscopy: 70% efficacy to diagnose
colorectal cancer.
2. Colonoscopy: more sensitive and specific test 95%
adenocarcinoma in colorectal.
3. CT Colonography: extra colonic histology
4. Double contrast barium enema: to look for apple
core lesion suggest malignancy
5. Single contrast barium enema (after rigid
sigmoidoscopy): is the investigation of choice

18. SIGMOIDOSCOPY

19. Mercury is the closest planet to the Sun and
the smallest one in the Solar System

20. Erect Chest X-ray: if any evidence of metastasize
- Pleural effusion
- Karley A line
- Widened mediastinum
- Cannon ball lesion
- Bony erosion

21. Mercury is the closest planet to the Sun and
the smallest one in the Solar System
MRI of the rectum is performed if the cancer is below the
peritoneal reflexion.
Tumour marker: CEA (Carcinoembryonic Antigen) to rule out
any metastasis.
CT TAP: To do staging of the colorectal ca

22. Mercury is the closest planet to the Sun and
the smallest one in the Solar System
Dukes staging of colorectal cancer
- Stage A - Tumour confined to mucosa
- Stage B - Tumour infiltrating through muscle
- Stage C - Lymph node metastases present
- Stage D - metastasis mainly to liver
Five year survival - 90%, 70% and 30% for Stages A,
B and C respectively

23. Mercury is the closest planet to the Sun and
the smallest one in the Solar System

24. Mercury is the closest planet to the Sun and
the smallest one in the Solar System
Blood Tests
1. FBC: check Hb level (for anemia)
Platelet, TWC
1. BUSE: to check any electrolyte imbalance
2. LFT: if suspect any metastasize
3. Coagulation profile: pre- operative measurement

26. Management
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
1. Admit the patient (Multidisciplinary team approach)
2. ABC
a. Ensure airway patency
b. Check the respiratory rate and start oxygen therapy to maximize the
carrying capacity of RBCs
c. Circulation Check pulse, blood pressure, capillary refill time and
hydration status and correct abnormalities
3. Resuscitation
a. Establish 2 large IV lines
b. Best fluid for resuscitation is blood, (O -) can be used in urgent
settings
c. Other fluids crystalloid, colloids
4. Monitoring every 5, 10, 15 minutes depending on the vital signs
5. Bladder catheterization to monitor urin output and evalute kidney
function.

27. Management
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
1. Give antiemetics for vomiting
2. Proton pump inhibitors in case of bleeding, PPIs is given until UGIB is
ruled out by endoscopy and colonoscopy 80 mg IV (stat slow bolus) then
followed with 8 mg / hour infusion for 72 hour
3. Optimization of the patient:
a. Correct anemia and electrolyte imbalances
b. Correct coagulopathy
c. Optimize nutrition better wound healing
d. Treat & control underlying conditions DM, HTN, HPL
4. Endoscopy & colonoscopy with biopsy
a. With bowel preparation for hemodynamically stable patients
b. If no UGIB then PPIs are stopped

28. Management
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● If the patient developed intestinal obstruction subsequent to the
constipation then a stoma (colostomy) can be made to relieve the
intestinal obstruction initially.
● Antibiotic prophylaxis is given because the bacterial load in the colon
is high, which is done to promote good wound healing and prevent
infection.
● IV Augmentin 1.2 g stat / IV Cephaperazone 2 g stat
+ IV Metronidazole 100 – 500 g stat

29. Management
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● For carcinoma of caecum:
○ Right hemicolectomy
○ Resect 6 to 8 cm of terminal ileum
○ Caecum up to 1/3 of the transverse colon + regional lymph nodes
○ End to end anastomosis is fashioned between ileum and transverse
colon
● For carcinoma located at or near hepatic flexure:
○ Resection must be extended accordingly
● For carcinoma of transverse colon:
○ Excision of transverse colon + both hepatic and splenic flexures +
transverse mesocolon + greater omentum
● For carcinoma of splenic flexure or descending colon:
○ Extent of the resection is from right colon to descending colon

30. Management
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● For carcinoma of pelvic colon:
○ Left hemicolectomy

31. Management - Surgical
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● Management of rectal carcinoma:
1. Anterior resction (AR) +/- J-pouch
2. Abdominal perineal resection (APR)
3. Hartmann’s operation
4. Extensive operation

32. Management - Surgical
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● Anterior resection (AR) +/- J-pouch
● Treat most tumour of the middle third and lower third of rectum
● Single loop colon is used for anastomosis and a short J-shaped colonic
pouch may be constructed with the aim of increasing anorectal capacity to
reduce post-operative bowel frequency and urgency.

33. Management - Surgical
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● Abdominal perineal resection (APR)
● non-sphincter saving
● Indicated for tumours involving the lower third of the rectum and are
unsuitable for sphincter-saving procedure
● +Removal of the distal section of the large intestine
● Two incisions are needed which is the anterior and perineal incisions
● Followed by permanent colostomy

34. Management - Surgical
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● Hartmann’s procedure
○ The lesion is resected, the proximal bowel is made into an end
colostomy and distal remnant closed with sutures or staples
○ Several months later when local inflammation has resolved, a decision
may be made to reconnect the bowel, depending on the fitness and the
preference of the patient

35. Management - Surgical
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● Extensive procedure:
○ When rectal tumour spread adjacent structures
○ Male: cystectomy + resection of rectum
○ Female: hysterectomy + rectum resection
○ In female, Pelvic exenteration is done in case of spread to adjacent
structures such as bladder (Radical hysterectomy + cystectomy +
rectum resection) Hormonal therapy may be required.

36. Raiotherapy & Chemotherapy
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● Radiotherapy indications:
1. Radio-sanitizer effect: Help to make the cancer cells more responsive to
chemotherapy
2. Soft tissue infiltration and inoperable or recurrent tumour.
● Chemotherapy indications:
1. Lymph node involvement (Duke’s C / T4 tumours)
2. High preoperative CEA
● Regimes:
1. Bevacizumab: to correct angiogenesis (Immunotherapy)
2. Regorafenib
3. Levamisole + 5-Fluorouracil

37. Management - Surgical
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● 5 years survival:
1. For Duke’s A is about 90%
2. For Duke’s B is about 80%
3. For Duke’s C is about 60 - 70%
4. For Duke’s D is about 5 - 10%

38. Management - Surgical
Mercury is the closest planet to the Sun and
the smallest one in the Solar System
● Liver metastasis:
○ If metastasis to liver is resectable surgically then stage 4 pateint
survival/prognosis is as good as stage 3 patients (60%)
○ 30-40% is resectable, the rest are palliative.

39. REFERENCES
1. Kim, Kwangmin & John, Ernes & Castro, T & Shim, Hongjin &
Vincent, John & Advincula, G & Kim, Young-Wan. (2019). Differences
Regarding the Molecular Features and Gut Microbiota Between Right
and Left Colon Cancer. Annals of Coloproctology. 34. 280-285.
10.3393/ac.2018.12.17.
2. https://www.homage.sg/health/colorectal-cancer-screening/